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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.

Asthma control can be optimised by medication compliance, trigger avoidance and recognising when and how to react to worsening control and asthma attacks. Failure to support this, by the under-issuing of personalised asthma action plans (PAAPs) by healthcare professionals (HCPs) and under-utilisation by patients, contributes substantially to asthma deaths (NRAD. RCP 2014;27). Since there is evidence that mobile applications can improve chronic disease health outcomes, we hypothesised PAAP digitalisation can improve current asthma self-management approaches. To assess whether and how a digital PAAP could address barriers to PAAP implementation, we performed focus group discussions with primary (n=3) and secondary (n=5) care doctors and nurses involved in asthma care, and patients (n=5) of variable age (18-65) and disease severity (moderate to poor asthma control over 1 year). Within group coding and categorisation contributed to a cross-case thematic framework for analysis. We found that patients and HCPs experience decision-making uncertainty using current PAAPs. In primary care, there is no uniformity in PAAP usage and methods to evaluate self-management efficacy. A digital PAAP would enable longitudinal data recording with objective monitoring capabilities. Patients valued the interactive, real-time support it could provide in affirming treatment escalation and medication choices. Nevertheless, a digital tool may have adverse effects, with concerns over data overload, quality and overdependence on technology. However, if built using a validated algorithm and in collaboration with key stakeholders, digital PAAPs could optimise self-management assessment and execution for patients and HCPs.

A less hospital-centric approach to healthcare with specialists working nearer to patients in the community has been strongly advocated in several recent publications. In the field of respiratory medicine a team approach to the care of those with long-term respiratory conditions has been in practise for decades with such integrated approaches being shown to significantly improve outcomes. This approach is now gaining momentum with an increasing number of UK respiratory specialists undertaking sessions outside hospitals. Specific suggestions regarding the scope of this work, training, mentorship and governance have now been suggested by the specialist British Thoracic Society.

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.

The Montreal Protocol on Substances That Deplete the Ozone Layer was an example of an amazing international collaboration that has already led to improvements in the ozone layer, although the full effects will not be seen for decades. As part of the process, large numbers of medical aerosols were reformulated such that chlorofluorocarbons were replaced as propellants in pressurised metered dose inhalers (pMDIs) by new hydrofluoroalkane (HFA) propellants. This involved a massive commitment by the pharmaceutical industry to ensure that those with respiratory ill health continued to receive their medication in familiar but improved inhalers. However, these HFA propellants have a global warming effect, and this has led specialist societies and health service leaders to more recently call for prescribers and patients to consider switching from pMDIs to inhaler devices without propellants, although many patients will still need a pMDI for use in an emergency.1 Others have recently additionally drawn attention to the benefits of using small-volume HFA 134a pMDIs or those containing …

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.

Introduction: Social media is increasingly being used as a tool to disseminate & communicate information on diseases to increase public awareness. However, data on the impact of online campaigns is not widely published. Aims: The ‘Friends or Foe’ campaign was launched by Asthma Malaysia (AM) to create awareness on asthma triggers amongst the Malaysian public. We analysed the campaign9s impact on social media conversations and conducted web behavioural analysis in order to determine if the campaign led to an increase of public interest in asthma. Methods: Public awareness was measured by postings on social media & digital media channels. Data extraction & cleaning was performed via a social media monitoring tool to measure awareness levels. This was performed using asthma-related keywords in the English & Malay languages before & after the campaign. Data on visitors to the AM website was analysed to understand visitors’ demographics & psychographics. Results: Almost 90% of Malaysians use social media. The number of online conversations increased by 908% following the campaign. Total mentions on asthma in Malaysia was recorded at 35,150 posts across all media channels, with a total impression of approximately 71.6 million people. Most conversations were related to asthma triggers, symptoms, treatments & precautions. The campaign left significant digital footprints with AM’s website becoming the preferred source of information on asthma for Malaysians as evidenced by related keyword search results on Google. Conclusion: In countries where asthma is not widely discussed, a comprehensive communication strategy involving social media can significantly improve public awareness.

