Abstracts

COPD: Journal of Chronic Obstructive Pulmonary Disease, 5:395–401ISSN: 1541-2555 print / 1541-2563 onlineCopyright c© 2008 Informa Healthcare USA, Inc.DOI: 10.1080/15412550802577498

Abstracts

MMP-9 AND TNF-α GENE POLYMORPHISMS INKOREAN PATIENTS WITH CHRONICOBSTRUCTIVE PULMONARY DISEASE

Sung Chul Lim, Jin Yung Ju, and Yu II Kim Departments of In-ternal Medicine, Chonnam National University Medical School,Gwangju, South Korea

Background: Cigarette smoking has been known to be one ofthe important contributing factors for developing COPD. How-ever, only 10 to 20% of heavy cigarette smokers can be affectedwith COPD, and they can have airway obstruction and respi-ratory symptoms. These facts imply that genetic factors mighthave an important role in the genetic susceptibility to COPD.Matrix metalloproteinase (MMP) 9 and tumor necrosis factoralpha (TNF-α) appear to play an important role in the develop-ment of COPD. To study whether such protease and cytokinecontribute to genetic susceptibility to Korean COPD, we haveperformed a study on MMP-9 and TNF-α gene polymorphism inKorean COPD. Materials and Methods: Twenty-eight patientswith COPD and 16 smoker control subjects were included in thisstudy. Genomic DNA was used as a template for amplification byPCR to determine the MMP-9 and TNF-α polymorphism. Theproducts were investigated by auto-sequencing analysis. Results:The frequencies of CT genotype in MMP-9 (C-1562T) gene pro-moter region were 46% (13/28) in the COPD patients and 6%(1/16) in the smoker control subjects. There were statisticallysignificant differences between the two groups (p = 0.007).And the frequencies of GA genotype in TNF-α-308 gene pro-moter region were 14% (4/16) in the COPD patients and 31%(5/16) in the smoker control subjects. There were statisticallyno significant differences between the two groups (p = 0.250).Conclusions: The genetic polymorphism in promoters of MMP-9 (C-1562T) gene might be associated with the susceptibilityto smoking-related COPD in Korean population. But a role forthe TNF-α-308 gene promoter polymorphism in COPD devel-opment was not demonstrated in this study.

THE EFFECTS OF TIOTROPIUM AND INHALEDCORTICOSTEROID/LONG ACTINGBETA-AGONIST IN PATIENTS WITHTUBERCULOUS DESTROYED LUNG

Moon Jun Na, Mee Hye Kwon, Ji Woong Son, and Eu GeneChoi Konyang University Hospital, Gasuwon-dong 685, Seo-gu, Daejeon, Korea

Background: Pulmonary tuberculosis often complicated byextensive destruction of lung parenchyme and airflow obstruc-tion similar to chronic obstructive pulmonary diseases. The ob-jective is to evaluate the effects of tiotropium and ICS/LABAin TDL patients with severe obstructive airway disease. Meth-ods: We selected 19 TDL patients with history of treatment ofpulmonary tuberculosis who were treated with tiotropium andICS/LABA over at least 2 months. They had severe obstruc-tive airway disease whose predicted value of forced expiratoryvolume for 1 second (FEV1%), predicted value of forced vitalcapacity (FVC%), and FEV1/FVC ratio were 41.76 ± 15.21%,70.99 ± 17.06%, and 46.34 ± 12.83%, respectively. We mea-sured and compared the pulmonary function before and af-ter treatment. Results: After short-term treatment (3.6 ± 1.34month, n = 14) with tiotropium and ICS/LABA, the FEV1 andFEV1% were increased by 0.18 ± 0.23 L and 8.71 ± 9.69%,FVC and FVC% were increased by 0.10 ± 0.40 L and 6.64 ±10.09%, and FEV1/FVC ratio was improved by 5.18 ± 10.88%.And, after long-term treatment (12.0 ± 1.9 month, n = 7) withtiotropium and ICS/LABA, the improvement of FEV1, FEV1%,FVC, FVC%, and FEV1/FVC were 0.08±0.29 L, 5.44±9.48%,0.04 ± 0.48 L, 4.03 ± 12.78%, and 2.68 ± 8.51%, respectively.Discussion: The treatment with tiotropium and ICS/LABA waseffective in improvement of airway obstruction in TDL patientswith severe obstructive airway disease.

