European Respiratory Society
Controversies in COPD

COPD is one of the most common diseases worldwide and is projected to be the third leading cause of death by 2020. But that does not mean it is easy to understand or manage. In everyday practice, pulmonologists face areas of controversy in COPD, for which evidence-based medicine is often unavailable. This ERS Monograph considers where the current controversies in COPD lie, discussing areas such as screening, premature birth, asthma-COPD overlap syndrome, treatment, rehabilitation and palliative care. This book will be of great interest to both clinicians and scientists, and aims to stimulate further discussion about this diverse and fascinating disease.

  • ERS Monograph
  1. Page vii
  2. Page ix
  3. Page xi
  4. Page 1
    Abstract
    Joan B. Soriano, Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Cátedra UAM-Linde, Diego de León 62, 28030 Madrid, Spain. E-mail: jbsoriano2@gmail.com

    Case history: A 60-year-old male presents to his general practitioner with grade 2 dyspnoea on the modified Medical Research Council (MRC) Dyspnoea Scale. In the previous week, at his yearly occupational (a large car repair workshop) check-up, his peak flow was measured and simple spirometry was performed. The occupational nurse identified potential airflow limitation. He is atopic and was a smoker up to 10 years ago, totalling a 20 pack-year smoking history. He was/is very physically active: he walks 2 km to work every work day and still plays football once a week, although he states that since last winter he has had to play in goal for the second half. He has never received any respiratory medication. What are the next steps?

    Chapter summary: Our knowledge of COPD has widely expanded after decades of intensive clinical research. However, there remain many controversies surrounding when, where, by whom and for whom COPD screening and case finding with spirometry and other tools should be conducted, and often recommendations are not evidence based. Is a case like that described above worth further exploration? If it is confirmed, why was a signal of airflow limitation not picked up in previous annual check-ups (figure 1)? When does such an active worker (and sportsman) become a patient? And would you rule out asthma or ACOS? Meanwhile, COPD remains significantly underdiagnosed, with diagnosis commonly missed or delayed until the condition is advanced. It is envisaged that early diagnosis of COPD should have an impact on individual and population outcomes, but definitive confirmation proves elusive. Despite significant effort and investment, the implementation of quality spirometry is limited because of a number of hurdles and limitations, some of which are described in this chapter. The routine use of spirometry in primary care in all patients with respiratory symptoms should reduce COPD underdiagnosis.

  5. Page 26
    Abstract
    Charlotte E. Bolton, Nottingham Respiratory Research Unit, Clinical Sciences Building, School of Medicine, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK. E-mail: charlotte.bolton@nottingham.ac.uk

    Case history: A 40-year-old woman is newly diagnosed with COPD in the UK. The degree of airflow obstruction appears severe for her age and smoking history. She does not have α1-ATD, has smoked only tobacco and has not had significant passive smoke exposure. On direct questioning, she tells you that she was born at 32 weeks gestation and with low birth-weight. How might this have impacted her risk of developing airflow obstruction?

    Chapter summary: There is an increasing awareness of the longer-term respiratory sequelae of being born premature. With publications reporting a chronic obstructive airways pattern and an increased susceptibility to respiratory infections and hospitalisations, is this a cause of COPD? With about 8% of births being preterm (<37 weeks of gestation) and survival improving, there are important respiratory implications. This chapter will discuss the available literature on the respiratory state of adults born preterm and consider whether this can be regarded as COPD. It will also highlight many important gaps in our understanding.

