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Chronic obstructive pulmonary disease: exacerbations and clinical aspects

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1HJ Starkie, 1AH Briggs, 1CL Hart, 1M Gillies, 1K MacIntyre, 2MC Shepherd. 1Section of Public Health and Health Policy, University of Glasgow, Glasgow, UK, 2Division of Immunology, Infection and Inflammation, University of Glasgow, Glasgow, UK

Objective: To compare chronic obstructive pulmonary disease (COPD) prevalence and mortality risk in a single population using alternative diagnostic criteria.

Methods: The global initiative for chronic obstructive lung disease (GOLD) is based on lung function alone, whereas the UK National Institute for Health and Clinical Excellence (NICE) criteria include lung function, respiratory symptoms and other risk factors. These criteria were applied to a Scottish prospective cohort (Renfrew/Paisley (Midspan) study) of 15 402 men and women aged 45–64 years at baseline and followed for over 30 years. All-cause and COPD mortality were modelled using Cox regression analysis.

Results: Overall COPD prevalence for men (women) was 31% (20%) applying GOLD criteria compared with 12% (5%) applying NICE criteria. Prevalence was strongly related to age (see table). Kaplan–Meier curves for COPD mortality by disease severity showed greater separation under NICE criteria compared with GOLD. Following Cox regression analysis (adjusting for age, smoking pack years, diastolic blood pressure, cholesterol, body mass index and social class), participants meeting NICE diagnostic criteria were found to have increased hazard ratios (HR) by disease severity for both all-cause and COPD mortality, compared with those meeting the GOLD criteria. The HR for COPD mortality for men in the most severe COPD group, compared with those without COPD, was 92 (95% CI 58 to 148) applying GOLD and 110 (95% CI 70 to 171) applying NICE. A separate analysis showed respiratory symptoms and pack years, independent of lung function, to be significant contributors to mortality risk for all-cause and COPD mortality.

Abstract S150 Table COPD prevalence by age, sex and diagnostic criteria (%) in the Renfrew/Paisley study

Conclusion: COPD prevalence in this population is high. GOLD diagnostic guidelines are often considered the “gold standard” in COPD, yet they may overestimate the COPD burden: prevalence of 31% (20%) compared with 12% (5%) has important ramifications by way of planning and funding decisions at the micro and macro level. Mortality risk increased with disease severity and was higher using NICE compared with GOLD criteria: the inclusion of symptoms and risk factors within the diagnostic criteria enabled high-risk and low-risk participants to be better distinguished. Independent of reduced lung function, symptoms and pack years were found to be associated with premature all-cause and COPD mortality.


1R Buckingham, 2P Mallia, 2R Kaiser, 2A Patel, 1RS Stone, 2CM Roberts. 1Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK, 2Whipp’s Cross University Hospital, London, UK

Background: Patients with chronic obstructive pulmonary disease (COPD) often require assessment for provision of domiciliary oxygen in various forms including long-term oxygen therapy (LTOT), ambulatory oxygen and short-burst oxygen. The British Thoracic Society (BTS) has published guidelines regarding assessment and follow-up of patients requiring home oxygen provision. We examined the availability of home oxygen assessment and standards of care provided by respiratory medicine departments in the UK.

Methods: As part of the National COPD audit 2008 we surveyed 239 acute secondary care units in the UK using an online questionnaire to assess home oxygen services.

Results: 96% of units had some form of hospital based LTOT assessment and 73% screened all patients in clinic to detect SaO2 less than 92%. 97% of units optimised oxygen flow to achieve a PaO2 greater than 8 kPa but only 46% always used a concentrator machine as the oxygen source. Only 56% of units met in full the BTS criteria for follow-up arrangements for patients prescribed LTOT. Only 58% of units met in full the provision of written information to all patients receiving oxygen. 56% of units provided ambulatory oxygen for all suitable patients and 39% screened all patients before referral for assessment. Only 41% of units met in full the BTS criteria for follow-up of patients prescribed ambulatory oxygen. 75% of units provided short-burst oxygen for all suitable patients but only 47% assessed all patients for suitability for short-burst oxygen. 71% of units carried out regular audits of oxygen prescribing. We also surveyed funding for oxygen services and the majority of units (60%) did not receive funding for providing this service.

Conclusions: The majority of respiratory medicine departments in the UK provide assessment of suitability for LTOT, but only just over half have adequate follow-up arrangements. Provision of ambulatory oxygen and short-burst oxygen is much less widely available. Despite providing these services the majority of units in the UK do not receive funding for this.