MANAGING COPD: THE PLYMOUTH MODEL

Margaret Barnett Plymouth PCT, Chest clinic level 6, DerrifordHospital, Plymouth, Devon. PL6 8DH

The Plymouth COPD service was set up in 2000 to providesupport to patients with moderate to severe COPD living withinthe Plymouth area. Monies from the winter pressures budgetprimarily funded this initiative, and over time further funds havebeen obtained from the commissioning directorate to developthe service further. The service structure includes an Inreachservice to secondary care, which facilitates an early dischargescheme, an outreach service within primary care which aimsto optimize and manage patients in the community preventinghospital admissions whereby over a 1000 hospital bed days peryear have been saved, as well as a home and community-basedpulmonary rehabilitation program. Audit has demonstrated thatimplementation of this service has proved safe and effectivewith many benefits. The response from general practitioners hasbeen very positive. From a patient perspective, 84% felt that the

COPD: Journal of Chronic Obstructive Pulmonary Disease December 2008 395

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specialist nurses had a good understanding of their conditionand 80% were very satisfied with the service provided. In termsof controlling and stabilizing their symptoms, 47% stated thattheir condition had improved, whereas 44% felt that it was muchthe same. Many patients indicated that the provision of expertcare has improved their self-confidence and their quality of life.

THE EVALUATION OF A HOME-BASED COPDPULMONARY REHABILITATION PROGRAM

Sherrie Choy and Margaret Barnett Plymouth PCT, Chest Clinic,Level 6, Derriford Hospital, Plymouth Devon. PL6 8DH

Many patients with advance COPD suffer from a reducedfunctional capacity, mainly due to breathlessness on exertion.Various studies have demonstrated the benefits of pulmonary re-habilitation, and the NICE guidelines (2004) suggest that all pa-tients with an MRC dyspnoea score of 3 should have the option ofattending a pulmonary rehabilitation program. However, manypatients with this disability are unable to travel to a communityor hospital-based venue for one reason or another. To address thisneed, an 8-week home-based exercise program has been set upin Plymouth and facilitated by the COPD team physiotherapist.Audit data have been collected pre and post the program usingvarious quality markers including the 6-minute walking test, theBorg scale, measurement of oxygen saturations, and spirometry,as well as completion of quality of life (CRQ) and depression(HADS) questionnaires. Results demonstrate that many patientsincreased their exercise capacity by over 50%, which correlatedwith the quality-of-life scores in particular showing over 50%of patients reported an improvement related to fatigue. The pro-gram has been well received by patients and the data encouragingenabling COPD patients to receive optimal care and to achievean enhanced quality of life.

SURVEY OF COPD MANAGEMENT AMONGTHE PRIMARY CARE PHYSICIAN IN KOREA

Myung Jae Park, Young Kyoon Kim, Kyung Ho Kang, KwanHo Lee, Jin Hwa Lee, Sung-Chul Lim, Ki-Suck Jung, DongHo Shin, and Jee-Hong Yoo Kyung Hee University, YeungnamUniversity, Chonnam Univeristy, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea

Background: Chronic obstructive pulmonary disease (COPD)is increasing and becoming an important cause of morbidity andmortality worldwide. The aim of this survey is to investigatepattern of COPD management among primary care physicians(PCPs) and to consider it to the development of Korean COPDguideline. Methods: Web-based questionnaire consisted of 25questions for the pattern of COPD management. Two hundredseventeen PCPs participated in the survey. Results: Many PCPs(61.8%) possessed the spirometer but application rate was rel-atively low (35.8%), and more than half of the COPD patients

(57%) were not diagnosed based on spirometry. When it comesto the medication, oral medication was preferred than inhaledmedication for both stable and acutely exacerbate state of COPD.It was noted that PCPs were aware of the GOLD guideline in56.7% but only 7.3% tended to fully implement the guidelines.Conclusion: The result of the survey shows that, despite the highawareness rate of the COPD guidelines, deficits exist amongPCPs with respect to diagnosis and treatment of COPD. It isrequired to apply the results of this survey to the development ofCOPD guideline in order to decrease the discrepancy betweenguideline and daily practice of PCPs.

ALTERED ALVEO-VASCULAR CHANGES IN ACHRONIC TOBACCO SMOKE INHALATIONMOUSE MODEL

Nirmal Parajuli, Michael Seimetz,1 Markus Roth,1 BeateFuchs,1 Ralph Theo Schermuly,1 Hossein Ardeschir Ghofrani,1

Christian Schudt,2 Christian Hesslinger,2 Werner Seeger,1

Friedrich Grimminger,1 and Norbert Weissmann,1 1Departmentof Internal Medicine, University of Giessen Lung Center,Giessen, Germany, 2Nycomed GmbH, Konstanz, Germany

