COPD World News     Week of June 28, 2009

Rehab Helps in Moderate COPD

San Diego, CA - According to Dutch researchers. pulmonary rehabilitation can have a marked effect on quality of life even in patients with less-advanced cases of chronic obstructive pulmonary disease (COPD).

In a two-year randomized trial, an intensive community-based rehab program was both cost-effective and had significant health benefits, according to Annemie Schols, Ph.D., of Maastricht University Medical Center in the Netherlands. Often, such care is aimed at patients with advanced COPD and is delivered in specialized institutions, Dr. Schols said in San Diego, CA at the annual meeting of the American Thoracic Society.  "I think we should shift toward a personalized lifestyle intervention" for less-advanced patients, Dr. Schols told reporters.

In the study, Dr. Schols and colleagues randomized 199 newly diagnosed patients with moderate disease - defined as a one-second forced expiratory volume of 60% of predicted valu - to usual care or to the rehab program. The rehab program consisted of four months of exercise training, smoking cessation, nutritional advice, and other support, followed by 20 months of maintenance. The endpoints were between-group differences in quality of life (measured on the St. George's Respiratory Questionnaire), shortness of breath (measured on the Medical Research Council five-point scale), and exercise capacity as tested by endurance on a stationary bicycle.

Compared with the usual care group, those getting the rehab program showed improvement in quality of life, cycle endurance  and improvement in shortness of breath.  They also had a greater level of perceived effectiveness, among both patients and caregivers.

Individual two-year costs were about $3,700 higher in the rehab program group than in the usual care group, the researchers said, and the incremental cost-effectiveness ratios was about $44,600 per quality-adjusted life-year (QALY). However, five patients saw their condition worsen markedly and were given hospital rehabilitation. If they were excluded, the cost per QALY was about $11,500.

Similar programs in the U.S. may be facilitated by planned changes in reimbursement for pulmonary rehabilitation, according to Dennis Doherty, M.D., of the Lexington Veterans Affairs Medical Center in Kentucky, who moderated a press conference at which the study was discussed.

Starting next January, the Centers for Medicare and Medicaid Services will be required to have a fee schedule for such care, Dr. Doherty said, which may lead to wider use of rehabilitation programs.

The Dutch study, he said, was unusual in that very few interventions show a four-point improvement on the St. George's scale. "It's tremendously difficult in these patients," he said. He added that a one-third of a point improvement on the MRC scale is also "pretty good."

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COPD World News     Week of June 21, 2009

Significant gaps in COPD patients’ knowledge

Halifax, NS - Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. However, little is known about the impact of COPD on the lives and attitudes of individuals living with this condition.

Researchers here and in other Canadian cities undertook a study to determine whether Canadians with COPD are properly educated and supported, and to recommend solutions to any care gaps identified.
In the study a total of 389 Canadians were surveyed who were 40years of age and older, physician diagnosed with COPD, and current or former smokers.

The telephone survey contained 68 items and took 35min to complete. COPD severity was classified according to symptom severity using the Medical Research Council (MRC) score.

Respondents tended to overestimate their disease severity and reported substantial symptom burden and psychosocial impact of living with COPD. Most individuals claimed to be well informed about COPD; however, their knowledge was poor in several domains including the causes of COPD, the consequences of inadequate therapy and the management of exacerbations.

Family physicians were the main health care providers. A minority of respondents had seen a lung health educator. And, it was determined that only 34% had ever received a written action plan and only 33% had been told how to prevent an exacerbation.

The symptom burden and psychosocial impact of living with COPD is substantial. However, there are significant gaps in patients’ knowledge about the management of COPD and little contact with lung health educators.

It was concluded that increased use of COPD-specific, self-management education programs may help rectify these care gaps.

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COPD World News     Week of June 14, 2009

Vitamin D may slow the progressive decline in asthma and COPD

Philadelphia, PA - Vitamin D may slow the progressive decline in the ability to breathe that can occur in people with asthma as a result of human airway smooth muscle (HASM) proliferation, according to researchers at the University of Pennsylvania.

The group found that calcitriol, a form of vitamin D synthesized within the body, reduced growth-factor-induced HASM proliferation in cells isolated from both persons with asthma and from persons without the disease. The proliferation is a part of process called airway remodeling, which occurs in many people with asthma, and leads to reduced lung function over time.

The researchers believe that by slowing airway remodeling, they can prevent or forestall the irreversible decline in breathing that leaves many asthmatics even more vulnerable when they suffer an asthma attack. “Calcitriol has recently earned prominence for its anti-inflammatory effects,” said Gautam Damera, Ph.D., who presented the research at the American Thoracic Society’s International Conference in San Diego last month.

“But our study is the first to reveal the potent role of calcitriol in inhibiting ASM proliferation.” The experiments were conducted with cells from 12 subjects, and the researchers compared calcitriol with dexmethasone, a corticosteroid prescribed widely for the treatment of asthma. Although, dexmethasone is also a powerful anti-inflammatory agent, the researchers found that it had little effect on HASM growth.

Dr. Damera and his colleagues found calcitriol inhibits HASM in a dose-dependent manner, with a maximum inhibitory effect of 60 percent.  As part of the University of Pennsylvania’s Airway Biology Initiative, the researchers are planning a randomized control trial of calcitriol in patients with severe asthma and expect to have data from the trial in about a year’s time.

With its anti-inflammatory qualities and its ability to inhibit smooth muscle proliferation, Dr. Damera said, calcitriol may become an important new therapy, used alone or in combination with already prescribed steroids, for treating steroid-resistant asthma. Dr. Damera and his colleagues have also conducted experiments to determine the mechanism by which calcitriol retards HASM proliferation. They believe the vitamin works by inhibiting activation of distinct set of proteins responsible for cell-cycle progression.

The investigators have also conducted experiments to determine whether calcitriol, which is currently used to treat psoriasis, could be an effective therapy for COPD. Although preliminary, their data shows that calcitriol appears to reduce pro-inflammatory cytokine secretions in COPD. As with asthma, the researchers believe, calcitriol may also have the added benefit of slowing, if not stopping, the progression of airway remodeling. Others in the field believe calcitriol may also have the potential to inhibit the development and growth of several types of cancer.

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COPD World News     Week of June 7, 2009

Relatively Low Levels of Smoking Can Lead to Severe COPD in Women

Bergen, Norway - Women seem to be more susceptible to the harmful effects of smoking than their male counterparts, according to findings from a case-control study of subjects with chronic obstructive pulmonary disease (COPD), presented at the international conference of the American Thoracic Society in San Diego.

The current study is not the first to suggest that smoking-related damage is worse in women than in men, reports lead researcher Dr. Inga-Cecilie Soerheim, from the University of Bergen, Norway,  "The novel aspect of our study is that we specifically examined subgroups of COPD subjects with either early-onset of disease or low smoking exposure."

Dr. Soerheim said that her team hypothesized that "if women are more susceptible to smoking-related lung damage, they will likely experience reduced lung function at an earlier age or after less smoking exposure than men."

