Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease

Maintaining exercise capacity and quality of life following pulmonary rehabilitation

OBJECTIVE

The optimum method for sustaining the benefits gained from pulmonary rehabilitation (PR) has not been determined. In this report the authors describe the 4-year referral and uptake patterns to a hospital-based outpatient PR programme, and the sustained benefits of PR in patients with COPD attending a community-based maintenance exercise programme.

METHODS

Entry and exit data were mapped for all patients referred to the PR service over the review period. All eligible patients were offered a community-based maintenance exercise programme upon completion of PR. A total of 21 patients underwent follow-up assessment of functional exercise capacity, quality of life (QOL) and health-care utilization.

RESULTS

Over a 4-year period, 467 patients (80% with COPD) were referred to the programme, of whom 230 entered PR. In total, 172 patients completed PR, with attrition (25%) being mostly due to medical problems. Of the 84 patients who elected for the community-based programme, 46 were still attending at follow up and 21 patients with moderate-to-severe COPD (44.9 +/- 12.6 (mean +/- SD) FEV(1)% predicted) were reassessed at 18.4 +/- 11.9 months post PR. Significant improvements (mean change (95% confidence interval)) persisted in 6-min walk distance (41.1 m (15.7-66.5)), distance walked in 20 min (195.1 m (82.3-308)) and in QOL (Chronic Respiratory Disease Questionnaire) (11.0 points (4.4-17.6)) (P < 0.01). The QOL improvements exceeded the minimum clinically important difference. A trend towards a reduction in COPD-related hospital admissions, bed-days and emergency department presentations was observed in the 12 months following PR. Self-reported adherence with the home exercise programme indicated that 67% of patients were exercising at least 3-5 days each week in addition to attending a class.

CONCLUSION

For patients with moderate-to-severe COPD, a weekly community-based maintenance exercise class, supervised by a physiotherapist, combined with a home exercise programme is an effective intervention for maintaining improvements following PR.

COPD exacerbations.5: management

A review of the most relevant evidence based therapeutic options currently available for the management of exacerbations of COPD.

Should patients with acute exacerbation of chronic bronchitis be treated with antibiotics? Advantages of the use of fluoroquinolones

The pathological changes in chronic bronchitis (CB) produce airflow obstruction, reduce the effectiveness of the mucocilliary drainage system and lead to bacterial colonisation of bronchial secretion. The presence of bacteria induces an inflammatory response mediated by leukocytes. There is a direct relationship between the degree of impairment of the mucocilliary drainage system, the density of bacteria in mucus and the number of leukocytes in the sputum. Purulent sputum is a good marker of a high bacterial load. Eventually, if the number of leukocytes is high, their normal activity could decrease the effectiveness of the drainage system, increase the bronchial obstruction and probably damage the lung parenchyma. Whenever the density of bacteria in the bronchial lumen is >or=10(6) CFU/mL, there is a high probability that the degree of inflammatory response will lead to a vicious cycle which in turn tends to sustain the process. This situation can arise during the clinical course of any acute exacerbation of CB, independently of its aetiology, provided the episode is sufficiently severe and/or prolonged. Fluoroquinolones of the third and fourth generation are bactericidal against most microorganisms usually related to acute exacerbations of CB. Their diffusion to bronchial mucus is adequate. When used in short (5-day) treatment they reduce the bacterial load in a higher proportion than is achieved by beta-lactam or macrolide antibiotics given orally. Although the clinical cure rate is similar to that obtained with other antibiotics, the time between exacerbations could be increased.

Respiratory Syncytial Virus, Airway Inflammation, and FEV1Decline in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Respiratory syncytial virus (RSV) is increasingly recognized as an important pathogen in adults with cardiopulmonary disease. It has been associated with acute exacerbations of chronic obstructive pulmonary disease (COPD); however, it has also been detected in the lower airway in the stable state, but the consequences of RSV in stable disease have not previously been determined. We therefore studied the consequences of RSV persistence in adults with COPD and its effect on airway inflammation and lung function decline.

METHODS

A total of 241 sputum samples from 74 patients with COPD (FEV(1)% predicted, 39.2%; interquartile range, 29.6-57.8%) were collected quarterly in the stable state over 2 yr. RSV was detected by polymerase chain reaction (PCR), quantitative microbiology was performed, and inflammatory cytokines were quantified by ELISA.