  6. Page 35
    Abstract
    Alejandra Ramírez-Venegas, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosio Villegas, México City, Tlalpan No. 4502, 14080 México DF, México. E-mail: aleravas@hotmail.com

    Case history: A 75-year-old female from a rural area of Oaxaca, Mexico, reported cough and phlegm for >30 years, exertional breathlessness for 4 years and wheezing during the winter. She reported suffering from frequent respiratory infections during childhood and adolescence. The patient had cooked with wood smoke for >50 years. As a child, she helped her mother with housework, spending time in an unventilated, smoky kitchen for long periods of time. She reported no history of tobacco smoking. She is illiterate and has a very low income. The patient is overweight and presented to the COPD clinic with a moderate increase of cough, green sputum and dyspnoea. Spirometry showed an FEV1 of 65% predicted and an FEV1/FVC of 66. Oxygen saturation at rest was 85% and the CT showed air trapping. Is this chronic asthma, ACOS or COPD?

    Chapter summary: This chapter addresses COPD causes beyond smoking, with emphasis on COPD associated with biomass (BE-COPD). Most of the information obtained from meta-analyses that focus on risk factors of COPD in nonsmokers points out that biomass is the main cause of COPD. Almost 50% of deaths from COPD in developing countries may be attributed to biomass; ∼75% of these deaths are reported in women. There are clinical differences between BE-COPD and COPD associated with tobacco smoke (TE-COPD). In contrast to smokers, these subjects mainly have the chronic bronchitis phenotype. Air trapping predominates on CT and necropsy demonstrates more severe bronchiolitis. However, lung function, exercise capacity and molecular inflammation are similar, as are comorbidities. Information relating to genetic causes, pathogenesis and treatment is scarce. Current evidence suggests that further research is needed on this topic.

  7. Page 47
    Abstract
    Bibek Gooptu, Division of Asthma, Allergy and Lung Biology, King’s College London, 5th Floor, Tower Wing, Guy’s Hospital, Great Maze Pond, London, SE1 9RT, UK. E-mail: bibek.gooptu@doctors.org.uk

    Case history: Routine screening of a newly referred COPD patient reveals a low serum level of α1-AT, and subsequent tests confirm that the patient is homozygous for the Z α1-ATD allele. What is the current evidence for the use of α1-AT augmentation therapy? What is the significance for family members and should they be screened for α1-ATD? How would you explain why the disease can cause both lung and liver disease? What other diseases are linked with this condition?

    Chapter summary: The emphysema of α1-ATD is the best understood subphenotype of COPD in terms of its genetic basis, disease behaviour and major pathogenic mechanisms. However, this level of insight has not yet translated to a definitive cure, or even a tailored treatment that has proven robustly effective, for α1-ATD. This apparent paradox drives controversy, by implying an urgent need to identify where knowledge is incomplete or existing data are misunderstood. From another perspective, it highlights how subphenotyping is a necessary element but is not sufficient for development of specific treatments to provide the best possible patient-centred care. In this review of ongoing debates in α1-ATD we address, in turn, the involvement of different cell types, the extent of associated clinical phenotypes, the need to identify the optimal role of existing therapeutic options and how to develop new treatments. In doing so, we define important areas that are the subject of further active research, or that in our view require it.

  8. Page 85
    Abstract
    Marc Miravitlles, Pneumology Department, Hospital Universitari Vall d'Hebron, P. Vall d'Hebron 119–129, 08035 Barcelona, Spain. E-mail: mmiravitlles@vhebron.net

    Case history: A 58-year-old female presents with exertional breathlessness and spirometry shows post-bronchodilator FEV1 of 69% predicted and FEV1/FVC of 0.63. The bronchodilator test showed an increase in FEV1 of 316 mL and 15%. She is a smoker of 10 cigarettes a day (18 pack-years) and reports frequent episodes of bronchitis with wheezing during childhood that were treated with parenteral corticosteroids and occasionally with antibiotics. Is this chronic asthma, COPD or another entity, and how does it alter her management?

