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Objectives Pulmonary rehabilitation involves a significant component of education, but little has been published on what educational content is covered or how it is delivered. This survey study set out to investigate how pulmonary rehabilitation education is delivered in practice. Methods A survey was designed to investigate current educational delivery and which topics respondents reported should be included in a pulmonary rehabilitation programme. The survey was sent to 11 Scottish Pulmonary Rehabilitation Action group regional leads. Results Nine completed the questionnaire (81.8%). Education was reported to be predominately group-based and face-to-face (n=9, 100%) consisting of between 6-12 sessions. Most educational topics lasted 15 minutes or less, some topic areas were not consistently covered. The educational content was variable and not personalised to individual needs. Three health areas undertook informal literacy assessment at baseline assessment and when tailoring COPD plans. Often attendance at educational sessions was not needed to "complete" pulmonary rehabilitation (PR). Conclusions Content and delivery of educational topics was varied, and no consistent outcome measure to assess the effectiveness of education was used. Practice implications Education needs to be delivered in a patient centred way tailoring for literacy skills using a range of different teaching approaches and aids.

Background Females with exacerbations of Chronic Obstructive Pulmonary Disease now account for one half of all hospital admissions for that condition and rates have been increasing over the last few decades. Differences in presentations of disease between genders have been shown in several conditions and this study explores whether there are inter gender biases in probable diagnoses in those suspected to have COPD. Methods 445 individuals with a provisional diagnosis by their General Practitioner of “suspected COPD” or “definite COPD” were referred to a community Respiratory Assessment unit (CRAU) for tests including spirometry. Gender, demographics, respiratory symptoms and respiratory medical history were recorded. The provisional diagnoses were compared with the final diagnosis made after spirometry and respiratory specialist nurse review and the provisional diagnosis was either confirmed as correct or refuted as unlikely. Results Significantly more men (87.5%) had their diagnosis of “definite COPD” confirmed compared to 73.9% of women (p = 0.021). When the GP suggested a provisional diagnosis of “suspected COPD” (n = 265) at referral, this was confirmed in 60.9% of men and only 43.2% of women (p = 0.004). There was a different symptom pattern between genders with women being more likely to report allergies, symptoms starting earlier in life, and being less likely than men to report breathlessness as the main symptom. Conclusions: These results may suggest a difference between genders in some of the clinical features of COPD and a difference in likelihood of a GPs provisional diagnosis of COPD being correct. The study reiterates the absolute importance of spirometry in the diagnosis of COPD.

Introduction Pulmonary rehabilitation (PR) is a core component of Chronic Obstructive Pulmonary Disease (COPD) management with well recognized benefits. While suggestions for educational content within pulmonary rehabilitation have been detailed in clinical guidance, it is unclear what educational content is delivered as part of pulmonary rehabilitation, who delivers it, and how it is delivered. Methods A systematic review was conducted to identify what educational content is delivered as part of pulmonary rehabilitation, how is this delivered and who delivers it. Databases were searched from 1981 to 2017 using multiple search terms related to “pulmonary rehabilitation” and “education”. Results Fourteen studies were identified. This included 6 survey studies, 5 quasi-experimental studies and 3 RCTs. Five key topics that were consistently included within PR programmes were identified as: 1) Anxiety/depression and stress management. 2) Early recognition of signs of infection. 3) Dyspnea and symptom management. 4) Nutrition. 5) Techniques using inhalers and nebulizers. Broader topics such as welfare/benefits, sexuality, and advance care directives did not frequently feature. Only four studies used tools to measure knowledge or learning pre and post rehabilitation in an attempt to evaluate the effectiveness of the education delivered as part of PR. Conclusions The delivery of education in PR programmes is variable and does not follow suggested educational topics. Education needs to take a patient centered motivational approach to ensure effective delivery. Further research into appropriate educational outcome measures are needed, in order to evaluate the changes in behaviour associated with education.