To look into that, the researchers studied 954 subjects with moderate or severe COPD and 955 controls. All of the subjects were either current or former smokers. The researchers found that women had worse lung function and more severe disease than men in subgroups with early-onset COPD (less than 60 years of age) and low smoking exposure COPD (less than 20 cigarettes/day for less than 20 years). "In the low exposure group in this study, half of the women actually had severe COPD," Dr. Soerheim noted in a press release.

Dr. Soerheim commented that she and her colleagues were somewhat surprised by how many female smokers had severe COPD with relatively modest smoking histories. These findings have an important public health message, Dr. Soerheim emphasized.

"Many people believe that their own smoking is too limited to be harmful -  that a few cigarettes a day represent a minimal risk. But there is no such thing as a safe amount of cigarette smoking. Our data suggest that this is particularly true for female smokers." In addition, she said that the results, "together with other studies demonstrating similar findings, should definitely urge all physicians to be aware of COPD development in female smokers." 

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COPD World News     Week of May 31, 2009

Pulmonary Rehab modifies COPD progression

London, UK - Researchers have found that three years of pulmonary rehabilitation (PR) has shown to inhibit the decline in airflow obstruction, improve exercise endurance time, and body-mass index, in chronic obstructive pulmonary disease.

Pulmonary rehabilitation is known to be a beneficial treatment for COPD patients, however,to date, there is no agreement for how long a rehabilitation program should be implemented. In addition, current views are that pulmonary rehabilitation does not improve FEV1 or even slow its decline in COPD patients.

The aim of a recent study was to examine the efficacy of a 3 year outpatient pulmonary rehabilitation (PR) program for COPD patients on pulmonary function, exercise capability, and body mass index (BMI). Methods used in the study included a matched controlled trial that was performed with outcome assessments evaluated at 6, 12, 18, 24, 30, and 36 months.

Eighty patients with moderate to severe COPD were recruited with an average age of 63 and an FEV 1 rating of 48%.  The control group received standard care only, while the case study group received PR for duration of three years. These groups were matched for age, sex, BMI, FEV1% and number of pack-years smoked.

Results of the study showed that the decline in FEV1 after the three years was significantly lower in the PR group compared to the control group. Maximal sustained work and endurance time improved after a short period of PR and was maintained throughout the study, in contrast to the control group. As well, a decreased BMI was noted in the control group after three years, while in the PR group a mild improvement was seen. 

Researchers have concluded that three years of outpatient pulmonary rehabilitation resulted in modifying the disease progression of COPD, as well as improving physical performance in these patients. 

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COPD World News     Week of May 24, 2009

Diet, exercise and smoking cessation cuts COPD Symptoms

Maastricht, Netherlands - A lifestyle intervention program that promoted exercise, healthy eating and quitting smoking improved the health of people with mild to moderate chronic obstructive pulmonary disease (COPD) and was cost-effective, a new study shows. The patients in the study were randomly assigned to receive usual care or to participate in an interdisciplinary, community-based program (INTERCOM).

The first four months of the intervention program featured intensive lifestyle moderation. That was followed by 20 months of less intensive maintenance in which the patients were offered guidance but not rigorous intervention. After 24 months, the patients in the intervention program showed significant improvements in health status, exercise capacity, and breathing problems (dyspnea), compared to those in the usual care group.

Among those in the intervention group, improvements were noted at four months in COPD-specific quality of life, walk distance, exercise capacity, dyspnea, handgrip force and fat free mass index. After 24 months, significant improvements remained in exercise capacity, dyspnea and disease-specific quality of life.

During the two-year study, the overall cost per patient was about $3,686 more for the intervention group. But the researchers noted that the cost for patients in the intervention group is "front-loaded" and that maintenance costs were minimal.

"This is the first randomized controlled trial showing that community-based pulmonary rehabilitation is feasible and effective, even for patients with less advanced airflow obstruction, and that the INTERCOM program improves functional exercise capacity and health-related quality of life during 24 months relative to usual care at acceptable costs," Annemie Schols, a professor of nutrition and metabolism in chronic diseases at Maastricht University in the Netherlands, said in an American Thoracic Society news release.

"The INTERCOM program is based upon an integrated view on pulmonary and extra pulmonary manifestations of chronic obstructive pulmonary disease resulting from smoking, suboptimal diet, inactivity and disease susceptibility. These new findings from the INTERCOM trial could lead to a shift in clinical medicine and public health towards personalized lifestyle intervention," Schols said.

The study was presented at
the international conference of the American Thoracic Society, in San Diego, CA.

For more information:

COPD World News     Week of May 17, 2009

Exercising Throat Muscles May Relieve Sleep Apnea

Sao Paulo, Brazil - Tongue and throat exercises may help people with mild to moderate obstructive sleep apnea (OSA) find relief, a new report says.

A three-month program helped reduce OSA severity by 40 percent in the test subjects and improved symptoms such as low oxygen saturation levels in blood, sleepiness, snoring and poor sleep quality, according to the findings in the American Journal of Respiratory and Critical Care Medicine. Of the 10 moderate OSA sufferers who did the exercises, eight were reclassified afterward as having only a mild condition and two were upgraded to having no OSA.

"It was commonly thought among doctors that strengthening and toning oropharyngeal muscles would have no benefit to the patient during sleep, but a recent study showed that didgeridoo playing helped decrease snoring and OSA," study investigator Dr. Geraldo Lorenzi-Filho of the sleep laboratory at the University of Sao Paulo, Brazil, said in an American Thoracic Society news release. "This was a change of paradigm, and indicated that not everything you do during the day is lost during sleep.

"For the study, 16 people diagnosed with mild to moderate OSA performed a daily and weekly regimen of tongue and pharyngeal exercises, while 15 other sufferers performed a placebo treatment of deep breathing and nasal rinsing with saline solution. The control group experienced no change in their condition, and neither group experienced a change in weight or body size, two factors in the cause of OSA.

"The muscles of the upper airways are extremely complex, and the mechanisms leading to OSA are far from being well understood," Lorenzi-Filho said. "A strong muscle may be working on the wrong direction and not necessarily helping to open the airways. The overall set of exercises we tested target the correct physiology of the upper airway and should promote remodeling of the upper airways."

He said the researchers were unsure exactly how the exercises caused the change and if all of them were equally effective, but suggested further research would explore these questions.

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COPD World News     Week of May 10, 2009

Depression Increases Risk of Death in Stable COPD

Groningen, The Netherlands - Depression worsens the survival outlook for patients with stable chronic obstructive pulmonary disease (COPD), as well as those with uncontrolled COPD, researchers here found.

Among patients with stable disease, those who also had moderate to severe depressive symptoms were nearly twice as likely to die from any cause during follow-up as those with lesser symptoms, according to Jacob de Voogd, M.S., of University Medical Center Groningen, and colleagues.

"What is needed next is explication of both the determinants of depressive symptoms and of the pathway between these symptoms and mortality," the researchers reported in a recent issue of Chest.
Future studies should examine whether improvement in depressive symptoms will decrease mortality in these patients, they said.

