Impact of home mechanical ventilation on health-related quality of life in patients with chronic alveolar hypoventilation: a prospective study.

BACKGROUND: Nocturnal ventilatory support by nasal positive pressure ventilation (NPPV) is an established treatment method in patients with chronic alveolar hypoventilation (CAH). The knowledge about its long-term effects on health-related quality of life (HRQL) is limited. METHODS: In a prospective, longitudinal, single-strand study, patients with CAH caused by non-COPD conditions, consecutively recruited among referral patients in three Swedish university hospital pulmonary departments, were examined at baseline and after 9 months (n = 35) and 8 years (n = 11) on NPPV treatment. Both volume pre-set and pressure pre-set ventilators were used. Patients completed a battery of condition-specific and generic HRQL questionnaires at baseline and follow-up. Spirometry and blood gases were measured. Compliance with treatment, side effects and patient satisfaction were evaluated. RESULTS: After 9 months of NPPV, improvements were seen primarily not only in sleep-related domains, but also in emotional behaviour, ambulation and sleep/rest functioning as measured with the Sickness Impact Profile (SIP). Improvements in sleep-related symptoms were related to effectiveness in ventilation, evaluated by morning PaCO(2), and remained by 8 years. Mental well-being was stable over time, while emotional distress improved by 8 years. Satisfaction with treatment was high in spite of frequent side effects. CONCLUSION: NPPV improves HRQL, particularly in condition-specific areas. Improvements are related to effectiveness in ventilation. Side effects are common, but compliance is good and patient satisfaction is high.

Potency ratio fluticasone propionate (Flixotide Diskus)/budesonide (Pulmicort Turbuhaler).

In the choice of, or switch between, various inhaled corticosteroids (ICS) it is important to know equipotent doses for clinical treatment effects of the alternatives. Various ICS do have different inherent potency. Further, the ICS are delivered from inhalers that may differ markedly in output characteristics and drug delivery to intrapulmonary airways. Therefore, clinical efficacy comparisons must include drug-inhaler comparisons. We estimated the therapeutic potency ratio of the Flixotide Diskus (fluticasone propionate, FP) and the Pulmicort Turbuhaler (budesonide, BUD) in steroid-naive asthma patients, using a dose-reduction technique (FP 500-0 mcg/day, BUD 800-0 mcg/day). The dose defining end point was loss of asthma control in this paper denoted as exacerbation. In total, 282 patients with proven asthma were enrolled in the study, and 103 in the FP group and 98 in the BUD group completed the study per protocol. In total, 80 patients in the FP-group and 79 in the BUD-group experienced a dose defining exacerbation. The exacerbation frequency increased in a dose-dependent way as the dose was titrated down. From these data the potency difference between the present drug inhaler combinations, Flixotide Diskus and Pulmicort Turbuhaler, was calculated to be between 1.50:1 (95% CI 1.10:1-2.05:1) and 1.75:1 (CI 1.26:1-2.43:1) depending on if patients with insufficient steroid-response were excluded from the calculations or not. In these steroid-naïve patients, the potency difference was evident only at low daily doses, below 200 mcg.

The effects of hypoxia and hypercapnia on renal and heart function, haemodynamics and plasma hormone levels in stable COPD patients.

BACKGROUND: Fluid retention with oedema is an important clinical problem in advanced chronic obstructive pulmonary disease (COPD). OBJECTIVE: The aim of this study was to investigate cardiovascular, hormonal, renal and pulmonary function data and their possible relation to fluid retention in COPD. METHODS: The study group consisted of 25 stable outpatients with COPD. The presence of oedema was assessed by clinical examination and the intake of diuretics was recorded. Glomerular filtration rate (GFR) and the renal blood flow (RBF) were measured. Lung function was assessed with standard spirometry. Cardiac function and haemodynamic variables were studied using echocardiography and equilibrium radionucleotide angiography. The plasma levels of noradrenaline, plasma renin activity, angiotensin II, aldosterone, atrial natriuretic peptide, brain natriuretic peptide and antidiuretic hormone were measured. RESULTS: Systolic and diastolic cardiac functions were found to be well preserved in the patients. Hypercapnia and impaired lung function, but not hypoxia, were clearly associated with oedema/intake of diuretics, low diuresis, low GFR, low RBF and high renal vascular resistance. These effects had no significant relationship to central haemodynamics or the measured plasma hormone levels. CONCLUSIONS: In stable COPD, renal fluid retention and oedema are enhanced by hypercapnia-induced renal vasoconstriction and antidiuresis. In contrast to some earlier reports, this effect does not seem to be mediated via the central haemodynamic reflex systems or the measured plasma hormones. In addition, hypoxia had no significant effect on fluid retention in this group of patients.

Comparison of lung volume reduction surgery and physical training on health status and physiologic outcomes: a randomized controlled clinical trial.

STUDY OBJECTIVES: In 1996, researchers in Sweden initiated a collaborative randomized study comparing lung volume reduction surgery (LVRS) and physical training with physical training alone. The primary end point was health status; secondary end points included survival and physiologic measurements. DESIGN: After an initial 6-week physical training program, researchers' patients were randomized to either LVRS (surgical group [SG]) with continued training for 3 months, or to continued training alone (training group [TG]) for 1 year. SETTING: All seven thoracic surgery centers in Sweden. PATIENTS: All patients in Sweden with severe emphysema fulfilling inclusion criteria for LVRS. INTERVENTIONS: Patients randomized to surgery underwent a median sternotomy, except for a few patients in whom thoracotomy or video-assisted thoracoscopy were performed. In the TG, supervised physical training continued for 1 year; in the SG, supervised physical training continued for 3 months postoperatively. MEASUREMENTS AND RESULTS: Fifty-three patients were included in each group. Six in-hospital deaths occurred after surgery (12%), and one more death occurred during follow-up. Two deaths occurred in the TG. The difference in death rates between the groups was not statistically significant. Health status, as measured by St. George Respiratory Questionnaire (SGRQ) [total scale score mean difference at 1 year, 14.7; 95% confidence interval (CI), 9.8 to 19.7] as well as by the Medical Outcomes Study Short-Form General Health Survey (physical function scale score mean difference at 1 year, 19.7; 95% CI, 12.1 to 27.3) was improved from baseline in the SG compared with the TG. FEV(1), residual volume, and shuttle walking test values also improved in the SG but not in the TG after 6 months and 12 months. CONCLUSIONS: In severe emphysema, LVRS can improve health status in survivors but is associated with mortality risk. The effects are stable for at least 1 year. Physical training alone failed to achieve a similar improvement.

[Dose-effect relation of inhalation steroids in asthma should be paid attention to. Comment to a Cochrane report]. / Dos-effektkurva för inhalationssteroider vid astma bör beaktas vid dosökning. Kommentar till en Cochrane-rapport.

The Cochrane collaboration has performed a meta-analysis of all studies found on the dose-effect relation with beclomethasone dipropionate (BDP) in the treatment of asthma. Fifteen studies were found and included, of which only two comprised children. Daily doses of 100 to 2000 micrograms were used. A two-fold increased dose was used in 9 studies but only few significant improvements were seen with the higher dose. A four- to fivefold increased dose gave significant improvement in one of two studies with an improvement of FEV1 of 16% versus 7% with the lower dose. The dose-effect of BDP seems to be very flat and a four-fold increase of the dose seems more reasonable than the two-fold commonly used today, when improved effect is desired. This increases the risk of side effects, and for long-term therapy other alternatives should be considered.