The concept of integrated care has been advocated for many years to address some of the challenges faced by the NHS. This report examines the experiences of respiratory healthcare specialists working in an integrated role. Twelve qualitative telephone interviews were undertaken with a range of integrated respiratory specialists and their teams working in both hospitals and the community. A descriptive and thematic approach to data analysis was adopted.Participants were very enthusiastic about their roles and saw themselves as ambassadors for this new way of working. Several key themes were identified from the analysis which participants identified as barriers or enablers to the successful undertaking of an integrated respiratory specialist role. These included the participants’ previous work experience and background, the range of multi-disciplinary expertise within or needed for the team, the structure of the team leadership and the measurement of outcomes to evaluate the team. Participants identified the need for clear job descriptions and roles, shared training and standards and appropriate outcome evaluation. More research is needed to understand how these new ways of working are developing and how they can be evaluated.

We invite comments from primary care on a proposal made in an article in Lancet Respiratory Medicine 1 that patients with asthma and COPD who have had, or are at risk of having, an exacerbation should be given standardised emergency inhaled treatment packs containing the appropriate pMDI or pMDIs (salbutamol for COPD, salbutamol and beclomethasone 250 mcg for asthma) and a spacer. These packs, with simple instructions for their use, should be …

To understand the needs of people with asthma and COPD, and to identify opportunities for improved care. Quantitative questionnaire-based survey performed in five European countries on patients with asthma and COPD. Questionnaires were administered to patients using Computer Assisted Web Interview methodology. 1022 patients with asthma (UK [n=190]; Germany [n=214]; France [n=200]; Italy [n=222]; Spain [n=196]) and 719 patients with COPD (UK [n=153]; Germany [n=147]; France [n=145]; Italy [n=140]; Spain [n=134]) were enrolled in the study. 32% of those with asthma and 67% of those with COPD considered that their condition had a significant effect on their quality of life, and stigma and emotional distress was common. Many expressed concern regarding potential medication side effects or that medicines might lose their effect with time. Major discrepancies between expectations and patient satisfaction with the doctor-patient relationship were observed, including a need to be consulted in the choice of inhalers. Consultations were infrequent, and 75% of respondents sought additional information beyond that received during consultations - commonly from the internet. Patient satisfaction was high but information needs were not addressed and the emotional burden of disease is underappreciated.

Background Hospital admission rates for chronic obstructive pulmonary disease (COPD) are known to be strongly associated with population factors. Primary care services may also affect admission rates, but there is little direct supporting evidence. Objectives To determine associations between population characteristics, diagnosed and undiagnosed COPD prevalence, primary healthcare factors, and COPD admission rates primary care trust (PCT) and general practice levels in England. Design, setting, and participants National cross-sectional study (53,676,051 patients in 8,064 practices in 152 English PCTs), combining data on hospital admissions, populations, primary healthcare staffing, clinical practice quality and access, and prevalence. Main outcome measures Directly and indirectly standardised hospital admission rates for COPD, for PCT and practice populations. Results Mean annual COPD admission rates per 100 000 population varied from 124.7 to 646.5 for PCTs and 0.0 to 2175.2 for practices. Admissions were strongly associated with population deprivation at both levels. In a practice-level multivariate Poisson regression, registered and undiagnosed COPD prevalence, smoking prevalence and deprivation were risk factors for admission (p Conclusion Associations of COPD admission rates with deprivation, primary healthcare access and supply highlight the need for adequate services in deprived areas. An association between admission rates and undiagnosed COPD prevalence suggests that case-finding strategies should be evaluated. Of the COPD clinical quality indicators, only influenza immunisation was associated with reduced admission rates. Patients9 experience of access to primary care may also be clinically important.

Telemonitoring, telemedicine, clinical and medical informatics or telecare, are terms used to describe the use of technology along with local clinical protocols to monitor remotely a patient's medical condition in their own home. In respiratory medicine, where large numbers of people have long term conditions such as asthma and chronic obstructive pulmonary disease (COPD), the role of such monitoring technology in the management of patients is of great interest. This review seeks to explore what evidence exists to support the deployment of technology to improve the care of people with respiratory conditions. Narrative review. A wide variety of technologies have been involved in asthma and COPD care, from management systems to self monitoring devices. Many studies report that staff and patients ‘liked’ the technology. The service, care and financial benefits to both patients and the health care system were less obvious. Many studies suffered from poor methodology and lacked clear endpoints. There is an enormous potential for telemonitoring to assist in the provision of better care for those with long term lung diseases. However, evidence of benefit is unclear and there remains a need for robust studies and answers to clear research questions for specific patient populations before such technologies can be recommended for widespread implementation.