Introduction: COPD is a progressive disease having nonfullyreversible airflow limitation associated with chronic obstructivebronchitis and emphysema. Genetic factors, environmental pol-lution, and tobacco smoke inhalation are the major factors forinduction of this disease. The aim of this study was to estab-lish and to identify the pathogenesis of lung emphysema de-velopment in chronic tobacco-smoke inhalation COPD mousemodel. Material and Methods: Wild-type mice (C57/Bl6J) wereexposed to cigarette smoke for 6 hours/day, 5 days per weekup to 8 months. Exposure of smoke was maintained at a parti-cle concentration of 140 mg/m3. In parallel, wild-type controlmice were exposed to room air. After exposure, mice were anes-thetized for histological fixations of the lung to analyze alveolarair space, septal wall thickness, and mean linear intercept. Lungfunction and vasoreactivity were also measured with isolatedperfused ventilated mouse lung experiment. Weight changes ofall animals were examined weekly. Results: Tobacco smoke ex-posure resulted in an increase in mean linear intercept, alveolarairspace and a decrease in septal wall thickness of all lobes inlung (p < 0.05) within 8 months, but the diseases progressionstarted even earlier to upper extremities (p < 0.05). Increasedlung compliance and tidal volume were observed in smoke-exposed mice (p < 0.05). Increased vasoconstrictive responseand decreased vasodilator response were observed in smoke-exposed mice (p < 0.05). Body weight was also decreased si-multaneously in smoke-exposed mice (p < 0.05). Conclusion:Emphysema is induced by chronic tobacco smoke inhalation inC57/Bl6J mice with a higher susceptibility to the proximal re-gions of the lung. Lung function capacity is reduced and vascularresponse is altered. This model now allows studying mechanismsof emphysema in mice by investigation of transgenic animals.

396 December 2008 COPD: Journal of Chronic Obstructive Pulmonary Disease

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THE EFFECT OF CRP AND PROCALCITONINLEVELS ON THE ESTIMATION OF INFECTIONIN THE PATIENTS WITH COPD WHO AREADMITTED TO ICU WITH A DIAGNOSIS OFRESPIRATORY FAILURE

Ferah Ece, Levent Kilickan, Jale Aytac, Halim Issever, andOsman Bayindir Istanbul Bilim University Medical School,Avrupa Florence Nightingale Hastanesi Mehmetcik caddesi,No: 1Mecidiyekoy-Istanbul, Turkey

Background: Acute respiratory failure is one of the most fre-quent reasons for ICU admittance of patients with acute exac-erbation of COPD. Those patients almost always receive an-timicrobial treatment in the ICU. Unnecessary antibiotic usagecauses increase in antibiotic resistance, cost of hospitalization,and side effects. In this study we aimed to investigate whetherthe levels of CRP and procalcitonin affect the decision of antimi-crobial therapy in those patients. Methods: Twenty-four patientswho were consecutively admitted to the ICU with a diagnosisof acute respiratory failure after COPD exacerbation were ex-amined. CRP, procalcitonin, CPIS, and CURB-65 scores wereassessed for each patient at the time of admittance to the ICU.Microbial culture of tracheal secretions, urine, and blood sam-ples were done routinely as well. According to the results of an-tibiogram tests, patients received antimicrobial treatment. How-ever, if there was a suspicion of the infective disease such as fever(>40◦C, <35◦C), 30000< WBC < 4000, etc., empiric antibiotictreatment was given to the patients. Results: Patients with culturepositivity showed significantly higher levels of CRP and procal-citonin than culture (–) patients. CPIS and CURB-65 scoreswere comparable with the CRP and procalcitonin levels. Af-ter antimicrobial treatment, CRP and procalcitonin levels weredecreased in both empiric treatment and antimicrobial culture-positive group; however, it was statistically significant only inthe latter. Conclusion: The initiation of antimicrobial therapymay be manipulated by the levels of CRP and procalcitonin.

HYPEROXIC EFFECTS ON INSPIRATORYMUSCLE FATIGUE IN CYCLING HEALTHYHUMANS

Marina Segizbaeva Pavlov Institute of Physiology 199034, Rus-sia, St. Petersburg, nab. Makarova 6, Laboratory of RespiratoryPhysiology

During high-intensive exercise to exhaustion and/or respira-tory load the inspiratory muscles of healthy trained human canfatigue. The aim of the present study was to determine the rate ofthe inspiratory muscle fatigue development in healthy man dur-ing incremental cycling under low- and high-resistive loadedbreathing in air and oxygen. VT, VE, TI, TT, PACO2, PmI,and parasternal-integrated EMG activities were recorded eachminute during incremental cycling test under resistive load 12

