Systematic review: chronic obstructive pulmonary disease and work-related outcomes.

Background: Several studies have assessed the impact of chronic obstructive pulmonary disease (COPD) on work ability and work productivity; however, this relationship is poorly understood. Aims: To undertake a systematic review to assess the effects of COPD on employment, absenteeism and presenteeism. Methods: A comprehensive search using CINAHL, Embase, MEDLINE and the Cochrane Library was conducted to include epidemiological studies from 1937 to August 2017. One reviewer screened all citations. Shortlisted full-text articles were independently assessed by a second reviewer. Data were extracted by one reviewer with a random sample of papers (45%) checked by a second reviewer. Results: Forty-four studies were included; the majority of evidence was from cross-sectional studies, and some cohort studies. COPD patients had lower employment rates than those without COPD. Among those in work, most studies showed patients with COPD took more time off work than those without and reported poorer work performance (presenteeism), although evidence for this association was weaker. The influence of disease severity on these outcomes was unclear; however, it appeared that increasing severity of airflow obstruction was associated with reduced likelihood of being employed. A number of methodological limitations were found among the evidence, including the lack of adjustment for important confounders. Conclusions: Future studies are required which assess the impact of COPD on presenteeism using validated presenteeism instruments and consistent reporting methods. Robust studies are now needed to identify modifiable factors associated with these poorer working outcomes to inform future interventions aimed at improving work productivity among those with COPD.

Patterns of domestic exposure to carbon monoxide and particulate matter in households using biomass fuel in Janakpur, Nepal.

Household Air Pollution (HAP) from biomass cooking fuels is a major cause of morbidity and mortality in low-income settings worldwide. In Nepal the use of open stoves with solid biomass fuels is the primary method of domestic cooking. To assess patterns of domestic air pollution we performed continuous measurement of carbon monoxide (CO) and particulate Matter (PM2.5) in 12 biomass fuel households in Janakpur, Nepal. We measured kitchen PM2.5 and CO concentrations at one-minute intervals for an approximately 48-h period using the TSI DustTrak II 8530/SidePak AM510 (TSI Inc, St. Paul MN, USA) or EL-USB-CO data logger (Lascar Electronics, Erie PA, USA) respectively. We also obtained information regarding fuel, stove and kitchen characteristics and cooking activity patterns. Household cooking was performed in two daily sessions (median total duration 4 h) with diurnal variability in pollutant concentrations reflecting morning and evening cooking sessions and peak concentrations associated with fire-lighting. We observed a strong linear relationship between PM2.5 measurements obtained by co-located photometric and gravimetric monitoring devices, providing local calibration factors of 4.9 (DustTrak) and 2.7 (SidePak). Overall 48-h average CO and PM2.5 concentrations were 5.4 (SD 4.3) ppm (12 households) and 417.6 (SD 686.4) µg/m3 (8 households), respectively, with higher average concentrations associated with cooking and heating activities. Overall average PM2.5 concentrations and peak 1-h CO concentrations exceeded WHO Indoor Air Quality Guidelines. Average hourly PM2.5 and CO concentrations were moderately correlated (r = 0.52), suggesting that CO has limited utility as a proxy measure for PM2.5 exposure assessment in this setting. Domestic indoor air quality levels associated with biomass fuel combustion in this region exceed WHO Indoor Air Quality standards and are in the hazardous range for human health.

A systematic review of associations between environmental exposures and development of asthma in children aged up to 9 years.

OBJECTIVES: Childhood asthma is a complex condition where many environmental factors are implicated in causation. The aim of this study was to complete a systematic review of the literature describing associations between environmental exposures and the development of asthma in young children. SETTING: A systematic review of the literature up to November 2013 was conducted using key words agreed by the research team. Abstracts were screened and potentially eligible papers reviewed. Papers describing associations between exposures and exacerbation of pre-existing asthma were not included. Papers were placed into the following predefined categories: secondhand smoke (SHS), inhaled chemicals, damp housing/mould, inhaled allergens, air pollution, domestic combustion, dietary exposures, respiratory virus infection and medications. PARTICIPANTS: Children aged up to 9 years. PRIMARY OUTCOMES: Diagnosed asthma and wheeze. RESULTS: 14,691 abstracts were identified, 207 papers reviewed and 135 included in the present review of which 15 were systematic reviews, 6 were meta-analyses and 14 were intervention studies. There was consistent evidence linking exposures to SHS, inhaled chemicals, mould, ambient air pollutants, some deficiencies in maternal diet and respiratory viruses to an increased risk for asthma (OR typically increased by 1.5-2.0). There was less consistent evidence linking exposures to pets, breast feeding and infant dietary exposures to asthma risk, and although there were consistent associations between exposures to antibiotics and paracetamol in early life, these associations might reflect reverse causation. There was good evidence that exposures to house dust mites (in isolation) was not associated with asthma risk. Evidence from observational and intervention studies suggest that interactions between exposures were important to asthma causation, where the effect size was typically 1.5-3.0. CONCLUSIONS: There are many publications reporting associations between environmental exposures and modest changes in risk for asthma in young children, and this review highlights the complex interactions between exposures that further increase risk.

