Chronic obstructive pulmonary disease

Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Lung Biology in Health and Disease, Volume 183. By Nikos M. Siafakis, Nicholas R. Anthonisen, and Dimitris Georgopoulos, eds. New York, NY: Marcel Dekker, 2004; 603 pp; $199.95

The Lung Biology series published by Marcel Dekker covers a wide range of topical issues. Some are collections of illuminating essays aimed at fellow researchers, while others target comprehensive coverage of their theme, in effect addressed "to whom it may concern." No. 183, cast in the latter mold, is a detailed review of the epidemiology, pathology, physiology, presentation, and treatment of acute exacerbations of COPD (AECOPD). This is timely, in view of the current investment of time and effort that at long last is being directed toward the amelioration of this distressing group of conditions. In total, 66 contributors from 10 countries (11, if we count Scotland separately) have written all of 32 chapters. These are headed conventionally: definition, epidemiology, pathology, radiology, and so on.

All hospital physicians know what is meant by acute exacerbations of COPD: patients experience worsening dyspnea and cough and an increase in the volume and purulence of their sputum. These clinical observations were encapsulated in 1987 by Anthonisen et al in the Annals of Internal Medicine, and a universal definition of AECOPD might have resulted from this work. Regrettably, many different definitions have emerged that muddied the waters and made it somewhat difficult to review the AECOPD literature.

The evidence-based answers to many common questions about AECOPD can be found in this book. Do steroids help? (yes); should antibiotics be prescribed? (yes, if the sputum is purulent); do bacterial infections damage the airways permanently? (probably); why does oxygen administration cause Pco2 to rise sometimes? (because it worsens ventilation/perfusion dispersion); does noninvasive positive pressure ventilation have a role? (sometimes). Strikingly, electrolyte and water balance have hardly been investigated since 1980; the causes of edema, the role of comorbid left ventricular dysfunction, and the effects of loop diuretics are still not well studied and are dismissed throughout the book as self-evident.

There is a great deal of thoroughly researched and well-presented material here, and a few contributors allowed their own contribution to shine through, such as Bshouty's description of his informative model of cardiopulmonary interactions. Disappointingly, though, the patients do not emerge from these pages to tell their own stories. A complex organization that cares for AECOPD at home is described in detail, but although it has been imitated widely throughout the world there is no systematic evaluation as yet, nor are we told how these new approaches might be viewed by patients and their caregivers. We are promised an essay on end-of-life planning, but nothing of any human or scientific value is offered. Good qualitative research is rare, but some attempt might have been made to encourage it. Unfortunately, systematic study is hampered by the index, which is rather thin and was not corrected after the final pages of the book were inserted; after about page 100, it is necessary to add 2 to the page number to find a subject.

Much of this material can be found in textbooks covering the whole topic of COPD. Nevertheless, this book provides detailed answers to many of the questions asked by students and generalists who may have to treat patients with AECOPD. Mercifully, guidelines have not dictated the contents, and the book corrects some of the worst features of these, such as the writing out of emphysema and the oversimplification of lung function to FE[V.sub.1] and peak flow. Teachers of respiratory medicine will enjoy seeing the relevant classical literature presented elegantly in a modern context.

Gabriel Laszlo, MD

Bristol, UK

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group