    Chapter summary: In the spectrum of chronic airway disease, some individuals share characteristics of asthma and COPD. The ACOS has been defined as symptoms of increased variability of airflow in association with non-fully reversible airflow obstruction. ∼15–20% of COPD patients may have ACOS and patients with ACOS present increased reversibility of airflow obstruction, more eosinophilic bronchial and systemic inflammation and increased response to ICSs, compared with the remaining patients with COPD. Patients with ACOS have more frequent exacerbations, more wheezing and dyspnoea and more severely impaired health status compared with COPD. From the clinician's point of view, the relevance of the ACOS is to identify patients with COPD who may have underlying eosinophilic inflammation that responds to ICSs. So far, no biomarker has been identified that allows the differentiation of ACOS from COPD, but intense investigation is being conducted to better characterise these patients at both primary and secondary healthcare levels.

  9. Page 96
    Abstract
    Miguel Ángel Martínez-García, Pneumology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain. E-mail: mianmartinezgarcia@gmail.com

    Case history: A CT scan performed when evaluating a 72-year-old female COPD patient with chronic purulent sputum for a lung nodule reveals airway wall thickening and dilatation that is described by the radiologist as bronchiectasis. How does the presence of radiological bronchiectasis affect the natural history of her COPD? Would you alter her management as a result of this? Is this a phenotype of COPD or a second, separate condition?

    Chapter summary: Both COPD and bronchiectasis are inflammatory airway diseases that are highly prevalent but also underdiagnosed. Apart from the fortuitous coexistence of the two diseases in some people, several studies have observed a higher prevalence than expected of bronchiectasis without any apparent cause in patients with COPD. The most important point is that COPD patients with bronchiectasis present specific clinical characteristics (greater clinical and functional severity, greater airway colonisation by PPMs and more exacerbations), which probably result in a poorer vital prognosis and a need for specific treatment. Consequently, patients with COPD and bronchiectasis may present an important clinical phenotype. Therefore, in accordance with our current knowledge of this subject, it seems reasonable to rule out the presence of bronchiectasis in patients with COPD and severe airflow obstruction, multiple exacerbations or chronic bronchial infection. Scientific research must focus on confirming the existence of any causal relationship and evaluating the most effective treatments for this special subgroup of patients with COPD.

  10. Page 109
    Abstract
    Matthew D. Jankowich, Providence VA Medical Center, 830 Chalkstone Ave., Office 158L, Providence, RI 02908, USA. E-mail: matthew_jankowich@brown.edu

    Case history: A 67-year-old man is referred for assessment of dyspnoea and elevated estimated pulmonary artery systolic pressures in the 50–60 mmHg range on an echocardiogram. He has already been started on sildenafil by the referring physician for presumed pulmonary arterial hypertension. He has a 50 pack-year smoking history. His pulmonary function testing shows normal spirometry and lung volumes but a severely reduced diffusion capacity for carbon monoxide. On exam, he has crackles at the lung bases and clubbing. You order a high-resolution chest CT, which shows extensive upper lobe bullous emphysema, subpleural reticular changes and honeycombing with traction bronchiectasis at the lung bases consistent with ILD. How should this patient's lung disease be classified – as COPD, idiopathic pulmonary fibrosis, or something else? Why are his lung volumes and spirometry normal despite significant parenchymal lung disease on chest imaging? What is this patient's prognosis and how should he be managed?

    Chapter summary: COPD and ILD coexist in patients not infrequently due to shared risk factors, especially tobacco smoke exposure. The coexistence of these conditions can make recognition through standard physiological studies such as spirometry and lung volume testing challenging. In such patients, recognition and diagnosis relies on measurement of lung diffusion capacity and HRCT. Coexistent COPD and ILD, frequently termed combined pulmonary fibrosis and emphysema, highlights the limitations of spirometry in the diagnosis of all COPD phenotypes as well as the central role of imaging in the assessment of patients with complex lung diseases. The natural history of coexistent COPD and ILD differs to that of either of these conditions when they occur alone. Controversies in management include the role of medications for the management of pulmonary hypertension, and the effectiveness of disease-specific medications such as bronchodilators or newer antifibrotic agents in such patients.