Voice disorders in Nigerian primary school teachers.

BACKGROUND: The prolonged use or abuse of voice may lead to vocal fatigue and vocal fold tissue damage. School teachers routinely use their voices intensively at work and are therefore at a higher risk of dysphonia. AIMS: To determine the prevalence of voice disorders among primary school teachers in Lagos, Nigeria, and to explore associated risk factors. METHODS: Teaching and non-teaching staff from 19 public and private primary schools completed a self-administered questionnaire to obtain information on personal lifestyles, work experience and environment, and voice disorder symptoms. Dysphonia was defined as the presence of at least one of the following: hoarseness, repetitive throat clearing, tired voice or straining to speak. RESULTS: A total of 341 teaching and 155 non-teaching staff participated. The prevalence of dysphonia in teachers was 42% compared with 18% in non-teaching staff. A significantly higher proportion of the teachers reported that voice symptoms had affected their ability to communicate effectively. School type (public/private) did not predict the presence of dysphonia. Statistically significant associations were found for regular caffeinated drink intake (odds ratio [OR] = 3.07; 95% confidence interval [CI]: 1.51-6.62), frequent upper respiratory tract infection (OR = 3.60; 95% CI: 1.39-9.33) and raised voice while teaching (OR = 10.1; 95% CI: 5.07-20.2). CONCLUSIONS: Nigerian primary school teachers were at risk for dysphonia. Important environment and personal factors were upper respiratory infection, the need to frequently raise the voice when teaching and regular intake of caffeinated drinks. Dysphonia was not associated with age or years of teaching.

Biomass fuel use and the exposure of children to particulate air pollution in southern Nepal.

The exposure of children to air pollution in low resource settings is believed to be high because of the common use of biomass fuels for cooking. We used microenvironment sampling to estimate the respirable fraction of air pollution (particles with median diameter less than 4 µm) to which 7-9 year old children in southern Nepal were exposed. Sampling was conducted for a total 2649 h in 55 households, 8 schools and 8 outdoor locations of rural Dhanusha. We conducted gravimetric and photometric sampling in a subsample of the children in our study in the locations in which they usually resided (bedroom/living room, kitchen, veranda, in school and outdoors), repeated three times over one year. Using time activity information, a 24-hour time weighted average was modeled for all the children in the study. Approximately two-thirds of homes used biomass fuels, with the remainder mostly using gas. The exposure of children to air pollution was very high. The 24-hour time weighted average over the whole year was 168 µg/m(3). The non-kitchen related samples tended to show approximately double the concentration in winter than spring/autumn, and four times that of the monsoon season. There was no difference between the exposure of boys and girls. Air pollution in rural households was much higher than the World Health Organization and the National Ambient Air Quality Standards for Nepal recommendations for particulate exposure.

Oxidative potential of smoke from burning wood and mixed biomass fuels.

More than half the world's population still rely on burning biomass fuels to heat and light their homes and cook food. Household air pollution, a common component of which is inhalable particulate matter (PM), emitted from biomass burning is associated with increased vulnerability to respiratory infection and an enhanced risk of developing chronic obstructive pulmonary disease. In the light of an emerging hypothesis linking chronic PM exposure during childhood and increased vulnerability to respiratory diseases in adulthood, in a chain of events involving oxidative stress, reduced immunity and subsequent infection, the aim of this study was to characterise the oxidative potential (OP) of PM collected during the burning of wood and mixed biomass, whilst cooking food in the Kathmandu Valley, Nepal. Our assessments were based on the capacity of the particles to deplete the physiologically relevant antioxidants from a validated, synthetic respiratory tract lining fluid (RTLF). Incubation of mixed biomass and wood smoke particles suspensions with the synthetic RTLF for 4 h resulted in a mean loss of ascorbate of 64.76 ± 16.83% and 83.37 ± 14.12% at 50 µg/ml, respectively. Reduced glutathione was depleted by 49.29 ± 15.22% in mixed biomass and 65.33 ± 13.01% in wood smoke particles under the same conditions. Co-incubation with the transition metal chelator diethylenetriaminepentaacetate did not inhibit the rate of ascorbate oxidation, indicating a negligible contribution by redox-active metals in these samples. The capacity of biomass smoke particles to elicit oxidative stress certainly has the potential to contribute towards negative health impacts associated with traditional domestic fuels in the developing world.

