Diagnosis and management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society.

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

[Chronic care model: an evidence-based approach to caring for people with chronic disease]. / Das Chronic Care Model: Ein evidenzbasierter Ansatz für eine Verbesserung der Versorgung chronisch kranker Menschen.

The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems.

["Real-life"-data on asthma control using budesonide/formoterol for both maintenance and relief: the Swiss experience]. / "Real-life"-Daten zur Asthmakontrolle mit Budesonid/Formoterol als Erhaltungs- und Bedarfstherapie: die Erfahrung in der Schweiz.

BACKGROUND: Asthma is not adequately controlled in many patients. A new approach in asthma treatment, known as Budesonide/Formoterol Maintenance and Reliever Therapy has shown improvement in asthma control compared to conventional therapy regimens. As Switzerland was the first European country to formally approve budesonide/formoterol maintenance and reliever therapy, a patient follow-up programme was commenced in January 2006 to investigate its efficacy and safety in a "real-life" environment. METHODS: A non randomized uncontrolled post-marketing survey involving 420 physicians in all language regions in Switzerland was carried out. 2035 patients with asthma were enrolled. Data on current asthma treatment, asthma control and unscheduled visits due to worsening asthma were recorded. Asthma control was assessed subjectively by both the patients and the physicians as well as by means of the validated 5-item Asthma Control Questionnaire (ACQ5). An ACQ score of 0.75 or less indicates well-controlled asthma. RESULTS: Data from 2006 out of 2035 patients were analysed (mean age 44.9 +/- 19.6 years, 50.5% female). With budesonide/formoterol maintenance and reliever therapy the mean ACQ5 score improved by more than 3-fold the defined minimal important difference (MID). The percentage of patients with an ACQ score < or =0.75 increased from 4.8% at baseline to 58.0% at the end of the follow-up programme. Patient satisfaction with budesonide/formoterol for both maintenance and relief was high. CONCLUSIONS: Budesonide/formoterol maintenance and reliever therapy improves asthma control in a non randomised real-life setting.

Predictors of asthma control in everyday clinical practice in Switzerland.

OBJECTIVE: To identify predictors of improved asthma control under conditions of everyday practice in Switzerland. RESEARCH DESIGN AND METHODS: A subgroup of 1380 patients with initially inadequately controlled asthma was defined from a cohort of 1893 asthmatic patients (mean age 45.3 + or - 19.2 years) recruited by 281 office-based physicians who participated in a previously-conducted asthma control survey in Switzerland. Multiple regression techniques were used to identify predictors of improved asthma control, defined as an absolute decrease of 0.5 points or more in the Asthma Control Questionnaire between the baseline (V1) and follow-up visit (V2). RESULTS: Asthma control between V1 and V2 improved in 85.7%. Add-on treatment with montelukast was reported in 82.9% of the patients. Patients with worse asthma control at V1 and patients with good self-reported adherence to therapy had significantly higher chances of improved asthma control (OR = 1.24 and 1.73, 95% CI 1.18-1.29 and 1.20-2.50, respectively). Compared to adding montelukast and continuing the same inhaled corticosteroid/fixed combination (ICS/FC) dose, the addition of montelukast to an increased ICS/FC dose yielded a 4 times higher chance of improved asthma control (OR = 3.84, 95% CI 1.58-9.29). Significantly, withholding montelukast halved the probability of achieving improved asthma control (OR = 0.51, 95% CI = 0.33-078). The probability of improved asthma control was almost 5 times lower among patients in whom FEV(1) was measured compared to those in whom it was not (OR = 0.23, 95% CI = 0.09-0.55). Patients with severe persistent asthma also had a significantly lower probability of improved control (OR = 0.15, 95% CI = 0.07-0.32), as did older patients (OR = 0.98, 95% CI = 0.97-0.99). Subgroup analyses which excluded patients whose asthma may have been misdiagnosed and might in reality have been chronic obstructive pulmonary disease (COPD) showed comparable results. CONCLUSIONS: Under conditions of everyday clinical practice, the addition of montelukast to ICS/FC and good adherence to therapy increased the likelihood of achieving better asthma control at the follow-up visit, while older age and more severe asthma significantly decreased it.

[Asthma management: overview and new aspects]. / Asthmamanagement: Uberblick und neue Aspekte.

Asthma is a common, chronic inflammatory disease of the airways associated with pronounced health and economic consequences. The clinical spectrum of asthma is highly variable and different clinical and inflammatory phenotypes are noticed. Improved understanding of these phenotypes in a complex disease like asthma will assist in management and targeted therapies for asthma. In the first National Heart Lung and Blood Institute (NHLBI) and Global Initiative for Asthma (GINA) guidelines the level of symptoms and airflow limitation and its variability subdivided asthma by severity into four subcategories (intermittent, mild persistent, moderate persistent, and severe persistent). In the new GINA guidelines the classification of asthma severity is now no longer recommended, but a periodic assessment of asthma control is recommended as being more relevant and useful. The three sub-categories are controlled, partly controlled and uncontrolled asthma. In this article several important considerations in definition and control of asthma in adults shall be addressed as well as pharmacotherapy and implications for treatment strategies and management plans to assess and gain control of asthma.

Patient education in asthma: a survey of physicians' knowledge of the principles and implementation of self management in practice.