  11. Page 121
    Abstract
    Samuel Y. Ash, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA. E-mail: syash@partners.org

    Case history: A 72-year-old man with severe COPD is referred to a pulmonary clinic for further evaluation. After a long discussion of his history, including extensive smoking as well as multiple admissions for COPD exacerbations over the past 5 years, the conversation turns to the question of CT screening for lung cancer. The patient is interested in having a CT but only if it will provide more information applicable to his immediate COPD treatment, as he is less interested in cancer screening alone. He asks his pulmonologist for his/her recommendation in this regard.

    Chapter summary: Advancements in CT imaging as well as the increased availability of CT images, thanks to their proliferation in routine medical care, present opportunities for the use of CT in the management of COPD patients. These opportunities not only include more long-standing areas, such as the use of densitometry, but emerging areas, such as quantitative analysis of more distal airways and pulmonary vasculature. The overlap with lung cancer screening also raises yet more challenges and opportunities for the secondary use of huge volumes of CT data acquired for other indications.

  12. Page 134
    Abstract
    Jørgen Vestbo, Education and Research Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT, UK. E-mail: jorgen.vestbo@manchester.ac.uk

    Case history: An 85-year-old man is seen for COPD review and his spirometry is repeated. The FEV1 appears to have been stable over the previous 3 years. Is this compatible with COPD? How have recent data refined our knowledge on the relevance of FEV1 decline in COPD?

    Chapter summary: An accelerated decline in FEV1 has for decades been regarded as the hallmark of COPD and most of our knowledge on risk factors for COPD comes from longitudinal studies examining a relationship between an exposure of interest and FEV1 decline. However, FEV1 is not a good overall measure of the processes leading to COPD and COPD progression. In particular, FEV1 decline is not a good measure of progression of emphysema. In addition, it has been very difficult to reduce FEV1 decline in intervention trials. As we learn more about factors in childhood affecting maximally attained lung function and different trajectories of FEV1 leading to COPD, we get a more balanced view of the importance of FEV1 decline.

  13. Page 143
    Abstract
    Bartolome R. Celli, Pulmonary Critical Care Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. E-mail: bcelli@copdnet.org

    Case history: A 66-year-old woman with COPD attends for review. She has an FEV1 of 48% predicted, a BMI of 21 kg·m−2, frequent exacerbations, exertional breathlessness when walking 100 m on the level and comorbid osteoporosis. What is the best way to predict her future mortality risk? How can multidimensional indices inform prognosis? What are the strengths and weaknesses of the available tools?

    Chapter summary: Because the hallmark of COPD is the presence of airflow limitation, its severity and progression have been defined using the degree of airflow limitation. Research has shown that extrapulmonary manifestations of COPD are important and that they relate to poor outcomes. COPD is now considered to be a disease with systemic manifestations; it is therefore clear that there is a need to quantify and to incorporate the consequences of those manifestations to better reflect the actual compromise of patients. To grade disease severity, the index must not only relate to all-cause mortality, it should also reflect specific organ involvement or failure. This chapter provides a summary of the strengths and weaknesses of most of the indices available. Perhaps the time has come not to develop new ones but rather to test their practical impact on the management of patients in the clinical arena.

  14. Page 161
    Abstract
    Arjun Mohan, Division of Pulmonary and Critical Care Medicine, Veterans Affairs Medical Centre, 3495 Bailey Ave, Buffalo, NY 14215, USA. E-mail: drarjunmohan@yahoo.com

    Case history: A 62-year-old male presents with chronic exertional dyspnoea, early morning productive cough and intermittent wheezing. He is a former smoker with a smoking history of 40 pack-years. He states that his symptoms are gradually progressive, he does have “bad days of increased dyspnoea, cough and sputum” quite often, but he does not seek medical care for them as he does not want to bother his doctors. Instead, he increases his inhaled bronchodilators and reduces his activities until these episodes resolve. He has had only one medically treated exacerbation in the past year, when he had to come to the emergency room because his breathing “got really bad”. Spirometry shows severe airflow obstruction without a bronchodilator response. His outpatient medication includes a tiotropium inhaler once daily and a budesonide–formoterol inhaler twice a day. Sputum cultures carried out at this visit show 3+ Nontypeable Haemophilus influenzae (NTHi). What is the significance of his sputum culture results? How did he get colonised with NTHi, is it of clinical significance, and does it need treatment? If yes, how do we treat such colonisation?