Although depression increases the risk of death in patients with COPD during or shortly after an exacerbation, conflicting data have clouded the nature of same relationship in patients with stable disease, the researchers said. To find out, the researchers monitored 121 patients (mean age 61.5) with stable COPD (mean forced expiratory volume in one second 36.9% of predicted). They were studied from hospital admission for pulmonary rehabilitation through follow-up lasting up to 8.5 years.

All patients were clinically stable for at least six weeks before entering the study. Depressive symptoms were measured using the Beck Depression Inventory, a 21-item self-administered survey measuring attitudes and symptoms of depression. A score of at least 19 out of 63 was used to indicate the presence of depressive symptoms. Nearly one in five patients (19.8%) met that threshold.

Through follow-up, 63% of the patients died. Overall median survival was 5.3 years.
In a multivariate analysis, depressive symptoms were associated with all-cause death, independent of gender, age, and exercise capacity.

There were two possible explanations for the link between depression and mortality in patients with COPD, according to the researchers. First, some studies have shown that depression can detrimentally affect the functioning of the hypothalamic-pituitary-adrenal axis, they noted. Second, depressive symptoms can result in patients paying less attention to personal care, as indicated by poor nutrition, smoking, sedentary lifestyle, poor medication compliance, and failure to seek adequate healthcare. However, the researchers did not collect information on either of these possibilities.

The study had several limitations, they said, including inability to generalize results to patients with COPD who were not referred for pulmonary rehabilitation; lack of information on comorbidities, cause of death, and medication; use of a single assessment of depressive symptoms that can change over time; and the lack of data on behavioral changes, interventions, and hospitalizations during follow-up.

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COPD World News     Week of May 3, 2009

Tobacco, Marijuana Combine to Increase COPD Risk

Vancouver, BC - Smoking both tobacco and marijuana increases the risk of respiratory symptoms and chronic obstructive pulmonary disease (COPD), but marijuana alone apparently does not, Canadian researchers said.

The combination of the two was associated with a greater risk than smoking tobacco alone, according to Wan Cheng Tan, M.D., of the University of British Columbia in Vancouver, and colleagues. "We were able to detect a significant synergistic effect between marijuana smoking and tobacco smoking," Dr. Tan and colleagues said in the April 14 issue of the Canadian Medical Association Journal. But smoking marijuana alone was not associated with an increased risk, although Dr. Tan and colleagues said their observational study was too small to rule out such a link definitively.

The findings come from a random sample of 856 people 40 or older, who answered questionnaires about their respiratory history and their use of tobacco and marijuana. They also underwent spirometric testing before and after administration of 200 micrograms of salbutamol. The researchers found that 45.5% of participants were current or former marijuana smokers and 53.1% were current or former tobacco smokers.

Current smokers of both drugs (in the previous 12 months) accounted for 14%. The prevalence of COPD on spirometric testing was 19.3% -- 148 participants out of 856. COPD was defined as a ratio of one-second forced expiratory volume to forced vital capacity of less than 0.70 after bronchodilation. At the same time, 7.4% reported a physician's diagnosis of COPD and 52.6% reported respiratory symptoms, such as chronic cough or current wheezing.

Compared with nonsmokers, participants who reported smoking only tobacco had more frequent respiratory symptoms. Tobacco-only smokers were also more likely to have COPD. Concurrent use of marijuana and tobacco was associated with increased risk of respiratory symptoms.

The authors noted several limitations of the study. "We lacked data on possible variations in the potency of marijuana smoked over a participant's lifetime, on individual differences in method of inhalation used by smokers of only tobacco and by smokers of both tobacco and marijuana, on the proportion of smokers who combine marijuana and tobacco in the same cigarette, and on the concomitant use of other illegal drugs," they wrote.

Dr. Tan and colleagues also noted that the study only had enough power to detect a 15% difference between marijuana smokers and nonsmokers.  A larger study is needed, they said, to settle the question definitively.

So far, evidence on the issue has been very mixed, according to Donald Tashkin, M.D., of the University of California Los Angeles. While it seems clear that marijuana is responsible for some respiratory symptoms, he wrote in an accompanying commentary, there has been a "consistently reported absence of an association between use of marijuana and abnormal diffusing capacity or signs of macroscopic emphysema."  Given that, Dr. Tashkin said, "we can be close to concluding that smoking marijuana by itself does not lead to COPD."

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COPD World News     Week of April 26, 2009

Ozone Pollution Taking Toll on Lives

Berkeley, CA - Thousands of Americans are dying each year from lung disease caused by atmospheric ozone, a new study finds.The greatest risk may for those living be in hot, dry cities such as Los Angeles, which has one of the highest concentrations of ozone.

Residents of Los Angeles may face a 25 percent to 30 percent higher annual risk of dying from a respiratory ailment versus people in low-ozone areas such as the Great Plains, the researchers said.

The report, published in the New England Journal of Medicine, also found that that tiny components of smog called “fine particulate matter” had a clear link to cardiovascular deaths. “This is one of the first studies where we’ve been able to report separate independent effect from both particulate matter and ozone,” said lead researcher Michael Jerrett, an associate professor of environmental health sciences at the School of Public Health, University of California, Berkeley.

“With particulate matter, we see effects very strongly for cardiovascular mortality such as heart attack and stroke and, for ozone, we see them in respiratory deaths.  That suggests that we can’t just regulate particulate matter or ozone,” Jerrett continued.

“We have to look at dealing with both pollutants because they’re both exerting major impacts, but on different mortality outcomes.”An estimated 240,000 people in the United States and 7.7 million people worldwide die of respiratory disease each year, according to data from the World Health Organization.

Efforts to reduce ground-level ozone have stalled in recent years, Jarrett said, and now one in three Americans lives in an area that exceeds the national standard for ozone levels.A year ago, the U.S. Environmental Protection Agency did issue stricter air quality standards for ground-level ozone, but many scientists advocate still lower levels.When hovering seven miles above the earth, ozone is actually beneficial because it blocks ultraviolet radiation from the sun. However, closer to the ground it infiltrates the lungs and may cause damage.

A number of studies have tried to link ozone exposure with mortality but they have been inconclusive, the researchers noted.In their study, Jerrett and his colleagues cross-referenced American Cancer Society data with pollution data from 96 metropolitan areas in the United States. In all, the study included information on almost 449,000 people and included 118,777 deaths occurring over nearly two decades of follow-up.  The results: each additional 10 parts per billion (ppb) of ozone concentration was linked to a 4 percent increase risk of dying from respiratory causes, most notably pneumonia and chronic obstructive pulmonary disease (COPD).

The findings carry the knowledge of air pollution and its effect on health a notch deeper, one expert said.”This is something we’ve seen before with high levels of pollution, though we had not identified ozone as something causing respiratory diseases,” said Dr. Len Horovitz, a pulmonary specialist with Lenox Hill Hospital in New York City.

