COPD World News     Week of June 29, 2008

As Smoke Clears, State Finds Fewer Coronary Heart Disease Deaths

Boston, MA - Ten years after enactment of a sweeping anti-smoking initiative in Massachusetts, the number of smokers had declined 29% and there was a 31% drop in coronary heart disease mortality among persons age 25 to 84.

From 1993 to 2003 there were 425 fewer deaths from coronary heart disease for a total of 3,365 life-years gained, according to an analysis published in the August issue of the American Journal of Public Health.

The smoking rate among Massachusetts residents ages 25 to 84 declined from 20.5% in 1993 to 14.5% in 2003. If that trend continues the rate will fall to 12% in 2010, according to Zubair Kabir, M.D., Ph.D., of the Harvard School of Public Health. That would translate to 150 fewer coronary heart disease deaths in 2010, Dr. Kabir said. Dr. Kabir and colleagues used IMPACT, a validated, dynamic, comprehensive model, to determine the effect of decreased smoking on coronary heart disease mortality.

The Massachusetts Tobacco Control Program, which was authorized by a 1992 ballot initiative, launched a statewide anti-tobacco program funded by a special cigarette tax in 1993. Using coronary heart disease deaths in 1993 as the baseline, Dr. Kabir and colleagues found "that approximately 3,030 fewer deaths occurred in 2003 (expected deaths, 8,821; observed deaths, 5,798)."

"Our estimate of approximately 14% fewer [coronary heart disease] deaths in Massachusetts attributable to reductions in smoking prevalence is consistent with similar estimates done for the entire U.S. population," the researchers wrote.

For more information:

COPD World News     Week of June 22, 2008

Mucolytic Agent Reduces COPD Exacerbations

Guangzhou, China - For patients with chronic obstructive pulmonary disease, year-long treatment with the mucolytic agent carbocisteine eased symptoms and was well tolerated, a large randomized study showed.

Treatment with carbocisteine reduced the frequency of self-reported exacerbations by 25% compared with placebo, Nan-Shan Zhong, M.D., of Guangzhou Institute of Respiratory Disease, and colleagues reported in a recent issue of The Lancet. The reduction remained significant after adjusting for smoking, disease stage, and use of other medications, they said. Adverse events occurred in similar numbers in each group, and there were no deaths.

The researchers concluded that "mucolytics, such as carbocisteine, should be recognized as a worthwhile treatment for the long-term management of COPD."

Mucolytics are widely used in Europe and Asia for the treatment of respiratory diseases with phlegm production, they said, noting that carbocisteine appears to play a role in antioxidation and anti-inflammation, in addition to mucolysis, which may help alleviate the symptoms of COPD. Past studies of the agent have been inconclusive because of limitations in study design, the researchers said, so they initiated a randomized, double-blind, placebo-controlled trial at 22 centers in China.

Symptom exacerbations were defined as at least a two-day persistence of at least two major symptoms; worsening dyspnea and an increase in sputum purulence, volume, or both; or of any single major symptom plus more than one minor symptom which could include upper airway infection, unexplained fever, and increased wheezing.  All symptoms were reported by the participants.

The authors noted that their results may differ from those of other studies because of the ethnicity of the participants. In an accompanying editorial, Paul Albert, M.D., and Peter Calverley, M.D., of the University of Liverpool, pointed out some unanswered questions, including carbocisteine's mechanism of action, which was not addressed in the study. They also questioned whether similar effects would be found in non-Chinese patients.

"What is clear from [the study is that rigorous clinical trials of existing drugs can offer new insights into COPD care," they concluded. "These insights should stimulate research into how the effects can be improved in the future, while offering a cost-effective and well-tolerated way of lessening the burden of exacerbations for the increasing numbers of patients in developing countries affected by this chronic and debilitating disorder."

For more information:

COPD World News     Week of June 15, 2008

Inhaler devices are still a major hurdle in asthma and COPD treatment

London, UK - Although the inhaled delivery of drugs has major advantages over other methods of administration, inhaler devices are often difficult to use and can indirectly have a negative impact on symptom control. Unfortunately, in a classic catch-22 situation, those devices that are developed to overcome the disadvantages of the majority of inhalers often lack broad availability across different therapeutic molecules and drug classes.

Offering physicians and patients a range of therapies in the same type of device will therefore improve proper use of inhalers, which can indirectly have a positive impact on the control of diseases like asthma and chronic obstructive pulmonary disease (COPD), according to a new report* by independent market analyst Datamonitor.

Benefits of inhalers obvious Respiratory diseases like asthma and COPD are mostly treated with inhaled drugs in order to relieve bronchoconstriction and target inflammation in the lungs. There are several advantages to administering these drugs via the inhaled route compared to oral therapy: a faster onset of action, lower drug doses and a better efficacy-to-safety ratio. Drug delivery by inhalation is also painless and is more convenient than injectable drugs.Despite this impressive list of benefits, several drawbacks remain for inhaled medicines, explains Datamonitor respiratory analyst Lisette Oversteegen.

"One of the biggest problems relates to the inhaler device through which the drug is delivered. Every type of device is different and requires a specific inhalation technique in order to get a sufficient amount of drug to the lungs. "Since there are so many different types of inhalers available, it can be difficult for the patient to learn and remember the correct use for each one of them. An incorrect inhalation technique is likely to have a big impact on a patient's daily life, since their asthma or COPD symptoms could be less well controlled than optimally possible," she says.  All types of inhaler devices have major disadvantages.

There are two main types of portable inhaler devices used in the treatment of asthma and COPD: metered dose inhalers (MDIs), including pressurized MDIs (pMDIs) and breath-activated MDIs (BAIs), and dry powder inhalers (DPIs) (including single-unit dose DPIs, multi-dose reservoir DPIs and multi-unit dose DPIs).The standard pMDI is the oldest and most often-used inhaler since it is cheap and available containing many different molecules. Nonetheless, a large proportion of patients cannot use them correctly.

One of the most common problems is a failure to co-ordinate inhalation with actuation of the device (pressing the canister to release the drug). Patients often actuate the inhaler before or at the end of inhalation, and some may even hold their breath while activating the inhaler. Other errors include failure to exhale fully before inhalation and failure to continuously inhale slowly after actuation. Because of the problems associated with pMDIs, attention has focused on the improvement of inhaler devices to optimize the delivery of medication. Breath-activated MDIs (BAIs) help to overcome the problem of co-ordinating actuation with inhalation, thus providing the opportunity to improve drug delivery and overall disease control. However, the major drawback of BAIs is that there are only a few drugs available in these devices due to the high cost involved in developing them, Miss Oversteegen says.