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.

While pharmacotherapy is important in the management of asthma and chronic obstructive pulmonary disease, it is also important to consider additional interventions that can further reduce the burden of ill health for patients, their families and the health care system. In this review, the evidence in favour of self-management support that leads to successful self-care by the patient is reviewed, and the key components of successful strategies are outlined; areas where more research is needed are identified. In addition to self-management support, other methods of delivering care, such as telemonitoring, admission avoidance, assisted discharge schemes and use of lay educators, are reviewed.

The health burden in most countries has changed. Although acute care is needed for trauma, acute illness and exacerbations of chronic disease, most of the burden is now long term. These patients need different approaches, with more emphasis upon supporting self-management, enhancing lifestyle changes, aiding compliance by shared decision-making and providing more convenient follow-up that appreciates the likelihood of multimorbidity. Integrated care will increasingly be offered from within the community. The current hospital- and doctor-centric focus needs to change to one where specialists work in the community as much as in hospitals and share this different type of care with others. For potential future doctors, the scientific basis of medicine will still underpin their unique role in diagnosis and prescribing, but they will need to understand these other changes and to be selected according to attributes compatible with their future role, and then be trained and assessed accordingly.

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 …

Cathrin Edelmann,1 Ramesh Ghiassi,2 Deborah R Vogt,3 Martyn R Partridge,2 Ramin Khatami,4 Jörg D Leuppi,1,5 David Miedinger1,5 1Medical Faculty, University of Basel, Basel, Switzerland; 2National Heart and Lung Institute, Imperial College London, London, UK; 3Clinical Trial Unit, University of Basel, University Hospital Basel, Basel, 4Barmelweid Clinic, Barmelweid, 5University Clinic of Medicine, Kantonsspital Baselland, Liestal, Switzerland Purpose: The aim of this study was to evaluate the validity of a new pictorial form of a screening test for obstructive sleep apnea syndrome (OSAS) – the pictorial Sleepiness and Sleep Apnoea Scale (pSSAS). Validation was performed in a sample of patients admitted to sleep clinics in the UK and Switzerland.Patients and methods: All study participants were investigated with objective sleep tests such as full-night-attended polysomnography or polygraphy. The pSSAS was validated by taking into account the individual result of the sleep study, sleep-related questionnaires and objective parameters such as body mass index (BMI) or neck circumference. Different scoring schemes of the pSSAS were evaluated, and an internal validation was undertaken.Results: The full data set consisted of 431 individuals (234 patients from the UK, 197 patients from Switzerland). The pSSAS showed good predictive performance for OSAS with an area under the curve between 0.77 and 0.81 depending on which scoring scheme was used. The subscores of the pSSAS had a moderate-to-strong correlation with widely used screening questionnaires for OSAS or excessive daytime sleepiness as well as with BMI and neck circumference.Conclusion: The pSSAS can be used to select patients with a high probability of having OSAS. Due to its simple pictorial design with short questions, it might be suitable for screening in populations with low health literacy and in non-native English or German speakers. Keywords: questionnaire, excessive daytime sleepiness, sleep associated disorders, screening, pictorial, occupation

There is an urgent need for consensus on what defines a chronic obstructive pulmonary disease (COPD) self-management intervention. We aimed to obtain consensus regarding the conceptual definition of a COPD self-management intervention by engaging an international panel of COPD self-management experts using Delphi technique features and an additional group meeting.In each consensus round the experts were asked to provide feedback on the proposed definition and to score their level of agreement (1=totally disagree; 5=totally agree). The information provided was used to modify the definition for the next consensus round. Thematic analysis was used for free text responses and descriptive statistics were used for agreement scores.In total, 28 experts participated. The consensus round response rate varied randomly over the five rounds (ranging from 48% (n=13) to 85% (n=23)), and mean definition agreement scores increased from 3.8 (round 1) to 4.8 (round 5) with an increasing percentage of experts allocating the highest score of 5 (round 1: 14% (n=3); round 5: 83% (n=19)).In this study we reached consensus regarding a conceptual definition of what should be a COPD self-management intervention, clarifying the requisites for such an intervention. Operationalisation of this conceptual definition in the near future will be an essential next step.