To determine diurnal variability of symptoms in chronic obstructive pulmonary disease (COPD) and to assess the impact of COPD upon patients' morning activities and routines.Quantitative internet interviews with 803 COPD patients from Europe and the USA, including 289 patients with severe COPD. Severe COPD was defined according to regular use of COPD medication, third level of breathlessness or above using the modified Medical Research Council (MRC) dyspnoea scale (MRC dyspnoea scoreor =3) and one or more COPD exacerbations in the preceding 12 months.Morning was the worst time of day for COPD symptoms, particularly in patients with severe COPD (reported by 46% of severe patients). In these patients, shortness of breath was the most frequently reported symptom, correlating strongly with problems experienced with morning activities. Morning activities most affected by COPD were walking up and down stairs, putting on shoes and socks, making the bed, dressing, showering or bathing and drying. The majority of patients were not taking their medication in time for it to exert its optimal effect.Many patients consider the impact of COPD on morning activities to be substantial. Physicians should question patients about morning activities to assess disease impact and to advise regarding the optimal time to use therapy. This was an internet-based questionnaire survey and possible bias in patient selection and self-reported diagnosis of COPD and its severity should be taken into account.

Noreen M Clark1, Julia A Dodge1, Martyn R Partridge2, Fernando J Martinez31Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI, USA; 2Imperial College of Science, Technology and Medicine, London, England, UK; 3Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USAAbstract: A number of excellent intervention studies related to clinical and psychosocial aspects of chronic obstructive pulmonary disease (COPD) have been undertaken in the recent past. A range of outcomes have been examined including pulmonary function, health care use, quality of life, anxiety and depression, ambulation, exercise capacity, and self-efficacy. The purpose of this narrative review was to a) consider clinical, psychosocial, and educational interventions for people living with COPD in light of the health related outcomes that they have produced, b) identify the type of interventions most associated with outcomes, c) examine work related to COPD interventions as it has evolved regarding theory and models compared to work in asthma, and d) explore implications for future COPD research. Studies reviewed comprised large scale comprehensive reviews including randomized clinical trials and meta-analysis as these forms of investigation engender the greatest confidence in clinicians and health care researchers. Extant research suggests that the most significant improvements in COPD health care utilization have been realized from interventions specifically designed to enhance disease management by patients. A range of interventions have produced modest changes in quality of life. Evidence of impact for other outcomes and for a particular type of intervention is not strong. Research in other chronic diseases, particularly asthma, suggests that interventions grounded in learning theory and models of behavior change can consistently produce desired results for patients and clinicians. Use of a model of self-regulation may enhance COPD interventions. Although the extent to which COPD efforts can benefit from the experience in other conditions is a question, more outcome focused intervention studies using more robust theoretical approaches may enhance COPD results, especially regarding health care use and quality of life.Keywords: COPD, disease management, self-regulation

Summary Background It is important that those taking part in research trials are as representative as possible of those with the disease being studied. In a study of those with chronic obstructive pulmonary disease involving pulmonary rehabilitation, 120 of 297 suitable patients responded that they did not wish to take part in the trial. We were keen to know why these patients declined to take part in the study. Methods A total of 120 patients who had responded that they did not wish to take part in the main trial were approached to ask if they would be willing to undertake a semi-structured face-to-face interview in their own home or by telephone. Those who were willing (n=39) underwent tape-recorded interviews and data analysis was performed using the framework method. Results This was a qualitative study which revealed that several themes influenced patients’ willingness or otherwise to take part in a research project involving pulmonary rehabilitation. Travelling to the hospital and location of the rehabilitation, along with competing commitments, and a variable perception of the benefits to the patient were clearly major factors and some had previous negative experiences of either the hospital, healthcare or research. While there was an element of negativity or impaired understanding regarding the research itself, the other factors appeared to be of greater importance. Conclusion Recruitment to pulmonary rehabilitation courses or recruitment to research involving pulmonary rehabilitation may be more successful if the location of the rehabilitation can be made as near to the patient's home as possible, and if the patient is given as much information as possible about what is involved.

