Confidence and understanding among general practitioners and practice nurses in the UK about diagnosis and management of COPD.

In order to assess the confidence of healthcare professionals in diagnosing and managing COPD telephone interviews were conducted with 60 practice nurses and 46 general practitioners (GPs) in 2001 and 61 nurses and 39 GPs in 2005. The nurses all ran respiratory clinics. 80% of GPs were confident about diagnosing COPD and this had increased from 52% in 2001. Fifty five percent of nurses were confident and there was no change from 2001. In 2005, 79% of GPs and 70% of nurses were confident about differentiating asthma and COPD. Smoking history, breathlessness, age of onset, lack of response to asthma therapy and cough were reported as features differentiating COPD from asthma. Most respondents stated that spirometry is essential to diagnose COPD and in 2005 nearly all practices had access to a spirometry service. GPs were more confident about interpreting spirometry results in 2005 than nurses and their confidence had increased significantly from 2001. In 2005, nearly all respondents had heard of pulmonary rehabilitation, and significantly more had a programme in their area in 2005 than 2001 (69% vs. 49% p=0.05). Fifty four percent of GPs were confident about which patients to refer for long term oxygen therapy in 2005 but nurses were less confident. There had not been any significant change between 2001 and 2005. In 2005 only 35% of respondents had access to a pulse oximeter. When presented with case scenarios, GPs self-reported confidence was not reflected in their diagnoses or investigation and management strategies and they seem to favour cardiac over respiratory diagnoses.

Health status impairment and costs associated with COPD exacerbation managed in hospital.

Exacerbations of chronic obstructive pulmonary disease (COPD) have serious health consequences for patients and are strongly associated with unscheduled healthcare resource use. This study used a preference-based quality of life measure questionnaire (EQ-5D) to evaluate the impact of exacerbation on health status and utility during a patient's admission to hospital and short-term follow-up. Costs of admission were calculated. In total, 149 patients consented to take part in the study representing 222 admissions to hospital. At admission patients reported high levels of problems for all dimensions of the EQ-5D. Mean utility (-0.077) and Visual Analogue Scale (25.9) values indicated great impairment, with 61% of patients having a negative utility value representing a health state equivalent to 'worse than death' at admission. Many problems were still reported at discharge. By 3 months follow-up patients had deteriorated, with percentages of patients reporting problems in mobility (98%) and usual activity (88%) almost back up to admission levels. Health status and utility values were similar regardless of lung function at admission and at discharge. Approximately half of the patients in each category had a negative utility value at admission representing a health state 'worse than death', with similar levels of improvement by discharge. The mean cost of an admission was 2130.34 pounds (SD 1326.09) with only a mean of 110.37 pounds(5%) because of medication. No differences were noted by lung function category. In conclusion, all COPD patients requiring admission for an exacerbation suffer a serious deterioration in health status which, although improves during admission, notably deteriorates by 3 months postdischarge.

Is high-dose fluticasone propionate via a metered-dose inhaler and Volumatic as efficacious as nebulized budesonide in adult asthmatics?

The efficacy and tolerability of fluticasone propionate (FP) 2 mg daily via a metered-dose inhaler and Volumatic (Glaxo Wellcome) spacer device was compared with nebulized budesonide (nBUD), 2 and 4 mg daily, in a multi-centre, open-label, cross-over study of adult asthmatics. Patients received, in random order, either 4 weeks of treatment with FP followed by 4 weeks of treatment with nBUD, or vice versa, with an intervening 4 week 'wash-out' period between treatments. Thirty patients completed the study, of whom 24 were evaluable. In terms of the primary efficacy parameter, change in mean morning peak expiratory flow (PEF) (l min-1) from baseline to the fourth week of each treatment period, FP was more effective than nBUD [mean difference (FP-nBUD) 21.1 l min-1, P = 0.007, 95% CI (6.5, 35.7)]. Sub-group analysis demonstrated FP to be superior to the 4 mg nBUD [mean treatment difference (FP-nBUD) 42.9 l min-1, P = 0.026, 95% CI (7.1, 78.8)] and at least as efficacious as the 2 mg nBUD sub-group [mean treatment difference (FP-nBUD) 10.2 l min-1, P = 0.211, 95% CI (-6.5, 26.9)]. Furthermore, larger reductions in diurnal variation were observed during FP treatment [mean treatment difference (FP-nBUD) -4.4 percentage points, P = 0.028, 95% CI (-8.4, -0.5)]. There was no significant difference between the treatments for the proportion of symptom-free 24 h periods. Of those expressing a preference, significantly more patients found FP via a metered-dose inhaler and spacer device both easier to administer (78%, P = 0.007) and more convenient to take (76%, P = 0.008) than nebulized budesonide. In addition, cost per patient analysis showed that nebulized budesonide was from 1.7 to 3.5 times more expensive than FP.

