The study was designed to assess the patterns of use of home mechanical ventilation (HMV) for patients with chronic respiratory failure across Europe.A detailed questionnaire of centre details, HMV user characteristics and equipment choices was sent to carefully identified HMV centres in 16 European countries.A total of 483 centres treating 27,118 HMV users were identified. Of these, 329 centres completed surveys between July 2001 and June 2002, representing up to 21,526 HMV users and a response rate of between 62% and 79%. The estimated prevalence of HMV in Europe was 6.6 per 100,000 people. The variation in prevalence between countries was only partially related to the median year of starting HMV services. In addition, there were marked differences between countries in the relative proportions of lung and neuromuscular patients using HMV, and the use of tracheostomies in lung and neuromuscular HMV users. Lung users were linked to a HMV duration of ,1 yr, thoracic cage users with 6-10 yrs of ventilation and neuromuscular users with a duration of o6 yrs.In conclusion, wide variations exist in the patterns of home mechanical ventilation provision throughout Europe. Further work is needed to monitor its use and ensure equality of provision and access.

Relationships between high-resolution computed tomography (HRCT) findings in chronic obstructive pulmonary disease (COPD) and bacterial colonization, airway inflammation, or exacerbation indices are unknown. Fifty-four patients with COPD (mean [SD]: age, 69 [7] years; FEV(1), 0.96 [0.33] L; FEV(1) [percent predicted], 38.1 [13.9]%; FEV(1)/forced vital capacity [percent predicted], 40.9 [11.8]%; arterial partial pressure of oxygen, 8.77 [1.11] kPa; history of smoking, 50.5 [33.5] smoking pack-years) underwent HRCT scans of the chest to quantify the presence and extent of bronchiectasis or emphysema. Exacerbation indices were determined from diary cards over 2 years. Quantitative sputum bacteriology and cytokine measurements were performed. Twenty-seven of 54 patients (50%) had bronchiectasis on HRCT, most frequently in the lower lobes (18 of 54, 33.3%). Patients with bronchiectasis had higher levels of airway inflammatory cytokines (p = 0.001). Lower lobe bronchiectasis was associated with lower airway bacterial colonization (p = 0.004), higher sputum interleukin-8 levels (p = 0.001), and longer symptom recovery time at exacerbation (p = 0.001). No relationship was seen between exacerbation frequency and HRCT changes. Evidence of moderate lower lobe bronchiectasis on HRCT is common in COPD and is associated with more severe COPD exacerbations, lower airway bacterial colonization, and increased sputum inflammatory markers.

Exacerbations are an important feature and outcome measure in chronic obstructive pulmonary disease (COPD), but little is known about changes in their severity, recovery, symptom composition or frequency over time.In this study 132 patients (91 male; median age 68.4 yrs and median forced expiratory volume in one second (FEV1) 38.4% predicted) recorded daily symptoms and morning peak expiratory flow.Patients Patients with chronic obstructive pulmonary disease (COPD) are prone to exacerbations that are an important determinant of health-related quality of life, morbidity and mortality [1,2]. Exacerbations are characterised by acute worsening of symptoms, increased airway inflammation and physiological deterioration [3]. They have become an important outcome measure in the study of therapy in COPD. Recently, two studies have suggested that exacerbations may affect disease progression by accelerating the forced expiratory volume in one second (FEV1), a decline characteristic of COPD [4,5]. The authors have estimated that exacerbations may account for y25% of the FEV1 decline in COPD [5]. However, to date there is no information about the history of exacerbations in COPD patients.The authors have also previously shown that a significant number of exacerbations do not recover to baseline levels in symptoms and/or lung function [6] and it is possible that this nonrecovery may be the mechanism by which exacerbations contribute to lung function decline. Alternatively, the impact of exacerbations may increase over time, resulting in greater airway inflammation, which contributes to the accelerated FEV1 decline. Previously, the authors have shown that exacerbation length (recovery) is related to the magnitude of the acute deterioration (severity) in lung function and symptoms at exacerbation, with exacerbation impact defined by the combination of the severity and the length of recovery [6]. However, there is no previous data available as to how exacerbation impact changes over time.This study followed 132 COPD patients over 6 yrs and collected data on 1,111 exacerbations. Patients recorded on diary cards daily peak expiratory flow (PEF) and/or spirometry and increase in symptoms. The authors used a set of indices, based on previous descriptions of the time course of symptoms and lung function associated with an exacerbation [6], which divided an exacerbation into a prodromal or baseline period, onset and recovery. The objective of the current study was to investigate whether the frequency, symptom composition and indices of severity and recovery of exacerbations changed over time. Methods PatientsA total of 177 patients with COPD were recruited from the outpatients dept of the London Chest Hospital in the first 5 yrs of this 6-yr study. In the first year, 99 patients were recruited consecutively and from then on those who subsequent withdrew or died were replaced. The recruitment criteria were an FEV1 v70% predicted from sex, age and height, a FEV1/forced vital capacity (FVC) ratio v70%, b 2 agonist reversibility...

The relationship between the upper and lower airways in chronic obstructive pulmonary disease (COPD) is unknown. We examined the prevalence of chronic nasal symptoms and the correlation with lower respiratory symptoms and parameters of severity of COPD such as exacerbation frequency and spirometry. 61 COPD patients from the East London COPD cohort were studied. [Mean (SD) age 70 (6.96) years, FEV1 0.98 (0.38) l, FVC 2.45 (0.72) l, FEV1%Pred 37.0 (12.3), and 47.6 (31.8) smoking pack years, 14 current smokers, 36 males]. COPD patients had a high prevalence of nasal symptoms (75%), more than half reporting nasal discharge (52.5%) and sneezing (45.9%). Associations were found between nasal score and daily sputum production (P = 0.005) and post-nasal drip and sputum production (P = 0.046) with a trend to increased nasal symptoms in frequent exacerbators compared to infrequent exacerbators. No significant relationship was found between nasal symptoms and FEV1 or any other lower respiratory airway symptom. Associations between nasal and respiratory symptoms were found suggesting that there is a relationship between the upper and lower airway in COPD.

Background:Structured care for people with chronic obstructive pulmonary disease (COPD) can improve outcomes. Delivering care in a deprived ethnically diverse area can prove challenging.Aims:Evaluation of a system change to enhance COPD care delivery in a primary care setting between 2010 and 2013 using observational data.Methods:All 36 practices in one inner London primary care trust were grouped geographically into eight networks of 4–5 practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary group, including a respiratory specialist and the community respiratory team, developed a ‘care package’ for COPD management, with financial incentives based on network achievements of clinical targets and supported case management and education. Monthly electronic dashboards enabled networks to track and improve performance.Results:The size of network COPD registers increased by 10% in the first year. Between 2010 and 2013 completed care plans increased from 53 to 86.5%, pulmonary rehabilitation referrals rose from 45 to 70% and rates of flu immunisation from 81 to 83%, exceeding London and England figures. Hospital admissions decreased in Tower Hamlets from a historic high base.Conclusions:Investment of financial, organisational and educational resource into general practice networks was associated with clinically important improvements in COPD care in socially deprived, ethnically diverse communities. Key behaviour change included the following: collaborative working between practices driven by high-quality information to support performance review; shared financial incentives; and engagement between primary and secondary care clinicians.