(low) and 40 (high) cm H2O/l s-1 in air and oxygen in 10 healthymen. The degree of inspiratory muscle fatigue was evaluated bythe dynamics of inspiratory mouth pressure, “tension-time” in-dex TTm, as well as the fall of the ratio of high-frequency tolow-frequency power (H/L) of the parasternal EMG. Oxygenbreathing during low-resistive load decelerates the developmentof inspiratory muscle fatigue compared to air, although the max-imal work performance was higher in oxygen than in air (210± 11 Wt and 181 ± 12 Wt, respectively). However, the inspi-ratory muscle fatigue develops at an equal rate during cyclingwith high-resistive load in air and oxygen and maximal workperformance was the same too (135 ± 9 and 139 ± 11 Wt inair and oxygen, respectively). Oxygen breathing has a positiveeffect on inspiratory muscles function only during low-resistiveload, whereas hyperoxia does not improve the energy supply ofthe inspiratory muscles as well as increase the maximal workperformance of human during high-resistive load. It is supposedthat in forced respiration with high-resistive load, the arterialsupply of the inspiratory muscles is impaired due to occlusionof intramuscular vessels during intense muscular contractionsand a significant shortening of the relaxation time of respiratorymuscles in the expiratory phase.

AN AUDIT OF THE COMMUNITY PULMONARYREHABILITATION SERVICE IN WAKEFIELDDISTRICT PRIMARY CARE TRUST

Tara Bader, Anna Phillips, Rachel Birmingham, MohammedHotak, Gethin Lane, Lizzie Lloyd, and Elizabeth HutchinsonSchool of Medicine, University of Leeds, Worsley Building, Uni-versity of Leeds, Leeds, LS2 9JT.

An audit of the community pulmonary rehabilitation servicewas carried out for Wakefield District Primary Care Trust (WD-PCT). Chronic Obstructive Pulmonary Disease (COPD) is amajor public health issue and remains the fifth leading causeof death in the United Kingdom. Pulmonary rehabilitation is amultidisciplinary program consisting of exercise and educationsessions that aim to reduce symptoms, decrease disability, andimprove quality of life for people with COPD. This audit aimedto assess WDPCT/s pulmonary rehabilitation service. The auditwas based on National Institute for Health and Clinical Excel-lence (NICE) guidelines and evaluated the location, content, andduration of the service. A postal questionnaire was designed andsent to service users of pulmonary rehabilitation. Service userfeedback on the program was then used to determine whetheror not WDPCT is meeting the recommendations set by NICE.Overall, the findings show that WDPCT is meeting the requiredstandards. However, the following aspects could potentially beimproved: attendance at the education sessions, increasing thebenefit received by patients, and the introduction of a follow-upprogram. This audit is the first of its kind and, therefore, newstandards had to be set. The audit cycle will be repeated by WD-PCT using the recommended standards and methods to ensurefuture monitoring of the community pulmonary rehabilitation


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service. (This presentation would give information on how toprovide effective community pulmonary rehabilitation to inter-ested service providers.)

A STAIR-CLIMBING TEST IN CHRONICOBSTRUCTIVE PULMONARY DISEASE(COPD) ASSESSMENT

Estelle Villiot-Danger, Gregory Reychler, Bertrand Selleron,Jean Christophe Villiot-Danger, and Hassan Razzouk Centre dePneumo-Allergologie Les Acacias, 46 Route de Grenoble, BP295107 Briancon cedex, France

Introduction: Exercise tolerance is a cornerstone of COPDassessment. Six-minute walking test (6MWT) is the gold stan-dard for its evaluation but it does not simulate walking up aslope. Objectives: To compare a stair-climbing test (SCT) tothe 6MWT and to observe specifically their sensitivity to dysp-noea. Material and method: A self-paced 2-minutes SCT and the6MWT were performed in 14 stable COPD patients (mean age= 65.9; SD = 13.8 years; FVC = 79.6 10.6% pred.val.; FEV1 =52 17.2% pred.val.; 10/4 GOLD II/III, BMI = 24.5 3.8 kg·m–2)without encouragement, on a separate day. SaO2, heart rate (HR),walking distance or height, and dyspnoea (modified Borg scale)were measured before and after the tests. The physiological costindex (PCI) was calculated. Results: Delta SaO2 and HR are sim-ilar after both tests. Dyspnoea and PCI were significantly higherwith SCT (6 2 vs 3 1.5, p < 0.001 and 0.29 0.12 vs 2.44 1.50,p < 0.001, respectively). There was a significant correlationbetween PCI and FEV1 only with 6MWT (r = 0.59, p < 0.05).Conclusion: These preliminary data suggest that SCT could bean alternative to assess exercise tolerance in COPD patients.SCT seems more sensitive than 6MWT regarding dyspnoea.