Summary Aims To establish a Community Respiratory Assessment Unit and to evaluate its role in enhancing the accuracy of respiratory diagnosis in primary care. Methods We established a central and peripatetic nurse-led service utilising semi-structured history taking, spirometry, oxygen saturation monitoring and semi-structured reporting, coupled with the provision of educational materials to both primary care physicians and patients. Results Phased access to the service was offered to 32 general practices. Use varied widely between practices and a total of 364 patients were referred in the first year. The single biggest diagnostic group consisted of patients with definite or suspected COPD, but the diagnosis was often not confirmed. Patient and GP satisfaction with the service was extremely high; without it misdiagnoses and inappropriate therapeutic trials are possible. Conclusion A community respiratory assessment unit such as this is one way of offering a centrally-directed, quality-controlled, diagnostic support service for primary care physicians.

Summary Aims To understand better which patients with which diagnoses or suspected diagnoses are referred for spirometry in primary care, and to assess whether all such referrals are appropriate. Methods 200 consecutive patient referrals to an open access spirometry service from ten local general practices were evaluated by perusing the request forms, and analysis of the spirometry results and the report sent to the general practitioner (GP). Results 51% of all referrals had suspected or stated COPD, but airway obstruction was demonstrated in only 53% of cases. A minority had a degree of reversibility which suggested an additional asthma component at least. Airway obstruction was rarely demonstrated in patients referred with stated or suspected asthma. 117 patients were referred with stated or suspected airway disease but had no evidence of airway narrowing on testing. 14.5% of these had an unexpected small lung (restrictive) disorder. Six of these had a BMI of more than 30. Conclusion Most referrals with stated or suspected COPD were highly appropriate since spirometry is required in order to establish the correct diagnosis. Referral of patients with suspected asthma is less likely to be helpful, and a period of home peak flow monitoring may be more useful. Restrictive disorders can be confused with airway disorders, and obesity may be underestimated as a cause of breathlessness.

Study objectives This study was conducted to gain insight into patients’ comprehension, recognition, and experience of exacerbations of COPD, and to explore the patient burden associated with these events. Design A qualitative, multinational, cross-sectional, interview-based study. Setting Patients’ homes. Patients Patients (n = 125) with predominantly moderate-to-very severe COPD (age ≥ 50 years; with two or more exacerbations during the previous year). Interventions Patients underwent a 1-h face-to-face interview with a trained interviewer. Measurements and results During the preceding year, patients experienced a mean ± SD of 4.6 ± 5.4 exacerbations, after which 19.2% (n = 24) believed they had not fully recovered. Although commonly used by physicians, only 1.6% (n = 2) of patients understood the term exacerbation , preferring to use simpler terms, such as chest infection (16.0%; n = 20) or crisis (16.0%; n = 20) instead. Approximately two thirds of patients stated that they were aware of when an exacerbation was imminent and, in most cases, patients recounted that symptoms were consistent from one exacerbation to another. Some patients (32.8%; n = 41), however, reported no recognizable warning signs. At the onset of an exacerbation, 32.8% of patients (n = 41) stated that they reacted by self-administering their medication. Some patients spontaneously mentioned a fear of dying (12.0%; n = 15) or suffocating (9.6%; n = 12) during exacerbations, and effects on activities, mood, and personal/family relationships were frequently reported. Physicians tended to underestimate the psychological impact of exacerbations compared with patient reports. Conclusions This study shows that patients with frequent exacerbations have a poor understanding of the term exacerbation . Patient recollections suggest that exacerbation profiles vary enormously between patients but that symptoms/warning signs are fairly consistent within individuals, and are generally recognizable. Exacerbations appear to have a significant impact on patient well-being, including psychological well-being, and this may be underestimated by physicians.