Patients referred to secondary care for specialist respiratory review frequently undergo multiple hospital attendances for investigations and consultations. This study evaluated the potential of a preclinic telephone consultation and subsequent coordination of tests and face-to-face consultations to reduce hospital visits. Total hospital attendances were recorded for three cohorts (participants, non-participants and comparators) for 6 months from first specialist contact. Patients completed the medical interview satisfaction scale-21 (MISS-21). The study showed that a preclinic telephone consultation can significantly reduce hospital visits over a fixed period without reducing patient satisfaction. In total, 20.8% of the participant group had three or more hospital attendances compared with 42.9% of the non-participant group (p = 0.001) and 44.7% of the comparator group (p = 0.002). Participants had fewer follow up visits and lower rates of non-attendance/late rearrangement of appointments. This service reduces unnecessary hospital visits, seems to improve patient compliance and may save costs associated with non-attendance and follow up consultations.

Background We sought to understand the barriers and facilitators to participation in research from the perspectives of South Asian people with asthma. Methods Eight focus groups were conducted in the preferred language of participants. Sampling was purposeful to ensure inclusion of males and females from differing ethnic, linguistic and religious backgrounds. Results The forming of trusting relationships was described as pivotal to the successful recruitment of minority ethnic groups into research; personalized approaches were likely to be better received than more impersonal written approaches. Notable barriers to participation included: the stigma of being labelled with asthma; concerns surrounding participation in pharmaceutical trials; major time or travel commitments and a failure to show respect by not making information available in minority ethnic languages. Flexibility, in terms of timing, location and respecting of cultural and religious sensitivities around gender segregation, together with the offer of incentives, were highlighted as key factors to promote participation. Conclusions The barriers to recruitment are largely surmountable, but these will necessitate the use of resource intensive and more personalized approaches than are commonly employed for the White European origin population. Our proposed model to enhance recruitment is likely to have transferability beyond the field of asthma.

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.

Personalised written action plans are increasingly regarded as an important component of chronic obstructive pulmonary disease (COPD) self-management support and yet they may not be understood by those with limited literacy skills. This study was designed to produce a comprehensible pictorial COPD action plan for use by patients and health care professionals. With advice from a group of doctors and nurses a 'standard' written COPD action plan was translated by a medical artist into a series of pictorial images. These were assessed using the techniques of guessability and translucency in 21 adults attending a COPD clinic in a London hospital. Guessability and translucency scores show that pictograms were reasonably well understood, with only 3 pictograms showing low score in both guessability and translucency questionnaires. These included images depicting increased sputum production, swollen ankles, and use of extra doses of reliever medication. However, after brief spoken reinforcement about self-management, most patients could use the pictorial plan to suggest appropriate self-management behaviour such as when to access medical care. We have developed a pictorial COPD action plan. Pictorial methods represent an effective method of reinforcing the spoken word for all ranges of literacy.

Stephen John Greenhill Semple (“Steve”) was professor of medicine at various times at several medical schools in London, but he will be remembered best for his time as professor of medicine and head of the department of medicine at the Middlesex Hospital School of Medicine (and subsequently head of the department of medicine in the joint School of Medicine of University College and the Middlesex Hospital School of Medicine). He had moved to the Middlesex after a year as a professor of medicine at his alma mater, St Thomas’ Hospital Medical School, in 1969-70. After leaving the Middlesex-UCH on reaching retirement age he became visiting professor of medicine to the Charing Cross and Westminster School of Medicine, and subsequently professor emeritus of medicine at Imperial College London. Educated at Westminster School, Steve …

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.

