No abstract

The first British Thoracic Society guideline on pulmonary rehabilitation in adults is published in the accompanying Thorax supplement. Focusing on delivery of a quality pulmonary rehabilitation service, the evidenced-based guideline encompasses recommendations on the composition of the service, referral of patients and who benefits, the expected patient-related outcome measures and markers, pulmonary rehabilitation following exacerbations, the post-rehabilitation period and areas requiring further research. In this commentary, we introduce the guideline and discuss pulmonary rehabilitation in the wider context of chronic disease management of respiratory patients.

Low-and middle-income countries (LMICs) bear a disproportionately high burden of the global morbidity and mortality caused by chronic respiratory diseases (CRDs) including asthma, chronic obstructive pulmonary disease, bronchiectasis and post-tuberculous lung disease. CRDs are strongly associated with poverty, infectious diseases, and other non-communicable diseases, and contribute to complex multi-morbidity, with significant consequences for the lives and livelihoods of those affected.The relevance of CRDs to health and socioeconomic wellbeing is expected to increase over time, as life expectancies rise and the competing risks of early childhood mortality and infectious diseases plateau. As such, the World Health Organization has identified the prevention and control of CRDs as an urgent development issue and essential to the achievement of the Sustainable Development Goals.In this review we focus on CRDs in low-and middle-income settings (LMICs). We discuss the early life origins of CRDs, challenges in prevention, diagnosis and management in LMICs, and pathways to solutions to achieve true Universal Health Coverage.

Background: A study was undertaken to test the hypothesis that patients respond better to lung volume reduction surgery (LVRS) if their emphysema is confluent and predominantly located in the upper lobes. Methods: A density mask analysis was used to identify voxels inflated beyond 10.2 ml gas/g tissue (-910 HU) on preoperative and postoperative CT scans from patients receiving LVRS. These hyperinflated regions were considered to represent emphysematous lesions. A power law analysis was used to determine the relationship between the number (K) and size (A) of the emphysematous lesions in the whole lung and two anatomical regions using the power law equation Y=KA -D . Results: The analysis showed a positive correlation between the change in the power law exponent (D) and the change in exercise (Watts) after surgery (r=0.47, p=0.03). There was also a negative correlation between the power law exponent D in the upper region of the lung preoperatively and the change in exercise following surgery (r=-0.60, p<0.05). Conclusions: These results confirm that patients with large upper lobe lesions respond better to LVRS than patients with small uniformly distributed disease. Power law analysis of lung CT scans provides a quantitative method for determining the extent and location of emphysema within the lungs of patients with COPD.

Health professionals recommend education of patients about COPD. There is no satisfactory instrument to measure their knowledge and therefore to assess the results of education. A multiple-choice questionnaire (BCKQ) has been designed and tested. Each of 13 topics contains five statements for which there is a right or wrong answer. Its validity and consistency has been assessed, and the test re-test reliability and responsiveness measured after an interval of eight weeks. A copy of the multiple-choice questionnaire is given in the Appendix. The questionnaire was judged by patients and health professionals to have good content and face validity. It has good internal consistency for the 65 items. (Cronbach's alpha 0.73). It can be completed and scored within twenty minutes. The average score in subjects who had not received prior education was 54.7%. In a group not receiving education there was good test-retest reliability (r ϭ 0.71). Following an eight-week education programme there was a significant improvement of 18.3 percentage points, and most of the increase was maintained for six months without any further formal education. BCKQ is suitable for both clinical and research purposes. It will test knowledge that is appropriate for COPD patients and can be used as an assessment tool for individual patients, or as a broad cross-sectional survey instrument. It will enable the effectiveness of education to be assessed and will be of value in developing and comparing different educational interventions. Chronic Respiratory Disease 2006; 3: 123-131