BackgroundThe effects of written action plans on recovery from exacerbations of chronic obstructive pulmonary disease (COPD) have not been well studied. The aims of this study were to assess the effects of adherence to a written action plan on exacerbation recovery time and unscheduled healthcare utilisation and to explore factors associated with action plan adherence. Methods This was a 1-year prospective cohort study embedded in a randomised controlled trial. Exacerbation data were recorded for 252 patients with COPD who received a written action plan for prompt treatment of exacerbations with the instructions to initiate standing prescriptions for both antibiotics and prednisone within 3 days of exacerbation onset. Following the instructions was defined as adherence to the action plan.Results From the 288 exacerbations reported by 143 patients, start dates of antibiotics or prednisone were provided in 217 exacerbations reported by 119 patients (53.8% male, mean age 65.4 years, post-bronchodilator forced expiratory volume in 1 s (FEV 1 ) 43.9% predicted). In 40.1% of exacerbations, patients adhered to their written action plan. Adherence reduced exacerbation recovery time with statistical (p¼0.0001) and clinical (À5.8 days) significance, but did not affect unscheduled healthcare utilisation (OR 0.94, 95% CI 0.49 to 1.83). Factors associated with an increased likelihood of adherence were influenza vaccination, cardiac comorbidity, younger age and lower FEV 1 as percentage predicted. Conclusions This study shows that adherence to a written action plan is associated with a reduction in exacerbation recovery time by prompt treatment. Knowing the factors that are associated with proper and prompt utilisation of an action plan permits healthcare professionals to better focus their self-management support on appropriate patients.

Exacerbations are an important cause of morbidity and mortality in COPD. We assessed treatment initiation and health care use at exacerbation in patients receiving a self-management education program including an action plan. COPD patients were randomly assigned to usual care or to a comprehensive self-management program "Living Well with COPD" including a written action plan and case manager support, and were followed-up for 12 months. Patients in the usual care were managed by their respective practitioners. Patients in the self-management program received, as part of a written action plan, a prescription of antibiotics and prednisone for self-initiation in case of aggravation of 2 or more symptoms (dyspnea, sputum volume, sputum purulence) for at least 24 hours, and they had the support of a case-manager for reinforcement and monthly telephone follow-ups. At 12 months, 166 patients presented with at least one exacerbation. Exacerbations (606) were confirmed by aggravation of at least one symptom; 403 (67.6%) presented 2 or more. Antibiotics were used in 61.6% of exacerbations and prednisone in 47.9%. In exacerbations presenting aggravation of 2 or more symptoms, antibiotics and prednisone were used together more often in the action plan than in the usual care group (54.4% vs. 34.8%, p < 0.001). In the action plan, compared to the usual care group, 17.2% vs. 36.3% exacerbations resulted in a hospitalization (p < 0.001). Self-management with the successful use of an action plan for acute exacerbation of COPD holds promise for reducing health care use.

patients and also by respiratory muscle limitation in 10% of the patients. Conclusions: Based on admission diagnosis of 40 patients, 90% were defined as subject to pulmonary rehabilitation and in 10% were receiving cardiac rehabilitation. They divided into three specific functional recovery programs: ventilatory function recovery program (60%), cardiac function recovery program (30%), respiratory muscles recovery program (10%). Background: In chronic obstructive pulmonary disease (COPD), leg muscle blood flow may be compromised during dynamic exercise due to the competing influence of respiratory muscle work for available cardiac output. This study examined the flow demand limits of skeletal muscle flow in varying muscle mass recruitment. It employed one leg knee extension (1L-KE) and two-leg knee extension (2L-KE) to examine the mass-specific work rates at which peripheral circulatory function may become compromised due to elevated respiratory demands. Methods: Three male COPD patients (70 ± 5 yr; FEV1 /FVC = 42 ± 11%) and two aged-controls (74 ± 1 yr; FEV1/FVC = 76 ± 5%) completed three sets of 7-minute steady state 1L-KE and 2L-KE at 20, 40 and 65% (SS20%; SS40%; SS65%) of previously determined ergometer-specific peak power, separated by rest periods of 15 min. Leg muscle blood flow (BF) was determined using pulsed Doppler sonography of the femoral artery during incremental exercise loads and post-exercise. ECG, blood pressure, ventilatory parameters and VO2 were obtained continuously, and dye dilution cardiac output was measured at rest and during exercise. Results: Preliminary data showed that, for each exercise intensity, the required VO2 is similar in both groups. However, the workloads in COPD are between 60% and 82% of the control group workloads. During 1L-KE and 2L-KE, BF is consistently higher in COPD compared to controls. For 1L-KE, the increase in BF from rest (mean ± SD in ml/min; COPD vs controls) are SS20%: 763 ± 244 vs 105 ± 34; SS40%: 1157 ± 597 vs 310 ± 97; SS65%: 1493 ± 348 vs 424 ± 45. BF relative to workload is at least 3-fold higher in COPD compared to controls for all exercise intensities. Conclusions: These data suggest that mean muscle blood flow may not be compromised during kneeextensor exercise in COPD patients, and ongoing data will clarify whether this is a compensatory response to altered peripheral muscle metabolic function. Leg Muscle Blood

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