Ambulatory monitoring of heart rate and blood pressure during the first week after smoking cessation.

To investigate the timecourse of cardiovascular changes immediately after smoking cessation, 16 subjects wore ambulatory monitors on alternate days during a 1-week residential smoking cessation program. Heart rate was significantly elevated at the time of cessation, then declined steadily until 6 h after cessation, when it reached the level of subsequent nonsmoking days. Systolic and diastolic blood pressures were elevated to a lesser degree for the same period after cessation. The timing of the decline in heart rate and blood pressure was coincident with the timing of an increase in withdrawal symptoms and has implications for laboratory and epidemiologic studies.

Relationship of cytomorphology to spirometric findings in cigarette smokers.

The objective of the study was to determine the relationship between sputum cytomorphology and pulmonary function. A cross-sectional correlation analysis of results from pulmonary function testing and eight cytomorphologic indices of inflammation and metaplasia was conducted in 143 smokers registered in a residential smoking-cessation program. Stepwise multiple regression analysis revealed that after adjusting for age and smoking history, lower levels of pulmonary function were related significantly to higher levels of macrophage pigmentation, neutrophils and metaplasia. Higher levels of macrophages were associated with higher levels of pulmonary function. The overall regression coefficient, 0.35, was highly significant (F[5,136] = 14.84, P = .0001). Categorical analyses revealed that smokers with high counts of neutrophils, macrophage pigmentation, columnar cells, spirals and metaplasia were two to three times more likely to have abnormal pulmonary function than were those with low counts. From these results we conclude that elevations in certain cytologic indices are associated with abnormal lung function. These findings may reflect the pathophysiology of obstructive lung disease. Longitudinal studies are required to determine whether cytomorphologic parameters can identify individuals at risk for functional deterioration at a stage amenable to intervention.

Reversibility of airways injury over a 12-month period following smoking cessation.

In this investigation, we examined changes in exfoliated tracheobronchial cells in sputum in 46 individuals (mean age = 49.2 years; mean packyears = 48.7) who discontinued smoking and 37 individuals (mean age = 54.9 years; mean packyears = 65.2) who continued to smoke over a 12-month period after participation in the St. Helena Hospital and Health Center one-week residential smoking cessation program. Before the beginning of the smoking cessation program, those who went on to quit were not different from those who did not quit with respect to baseline cytomorphology ratings. In those individuals with a minimum of three follow-up tests, results indicated significant reductions from precessation levels in macrophages, pigmented macrophages, and neutrophils after adjustment for differences in age, packyears, and pulmonary function (FEV1/FVC). Over the course of follow-up, quitters, in comparison with nonquitters, also had significantly lower mean levels of columnar cells, mucus, mucous spirals, and metaplasia. These results indicate a consistent effect of smoking cessation on cytomorphology and demonstrate that on cessation, some of the measured elements promptly return toward a more normal pattern.

Prognosis in chronic obstructive pulmonary disease.

Although many factors have been shown to relate to survival in patients with COPD, the patient's age and baseline postbronchodilator FEV1 are the best predictors of mortality. The presence of mild obstructive airway disease is not indicative of a progressive downhill course and shortened survival. Mortality in patients with a baseline postbronchodilator FEV1 greater than or equal to 50% of predicted was only slightly greater than that of a group of healthy smokers. Investigators attempting to compare survival in patients with COPD should attempt to exclude patients with asthma or asthmatic bronchitis, because these individuals have a much better prognosis than those with typical COPD (emphysema and chronic bronchitis). Patients should be matched closely for age and severity of impairment, because younger individuals and those with milder impairment are likely to live longer. Other factors besides age and baseline FEV1 have been shown to affect survival. Patients who stop smoking are likely to survive longer than those who continue to smoke. The presence of malnutrition has clearly been shown to worsen survival. Further studies will be necessary to determine if corticosteroid therapy can slow down progression of disease in patients with typical COPD. Oxygen therapy improves survival in COPD patients with significant hypoxemia, many of whom also have CO2 retention, polycythemia, and cor pulmonale. There are now multiple studies in the literature suggesting that the type of comprehensive respiratory care provided by pulmonary rehabilitation programs can not only improve the quality of life but also survival in patients with chronic obstructive pulmonary disease.