Achieving the optimal management of Chronic Obstructive Pulmonary Disease (COPD) is a major challenge facing all countries where smoking is and has been highly prevalent. The consequences of missed or delayed diagnosis represent a source of distress to patients, unnecessary expense to health care systems, and a missed opportunity to implement the many things we can now do to reduce the burden of this disease. Others have described the story of COPD as being a story with no beginning, a middle that is a way of life, and an unpredictable and unanticipated end [1]. If we are to give the story a beginning it can be achieved either by the recognition of symptoms leading to an accurate objective diagnosis, or less satisfactorily by a major event such as an exacerbation starting the story. In the latter case the opportunity for support with smoking cessation, pulmonary rehabilitation and initiation of guideline recommended therapies is missed. The immense value of flu vaccination, stop smoking support, pulmonary rehabilitation and simple bronchodilator therapy, compared to more complex therapies and interventions, has been graphically displayed in the Pyramid of value for COPD interventions to which further attention has been drawn recently [2]. So how do we start the story earlier to ensure that those with COPD are offered and take these cost effective interventions? In the article recently published in Multidisciplinary Respiratory Medicine [3] Sanguinetti and colleagues [3] report a nationwide study of this and related issues and whilst highlighting an appreciation of the role of spirometry in specialist and General Practice they report on the latters concern re difficulty in accessing spirometry and other barriers to implementation. This by itself is not new and others have demonstrated how easier access to well conducted spirometry can reveal how clinical impressions are insufficient to make a diagnosis and mistakenly lead to those with no evidence of airway narrowing receiving often expensive bronchodilators [4]. It is thus a challenge for all countries to address how well conducted spirometry can be promptly available and Sanguinetti’s study is encouraging in that it demonstrates GP recognition of this need. Others have also demonstrated GPs awareness of this, and that of Junior Doctors, although the latter report losing interest if specialists do not pay attention to the results [5]. It is quite possible for good quality spirometry to be undertaken safely and interpreted correctly in primary care but in the same way that arrangements for provision of Chest Radiographs are organised by locality, conducted to a high standard and reported accurately, a similar more central service for spirometry, if promptly available, would clearly be appreciated by General Practitioners. This is not however the end of the story. Case finding is essential if patients are to be referred for spirometry and accurate recording of smoking habits during all consultations for whatever cause, provides a data base of those needing to be investigated. In those presenting with suggestive symptoms a second caveat is to be aware of the problem of the patient with significant breathlessness who has only mild obstruction and where the brunt of damage is borne by the alveoli — dominant air sac disease or emphysema. Recording a breathlessness score at the time of performing spirometry can permit the reporter to highlight this possibility to the primary care physician, and some of these patients clearly need more detailed lung function tests and CT scans. Obesity as a confounding cause of breathlessness is also underappreciated [4]. In the ideal world a prompt diagnosis is made, the patient supported to stop smoking, appropriate vaccinations given and the patient referred for pulmonary rehabilitation to a programme that appreciates the importance of motivating the patient and supporting them as they self manage their own condition following appropriate behavioural change. Not all will require pharmacological interventions other than smoking cessation treatments, but many who are symptomatic will require a minimum of bronchodilator therapy. As Sanguinetti points out this and other regular therapies then need to be monitored by prescription monitoring, for non-adherence is common in long term conditions [6] and more focus on optimal doctor patient communication, determining the patients goals, shared decision making and permitting the patient to ask about any concerns regarding side effects is essential. Even within a large clinical trial when those with COPD knew that their use of therapy was being monitored a fifth of patients did not take medicine as previously discussed with the doctor with one trial showing a significantly deleterious effect of this behaviour on hospitalisation rates and upon mortality [7]. The Pneumocafe project [3] represents a further way of demonstrating the importance of this subject to primary care physicians. Integrated care approaches to the management of this common disease are proven to improve outcomes [8] and in a number of formats appropriate to a country’s health care system must surely be the way forward?

BACKGROUND: The literature shows that delayed or erroneous diagnosis of respiratory conditions may be common in primary care due to underuse of spirometry or poor spirometric technique. The Community Respiratory Assessment Unit (CRAU) was established to optimise diagnosis and treatment of respiratory disease by providing focused history-taking, quality-assured spirometry, and evidence-based guideline-derived management advice. AIMS: To review the service provided by the CRAU to primary care health professionals. Methods: Data from 1,156 consecutive GP referrals over 4 years were analysed. RESULTS: From the 1,156 referrals, 666 were referred for one of five common reasons: suspected asthma, confirmed asthma, suspected chronic obstructive pulmonary disease (COPD), confirmed COPD, or unexplained breathlessness. COPD was the most prevalent referral indication (445/666, 66.8%), but one-third of suggested diagnoses of COPD by the GP were found to be incorrect (161/445, 36%) with inappropriate prescribing of inhaled therapies resulting from this misdiagnosis. Restrictive pulmonary defects (56/666, 8% of referrals) were overlooked and often mistaken for obstructive conditions. The potential for obesity to cause breathlessness may not be fully appreciated. CONCLUSIONS: Misdiagnosis has significant financial, ethical, and safety implications. This risk may be minimised by better support for primary care physicians such as diagnostic centres (CRAU) or alternative peripatetic practice-based services operating to quality-controlled standards.