RESULTS

RSV RNA was detected in 32.8% of sputum samples. Patients in whom RSV was more frequently detected (> 50% of samples RSV PCR-positive, n=18) had higher airway inflammation and faster FEV(1) decline over the study (101.4 ml/yr [95% confidence interval, 57.1-145.8]) compared with those with less frequent detection of RSV (n=56; 51.2 ml/yr [31.7-70.8]; p=0.01). The observed relationship between RSV detection and accelerated lung function decline was independent of smoking status, exacerbation frequency, and lower airway bacterial load.

CONCLUSIONS

Persistent RSV detection in patients with COPD is associated with airway inflammation and accelerated decline in FEV(1). Chronic RSV infection may be a novel therapeutic target to alter the natural history of COPD.

Exacerbations, Hospital Admissions and Impaired Health Status in Chronic Obstructive Pulmonary Disease

Impaired health status may be a risk factor for frequent exacerbations and hospital admission and, in turn, exacerbations and admissions may further impair the health status of patients with COPD. We have investigated the variables associated with frequent exacerbations (3 or more per year) and admission, with particular interest in health status, in a cohort of ambulatory patients with moderate to severe COPD attended by chest physicians in Spain. A total of 227 investigators included 1057 patients with a mean predicted FEV1 of 41.8%. The mean total score on the St. George's Respiratory Questionnaire (SGRQ) was 47.9 units, and 300 patients (28.4%) had 3 or more exacerbations the previous year and 344 (32.6%) were admitted at least once during the same period. In multivariate analysis only the SGRQ total score was significantly associated with both frequent exacerbations (OR = 1.04; 95% CI = 1.01-2.12; p<0.0001) and admission (OR = 1.01; 95% CI = 1.00-1.02; p = 0.0008). Other variables significantly associated with frequent exacerbations were chronic mucus hypersecretion, increased baseline dyspnea, comorbidity, GOLD stage IV and treatment with inhaled corticosteroids. Variables associated with admission were lower educational level, increased number of exacerbations, use of long-term oxygen therapy and use of short acting beta-2 agonists. An impaired health status is associated with an increased number of exacerbations and with admission to hospital in the previous year. These results, together with previous studies, confirm that impairment in health status in COPD is both a marker of risk for, and a consequence of, frequent exacerbations and admissions.

Treatment of chronic obstructive pulmonary disease in older adults

This article summarizes some distinctive features of chronic obstructive pulmonary disease in the elderly and the ensuing diagnostic and therapeutic needs. It focuses on atypical presentation, systemic effects of the disease and comorbid conditions. The role of nonpharmacological measures, such as rehabilitation, physical exercise and nutritional support, is discussed. Finally, the author emphasizes that a comprehensive geriatric approach should guide the planning of therapy and monitoring of its efficacy.

Role of infection and antimicrobial therapy in acute exacerbations of chronic obstructive pulmonary disease

Over the past several years, the significance of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in patients with chronic airflow obstruction has become increasingly apparent due to the impact these episodes have on the natural history of disease. It is now known that frequent AECOPD can adversely affect a patient's health-related quality of life and short- and long-term pulmonary function. The economic burden of these episodes is also substantial. AECOPDs represent a local and systemic inflammatory response to both infectious and noninfectious stimuli, but the majority of episodes are likely related to bacterial or viral pathogens. Patients with purulent sputum and multiple symptoms are the most likely to benefit from treatment with antibiotics. Antibiotic choice should be tailored to the individual patient, taking into account the severity of the episode and host factors which might increase the likelihood of treatment failure. Current evidence suggests that therapeutic goals not only include resolution of the acute episode, but also prolonging the time to the next event. In the future, preventing exacerbations will likely become increasingly accepted as an additional therapeutic goal in chronic obstructive pulmonary disease patients.

COPD exacerbations .1: Epidemiology

The epidemiology of exacerbations of chronic obstructive pulmonary disease (COPD) is reviewed with particular reference to the definition, frequency, time course, natural history and seasonality, and their relationship with decline in lung function, disease severity and mortality. The importance of distinguishing between recurrent and relapsed exacerbations is discussed.

Effect of interactions between lower airway bacterial and rhinoviral infection in exacerbations of COPD

STUDY OBJECTIVES

The inflammatory responses and associated clinical severity of COPD exacerbations are greatly variable, and the determinants of these factors are poorly understood. We examined the hypothesis that bacteria and viruses may modulate this heterogeneity and that interactions between bacterial and viral infection may affect changes in airway bacterial load and the clinical features and inflammatory responses of exacerbations in patients with COPD.