"Since physicians cannot offer all of the medicines a patient needs in a BAI, they are forced to switch back to a pMDI or combine different devices in one treatment regimen." Dry powder inhalers offer an alternative response to the difficulties associated with pMDIs. These devices release the drug by passing air from the patient's inhalation effort through medication formulated as a dry powder. Although this partially resolves the co-ordination problem since the drug is only released when the patient inhales, there are other disadvantages to DPIs, Miss Oversteegen says.

"While the inhalation technique for pMDIs is generally the same, the wide variety of DPIs available means that inhalation instructions can be very different."Furthermore, to ensure that most of the drug emitted from a dry powder inhaler reaches the lungs, it is necessary for the patient to inhale deep and fast enough. A number of asthma and COPD patients are unable to do so, especially the elderly, children and people with severe airflow limitation," she says.

For more information:

COPD World News     Week of June 8, 2008

Smokers Get Snuffed Out of Social Circles

Boston, MA - Whole groups of friends and family members have quit smoking together over the past 30 years while those persons who didn't have risked social marginalization, researchers found.

In a study by the same pair who found obesity to be socially contagious, smokers in the long-running Framingham Heart Study became steadily less popular from 1971 to 2003, with progressively fewer and less important societal ties.  The reason may be that friends and family help one another quit, reported Nicholas A. Christakis, M.D., Ph.D., M.P.H., of Harvard, and James Fowler, Ph.D., of the University of California San Diego, in the May 22 issue of the New England Journal of Medicine.

A person in the study was 67% less likely to smoke if their spouse quit, while a friend quitting reduced the odds 36%, a sibling quitting decreased a person's chances of smoking by 25% and even a coworker in small firms quitting cut the odds of being a smoker by 34%.

Friends with more education influenced one another more than those with less education. Among friends who both had at least one year of college, the chance that one person smoked decreased by 61% (95% CI 28 to 81). The association was not significant among pairs of friends in which at least one person had finished high school or had less than a high school education.

Commented Steven Schroeder, M.D., of the University of California San Francisco, in an accompanying editorial, "The findings that smokers are increasingly peripheral resonate with how we encounter smokers in the United States today, many of whom we see furtively puffing outside their places of employment.  If these findings apply more broadly -- which appears to be likely -- a further reduction in the burden of smoking will require focusing on people who are socially marginalized and whose social networks may be limited," he said, "and it will require figuring out ways to harness the potent social forces that shape behavior."

Although it shouldn't be surprising that social cues play into smoking behaviors, the marginalization of smokers does raise some concerns, Dr. Schroeder said. For example, it may further isolate those with mental illness or substance abuse problems, two groups with among the highest rates of smoking, he said. "Perhaps the strategy of 'love the smoker, hate the smoke' could help these smokers quit while avoiding further stigmatization."

For more information:

COPD World News     Week of June 1, 2008

ATS: Hands-On COPD Program Reduces Hospitalizations

Toronto, ON - Low-intensity case-management sharply reduced hospital admissions and emergency room visits among high-risk patients with chronic obstructive pulmonary disease.  Regular home visits and frequent clinic visits have been shown to reduce the need for hospital care, according to Kathryn Rice, M.D., of Minneapolis Veterans Affairs Hospital. But a randomized study she and her colleagues carried out is the "first evidence that a more simplified model can have the same effect," she said at the annual meeting of the American Thoracic Society.

In the study, 743 patients were randomly assigned to maintain their usual care -- two or three visits with a doctor every year -- or to take part in the case-management program. In that program, patients first spent an hour with a respiratory therapist, during which they learned about the disease itself, reviewed their rescue and maintenance medications, and were counseled on smoking cessation, the need for vaccinations, and hand hygiene.

They also had their oximetry checked at rest and received a written action plan that included how to recognize a COPD exacerbation and what to do about it, including when to take prednisone, antibiotics, or both.  Each patient had a case manager who called once a month to check up and who was available for telephone consultation Monday through Friday.

The one-year study found that the rate of hospital admissions or emergency room visits combined was reduced by 41%. they also found that the rate of hospitalization fell by 31% and that the rate of emergency room visits fell by 51%.

The separation of the event rates was "immediate," Dr. Rice said, and continued until the end of the study. She said patients in the case-management group used their rescue medications twice as often as those in the usual care group, thereby probably avoiding having to go to hospital.

While the population in the study was mainly men, Dr. Rice said she thinks the model is applicable to all COPD patients. "I can't really think of a reason it would only work in men," she said.

The implication of the study is that more intense case management is "essential" in COPD, said Dennis E. Doherty, M.D., of the University of Kentucky, in Lexington, who was not part of the study. "We really need to empower patients and teach patients to take care of themselves," he said.

For more information:

COPD World News     Week of May 25, 2008

Friends help smokers quit

Boston, MA - Smokers became steadily less popular with progressively fewer and less important societal ties researchers find in the Framingham Heart Study.  The reason may be that friends and family help one another quit, reported Nicholas A. Christakis, M.D., Ph.D., M.P.H., of Harvard, and James Fowler, Ph.D., of the University of California San Diego, in the May 22 issue of the New England Journal of Medicine.

A person in the study was 67% less likely to smoke if their spouse quit, while a friend quitting reduced the odds 36%, a sibling quitting decreased a person's chances of smoking by 25% and even a coworker in small firms quitting cut the odds of being a smoker by 34%.

Friends with more education influenced one another more than those with less education. Among friends who both had at least one year of college, the chance that one person smoked decreased by 61% (95% CI 28 to 81). The association was not significant among pairs of friends in which at least one person had finished high school or had less than a high school education.

Commented Steven Schroeder, M.D., of the University of California San Francisco, in an accompanying editorial, "The findings that smokers are increasingly peripheral resonate with how we encounter smokers in the United States today, many of whom we see furtively puffing outside their places of employment."

