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Chronic obstructive pulmonary disease (COPD) is a leading cause of death, and constitutes a major medical and an increasing economic problem for acute and long term care. A low level of irreversible airway obstruction when in stable condition, hypercapnia, hypoxia, the presence of comorbid heart disease, right ventricular failure, and low serum albumin are the main factors related to risk of exacerbations. Bronchial infections, bronchospasm, left ventricular failure, pneumonia, pneumothorax and thromboembolism are described as the most frequent relapsing causes of COPD. During exacerbation, the inflammatory process, the ventilation/perfusion (V'A/Q') mismatching, an increased airflow resistance and dynamic hyperinflation (PEEPidyn) expose the respiratory muscles to the risk of fatigue, eventually leading to ventilatory pump failure and rising hypercapnia. Prevention of exacerbations and subsequent hospitalisations may be obtained with careful rehabilitation programs, a strict drug protocol, long term oxygen therapy and sometimes using home noninvasive mechanical ventilation (NMV). During exacerbation proper management of infection and lung mechanics derangement has to be adopted using an accurate assessment of severity and standardized treatment protocols. Patient history and examination and functional tests are beneficial to decide how and where to treat these patients. Mechanical ventilation (possibly noninvasive) may be required to reverse the acute episode. The aims of all these procedures remain: i) to prolong length and quality of life; ii) to save costs. Both hospital and post-discharge mortality of exacerbated COPD remain high while quality of life appears to be poor. Future studies will elucidate the relation between number and severity of exacerbations and prognosis.

Compliance is often poor in patients receiving long-term oxygen therapy (LTOT). We assessed some characteristics of LTOT patients and factors associated with non-effective use of LTOT in Turkey. A questionnaire was sent to 1100 patients who purchased their oxygen equipment between January 1995 and September 1999 from the largest oxygen company in Turkey. The questionnaire included items about daily duration of oxygen therapy, home situation, lifestyle, education level of the patient, smoking habits and side effects of oxygen therapy. In addition, patients were asked whether supplementary medical and technical education on oxygen therapy was explained to them. 379 patients responded. The patients had been receiving LTOT for 24.3 +/- 13 months. The mean duration of oxygen therapy was 9 +/- 6.8 hours/day. Only 28.2% of the patients managed to receive oxygen therapy for 15 h or more daily. 33.2% of the patients were told to use oxygen only when they had difficulty in breathing. 6.9% of the patients continued to smoke and 8.7% of the patients had complaints related to oxygen therapy. Logistic regression analysis identified that the likelihood of achieving effective oxygen therapy increased 4.5 fold (p < 0.001) when the physician gave pre-treatment education to the patient about the therapy, and effective use increased 3.8 fold (p < 0.002) when the patients were closely followed-up by the physician. We conclude that pre-treatment education of the patient about the therapy and close follow-up by the physician may increase the compliance rate to LTOT.

Rehabilitation in patients with chronic obstructive pulmonary disease (COPD) has been shown to be an effective treatment and can be carried out in different settings, i.e. inpatient, outpatient or home-based. This review focuses on home-based rehabilitation and four important issues are discussed. 1) Which patients should received home-based rehabilitation? 2) How should home-based rehabilitation be organized? 3) What are the effects of home-based rehabilitation? 4) What are the financial implications. Home-based rehabilitation is an attractive approach for most patients with COPD. However, there is some evidence that patients who are severely disabled due to dyspnoea do not gain benefit from home-based rehabilitation. This might not be the appropriate setting for this group, and these patients are probably better candidates for an inpatient or outpatient multidisciplinary approach. After initial evaluation of the patient by a pulmonary physician, home-based rehabilitation can be set up in two different ways. Firstly, the patients can receive their instructions at the hospital: a detailed exercise programme can be developed that the patients can perform unsupervised at home with regular follow-up at the outpatient clinic. Second, home rehabilitation can be fully addressed at home with instruction and regular supervision by a local team. At this moment, it is not clear which disciplines, i.e. what kinds of intervention, are needed in a home rehabilitation team. Nevertheless, the key element of home-based rehabilitation is exercise training, which is the same for the other settings. Short-term studies with a maximum duration of 12 weeks showed increased exercise tolerance, decreased dyspnoea and improved quality of life. Conversely, the effects of long-term home-based rehabilitation are not clearly established. The need for long-term supervision is still open to debate: contradictory results have been shown regarding dyspnoea and exercise tolerance. Cost/benefit analysis showed positive trends in reduction in hospitalization rate and reduction of total costs; however, these results came from uncontrolled studies.

The beneficial effects of pulmonary rehabilitation programmes on the overall quality of life in patients with chronic obstructive pulmonary disease (COPD) has been well documented. However, there has been a paucity of studies demonstrating the long-term benefits of short-stay inpatient pulmonary rehabilitation (SSIPR) programmes in patients with severe COPD (forced expiratory volume in one second (FEV1) < 40% of predicted). The authors have previously reported that their multidisciplinary SSIPR programme improved outcome measurements immediately post-rehabilitation in 38 patients with severe COPD. The purpose of this study was to evaluate the long-term (1-yr follow-up) benefits of SSIPR in these patients. The outcome measurements used were: timed 12-min walking distance, Borg dyspnoea scale, annual days of acute care hospitalization, and Pulmonary Functional Status Scale. All outcome measurements were significantly improved at 1 yr post-SSIPR as compared to pre-SSIPR values. The 12-min walking distance was significantly improved in patients 1 yr post-SSIPR (251 m) as compared to either pre-SSIPR (133 m, p < 0.0001) or immediately post-SSIPR (224 m, p < 0.01). The number of annual days of acute care hospitalization was reduced from 15.4 pre-SSIPR to 3.8 (p < 0.0001) 1 yr post-SSIPR. The Borg dyspnoea scale measurement showed improvement, both at rest and after 12 min walking at 1 yr post-SSIPR. Also, the Pulmonary Functional Status Scale analysis showed significant (p < 0.001) sustained improvement at 1 yr post-SSIPR as compared to pre-SSIPR. In conclusion, it has been demonstrated that long-term sustained outcome benefits can be achieved from a comprehensive short-stay inpatient pulmonary rehabilitation programme for patients with severe chronic obstructive pulmonary disease.

