Pulmonary hypertension during exercise is common in severe chronic obstructive pulmonary disease (COPD). It was hypothesised that the use of the endothelin-receptor antagonist bosentan can improve cardiopulmonary haemodynamics during exercise, thus increasing exercise tolerance in patients with severe COPD.In the present double-blind, placebo-controlled study, 30 patients with severe or very severe COPD were randomly assigned in a 2:1 ratio to receive either bosentan or placebo for 12 weeks. The primary end-point was change in the 6-min walking distance. Secondary end-points included changes in health-related quality of life, lung function, cardiac haemodynamics, maximal oxygen uptake and pulmonary perfusion patterns.Compared with placebo, patients treated with bosentan during 12 weeks showed no significant improvement in exercise capacity as measured by the 6-min walking distance (mean¡SD 331¡123 versus 329¡94 m). There was no change in lung function, pulmonary arterial pressure, maximal oxygen uptake or regional pulmonary perfusion pattern. In contrast, arterial oxygen pressure dropped, the alveolar-arterial gradient increased and quality of life deteriorated significantly in patients assigned bosentan.The oral administration of the endothelin receptor antagonist bosentan not only failed to improve exercise capacity but also deteriorated hypoxaemia and functional status in severe chronic obstructive pulmonary disease patients without severe pulmonary hypertension at rest. KEYWORDS: Endothelin-receptor antagonist, exercise capacity, pulmonary hypertension, treatment P ulmonary hypertension (PH) at rest and during exercise is a very frequent complication in the natural history of chronic obstructive pulmonary disease (COPD) [1,2]. Correspondingly, this condition has been reported in 20-91% of patients with severe COPD and/or emphysema [3,4]. The presence of PH is commonly associated with more frequent use of healthcare resources and worse clinical outcome [5]. Remarkably, pulmonary artery pressure has been suggested to be the single best predictor of mortality in COPD [6].In COPD, PH is generally of moderate severity, but the range of mean pulmonary artery pressures varies substantially [7]. Moderate and severe PH are present in 9.8 and 3.7%, respectively, of the patients undergoing right heart catheterisation before lung volume reduction surgery [7]. Despite many uncertainties, studies indicate that 35% of all patients with severe COPD have pulmonary artery pressures of .20 mmHg at rest [8]. In addition, pulmonary pressures during exercise are greater than predicted by the pulmonary vascular resistance (PVR) equation in COPD, suggesting active pulmonary vasoconstriction on exertion [9]. Hence, of those patients without PH at rest, a further 52% are estimated to develop PH during exercise [5].There are many pathological similarities between idiopathic pulmonary arterial hypertension (PAH) and PH related to COPD. Like idiopathic PAH, pulmonary arteries in patients with COPD show evidence of fibromuscula...

Combined sedation with a benzodiazepine and an opiate has been proposed as standard sedation for bronchoscopy. Propofol is a sedative-hypnotic with a rapid onset of action and fast recovery time, but carries the potential risk of respiratory failure.Consecutive patients (n5200) were randomly allocated to receive either the combination midazolam and hydrocodone or intravenous propofol. The primary end-points were the mean lowest arterial oxygen saturation during bronchoscopy and the readiness-for-discharge score 1 h after the procedure.The mean lowest arterial oxygen saturation during bronchoscopy did not differ across treatment groups (p50.422), and the number of patients recording an arterial oxygen saturation of f90% on at least one occasion was similar in both groups (p50.273). The median (interquartile range) readiness-for-discharge score 1 h after the procedure was significantly higher in the propofol group than in the combined sedation group (8 (6-9) versus 7 (5-9); p50.035). Patients assigned propofol exhibited less tachycardia during bronchoscopy and for o1 h after the examination. Minor procedural complications were noted in 71 (35.5%) patients and exhibited a similar incidence in both treatment arms (p50.460).Propofol is as effective and safe as combined sedation in patients undergoing flexible bronchoscopy, thus representing an appealing option if timely discharge is a priority.

Propofol and the combination of a benzodiazepine and an opiate have been established for sedation in flexible bronchoscopy. It is as yet unknown whether propofol in combination with an opiate is superior to propofol alone to suppress cough during the procedure. 300 consecutive patients undergoing flexible bronchoscopy at a tertiary care university hospital were randomly allocated to receive either the combination propofol and hydrocodone or propofol alone in a double-blind fashion. The primary end-point was the cough score during the procedure as estimated by the physician using a visual analogue scale.Demographics were similar in both groups. Compared with propofol alone, median (interquartile range) cough scores assessed by physicians, nurses and patients were significantly lower in the group randomised to the combination propofol and hydrocodone (2.5 (1.5-4.0) versus 2.0 (1.0-3.0), respectively, p50.011). Additionally, patients receiving the combination required significantly lower doses of propofol than those receiving propofol alone (200 mg (140-280) versus 260 mg (180-350), p,0.0001). Complex examinations, including bronchoalveolar lavage or transbronchial biopsy, benefited more from additional opiate. The duration of the procedure, time to discharge and complication rate were similar in both groups.The combination of propofol and hydrocodone is safe and superior to propofol alone for cough suppression in flexible bronchoscopy.

Role playing and interaction with real patients are equally efficient and both more powerful learning tools than web-based learning with or without a lecture.

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