In between exacerbations, chronic obstructive pulmonary disease (COPD) is usually regarded as a stable condition, but there is increasing recognition of variability in this state. This cross-sectional study assessed patients' perception of symptom variability. Participants were outpatients > 45 yrs old with COPD, current or ex-smokers, forced expiratory volume in 1 s (FEV₁)

Contains fulltext : 87567.pdf (Publisher’s version ) (Closed access) Asthma is a global health problem affecting around 300 million individuals of all ages, ethnic groups and countries. It is estimated that around 250,000 people die prematurely each year as a result of asthma. Concepts of asthma severity and control are important in evaluating patients and their response to treatment, as well as for public health, registries, and research (clinical trials, epidemiologic, genetic, and mechanistic studies), but the terminology applied is not standardized, and terms are often used interchangeably. A common international approach is favored to define severe asthma, uncontrolled asthma, and when the 2 coincide, although adaptation may be required in accordance with local conditions. A World Health Organization meeting was convened April 5-6, 2009, to propose a uniform definition of severe asthma. An article was written by a group of experts and reviewed by the Global Alliance against Chronic Respiratory Diseases review group. Severe asthma is defined by the level of current clinical control and risks as "Uncontrolled asthma which can result in risk of frequent severe exacerbations (or death) and/or adverse reactions to medications and/or chronic morbidity (including impaired lung function or reduced lung growth in children)." Severe asthma includes 3 groups, each carrying different public health messages and challenges: (1) untreated severe asthma, (2) difficult-to-treat severe asthma, and (3) treatment-resistant severe asthma. The last group includes asthma for which control is not achieved despite the highest level of recommended treatment and asthma for which control can be maintained only with the highest level of recommended treatment. 01 november 2010

The nebulized route of administration of drugs to the lungs may involve antibiotics in cystic fibrosis, bronchodilators in asthma, COPD and cystic fibrosis, and occasionally steroids in asthma and some other conditions. This review concerns the use of the nebulizer to administer bronchodilators in asthma. Such use may occur on a regular basis at home, but more usually is for management of acute episodes of worsening asthma, either self administered by patient or parent in the home or by health professionals in the emergency department (ED) and hospital. Use for acute situations appears to be common and may be especially prevalent in low income communities. The provision of nebulized bronchodilator therapies to manage asthma patients for management of home continues to puzzle. Use of nebulized treatment is accompanied by low levels of metered dose inhaler (MDI) and spacer use in general and in minority patients, particularly inner city children. One study showed that in minority children between the ages of 10 and 13, 48% were prescribed nebulized therapy and this use was not associated with age or severity of the asthma (Clark NM, Prescribed nebulized therapy in urban minority preteens with asthma. Unpublished data). Other studies have shown levels of use ranging from 33% to 71% in children under 12 years of age. A qualitative study of 35 low-income minority adolescents revealed that almost half had nebulizers available at home and there was no significant difference between those with and without nebulizers concerning outcomes related to asthma control.

This report concerns the development and validation of two patient-reported outcomes questionnaires developed to assess chronic obstructive pulmonary disease (COPD) patients' ability to perform morning activities and to evaluate their morning symptoms. Based on interviews with COPD patients, the Capacity of Daily Living during the Morning (CDLM) questionnaire and the Global Chest Symptoms Questionnaire (GCSQ) were developed, linguistically validated and incorporated into two multicentre, randomised trials involving a total of 1,100 COPD patients; those trials were registered at ClinicalTrials.gov (NCT00496470 and NCT00542880). Data from these trials were used to determine the reliability, validity and responsiveness of the questionnaires and to derive estimates of minimal important differences (MIDs). Both questionnaires displayed good-to-high reliability (Cronbach's alpha 0.75-0.93). Analysis of convergent validity showed that CDLM and GCSQ scores correlated significantly (p