Bambuterol: effective in nocturnal asthma.

Bambuterol was compared with placebo in 28 patients with nocturnal asthma in a randomized, double-blind cross-over study. All patients were symptomatic despite taking inhaled beta 2-agonists, inhaled corticosteroids (in 26 patients the median daily dose was 1500 micrograms) and oral corticosteroids (in eight patients the median daily dose was 10 mg). Patients demonstrated > or = 20% overnight fall in peak expiratory flow (PEF) for at least half of the 14-day run-in period. They then entered two treatment periods lasting 14 days when bambuterol 20 mg nocte and placebo were given in random order. Compared to placebo, bambuterol produced a 16% improvement in mean PEF on waking (271 l min-1 vs. 239 l min-1 P = 0.0002) and a 10% improvement in evening PEF measured 24 h after drug intake (318 l min-1 vs. 296 l min-1 P = 0.01). Bambuterol significantly reduced frequency of nocturnal awakening from 1.1 to 0.7 per night (P = 0.01) and nocturnal beta 2-agonist use from 2.7 to 2.1 puffs (P = 0.0004). Other nocturnal symptoms: cough, wheeze and dyspnoea were also significantly reduced during bambuterol treatment and patients quality of sleep was improved. The results indicate bambuterol (20 mg nocte) provides effective nocturnal bronchodilation with sustained effect for 24 h and may have a useful therapeutic role in the control of symptomatic nocturnal asthma.

Comparative assessment of enprofylline and theophylline for chronic obstructive airways disease in the elderly.

Enprofylline, a recently developed xanthine derivative, is a more potent bronchodilator than theophylline. This study compares the efficacy and safety of enprofylline with theophylline for chronic obstructive airways disease (COAD) in elderly subjects. The study was of a randomized double-blind parallel design and commenced with a 1-week reference period when oral bronchodilators were withdrawn. Patients were then treated with either enprofylline or theophylline 150 mg bd for 2 weeks (period 1) followed by 300 mg bd for a further 3 weeks (period 2). Patients recorded peak expiratory flow rate (PEFR) and adverse experiences, if any, in a diary, daily. Of 111 patients recruited for the study, 85 entered active treatment (theophylline, n = 44; enprofylline, n = 41). Mean age was 72 years and mean bronchodilator reversibility was 22%. Enprofylline increased mean morning PEFR by 11% (period 1) and 19% (period 2) whereas theophylline increased PEFR by 13% and 19%, respectively. From the enprofylline group 29% were withdrawn from the study due mainly to headache and nausea/vomiting and from the theophylline group 7% were withdrawn due mainly to nausea/vomiting. Mean plasma concentrations of enprofylline were 2.0 mg l-1 and 3.4 mg l-1, and with theophylline 5.4 mg l-1 and 10.0 mg l-1 at the end of periods 1 and 2, respectively. Enprofylline and theophylline produced similar improvements in lung functions and symptoms of chronic obstructive airways disease, but enprofylline was less well tolerated than theophylline.

Etoposide compared with the combination of vincristine, doxorubicin, and cyclophosphamide in the treatment of small cell lung cancer.

One hundred and three patients with small cell lung carcinoma were stratified according to stage of disease (47 limited disease, 56 extensive disease) and then randomised to receive etoposide 300 mg/m2 alone for two days or a combination (VAC) of vincristine 1 mg/m2, doxorubicin (Adriamycin) 50 mg/m2, and cyclophosphamide 1000 mg/m2. The drugs were given at three week intervals. Patients were assessed after three cycles of treatment and continued with the same regimen if in complete remission and with the alternative regimen if in partial remission; they were withdrawn if the disease had progressed. Twenty four patients (23%) achieved complete remission and this occurred more often when patients were receiving VAC (19 of 82) than etoposide (5 of 75). There was no difference, however, in overall survival between those initially treated with etoposide and those having combination chemotherapy, whether for limited disease (both 8 months) or extensive disease (7 and 5.5 months). Toxicity was less with etoposide. Survival was disappointing, especially with limited disease, even in patients who showed a complete response to treatment.

Lung function and exercise performance in hyperthyroidism before and after treatment.