BACKGROUND: Therapeutic patient education, particularly when including written instructions in self-management, improves outcomes in asthma. The education of patients in self-management requires specific knowledge and skills, which are not generally taught in under- or postgraduate training programmes. PURPOSE: To investigate physicians' knowledge of the principles and implementation of self-management in asthma care. METHOD: A 14-item questionnaire was developed, piloted and subsequently sent to 1039 general physicians (general practitioners and internists) and pulmonologists registered as members of the Medical Society of Zurich. RESULTS: 368 (35%) of the physicians returned the questionnaire. 352 (96%) stated that they care for patients with asthma, 312 (87%) provided asthma education, 264 (75%) gave information about the mechanisms of illness, 272 (77%) provided instructions on how to use inhalers although only 212 (60%) checked inhaler technique. 170 (48%) instructed patients in home measurement of peak flow recordings (PEFR). 21% of general physicians and 52% of pulmonologists provided written action plans outlining what actions to take if PEFR or symptoms deteriorated. The majority of physicians were aware of positive benefits of patient education and over 80% stated that all asthmatic patients should be offered education. Only 32% felt that they should personally be educating the patients whilst two-thirds expressed a preference for the education to be provided by a specialist centre. 66% of the physicians expressed a desire to undertake further training in effective patient education. CONCLUSION: Whilst most physicians in this study state to be aware of the benefits of patient education in asthma, only 24% actually provide their patients with asthma self-management plans. With a low response rate, our study is likely to be biased towards those physicians with a greater interest in asthma; hence actual use of self-management plans is likely be lower than in our sample.

[Management of COPD: a review]. / Management der COPD-Eine Ubersicht.

COPD is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, associated with immense economic costs. With the recent understanding of the pathogenesis of COPD, primary preventions should provide the best hope to control the rise of this disease and smoking cessation remains the key area to address. The early use of spirometry for diagnosis is of importance, many patients are underdiagnosed until the disease is far advanced. For patients who have developed COPD, a variety of treatment options are available and much can be done to improve the well being of patients with COPD. A review of the management of COPD is presented.

[Insidious aspects of small pulmonary coin lesions]. / Die Tücke kleiner Lungenrundherde.

After his girl friend had been diagnosed with active pulmonary tuberculosis, a 45-year old male was referred to rule out transmission of this disease. The chest x-ray showed no signs of tuberculosis, however a small retrosternal lung nodule was found on the lateral film. Three months later, the nodule showed an increase in size and a CT of the chest was performed: No nodule could be found in the expected retrosternal location, but incidentally a small nodule in the right upper lobe was identified. This nodule could retrospectively be identified on the previous chest X-rays, its size had been increasing. After surgical removal, the lesion was diagnosed to be an adenocarcinoma T1, N0, M0. Careful follow-up of small intrapulmonary nodules detected on chest X-rays is highly advisable, especially in smokers of middle and older age bronchial carcinoma and therefore a straight forward approach with excision of the nodule should be considered. Nodules have to be surgically removed if an increase in size can be noted.

[Asthma education and self-management: inevitable requirements to enhance disease control and achieve the goals for long-term asthma management]. / Asthmaschulung und Selbstmanagement: wichtige Voraussetzung für eine optimale Asthmakontrolle und den langfristigen Erfolg im Alltag.

The patient should be the primary manager of chronic disease guided and coached by a doctor and healthcare workers. The challenge now is to recognise that establishing patient-provider partnerships is an essential step in helping patients to learn and manage chronic illnesses like asthma. This article focuses on what is known about asthma patient education and on reducing the barriers to effectively applying what is known. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is self-efficacy, the confidence to carry out a behavior necessary to reach a desired goal (outcome-efficacy). Effective teaching on chronic diseases must be based more closely on the findings of behavioural research. Therefore, self-management education has to become an integral part of high-quality care in asthma.

[Description of Internet-based models for continuing medical education. First results and experiences with asthma patients]. / Beschreibung eines internetbasierten Modells für die ärztliche Fortbildung. Erste Resultate und Erfahrungen bei Patienten mit Asthma.

The Pilot study "Quality Development through the Internet" by the Horten Center is an integral part of a concept on dissemination of medical knowledge. It offers participants the possibility to compare interactively their own and their peers' performance with their competence and with accepted guidelines within a web-based Audit-Cycle. The participants can discuss the evidence-based recommendations which are offered. In addition, changes in behavior and care can be documented objectively.

[Lung infiltrations in Hodgkin lymphoma]. / Lungeninfiltrate bei Hodgkin Lymphom.

We report the case of a young patient presenting with cervical lymphadenopathy and interstitial pulmonary infiltrates due to Hodgkin's Disease. Although lung involvement regressed under chemotherapy, we observed new alveolar infiltrates during treatment. Steroid administration after exclusion of an infectious cause was followed by rapid clinical and radiological improvement, indicating the probable presence of pulmonary bleomycine toxicity.

Exertional dyspnea as initial manifestation of Takayasu's arteritis--a case report and literature review.

BACKGROUND: Takayasu's arteritis is a chronic systemic inflammatory disease that usually affects the aorta, its primary branches and occasionally the pulmonary and coronary arteries. Female gender in reproductive age and Asian origin are known factors associated with higher disease prevalence. The clinical manifestations vary considerably and are typically caused by limb or organ ischemia illness and fever. The estimated incidence rate in the western world is 2.6 cases per million persons per year. Occasionally, exertional dyspnea can be the sole primary clinical manifestation of Takayasu's arteritis. CASE PRESENTATION: We report the case of a 57-year-old woman who was referred to our institution with increasing exertional dyspnea caused by pulmonary artery involvement in Takayasu's arteritis. In a review of the literature we discuss demographic data, clinical and radiographic findings and available therapeutic options. CONCLUSIONS: Dyspnea due to pulmonary artery involvement can be the initial symptom of Takayasu's arteritis. Simple clinical tests, including a complete pulse-status and blood pressure measuring at both arms can lead to the right diagnosis and should always be done beyond the auscultation of the heart and lungs in patients with dyspnea.