Michael Greenstone

Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence

Abstract Objectives To evaluate the efficacy of hospital at home schemes compared with inpatient care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). Design A systematic review of randomised controlled trials. Main outcome measure Mortality and readmission to hospital. Results Seven trials with 754 patients were included in the review. Hospital readmission and mortality were not significantly different when hospital at home schemes were compared with inpatient care (relative risk 0.89, 95% confidence interval 0.72 to 1.12, and 0.61, 0.36 to 1.05, respectively). However, compared with inpatient care, hospital at home schemes were associated with substantial cost savings as well as freeing up hospital inpatient beds. Conclusions Hospital at home schemes can be safely used to care for patients with acute exacerbations of COPD who would otherwise be admitted to hospital. Clinicians should consider this form of management, especially as there is increasing pressure for inpatient beds in the United Kingdom.

An English kindred with a novel recessive tauopathy and respiratory failure

We present the clinicopathological features of two siblings from a consanguineous marriage who presented with respiratory hypoventilation and died 10 days and 4 years later, respectively. This disorder showed extensive tau neuropathology, and both had a novel homozygous S352L tau gene mutation. This is the first description of a pathologically proved young‐onset tauopathy with apparent recessive inheritance. Ann Neurol 2003;54:682–686

Changing Paradigms in the Diagnosis and Management of Bronchiectasis

The face of bronchiectasis may have changed in recent years but individual cases continue to pose difficult challenges. As childhood infection becomes less of a problem, alternative causes of bronchiectasis are increasingly recognized which themselves offer new problems of diagnosis and management. Evolving concepts of pathogenesis suggest alternative strategies for treatment but as yet the evidence base on which to make firm decisions is lacking.Antibacterial regimens are not universally applicable and individualized protocols with parenteral, nebulized or continuous antibacterial therapy are increasingly used in the treatment of patients with bronchiectasis. Despite the theoretical appeal of using mucolytic or anti-inflammatory drugs their roles are still uncertain and have yet to be examined in adequate clinical trials.The factors determining disease progression are still poorly understood but in some patients worsening airflow obstruction heralds the onset of ventilatory failure. The management of the latter requires bronchodilators and controlled oxygen therapy, and strategies including non-invasive ventilation are increasingly an option. Changing indications for surgery are evident with fewer palliative resections but a developing role for transplantation.

Tiotropium improved lung function and delayed exacerbations in poorly controlled asthma

Source Citation Kerstjens HA, Engel M, Dahl R, et al. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med. 2012;367:1198-207. 22938706

Diseases of the Pleura

Pleural disorders are a common reason for referral to respiratory specialists, with over 50 known conditions that can cause pleural effusion. Chest radiography remains the initial investigation of choice, as it can detect pneumothorax, pleural thickening, asbestos-related pleural disorders, and pleural effusion of at least 200 ml in volume. Pneumothorax is defined as the presence of air in the pleural cavity and is a common medical emergency. Common causes of exudative pleural effusions are infection, pulmonary embolism, and malignancy. Mesothelioma is an aggressive form of cancer that is an important cause of mortality worldwide, and arises from the mesothelial cells lining the pleura, usually because of exposure to asbestos fibres. Common causes of transudative pleural effusions include cardiac failure, and liver or renal diseases. Thoracic ultrasound, computed tomography, and positron emission tomography have become important imaging modalities in the investigation of pleural disorders.

Self-monitored, home-based pulmonary rehab was noninferior to outpatient, hospital-based rehab for COPD

Question Is self-monitored, home-based rehabilitation noninferior to outpatient, hospital-based rehabilitation for improving dyspnea in chronic obstructive pulmonary disease (COPD) at 1 year? Methods Design Randomized controlled trial. ClinicalTrials.gov NCT00169897; ISRCTN32824512. Allocation Concealed.* Blinding Blinded {data collectors and analysts, outcome assessors, and safety committee}.* Follow-up period 1 year. Setting 10 centers in Canada. Patients 252 patients 40 years of age (mean age 66 y, 56% men) who had stable COPD (no change in medication or symptoms for 4 wk), were current or former smokers of 10 pack-years, had an FEV1 < 70% of predicted value and FEV1FVC ratio < 0.70, and had a Medical Research Council (MRC) dyspnea score 2. Exclusion criteria included history of asthma, congestive left heart failure as primary disease, terminal disease, dementia, and uncontrolled psychiatric illness. Intervention Home-based exercise program (n =126) or outpatient, hospital-based exercise program (n =126). Both groups received an educational intervention in twice-weekly sessions for 4 weeks and strength and aerobic exercises in 3 sessions/wk for 8 weeks. The home-based program was self-monitored, and the hospital-based program was supervised by trainers. Outcomes Change in the dyspnea domain of the Chronic Respiratory Questionnaire (CRQ) at 1 year. A difference of 0.5 was selected as the minimum patient-important difference between groups. Secondary outcomes included adverse events. Patient follow-up 86% (intention-to-treat analysis). Main results The home-based program was noninferior to the hospital-based program for improving dyspnea at 3 months and 1 year (Table); adverse events did not differ between groups. Conclusion In patients with chronic obstructive pulmonary disease, self-monitored, home-based rehabilitation was noninferior to outpatient, hospital-based rehabilitation for improving dyspnea at 1 year. Home-based rehabilitation vs outpatient hospital-based rehabilitation for chronic obstructive pulmonary disease Outcome Follow-up Mean score change from baseline Difference in mean change from baseline (95% CI) Home Hospital Dyspnea 3 mo 0.82 0.78 0.05 (0.21 to 0.29) 1 y 0.62 0.46 0.16 (0.08 to 0.40) Dyspnea domain of the Chronic Respiratory Questionnaire; a difference of 0.5 was considered clinically important. Commentary Pulmonary rehabilitation is an evidence-based and effective treatment for COPD, which improves exercise tolerance at a magnitude similar to that of pharmacotherapy. Increasing access to this treatment is a priority for the health community. The study by Maltais and colleagues examined the feasibility and efficacy of a home-based program compared with more widespread hospital-based regimens. Rehabilitation programs initiated in the patients home were safe and as effective in reducing dyspnea during daily life as those initiated in secondary care. An important aspect of the maintenance phase was the prescription to continue exercising 3 times a week at home for 9 months after completing the program. As with most studies of rehabilitation, improvement was greater in the immediate period after the program was completed and was attenuated by 12 months, although both groups still had less dyspnea than at baseline. The groups were well-matched, with COPD of at least moderate severity (mean FEV1 43% to 46% predicted), but had a surprisingly well-preserved exercise tolerance with a mean 6-minute walking distance of 370 m. The improvement in this commonly used measure was negligible, but ability to cycle on exercise bikes (a less familiar activity) greatly increased, and average improvement in dyspnea scores at both 3 and 12 months exceeded the minimal important difference. Severely affected patients (MRC grade 5) have always found it difficult to access hospital-based programs and are particularly likely to want home treatment. This trial does not address how much improvement they might anticipate; indeed, they were relatively underrepresented in this study. This study shows the benefits that patients with COPD can expect from home-based programs. The issue remains whether local providers can address service-delivery issues to mount and sustain such programs.