Objective The Epworth Sleepiness Scale (ESS) was designed to be self-completed by the patient. However, it may not be understood by all, and unrecognised problems with literacy can impair the process. The ESS has been translated into a pictorial version for use in those with normal or diminished literacy skills. Methods An evaluation of the patients9 ability to self-complete the ESS was undertaken in sleep and non-sleep respiratory clinics. Errors or problems encountered were recorded on a standard questionnaire. With the aid of a medical artist, pictorial representations of the eight ESS questions were developed and the new pictorial ESS was offered to patients alongside the traditional ESS. The two scales were compared for agreement with a kappa statistic, and patients were asked to record a preference for either the written or the pictorial scale. Results Evaluation of the traditional ESS showed that 33.8% (27/80) of ESS-naive patients made errors and 22.5% (18/80) needed help completing the questionnaire. The translated pictorial ESS showed good agreement with the traditional ESS on most questions; median kappa score 0.63, IQR 0.04. Fifty-five per cent reported a preference for the pictorial scale compared with the standard written ESS. Despite the fact that errors were frequently made on the traditional ESS, 96.8% of participants in the second study reported both scales to be easy to complete. More people (75.6%) reported the pictorial ESS to be very easy, in comparison with (64.6%) the worded ESS questionnaire. Conclusion Errors are common when patients self-complete the traditional written ESS. Pictures with words have been shown to enhance the understanding and translation of medical information, and a pictorial translation of the ESS produces scores comparable with the traditional ESS and may be a suitable alternative for those with normal or diminished literacy.

Introduction Evaluation of the way in which respiratory care is delivered is increasingly recognised to be an important area for research. When service developments are reported, it is not always clear whether they are subsequently implemented within the reporting institution, and if not why not. Methods 3281 abstracts from three specialist journals and one general journal were reviewed, and 36 reported evaluated service developments identified. The authors of each of these were approached to determine whether the reported service developments were in use in their institution. Results 30 of the 36 authors responded (83%). 10 reports were of sharing care with nurses and five with other health professionals, and the remainder involved new technologies, education, patient information or guideline implementation. 15/30 had implemented the reported development into practice, 11 of which were implemented immediately. Delays were due to staffing, funding and organisational issues. 10/15 studies were not put into practice, the main reason being that the key person had left. Four respondents embarked upon further study to confirm their preliminary published findings. Conclusions Reports of apparently positive service developments are only implemented in approximately one-half of institutions reporting the development. In a third of cases, non-implementation reflects the original authors believing that further study is necessary to confirm effectiveness.

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.

Background. There is no comprehensive information available concerning the way in which care is provided for those with allergic conditions in Europe. Objective. To determine who cares for those with asthma, allergic dermatitis, and rhinitis in Europe and to determine the involvement of primary care and other healthcare professionals and the use of patient education and guidelines. Methods. A questionnaire survey of colleagues in 43 institutions in 33 European countries with results being related to published sources of information regarding prevalence of allergic diseases in different countries and published data regarding availability of doctors and expenditure on healthcare. Results. A total of 33 of 43 institutions completed the survey (76.7%) with information being obtained from 26 of the 33 countries surveyed (78.7%). There are wide differences in the use of different healthcare professionals in different countries, with those for asthma, for example, being most likely to be cared for by an allergologist in some countries and by a primary care physician in many others. There was much greater awareness of guidelines for asthma and little reported usage of guidelines in the management of those with allergic skin diseases, and while self-management education was offered most to those with asthma, there was a wide variation in the usage of group education. Conclusions. Many of the differences revealed by this survey cannot be explained by the availability of different healthcare professionals nor by differences in healthcare expenditure, and such differences need further evaluation to determine their effect on outcomes and the economics of healthcare so that we may determine that which is optimal.

