ABSTRACT: The aim of this study was to develop a clinical algorithm to assess chronic obstructive pulmonary disease exacerbation severity in a community setting.
An important aspect of community management of exacerbations is assessing patient safety. Although researchers have investigated risk factors for rapid deterioration, there is a lack of evidence validating clinical measures of exacerbation severity.
This was a prospective, community-based cohort study of patients enrolled in the Melbourne Longitudinal Chronic Obstructive Pulmonary Disease Cohort. The outreach team collected data on symptom severity at baseline and exacerbation onset using the Medical Research Council Dyspnoea Scale, St George Quality-of-Life Questionnaire and Symptom Severity Index.
Ninety-two patients were monitored from 2003 to 2005. There were 148 exacerbations: 121 (82%) were treated at home and 27 (17·5%) required hospitalization. An ordinal logistic regression model demonstrated that a combination of chronic obstructive pulmonary disease severity with dyspnoea and wheeze severity at exacerbation onset could differentiate severe from milder episodes [(OR 7·69, 95%CI: 3·9-11·5, P < 0·01), area under the receiver operating characteristics curve 0·75 (95%CI: 0·65-0·86)].
The majority of chronic obstructive pulmonary disease exacerbations can be safely managed in a community setting, but clinical assessment alone may not be sufficient to identify all patients who will develop complications such as respiratory failure. Further research is needed to validate clinical assessment and decision-making algorithms for community-management of chronic obstructive pulmonary disease exacerbations.
Journal of Advanced Nursing 11/2010; 66(11):2490-9. · 1.48 Impact Factor
ABSTRACT: Known inflammatory markers have limited sensitivity and specificity to differentiate viral respiratory tract infections from other causes of acute exacerbation of COPD (AECOPD). To overcome this, we developed a multi-factorial prediction model combining viral symptoms with inflammatory markers.
Interleukin-6 (IL-6), serum amyloid A (SAA) and viral symptoms were measured in stable COPD and at AECOPD onset and compared with the viral detection rates on multiplex PCR. The predictive accuracy of each measure was assessed using logistic regression and receiver operating characteristics curve (ROC) analysis.
There was a total of 33 viruses detected at the onset of 148 AECOPD, the majority 26 (79%) were picornavirus. Viral symptoms with the highest predictive values were rhinorrhoea [Odds ratio (OR) 4.52; 95% CI 1.99-10.29; P < 0.001] and sore throat (OR 2.64; 95% CI 1.14-6.08; P = 0.022), combined the AUC ROC curve was 0.67. At AECOPD onset patients experienced a 1.6-fold increase in IL-6 (P = 0.008) and 4.5-fold increase in SAA (P < 0.001). The addition of IL-6 to the above model significantly improved diagnostic accuracy compared with symptoms alone (AUC ROC 0.80 (P = 0.012).
The addition of inflammatory markers increases the specificity of a clinical case definition for viral infection, particularly picornavirus infection.
Influenza and Other Respiratory Viruses 01/2010; 4(1):33-9. · 4.16 Impact Factor
ABSTRACT: One of the public health challenges during an influenza pandemic is how to rapidly access groups of high-risk individuals to ensure that they have accurate information regarding prevention and management of infection. The aim of this survey was to evaluate the level of understanding of the H1N1-09 (Swine Flu) pandemic, amongst a high-risk group of individuals with chronic lung disease. This study was conducted in Melbourne, Australia towards the end of the 2009 pandemic.
Questions included in the survey were based on the consumer information sheets available from the Department of Health (Victoria) website (frequently asked questions for the general public). Participants were recruited from patients attending community-based programs for chronic lung disease.
Eighty participants were interviewed in August-September 2009, the majority 70/80 were aware of the H1N1-09 pandemic in Melbourne. Most participants gained their information from media reports rather than health care providers. Although they were aware of some ways to decrease the spread of infection, only 20/80 (25%) knew that there were antiviral treatments available if they did contract the infection. It is noteworthy that in a substantial minority (25%), information reported in the media caused some confusion or anxiety and it appears that there was a gap in the provision of evidence-based information to this high-risk group.
In the context of future pandemics, respiratory-outreach nurses and educators could be used to promote pertinent information regarding infection prevention and management to high-risk individuals. Currently this appeared to be an under-utilised means of imparting pandemic information to consumers.
Collegian Journal of the Royal College of Nursing Australia 01/2010; 17(4):199-205. · 0.90 Impact Factor
ABSTRACT: Respiratory viruses are associated with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) in hospitalized patients. However, exacerbations are increasingly managed in the community, where the role of viruses is unclear. In community exacerbations, the causal association between viruses and exacerbation maybe confounded by random fluctuations in the prevalence of circulating respiratory viruses. Therefore, to determine whether viral respiratory tract infections are causally associated with community exacerbations, a time-matched case-control study was performed. Ninety-two subjects (mean age 72 yrs), with moderate to severe COPD, (mean FEV(1) 40% predicted), were enrolled. Nasopharyngeal swabs for viral multiplex polymerase chain reaction and atypical pneumonia serology were obtained at exacerbation onset. Control samples were collected in synchrony, from a randomly selected stable patient drawn from the same cohort. In 99 weeks of surveillance, there were 148 exacerbations. Odds of viral isolation were 11 times higher in cases, than their time-matched controls (34 discordant case-control pairs; in 31 pairs only the case had virus and in three pairs only control). Picornavirus (26), influenza A (3), parainfluenza 1,2,3 (2), respiratory syncytial virus (1), and adenovirus (1) were detected in cases while adenovirus (1) and picornavirus (2) were detected in controls. In patients with moderate or severe COPD the presence of a virus in upper airway secretions is strongly associated with the development of COPD exacerbations. These data support the causative role of viruses in triggering COPD exacerbations in the community.
Respiratory Medicine 01/2008; 101(12):2472-81. · 2.47 Impact Factor