    Chapter summary: It is likely that chronic bacterial presence in COPD airways, usually referred to as colonisation, is in fact a chronic infectious state. Several investigations have now demonstrated that the presence of bacteria in the lower respiratory tract in stable COPD is associated with increased inflammation. Pathological and radiological findings in COPD support chronic infection, as do recent mouse models. Increased daily respiratory symptoms and unreported exacerbations are clinical manifestations of chronic infection in COPD. Chronic infection in this disease results from multiple impairments of innate lung immunity induced by exposure to noxious particles or gases such as tobacco smoke.

  15. Page 172
    Abstract
    Pan-Chyr Yang, Dept of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-zheng District, Taipei 10002, Taiwan. E-mail: jywang@ntu.edu.tw

    Case history: A 53-year-old woman with COPD has had a cough with sputum for the last 8 years and received maintenance ICS therapy. She suffered from recurrent episodes of exacerbation of airway symptoms, often requiring antibiotic therapy. Erythromycin has been given in the last 6 months. She presented with more severe cough, copious sputum and exertional dyspnoea. Chest CT revealed bronchial wall thickening and multifocal tree-in-bud lesions. All three sputum samples collected within 1 week grew Mycobacterium avium complex. Is this AECOPD, non-tuberculous mycobacterial lung disease, or both?

    Chapter summary: Non-tuberculous mycobacteria (NTM) are common organisms that can infect patients with chronic debilitating lung diseases. The incidence of NTM lung disease (NTM-LD) is increasing in patients with COPD. Lung structural changes due to NTM-LD may make the host more vulnerable to NTM infection. The diagnosis of NTM-LD requires the fulfilment of both clinical and microbiological criteria. However, a correct diagnosis of NTM-LD in COPD patients is usually difficult. The decision for NTM treatment should be based on the potential risk and benefit of therapy. Particular therapeutic concerns exist, especially regarding corticosteroids and macrolides. Since the presence of NTM may lead to worsening lung function and AECOPD, the outcome of patients with concomitant NTM-LD and COPD is likely to be worse. However, significant controversy exists in many areas, and further longitudinal studies are urgently needed.

  16. Page 185
    Abstract
    Marcos I. Restrepo, 7400 Merton Minter MC 111E, San Antonio, TX 78229, USA. E-mail: restrepom@uthscsa.edu

    Case history: A 55-year-old obese woman presents with dyspnoea, increased production of green sputum, and low-grade fever. She has smoked for 35 years, one pack every day. A chest radiograph is equivocal for a new pulmonary infiltrate, due to her body habitus. What is the most likely diagnosis: acute pneumonia or an exacerbation of COPD?

    Chapter summary: From a clinical perspective, the distinction between pneumonia and exacerbations of COPD can be challenging. Chest radiography is often required to make the distinction, but its findings may be obscured by pre-existing conditions. Biomarkers have shown the most promise: both CRP and procalcitonin can reliably distinguish between COPD exacerbations and pneumonia, but further studies are required to make final recommendations on their use. Specific and distinctive inflammatory patterns in both pneumonia with concurrent COPD and exacerbations of COPD have been typified. Although they share some similarities, the cytokine profiles and macrophage activation are different in these conditions. Inhaled steroids are used widely in COPD and are associated with an increased risk for pneumonia but not for mortality, suggesting multiple underlying mechanisms.