“We know it’s air pollution, but what in air pollution? Ozone is also a powerful greenhouse gas, Jerrett said, so measures to improve health might have the added benefit of slowing climate change. “Everybody knows we need to go greener. It’s just a question of how we do that,” Horovitz stated.

For more information:

COPD World News     Week of April 19, 2009

Eating Can Be Risky Business for COPD Patients

Pittsburgh, PA - Poor coordination between swallowing and breathing in chronic obstructive pulmonary disease (COPD) may increase risk of aspiration pneumonia and exacerbations, researchers warned.

COPD patients swallowed solid food during inhalation twice as often as healthy individuals, Roxann Diez Gross, Ph.D., of the University of Pittsburgh, and colleagues found. Patients inhaled after swallowing soft food four times more often, they reported in the April 1 issue of the American Journal of Respiratory and Critical Care Medicine.

Their experimental results showed that COPD patients don't always follow the normal and preferred exhale-swallow-exhale pattern, they said. Disruption of the normal breathing-swallowing pattern could increase risk for aspiration.  "The negative pressure of inhalation has the potential to draw food and liquid residue toward the lungs," they wrote.

Although aspirations may go unnoticed because these patients cough frequently anyway, importing oral bacteria and food particles into the lungs may increase pneumonia risk and contribute to exacerbations, Dr. Gross said. Oropharyngeal dysphagia is an underdiagnosed comorbidity in patients with COPD.  Indeed, COPD has been shown to be the most significant risk factor for aspiration pneumonia in nursing home patients in a prior study, the researchers noted.

To measure the extent of the breathing-swallowing problem, the researchers conducted a prospective study with 25 patients who had moderate to severe COPD and 25 matched, healthy controls. Participants were seated at a table and asked to eat vanilla wafer cookies and pudding. Each time a subject swallowed, respiratory inductance plethysmography and nasal thermistry simultaneously tracked the timing and volume of breathing; electromyography marked each swallow.

Healthy individuals almost exclusively swallowed during exhalation -- 94% of swallows exhibited this pattern as expected from prior studies -- and timed swallows to occur at a higher tidal volume whether at early to mid-exhalation, late inspiration, or inhalation-to-exhalation transition.  Likewise, 90% of swallows were followed by exhalation.

COPD patients, however, were 4.62 times more likely than controls to swallow bites of cookie during inhalation, 2.5 times more likely to inhale after swallowing pudding, and 2.81 times more likely to swallow pudding at a low tidal volume.  Whereas COPD patients were just as likely to have inhaled while swallowing soft food as solid food, among controls, it happened 80.5% more often while eating pudding than cookie.  Conversely, post-swallow inhalation didn't depend on food consistency among controls but occurred more often with pudding than cookies for COPD patients. Together, the findings suggested a disrupted pattern in COPD patients, that "seems to suggest that ventilatory drive or 'air hunger' can take precedence over deglutition when necessary" in these patients, the researchers said.

Other causes could include muscle fatigue of the upper aerodigestive tract, alterations in airway protective mechanisms, and anxiousness, they added.  Although the study was limited in size and ability to assess the impact of COPD severity because of inclusion/exclusion criteria, Dr. Gross said pulmonologists should be more alert to ordering swallowing studies for their COPD patients.  Another limitation of the study noted by the authors is that swallowing function was not measured. Patients can change their diet consistency or position while eating and even learn to recoordinate breathing and swallowing, she said. "There is something we can do about it."

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COPD World News     Week of April 12, 2009

Inhaling Helium Boosts COPD Pulmonary Rehabilitation

Calgary, Alta - For decades, scientists and youngsters at birthday parties have known that breathing helium has one powerful but short-lived side effect: it makes your voice sound like Donald Duck. Now there's a more useful application: researchers here say that breathing a heady mix of helium and oxygen may boost pulmonary rehabilitation for patients with chronic obstructive pulmonary disease. 

Patients who breathed 60% helium and 40% oxygen during rehabilitation were able to exercise longer and harder throughout the program compared with those who breathed normal air, Neil D. Eves, Ph.D., of the University of Calgary here, and colleagues reported in the March issue of Chest. The standard mix of gases in the air is dominated by nitrogen (78%) with 21% oxygen and only a trace of helium.  Providing extra oxygen reduces demand on the lungs while replacing the other gases with lighter-than-air helium cuts down on the problem of expiratory flow limitation to ease exhalation, Dr. Eves' group said. 

In an accompanying editorial, Roger S. Goldstein, M.D., and Thomas E. Dolmage, both of the West Park Healthcare Center in Toronto, called the intervention a creative and promising way to reduce the load on the lungs to reduce dyspnea during training.  "Although pulmonary rehabilitation improves symptoms and quality of life, it is challenging for most COPD patients to train at levels sufficiently high to improve peak oxygen uptake," they wrote. But it remains to be seen whether helium is better than supplemental oxygen, a nitrogen-oxygen gas mixture, a ventilator to take over some of the work of breathing, or a training program with short bursts of intense exercise, they added. 

"The possibility of longer term improvements in health risk and even mortality, in keeping with the rationale for most fitness programs, makes pursuing this theme worthwhile," Dr. Goldstein and Dolmage said.  So Dr. Eves' group randomized 38 nonhypoxemic patients with stable COPD to a pulmonary rehabilitation program in which they breathed either normal room air or a mix of 60% helium and 40% oxygen.  They exercised with 30 minutes of cycling, three days per week for six weeks at an intensity level that increased as they were able to tolerate it.  Patients breathed their designated gas through a tightly sealed mask supplied by a bag hung from the ceiling above. They weren't allowed to talk during or shortly after their exercise, lest the high-pitched voices of the helium give them away and unblind the intervention. 

For the primary outcome, exercise tolerance rose in both groups. But by the end of the study, the helium group had a significantly greater change in constant-load exercised time than the regular air breathers.  Likewise, substantially more patients in the helium-oxygen group were able to achieve a clinically relevant improvement of 1 minute, 45 seconds or more.  The helium-oxygen group also showed higher oxygen consumption at peak incremental exercise , and they worked at a higher output rate without a difference in exertional symptoms or heart rate.  Patients who breathed the helium mix showed a clinically meaningful improvement in health-related quality of life, measured on the St. George Respiratory Questionnaire, compared with those who breathed air.

Peak exercise exertional symptoms were similar between groups. For the same exercise time, patients who breathed helium and oxygen had a decrease in leg discomfort not seen in the air group, but without any significant differences between treatment groups.  One potential downside: researchers noted that the helium-oxygen mix -- at about $190 per patient for six weeks -- is more expensive than supplemental oxygen alone. The large suspension bags of gas also complicate the treatment regimen. 

Given this proof-of-concept, the researchers concluded that a larger randomized trial with cost-benefit analysis is needed to compare the helium treatment with supplemental oxygen in a real-world pulmonary rehabilitation setting.