"If these findings apply more broadly -- which appears to be likely -- a further reduction in the burden of smoking will require focusing on people who are socially marginalized and whose social networks may be limited," he said, "and it will require figuring out ways to harness the potent social forces that shape behavior."

Although it shouldn't be surprising that social cues play into smoking behaviors, the marginalization of smokers does raise some concerns, Dr. Schroeder said. For example, it may further isolate those with mental illness or substance abuse problems, two groups with among the highest rates of smoking, he said. "Perhaps the strategy of 'love the smoker, hate the smoke' could help these smokers quit while avoiding further stigmatization."

For more information:

COPD World News     Week of May 18, 2008

Smoking Cessation Leads to Early and Late Mortality Benefits

Boston, MA - Within five years of a woman's last cigarette, excess vascular risk has virtually disappeared, but lung mortality remains elevated for 15 additional years, according to the Nurses' Health Study.

After 22 years of follow-up, data from the study showed that smoking cessation reduced the risk of every cause-specific mortality outcome evaluated, Stacey Kenfield, Sc.D., of the Harvard School of Public Health, and colleagues reported in the May 7 issue of the Journal of the American Medical Association. The full mortality benefit of smoking cessation accrued over 20 years, but over a variable timeframe, they added.  "Our findings indicate that 64% of deaths in current smokers and 28% of deaths in past smokers are attributable to smoking," they added. "Quitting reduces the excess mortality rates for all major causes of death examined."

Launched in 1976, the Nurses' Health Study originally involved 121,700 female RNs in the United States, ages 30 to 55. Participants provided detailed information about their medical history and risk factors for cancer, heart disease, and other conditions. In 1980, 28% of the participants were smokers, 26% former smokers, and 46% never smokers. By 2002, only 8% of surviving participants were smokers.

From the outset, the information has been updated by biennial questionnaires. After 12 years of follow-up, the data showed that current smoking and starting at a younger age increased the risk of all-cause and cause-specific mortality. With an additional 10 years of follow-up, the current study had the statistical strength to characterize smoking's effect on more causes of death, particularly respiratory disease and cancer. Current smokers had almost a three-fold greater mortality risk compared with never-smokers. There was a similar difference in analyses limited to major cause-specific mortality. Risks increased significantly with the number of cigarettes smoked daily.

For all respiratory causes of death, smoking increased the risk 10-fold compared with never smokers.  It was also found that smokers had more than a three-fold greater risk of vascular death compared with never smokers.

For more information:

COPD World News     Week of May 11, 2008

COPD, Respiratory Failure Patients at High Risk for Hospital Readmission

Puglia, Italy - Patients admitted to hospital with chronic obstructive pulmonary disease (COPD) or respiratory failure (RF) are more likely than other patients to require readmission within a year, say Italian scientists.

Repeated admission to hospital for patients with chronic-degenerative conditions implies that the patient has passed from an acute phase to another acute phase or that their condition has worsened and so represents a transition between states.

Nicola Bartolomeo, from the University of Bari, and colleagues studied 123,162 patients aged at least 55 years with a first admission for COPD or RF, listed as either a primary or secondary diagnosis, between 1998 and 2005.

Of the patients, 22.4% were readmitted to hospital within a year, and 33.5% of those readmissions to hospital were recorded as COPD or respiratory failure as the principal diagnosis. The team also reports that of the 36.4% of patients who had a third readmission, 57.6% had COPD or RF as the principal diagnosis.

Patients with an initial diagnosis of respiratory failure had an increased probability for readmission compared with other patients, at odds ratios of 1.6 for the first readmission and 1.3 for the second. In addition, patients with an initial diagnosis of COPD as the principal diagnosis had a significantly increased risk for readmission, at odds ratios of 1.6 for the first admission and 1.2 for the second.

A principal diagnosis of COPD or respiratory failure at entry is a strong predictive factor for the probability of readmission, they conclude.

For more information:

COPD World News     Week of May 4, 2008

COPD could be Auto-immune Disease

Pittsburgh, PA - Looking back, doctors admit the experiment had a good chance of yielding useful results and promising clues to a cure. But in 2006, the University of Pittsburgh School of Medicine doctors thought it was a bit of a gamble when they decided to gather cells from patients with a killer lung disease and test them in healthy cadaver lungs.

"I really enjoy going to casinos, and sometimes you win," said Dr. Steven Duncan, a professor in the School of Medicine. "With this study, we won. It was pure speculation, and it worked out." Duncan and Dr. Frank Sciurba, director of Pitt's Emphysema Research Center, recently reported their experiment gave solid evidence that chronic obstructive pulmonary disease, or COPD -- which kills about 130,000 people in the United States every year -- is an autoimmune disease, in which the body attacks itself.

Now they're enrolling Western Pennsylvanians to test a drug treatment with the potential of becoming the first to halt progression of the lung disease. "Existing therapies don't really have an effect on lung function," Sciurba said.

"They help people feel better, and that is really important, but there is no compelling evidence that the current therapies change the long-term outcome." COPD is an umbrella term for some lung conditions that limit a person's ability to get air into or out of the lungs, keeping oxygen from the blood. It almost always is associated with a history of cigarette smoking.

The lungs are damaged from long-term, continuous irritation. "It was like an asthma attack all the time. I just couldn't breathe," said Vearl Franke of Latrobe, a COPD patient who was misdiagnosed for several years and now has his COPD under control.

"Our first step is really to prevent the progression of the disease, and I think we're close to that," Shapiro said. "In terms of reversing or curing it, that is much more complicated, but I think this place is positioned well. There's a lot of potential in the things we're doing here." COPD is perplexing because it doesn't improve or even stop worsening after patients stop smoking, Sciurba said.

If cigarette smoke destroys lung tissue, common sense says once the irritant is removed the still-healthy portions of the lungs should remain so, he said. Something else must perpetuate the lung destruction,

For more information:

COPD World News     Week of April 27, 2008

Computer Game Helps COPD Patients Breathe Better

Hines, IL - Patients with chronic obstructive pulmonary disease (COPD) may gain better control over their breathing and breathe more efficiently by using their breath to play a computer game, according to new research.

COPD is a double-edged sword: the incapacitating lung condition can cause such serious shortness of breath that every-day physical activity, such as walking a flight of stairs, becomes unduly burdensome-and yet one of the few effective symptomatic treatments for COPD is the very thing that its victims dread most: exercise," said leading researcher Eileen G. Collins, Ph.D., of the Edward Hines Jr. VA Hospital in Hines, Illinois and UIC. "This computerized program is still in the research stages, but shows promise for future use in pulmonary rehabilitation programs."