DESIGN

Prospective cohort study.

SETTING

Outpatient Department, London Chest Hospital, London, UK.

PATIENTS

Thirty-nine patients with COPD.

MEASUREMENTS

We prospectively studied 56 COPD exacerbations, obtaining clinical data and paired sputum and serum samples at baseline and exacerbation. Qualitative and quantitative microbiology, polymerase chain reaction detection for rhinovirus, and estimation of cytokine levels by enzyme-linked immunosorbent assay were performed.

RESULTS

A total of 69.6% of exacerbations were associated with a bacterial pathogen, most commonly Haemophilus influenzae. Rhinovirus was identified in 19.6% of exacerbations. The rise in bacterial load at exacerbation correlated with the rise in sputum interleukin (IL)-8 (r = 0.37, p = 0.022) and fall in FEV1 (r = 0.35, p = 0.048). Exacerbations with both rhinovirus and H. influenzae had higher bacterial loads (10(8.56) cfu/mL vs 10(8.05)cfu/mL, p = 0.018) and serum IL-6 (13.75 pg/mL vs 6.29 pg/mL, p = 0.028) than exacerbations without both pathogens. In exacerbations with both cold symptoms (a marker of putative viral infection) and a bacterial pathogen, the FEV1 fall was greater (20.3% vs 3.6%, p = 0.026) and symptom count was higher (p = 0.019) than those with a bacterial pathogen alone.

CONCLUSIONS

The clinical severity and inflammatory responses in COPD exacerbations are modulated by the nature of the infecting organism: bacterial and viral pathogens interact to cause additional rises in inflammatory markers and greater exacerbation severity.

Exacerbations de BPCO: Audit de pratique dans les services d’urgences en France

INTRODUCTION

Exacerbations of COPD are potentially serious events, the recognition and treatment of which appear to be poorly understood by both patients and doctors. The aim of this study is to describe, on the basis of two case histories, the management of exacerbations of COPD in emergency departments, to compare it with the current guidelines and to evaluate the extent of use of non-invasive ventilation in decompensated COPD.

METHODS

The study took place between February and June 2004. Two case histories describing one moderate and one severe exacerbation with respiratory failure were written by the authors of the study and submitted to an emergency physician in a university hospital and a district hospital in each region.

RESULTS

110 questionnaires were returned from 20 university hospitals and 25 district hospitals. Only 38% of the episodes were identified correctly. 20% of doctors did not regard dyspnoea as a clinical sign of an exacerbation. 22% of doctors never prescribed bronchodilators, even in severe cases. Finally, non-invasive ventilation (NIPV) was used for only 9% of the moderate and 56% of the severe exacerbations.

DISCUSSION

This study, although limited by certain factors, illustrates a number of points in need of improvement in the recognition and treatment of exacerbations of COPD in emergency departments, the use of NIPV, and the collaboration between emergency physicians, intensivists and respiratory physicians.

Therapeutic prospects to treat skeletal muscle wasting in COPD (chronic obstructive lung disease)

Chronic obstructive pulmonary disease (COPD) is an incurable group of lung diseases characterised by progressive airflow limitation and loss of lung function, which lead to profound disability. It is mostly caused by cigarette smoke. Although COPD is one of the most prevalent diseases worldwide and its incidence is increasing, current therapies do little to improve the condition. Much current research focuses on strategies to halt the accelerated rate of decline in lung function that occurs in the disease. However, as most symptoms occur when the lungs are already extensively and irreversibly damaged, it is uncertain whether an agent able to slow or halt decline in lung function would actually provide relief to COPD patients. As lung function worsens, systemic comorbidities contribute markedly to disability. Loss of lean body mass (skeletal muscle) has recently been identified as a major determinant of disability in COPD and an independent predictor of mortality. In contrast to lung structure damage, skeletal muscle retains regenerative capacity in COPD. In this review, we discuss mechanisms of wasting in COPD, focusing on therapeutic strategies that might improve the health and productive life expectancy of COPD patients by improving skeletal muscle mass and function. Single or combination approaches exploiting the suppression of procatabolic inflammatory mediators, inhibition of ubiquitin ligases, repletion of anabolic hormones and growth factors, inhibition of myoblast apoptosis, remediation of systemic oxidative stress and promotion of repair, and regeneration via stimulation of satellite cell differentiation hold considerable therapeutic promise.