For more information:

COPD World News     Week of April 5, 2009

Smoking Cessation Ads and Services have Impact in USA

Washington, DC - Differences in tobacco marketing and promotion and tobacco-control programs are among the reasons why adult smoking rates are almost twofold higher in some states than others, according to a new report by the U.S. Centers for Disease Control and Prevention.  About 28 percent of adults in Kentucky smoke, and 27 percent in West Virginia, compared with 14 percent of adults in California and 12 percent in Utah, the report found. 

Rates of decline in adult smoking will probably be too slow in almost all states, other than Utah, to achieve the federal government's Healthy People 2010 goal of reducing adult smoking rates to 12 percent or less, the report stated.  But, the authors said that it might be possible to meet that objective if all states implement comprehensive, evidence-based tobacco-control programs, including expanded access to smoking cessation services, such as quit phone lines. The findings are published in the March 13 issue of the CDC's Morbidity and Mortality Weekly Report.

The analysis of data from the 2007 Behavioral Risk Factor Surveillance System found that adult smoking rates varied from 31.1 percent to 8.7 percent among the 50 states, District of Columbia and the territories of Guam, Puerto Rico and the U.S. Virgin Islands.  Only Utah and the Virgin Islands met the goal of 12 percent or less.  In 2007, nearly 20 percent of adults in the United States were smokers.

Among states and the District of Columbia, smoking rates were highest in Kentucky, West Virginia and Oklahoma (26 percent) and lowest in Utah, California and Connecticut (15.5 percent). The smoking rate was 31 percent in Guam, 12 percent in the U.S. Virgin Islands and 9 percent in Puerto Rico.

Median smoking rates ranged from 15 percent to 29 percent for men and 8 to 28 percent for women. In 30 states, the District of Columbia and all three territories, men had significantly higher smoking rates than women, the report found.

Between 1998 and 2007, smoking rates declined in 44 states, the District of Columbia and Puerto Rico, but there were no declines in six states. The 2007 survey included 430,912 respondents. Cigarette smoking in the United States causes about 443,000 premature deaths and is responsible for $193 billion in direct health-care costs and productivity losses each year, the CDC said.

According to the Institute of Medicine, full implementation of comprehensive, evidence-based tobacco-control programs at CDC-recommended funding levels are needed to achieve major reductions in tobacco use in all states and areas.

For more information:

COPD World News     Week of March 29, 2009

Genetics Linked to COPD in Smokers

Winston-Salem, N.C. - Genetic variation may explain why some long-term smokers develop chronic obstructive pulmonary disease (COPD) while others don't, researchers here said.

In a case-control study, five variants in the gene ADAM33 were significantly associated with COPD, according to Eugene Bleecker, M.D., of the Wake Forest School of Medicine, and colleagues.More research is needed to tease out the biological significance of the variants in the pathogenesis of the disease, Dr. Bleecker and colleagues said online in Respiratory Research.

About 90% of COPD is attributed to smoking, but only 25% of chronic smokers actually develop it, for reasons that remain unclear, the researchers said. It's known that tobacco exposure, measured in pack-years of smoking, correlates with COPD risk, but that only explains part of the relationship, Dr. Bleecker and colleagues said.

Growing evidence -- including family history of obstructive airway disease or asthma -- suggests that "host or genetic factors appear to predispose some individuals with tobacco exposure to the development of smoking related respiratory disease," they said.

To clarify the issue, they looked at variation in ADAM33, a disintegrin gene within the metalloproteinase family previously linked with asthma. It was also linked with COPD in smokers, but in a study using the general population as a control group, which is "inappropriate," the researchers said. For this study, Dr. Bleecker and colleagues assembled a cohort of 880 Caucasian smokers, all over 50, who had smoked 20 or more pack-years. 

It divided them into two groups: those with COPD and those without.   Participants were said to have COPD if the ratio of one-second forced expiratory volume (FEV1) to forced vital capacity (FVC) was less than 70%, and if the predicted FEV1 was less than 75%. The control group was made up of participants whose FEV1/FVC was at least 70% and whose predicted FEV1 was 75% or greater.

Volunteers who didn't fall into either category were excluded from the main analysis. Most demographic variables were similar between the groups, but those with COPD tended to be older (67.3 years versus 64.4) and to have smoked more heavily (58.6 pack years compared with 45.9). Smoking history in pack years was significantly correlated with predicted FEV1.

The researchers genotyped 25 single nucleotide polymorphisms (SNPs) in the ADAM33 gene, looking for those that were significantly different in cases and controls. At first cut, they found five that were significant.  But only two remained significant after a correction for multiple tests. 

A limitation of the study is that the researchers did not formally test for population stratification, Dr. Bleecker and colleagues said.

For more information:

COPD World News     Week of March 22, 2009

Body's Defenses may Worsen Chronic Lung Diseases in Smokers

Cincinnati, OH - Although the immune system is designed to protect the body from harm, it may actually worsen COPD, according to new University of Cincinnati (UC) research.

In a preclinical research study, UC environmental health scientists have identified a link between cigarette smoke and activation of a specific cellular receptor (NKG2D) critical to immune system activation. They say the finding is key to understanding COPD disease progression and developing future interventional drug therapies. "People have historically believed that if you smoke, you suppress the immune system. We’ve shown that you actually activate certain parts of the immune system and it could potentially work against you."

The findings will be reported in an upcoming issue of the Journal of Clinical Investigation. It is the first study to report data defining a link between the immune system and COPD disease progression and severity.

Researchers hypothesized that when tissue was damaged, the cells would send signals to the immune system indicating they are transformed—similar to cancer or virally infected cells—and must be destroyed.

Scientists examined molecular signaling pathways in lung tissue exposed to cigarette smoke and found a strong correlation between cellular stress signals, activation of the immune system and development of COPD-like disease. This method was repeated and cross-referenced in tissue samples from a human cohort that included non-smokers, smokers with COPD and smokers who did not develop COPD.  In patients who had never smoked, there was a complete absence of the NKG2D signal.  Current and former smokers who developed the disease expressed signals that correlated with severe COPD disease.

By combining both sets of data, they determined that cigarette smoke set off a molecular chain of events resulting in activation of a specific receptor—NKG2D—in lung cells, causing the immune system to attack stressed (damaged) lung tissue.

"Our study is evidence that when the lungs are exposed to chronic damage from cigarette smoke, at some point that damage exceeds the body’s natural ability to repair tissue and can start to contribute to COPD instead of protecting against it."

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COPD World News     Week of March 15, 2009

Respiratory Problems Rise on Hot, Humid Days

New York, NY - Hospitalizations for respiratory problems rise on hot, humid days -- foretelling what global warming may bring -- a study of 12 European cities suggests.

The study, which tracked weather data and hospital admissions over several years, found that on days when a city's temperature approached its typical maximum, hospital admissions for respiratory causes tended to spike. Adults age 75 and older appeared particularly vulnerable, the researchers report in the American Journal of Respiratory and Critical Care Medicine.

The findings are important, the researchers write, because climate change is expected to increase "extreme weather events" and boost air pollution -- which could exacerbate respiratory ills like chronic obstructive pulmonary disease (COPD).