Low back pain among textile workers: a cross-sectional study.

BACKGROUND: Low back pain (LBP) is one of the most prevalent occupational health problems in industrialized countries. Little is known about the epidemiology of LBP in developing countries. AIMS: To determine the prevalence of LBP among Nepalese textile workers and to investigate the influence of exposure to mechanical and other factors on LBP reporting. METHODS: Interviewers completed questionnaires with study subjects, and work-related mechanical exposures were measured by self-completed questionnaires. Associations of LBP with mechanical factors and somatic symptoms were determined by logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CI). RESULTS: Nine hundred and thirty-eight workers took part, a participation rate of 92%. The 1 month period prevalence of LBP was 35% (n = 324), being higher in females than males (45% versus 28%; P < 0.001). Several work-related mechanical factors were associated with increased odds of reporting LBP: lifting heavy weights with one hand (OR 1.7; 95% CI 1.1-2.8), pushing weights (OR 1.6; 95% CI 1.2-2.3 and pulling weights (OR 1.6; 95% CI 1.1-2.1). No association was found with working posture. Strong associations were found for reporting one (OR 2.4; 95% CI 1.7-3.4) or two somatic symptoms (OR 2.7; 95% CI 1.4-5.1). On multivariable analysis, reporting of somatic symptoms (OR 2.8; 95% CI 1.5-5.4), female gender (OR 2.2; 95% CI 1.5-3.1) and increasing age were significantly associated with increased risk of reporting LBP (OR 1.7; 95% CI 1.2-2.5), but no associations were found with mechanical factors. CONCLUSIONS: This study suggests that mechanical load may not be the leading cause of LBP and adds to evidence that psychological factors play an important role in LBP in non-industrialized countries.

Thunderstorm asthma: an overview of the evidence base and implications for public health advice.

Thunderstorm asthma is a term used to describe an observed increase in acute bronchospasm cases following the occurrence of thunderstorms in the local vicinity. The roles of accompanying meteorological features and aeroallergens, such as pollen grains and fungal spores, have been studied in an effort to explain why thunderstorm asthma does not accompany all thunderstorms. Despite published evidence being limited and highly variable in quality due to thunderstorm asthma being a rare event, this article reviews this evidence in relation to the role of aeroallergens, meteorological features and the impact of thunderstorm asthma on health services. This review has found that several thunderstorm asthma events have had significant impacts on individuals' health and health services with a range of different aeroallergens identified. This review also makes recommendations for future public health advice relating to thunderstorm asthma on the basis of this identified evidence.

Audit of the recording of occupational asthma in primary care.

BACKGROUND: Occupational asthma (OA) remains common; 1 in 10 cases of adult-onset asthma is due to work. Health outcomes are better with early diagnosis, but there is considerable delay, largely due to lack of enquiry about work effect in primary care. National guidelines (2008) recommend asking two screening questions, which together have a high sensitivity in identifying OA. AIMS: To audit how working-age asthmatics are currently screened for OA in a local primary care population. METHODS: An audit of the electronic patient records of working-age asthmatics, from four Birmingham primary care practices was undertaken. Practice-level data (list size, gender, prevalence of asthma and OA and socio-economic status) and patient-level data (gender, age, onset, occupation and work-effect enquiry and lung function) were collected. RESULTS: The total practice population was 27,295 of which 17,564 (64%) were of working age. The audit sample was 396 of whom 49% were male. The prevalence of asthma in working-age adults was 12% (8-15%) and the prevalence of OA in working-age asthmatics was 0.3% (0-0.8%). Occupation was recorded in only 55/396 (14%) cases with very few (2) documented within the asthma-review template. Occupation was only recorded in 13/55 adult-onset asthmatics in high-risk occupations. Of 396, 9 (2%) had any work-effect enquiry and 4 patients had work-effect enquiry at diagnosis in those with traceable notes (n = 117). CONCLUSIONS: The prevalence of OA was low, suggesting under-diagnosis plus under-reporting in primary care. Occupation and work-effect enquiry is lacking despite guidelines for identifying OA. Existing electronic templates for recording asthma review could be modified to include these elements.