Exacerbations of chronic obstructive pulmonary disease and chronic mucus hypersecretion

Chronic obstructive pulmonary disease (COPD) exacerbations are an important cause of the considerable morbidity and mortality found in COPD. COPD exacerbations increase with increasing severity of COPD, and some patients are prone to frequent exacerbations leading to hospital admission and readmission. These frequent exacerbations may have considerable impact on quality of life and activities of daily living. Factors that increase the risk for COPD exacerbations are associated with increased airway inflammation caused by common pollutants and bacterial and/or viral infections. These inflammatory responses cause mucus hypersecretion and, thereby, airway obstruction and associated exacerbations. While chronic mucus hypersecretion is a significant risk factor for frequent and severe exacerbations, patients with chronic mucus hypersecretion have a lower rate of relapse after initial treatment for acute exacerbation. The benefit of antibiotics for treatment of COPD exacerbations is small but significant. While the mechanisms of actions are not clear, mucolytic agents reduce the number of days of disability in subjects with exacerbations. Reducing mucous cell numbers in small airways could be a useful way to reduce chronic mucus hypersecretion. Our studies suggest that programmed cell death is crucial in the resolution of metaplastic mucous cells, and understanding these mechanisms may provide novel therapies to reduce the risk of COPD exacerbations.

Exacerbations as a starting point of pro-active chronic obstructive pulmonary disease management

Chronic obstructive pulmonary disease (COPD) exacerbations could represent an opportunity for pro-active COPD management rather than mere treatment if previously unknown disease is discovered; the extent of underdiagnosis and undertreatment of COPD in patients attending an emergency department (ED) with an exacerbation is not known. During 2002, we recalled 131 COPD patients in stable conditions, 4-8 weeks after they had attended the ED or been discharged from our University Hospital (North-West of Italy). Information on diagnosis and management prior to the ED attendance were collected; spirometry and arterial blood gas analyses were performed. One-third of patients had never been diagnosed and treated even though 83% of them had moderate-to-very-severe COPD and about 30% already had respiratory failure. Only 20% had received information on the nature of the disease and none had received a written action plan. Only 60% were receiving long-acting bronchodilators and 41% of patients with respiratory failure were receiving long-term oxygen. A substantial number of undiagnosed and untreated patients with moderate-to-very-severe COPD came to our attention through an exacerbation. This enforces the importance of exacerbations as the starting point of pro-active COPD management and of the ED as a valuable sentinel to identify this subset of patients.

Action plans for chronic obstructive pulmonary disease

BACKGROUND

The effectiveness of action plans as treatment for chronic obstructive pulmonary disease (COPD) is not known.

OBJECTIVES

To assess the efficacy of action plans in the management of COPD.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, CINAHL and the National Research Register of Ongoing Trials. We also searched reference lists of identified studies. The search was completed in August 2004.

SELECTION CRITERIA

Randomised controlled trials of action plans in COPD. Studies with a primary diagnosis of asthma excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information when necessary. Study results were combined in meta-analyses using the Cochrane Collaboration software RevMan.

MAIN RESULTS

There was evidence of a positive effect of action plans on self-management knowledge. The mean difference (MD) for recognition of a severe exacerbation was 2.50; 95% confidence interval 1.04 to 3.96, for self-action in severe exacerbations MD 1.50; 95% confidence interval 0.62 to 2.38 and the use of antibiotics MD 6.00; 95% confidence interval 2.68 to 9.32. There was also evidence of a positive effect on the initiation of antibiotics (odds ratio (OR) 10.16; 95% confidence interval 2.02 to 51.09) and/or oral steroids (OR 6.58; 95% confidence interval 1.29 to 33.62). However, there was no evidence of significant effects on healthcare utilisation, health-related quality of life, lung function, functional capacity, symptom scores, mortality, anxiety, or depression. No trials used as outcomes: number of exacerbations, length of exacerbations, or days lost from work.

AUTHORS' CONCLUSIONS

This review shows there is evidence that action plans aid people with COPD in recognising and reacting appropriately to an exacerbation of their symptoms via the self-initiation of antibiotics or steroids. Further research needs to be completed with more comprehensive outcomes measures in order to ascertain whether this results in significantly decreased morbidity and/or mortality.