SPIROMETRIC SCREENING ON WORLDCOPD DAY

Tanja Grzetic-Romcevic, Boris Devcic, and Silvana Sonc De-partment of pneumology, Clinical department for respiratorydiseases and allergy, University, Clinical center , Ljubljana,Slovenia, Hospital Sezana, Cankarjeva 4, 621, Slovenia

Objectives: To determine the importance of spirometricscreening for early detection of chronic obstructive pulmonarydisease (COPD). Methods: Spirometric screening has been per-formed annually on World COPD day in Sezana from 2003.Sezana is a semiurban region of Slovenia, with 12.002 inhab-itants. A total of 646 persons were enrolled (342 women and304 men). The participators completed a questionnaire andhad spirometry performed. Subjects with postbronchodilatorFEV1/FVC < 0.70 were defined as having COPD, according toGOLD guidelines. Results: A total of 14.4% subjects with im-paired lung function were found .Of these, obstructive pattern ofventilatory impairment had 72% and 28% a restrictive pattern.

We identified 63 individuals with COPD and 4 with bronchialasthma. Subjects with COPD were >70 years old in 46%. Themajority of individuals with COPD were men (77.7%).A totalof 90% of patients with COPD were smokers and in 10% werenonsmokers. Patients with COPD had mild disease in 46%, mod-erate in 38%, and severe in 16%. The majority of the patientshad mild disease. A total of 94% of those with COPD (59/63)have not been recognized prior. Conclusions: These results sug-gest that with spirometry screening patients with COPD couldbe detected in the earlier stages of the disease.

AMBULATORY OXYGEN ASSESSMENT:ENDURANCE SHUTTLE WALK VERSUS THE6-MINUTE WALK TEST

S. Revill, Noor, G. Butcher, and M.J. Ward Sherwood ForestHospitals NHS Trust, Ashfield Community Hospital, Kirkby-in-Ashfield, Notts, NG17 7AE

Assessment of exertional desaturation and correction withambulatory oxygen involves monitoring the response to a stan-dard walking test. Previous studies have shown a variable re-sponse with the 6-minute walk test (6MWT), while there havebeen few studies on the response of the endurance shuttle walk-ing test (ESWT). The aim of this study was to evaluate theresponsiveness of the ESWT and the 6MWT to the acute effectsof ambulatory oxygen in patients with COPD. Methods: A to-tal of 23 patients performed, in random order, the ESWT andthe 6MWT on air and while breathing oxygen at 2 l/min. Oxy-gen saturation and Borg scores were recorded. On a third day,11 patients repeated the ESWT with oxygen in order to mea-sure repeatability. Results: The change in distance walked whenbreathing oxygen was significantly greater on the ESWT thanthe change on the 6MWT (66 (91) vs 6 (28) m, respectively; p <

0.05). When repeated, the mean difference (95% CI) betweendistances walked with oxygen on the ESWT was 0.91 (–47, 49)m. Conclusion: The ESWT is more responsive than the 6MWTfor detecting improvements in walking capacity while breathingambulatory oxygen.

INCREASED CD8+ T LYMPHOCYTES INSMALL AIRWAYS AND ALVEOLAR WALL INCENTRILOBULAR EMPHYSEMA

Won-Dong Kim,1 Kang-Hyeon Choe,2 Woo-Sung Kim,1 Youn-suck Koh,1 Sang-Do Lee,1 Chae-Man Lim,1 Tae-Sun Shim,1,Yeon-Mok Oh,1, Sang-Bum Hong,1, Dong-Soon Kim,1, andKyu-Rae Kim3 1Division of Pulmonary and Critical CareMedicine, Department of Internal Medicine; 3Department ofPathology, University of Ulsan College of Medicine, Seoul; and2Department of Internal Medicine, Chungbuk National Univer-sity College of Medicine, Cheongju, Republic of Korea

Subjects with COPD have an increased number of CD8+ Tlymphocytes in the peripheral airways and lung parenchyma.