For the study, researchers led by Dr. Paola Michelozzi of the Local Health Authority in Rome used weather data collected over at least three years to calculate a "maximum apparent temperature" for each city.  The measure was based on both temperature and humidity.In most of the dozen cities, the researchers found, hospitalizations for breathing problems increased when the temperature went beyond 90 percent of a city's maximum apparent temperature.

Among elderly adults in Mediterranean cities, hospital admissions rose by 4.5 percent for each degree increase beyond the 90-percent threshold, Michelozzi and her colleagues found. That figure was 3 percent in Northern European cities.

Hospital admissions for respiratory causes included infections, such as the flu and pneumonia, and flare-ups of chronic conditions like asthma and COPD -- which includes emphysema and chronic bronchitis.

Worsening COPD is a common cause of hospitalizations among the elderly, the researchers point out. Excessive heat, they explain, may create inflammation in the airways, and cause elderly COPD patients to hyperventilate and become breathless.

"Under climate change scenarios," the researchers write, "the increase in extreme weather events and certain air pollutants, especially ozone, are likely to further aggravate chronic respiratory diseases. "They conclude, "Public health interventions should be directed at preventing this additional burden of disease during the summer season.

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COPD World News     Week of March 8, 2009

FDA Approves Symbicort for COPD

Silver Spring, Md.  - The FDA has expanded the indication of the asthma treatment budesonide/formoterol fumarate dihydrate (Symbicort) to also treat airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), drugmaker AstraZeneca announced here.

The twice-daily 160/4.5 mcg dose of the drug is indicated to treat airflow obstruction related to chronic bronchitis and emphysema.

The approval followed results from two phase III trials of more than 3,600 COPD patients over age 40 in which the drug significantly improved lung function within five minutes of the first dose and sustained the improvement for the duration of the studies -- six months in one case and 12 in the other.

Incidence of pneumonia was similar between the drug group and the placebo group in both trials, but there was a higher incidence of potential lung infections such as bronchitis and viral lower respiratory tract infections among patients receiving the drug than among those who took formoterol 4.5 mcg or placebo, according to the company.

Common adverse events included the common cold, oral candidiasis, bronchitis, sinusitis, and viral upper respiratory tract infection.  The drug has been available in the U.S. in inhaler form since June 2007 for the long-term treatment of asthma in patients 12 and older.

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China Study Blames Indoor Burning for Causing COPD

Hong Kong, China - A study of more than 20,000 people in China has shown that exposure to burning solid fuel indoors for heat and cooking may cause COPD. The finding, published in the European Respiratory Journal, is significant because COPD has long been associated with smoking and very little research has been done to find out why non-smokers also suffer from the disease.

The study covered 20,245 people over 40 years of age in seven Chinese cities and provinces who were interviewed about their smoking habits, family health history and exposure to smoke from solid fuels, such as wood, coal, grass and dung. Among the participants, 12,471 were non-smokers and 5.2 percent of them were diagnosed as suffering from COPD.

The prevalence of COPD among non-smokers varies widely from country to country: 6 percent in Mexico City, 9 percent in the United States and 16 percent in Santiago de Chile. These statistics suggest the illness may be linked to other causes such as differences in lifestyle, behavior and exposure to various toxic substances. After adjusting for other possible causes, including passive smoking, the Chinese researchers found that exposure to various types of smoke in the home, such as that produced by burning coal and biomass, was the leading cause of COPD in non-smokers.

Around 73 percent had been exposed for at least a year to burning fuel indoors for the purpose of heating or cooking. In four out of 10 cases, kitchen ventilation was poor and both men and women were harmed, they added. Nearly four-fifths of the non-smokers, or 78 percent, were also found to have lived with tobacco fumes.

It is well known that children of smoking parents are more likely to suffer from respiratory disease as adults and the researchers said the problem will be more acute in China, where nearly 40 percent of adults smoke. "Our results can probably be applied to other developing countries, such as India and Nepal, which have a similar indoor pollution problem", wrote the researchers. They hoped a substantial number of COPD cases could be avoided through health education, better ventilation in kitchens and getting people to quit smoking.

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COPD World News     Week of March 1, 2009

Video Imaging Provides Dynamic View of Airway Obstruction in Those With Sleep Apnea

Seongnam, South Korea - A video imaging technique demonstrates that the soft palate is more elongated and angled in patients with obstructive sleep apnea both when they sleep and when they are awake, according to a study published in the February issue of Archives of Otolaryngology-Head & Neck Surgery.

The identification of the obstruction site of upper airway in patients with obstructive sleep apnoea is essential in choosing the appropriate treatment, especially surgical intervention,” the authors wrote.

A variety of methods, including computed tomographic (CT) scanning or magnetic resonance imaging, have been used and previous studies conducted to identify changes in the upper airway of patients with this condition. However, most of the research has been performed when patients were awake or using techniques that produce static, non-moving images.

Chul Hee Lee, MD, Seoul National University College of Medicine, Seongnam, South Korea, and colleagues used sleep videofluoroscopy—a method combining X-ray images with video recording to enable visualisation of airway changes—to evaluate 63 consecutive patients. Of these, 53 were classified as having obstructive sleep apnoea and 10 were diagnosed as simple snorers.

Participants underwent polysomnography at night and then sleep videofluoroscopy before and after sleep was induced by intravenous administration of midazolam. Respiratory events lasting 15 seconds in which blood oxygen levels did not decrease, as well as any drop in blood oxygen levels of 4% or more, were recorded.

Desaturation sleep events were detected in all of the patients with obstructive sleep apnoea but were not observed in simple snorers. When the patients were awake and breathing in, the length and angle of the soft palate increased in patients with obstructive sleep apnoea but not in simple snorers; the soft palate also changed length and angle during desaturation sleep events.

The sites of airway obstruction could be identified with the sleep videofluoroscopy during desaturation sleep events. The most common obstruction was soft palate plus tongue base (43.5%), followed by soft palate (34%), and tongue base alone (22.5%).

”Sleep videofluoroscopy quantitatively showed that the soft palate was considerably elongated and angulated in patients with obstructive sleep apnoea even in an awake state,” the authors wrote. “It is an easy way to measure the soft palate changes and may be a useful technique to differentiate obstructive sleep apnoea from simple snoring with short examination time.”

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COPD World News     Week of February 22, 2009

Discriminate use of antibiotics for exacerbation of COPD

Basel, Switzerland - The relevance of antibiotics in the treatment of acute COPD exacerbation has been a matter of debate for several years.

Although expert recommendations may vary, there is general agreement about the fact that not all patients will equally experience benefits from antibiotics. Apart from decreasing costs, discriminate use of antibiotics is capable of significantly reducing subsequent colonization or infection with antibiotic-resistant bacteria.