Background: Patients with chronic obstructive pulmonary disease (COPD) often experience symptoms and problems with activities early in the morning. This is the first study to compare the effect of budesonide/formoterol and salmeterol/fluticasone on lung function, symptoms and activities early in the morning. Methods: Lung function (peak expiratory flow [PEF] and forced expiratory volume in 1 second [FEV 1]) and symptoms were measured at bedside and activities were measured during the morning using a six-item questionnaire concerning basic morning routines. In a randomised, double-blind, multicentre, cross-over study, 442 patients with COPD aged ≥40 years (pre-bronchodilator FEV1 ≤50%; FEV1/vital capacity 1) shortly after rising from bed in the morning, symptoms and basic morning activities were assessed by electronic diary (e-Diary) recordings. Results: Budesonide/formoterol and salmeterol/fluticasone treatment increased morning PEF 5 minutes post-dose, measured as a mean improvement from baseline over the full study period (primary endpoint; adjusted mean change: 15.1 l/min and 14.2 l/min, respectively [difference 1.0 l/min; p = 0.603]). Mean morning FEV1 improved more following budesonide/ formoterol treatment versus salmeterol/fluticasone at 5 minutes (0.12 l versus 0.09 l; p = 0.090) and 15 minutes (0.14 l versus 0.10 l; p < 0.05) post-dose. Budesonide/formoterol demonstrated a more rapid onset of effect as reflected by increases in e-Diary-recorded PEF and FEV 1 from pre-dose to 5 and 15 minutes post-dose (all p < 0.001) and spirometry at the clinic measured after the first dose (FEV1 p < 0.001; 5 minutes post-dose). Improvements in symptom scores within 15 minutes after drug administration were similar for both drugs, but budesonide/formoterol treatment resulted in significantly greater improvements in total morning activities score (getting washed, dried, dressed, eating breakfast and walking around the home; 0.22 versus 0.12 respectively, p < 0.05). Both treatments were well tolerated. Conclusions: Short-term treatment with budesonide/formoterol DPI or salmeterol/fluticasone DPI was effective in patients with COPD. Budesonide/formoterol had a more rapid onset of effect compared with salmeterol/fluticasone and resulted in greater improvements in ability to perform morning activities despite the lower inhaled corticosteroid dose.

The world's press frequently contains stories of failed rehabilitation attempts 1 by media personalities, and popular songs on this topic can galvanize strong views 2. Such events highlight the popularisation of a faulty view that rehabilitation offers only a marginal opportunity for benefit and as such should be avoided at all costs. It is unclear if such scepticism, reinforced by the media, impacts upon those with long-term illness and whether it limits, for example, what pulmonary and cardiac rehabilitation programmes have to offer. In a recent local Primary Care Trust chronic obstructive pulmonary disease (COPD) service evaluation report, patients voiced their concern over the term “rehab” 3 as they believe that there is stigma attached to the term. This previously unrecognised concern may form a new barrier to pulmonary rehabilitation programmes. Clearly, any such concern needs to be addressed as these are interventions of great benefit to our patients 4, 5. However as recruitment and retention of patients into rehabilitation programmes is not easy, as a specialty we need to reflect upon the terminologies we use and how best we “sell” or market these interventions to our patients. COPD represents a global health burden 6 and will move from being the 12th cause to the 5th cause of disability adjusted-life years lost by the year 2020 7. In the UK, >5% of all deaths have been attributed to COPD and up to one in eight emergency hospital admissions may be due to the condition 8. Patients who experience acute exacerbations of COPD have: 1) more frequent visits to the emergency department and hospitalisation 9, 10; 2) a more rapid decline in lung function 11; and 3) a reduced quality of life 12. Pulmonary rehabilitation, which contains elements of …

Objectives:To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Design:Randomised controlled trial.Setting:Community and hospital care in west London.Participants:122 patients with COPD.Intervention:A care package incorporating initial pulmonary rehabilitation and self-management education, provision of a written, personalised COPD action plan, monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years.Main outcome measure:Hospital readmission rate.Secondary outcomes:Unscheduled primary care consultations and quality of life.Results:There were no differences in hospital admission rates or in exacerbation rates between the two groups. Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics, and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves. 12 patients in the control group died during the 2 year period, eight as a result of COPD, compared with six patients in the intervention group, of whom one died from COPD. This is a significant difference. When the numbers were adjusted to reflect the numbers still alive at 2 years, in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner (GP) and in the control group, 280 contacts. The number needed to treat was 0.558—ie, for every one COPD patient receiving the intervention and self-management advice, there were 1.79 fewer unscheduled contacts with the GP.Conclusions:An intermediate care package incorporating pulmonary rehabilitation, self-management education and the receipt of a written COPD action plan, together with regular nurse contact, is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate.