  17. Page 197
    Abstract
    David J. Serisier, Dept of Respiratory Medicine, Lvl 9 Mater Adult Hospital, Raymond Tce, South Brisbane, Queensland, Australia. E-mail: david.serisier@mater.org.au

    Case history: A 65-year-old male ex-smoker with COPD and moderately-severe airways obstruction (FEV1 48% predicted) presents with an exacerbation which is successfully managed with short-course, outpatient oral amoxicillin and prednisone. He has not had any other exacerbations in the past 12 months. You wonder whether he should be prescribed maintenance prophylactic azithromycin.

    Chapter summary: Convincing data supporting the use of typical antibacterial agents as prophylaxis for infective exacerbations of COPD are lacking, in spite of the apparent importance of bacterial infection in these episodes. Only macrolide antibiotics have shown consistent benefits on exacerbation prevention, although perhaps not primarily by a traditional antibacterial mechanism.

    There does not appear to be any net increased cardiovascular risk with macrolides when used for appropriate clinical indications, at least for azithromycin. Arguably the greatest risks relate to the use of these agents in COPD are microbiological, as widespread use will promote further increases in population bacterial resistance. Additionally, recent data reveal that prophylactic macrolide therapy fosters a shift in respiratory microbiota composition towards communities with more antibiotic resistant bacteria particularly Pseudomonas aeruginosa.

    Achieving an appropriate balance of risk–benefit with macrolide antibiotics can be realised by limiting their use to COPD patients at high risk of hospitalisation, and by preferentially using less potent (low-dose erythromycin) over potent, long-acting (azithromycin) macrolides.

  18. Page 213
    Abstract
    Mario Cazzola, Dipartimento di Medicina dei Sistemi, Università di Roma Tor Vergata, Via Montpellier 1, 00133 Rome, Italy. E-mail: mario.cazzola@uniroma2.it

    Case history: A 50-year-old man is seen in the clinic with newly diagnosed COPD. He is referred for smoking cessation and pulmonary rehabilitation but you feel he will also benefit from an inhaled long-acting bronchodilator. What factors would you consider in choosing the optimal medication for this man, with specific regard to the range of inhaler devices now available?

    Chapter summary: Inhalation devices are a mainstay in the management of COPD. They include the pressurised metered-dose inhaler, dry powder inhaler, metered-dose inhaler with spacer, breath-actuated metered-dose inhaler, nebuliser and soft mist inhaler. Each type of device has its own advantages and disadvantages. The choice of device has to be tailored according to patient's needs, situation and preference. Certain factors, such as the age of the subject, the cognitive and psychomotor deficits occurring with the ageing process as well as a COPD-specific cognitive impairment, the availability of the drug formulation, the clinical setting as well as the disease being treated, the patient's ability to generate an adequate inspiratory flow, the capacity to handle the device appropriately and, importantly, its coordination with the inspiratory effort and the patient's preference for a device affect choice for the individual patient. Unfortunately, guidelines provide limited guidance regarding choice of devices, likely because of the lack of robust clinical data that can be translated into guideline recommendations.

  19. Page 224
    Abstract
    Daniel Langer, Laboratory of Respiratory Diseases, KU Leuven, Campus Gasthuisberg, O&N1, Herestraat 49 box 706, B-3000 Leuven, Belgium. E-mail: daniel.langer@faber.kuleuven.be

    Case history: A 69-year-old man with COPD (FEV1 59% predicted, 6MWD 85% pred) visits the outpatient clinic after 1 week of wearing an activity monitor. The device shows that the patient currently has a physical activity level of 4500 steps·day−1. Is this patient sufficiently active? Would you coach him towards a higher physical activity level?