The results of this randomized, controlled study appeared in the April 15 issue of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

COPD patients with the greatest disability are also those most likely to be unable to exercise long enough to reap the benefits rehabilitation can offer them. "One of the key mechanisms of shortness of breath and exercise impairment in these patients," Dr. Collins said, "is their inability to fully exhale air when active." This phenomenon causes trapping of air in the lungs (i.e., dynamic hyperinflation) and diminishes the patient's breathing efficiency.

Dr. Collins and colleagues designed a randomized, controlled trial, the first of its kind, to test whether this computer program could decrease the extent of air trapping during exercise and thus improve the results of rehabilitation in COPD patients. "Our primary goal was to determine if patients with COPD would achieve longer exercise duration if they were engaged in ventilation feedback, in addition to the regular exercise program over either ventilation feedback or exercise alone," said Dr. Collins.

A total of 64 patients were randomized to three groups- exercise alone, exercise plus ventilation feedback (VF) or VF alone. VF patients had their breathing monitored by a computer program which provided them with real-time biofeedback and set individualized goals, presented graphically on a screen in front of them. Patients could see their current speed and depth of breathing in relation to the set goal, encouraging them to inhale more slowly and exhale more completely in order to achieve the goal.

At baseline, the groups all performed similarly in exercise tolerance tests. Comparing all the groups, those that underwent a regimen of exercise and ventilation feedback showed significant improvements in exercise duration, and those who underwent exercise alone fared much better than those who only received ventilation feedback. Because of the multiple comparisons between groups, the exercise-plus-ventilation feedback group did not attain statistically significant improvements over the exercise-only group, but the results indicated a strong trend in that direction.

Exercise-induced hyperinflation was also reduced in patients randomized to exercise-plus-ventilation feedback over either program by itself. Duration of exercise tolerance in the exercise-plus-ventilation feedback group also showed a significant trend toward improvement.

If patients can be taught to translate these breathing techniques from the computer game to activities of daily living, they could potentially greatly improve their quality of life. "We are conducting a follow-up clinical trial to compare computerized breathing feedback with other unique methods of pulmonary rehabilitation," said Dr. Collins.

For more information:

COPD World News     Week of April 20, 2008

Factors linked to elderly lower respiratory tract infections uncovered

Leiden, The Netherlands - The occurrence of lower respiratory tract infection among very elderly individuals is associated with smoking, chronic obstructive pulmonary disease (COPD), stroke, and reduced functional status, conclude Dutch scientists.

Very elderly individuals experience a high impact from lower respiratory tract infections, not only because they suffer a high incidence but also because they are likely to develop medical complications, be hospitalized, or die.

To examine predictive factors for lower respiratory tract infection in the very elderly, Jacobijn Gussekloo, from Leiden University Medical Center, and colleagues studied 587 participants aged 85 years from the Leiden 85-plus Study, who were followed-up for 5 years until 90 years or age or death.

Information was obtained from general practitioners or nursing home physicians on the development of lower respiratory tract infections, with sociodemographic and medical history data gathered from baseline interviews and medical records. In addition, the participants completed the Mini-Mental State Examination, the Geriatric Depression Scale-15, and the Groningen Activity Restriction Scale.

At the end of the study period, there were 273 participants aged 90 years, with 50 individuals having refused further participation and 264 having died. Of those who died, 39.5% did so as a result of cardiovascular causes.

There were 173 first-episodes of lower respiratory tract infections, giving an overall incidence of 94 per 1000 person-years. In addition, 53 participants experienced recurrent lower respiratory tract infection.

Cox regression analysis revealed that factors independently associated with lower respiratory tract infections were history of COPD, smoking, oral glucocorticosteroid use, severe cognitive impairment, and history of stroke.  Smoking was found to be the greatest contributing factor, at a population attributable risk of 32%.

For more information:

COPD World News     Week of April 13, 2008

Dry Airways Play key role in COPD and Asthma

Heidelberg, Germany - Dry airways may not only play a central role in the development of the inherited lung disease cystic fibrosis, but also in much more common acquired chronic lung diseases such as asthma and smokers lung, the cigarette smoke-induced COPD.

This is the conclusion reached by scientists at Heidelberg University Hospital and the University of North Carolina at Chapel Hill. In animal studies, they found that insufficient hydration of the airway surfaces leads to pathologies typical of COPD in humans. Thus, these findings point to a new approach for the treatment of these diseases.

There are currently no causal therapies available for treating these diseases; only the symptoms such as shortness of breath and oxygen deficiency can be treated. In the hereditary disease cystic fibrosis, a defective gene causes a change in the transport of salt and water across the mucosal surfaces in the lungs, the intestine and other organs, and thus produce a change in the composition of the secretions.

Using a mouse model he developed, Dr. Mall succeeded in proving a direct relationship between the defective gene and development of lung disease certain sodium channels on the surface of airway cells that are responsible for the resorption of salt and water are hyperactive. The cells absorb too much fluid, causing the airway surfaces to dry out. This gives rise to thick dry mucus that cannot be cleared. As a consequence, the respiratory tract gets clogged with mucus the lungs cannot be cleaned effectively of inhaled allergens, toxins and pathogens, giving rise to chronic pulmonary inflammation and respiratory insufficiency.

The researchers conclude that dehydrated airway surfaces could play a key role in the development of COPD in humans.  These results indicate that improving hydration of airway surfaces and thus mucus clearance of the lungs, for example by blocking the sodium channels in the cells of the respiratory tract, could be a successful strategy for treating chronic obstructive pulmonary diseases of different etiologies.

The Heidelberg research team now wants to test the benefits of this new therapeutic approach in animals.

For more information:

COPD World News     Week of April 6, 2008

COPD patients show bronchodilator reversibility

Sheffield, UK - Many patients with chronic obstructive pulmonary disease (COPD) show substantial acute bronchodilator reversibility despite having no other features of asthma and regardless of the method used to define reversibility, researchers report.

Writing in the European Respiratory Journal, Donald Tashkin (University of California in Los Angeles, USA) and colleagues explain that the most important aspect of their findings is that the magnitude of bronchodilator responsiveness was greater than expected.

