Richard ZuWallack

Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper

The Standards for the Diagnosis and Treatment of Patients with COPD document 2004 updates the position papers on chronic obstructive pulmonary disease (COPD) published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) in 1995 1, 2. Both societies felt the need to update the previous documents due to the following. 1) The prevalence and overall importance of COPD as a health problem is increasing. 2) There have been enough advances in the field to require an update, especially adapted to the particular needs of the ATS/ERS constituency. 3) It allows for the creation of a “live” modular document based on the web; it should provide healthcare professionals and patients with a user friendly and reliable authoritative source of information. 4) The care of COPD should be comprehensive, is often multidisciplinary and rapidly changing. 5) Both the ATS and the ERS acknowledge the recent dissemination of the Global Initiative of Obstructive Lung Disease (GOLD) 3 as a major worldwide contribution to the battle against COPD. However, some specific requirements of the members of both societies require adaptation of the broad GOLD initiative. Those requirements include specific recommendations on oxygen therapy, pulmonary rehabilitation, noninvasive ventilation, surgery in and for COPD, sleep, air travel, and end-of-life. In addition, special emphasis has been placed on issues related to the habit of smoking and its control. ### Goals and objectives The main goals of the updated document are to improve the quality of care provided to patients with COPD and to develop the project using a disease-oriented approach. To achieve these goals, both organisations have developed a modular electronic web-based document with two components. 1) A component for health professionals that intends to: raise awareness of COPD; inform on the latest advances in the overall pathogenesis, diagnosis, monitoring and management of COPD; and …

A long-term evaluation of once-daily inhaled tiotropium in chronic obstructive pulmonary disease

Currently available inhaled bronchodilators used as therapy for chronic obstructive pulmonary disease (COPD) necessitate multiple daily dosing. The present study evaluates the long-term safety and efficacy of tiotropium, a new once-daily anticholinergic in COPD. Patients with stable COPD (age 65.2±8.7 yrs (mean±sd), n=921) were enrolled in two identical randomized double-blind placebo-controlled 1-yr studies. Patients inhaled tiotropium 18 µg or placebo (mean screening forced expiratory volume in one second (FEV1) 1.01 versus 0.99 L, 39.1 and 38.1% of the predicted value) once daily as a dry powder. The primary spirometric outcome was trough FEV1 (i.e. FEV1 prior to dosing). Changes in dyspnoea were measured using the Transition Dyspnea Index, and health status with the disease-specific St. Georges Respiratory Questionnaire and the generic Short Form 36. Medication use and adverse events were recorded. Tiotropium provided significantly superior bronchodilation relative to placebo for trough FEV1 response (∼12% over baseline) (p<0.01) and mean response during the 3 h following dosing (∼22% over baseline) (p<0.001) over the 12-month period. Tiotropium recipients showed less dyspnoea (p<0.001), superior health status scores, and fewer COPD exacerbations and hospitalizations (p<0.05). Adverse events were comparable with placebo, except for dry mouth incidence (tiotropium 16.0% versus placebo 2.7%, p<0.05). Tiotropium is an effective, once-daily bronchodilator that reduces dyspnoea and chronic obstructive pulmonary disease exacerbation frequency and improves health status. This suggests that tiotropium will make an important contribution to chronic obstructive pulmonary disease therapy.

Variables related to increased mortality following out-patient pulmonary rehabilitation.