Several meta-analyses support the concept that patients with increased dyspnea, increased sputum volume, and increased sputum purulence will benefit from antimicrobial therapy. Evidence from randomized trials substantiates the prescription of antibiotics in patients receiving mechanical ventilation and the avoidance of antibiotics in those admitted with low serum procalcitonin levels.

Most of the proposed criteria for prescribing or withholding antibiotics for acute exacerbation have been analyzed in different retrospective study designs. Patients requiring ICU care and mechanical ventilation for chronic obstructive pulmonary disease exacerbation should receive antibiotics. Conversely, antibiotics can be withheld in patients admitted to the emergency department with low serum procalcitonin levels.

Patients with type I Anthonisen exacerbation and those with severe functional impairment are likely to benefit from antibiotics. Further investigations are needed to compare long-term outcome in patients treated according to clinical and functional criteria.

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COPD World News     Week of February 15, 2009

Long-term Erythromycin cuts COPD Complications

New York, NY - People with moderate to severe COPD may be able to reduce the frequency of exacerbations through a regular, low dose of a common antibiotic, a new report says.

The study, published in the American Journal of Respiratory and Critical Care Medicine, found that twice-daily 250-milligram doses of erythromycin reduced exacerbations by as much as 35 percent. The double-blind, placebo study found that more than twice as many COPD-related hospitalizations occurred among the placebo group, and that the median duration of the exacerbations was nine days in the erythromycin group, compared with 13 days in the placebo group.

"Our results did not allow us to determine a mechanism for these findings. However, based on in-vitro studies, we suspect that the mechanism is likely to involve the anti-inflammatory properties of erythromycin. Dr. John Heffner, past president of the American Thoracic Society, said "Exacerbations occur about once a year among patients with moderate to severe COPD...Many patients with advanced COPD receive highly potent, extended spectrum antibiotics during acute exacerbations".

He added, "The relative risks of breeding resistance with a long-term preventative use of erythromycin versus more frequent short-term dosing of highly potent antibiotics for acute exacerbations require careful analysis. If future studies demonstrate similar efficacy of prolonged erythromycin therapy, especially if patients are already receiving inhaled steroids and long-acting bronchodilators, the benefits likely will outweigh the risks."

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COPD World News     Week of February 8, 2009

Loss of Height Linked to Respiratory Problems

Newcastle upon Tyne, UK - When the ratio of arm span to standing height is high in older patients, it may be an indicator of respiratory problems, researchers here said.

Increased ratios were significantly associated with reduced respiratory airflow volumes and increased severity of dyspnea (P>0.001), Maw P. Tan, M.D., of Newcastle University, and colleagues reported in the February issue of CHEST.The measurement was also associated with right heart chamber dilation.

"Our study should draw attention to the potential importance of arm span measurements in spirometry assessments . . . as well as the potential clinical significance of the discrepancy between arm span and height," the researchers said.  Arm span is the closest physiologic measurement to height, the researchers noted. Increased arm span-to-height ratio, therefore, indicates a loss of height, a feature of aging.

To determine whether the discrepancy between arm span and height is associated with respiratory problems, the researchers conducted a single-center study of 66 older patients (41 female, mean age 71) who were evaluated for suspected pulmonary heart disease. Each was evaluated with a clinical history and physical examination followed by measurements of arm span, standing height, weight, and spirometry.  Arm span-to-height ratio was significantly negatively correlated with forced expiratory volume (FEV1) and forced vital capacity (FVC) (P<0.001), and was positively correlated with the New York Heart Association classification for dyspnea (P<0.05).

The generalizability of the findings was limited by the small study size and enrollment only of patients with an elevated transtricuspid pressure gradient.  Arm span-to-height measurements also were not obtained at more than one time point. Right atrial and right ventricular dilation were also associated with a significantly higher arm span-to-height ratio, which suggests that "respiratory compromise due to loss of height may be complicated by right heart failure, further increasing our suspicion of a previously under-recognized chronic respiratory disorder," the researchers said.

They added that the association between increasing ratio and right heart dilation could be explained by the presence of chronic hypoxia as a result of reduced functional capacity or hypoventilation "from increased work of breathing due to skeletal deformities."

They concluded that their findings necessitate further research into the relationship between loss of height and dyspnea, as well as the "importance of arm span measurements in lung function assessments."

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COPD World News     Week of February 1, 2009

Vitamin D may help reduce inflamation

Leuven, Belgium - Researchers from the Respiratory Division, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium, stated recently that the discovery that the vitamin D endocrine system regulates a very large number of genes and their associated biological processes improved insight into the fundamental role of vitamin D and sun-exposure for human health .

Accumulating epidemiological data are linking a low vitamin D nutrional status to highly prevalent diseases such as cancer, auto-immune diseases and chronic infections.

About half of the world's elderly and to a lower extent also the adult population has insufficient to deficient 25-OHD serum levels and so, several intervention studies are currently being undertaken to study the impact of adequate vitamin D supplementation in chronic diseases. In this perspective researchers here claim that COPD is such a candidate disease for which vitamin D supplementation might be beneficial.

Epidemiological studies revealed a dose-dependent association between serum 25-OHD levels and pulmonary function so that adequate vitamin D supplementation may extend beyond the protection against osteoporotic fractures.

In line with the novel insights on its immune function, it is tempting to speculate that vitamin D may down-regulate the inflammatory immune response in the airways whilst boosting innate immune defense against different micro-organisms.

Apart from its effects on osteoporosis, vitamin D may also interfere with other co-morbidities of COPD such as skeletal muscle weakness, cardiovascular disease, and cancer. As current respiratory treatments in COPD fail to reverse disease progression, interventional trials that may exploit the broader potential of vitamin D, are warranted.

An additional challenge of such studies will be to define optimal serum 25-OHD levels for such non-calcemic endpoints.

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COPD World News     Week of January 25, 2009

More Gender Injustice: Smoking Cessation Harder for Women

Philadelphia, Pa - Smoking is bad news for everyone, but judging by some recent studies, it's extremely problematic for women.

Researchers at the Mayo Clinic say there is no evidence to confirm if men or women have more success in smoking cessation, but that the process is more intense for women.  Apparently, women report more depression, irritability, anxiety and lethargy. Sound bad? That's only the half of it.

The study also suggests that women experience more weight gain after quitting. The average is five to 10 pounds, and researchers say this makes women tense and thus leads them back to smoking. And, still women face even more smoking-related problems. The Mayo Clinic study also indicated they also have a reduced ability to concentrate post-cessation. This is doubly problematic for women who carry a particular gene for an enzyme that regulates dopamine in the brain.

The University of Pennsylvania School of Medicine says the enzyme can result concentration problems and other cognitive deficits when abstaining from nicotine and this can support relapse. While, that last problem can affect male smokers as well, the deck is obviously stacked against women when it comes to smoking cessation.

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One Patch Doesn't Fit All

Philadelphia, Pa - For David Sachs, MD, who estimates he has tried to wean 20,000 smokers off tobacco in the past 25 years, this is a "paradoxical" time for anyone trying to kick the habit. "It's the best of times because never have physicians had more effective tools to treat tobacco dependence," Dr. Sachs declared at the 2008 American College of Chest Physicians conference in Philadelphia. "It's the worst of times because few know how to use them."