Patients with COPD are still commonly thought to show diminished acute bronchodilator responsiveness compared with asthmatics, the authors explain, and reversibility testing is still sometimes proposed as a method of discriminating between asthma and COPD.

Tashkin and team used data from the Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT) trial to examine acute bronchodilator responsiveness in a large cohort of 5756 patients (average age 64.5 years) with moderate-to-very-severe COPD.

"The present results in 5,756 COPD patients confirm and extend previous reports of substantial acute bronchodilator reversibility in patients with COPD who had no other features of asthma, regardless of the method used to define reversibility," the authors write.

"The majority of patients with moderate-to-very-severe chronic obstructive pulmonary disease demonstrate meaningful increases in lung function following administration of inhaled  bronchodilators," Tashkin and team conclude.

For more information:

COPD World News     Week of March 30, 2008

Smoking May Increase Brain Aneurysm Recurrence

Philadelphia, PA - Cerebral aneurysms recurred 4.53 times more often among smokers than nonsmokers despite successful endovascular coil embolization, researchers found.

Smokers also comprised the majority of patients who required retreatment, Erol Veznedaroglu, M.D., of Thomas Jefferson University and Jefferson Hospital for Neuroscience here, and colleagues reported in the April issue of the Journal of Neurosurgery.

These findings from the retrospective study suggest that surgery to clip off the aneurysm may be a better option than coiling for patients who smoke, Dr. Veznedaroglu said.  "If the patient is a heavy smoker and has been a heavy smoker for many years," he said, "that really may make you lean toward doing a craniotomy for clip ligation, which is a more durable procedure."  At the very least, patients and their families should be counseled about the additional risk posed for smokers with coiling, he said.

Treatment with endovascular coil embolization rather than traditional surgical clipping improves survival without disability, but one disadvantage has been the higher risk of recurrence when the coils become compacted, the researchers said.

Smoking presents a greater risk for growth and rupture of known aneurysms than hypertension, family history, or any other factor, Dr. Veznedaroglu said. It is also the only environmental factor consistently linked to risk of developing brain aneurysm.

For more information:

Sewer Gas Puts Heart and Lungs on Hold

Boston, MA - A whiff of the rotten-egg scented hydrogen sulfide gas may make people hold their breath, but longer, controlled doses could be used to put the lungs, heart, and metabolism into hibernation, researchers found.

Low doses of hydrogen sulfide dropped the respiratory, metabolic, and heart rate of mice without reducing oxygen levels or blood pressure, reported Warren M. Zapol, M.D., of Massachusetts General Hospital, and colleagues in the April 2008 issue of the journal Anesthesiology.

Hydrogen sulfide, emitted by sewers, volcanoes, sulfur springs, and various sulfur-containing products, can be toxic at high concentrations. However, these findings suggest controlled doses could be used to preserve organ function when oxygen supply is limited, such as after a traumatic injury or cardiac arrest, the researchers said.

Previous animal studies showed hydrogen sulfide lowered body temperature and metabolic rate and improved survival of mice with acute hypoxia.  During exposure, the mice gradually became less active until they appeared asleep by three hours. However, they responded to tapping on their cage and painful stimulus, which suggested they were not anesthetized. These effects were reversible by stopping hydrogen sulfide exposure.

The findings offer "exciting" possibilities for treatment, but further study is needed, Dr. Zapol and colleagues concluded. One important question is whether intravenous use would be required for humans or larger animals to prevent lung toxicity, they said.

For more information:

COPD World News     Week of March 23, 2008

Spiriva Linked to Possible Increased Risk of Stroke

Washington, DC - The US Food and Drug Administration (FDA) is reporting a possible increased risk of stroke with use of tiotropium (Spiriva HandiHaler, Boehringer Ingelheim Pharmaceuticals, Inc), according to an ongoing safety review posted March 18 on MedWatch, the FDA's safety information and adverse event reporting program. Spiriva contains tiotropium bromide and is used to treat bronchospasm associated with chronic obstructive pulmonary disease (COPD).

"Boehringer Ingelheim and [the] FDA notified healthcare professionals that ongoing safety monitoring has identified a possible increased risk of stroke in patients who take Spiriva," MedWatch states. "It is important to interpret these preliminary results with caution. FDA is working with Boehringer Ingelheim to further evaluate the potential association between Spiriva and stroke."

A pooled analysis by Boehringer Ingelheim of the safety data from 29 placebo-controlled clinical studies yielded preliminary estimates of stroke risk of 8 of 1000 patients treated for 1 year with Spiriva and 6 of 1000 patients treated for 1 year with placebo. In these trials, which included approximately 13,500 patients with COPD, the estimated excess risk of any type of stroke caused by Spiriva is 2 patients for each 1000 patients using Spiriva for 1 year.

The FDA cautions that it has not yet confirmed these analyses with the manufacturer. Although pooled analyses are useful in highlighting potential safety issues, they have inherent limitations and uncertainty, mandating further investigation with other data sources.

"Patients should not stop taking Spiriva HandiHaler before talking to their doctor, if they have questions about this new information," MedWatch concludes. "This early communication is in keeping with FDA's commitment to inform the public about its ongoing safety reviews of drugs."

For more information:

COPD World News     Week of March 16, 2008

Telling Smokers Their Lung Age Motivates Quitting

Hertfordshire, England - A simple lesson in how smoking prematurely ages lungs was twice as effective in getting patients to quit as was an FEV1 result with no explanation, a study here found.

Telling smokers their spirometry-estimated lung age as part of an intervention was associated with a smoking reduction of 7.2%, compared with a group given only their raw FEV1 results, Gary Parkes, M.D., of Limes Surgery, a private practice here, and colleagues reported in BMJ Online First. These results, the researchers concluded, suggest that lung-age testing, a quick office-based test that can be done by a healthcare assistant, should be considered as part of a brief intervention, either in all smokers over age 35 (the lower limit in this study) or all smokers.

"Given the heavy health and economic burden of smoking, we believe that formal economic evaluation of this new and simple intervention should be a research priority," they wrote.

The findings came from a search of the computerized records of five general practices in Hertfordshire, near London. The review identified 561 patients older than 35 recorded as smokers in the previous 12 months. Recruitment started in February 2004 and follow-up was completed in March 2007.