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Centrilobular emphysema (CLE) has greater abnormalities insmall airway wall than panlobular emphysema (PLE). Smallairway wall thickness is associated with the degree of emphy-sema in CLE. We hypothesized that CLE would have a highernumber of CD8+ T lymphocytes in small airways and alveolarwall than PLE. Immunohistochemical staining was performedto identify CD8+ T lymphocytes in small airways and alveolarwall of surgically resected lungs from 8 normal, 8 PLE, and 14CLE subjects. A higher number of CD8+ T lymphocytes permm2 of small airway wall (p < 0.05, respectively) and per mmof alveolar wall (p < 0.01, respectively) were found in CLE thanin normal or PLE. The number of CD8+ T lymphocytes in smallairway walls was correlated with those in alveolar wall in CLE(rho = 0.763, p = 0.002). The results suggest that CD8+ T lym-phocytes might simultaneously play a role in the pathogenesis ofsmall airway wall thickening and centrilobular emphysematouslung destruction. It is suspected that small airway disease andcentrilobular emphysema could be the dual manifestations of asingle disease process.

CORRELATIONS OF PLASMA C-REACTIVEPROTEIN WITH OUTCOME MEASURES INALPHA-1-ANTITRYPSIN DEFICIENCY

Paul A. Dawkins, Darren L. Bayley, and Robert A. StockleyUniversity Hospital Birmingham, Edgbaston, Birmingham. B152TH

C-reactive protein (CRP) is an acute phase protein and a mea-sure of systemic inflammatory response. High-sensitivity CRPassays were performed on plasma samples from patients withPiZ phenotype on the UK alpha-1-antitrypsin (A1AT) registry.Correlations were made between plasma CRP and lung func-tion, exacerbation rates, health status scores, CT scan emphy-sema scores, body mass index (BMI), and chronic bronchitis(CB). CRP was also studied in relation to mortality and speedof FEV1 decline over 3 years. Results: CRP correlated withFEV 1% predicted (r = 0.193, p = 0.007, n = 192) and therewas a direct relationship of CRP with GOLD severity groups.However, there was no significant correlation with gas trans-fer (DLCO/VA). CRP correlated with St. George’s RespiratoryQuestionnaire (SGRQ) total score (r = 0.207, p = 0.003, n =197), activity score (r = 0.198, p = 0.005, n = 197), and im-pact score (r = 0.202, p = 0.004, n = 197) but not symptomsscore. CRP also correlated with SF36 physical component score(r = 0.222, p = 0.002, n = 199) but not mental componentscore. There was a correlation of CRP with CT scan lower zoneexpiratory Voxel Index scores (r = 0.216, p = 0.029, n = 107)and upper zone expiratory scores (r = 0.165, p = 0.050, n =101), but not inspiratory scores. CRP also correlated with BMI(r = 0.228, p = 0.001, n = 208). Average CRP in patients withCB (n = 90) was 10.6 mg/l; average CRP in patients without CB(n = 122) was 9.3 mg/l; p = 0.035. There was no correlationwith exacerbation rates over 3 years (r = 0.092, p = 0.424,n = 77). Mortality was similar in 198 survivors compared with

16 nonsurvivors, and there was no difference between the 50%of patients with fastest decline of FEV1 over 3 years comparedwith the 50% of patients with slowest decline of FEV1 over 3years. In conclusion, CRP measurements correlate with a vari-ety of outcome measures in A1AT deficiency, including FEV1,health status, CT scan emphysema scores, BMI, and CB but notwith mortality or speed of FEV1 decline.

PATIENT INSIGHTS ON THE IMPACT OFMORNING SYMPTOMS OF COPD

Martyn R. Partridge and Niklas Karlsson Faculty of Medicine,Imperial College London, NHLI Division at Charing Cross Hos-pital, St Dunstans Road, London W6 8RP, UK

Many diseases are associated with symptoms that are worseat one particular time of the day. In respiratory medicine asthmais well-known to be associated with worsening during sleep andin the early morning. In COPD there are a number of patho-physiological reasons why the disease may be worse in the earlymorning: these include the effects of recumbency, ciliary slow-ing, diminished sighing, reduced frequency of coughing, lowlung function, and relative nocturnal hypoventilation. Whetherthese changes result in increased symptoms in the early morn-ing is not clear from the published literature. We, therefore,retrospectively reviewed in-depth interviews with 78 patientsfrom four European countries. The transcripts were themed andwhile these were qualitative studies it was clear that at least50% of patients with COPD spontaneously reported that symp-toms of cough, wheezing, and breathlessness were worse in themorning. Many patients spontaneously mentioned that morningsymptoms significantly limited their activities of daily living andnecessitated use of reliever medication. If symptoms are worse,first thing in the morning we need is new tools to assess the bur-den of this on patients and, therapies may need to be specificallystudied and directed for use at this time of day.