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

Objectives: To determine whether well trained lay people could deliver asthma self-management education with comparable outcomes to that achieved by primary care based practice nurses. Design: Randomised equivalence trial. Setting: 39 general practices in West London and North West England. Participants: 567 patients with asthma who were on regular maintenance therapy. 15 lay educators were recruited and trained to deliver asthma self-management education. Intervention: An initial consultation of up to 45 min offered either by a lay educator or a practice based primary care nurse, followed by a second shorter face to face consultation and telephone follow-up for 1 year. Main outcome measures: Unscheduled need for healthcare. Secondary outcome measures: Patient satisfaction and need for courses of oral steroids. Results: 567 patients were randomised to care by a nurse (n = 287) or a lay educator (n = 280) and 146 and 171, respectively, attended the first face to face educational session. During the first two consultations, management changes were made in 35/146 patients seen by a practice nurse (24.0%) and in 56/171 patients (32.7%) seen by a lay educator. For 418/567 patients (73.7%), we have 1 year data on use of unscheduled healthcare. Under an intention to treat approach, 61/205 patients (29.8%) in the nurse led group required unscheduled care compared with 65/213 (30.5%) in the lay led group (90% CI for difference −8.1% to 6.6%; 95% CI for difference −9.5% to 8.0%). The 90% CI contained the predetermined equivalence region (−5% to +5%) giving an inconclusive result regarding the equivalence of the two approaches. Despite the fact that all patients had been prescribed regular maintenance therapy, 122/418 patients (29.2%) required courses of steroid tablets during the course of 1 year. Patient satisfaction following the initial face to face consultation was similar in both groups. Conclusions: It is possible to recruit and train lay educators to deliver a discrete area of respiratory care, with comparable outcomes to those seen by nurses. Trial registration number: NCT00129987

AIMS: Amongst general practices in the NHS Borders region of Scotland, we aimed to determine compliance with the three key recommendations of the British Guideline for the Management of Asthma and to understand the nature of barriers and facilitators to their implementation. METHODS: Using piloted audit tools, a researcher extracted data from computerised and/or paper patient medical records to assess compliance with recommendations for objective diagnosis and stepwise management. Provision of asthma action plans was assessed by patient survey. Clinicians' attitude to guidelines was assessed by postal survey. RESULTS: Fifteen of the 24 practices in the NHS Borders region participated. Audited compliance with the three key recommendations varied markedly amongst and within practices. Whilst 367/547 (67%) of patients were treated appropriately with add-on therapy, only 58/254 (23%) of patients reported having been given an asthma action plan. Barriers to implementation identified by the clinicians' survey (response rate 64/84 - 76%) were theoretical (doubt about the evidence base and relevance to primary care, lack of knowledge and skills, misconceptions) as well as practical (lack of time and resources) and were exacerbated by poor teamwork. Facilitators were good teamwork and appropriate organisation of work within the practice. CONCLUSIONS: Implementation of key recommendations was variable, particularly in the more complex intervention of issuing asthma action plans. An intervention to enhance compliance with these guideline recommendations will need to address both theoretical and practical barriers within the context of improved teamwork.

The NHS Plan suggests that all patients should be offered copies of letters regarding their treatment which are currently sent from a specialist clinic to their general practitioner (GP). Previous work has suggested that this enhances patient satisfaction, but medical letters can be difficult to understand. This report concerns the production and evaluation of a lung disease glossary to enhance patient understanding of terms used within the letter sent to their GP. Non-clinical staff reviewed 219 letters sent to GPs and words not likely to be understood by patients were listed and used to produce a glossary of 133 terms. One hundred and thirty-one participants from nine respiratory outpatient clinics in a London teaching hospital were sent the glossary and a questionnaire with their copy of the letter also sent to their GP. Of the 131 participants, 93 patients (71%) returned the questionnaire. Eighty-three (89%) found the glossary useful and the number of words checked ranged from 0 to 14 with a median of three words. Those who did not find the glossary useful explained that their understanding was already optimal or that the words they did not understand were not contained within the glossary. This was usually because the words related to non-respiratory comorbidities. This study confirms that the inclusion of a specialty specific glossary with the patients' copy of the letter being sent to their GP is appreciated by patients and appears to aid their understanding.

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.

