The present paper reviews current knowledge of the pulmonary cachexia syndrome with reference to chronic obstructive pulmonary disease (COPD). Aspects of incidence, aetiology and management are discussed. Malnutrition occurs in approximately one-quarter to one-third of patients with moderate to severe COPD. Both fat mass and fat-free mass become depleted. Loss of fat-free mass is the more important and appears to be due to a depression of protein synthesis. Weight loss is an independent prognostic indicator of mortality, and is associated with increased morbidity and decreased health-related quality of life. The aetiology of malnutrition in COPD is not well understood. Reduced food intake does not seem to be the primary cause. Resting energy expenditure (REE) is elevated in a proportion of patients and probably contributes to negative energy balance. Measurement of actual REE is helpful when considering the adequacy of nutritional supplementation. The underlying reason for a hypermetabolic state is not known. Although weight-losing COPD patients are not catabolic, nutritional supplementation alone does not appear to reverse the loss of fat-free mass. Strategies involving nutritional supplementation in combination with a second intervention are being explored, and there are some encouraging results using anabolic hormones.

This first validation of the NEWS in AECOPD found modest discrimination to predict mortality. Lower specificity of NEWS in patients with AECOPD versus other AMU patients reflects acute and chronic respiratory physiological disturbance (including hypoxia), with resultant low PPV at NEWS=5. CREWS and Salford-NEWS, adjusting for chronic hypoxia, increased the specificity and PPV but there was no gain in discrimination.

Breathlessness is a common symptom in patients with primary bronchial carcinoma and is often not well-controlled. Most patients are ex- or current smokers, and therefore are at high risk for co-existing chronic obstructive pulmonary disease (COPD). The incidence of airflow obstruction in patients with bronchial carcinoma, its relation to breathlessness, and response to bronchodilator therapy was examined prospectively. Fifty-seven consecutive patients attending our outpatient clinic with bronchial carcinoma diagnosed in the preceding 12 months were studied (22 female, 35 male, mean age 68.4 years). Spirometry was performed and breathlessness rated. Those with airflow obstruction (FEV1:FVC < 65% and FEV1 < 70% predicted) and who judged themselves to have moderate or severe breathlessness, were offered a trial of bronchodilator therapy. The response to regular inhaled fenoterol and ipratropium bromide by metered dose inhaler (MDI) and large volume spacer, and to regular nebulized salbutamol and ipratropium bromide was assessed by home peak flow recordings, spirometry and two subjective scores: (a) rating of breathlessness on a simple four-point scale, and (b) activity score of the St George's Respiratory Questionnaire. There was very strong association between airflow obstruction and breathlessness. Twenty-eight patients (49%) had airflow obstruction, and we had breathlessness ratings on 26 of these patients of whom 18 (69%) had rated it as moderate or severe. Only four of the patients with airflow obstruction and breathlessness were using bronchodilator therapy. There was no significant difference in the mean age, time from diagnosis, tumour site, or smoking history between the groups with, and without, airflow obstruction. There was no association between cell type and the presence of airflow obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Background -Cystic fibrosis is an inherited condition with a high mortality and morbidity. The aims of this study were to assess quality of life in a population of adults with cystic fibrosis, to compare quality oflife with published scores from a healthy population and other patient groups, and to examine the relation between quality oflife and other measured clinical variables. (Thorax 1996;51:936-940)

Background -Patients admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD) are often prescribed ipratropium bromide in combination with a P2 agonist such as salbutamol. Studies have not shown any benefit in adding ipratropium bromide to salbutamol in acute exacerbations of COPD, but these studies have only assessed patients for 60-90 minutes and short term studies may not predict long term clinical response. Combination therapy with the two drugs was compared with salbutamol alone in the treatment of acute exacerbations of COPD during a hospital admission. Methods -Seventy patients admitted to hospital with an acute exacerbation of COPD were randomly allocated to receive either nebulised salbutamol 5 mg and ipratropium bromide 500 tg, or nebulised salbutamol 5 mg alone (all four times a day) on admission. All other treatment was prescribed at the discretion of the attending physician. Length ofstay in hospital and spirometeric values on days 1, 3, 7, 14, and discharge were assessed. Patients completed a subjective symptom score each day. Results -There was no difference between the two groups in the mean (SD) length of stay (salbutamol 10-5 (4.7) days, salbutamol + ipratropium bromide 11*8 (4.4) days; 95% CI -1-02 to 3.62). There was no difference in spirometric values on days 1, 3, 7, 14, or discharge between the two groups. The subjective improvement was similar with both treatments. Conclusions -The routine addition of nebulised ipratropium bromide to salbutamol appears to be of no benefit in the treatment of acute exacerbations of COPD. (Thorax 1995;50:834-837) Keywords: chronic obstructive pulmonary disease, P2 agonist, ipratropium bromide.Patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD) are usually treated with a high dose P2 agonist as part of their therapy. It is now commonplace for patients to receive, in addition, nebulised ipratropium bromide with obvious additional cost. This is logical pharmacologically as ipratropium has a different mode of action, inhibiting vagally-mediated bronchomotor tone.' There is evidence that adding ipratropium bromide to a nebulised 12 agonist is valuable in the long term management of COPD2A and in acute severe asthma.5 There have been no studies, however, on the place of ipratropium bromide in the management of acute exacerbations of COPD. Additionally, it has been known for some years that atropine-like drugs may be more effective in remissions of airways obstruction than in relapse.67 We have therefore compared nebulised salbutamol with nebulised salbutamol plus ipratropium bromide (combination therapy) in the treatment of acute exacerbations of COPD in a randomised trial. MethodsPatients admitted as emergencies to acute medical units with a diagnosis of an acute exacerbation of COPD who were not taking regular nebulised bronchodilators at home were eligible for the study. All were aged over 45 years and had a smoking history of more than 10 pack years. All had a forced expir...