Extending a home from hospital care programme for COPD exacerbations to include pulmonary rehabilitation

The principals of rehabilitation medicine are to prevent muscle atrophy and improve mobility. Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with muscle atrophy and yet many patients do not undergo pulmonary rehabilitation until they have been in stable health for some time. We investigated the outcome of a supervised home exercise programme initiated immediately after hospitalisation for an exacerbation of COPD. Thirty-one patients were randomised into an exercise group (n=16, FEV(1) 0.94+/-0.34 L) and a control group (n=15, FEV(1) 1.08+/-0.33 L). The exercise group received a twice-weekly supervised exercise programme, in their homes, for 6 weeks. Spirometry, exercise capacity, isometric muscle strength, dyspnea level, quality of life at baseline and 6 weeks as well as subsequent exacerbations were quantified. At 6 weeks, the exercise group, improved the shuttle walk test (198 m+/-95-304+/-136 m) and increased 3 min step test capacity (119+/-40-163+/-26s) (both P<0.001). Knee extensor muscle strength and quality of life scores also increased. Neither exercise capacity nor muscle strength altered in the control group. Follow-up at 3 months showed that three of the control group and none of the exercise group had experienced subsequent exacerbations (P=0.06). Early rehabilitation via a home from hospital programme improved exercise tolerance, muscle strength, dyspnea scores, quality of life in COPD patients and reduced the number of subsequent exacerbations.

Differences in COPD care among doctors who control the disease: general practitioner vs. pneumologist

AIM

To assess the role of doctors who patients report as responsible of their disease, in moderate-severe chronic obstructive pulmonary disease (COPD), describing characteristics of patients and treatments use according to each type of doctor, and relating it to the way of access to hospital at the time of an exacerbation.

MATERIALS/PATIENTS AND METHODS

A systematic sample of 1:2 patients admitted for a COPD exacerbation during 1 year in four tertiary hospitals in the Barcelona area, Spain, was recruited. Information about health services was obtained by an administered questionnaire.

RESULTS

A total of 346 patients were recruited: mean age 69 (+/-9) years, percent of predicted FEV(1) of 35 (+/-16)%, PO(2) of 64 (+/-13)mmHg. At the time of admission, 17% of patients reported being controlled by a general practitioner (GP) and 56% by a pneumologist whereas 21% reported its COPD not being under the regular control of any doctor. Patients not controlled by a pneumologist did not suffer from milder COPD than the remaining, but were less likely to receive pharmacological and non-pharmacological treatments and less likely to perform correctly the inhalation manoeuvres. During the course of the exacerbation 70% of patients reported a visit to a hospital emergency room department without a previous medical visit, this proportion being higher among those controlled by a pneumologist.

CONCLUSIONS

Lack of control and variability in the patterns of care among patients controlled by different types of physicians are common in moderate-to-severe COPD patients admitted for a COPD exacerbation, despite the lack of differences in COPD severity. Medical control of COPD patients needs more investigation and a wider inclusion in international guidelines.

Clinical Significance of the Infection-FreeInterval in the Management of Acute Bacterial Exacerbations of Chronic Bronchitis

Rational and appropriate antibiotic use for patients with acute exacerbation of chronic bronchitis (AECB) is a major concern, as approximately half of these patients do not have a bacterial infection. Typically, the result of antimicrobial therapy for patients with acute bacterial exacerbation of chronic bronchitis (ABECB) is not eradication of the pathogen but resolution of the acute symptoms. However, the length of time before the next bacterial exacerbation can be another important variable, as the frequency of exacerbations will affect the overall health of the patient and the rate of lung deterioration over time. Clinical trials comparing antimicrobial therapies commonly measure resolution of symptoms in AECB patients as the primary end point, regardless of whether the exacerbation is documented as bacterial in nature. Ideally, the scientific approach to assessing the efficacy of antibiotic therapy for ABECB should include a measurement of acute bacterial eradication rates in patients with documented bronchial bacterial infection followed by measurement of the infection-free interval (IFI), ie, the time to the next ABECB. The use of these variables can provide a standard for comparing various antimicrobial therapies. As we learn more about how antibiotics can affect the IFI, treatment decisions should be adapted to ensure optimal management of ABECB for the long-term.

The quality of life impact of acute exacerbations of chronic bronchitis (AECB): A literature review

BACKGROUND

The impact of acute exacerbations of chronic bronchitis (AECB), a common consequence of chronic obstructive pulmonary disease (COPD), is extensive, with symptoms ranging from mild to life threatening. Health-related quality of life (HRQL) is impaired in patients with COPD, but little is known about the direct effect of exacerbations on HRQL.

METHODS

MEDLINE and EMBASE literature searches were conducted; reference lists of identified articles were reviewed.