Key points The spectrum of disease seen by health services has changed over time, but in many cases the mode of consultation has remained the same. Patients can be encouraged to attend either by making consultations more convenient or by using reminders. Preparation and follow-up are vital aspects of a successful consultation. Patients who are helped to understand their treatment may be more compliant. Educational aims To increase awareness of the need for specialist consultation clinics to be configured in a manner that is convenient for patients with long-term respiratory conditions. To encourage clinicians to consider the problems associated with non-attendance of patients in specialist clinics. To provide clinicians with the necessary knowledge to improve patient satisfaction with specialist outpatient consultations. Summary Consultations with those with respiratory disease increasingly involve those with longterm conditions. Such conditions merit greater attention being paid to the selection of simple treatment regimens, self-management education, enhancing compliance and good communication. The design and running of a respiratory consultation service can be enhanced by addressing the best use of the time before the consultation, the consultation itself and methods for reinforcing messages during follow-up.

Background Self-management improves outcomes in asthma and COPD and is strongly recommended in national and international guidelines; however implementation of the guidelines such as use of written action plans in practice is often poor. Setting A questionnaire survey was undertaken to identify the healthcare professional barriers to implementation of self-management for asthma and COPD in West London. Question Why is self-management education not being undertaken in respiratory conditions? Methods A questionnaire was designed to elicit healthcare professionals' views about barriers to implementation of self-management in asthma and COPD. Results Response rates were 33% (58/175). Results showed strong support for guideline recommendations, however implementation was patchy. Seventy six percent of respondents discussed asthma self-management with patients; however only 47.8% of patients received a written action plan. For COPD patients, 55.1% discussed self-management, with 41% receiving a written action plan. In COPD, there was greater GP involvement and less delegation of self-management. Barriers to implementation included patient factors (compliance, literacy and patient understanding), time constraints and insufficient resources. Those who believed they had witnessed improved health outcomes with self-management (53%, 31/58) were more likely to give written action plans (78%, 24/31, 'nearly always/sometimes' gave written action plans), Nearly a third of healthcare professionals reported lacking confidence in constructing written action plans (33% 19/58; GPs 43%, nurses 43%). Conclusion Despite overwhelming evidence self-management support is still not being implemented into routine clinical practice, identified barriers included time constraints, lack of training, lack of belief in patients ability to self-manage and lack of confidence completing self-management plans. Practice implications These issues need to be addressed if self-management support is to be delivered in a meaningful and effective way.

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.

INTRODUCTION: A significant minority of otherwise healthy adults may suffer from disordered breathing during sleep. The commonest problem, known as Obstructive Sleep Apnoea Syndrome (OSAS), results in poor quality sleep, daytime hypersomnolence and excess risk of road traffic crashes. It is also associated with occupational injuries. OSAS can be successfully treated, reducing costs of hospitalisation. There is a gap in the literature regarding the burden of patients with OSAS in primary care, particularly because there is no agreed method for screening. OBJECTIVES: This pilot study was designed to determine the feasibility of screening for OSAS in a UK inner-city multi-ethnic primary care population, to investigate ways in which it might be detected, and to gain an awareness of the potential size of the burden of OSAS METHODS: We tested two methods of screening: firstly, postal questionnaires to a random sample of 240 patients from a subset of the population at highest risk of OSAS (men aged 35-65 years); and secondly, the same questionnaire plus two screening tools for detecting hypersomnolence, given to patients attending the practice for pre-registration health checks. RESULTS: Despite reminders, only 40% of postal questionnaires were returned and there were only 67 (28%) usable responses. The prevalence of snoring was 55%. Almost half of those patients who responded (46%) had a Body Mass Index (BMI) associated with a high risk of OSAS. This was not a positive responder bias because there were no significant differences in BMI between responders and non-responders. 12% had a collar size of greater than 17.5, whilst 34% reported daytime sleepiness, and 24% reported witnessed apnoea. Screening during pre-registration health checks proved both feasible and productive with 38 patients of differing linguistic abilities completing the assessment. CONCLUSION: Screening for OSAS in primary care by means of a postal questionnaire produced a low response. Whilst there was no evidence of a responder bias in terms of BMI, the numbers reporting large collar size, daytime sleepiness and witnessed apnoea suggest that a sizeable proportion of the population is at risk of OSAS. Questionnaires used in this study provide a means of identifying patients with symptoms suggestive of OSAS, although the sensitivity, specificity and positive predictive value of a self-administered instrument needs to be confirmed by a larger study incorporating ventilatory monitoring during sleep. The addition of screening to pre-registration health checks is feasible, but it would take a long time to screen all those at risk for OSAS by this route.