Pulmonary rehabilitation.

Any COPD patient with symptoms is a candidate for pulmonary rehabilitation. A careful assessment of the individual to determine the patient's precise disease process and needs is essential to outlining an appropriate treatment program. Following the sequence described in the ATS Statement on Pulmonary Rehabilitation included in the appendix to this article provides the best potential for successfully returning the patient to the highest level of function possible. An increase in the availability of pulmonary rehabilitation programs should allow more COPD patients to participate in this process, resulting in an enhanced ability to carry out daily activities, an improved quality of life, and a reduction in the long-term costs of caring for such individuals.

Applications of a method for setting air quality standards based on epidemiological data.

A method for setting air quality standards for long-term cumulative exposures of a population based on epidemiological studies has been developed. It uses exposure estimates interpolated from monitoring stations to zip code centroids, each month applied to zip code by month residence histories of the population. Two alternative cumulative exposure indices are used--hours in excess of a threshold, and the sum of concentrations above a threshold. The indices are then used with multiple logistic regression models for the health outcome data to form dose response curves for relative risk, adjusting for covariates. These curves are useful for determination of at what exposure amounts and threshold levels, effects which have both statistical and public health significance begin to occur. The method is applied to a ten year follow-up of a sub cohort of 7,343 members of the National Cancer Institute-funded Adventist Health Study. Up to 20 years of residence history was available. Analysis for prevalence of symptoms was conducted for four air pollutants--total oxidants, sulfur dioxide, nitrogen dioxide, and total suspended particulates. For each pollutant, cumulated exposures were calculated above each of five different thresholds. Statistically significant effects were noted for total suspended particulates, total oxidants, sulfur dioxide, past and passive smoking.

Chronic obstructive pulmonary disease symptom effects of long-term cumulative exposure to ambient levels of total oxidants and nitrogen dioxide in California Seventh-Day Adventist residents.

To assess the risk of chronic obstructive pulmonary disease symptoms due to long-term exposure to ambient levels of total oxidants and nitrogen dioxide (NO2), symptoms were ascertained using the National Heart, Lung, and Blood Institute (NHLBI) respiratory symptoms questionnaire. A total of 7,445 Seventh-day Adventist (SDA) nonsmokers who were 25 yr of age or older and had resided at least 11 yr in areas of California with high to low photochemical air pollution were included in this study. Cumulative exposures to each pollutant in excess of four thresholds were estimated for each participant, using zip codes for months of residence and interpolated dosages from state air-monitoring stations. Multiple logistic regression analyses were conducted individually and together for pollutants and included eight covariables, including passive smoking. A statistically significant association with chronic symptoms was seen for total oxidants above 10 pphm (196 mcg/m3) (p less than .004, relative risk of 1.20 for 750 hr/yr). Chronic respiratory disease symptoms were not associated with relatively low NO2 exposure levels in this population. When these pollutant exposures were studied with exposures to total suspended particulates (TSP) and sulfur dioxide (SO2), only TSP exposure above 200 mcg/m3 showed statistical significance (p less than .01). Exposure to TSP is either more strongly associated with symptoms of chronic obstructive pulmonary disease than the other measured exposures or is the best single surrogate representing the mix of pollutants present.

Chronic obstructive pulmonary disease symptom effects of long-term cumulative exposure to ambient levels of total suspended particulates and sulfur dioxide in California Seventh-Day Adventist residents.