The purpose of this study was to critically appraise overviews of respiratory rehabilitation in chronic obstructive pulmonary disease (COPD) in order to verify to what extent they convey evidence-based information helpful in implementing new rehabilitation programmes. A Medline search (1985-September 1995) for overviews related to rehabilitation, exercise therapy, education and/or psychological support in COPD was conducted. Chapters of major textbooks of respiratory medicine were also included. The search was limited to the English literature. Two independent reviewers assessed the overviews according to a validated index of scientific quality of research overviews using the following criteria: 1) the literature search method; 2) the inclusion criteria for original articles in the overview; 3) the validity assessment of the original articles; 4) the synthesis of findings; and (5) the conclusion of the overview. Thirty-eight overviews were included. Overall, the methodological quality of the overviews was low (quality score: median 2/7; range 1-5). In only one overview did the author state that the work was based on the results of a literature search. The methodological quality of the primary studies included in the overviews was not included in any of the reviews. The conclusions were only partially supported by the results extracted from the cited primary studies. The widespread application of respiratory rehabilitation in chronic obstructive pulmonary disease should be preceded by demonstrable improvements in function attributable to the intervention. Evidence-based overviews of the literature could assist in implementing new rehabilitation programmes.

Mucus hypersecretion and impaired mucus clearance are well-known symptoms in patients with chronic obstructive pulmonary disease and cystic fibrosis. These symptoms should not be considered as innocent but they deserve treatment. A well known therapy to improve mucus transport is chest physiotherapy. Forced expiratory manoeuvres are probably the most effective part of chest physiotherapy. Essential in the application of forced expiratory manoeuvres to improve mucus transport is whether airway compression should be used or prevented. The variables that influence the localization and degree of airway compression are expiratory force, lung volume and possibly mouth pressure. With these variables the patient should learn the most efficient form of forced expiration, according to the individual condition of the patient.

The benefit of chest physiotherapy in patients with cystic fibrosis has been well documented. However, the benefit of similar rehabilitation in patients with large amounts of sputum who have diagnoses other than cystic fibrosis has not been clearly demonstrated. The aim of this study was to evaluate the acute effectiveness of a device advised for home chest physiotherapy in comparison to postural drainage combined with chest percussion in removing secretions in patients with high sputum production due to diseases other than cystic fibrosis. Fourteen in-patients, known to spontaneously produce more than 25 mL sputum.day-1, underwent two sessions each of two treatment modalities in random order. Treatment A consisted of postural drainage and manual chest percussion. Treatment B included breathing through a commercial device claimed to combine oscillating positive expiratory pressure with oscillations of the airflow. Expiratory flows and oxygen saturation were monitored and recorded throughout the study. The amount of sputum produced in the 30 min preceding, during, and in the 60 min after completing each treatment session was recorded, together with the sensation of "chest unpleasantness due to secretions" as assessed by means of a modified visual analogue scale. The mean time that the patients tolerated treatment was not different for A and B (18.7 +/- 5 and 19.3 +/- 5 min, respectively). Sputum significantly increased during both treatment periods and in the same amount for the two modalities (2.9 +/- 2.9 to 10.9 +/- 7.1 and 2.8 +/- 3.1 to 10.1 +/- 10.8 mL for A and B, respectively). Visual analogue scale score significantly decreased at the end of each treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients with chronic obstructive lung disease represent a major impact on the utilization of health care resources. The high prevalence of impairment, disability and handicap among this population has led to the development of programmes in respiratory rehabilitation that aim to increase exercise tolerance and quality of life. Programme requirements may be quite modest but candidate evaluation will as-sist in selecting those most likely to benefit. The programme content should include supervised exercise, education and patient support. It is essential to employ appropriate outcome measures to evaluate the effectiveness of respiratory rehabilitation.

Oxygen therapy for the end-stage COPD patient should include a portable component. Accordingly, any system should be small and lightweight in order to enable the chronically debilitated patient to be as active and mobile as possible. Standard continuous flow oxygen via nasal cannulae is reliable and effective but it is also very wasteful. As a result, oxygen conserving methodologies have emerged to improve the efficiency of oxygen delivery and have served to lighten the load for these patients. These devices include: reservoir cannulas, transtracheal catheters and demand pulsing delivery devices. They provide oxygen savings from 2:1 to 7:1 over continuous flow delivery. In addition to rendering the newer oxygen systems more portable, they can also reduce the cost of oxygen and its associated service. As patient requirements are highly individual, the wide choice of available methodologies permits the clinician to prescribe the system that best suits the needs of the patient.