Contribution of solid fuel, gas combustion, or tobacco smoke to indoor air pollutant concentrations in Irish and Scottish homes.

UNLABELLED: There are limited data describing pollutant levels inside homes that burn solid fuel within developed country settings with most studies describing test conditions or the effect of interventions. This study recruited homes in Ireland and Scotland where open combustion processes take place. Open combustion was classified as coal, peat, or wood fuel burning, use of a gas cooker or stove, or where there is at least one resident smoker. Twenty-four-hour data on airborne concentrations of particulate matter<2.5 µm in size (PM2.5), carbon monoxide (CO), endotoxin in inhalable dust and carbon dioxide (CO2), together with 2-3 week averaged concentrations of nitrogen dioxide (NO2) were collected in 100 houses during the winter and spring of 2009-2010. The geometric mean of the 24-h time-weighted-average (TWA) PM2.5 concentration was highest in homes with resident smokers (99 µg/m3--much higher than the WHO 24-h guidance value of 25 µg/m3). Lower geometric mean 24-h TWA levels were found in homes that burned coal (7 µg/m3) or wood (6 µg/m3) and in homes with gas cookers (7 µg/m3). In peat-burning homes, the average 24-h PM2.5 level recorded was 11 µg/m3. Airborne endotoxin, CO, CO2, and NO2 concentrations were generally within indoor air quality guidance levels. PRACTICAL IMPLICATIONS: Little is known about indoor air quality (IAQ) in homes that burn solid or fossil-derived fuels in economically developed countries. Recent legislative changes have moved to improve IAQ at work and in enclosed public places, but there remains a real need to begin the process of quantifying the health burden that arises from indoor air pollution within domestic environments. This study demonstrates that homes in Scotland and Ireland that burn solid fuels or gas for heating and cooking have concentrations of air pollutants generally within guideline levels. Homes where combustion of cigarettes takes place have much poorer air quality.

Occupational asthma and rhinitis due to detergent enzymes in healthcare.

BACKGROUND: The use of proteolytic enzymes to improve the cleaning efficacy of washing powders was introduced in the mid 1960s. Many microbial enzymes are known to be potent respiratory sensitizers but previously there has been only one case of occupational asthma associated with workplace exposure in a healthcare worker. AIMS: To report two cases of occupational asthma associated with exposure to biological enzymes in health-care workers and related occupational cases. METHODS: Reporting of clinical case reports from three different work places. RESULTS: One case of occupational asthma and three other cases with work-related asthma or rhinitis occurred in one workplace. A single case of probable occupational asthma presented at a second workplace with another case of work-related asthma at a third workplace. Exposures occurred in areas used for cleaning medical instruments and endoscopy suites. Hygiene measurements confirmed the potential for exposure. Control measures were not in place and recognition of the hazard was missing in these workplaces. CONCLUSIONS: Detergent enzymes when used in healthcare settings should be recognized as potential respiratory sensitizers. Healthcare institutions and professional bodies that recommend the use of detergent enzymes should review their risk assessments to ensure that the most appropriate methods for preventing or reducing exposure are in place.

Effect of inspired air conditions on exercise-induced bronchoconstriction and urinary CC16 levels in athletes.