All participants were offered spirometric assessment of lung airflow, after which they were randomized to intervention or control groups. The mechanisms by which this intervention achieved its effect are unclear, and further research is needed to explain the psychological forces active in successful quitting in different circumstances.

The cost per successful quitter was estimated at $556, the researchers said. These estimates suggest that lung age is of comparable effectiveness, and potentially cheaper, than other currently available treatments, including nicotine replacement therapy and various forms of counseling.

In an accompanying editorial, Raphael Bize, M.D., and Jacques Cornuz, M.D. of the University of Lausanne in Switzerland, wrote that on the basis of the evidence so far, primary care practitioners have to decide whether to wait for a trial comparing the potential benefit for spirometry testing versus no such testing or whether to adopt the strategy suggested by Dr. Parkes and colleagues.

For more information:

COPD World News     Week of March 9, 2008

Smoking and Heredity Share Culpability for Chronic Bronchitis

Stockholm, Sweden - A key reason why some smokers develop chronic bronchitis and others don't is that 40% of the risk for the condition is genetic, a study of twins here revealed.

Only 14% of the genetic factors for chronic bronchitis are also associated with smoking behavior, Jenny Hallberg, M.Sc., of the Karolinska Institute, and colleagues reported in a recent issue of the American Journal of Respiratory and Critical Care Medicine.

"From the results of this study," they wrote, "we conclude that heritability has a moderate influence on the development of chronic bronchitis, and that the genes that are involved are largely independent of those related to smoking habits." On the other hand, they noted, this should "not be interpreted to mean that smoking has no effect in certain individuals." The prevalence of chronic bronchitis in smokers is twice as high as in nonsmokers, the researchers noted, and "smoking may directly influence development of chronic bronchitis regardless of the (genetic) reasons for smoking."

Previous studies have revealed a genetic effect on the development of chronic bronchitis but they were unable to quantify the relative contributions from environmental and genetic factors, the researchers said.  Also, the prevalence of chronic bronchitis has been shown to be higher in women, although whether this gender difference in the condition has a genetic foundation is unclear, they said.

From 1998 through 2002, as part of the Screening Across the Lifespan Twin (SALT) study, the researchers got in touch with all living twins born before 1958 in the Swedish Twin Registry.  A total of 36,772 participants completely answered the questions about respiratory symptoms and smoking behavior. Those who reported recurrent cough with phlegm production or said they had chronic bronchitis or emphysema were defined as having chronic bronchitis and made up 7.1% of the study population.

This study was limited by the questionnaire-based collection of data and the fact that only those with more than 10 pack-years were considered smokers, the authors said. Furthermore, "it is conceivable that part of the genetic influence attributed to chronic bronchitis could partly be due to heritability for atopy, which is a known risk factor for the development of asthma," they wrote.

For more information:

COPD World News     Week of March 2, 2008

One-legged exercise may help COPD Patients get fit

Toronto, ON - Exercising one leg at a time can improve aerobic capacity more than two-legged exercise in patients who have stable COPD, according to a report in the latest issue of the medical journal Chest.

"We may have a new approach to enable patients with severe lung disease to improve their fitness," Dr. Roger S. Goldstein told Reuters Health. "Hopefully this also increases their mobility, activities, and quality of life."

Goldstein from the University of Toronto, Ontario, and Thomas E. Dolmage note that shortness of breath limits exercise intensity for most COPD patients. "One-legged exercise," at half the work load of exercise using two legs, "places the same metabolic demands on the targeted muscles." However
the stress on the lungs is reduced, permitting patients to increase their exercise capacity, the researchers point out.

They investigated the effects of one-legged training on the peak oxygen uptake on patients during stationary bicycle exercise compared with conventional two-legged training. "Both groups were able to increase their training intensity over the duration of the training program, the investigators report, and both groups significantly increased their total work per session.

The researchers found that the improvement in peak oxygen uptake was significantly higher in the one-legged training group than in the two-legged group. The one-legged group also had a significantly greater increase in peak ventilation and lower submaximal heart rate than the two-legged group.

Whether this approach is "ready for prime time" or just represents an interesting study will require additional trials with a larger number of patients, along with evaluation of actual patient benefits.

For more information:

COPD World News     Week of February 24, 2008

COPD in Women Increasing at Alarming Rate

Hamilton, ON -  Dr. Kenneth Chapman, director of the Asthma and Airway Centre of the University Health Network Toronto, says lung disease caused by tobacco smoke and air pollution will overtake breast cancer as a killer of Canadian women within seven years.

During an air quality conference, called Upwind Downwind 2008, held at the Hamilton Convention Centre, Dr. Chapman reported that in 1985 twice as many men as women were hospitalized with chronic pulmonary obstructive disorder.  The male/female numbers are equal today but by 2015 it is projected that women with COPD will outnumber men by a factor of two to one.

There are many theories why COPD is affecting women more than men, one is that size matters - that they (women) are on average smaller and that their lungs and breathing passages are smaller, so women suffer far greater consequences from smoking and air borne particulates.  It is believed that the increase in diagnosed COPD among women in part reflects the increase in those who smoked in the latter half of the 20th century.  He also said COPD is as common or more common than asthma, but is greatly under-diagnosed because its effects worsen gradually "so patients don't recognize the symptoms developing."

"The health trend data suggest more Canadian women will lose their lives to COPD than breast cancer by 2015."  Chapman said COPD is "the third most common cause of death on this planet" and "an enormous epidemic that most of the public doesn't even know the name of."

He also stated that inhaled steroids have been shown to cut deaths not just from respiratory disease but from cardiovascular disease, cancer and other illnesses - because the anti-inflammatory effect of steroids is not confined to air passages.

For more information:

Cigarette Smoking Causes Sleep Disturbances

Baltimore, MD - Smoking cigarettes impairs sleep quality, possibly because of nicotine withdrawal, according to a study published in Chest, the journal of the American College of Chest Physicians.

The study is among the first to isolate the effects of smoking on sleep. In previous research, it was unclear whether changes in sleep patterns were from smoking itself or from the medical conditions underlying smoking such as heart or respiratory disease, said study author Naresh M. Punjabi, MD, PhD, associate professor of medicine and epidemiology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.