RESULTS

Eighteen studies reporting the impact on HRQL of acute exacerbations were identified. Study design and patient population varied. Six studies evaluated HRQL once; only four studies used both generic and disease-specific HRQL measures. Cross-sectional studies reported HRQL decrements during exacerbations and suggested that HRQL is a good predictor of health care resource utilization. Pharmacological treatment led to within-group improvements following AECBs. Non-pharmacological intervention studies were small and inconclusive. Longitudinal studies, assessing pharmacological and non-pharmacological interventions, found that HRQL improved from exacerbation to recovery, with responsiveness depending on sensitivity of the measure. Frequency of exacerbations was a significant predictor of HRQL.

CONCLUSIONS

Exacerbations lead to substantial reductions in HRQL, both in physical as well as other domains. Further research should assess the impact of specific treatment regimens and the timeline for the recovery process.

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

COPD is a common condition, mainly related to smoking. The burden of the disease is increasing and it is projected to rank fifth in 2020 for the world-wide burden of disease. Acute exacerbations of COPD, usually related to superimposed infection occur commonly and systemic corticosteroids are widely used in their management in combination with other treatments including antibiotics, oxygen supplementation and bronchodilators.

OBJECTIVES

To determine the efficacy of corticosteroids, administered either parenterally or orally, on the outcome in patients with acute exacerbations of COPD.

SEARCH STRATEGY

Searches were carried out using the Cochrane Airways Group COPD RCT register with additional studies sought in the bibliographies of randomised controlled trials and review articles. Authors of identified randomised controlled trials were contacted for other published and unpublished studies. The last search was carried out in August 2004.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroids, administered either parenterally or orally, with appropriate placebo. Other interventions e.g. bronchodilators and antibiotics were standardised. Clinical studies of acute asthma were excluded.

DATA COLLECTION AND ANALYSIS

Data was extracted independently by two reviewers. Outcome data was sent to authors for verification. All trials were combined using Review Manager (version 4.2.4) for analyses.

MAIN RESULTS

Ten studies were identified that fulfilled the inclusion criteria. There were significantly fewer treatment failures within thirty days in patients given corticosteroid treatment, odds ratio 0.48; 95% confidence interval 0.34 to 0.68 and Hazard Ratio 0.78; 95% confidence interval 0.63 to 0.97. It would have been necessary to treat 9 patients (95%CI 6 to 14) with systemic corticosteroids to avoid one treatment failure in this time period. There was no significant difference in mortality. The early FEV1, up to 72 hours, showed a significant treatment benefit, weighted mean difference 140 mls (95% confidence interval 80-200 mls), although this benefit was not found for later time points. There was a significant improvement in breathlessness and blood gases between 6 - 72 hours after treatment. There was an increased likelihood of an adverse drug reaction with corticosteroid treatment, odds ratio 2.29; 95% confidence interval 1.55 to 3.38. Overall one extra adverse effect occurred for every 6 people treated (95% CI 4 to 10). The risk of hyperglycaemia was significantly increased, odds ratio 5.48; 95% confidence interval 1.58 to 18.96.

AUTHORS' CONCLUSIONS

Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment . It increases the rate of improvement in lung function and dyspnoea over the first 72 hours, but at a significantly increased risk of an adverse drug reaction.

Exacerbations and time spent outdoors in chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease have a progressive reduction in activity, although its time scale and the contribution of exacerbations are unknown. A rolling cohort of 147 patients (101 male; mean age, 88.5 years; and forced expiratory volume in 1 second as percent predicted, 38.4%) were monitored for a median of 1,044 days (interquartile range, 685 to 1,779) over an 8-year period starting in March 1996. Patients recorded any increase in daily respiratory symptoms and time spent outside their home. They completed the St. George's Respiratory Questionnaire yearly. They experienced 1,465 exacerbations and time outdoors decreased by -0.16 hours/day per year (p < 0.001). This decline was faster in frequent exacerbators (p = 0.011). Before exacerbation, the patients stayed indoors all day for 2.1 days/week (on any day 34.1% were at home), but for 5 weeks postexacerbation they spent 2.5 days/week at home (p < 0.001) (44.4% remaining at home at onset; p = 0.021). St. George's total, activity, and impact scores were independently associated with time outdoors (p < 0.005), but not with symptom score. In conclusion, time spent outside the home declines over time and acutely at exacerbation. Patients with frequent exacerbations are more likely to become housebound and need targeting in rehabilitation programs.