Abebaw M. Yohannes

Background: Respiratory disease is a common cause of disability in middle and late life. Pulmonary rehabilitation programmes improve exercise capacity and quality of life in patients with chronic lung diseases. However, currently, in the UK the availability of pulmonary rehabilitation programmes and their characteristics are unknown. Methods: We surveyed pulmonary rehabilitation programmes in terms of number, size, duration, content of educational and exercise programme, and staffing. We mailed a 17-item questionnaire previously used in Canadian study to 190 physiotherapy departments within acute hospitals in UK. Results: One hundred and seventy-one (90%) responses were received. Sixty-eight centres (40%) run a pulmonary rehabilitation programme (99% outpatient). Mean age of subjects was]=70 in only seven centres (10%), though most cited no upper age limit. Ninety-nine per cent of centres incorporated exercise training. Programmes recruited a median group size of 10 patients (range 4 - 17) at a given time with a median duration of eight weeks (range 5 - 24) weeks. Most (71%) run twice per week with a duration of 2 hours (63%). Only half offered smoking cessation support, and a minority gave advice on coping with disease, travel and sexual matters. Conclusion: Around 40% of surveyed hospitals run a pulmonary rehabilitation programme and most of the programmes are similar in their format, content and staffing. Despite the high prevalence of chronic obstructive pulmonary disease (COPD)-related disability in old age most programmes chiefly included younger subjects. This may reflect lack of referral. Greater awareness and expansion of availability of programmes is indicated.

Objectives: We hypothesized that COPD patients with sub‐threshold depression would have levels of disability and impaired quality of life approaching that for major depression and significantly greater than for non‐depressed COPD patients.Setting: A university teaching hospitalMethod: 137 outpatients (69 men), with a mean age of 73 years (range 60–89 years) with symptomatic irreversible, moderate to severe COPD were recruited. Subjects were interviewed using the Geriatric Mental State Schedule (GMS), a structured psychiatric interview schedule, along with its diagnostic algorithm AGECAT. A GMS/AGECAT score of 3 or more is indicative of a case‐level of depression, a GMS/AGECAT score of 1–2 indicates sub‐threshold depression and GMS/AGECAT of 0, no depression. Physical disability was measured by the Manchester Respiratory Activities of Daily Living questionnaire (MRADL) and quality of life was assessed by the Breathing Problems Questionnaire (BPQ).Results: Mean (SD) one second forced expiratory volume was 0.89 (0.33) litres. The prevalence of GMS/AGECAT case‐level depression (≥ 3) was 57 cases (42%); of GMS/AGECAT sub‐threshold depression (1–2) 34 (25%); and GMS/AGECAT non‐depression (0) 46 (33%). Comparison of MRADL score in the three groups (mean, 95% confidence intervals) revealed [GMS ≥ 3 = 9.9 (8.4 to 11.3) vs GMS = 1–2, 12.9 (11.2 to 14.4) vs GMS = 0, 15.6 (14 to 16.6) p < 0.0001]. BPQ scores (mean, 95% confidence intervals) showed [GMS ≥ 3 = 54 (50 to 57) vs GMS = 1–2, 40 (36.3 to 44) GMS = 0, 33 (30.6 to 36.7) p < 0.0001]. There was no significant difference in FEV₁ between the three groups.Conclusion: Sub‐threshold depression accounted for 25% of the sample. In this study disability associated with sub‐threshold depression in patients with COPD was intermediate to that associated with case‐level depression and no with depression and significantly worse than in the latter group. Sub‐threshold depression is associated with substantial morbidity in COPD. Copyright © 2003 John Wiley & Sons, Ltd.

Chronic obstructive pulmonary disease (COPD) is a common disability, largely encountered in the elderly population, in whom it causes significant morbidity and mortality. The general perception of health professionals is that COPD is often a self-inflicted disorder affecting the more socio-economically disadvantaged segment of the population with significant comorbidity. COPD is the least funded in terms of research in relation to illness burden compared with other chronic diseases. However, recently published guidelines of both the British Thoracic Society and the Global Initiative for Chronic Obstructive Lung Disease have highlighted best management strategies both of chronic symptoms and acute exacerbations in this patient group. The chronic management of COPD should, like asthma, involve a stepwise approach with smoking cessation being pivotal for all severities of COPD, regardless of patient age. The mainstay of therapeutic treatment remains regular bronchodilators, both β₂-adrenoreceptor agonists and anticholinergic agents. Current evidence suggests that long-acting β₂-adrenoreceptor agonists such as salmeterol and the new long-acting anticholinergic agent tiotropium bromide are more efficacious than their shorter acting equivalents such as salbutamol and ipratropium bromide in terms of bronchodilation, improved well-being and a reduction in acute exacerbation rates. Additionally since they are taken once or twice daily compliance should be improved. The role of long-term inhaled corticosteroids in the chronic management of COPD is contentious. Only those patients with COPD who have been shown to respond to a formal corticosteroid trial, preferably with a 2-week course of oral corticosteroid, should receive long-term inhaled corticosteroids. In the management of acute exacerbations in acidotic patients nasal ventilation is the treatment of choice in addition to conventional treatment with bronchodilators and oral corticosteroids. Antibacterials need not be prescribed universally in all exacerbations of COPD. Pulmonary rehabilitation classes either individually or in groups have been shown to be beneficial in the management of patients with COPD and their use in secondary care is to be encouraged. Most treatment modalities do not improve pulmonary function in patients with severe COPD. Therefore, pulmonary function including spirometry should be used to make the diagnosis of COPD but not as a monitor of efficacy of treatment. Assessment of severity of COPD and improvement with treatment modalities is best done with dynamic exercise testing such as 6-minute walk tests and incremental shuttle walk tests or with the administration of disease-specific physical disability and quality-of-life questionnaires. Most COPD research does not specifically target the older COPD patients and these patients may merit special consideration for their optimum assessment and management.