Injury to the airway epithelium has been proposed as a key susceptibility factor for exercise-induced bronchoconstriction (EIB). Our goals were to establish whether airway epithelial cell injury occurs during EIB in athletes and whether inhalation of warm humid air inhibits this injury. Twenty-one young male athletes (10 with a history of EIB) performed two 8-min exercise tests near maximal aerobic capacity in cold dry (4°C, 37% relative humidity) and warm humid (25°C, 94% relative humidity) air on separate days. Postexercise changes in urinary CC16 were used as a biomarker of airway epithelial cell perturbation and injury. Bronchoconstriction occurred in eight athletes in the cold dry environment and was completely blocked by inhalation of warm humid air [maximal fall in forced expiratory volume in 1 s = 18.1 ± 2.1% (SD) in cold dry air and 1.7 ± 0.8% in warm humid air, P < 0.01]. Exercise caused an increase in urinary excretion of CC16 in all subjects (P < 0.001), but this rise in CC16 was blunted following inhalation of warm humid air [median CC16 increase pre- to postchallenge = 1.91 and 0.35 ng/µmol in cold dry and warm humid air, respectively, in athletes with EIB (P = 0.017) and 1.68 and 0.48 ng/µmol in cold dry and warm humid air, respectively, in athletes without EIB (P = 0.002)]. The results indicate that exercise hyperpnea transiently disrupts the airway epithelium of all athletes (not only in those with EIB) and that inhalation of warm moist air limits airway epithelial cell perturbation and injury.

High prevalence of skin symptoms among bakery workers.

BACKGROUND: Occupational skin disease is common and bakery workers are at increased risk of hand dermatitis. AIMS: To explore the frequency of, and to identify risk factors for, skin symptoms in a small bakery. METHODS: A cross-sectional survey of workers in a small bakery in Scotland, using a self-completed questionnaire regarding skin symptoms over the last 12 months. Additionally, data on self-reported atopy status, glove use and daily hand washing frequencies were obtained. Workers were classed as being at low, medium or high risk of occupational skin disease based on their job titles. RESULTS: The overall response rate was 85% (52 women, 41 men) with a mean age of 41 (range 17-72). Eleven per cent of bakers, confectioners and packers and 31% of cleaners, cooks and food production workers reported at least one skin symptom. Thirty-three per cent of symptomatic low-risk workers, 50% of symptomatic medium-risk workers and 75% of symptomatic high-risk workers stated their symptoms usually improved away from work. While washing hands more frequently than 20 times a day had an increased risk of skin symptoms, this was not significant [OR 3.5 (95% CI 0.9-13.2)]. CONCLUSIONS: There was a high prevalence of skin symptoms among these bakery workers which was more than double that previously reported in UK bakeries. Frequent washing of hands as a risk factor for skin symptoms may warrant further investigation in bakery workers.

Projections of the effects of climate change on allergic asthma: the contribution of aerobiology.

Climate change is unequivocal and represents a possible threat for patients affected by allergic conditions. It has already had an impact on living organisms, including plants and fungi with current scenarios projecting further effects by the end of the century. Over the last three decades, studies have shown changes in production, dispersion and allergen content of pollen and spores, which may be region- and species-specific. In addition, these changes may have been influenced by urban air pollutants interacting directly with pollen. Data suggest an increasing effect of aeroallergens on allergic patients over this period, which may also imply a greater likelihood of the development of an allergic respiratory disease in sensitized subjects and exacerbation of symptomatic patients. There are a number of limitations that make predictions uncertain, and further and specifically designed studies are needed to clarify current effects and future scenarios. We recommend: More stress on pollen/spore exposure in the diagnosis and treatment guidelines of respiratory and allergic diseases; collection of aerobiological data in a structured way at the European level; creation, promotion and support of multidisciplinary research teams in this area; lobbying the European Union and other funders to finance this research.

Assessment of respiratory health surveillance for laboratory animal workers.

BACKGROUND: Occupational asthma is the most common work-related respiratory disease in the UK. Individuals whose work potentially puts them at risk include those exposed to laboratory animals. Workplace health surveillance programmes aim to minimize these health risks but are recognized to be challenging to implement effectively. AIMS: To evaluate the efficacy of the respiratory health surveillance programme provided by a National Health Service occupational health service (OHS) to individuals potentially exposed to respiratory sensitizers at work with laboratory animals. METHODS: Case notes from the OHS respiratory health surveillance programme over a 2 year period were examined. Symptom detection by the OHS surveillance questionnaire was compared to a cross-sectional survey using items from the validated International Union Against Tuberculosis and Lung Disease (IUATLD) questionnaire. The surveillance spirometry records were audited against good standards of practice. RESULTS: The response rate for the anonymized survey using IUATLD questions was 60% and detected similar numbers of potential work-related symptoms to the OHS surveillance questionnaire. Over 80% of spirometry records met accepted standards for technique, effort and recording. In this study of 85 individuals over 2 years, three cases of occupational asthma were identified. CONCLUSIONS: The current surveillance appears to be effective in identifying potential cases of occupational asthma. Modification of the questionnaire content and layout might improve response rates. This study suggests that spirometry does not detect new cases other than those already identified by questionnaire.

