Numerous guidelines have now been produced both nationally and internationally for the management of respiratory and nonrespiratory disease. They should be regarded as useful tools designed to aid the busy clinician, but their method of production, their value and especially their applicability to primary care and to low income countries need to be assessed critically.The production of guidelines needs to be carefully incorporated into a planned dissemination and implementation programme. This is likely to be most successful when use is made of interactive educational methods associated with intraconsultation prompting and use of reminders. Updating and life-long learning is necessary and guideline revisions need to be closely incorporated into continuing medical education programmes. National campaigns, the use of media and the “training” of patients to make them more effective partners in healthcare can all enhance a beneficial change in health professional behaviour.Recent research has enhanced the knowledge of a wide range of respiratory conditions and very effective therapies now exist for many conditions. However, too little attention is often given to the ways in which care is organised and to the important aspects of management that are nonpharmacological. When dealing with long-term conditions, long-term supervision and the teaching of self-management skills are as important as the prescription.In many parts of the world the ideals, as laid out in guidelines, remain dreams and will continue to be dreams until there is some global redistribution of wealth. Only then will research be translated into practice everywhere.

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Summary In a study of chemotherapy as palliative treatment, 300 patients with untreated limited and extensive stage small cell lung cancer (SCLC), who did not have progressive disease after the first cycle of chemotherapy, were randomised to receive either regular 'planned' chemotherapy or chemotherapy given 'as required' (AR). All patients received the same chemotherapy: cyclophosphamide 1 gm m-2 i.v., vincristine 2 mg i.v., and etoposide 120 mg m-2 i.v. on day 1, and etoposide 100 mg b.d. orally on days 2 and 3. Planned chemotherapy was given regularly every 3 weeks. AR chemotherapy was given for tumour-related symptoms, or for radiological progression of disease. Both groups of patients were assessed every 3 weeks and a maximum of eight cycles of chemotherapy was given. A detailed quality of life assessment was made using daily diary cards.The median survival (MS) of patients given AR chemotherapy was not significantly worse than those receiving planned treatment [MS: Planned = 36 weeks (95% C.I. 32-40 weeks), AR = 32 weeks (95% C.I. 28-37 weeks) P = 0.960]. In the AR patients the median interval between treatments was 42 days. On average AR patients received half as much chemotherapy as planned patients. AR patients with a treatment-free interval (TFI) of more than 8 weeks between the first and second cycles of chemotherapy survived longer than those in whom this interval was less than 4 weeks; [MS: TFI >8 =47 weeks (95% C.I. 32-53 weeks); TFI <4 = 24 weeks (95% C.I. 17-34 weeks) P = 0.013]. Contrary to expectation, in the quality of life assessment the AR patients scored themselves as having more severe symptoms than patients receiving planned treatment.AR chemotherapy is a novel method of attempting to use cytotoxic drugs palliatively, which resulted in less drug treatment for approximately equivalent survival. However the palliative effect seen with as required treatment was less satisfactory than with planned chemotherapy.

Assessing the risk of hypoxia in flight: the need for more rational guidelines. R.K. Coker, M.R. Partridge. #ERS Journals Ltd 2000. ABSTRACT: This study aimed to test the hypothesis that advice currently given by respiratory physicians to potentially hypoxic patients planning air travel varies and is not evidence-based.A prospective observational study was performed, surveying respiratory physicians in England and Wales.Sixty-two per cent responded. Nearly two-thirds worked in district general hospitals, a quarter in university hospitals, and the rest in tertiary referral (specialist) centres or a combination thereof. Most provide advice routinely; most of the remainder do on request or if concerned. Assessments comprise spirometry, blood gas level measurement, oximetry, predictive equations and hypoxic challenge tests. Twenty-five per cent of physicians measuring blood gas levels recommend in-flight oxygen when arterial oxygen tension (Pa,O 2 ) <7.3 kPa, 50% when Pa,O 2 is 7.3±8.0 kPa. Over twothirds using spirometry recommend oxygen when the forced expiratory volume in one second <40% of the predicted value. Half recommend oxygen when arterial oxygen saturation (Sa,O 2 ) <90%, 33% when Sa,O 2 is 90±94%. Fewer than 10% of district hospital physicians (and none in other hospitals) use predictive equations. More than half of specialists but fewer than 10% of district hospital physicians perform hypoxic challenge tests.The risk of hypoxia at altitude is recognized by most respiratory physicians in England and Wales, but assessment methods and criteria for recommending oxygen vary widely. This suggests that most current advice is not evidence-based. The number of passengers on scheduled commercial flights was recorded at 1,285 million world-wide in 1995 and is predicted to exceed 2,000 million by the year 2005 [1]. Given the high prevalence of respiratory disease, especially chronic obstructive pulmonary disease (COPD), the rising age of Western populations and the increasing numbers of adults with cystic fibrosis, significant and increasing numbers of air passengers are likely to have respiratory disease. This study aimed to determine whether evidence-based advice is currently given by respiratory physicians in England and Wales to potentially hypoxic patients planning air travel. MethodsA prospective observational study was performed in 1997. All consultant respiratory physicians in England and Wales [2] were circulated a letter explaining the study and a short anonymous questionnaire. This requested information on hospital workplace (district general hospital, university or tertiary referral) and on whether advice was routinely given to hypoxic patients planning air travel, or only following a request by the patient. Those respondents who gave advice were asked to provide information about which assessments they perform before recommending in-flight oxygen. Options included spirometry, oximetry, blood gas level measurement, predictive formulae [3,4] or hypoxic challenge testing [5]. The criteria for recommendin...

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