That's a pity because smokers are 30 percent more likely to quit with assistance from their health care providers, according to Virginia Reichert, NP, another veteran nicotine dependence counselor.

It isn't that America has not made progress in tobacco control. About 20.8 percent of U.S. adults smoke today, less than half the rate (about 44 percent) who smoked in the 1960s, according to the AHRQ. Former smokers outnumber current smokers. But if clinicians don't know the contraindications related to cessation medications, or don't bother to learn about nicotine withdrawal symptoms, it's far less likely their patients will sustain quit attempts.

As the new HHS guideline makes clear, the U.S. Food and Drug Administration has now approved seven medications it says dramatically increase the success of quitting. Will Medicare's recent decision to reimburse for smoking cessation counseling motivate more physicians to master all these treatment options, digest the new HHS guidelines, and pursue smoking cessation seriously? "That remains to be seen," Reichert said.

For more information: "Treating Tobacco Use and Dependence: 2008 Update" is available online -

COPD World News     Week of January 18, 2009

Diesel fumes increase COPD risk

Boston, MA -  Long-term exposure to diesel exhaust fumes may increase the risk of chronic obstructive pulmonary disease (COPD), which includes lung conditions - bronchitis and emphysema.

U.S. researchers studied the job and health records of more than 30,000 railway workers and found that those who worked on diesel trains (engineers, brakemen, conductors) were more likely to die of COPD than those who worked in ticketing, signaling, maintenance, or administration. The health records used were from the U.S. Railroad Retirement Board, dating back to 1959.

Diesel exhaust includes fine particulate matter and combustion gases that can be inhaled deep into the lungs. Previous studies have made a link between the organic compounds in diesel exhaust and allergy, airway inflammation, and changes in airway functioning.

The COPD risk for workers directly exposed to diesel exhaust increased by 2.5 percent per year of employment. That risk fell slightly after adjusting for smoking, a known risk factor for COPD, said lead researcher Dr. Jaime Hart, of Brigham and Women's Hospital and Harvard Medical School in Boston, according to a news release from the two institutions.

The study was published in the journal Occupational and Environmental Medicine.

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COPD World News     Week of January 11, 2009

GERD More Common in People with COPD

Madrid, Spain - According to researchers with the Spanish Centre for Pharmacoepidemiologic Research gastroesophageal reflux symptoms may be more common in patients with COPD than in control subjects. The aim of their recent study was to investigate the relationship between diagnoses of COPD and gastroesophageal reflux disease (GERD) in primary care.

Gastroesophageal reflux disease (GERD) is a common GI disease that has recently been defined, by the Montréal definition, as "a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications."  The Montréal definition identified a number of extraesophageal syndromes that are associated with GERD. These include reflux cough and reflux asthma syndromes. Several small studies have also suggested that gastroesophageal reflux symptoms are more common in patients with COPD than in those without the condition. COPD is characterized by airflow limitation that is not fully reversible by β2-agonist agents.

Patients with COPD often experience acute exacerbations of the disease, which are a major cause of morbidity and mortality. These are characterized by the presence of worsening dyspnea, increased sputum production, and the development of purulent sputum.

It has also been suggested that an increase in the frequency of COPD exacerbations can be associated with the presence of GERD. However, little is known about the temporal relationship between the two diseases. The researchers have previously shown that a diagnosis of COPD is associated with an increased likelihood of a subsequent diagnosis of GERD, but the reverse relationship has not been investigated.

In the current study, they sought to explore further the relationship between COPD and GERD that are diagnosed in the primary care setting, and to identify patient characteristics that are associated with diagnoses of these two diseases. The researchers conducted two longitudinal cohort studies to investigate this relationship in UK primary care using the General Practice Research Database (GPRD).

Although the association they found between GERD and COPD was fairly modest, this study emphasizes that these two diseases coexist, and that COPD may predispose patients to GERD. Although their results show that GERD does not appear to predispose patients to the development of COPD, it is possible that GERD may worsen the frequency of COPD exacerbations. This may help to explain the results of a recent study that found patients with GERD and COPD had worse health-related quality of life than patients with COPD alone.

The researchers stated that improvements in respiratory symptoms have been observed in patients receiving acid-suppressive therapy for GERD. While GERD therapy is unlikely to slow the development of COPD, it may reduce the overall symptom burden of patients with GERD and COPD, thereby improving overall health-related quality of life. Primary care physicians should keep in mind that COPD patients may also be struggling with the symptoms of GERD. Validated questionnaires could also be used to diagnose GERD to assess the impact that it has on the patient's quality of life and also to ensure that they are managed appropriately.

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COPD World News     Week of January 4, 2009

Home-Based Rehabilitation Helpful for Patients With COPD

Montreal, PQ - For patients with chronic obstructive pulmonary disease (COPD), home-based pulmonary rehabilitation is a useful, comparable alternative to outpatient rehabilitation, according to the results of a randomized, multicenter, noninferiority trial reported in the December 16 issue of the Annals of Internal Medicine.

"By focusing on the multiple needs of patients with COPD, pulmonary rehabilitation offers the best chance to address the disability associated with this chronic, progressive disease," write Francois Maltais, MD, and colleagues from the Chronic Obstructive Pulmonary Disease Axis of the Respiratory Health Network, Fonds de la recherché en santé du Québec. "Home-based rehabilitation is a promising approach to improve access to pulmonary rehabilitation."

The goal of this study was to evaluate whether self-monitored, home-based rehabilitation is comparably effective to outpatient, hospital-based rehabilitation in patients with COPD. At 10 academic and community medical centers in Canada, 252 patients with moderate to severe COPD received a 4-week education program and were then randomly selected to receive 8 weeks of home-based rehabilitation or outpatient, hospital-based rehabilitation. Follow-up continued for an additional 40 weeks.

The main endpoint was the change in Chronic Respiratory Questionnaire (CRQ) dyspnea subscale score at 1 year. By including all patients with analyzable data at the specified follow-up time, regardless of their level of adherence, data were analyzed with a modified intent-to-treat approach with use of regression modeling and adjustment for the effects of center, sex, and baseline level. Differences between interventions were calculated as home intervention minus outpatient intervention. At 1 year, improvements in the breathlessness subscale were similar in both groups.

"Home rehabilitation is a useful, equivalent alternative to outpatient rehabilitation in patients with COPD," the study authors write. Limitations of this study include inability to determine the contribution of the educational program to the observed improvements in health status and exercise tolerance, lack of blinding, missing primary outcome results for 14% of participants, and self-reported primary outcome.

"Poor access to pulmonary rehabilitation programs impedes widespread use of this effective intervention," the study authors conclude. "We propose that self-monitored, home-based pulmonary rehabilitation could be easily implemented in many countries. The opportunity to offer different pulmonary rehabilitation settings tailored to individual needs should improve the accessibility to this intervention."

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