1S Barratt, 1JW Dodd, 2RJ Buckingham, 2NA Pursey, 2D Lowe, 2CM Roberts, 2RA Stone. 1Somerset Lung Centre, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK, 2The Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK

Background: Little is known about the course of chronic obstructive pulmonary disease (COPD) patient care before admission or the opportunities to improve primary care interventions. As part of the 2008 National COPD Audit, hospital teams were asked to send questionnaires to the general practitioners (GPs) of the first 30 patients admitted with a COPD exacerbation during the audit period. This detailed patient care in the 12 months before the index admission.

Results: 2521/6660 (38%) GP responses were received. Missing data for specific questions were omitted from the relevant analysis and are reflected by denominators of 2521 or less. 90% of patients were recorded by GPs to have COPD before their index admission. Patient contacts with primary care in the 12 months before admission are given in the table. A median (interquartile range; IQR) of two (0–4) courses of prednisolone and three (1–6) courses of antibiotics was prescribed to each patient in the previous 12 months. 34% (686/2041) of patients were prescribed a rescue pack of antibiotics. Spirometry information was available for 84% (1893/2244) of those known to have COPD with a median FEV1 of 0.89 (0.65–1.21) recorded a median (IQR) of 8 (4–15) months before their admission. 74% (1786/2400) of patients were using a combination inhaler (Symbicort/Seretide) and 11% were not on any long-acting BD or inhaled corticosteroid medications at all. 15% (313/2054) had undergone pulmonary rehabilitation in the past 12 months. GPs rated the communication of discharge information about COPD exacerbations as average, poor or very poor in 45% (1068/2384).

Conclusion: This is the first UK survey of COPD patient characteristics before admission. Most are known to have COPD and are characterised by frequent exacerbations. They have multiple contacts with primary care. Despite this, many are not seen in practice airway clinics and are not treated with LABA and inhaled steroids. Only one-third are given rescue antibiotics. Few patients undergo pulmonary rehabilitation and GP’s report dissatisfaction with hospital discharge summaries. There appears to be an opportunity for primary care interventions to reduce admission and exacerbation frequency. Communication between hospital and primary care must be improved if interventions are to be effective.

Abstract S152 Table


JK Quint, JJP Goldring, JR Hurst, GC Donaldson, JA Wedzicha. University College London, London, UK

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with a rise in sputum and systemic inflammatory markers. We investigated whether this rise varied depending upon the pathogen detected at exacerbation and whether viral load affects cytokine response.

Methods: We studied 24 patients (15 men) from April 2006 to April 2008; mean age 74.1 years (SD 9.3), FEV1 1.13 litres (0.44), FEV1% predicted 49.3% (17.9), body mass index 27.5 kg/m2 (5.3) and smoking history 41.5 pack years (25.8). All patients were sampled at baseline (>42 days post and >14 days pre an exacerbation) and within 7 days of the onset of an exacerbation, before initiation of treatment. Exacerbations were defined using diary cards according to our usual definition of two symptoms (major and/or minor), or if in the opinion of the clinician the patient had an exacerbation. All patients had sputum samples sent for routine bacterial culture, real time PCR for quantification of viral load for human rhinovirus (HRV) and cytokine analysis (IL-6 and IL-8). 38 patients had blood for IL-6, 22 for IL-8. All baseline sputum samples were negative for bacteria or HRV.

Results: 42 exacerbations were studied; 19 no pathogen detected, five HRV only, 14 bacteria only and four HRV and bacteria. In all there was a statistically significant increase in sputum IL-8 and blood IL-6 from baseline to exacerbation (both Wilcoxon p<0.001). The increase in blood IL-6 was greater with bacterial detection at exacerbation compared with HRV (mean 80.2 (116.0) vs −0.73 (8.4), Mann–Whitney p = 0.001). Absolute sputum IL-8 and blood IL-6 levels were higher at exacerbation if bacteria was detected (Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pneumoniae) compared with HRV; log sputum IL-8 mean 3.9 (0.31) versus 3.5 (0.36); analysis of variance (ANOVA) p = 0.04 and log blood IL-6 mean 1.5 (0.67) versus 0.46 (0.32); ANOVA p = 0.008. The cytokine response at exacerbation was independent of viral load; sputum IL-8 ANOVA p = 0.42 and blood IL-6 ANOVA p = 0.40.