BACKGROUND: In asthma, self-management programmes have been proven to be effective. In COPD, their value is not clear. OBJECTIVES: To assess the efficacy of COPD self-management/ education programmes on health outcomes and use of health services SEARCH STRATEGY: We searched the Cochrane Airways Group trial registers, MEDLINE (January 1985 to October 2001), reference lists, and abstracts of medical conferences. We also contacted research groups in the field for ongoing trials and unpublished material. SELECTION CRITERIA: Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on physical pulmonary rehabilitation were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information. MAIN RESULTS: The reviewers included 12 articles describing 8 randomised-controlled trials and 1 controlled clinical trial. Self-management education was compared with usual care in 8 studies. The studies in this review assessed a broad-spectrum of outcome measures with different follow-up times. Synthesis of the results using meta-analysis was always not possible. The studies showed no effect of self-management education on hospital admissions, emergency room visits, days lost from work and lung function. Inconclusive results were observed on health-related quality of life (HRQoL): studies using the disease specific SGRQ showed a better quality of life in the patients in the intervention group, but only in the activity component where there was heterogeneity between the results of the two included studies. A potential reason for the absence of convincing effects on HRQoL is the limited use of COPD-specific instruments. Inconclusive results were observed on COPD-symptoms and use of other health care resources such as doctor and nurse visits. Self-management education reduced the need for rescue medication, and led to an increased use of courses of oral steroids and antibiotics for respiratory symptoms. REVIEWER'S CONCLUSIONS: The data available for this review are insufficient for forming recommendations. Further research on the effectiveness of self-management programmes should be focussed on behavioural change evaluated in well designed randomised controlled trials with standardised outcomes designed for use in COPD patients, and with long follow-up time so that definite conclusions can be made.

Publisher Summary This chapter is concerned with patient education and self-management and reviews the evidence in favor of those interventions and highlight similarities and differences between self-management education in asthma and chronic obstructive pulmonary disease (COPD). The term patient education has an unpleasant inference suggesting some inadequacy on the patient's behalf, which needs rectifying. It seems preferable to make the concept more positive and to list the constituent parts. For the health care professional an essential prerequisite to patient education is an understanding of how the patients feels about their long-term condition and its management and provide them with optimal care. Personalized self-management advice, which helps them to adjust their lifestyle or treatment to keep well, is necessary. Such advice needs to be produced in a suitable format to ensure it is usable by those with varying literacy skills. The wealth of evidence in favor of self-management education, regular follow up, and the use of written action plans has not unfortunately led to widespread implementation. The reasons why doctors are not implementing a core part of self-management education, which is of proven benefit, are not clear, but probably revolve around a perceived lack of time, lack of suitable templates, and possibly a lack of understanding as to what is involved in this process and what needs to be written down for patients. Current evidence is that self-management education is of significant value in those with asthma but more marginal value in COPD, where it may only be beneficial if combined with other interventions such as pulmonary rehabilitation and case management.

A pilot study was undertaken to assess the respiratory component of primary care nurses' working time. 13 nurses were interviewed and 10 completed a diary during one working week. The nurses spent a mean 6.6% of their time caring for those with respiratory disease and were of the opinion that during this time they undertook 68% of the management of long term respiratory illness in the practices. More time was spent with those with asthma than with other respiratory conditions and the nurses felt that they were appropriately trained for the tasks undertaken. However, with more training they felt that they could undertake more basic care of those patients with COPD, and more advanced care of those patients with asthma.

Nicola J Roberts, Ramesh Ghiassi, Martyn R PartridgeDepartment of Respiratory Medicine, NHLI at Charing Cross Hospital, Imperial College London, UKAbstract: If patients are to participate fully in their care and in the management of a long term condition such as chronic obstructive pulmonary disease, good communication is essential. However, not all patients are able to use the written word and we need to be aware of the size of this problem and its implications for the way in which we give information and conduct medical consultations. The impact of health literacy on outcomes can be considerable and improvements can be made by being aware of the problem, offering information in several different forms, and by reinforcing the spoken word with pictorial images.Keywords: health literacy, reading, compliance, pictograms, communication, consultations