Although patients with advanced pulmonary diseases have significant improvement in exercise ability and functional status following comprehensive out-patient pulmonary rehabilitation (OPR), their long-term prognosis once they have reached this stage of their diseases remains poor. To further evaluate predictors of increased mortality in these patients, we related patient characteristics and short-term outcome obtained during OPR assessment of 158 patients to subsequent survival. The time period from OPR to death or collection of survival data was 40.0 +/- 17.1 months. The following variables were tested individually and in stepwise fashion using a proportional hazards model: 1) age; 2) gender; 3) pulmonary diagnosis; 4) prebronchodilator forced expiratory volume in one second (FEV1); 5) arterial oxygen tension (Pa,O2) and arterial carbon dioxide tension (Pa,CO2); 6) body mass index (BMI); 7) pre- and post-OPR 12 min walking distance (12-MW); 8) pre- and post-OPR quality of life, using the Chronic Respiratory Disease Questionnaire (CRDQ); 9) number and type of nonpulmonary diagnoses; and 10) number of medications. Separate survival analyses were performed for all deaths (the total group), respiratory deaths only (nonrespiratory deaths excluded), and nonrespiratory deaths only (respiratory deaths excluded). Forty three patients (27%) died during the study period; and the 3 year survival was 80%. For all three survival analyses, the post-OPR 12-MW was the most significant variable related to prognosis: patients with low timed walking distance had increased mortality both from respiratory and nonrespiratory causes. Other variables related to increased mortality included: elevated Pa,CO2; low pre-OPR 12-MW; reduced Pa,O2; low FEV1; low BMI, increased number of medications, and increased CRDQ dyspnoea. These results indicate that the timed walking distance following out-patient pulmonary rehabilitation is an important predictor of survival in patients with advanced pulmonary disease.

Pulmonary Rehabilitation for Management of Chronic Obstructive Pulmonary Disease

A 61-year-old black woman with chronic obstructive pulmonary disease is referred for enrollment in a pulmonary rehabilitation program. Pulmonary rehabilitation includes high-intensity exercise to improve muscle function and reduce dynamic hyperinflation of the lungs, as well as education to promote collaborative self-management strategies. Patients with unstable angina or recent myocardial infarction may not be good candidates for pulmonary rehabilitation.

Body composition and health-related quality of life in patients with obstructive airways disease

This study evaluated the effects of body weight and lean mass abnormalities on health-related quality of life (HRQL) in obstructive airways disease. Body weight, lean mass (using dual-energy X-ray absorptiometry), and HRQL (using the St Georges Respiratory Questionnaire (SGRQ)) were measured in 50 patients. Low lean mass was defined as a lean mass index (lean mass/height2) below the fifth percentile of a control population. Dyspnoea was measured by the baseline dyspnoea index. The mean (SD) age was 69+/-9 yrs; the forced expiratory volume in one second (FEV1) was 39+/-19% of predicted. Patients had 2.4+/-4.1 kg less lean mass than predicted. Increased dyspnoea was the most influential predictor of poor HRQL. Compared to normal-weight patients, those who were underweight had significantly greater impairment in activity, impact, and total SGRQ scores, while those who were overweight had greater impairment in impact and total SGRQ scores. Low lean mass was associated with greater impairment in symptoms, activity and impact subscores and the total SGRQ score. When dyspnoea was added to the model as a covariate, neither weight nor lean mass remained significantly related to HRQL. Thus, although body weight and lean mass abnormalities influence health-related quality of life, their effects appear to be mediated through increased levels of dyspnoea.

An official European Respiratory Society statement on physical activity in COPD

This European Respiratory Society (ERS) statement provides a comprehensive overview on physical activity in patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary Task Force of experts representing the ERS Scientific Group 01.02 “Rehabilitation and Chronic Care” determined the overall scope of this statement through consensus. Focused literature reviews were conducted in key topic areas and the final content of this Statement was agreed upon by all members. The current knowledge regarding physical activity in COPD is presented, including the definition of physical activity, the consequences of physical inactivity on lung function decline and COPD incidence, physical activity assessment, prevalence of physical inactivity in COPD, clinical correlates of physical activity, effects of physical inactivity on hospitalisations and mortality, and treatment strategies to improve physical activity in patients with COPD. This Task Force identified multiple major areas of research that need to be addressed further in the coming years. These include, but are not limited to, the disease-modifying potential of increased physical activity, and to further understand how improvements in exercise capacity, dyspnoea and self-efficacy following interventions may translate into increased physical activity. The Task Force recommends that this ERS statement should be reviewed periodically (e.g. every 5–8 years). An official ERS statement providing a comprehensive overview on physical activity in patients with COPD http://ow.ly/C6v78