Risk of chronic obstructive pulmonary disease symptoms due to long-term exposure to ambient levels of total suspended particulates (TSP) and sulfur dioxide (SO2) symptoms was ascertained using the National Heart, Lung, and Blood Institute (NHLBI) respiratory symptoms questionnaire on 7,445 Seventh-Day Adventists. They were non-smokers, at least 25 yr of age, and had lived 11 yr or more in areas ranging from high to low photochemical air pollution in California. Participant cumulative exposures to each pollutant in excess of four thresholds were estimated using monthly residence zip code histories and interpolated dosages from state air monitoring stations. These pollutant thresholds were entered individually and in combination in multiple logistic regression analyses with eight covariables including passive smoking. Statistically significant associations with chronic symptoms were seen for: SO2 exposure above 4 pphm (104 mcg/m3), (p = .03), relative risk 1.18 for 500 hr/yr of exposure; and for total suspended particulates (TSP) above 200 mcg/m3, (p less than .00001), relative risk of 1.22 for 750 hr/yr.

The National Institutes of Health Intermittent Positive Pressure Breathing trial--pathology studies. III. The diagnosis of emphysema.

In an attempt to predict the severity of emphysema in patients with moderately severe and severe chronic air-flow obstruction, antemortem pulmonary function data, including spirometry, subdivisions of lung volumes, diffusing capacity (transfer factor) for carbon monoxide, and elastic recoil were assessed in 46 patients who were autopsied during the National Institutes of Health Intermittent Positive Pressure Breathing Clinical Trial and we compared these to the morphologic severity of emphysema. The severity of emphysema was graded by the panel grading method using whole lung, paper-mounted (Gough-Wentworth) sections and the mean linear intercept (Lm). The FEV1 and FEF25-75 of the FVC, the DLCO, the diffusing capacity for carbon monoxide, and subdivisions of lung volumes showed significant but low order correlations with the emphysema score and Lm. Total lung capacity, determined by plethysmography, was better related to emphysema in this study than in others in which TLC was measured by helium dilution. Volume-pressure data fitted to the exponential equation (V = A - Be-KP) yielded a low order, but a significant relationship between Lm and the exponential constant (K), but not between K and the panel emphysema score. We conclude that the recognition of the presence and severity of emphysema continues to require a multivariate approach including clinical history, assessment of air-flow obstruction via routine spirometry, radiologic assessment of the lung with emphasis on total lung capacity, and evaluation of the diffusing capacity for carbon monoxide.

Organization of a pulmonary rehabilitation program.

In order for pulmonary rehabilitation to be successful, the organization of the program must be carefully planned. If a program seems feasible, based on an initial study, attention must be given to proper team structure, space needs, and services to be provided. A well thought out marketing plan is crucial to the success of the program, and of course obtaining maximal reimbursement is critical.

United States audit of asthma therapy.

While variations observed in the approach to treatment among specialists in the United States may be partly related to differences in the types of patients seen, the differences are more likely related to a varied level of awareness among the specialties regarding new concepts of asthma therapy. A heightened awareness in the US of the results of therapeutic interventions often tried in other countries for years prior to their introduction in the US can benefit asthma patients by hastening the adoption of therapeutic advances by physicians in this country. Education of physicians and their patients is essential to improving the quality of life and survival in asthma patients. Physicians must inform patients and their families of the critical importance of prophylactic care and aggressive early intervention at the first sign of an exacerbation in order to once again achieve a declining mortality rate in individuals with asthma.

Prognosis in chronic obstructive pulmonary disease.

We recruited 985 patients with COPD but without hypoxemia or other serious disease, treated them in a standard fashion, and followed them closely for nearly 3 yr. At the time of recruitment the patients were carefully characterized as to symptom severity, lung function, exercise tolerance, and quality of life, and studies of lung function were repeated during follow-up. Overall mortality was 23% in 3 yr of follow-up. Patient age and the initial value of the FEV1 were the most accurate predictors of death; when FEV1 before bronchodilator was used, the response to bronchodilators was directly related to survival, but this relationship became nonsignificant when postbronchodilator FEV1 was used as a primary predictor. After adjustment for age and FEV1, mortality was related positively to TLC, resting heart rate, and perceived physical disability, and related negatively to exercise tolerance. These relationships, though significant, were relatively weak. When standardized for age and FEV1, mortality in the present series was less than that of a previous series (4), and the same as that of hypoxemic patients with COPD who received continuous home O2 therapy. Changes in FEV1 with time averaged -44 ml/yr, but the standard deviation was large. Patients with low initial values of FEV1 showed relatively little further decline, probably indicating a survivor effect. In patients with well-preserved initial FEV1, rate of decline correlated negatively with bronchodilator response, symptomatic wheezing, and psychological disturbances.