Conclusions: Bacterial exacerbations of COPD result in greater cytokine increases of sputum IL-8 and blood IL-6 than HRV exacerbations. HRV may trigger a different type of cytokine response.

Funding: This abstract was funded by NIH RO1 HL082578.


1S Baird, 1A Ashish, 1J O’Connor, 1L Davies, 2J Hadcroft, 1R Angus. 1University Hospital Aintree, Liverpool, UK, 2Royal Liverpool University Hospital, Liverpool, UK

Introduction: We have previously reported a pilot of a respiratory assessment centre (RAC) that consists of a 14-bed unit alongside the medical admissions unit. Patients with respiratory conditions are admitted direct from A&E and the GP assessment area and are then looked after by a dedicated consultant respiratory physician and training medical staff from 09:00 to 17:00 hours, 7 days per week. We postulated this improved quality and possibly the efficiency of respiratory care.

Methods: A prospective audit of numbers of chronic obstructive pulmonary disease (COPD) patients taken home with the early supported discharge (ESD) team during the pilot phase and since the formal establishment of the RAC was performed and compared with the 2 years prior to this. In addition, as a control we compared the data with the same period at the Royal Liverpool University Hospital (RLUH), which utilises the same ESD team and protocols and has very similar admission patterns.

Abstract S154 Table

Results: In 2007 between January and May 195 patients went home with ESD, in 2008 244 when the RAC was operating, before this 126 and 125 went home in 2005 and 2006, respectively. This is therefore almost double the number of patients able to go home with the ESD in 2008 compared with the years before the RAC existed. The numbers of patients from RLUH going home with ESD over this time period were stable: 2005, 88; 2006, 89; 2007, 62; 2008, not available. During the summer months (June–November) when the RAC was not operating numbers were stable: 2005, 142; 2006, 164; 2007, 168. In the RLUH there was no change seasonally (see table).

Conclusion: These results demonstrate that the RAC increases the discharges achieved by the ESD team. In the summer months with no RAC the numbers approximate to historic levels and when compared with the control site numbers are higher. On reviewing case notes this difference could not be explained by protocol variances and we postulate that this is due to more effective utilisation of the ESD team. These data support the development of speciality-based acute care such as RAC.


1S Kennedy, 1C Ward, 2M Toufexis, 2M Bubb, 1M Stern, 1L Restrick. 1Department of Respiratory Medicine, Whittington Hospital, London, UK, 2Pharmacy Department, Whittington Hospital, London, UK

Introduction and Objectives: Early use of oral corticosteroids for acute exacerbations of chronic obstructive pulmonary disease (COPD) is recommended but not routine locally (Thorax 2007;62:IIIA117). This study evaluated the practicalities of providing emergency “exacerbation packs” (EEP) to inpatients with COPD to treat subsequent acute exacerbations of COPD and the effect on re-admission over 3 months.

Methods: Patients admitted with COPD (November 2007 to May 2008) were seen by a respiratory nurse specialist. Patients meeting the criteria for safe provision of EEP (7 days prednisolone 30 mg and amoxicillin/doxycycline) received one with discharge medication. EEP usage was assessed by monthly telephone follow-up. 3-month data on admissions and bed-days were analysed.

Results: Of 145 patients assessed, only 11/145 (8%) met the inclusion criteria (six women, five men; mean (range) age 70 years (61–80); mean (SD) FEV1 0.73 litres (0.33); FVC 1.63 litres (0.72); MRC dyspnoea score 3.7 (0.7); new COPD diagnosis in 3/11 (27%); first admission in 8/11 (73%)). The EEP was used appropriately by 6/11 (55%) patients; one had a further admission. It was not used appropriately by two patients; one with two further admissions. The EEP was not needed by three patients. Hence 2/11 (18%) patients were re-admitted within 3 months. In the year before EEP, the 11 patients used a total of 187 bed-days per year. After EEP the patients used 41 total bed-days at 3 months equivalent to 164 bed-days per year.

Conclusions: EEP were of limited value for our patients admitted with severe COPD. Fewer than 10% patients were suitable for EEP, mainly because of other medical problems or inability to master using one. In the small group given an EEP, half used it appropriately within 3 months. Patients admitted with COPD have complex medical and educational needs, which are not specifically addressed by a self-administered EEP.

Abstract S155 Table
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