The influence of demographic and socioeconomic factors on health-related quality of life in asthma

BACKGROUND Although health-related quality of life (HRQL) in asthma is strongly influenced by disease severity, demographic and socioeconomic variables may also be important factors. OBJECTIVE We related demographics, asthma severity, and socioeconomic factors to HRQL. METHODS We interviewed 50 patients with moderate or severe asthma recruited from outpatient health center-based clinics to determine demographics, socioeconomic status, asthma severity, medication use, and HRQL. For HRQL, the mean total score of the Asthma Quality of Life Questionnaire (AQLQ) and the Medical Outcomes Study Short-Form 36 questionnaires physical and mental component summary scores (PCS and MCS, respectively) were used. RESULTS The mean patient age was 46 +/- 14 years, and the FEV1 was 75% +/- 21% of predicted value. Twenty-nine subjects had been hospitalized for asthma, 29 belonged to a minority racial/ethnic group, and 16 had less than 12 years of education. The mean total AQLQ score was 4.12 +/- 1.42, the PCS was 37 +/- 10, and the MCS was 45 +/- 13. In univariate analyses, severity (nighttime awakenings, prednisone use, and a history of emergency department visits), racial/ethnic group (African American, white, or Hispanic), and socioeconomic status (low educational level, unemployed, family income under

Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence.

20,000, public assistance, or no health insurance) were related to HRQL. These factors explained 67% of the variance of AQLQ and 48% of the variance of the PCS. Much of the quality of life variance was shared among these variables. Explanatory variables were not related to MCS in multivariate analysis. CONCLUSION Socioeconomic status is an additional important independent factor influencing HRQL in asthma. In this study it was difficult to separate out the unique effects of socioeconomic status and race/ethnicity.

An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation

STUDY OBJECTIVES To evaluate whether direct feedback discussion on inhaled steroid use might influence subsequent adherence with this therapy. DESIGN AND SETTING A 10-week, single-blind, randomized trial in asthma patients. Inclusion criteria included forced expiratory volume in 1 second <80%, one or more markers for low socioeconomic status, and the use of inhaled steroids. Inhaled steroid and beta-agonist use were electronically monitored. All patients received standard asthma care. The treatment group received direct clinician-to-patient feedback discussion on their inhaled steroid and beta-agonist use on all subsequent visits, whereas this information was withheld during the study period in the control group. MEASURES 1) Mean weekly inhaled steroid adherence [(number of actuations/prescribed number of actuations) x 100]; 2) number of days with overuse of inhaled steroids; 3) 24-hour and nighttime albuterol use; 4) included forced expiratory volume in 1 second; and 5) Asthma Quality of Life Questionnaire total score. RESULTS Ten treatment and nine control patients completed the study. Mean weekly inhaled steroid adherence over the first week was not significantly different in the treatment and control groups: 61 +/- 9% versus 51 +/- 5%, respectively. However, by the second week, adherence increased to 81 +/- 7% in the treatment group, whereas it decreased to 47 +/- 7% in the control group (P = 0.003). Adherence remained above 70% in the treatment group for the entire trial, but continued to decrease in the control group. Overuse of inhaled steroids was low in both groups. There were no group differences in any of the asthma outcomes. CONCLUSIONS Direct clinician-to-patient feedback discussion on inhaled steroid use using electronic printouts did improve adherence in the short-term in asthma patients at high-risk for poor adherence.

An official American Thoracic Society/European Respiratory Society statement: research questions in COPD

RATIONALE Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients. OBJECTIVES The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide. METHODS Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS. MAIN RESULTS This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR. CONCLUSIONS The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.