The BTS/SIGN British Guideline on the Management of Asthma was published in February 2003 (4). If health outcomes are to be influenced successfully, dissemination of the guideline and implementation of recommendations is essential. We report the dissemination activities undertaken during the 18 weeks following the guideline launch. To facilitate implementation a range of educational materials were produced reflecting the key messages from the guideline. In addition to postal mailing of the guideline to appropriate healthcare professionals, both educational materials and the guidelines were made freely available from the BTS and SIGN websites. In total, 135,710 copies of the guideline and 90,198 copies of the Quick Reference Guide were downloaded in the first 18 weeks, representing a considerable increase over the number of copies of the 1997 guidelines disseminated by mailing alone. Large quantities of educational materials were downloaded with many used for teaching purposes. An on-line survey suggested that most respondents rated the materials as useful or very useful. Using websites to disseminate guidelines is a cost-effective method of informing health professionals of their content and is a more active process than the passive receipt of mailed copies. The availability of interactive educational materials for use in teaching appears to have been popular.

This article focuses on reducing the barriers to effectively applying what is known about asthma patient education. One barrier to effective asthma control in individuals and populations is failure to recognize the range of influences on patients trying to manage their disease, including actions of family, clinicians, friends and neighbors, work or school mates, and significant people and organizations in the wider social environment. Another deterrent is failing to assist patients in developing their self-regulation skills. Other barriers are the lack of attention to the patients' asthma management goals (as opposed to clinical objectives) and overlooking signs that indicate follow-up education is needed. Five actions taken by health-care professionals could significantly enhance the effectiveness of asthma education: (1) make messages to patients and core skills taught consistent with national asthma guidelines; (2) focus on developing the patient's ability to self-regulate; (3) develop comprehensive plans for treatment and education that assign clinicians to appropriate educative roles; (4) use clinician communication techniques demonstrated to enhance asthma management by patients; and (5) ensure that all providers of education are themselves trained to achieve actions 1 to 4.

It is with great sadness that we inform you that Abe Guz passed away on April 11, 2014 at the age of 84. Abe Guz was Professor of Medicine at the Charing Cross Hospital Medical School in London, UK between 1973 and 1982, and subsequently became Professor and Head of the Department of Medicine of the joint Charing Cross and Westminster Medical School, University of London until September 1994. He will be remembered for his contribution to our understanding of breathing control and of breathlessness. Abe Guz was born in 1929 in East London to Russian Jewish parents who came to England in the 1920s. In 1947, he attended Charing Cross Hospital Medical School where he was a brilliant student, winning the Gold Medal of the School and graduating with the highest honours in medicine and surgery. After serving in the army for 2 years as part of National Service as Chief Medical Officer in Germany, Abe returned to London as a senior house officer at the Hammersmith Hospital. Like many budding clinical scientists of the time, he shortly left for the USA to become a Research Fellow at Harvard University and then Senior Fellow at the Cardiovascular Research Institute (CVRI), University of California San Francisco. He trained under Julius Comroe whom he said taught him to “think” and whom he described as someone who had “the great facility of summarising what was not known”. At the CVRI, he collaborated with Julien Hoffman, a paediatric cardiologist, to develop methods of measuring blood flow and cardiac output. Abe returned to the UK in 1961, as Assistant Lecturer in the newly created Department …

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?