CLINICAL ASSESSMENTS OF COPD INPRIMARY CARE: THE ROLE OF SUBJECTIVEAND OBJECTIVE ASSESSMENTS

Chris Loveridge, Hazel Madoc-Sutton, Monica Fletcher, andJane Upton Education for Health, The Athenaeum, 10 ChurchStreet, Warwick, CV34 4AB

Introduction: The UK primary care nurses are increasinglyresponsible for the follow-up care of patients with chronic ob-structive pulmonary disorder (COPD). Here we assess the ex-tent to which they perform both objective and subjective as-sessments in accordance with current guidelines. Methods: Atotal of 500 randomly selected UK general practices were sentquestionnaires. Lead COPD nurses recorded the frequency theyperformed key follow-up tasks on a 4-point Likert-type scale(always to never). Results: A total of 74% of nurses responded


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(n = 368). Of the 95% who gave follow-up care, the follow-ing always or often performed objective measurements: 98%checked inhaler technique, 95% checked symptom control, 93%checked exacerbation frequency, 86% recorded spirometry, and85% recorded body mass index (BMI). Fewer performed sub-jective assessments: 51% always or often assessed patients’psychosocial problems and 48% always or often used a vali-dated score to measure quality of life. Conclusion: Respondentsperformed objective assessments more frequently than subjec-tive assessments. This may be due to the General Medical Ser-vices Contract (2003), which while raising the profile of COPD,focuses care on objective assessments. Practice nurses shouldstrive to conduct broad assessments in which the psychoso-cial impact of COPD and its impact on quality of life are alsoassessed.

CLINICAL PATHWAY FOR ACUTEEXACERBATIONS OF CHRONIC OBSTRUCTIVEPULMONARY DISEASE (AECOPD):DEVELOPMENT AND 5-YEAR EXPERIENCE

Koichi Nishimura,1 M. Santo, Y. Hoko,1 T. Kondo,1 A.Takahagi,1 K. Tamura,1 S. Ito,1, T. Yoshimura,1, N. Yamashita,1

T. Hanawa,1 Y. Matsubara,1 M. Okamoto,2 and T. Oga3

1Respiratory Division, Kyoto-Katsura Hospital, Kyoto, Japan;2The First Department of Internal Medicine, Kansai MedicalUniversity, and 3Department of Respiratory Care and SleepControl Medicine, Respiratory Division, Kyoto-Katsura Hos-pital, 17 Yamadahirao, Nishikyo-ku, Kyoto, 615-8256, Japan

Background: A clinical pathway is a part of total qualitymanagement concept. The paucity of the pathway in AECOPDmay be related to the difficulty in acute severe illness and aconcern about treatment failure. Methods: The clinical path-way was formalized by a multidisciplinary group in Novem-ber 2002. The pathway provided general rules for frequencyof patient assessment and laboratory evaluation, pharmacother-apy including bronchodilator, oral corticosteroid and antibiotics,oxygen administration, NPPV (PaCO2 > 45–50 mm Hg), us-age of rehabilitation program, education of inhalation technique(pharmacist intervention), nutritional support, social work in-tervention, and discharge planning. Exclusion criteria includedpneumothorax-related exacerbations and mechanical ventila-tion with intubations. Results: The pathway has been appliedto 241 hospitalizations by 154 patients. Seven patients diedduring the hospitalization (3%). Treatment with the pathwaywas interrupted and defined as a dropout in 27 hospitalizations(11%). Eight cases required intubations and mechanical venti-lator use. Treatment with the pathway was completed in 214out of 241 hospitalizations (89%). NPPV was administrated in97 treatment arms. Hospital length of stay was over 30 daysin 30 admissions, mainly due to the complications. Conclu-sions: AECOPD can be treatable via a clinical pathway. Thepathway could fill in the gaps between guidelines and clinicalpractice.

TOTAL CALORIC INTAKE IN COPD PATIENTSCORRELATES WITH TOTAL LUNG CAPACITYAND DIFFUSING CAPACITY

Ho I Yoon, Young Ae Kang, Jae Ho Lee, and Choon-TaekLee Department of Internal Medicine, Seoul National Uni-versity Bundang Hospital, Seoul National University Col-lege of Medicine. 300 Gumi-dong, Bundang-gu, Seongnam-si,Gyeongi-do, 463-707, Korea

Typical emphysematous changes were demonstrated instarved animals. In addition, the previous report aboutemphysema-like changes in the lungs of patients with anorexianervosa suggests that the possibility of malnutrition affectsseverity of emphysema in COPD patients. Our research aimedto find correlation between total caloric intake and lung func-tion parameters in stable COPD patients. A total of 51 COPDpatients were enrolled in this study. Total caloric intake wasevaluated through a 3-day-record by a dietician. Total caloricintake correlated with FVC (r = 0.305, p = 0.035) and FEV1