Parental occupation is a risk factor for childhood wheeze and asthma.

The present birth cohort study investigated whether or not childhood wheeze and asthma are associated with parental exposure to occupational sensitisers that cause asthma. Parental occupation, from the Avon Longitudinal Study of Parents and Children (ALSPAC), was related to wheeze, asthma, ventilatory function, airway responsiveness and atopic sensitisation in children aged 0-102 months. Occupation was recorded for 11,193 mothers and 9,473 fathers antenatally, and for 4,631 mothers and 5,315 fathers post-natally. Childhood respiratory outcomes were not associated with parental occupational exposure to diisocyanates, glues/resins, dyes, animal dust, solder, enzymes and wood dust. Maternal post-natal occupational exposure to latex and/or biocides/fungicides increased the likelihood of childhood wheeze and asthma. High levels of latex or biocide/fungicide exposure were associated with an OR (95% CI) of 1.26 (1.07-1.50) and 1.22 (1.02-2.05), respectively, for wheezing up to 81 months. Combined maternal latex and biocide/fungicide exposure increased the likelihood of childhood wheeze (1.22 (1.03-1.43)) and asthma. High paternal occupational flour dust exposure was associated with an increased likelihood of wheeze after 30 months (2.31 (1.05-5.10)) and asthma by 91 months (3.23 (1.34-7.79)). Maternal occupational exposure to latex and/or biocides and paternal exposure to flour dust increases the risk of childhood asthma. Further studies in this area are justified.

Lung function and indicators of exposure to indoor and outdoor particulate matter among asthma and COPD patients.

OBJECTIVES: Misclassification of exposure related to the use of central sites may be larger for ultrafine particles than for particulate matter < or =2.5 microm and < or =10 microm (PM(2.5) and PM(10)) and may result in underestimation of health effects. This paper describes the relative strength of the association between outdoor and indoor exposure to ultrafine particles, PM(2.5) and PM(10) and lung function. METHODS: In four European cities (Helsinki, Athens, Amsterdam and Birmingham), lung function (forced vital capacity (FVC), forced expiratory volume in 1 second (FEV(1)) and peak expiratory flow (PEF)) was measured three times a day for 1 week in 135 patients with asthma or chronic obstructive pulmonary disease (COPD), covering study periods of >1 year. Daily concentrations of particle number, PM(2.5) and PM(10) were measured at a central site in each city and both inside and outside the subjects' homes. RESULTS: Daily average particle number concentrations ranged between 2100 and 66 100 particles/cm(3). We found no association between 24 h average particle number or particle mass concentrations and FVC, FEV(1) and PEF. Substituting home outdoor or home indoor concentrations of particulate air pollution instead of the central site measurements did not change the observed associations. Analyses restricted to asthmatics also showed no associations. CONCLUSIONS: No consistent associations between lung function and 24 h average particle number or particle mass concentrations were found in panels of patients with mild to moderate COPD or asthma. More detailed exposure assessment did not change the observed associations. The lack of association could be due to the high prevalence of medication use, limited ability to assess lagged effects over several days or absence of an effect.

A randomised trial of home energy efficiency improvement in the homes of elderly COPD patients.

A randomised trial of 178 patients in Aberdeen, UK with a previous hospital admission for chronic obstructive pulmonary disease (COPD) was carried out in order to determine whether improving home energy efficiency improves health-related quality of life in COPD patients. 118 patients were randomised and 60 agreed to monitoring only. Energy efficiency upgrading was carried out in 42% of homes randomised to intervention. Independent energy efficiency action was taken by 15% of control participants and 18% in the monitoring group. The main outcome measures were respiratory and general health status, home energy efficiency and hospital admissions. Intention-to-treat analysis found no difference in outcomes between the two groups. In 45 patients, who had energy efficiency action independent of original randomisation, there were significant improvements in respiratory symptom scores (adjusted mean 9.0, 95% CI 2.5-15.5), decreases in estimated annual fuel costs (- pound65.3, 95% CI - pound31.9- - pound98.7) and improved home energy efficiency rating (1.1, 95% CI 0-1.4). COPD patients are unlikely to take up home energy efficiency upgrading, if offered. Secondary "pragmatic" analysis suggests that those who do take action may achieve clinically significant improvement in respiratory health, which is not associated with an increase in indoor warmth.