"Believe it or not, despite all the literature on smoking and medical conditions, not much has been done on smoking and EEG (electroencephalogram) activity," he told Medscape Neurology & Neurosurgery.  Researchers asked the subjects about their caffeine and alcohol consumption and used various tools to measure their mental health. Self-reported alcohol consumption was similar in both groups as were measures of mental health status. Although a higher proportion of smokers reported daily consumption of caffeine, this was not associated with the results of the EEG power spectral analysis.

The study shows that cigarette smoking "can alter sleep architecture independent of factors such as age, gender, race, anthropometric measures, caffeine and alcohol consumption, medial comorbidity and mental health status," the study authors conclude.

The direct effects of smoking on sleep seen in this study should provide further ammunition for public health campaigns to reduce smoking. "The people who smoke are not getting a restful sleep and that has ramifications for them on a daily basis; they're tired, they're going to be tired the next day, and most likely they will have diminished level of alertness," said Dr. Punjabi. "Those are direct effects that poor sleep quality will have on their daily living.

For more information:

COPD World News     Week of February 17, 2008

Racial Differences in Surgical Waiting List Outcomes in COPD

New York, NY - Researchers at Columbia University in New York, looked at different outcomes of black and white patients with COPD after listing for lung transplantation in the United States. 

The study was a retrospective cohort study of non-Hispanic black and non-Hispanic white adults, 40 years old, with chronic obstructive pulmonary disease, who were listed for lung transplantation in the United States between 1995 and 2004. The health outcomes of minorities with COPD - on the lung transplant waiting list - had not been previously studied.  Researchers at Columbia University found that in the United States, blacks with chronic illness have poorer health outcomes than whites.

They also noted that blacks with COPD were more likely to have pulmonary hypertension, obesity, and diabetes than their white counterparrts.  As well, blacks have less private health insurance and live in poorer neighborhoods than whites. Blacks were also less likely to undergo transplantation after listing compared to whites, despite adjustment for age, lung function, pulmonary hypertension, cardiovascular risk factors, insurance coverage, and poverty level.

The researchers concluded that, following listing for lung transplantation, black patients with chronic obstructive pulmonary disease were less likely to undergo transplantation and more likely to die or be removed from the list compared to white patients. Unequal access to care may have contributed to these differences.

For more information:

Patients Given Hope of Lung Repair Drug

Coventry County, UK - A new drug that has the potential to repair lung damage in patients with emphysema is to be tried out at Coventry's University Hospital. Coventry is one of 70 worldwide research centres - and the only UK hospital - taking part in pioneering new research into the causes and treatment of COPD. Patients with COPD are being invited to take part in the two-year research study.

Dr David Parr, a consultant respiratory physician at University Hospital,said: "We are performing a trial of a potential new drug which could repair lung damage in patients with emphysema. Research is needed to provide evidence that patients who take a daily tablet of the drug, which is related to Vitamin A, experience health benefits as a result of repair to areas of damaged lung." Patients needed for the study must have emphysema and must not have smoked for at least 12 months.

A second research study will look at finding the genes responsible for the development of COPD. Dr Parr said: "We hope that by identifying the genes we will be able to discover why COPD occurs, so
that in the future we can find better treatments." Both of these studies have been made possible because of technical advances in the scanners used to take pictures of the lungs.Images can be transferred onto computers, allowing more accurate assessments of lung disease. Dr Parr added: "We are looking for people from across the country, as well as those living in the
Midlands, to take part in these two important research studies."

For more information:

COPD World News     Week of February 10, 2008

Respiratory Disturbances During Sleep Increase with Age

Boston, MA - The frequency of breathing irregularities during sleep started to increase after age 50 in completely healthy individuals and rose dramatically after 65, a study found. However, such disturbances may be part of normal aging, leaving open the question of whom to treat for obstructive sleep apnea, Steven A. Shea, Ph.D., of Harvard, and colleagues reported in the latest issue of Sleep.

Polysomnographic respiratory abnormalities have been extensively studied in the general population, but studies have not targeted completely healthy individuals, the researchers said. Furthermore, they said, the criteria and measuring techniques have changed since the earlier studies were done.

In a study spanning four years, the researchers did a cross-sectional analysis of 163 consecutive healthy volunteers (106 men, ages 25 to 71) who were given elaborate screening for chronic illness, drug and alcohol dependence, and psychiatric history. Obese individuals and those taking medications were excluded.

Eligibility for inclusion in the study was confirmed by extensive questionnaires, physical examination, electrocardiography, and sleep lab analysis. After selection, the volunteers underwent full nocturnal polysomnography in an accredited sleep laboratory using current standard recording and scoring techniques. Data collected included sleep stages, arterial oxyhemoglobin saturation, airflow, abdominal and thoracic breathing-movement gauges, electrocardiography, and detection of periodic limb movements in both legs.

There was a remarkable increase in respiratory disturbances with age, particularly after 50, the researchers found. For example, only 5% of currently healthy subjects younger than 50 had more than 15 disturbed breathing events in an hour of sleep, whereas 50% of individuals older than 65 had 15 or more events an hour.

In the oldest group, the respiratory disturbance index was 32.5 events per hour of sleep. The increasing breathing disturbance index with age was also associated with a concomitant lower minimum arterial oxyhemoglobin saturation level.

In a comparison of the frequency distributions of breathing events between age groups, five of six comparisons showed significant advances with age  except for comparisons between age groups 35-49 versus 50-65, the researchers reported.

Men had a higher disturbance index than women. The effect of age on the sleep disturbance index was similar in men and women, although no formal analysis was possible given the small number of individuals, the researchers reported.

For more information:

COPD World News     Week of February 3, 2008

Femoral Artery-to-Vein Shunt Aims to Improve COPD Quality of Life

Hollywood, Fla. - For chronic obstructive pulmonary disease, an innovative minimally invasive treatment on leg vessels may greatly improve quality of life, suggested results in the first patient studied.

The approach is to create an arteriovenous fistula by implanting a shunt-like device between two major leg blood vessels, utilizing cardiovascular reserve to overcome respiratory insufficiency and improve oxygenation to the lungs.

"The objective of this new procedure is to improve quality of life in patients suffering severe COPD by increasing oxygen delivery," said Horst Sievert, M.D., of the Cardiovascular Center in Frankfurt, Germany, at the International Symposium on Endovascular Therapy.