    Chapter summary: The promotion of a physically active lifestyle is recommended for all patients with COPD, based on a large evidence base of the health benefits of being physically active. The available physical activity recommendations differ considerably. It has been demonstrated that these differences have a significant impact on the classification of patients with COPD into categories of sufficient and insufficient physical activity. Functional capacity and functional reserve become increasingly limited with progressing disease severity. This makes it difficult for many patients to achieve the recommended time in physical activity of at least moderate intensity. Reducing sedentary time might be a relevant and more realistic treatment goal in these patients. Objective measures are available to measure physical activity and their characteristics make these tools suitable for use in clinical practice. Treatment approaches to modify physical activity have gained popularity in recent years. Self-monitoring of daily activities and goal setting with feedback from a pedometer are common elements in these interventions, which have the potential to improve health in patients with COPD.

  20. Page 240
    Abstract
    Thierry Troosters, Respiratory Rehabilitation and Respiratory Division, UZ Gasthuisberg, Herestraat 49 bus 706, Onderwijs & Navorsing I, Labo Pneumologie, B-3000 Leuven, Belgium. E-mail: thierry.troosters@kuleuven.be

    Case history: Mr X is a 65-year-old patient with severe COPD (FEV1 35% predicted) referred to PR 2 weeks after discharge from an acute exacerbation. He has now completed 12 weeks of PR, consisting of exercise training three times per week. In addition to training, Mr X received dietary support (high protein/calorie advice), prescription of a rollator walking aid, occupational therapy (energy conservation techniques) and consultations with a respiratory nurse to develop self-management skills aiming to enhance appropriate actions upon subsequent exacerbations. Mr X improved his 6MWD by 52 m and his FEV1 by 150 mL compared with the assessment upon entry to PR. Is this a comprehensive outcome assessment? How should the benefits of PR best be assessed?

    Chapter summary: This chapter summarises the methods for assessing the effectiveness of comprehensive PR programmes, with consideration given to the different perspectives of patients, therapists, referrers and funding bodies. The assessment and treatment of PR attendees should be specific and patient centred, to maximise the attainment of individual goals across a diverse range of clinically important outcomes. The main domains of assessment include evaluation of exercise capacity, peripheral muscle strength, health-related quality of life, symptoms and physical activity levels. Assessment of additional, specific factors (e.g. nutrition, anxiety/depression, self-efficacy) may be indicated for selected patients if problems are identified upon admission to PR. Finally, consideration is given to some of the important issues affecting PR in order to improve the standardisation and comparability of future programmes.

  21. Page 256
    Abstract
    Jan H. Vercoulen, Dept of Medical Psychology and Dept of Pulmonary Diseases, Radboud University Medical Centre, PO Box 66, 6500 HB, The Netherlands. E-mail: jan.vercoulen@radboudumc.nl

    Case history: A 47-year-old female patient has COPD at Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II, and is underweight. She reports taking her medication. She works 3 days a week as a housekeeper. She does not do any sports activities (“too tired after work”) but has adequate physical condition. When asked, she reports no problems in daily life: “everything is fine”. But what do we really know about this patient? Is everything really fine? Are a disturbed lung function, being underweight and feeling tired after work her only impairments in health status?

    Chapter summary: A detailed assessment of the many aspects of health status is a prerequisite for patient-tailored treatment. The assessment of a patient's physiological functioning is standard in clinical practice. However, health status is an overall concept that covers many other elements in addition to physiological functioning, such as symptoms, functional impairment and quality of life. The latter three are highly subjective phenomena, in which psychological processes (cognitions, emotions and behaviour) play an important role. Therefore, these aspects of health status and psychological processes can only be measured using (self-reported) questionnaires. Many questionnaires exist, each with their own strengths and weaknesses. To measure all aspects of health status, many instruments must be integrated, with each instrument measuring a different concept. This process should be driven by a conceptual framework and should be subsequently tested empirically. The outcome of these questionnaires can also be used as an intervention to motivate the patient to change their behaviour in order to optimise self-management. Implementing questionnaire use in clinical practice will enhance treatment selection and improve patient-tailored treatment.