(r = 0.377, p = 0.008) but not with % predicted FVC (r =0.022, p = 0.883) and % predicted FEV1 (r = 0.221, p =0.131). It correlated with % predicted diffusing capacity of car-bon monoxide (DLCO) (r = 0.367, p = 0.018), % predictedDLCO/VA (r = 0.381, p = 0.014), and inversely correlatedwith % predicted total lung capacity (TLC) (r = –0.344, p =0.037). In conclusion, total lung capacity and diffusing capacityof carbon monoxide (DLCO) correlate with total caloric intakein COPD patients. Whether total caloric intake affects severityof emphysema needs to be further elucidated. Supported by agrant of the Korean Health 21 R&D Project, Ministry of Health& Welfare, Republic of Korea (A040153).

TUBERCULOSIS, SMOKING, AND COPD: THEGUANGZHOU BIOBANK COHORT STUDY

KH Lam,1 P Adab,1 RE Jordan,1 MR Miller,2 CQ Jiang,3

KK Cheng,1 and TH Lam4 1Department of Public Healthand Epidemiology, University of Birmingham, Birmingham,UK; 2Department of Medicine, University Hospital Birm-ingham NHS Trust, Selly Oak Hospital, Birmingham, UK;3Guangzhou Number 12 People’s Hospital, Guangzhou, China;and 4Department of Community Medicine and School of PublicHealth, The University of Hong Kong, Hong Kong

The contribution of pulmonary tuberculosis (TB) to chronicobstructive pulmonary disease (COPD) and its interactionwith smoking remains unclear. Participants in the GuangzhouBiobank Cohort Study undertook spirometry, chest radiography,and an interview. COPD was defined as FEV1/FVC < 0.7 with-out asthma. The presence of previous TB was based on eitherself-report or changes consistent with TB on X-ray. The preva-lence of previous TB in this sample (n = 8076, mean age 61.9)was 25.2% (men: 35.2%; women: 21.5%). Past TB and smoking


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(adjusted for age and sex) both independently increased the riskof COPD. The interaction between the two caused an additional23.6% increase in risk (Table 1). Adjustment for exposure topassive smoking, dust, and biomass fuel did not alter the re-lationship. TB is an independent risk factor for COPD, whichmay partly explain the higher prevalence of COPD in China. AsTB is now renascent, clinicians should be aware of this long-term risk in people who have had TB, irrespective of smokingstatus.

Table 1. Separate and joint risk of COPD by TB and smoking status

TB history Never smoker Ever smoker

No 1.00 1.40 (1.05—1.87)Yes 1.36 (1.09—1.70) 2.35 (1.73—3.19)

OR (95% CI) adjusted for sex, age, pack years.

USE OF RELIEF MEDICATION IN SEVERECOPD PATIENTS: RESULTS FROM THE INSPIRESTUDY (INVESTIGATING NEW STANDARDSFOR PROPHYLAXIS IN REDUCTION OFEXACERBATIONS, SCO40036; NCT00361959)

Robert Stockley, Terence Seemungal, Peter Calverley, LisaWillits, John Riley, and Jadwiga Wedzicha University HospitalBirmingham NHS Foundation Trust. Department of Medicine,University Hospital Birmingham NHS Foundation Trust, Birm-ingham, UK

Inspire compared salmeterol/fluticasone propionate (SFC)50/500 mcg BD with tiotropium (Tio) 18 mcg OD in 1323 indi-viduals (mean age 64 years, 39% postbronchodilator FEV1) ina randomized, double-blind, parallel 2-year study. The primaryend point was health care utilization (HCU) exacerbation rate.Use of Ventolin as a relief medication was an additional efficacyend point. There were no differences in HCU exacerbation ratebetween treatment groups. Compared with SFC, subjects on Tiowere more likely to withdraw from the study, used more oralsteroids for exacerbations, and were more likely to die duringthe study. On the other hand, antibiotic use for exacerbationsand pneumonia reporting was higher in the SFC treatment arm.(Wedzicha J, AJRCCM 2008; 177: 19–26). Subjects on Tio usedmore relief medication than those on SFC. The difference in av-erage relief medication usage was 0.33 uses/day in weeks 1–12(95% CI: 0.21–0.46, p < 0.001) and 0.74 uses/day in weeks 85to 104 (95% CI: 0.51–0.98, p < 0.001); the difference was alsostatistically significant at all other time intervals (p < 0.001).SFC subjects also had significantly more relief medication-freedays than Tio subjects. The higher use of relief medication onTio was maintained during exacerbations.


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