COPD prevalence in nonsmokers in high and low photochemical air pollution areas.

The prevalence of respiratory symptoms, as ascertained by questionnaire, was evaluated in 6,666 nonsmokers who had lived for at least 11 years in either a high photochemical pollution area (4,379 individuals) or a low photochemical pollution area (2,287 individuals). Of these, 5,178 had never smoked, and none was currently smoking. The risk estimate for "definite" COPD, as defined in this study, was 15 percent higher in the high pollution area (p = 0.03), after adjusting for sex, age, race, education, occupational exposure, and past smoking history. Past smokers had a risk estimate 22 percent higher than never smokers (p = 0.01). Multivariate analysis showed a significant effect of air pollution on the prevalence of "definite" COPD which univariate analysis failed to demonstrate.

Strategies for developing a cost-effective pulmonary rehabilitation program.

A cost-effective pulmonary rehabilitation program can be created by using strategic planning, a thorough budgetary process, and then promotion of the program. Strategic planning assesses the need for such a program, develops its overall direction, establishes priorities, assesses economic factors and the presence or absence of similar services already in existence, and identifies the proposed scope of the program. The budgetary process identifies the specific services to be offered and estimates the volume of services, their costs, and revenues. Promotion of the program serves to acquaint potential referring physicians and patients with the services to be offered. If preliminary investigation indicates that a pulmonary rehabilitation program is needed in the community, then strategic planning, careful budgeting, and creative promotion can help assure that the program is financially viable.

Self-administration of medical modalities (SAMM): another method of rehabilitation education.

In order to train patients to carry out home pulmonary care adequately, we developed a hospital-based patient-education program we call Self-Administration of Medical Modalities (SAMM). This teaches patients about their pulmonary disease; about their medications' purposes, side effects and what to do if they occur, possible conflict with other medications, and the medication schedule; about use, care, and cleaning of aerosol inhalation devices and scheduling of aerosol medication treatments; and about chest physical therapy if it is indicated. Nurses, respiratory therapists, and physical therapists in the hospital teach and reinforce these concepts and evaluate the patient's progress in learning. The patient advances through three levels of competency. At Level I he is responsible only for keeping track of his medication and treatment schedules. At Level II the patient initiates requests for medication and treatments on schedule, takes them under supervision, and makes a written record of having done so. At Level III the patient's medications are kept at his bedside, he prepares and takes the medications himself, takes treatments himself, and he keeps written records. At this level the program simulates home conditions as much as possible. Patients have reported that they liked administering their own medications and treatments and that the SAMM Program was helpful in preparing them for self-care at home.

Clinical and physiological outcomes of a university-hospital pulmonary rehabilitation program.

Pulmonary rehabilitation programs have resulted in improvements in quality of life, capacity for carrying out daily activities, and physical conditioning, as well as reduced hospitalization and cost of care. In our retrospective study, we reviewed the data of 75 patients who had participated in Loma Linda University Medical Center's pulmonary rehabilitation program--in order to determine its effect on survival, progression of disease, and quality of life for a selected group of patients with chronic obstructive pulmonary disease (COPD). A multidisciplinary rehabilitation team evaluated each patient and developed for him a plan of care that included a 2-week inpatient education program. The cumulative survival rate of our group computed by the life table methods was 86.5% at 5 years of rehabilitation, and 64% at 10 years. The mean FEV1 at the beginning of the program was 1.53 1 and the mean FVC was 2.87 1; the mean change in FEV1 was - 45 ml/yr, and in FVC, - 70 ml/yr. By use of a questionnaire, we also found that most of our responding patients felt that their quality of life had improved. Our findings compare favorably with other published data and suggest that it is possible to improve the survival of patients with COPD by early diagnosis, comprehensive treatment, continuing medical care, and home visitation.