  22. Page 269
    Abstract
    Roger S. Goldstein, Dept of Respiratory Medicine, West Park Healthcare Centre, 82 Buttonwood Ave, Toronto, ON, M6M 2J5, Canada. E-mail: rgoldstein@westpark.org.

    Case history: A male patient was diagnosed with COPD by his primary care physician, who confirmed moderate airflow limitation using spirometry. His main complaint was of progressive dyspnoea. He was referred for teleconsultation by his primary care physician, which involved attendance at a local medical clinic where he was interviewed by a respiratory physician located at a large medical centre 60 miles away. His medical chart, cardiogram, spirometry and chest radiograph were forwarded to the respiratory physician. During the consultation, he was advised to stop smoking, receive regular influenza vaccinations and maintain his activity levels. The patient complained of reduced exercise tolerance and said he was becoming housebound. Although a large rehabilitation programme was operational at the main health centre 70 miles away, a small satellite six-person programme was available at a neighbouring community centre. Following referral to this programme, the patient underwent a telemedicine assessment. Once enrolled, he received online lectures in real time, simultaneously with the main rehabilitation programme. He undertook onsite exercise training supervised by a healthcare professional who was linked in real time to the physical therapist at the main centre. Following programme completion, he was followed up via teleconsultation with the nurse coordinator at the central site.

    Chapter summary: Telemedicine, the provision of healthcare at a distance, is a novel approach to the management of individuals with COPD, driven by the need to facilitate access to healthcare for patients living in geographically remote regions and communities. Telemedicine applications may involve teleconsultation, telemonitoring, telehealth and telerehabilitation. Telemedicine may facilitate the early detection and management of a clinical deterioration. It aims to improve patient self-monitoring and can be used to provide patient education and rehabilitation. While patient attitudes towards this model of healthcare delivery are generally positive, the clinical benefits of telemedicine in COPD are variable and the cost-effectiveness of these interventions has not yet been determined. Despite mixed results, a select group of patients with COPD appear to benefit from differing models of telemedicine.

  23. Page 297
    Abstract
    Jennifer K. Quint, Dept of Respiratory Epidemiology, Occupational Medicine and Public Health, G48, Emmanuel Kaye Building, Manresa Road, National Heart and Lung Institute, Imperial College, London, SW3 6LR, UK. E-mail: j.quint@imperial.ac.uk

    Case history: A 75-year-old woman with an FEV1 of <0.4 L is admitted to hospital for the second time in 6 months with an exacerbation of COPD. She is an ex-smoker, and takes inhaled long-acting antimuscarinics, long-acting β-agonists and ICSs regularly. She does not meet criteria for long-term home oxygen. Prior to admission, she walked short distances indoors, limited by dyspnoea, and used a mobility scooter to get to the local shop. Her functional abilities have declined over the last year, and she has lost 10% body weight such that her BMI is now 20 kg·m−2. Following acute treatment with controlled oxygen, oral steroids and antibiotics, and a prolonged hospital stay, she remains breathless at rest with severe fatigue and anxiety. A trial of low-dose opioids has been suggested but she is reluctant to start this treatment due to fears of dependence and drowsiness. A case-conference is planned to address her ongoing needs and preferences for future care. Her daughter has asked about her likely prognosis, and how her symptoms and quality of life can be improved.

    Chapter summary: As the prevalence of COPD increases globally, there are a growing number of patients living with disabling symptoms and impaired quality of life, before a premature death. Such patients may benefit from a more holistic approach to their condition, including better symptom control and earlier referral to palliative care. Barriers preventing COPD patients accessing palliative care include prognostic uncertainty and a limited evidence base for both pharmacological and non-pharmacological interventions. Interventions that are evidence-based are not widely available to patients with COPD, partly due to models of care that are based on acute crises rather than longer-term support. Further research into treatment for breathlessness, anxiety, panic disorder, fatigue and pain in COPD is needed, as well as evaluation and optimisation of new models of care. Respiratory and palliative care specialists must work in parallel to better support patients and their carers.

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