In order to investigate the mechanism of dyspnoea in hyperthyroidism measurements of spirometry, lung volume, transfer factor for carbon monoxide and its subdivisions, maximal respiratory pressures, methacholine challenge, arterial blood gases were made and exercise studies performed on 16 patients before treatment for hyperthyroidism. Methacholine challenge showed that only three of 14 patients increased airway reactivity, which was mild. Maximal pressures which could be generated by the respiratory muscles were reduced in some patients, as was functional residual capacity. Exercise ventilation and breathing frequency were increased and the respiratory exchange ratio was abnormally high. Anaerobic threshold was measured in nine of 15 subjects and was below normal in each case. All but two subjects stopped exercise because of dyspnoea, and the maximum oxygen uptake achieved by the group was 53 per cent (n = 15, range 26-66 per cent) of predicted maximum oxygen consumption. The maximum ventilation averaged only 43 per cent (n = 15, range 16-96 per cent) of the maximal breathing capacity predicted from spirometric tests. Nine patients were studied shortly after being rendered euthyroid by treatment. At rest, only maximal respiratory pressures increased significantly. On exercise, the maximal workload attained and the ventilation achieved increased significantly. Breathing patterns, maximal oxygen consumption, ventilation, anaerobic threshold and cardiac frequency remained unchanged. We conclude that: patients with hyperthyroidism do not generally have increased airway reactivity; when hyperthyroid, respiratory muscles are weak, and improve following treatment; exercise capacity is impaired in hyperthyroid patients probably because of a combination of an inefficiently rapid and shallow breathing pattern, an increase of anaerobic metabolism and discomfort associated with the act of breathing. Although exercise capacity increases and the sensation of dyspnoea may decrease after treatment the pattern of breathing does not immediately return to normal.

Domiciliary comparison of terbutaline treatment by metered dose inhaler with and without conical spacer in severe and moderately severe chronic asthma.

The bronchodilator response to cumulative doses of terbutaline administered by metered dose inhaler with and without a conical spacer device and by Acorn nebuliser has been compared in groups of patients with chronic severe and moderately severe asthma. After laboratory studies the patients undertook a randomised domiciliary crossover comparison of bronchodilator response to terbutaline given by metered dose inhaler with and without a spacer device, during which the severity of asthma was assessed by thrice daily recordings of peak expiratory flow (PEF) and symptom score. Improvement in FEV1 produced in the laboratory by the metered dose inhaler with spacer device was significantly greater than by metered dose inhaler alone (p less than 0.001) and similar to that from the nebuliser in both asthmatic groups throughout a range of terbutaline doses. In the domiciliary comparison mean midday and evening PEF rates were significantly higher with the use of the spacer device both in those with severe (p less than 0.01) and in those with moderately severe (p less than 0.05) asthma, and mean morning PEF was significantly higher in the severe group (p less than 0.05). The spacer device also produced a significant improvement in symptom score in both the severe and the moderately severe groups (p less than 0.05). Regular domiciliary use of the spacer device with the metered dose inhaler improves bronchodilator response, particularly in patients with chronic severe asthma, and may be a useful alternative to nebuliser treatment.

Prolonged coma and delayed peripheral neuropathy after ingestion of phenoxyacetic acid weedkillers.

A case of prolonged coma and delayed peripheral neuropathy is reported following self-poisoning with a widely available domestic weedkiller containing phenoxyacetic acids. Attention is drawn to the potential toxicity of these weedkillers which may be delayed in onset, and to the possibility of spontaneous recovery from neurological abnormalities which may be severe and prolonged or late in onset.

The use of the 12 minute walking test in assessing the effect of oral steroid therapy in patients with chronic airways obstruction.

The reproducibility of the 12 minute walking distance (12 MD) was assessed in ten men with chronic airways obstruction, and the 12 MD was used, together with spirometry, transfer factor and three subjective assessments of breathlessness to evaluate the effects on respiratory function of prednisone 30 mg daily given orally in double-blind placebo-controlled fashion for two weeks. Like others, we found the 12 MD reproducible on a single day with a mean variation of 3.1%. Tests performed two weeks apart showed greater variability ranging from 0.2% to 30.9%, (mean 9.1%). During placebo and prednisone therapy the 12 MD and assessments of breathlessness correlated significantly with each other and with TLCO, but not with spirometry. Following steroid therapy there was a significant increase in mean TLCO but no significant change in 12 MD, spirometry or subjective assessments. Changes in 12 MD and TLCO correlated significantly with each other and with changes in subjective assessments. Changes in FEV1 correlated with changes in breathlessness, and also with variability in FEV1 while receiving placebo. Individuals with the greatest changes in 12 MD and FEV1 were those with the greatest variability on placebo. The variability of the 12 MD and FEV1 should be measured in individuals before using these tests to assess response to steroid therapy.

Assessment of steroid responsiveness in patients with chronic airflow obstruction.

A simple steroid trial was conducted to assess whether 31 patients with chronic airflow obstruction would benefit from oral steroid therapy. Peak expiratory flow (PEF), forced expired volume in 1 s (FEV1), and ratio of FEV1, to forced vital capacity (FVC) were monitored during a 6-month period (when patients were on maximum bronchodilator therapy), after 2 weeks on placebo and after 2 weeks on prednisolone 30 mg daily. Patients also measured that PEF at home thrice daily. None had a significant degree of steroid reversible airflow obstruction. The preliminary observation period (of at least 3 months) is important to prevent an improvement being attributed to steroids, when it has in fact occurred spontaneously or is the result of bronchodilator therapy or cessation of smoking.