To the Editor:
Wilkinson and colleagues (1) have published the first prospective study demonstrating the importance of early treatment on outcomes of chronic obstructive pulmonary disease (COPD) exacerbations. They defined an exacerbation as the presence for at least two consecutive days of an increase in any two major symptoms (dyspnea, sputum purulence, sputum amount) or increase in one major and one minor symptom (wheeze, sore throat, cough, symptoms of a common cold). Patients who received prompt treatment after the onset of an exacerbation were likely to recover more rapidly than those who delayed reporting their exacerbation and thus began treatment later. Patients who habitually failed to seek therapy for their exacerbations had poorer quality of life and were more likely to be hospitalized for management of an exacerbation.
The authors point out the need for improved symptom recognition and earlier reporting of exacerbations by patients. They suggest patient education, methods of improving compliance, and self-management plans as suitable subjects for investigation.
The literature on self-management of COPD is controversial. Monninkhof and colleagues (2) did a 1-year randomized, controlled trial (RCT) on 248 patients with COPD, and Hermiz and colleagues (3) reported an RCT on 177 patients with COPD. Both of these studies failed to show positive effects of a selfmanagement program. Bourbeau and coworkers (4) performed an RCT on the effects of self-management in patients with moderate to severe COPD; they showed reduction in use of health care services and improved health status. Gallefoss (5), in an RCT on 62 patients with mild and moderate COPD, showed improved patient outcomes and reduced costs in a 12-month follow-up.
The definition of an exacerbation used by Wilkinson and colleagues (1) required symptoms to be present for at least two consecutive days. It is reasonable to ask whether with self-management, treatment could start earlier, say after 24 hours of symptoms.
Additional research is needed to establish, in practice, the best way of starting treatment earlier for exacerbations of COPD. It would also be useful to determine whether self-management has a place in this schema.
Conflict of Interest Statement: C.LS. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
Dr. Wedzicha was given an opportunity to respond to this letter but declined to do so.
References
1. Wilkinson TM, Donaldson GC, Hurst JR, Seemungal TA, Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004;169:1298-1303.
2. Monninkhof E, van der Valk P, van der Palen J, van Herwaarden C, Zielhuis G. Effects of a comprehensive self-management programme in patients with chronic obstructive pulmonary disease. Eur Respir J 2003; 22:815-820.
3. Hermiz O, Comino E, Marks G, Daffurn K, Wilson S, Harris M. Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease. BMJ 2002;325:938-942.
4. Bourbcau J, Julien M, Maltais F, Rouleau M, Beaupre A, Begin R, Renzi P, Nault D, Borycki E, Schwartzman K, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med 2003;163:585-591.
5. Gallefoss F. The effects of patient education in COPD in a 1-year follow-up randomised, controlled trial. Patient Educ Couns 2004;52:259-266.
GORDON L. SNIDER
Boston University School of Medicine
Boston, Massachusetts
Copyright American Thoracic Society Oct 15, 2004
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