Dr. Sievert described a case study in which a 57-year-old truck driver and a five-pack-a-day smoker was severely disabled by COPD. He could not leave his home without oxygen supply, and required oxygen for several hours a day even when at rest. Without oxygen the man was able to walk 420 meters; with oxygen he could walk 510 meters in six minutes.

Dr. Sievert said the implantation of the shunt can increase cardiac output by about one liter per minute, without impacting heart rate or oxygen consumptions. Instead, Dr. Sievert said the treatment increases venous oxygen content and arterial oxygen content.

In the procedure, clinicians perform simultaneous arterial and venous angiograms to locate the region where the femoral artery and the iliac lie near each other in the leg. The vein is punctured and then the artery is punctured. A 5-mm-wide stent-like shunt connects the blood vessels, creating the fistula.

Dr. Sievert said his "first-in-man" use of the procedure produced tangible results in his case study patient. In the three-month follow-up, the patient was able to walk 540 meters without oxygen -- further than he formerly could walk with oxygen, Dr. Sievert said. Lung function tests also improved. The patient also quit smoking.

Supplemental oxygen during exercise was reduced by 50%, he said. "Most striking for him was that there was no more need at rest," Dr. Sievert said.

"What happens," commented Ramon Quesada, M.D., of the Baptist Cardiac and Vascular Institute in Miami, "is that some of the oxygen rich blood in the femoral artery is shunted into the iliac vein." The oxygen-enriched blood eventually reaches the lungs, improving pulmonary function. "This is a very simple procedure and a very simple device," Dr. Quesada said. "To be able to improve oxygen by a liter per minute is extraordinary. You can really improve quality of life."

For more information:

COPD World News     Week of January 27, 2008

Work-related environmental tobacco smoke causes death

E. Lansing, Michigan - Three public health surveillance systems were used to identify and conduct a follow-up investigation of a reported acute asthma death of a young waitress in a bar.

The waitress collapsed at the bar where she worked and was declared dead shortly thereafter. Evaluation of the circumstances of her death and her medical history concluded that her death was from acute asthma due to environmental tobacco smoke at work.

This is the first reported acute asthma death associated with work-related ETS. Recent studies of asthma among bar and restaurant workers before and after smoking bans support this association. This death dramatizes the need to enact legal protections for workers in the hospitality industry from secondhand smoke. The results of this study were published in the American Journal of Industrial Medicine.

For more information:

COPD World News     Week of January 20, 2008

Cape Town is lung disease capital of World

Portland, Ore. - Cape Town has the highest incidence of COPD in the world, according to US researchers. This is possibly because of the effects of tuberculosis and occupational exposure.

COPD rates were found to be 22.2% among men and 16.7% among women. This study, published in The Lancet, found the global incidence of non-cancerous chronic lung disease is far higher than usually estimated.

The study was conducted by a team led by Sonia Buist of Oregon Health and Science University, who looked at the respiratory health of 9,425 people from 12 countries. They found that around 10% of people aged 40 around the world have advanced COPD. This compares with previous estimates of four percent or less.  Lowest incidence was in Hanover, Germany, where it was 8.6% and 3.7% respectively.

Smoking and aging populations are to blame for the rise of COPD, and the burden will weigh more and more heavily on health systems in the decades to come, the paper warns.

For more information:,41843.asp

COPD World News     Week of January 13, 2008

New therapy reduces mortality in patients with severe COPD

London, UK - Patients with severe COPD may benefit more from therapy that combines salmeterol and fluticasone [SFC] than treatment with tiotropium, according to results from a long-term, multi-center study, Investigating New Standards for Prophylaxis in Reducing Exacerbations (INSPIRE) that directly compared the two therapies.

"Although we found no difference in the overall rate of exacerbations between treatment groups, SFC treatment was associated with better health status, fewer patient withdrawals, and a lower mortality rate than occurred during tiotropium therapy," said lead author if the study, Jadwiga Wedzicha, M.D., of the Royal Free & University College Medical School in London.

This was the first large-scale trial to directly compare the two different treatment approaches. The results appeared in the first issue for January of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.

"This finding provides indirect evidence that these treatments affect apparently similar patients in different ways that affect clinical judgment," wrote Dr. Wedzicha in the article. "This difference warrants further study to determine the factors that affect therapeutic choice."

There was also a small but statistically significant improvement in the SGRQ scores for patients on SFC. While this difference did not reach the standard of clinical significance, it did indicate that overall, SFC patients experienced a slightly higher overall quality of life and a post-hoc analysis revealed that more patients on SFC had a clinically significant improvement in health status than those on tiotropium therapy.

Most strikingly, mortality was significantly lower in the SFC group during the study period, even though the trial was not powered to detect such a difference. There was more than a 50 percent reduction in the risk of on-therapy all-cause death at any time during the study period for the SFC patients. Patients undergoing SFC treatment were also significantly less likely to withdraw from the trial than others.

"Our study raises several important questions," noted Dr. Wedzicha. "Why is there a difference between treatments" What is the biological basis of the differential effect on exacerbations, and is it related to the difference in mortality between the two treatments."

Despite no difference in the overall rate of exacerbations between treatment groups, SFC treatment was associated with better health status, fewer patient withdrawals, and a lower mortality rate than occurred during tiotropium therapy and this may have important implications for the clinical management of COPD.

For more information:

COPD World News     Week of January 6, 2008

Hereditary Diseases Attack Lungs More Often Than Suspected

Werne, Germany - Hereditary defects are a larger contributing factor to COPD than previously suspected, according to the German Society for Pneumology and Respiratory Medicine (DGP).

So far, it had been widely assumed in Germany that an estimated 8,000 people suffered from an inherited deficiency of Alpha-1- Antitrypsin. "We now have indications that the numbers are significantly higher," said DGP President Helmut Teschler.

People with the defect have reduced levels of certain proteins in their blood that also protects connective tissues.  Sufferers also lose pulmonary alveoli, the part of the lung that helps transfer gases to the bloodstream. The disease also attacks bronchial passages and lung passages.

"A lot of sufferers develop symptoms like persistent coughing and breathing,especially during physical exertion, between their 30th and 40th birthdays." A lung specialist can use a variety of tests to confirm whether there's a genetic basis for the alpha-1-antitrypsin deficit.

For more information: