Chronic Respiratory Disease

The outcomes of quantitative investigations examining the effectiveness of exercise interventions for people with COPD are limited by the small number of measurement tools that can be included. In contrast, qualitative inquiry allows broader exploration of the perceived outcomes of an intervention. The purpose of this investigation is to explore the qualitative outcomes of a progressive resistance exercise (PRE) program for people with COPD. People with COPD, enrolled in a randomized controlled trial of PRE, were invited to participate in two semi-structured interviews conducted at the end (12 weeks) and 12 weeks after the training intervention (24 weeks). Interviews were audiotaped, transcribed and then coded independently by two researchers. Themes relating to training outcomes were then developed and described. Twenty-two participants were interviewed at 12 weeks, and 19 participants at 24 weeks. After PRE, participants reported a range of physical gains, particularly with regard to improved strength and reduced breathlessness during daily activities. Improved control and confidence during activities of daily living were important psychological benefits perceived by people with COPD, as was the social support experienced during group training sessions. At 24 weeks, confidence persisted despite a perceived plateau or dissipation of physical gains. People with COPD reported physical, psychological and social benefits after PRE, which had a positive effect on activity performance. Although the perceived physical benefits of training were not prominent at 24 weeks, feelings of increased confidence and control persisted. Chronic Respiratory Disease 2007; 4: 135—142

Patients with chronic obstructive pulmonary disease (COPD) are often given a prescription for a short course of oral steroids and antibiotics for self-administration during an acute exacerbation. The main objective of this study was to determine the impact of such prescriptions on medical care utilization, and steroids and antibiotics intake. This retrospective cohort study included patients with moderate to severe COPD participating in a self-management programme. We compared the number of unplanned medical visits (including hospitalizations) and the utilization of systemic steroids (number of short courses, number of days on treatment) and antibiotics (number of treatments) over a period of six months following registration to the programme in patients who received such a prescription and those who did not. Data were collected from hospital and community pharmacy files. A total of 89 patients were included; 46 received a self-administered prescription. During the study period, we found no difference between the two groups in the number of unplanned medical visits. However, we observed small but significant differences in the number of short courses of Prednisone (P = 0.018) and antibiotics (P = 0.006). This translated in an important difference in the number of days on steroids over the same period (`Prescription' group: 26; controls: 8; P = 0.005). Self-administered prescriptions may increase steroids and antibiotics utilization in patients with moderate to severe COPD, without reducing the number of unplanned medical visits. Chronic Respiratory Disease 2007; 4: 143—147

Spirometry is available in most GP surgeries and provides an invaluable tool for assessing respiratory function in chronic obstructive pulmonary disease (COPD) and asthma. Spirometry alone may not provide the clinician with an accurate assessment of lung disease as it misses two important measurements of lung volume. By measuring Residual Volume (RV) and Total Lung Capacity (TLC) it is possible to determine true restrictive or hyperinflated disease processes.

Helium dilution, body plethysmography and nitrogen washout are three different methods which may be used to measure lung volume. These tests are normally only provided in the acute setting. Comparing values of RV and TLC to predicted values makes it possible to grade the severity of disease far more accurately than spirometry.

Four case studies of asthma, obesity, COPD and pulmonary fibrosis clearly demonstrate anomalies that may arise when interpreting lung disease from spirometry compared to the interpretation made with additional lung volume data. Chronic Respiratory Disease 2007; 4: 151—157

Cough is an important defensive reflex of the respiratory tract needed to clear and protect the upper airways; however, it may become exaggerated and interfere with quality of life. Although chronic cough may be successfully treated when associated with the common causes such as asthma and eosinophilic bronchitis, gastrooesophageal reflux disease and post-nasal drip syndrome or rhinosinusitis, increasingly, idiopathic cough or cough with no associated cause is recognised. Chronic cough is often associated with an increased response to tussive agents such as capsaicin, used as an index of the cough reflex. Some airway receptors mediate or influence cough through activation of vagal afferent pathways which converge on brain stem respiratory networks and of supramedullary centres. Plastic changes in intrinsic and synaptic excitability at the brain stem, spinal or ganglionic level may be the mechanism by which the cough reflex is enhanced in chronic cough. Subjective and objective measurements of cough in the clinic are now available but a major unmet need in chronic cough is the availability of effective antitussives. Future directions in chronic cough include the pathophysiological mechanisms of the enhanced cough reflex, and the discovery of effective antitussives that can successfully alleviate chronic cough. Chronic Respiratory Disease 2007; 4: 159—165

Chronic respiratory insufficiency is inevitable in the course of disease progression in patients with Duchenne muscular dystrophy (DMD). Without mechanical ventilation (MV), morbidity and mortality are highly likely towards the end of the second decade of life. The present review reports evidence and clinical implications regarding DMD patients treated with MV. There is no doubt that nocturnal hypercapnia precedes daytime hypercapnia. Historical comparisons have provided evidence that non-invasive intermittent positive pressure ventilation (NIPPV) at night is effective and improves quality of life and survival by 5—10 years. By contrast, the optimal criteria and timing for initiation of NIPPV are inconsistent. A recent randomized study however demonstrated the benefits of commencing NIPPV as soon as nocturnal hypoventilation is detected (Ward S, et al., Randomised controlled trial of non-invasive ventilation (NIV) for nocturnal hypoventilation in neuromuscular and chest wall disease patients with daytime normocapnia. Thorax 2005; 60: 1019—24). The respective role of the three hypotheses of the indirect action of nocturnal NIPPV on daytime blood gases may be complimentary; the main improvement may be due to improved ventilatory response to CO2. The ultimate time to offer full time ventilation with the most advantageous interface is lacking in evidence. Full time NIV is possible with a combination of a nasal mask during the night and a mouthpiece during the day, however tracheostomy may be provided when mechanical techniques of cough-assistance are useless to treat chronic cough insufficiency. Chronic Respiratory Disease 2007; 4: 167—177