[Show abstract][Hide abstract] ABSTRACT: To analyze prospectively the hypothalamic-pituitary-adrenal (HPA) axis and clinical outcome in patients treated with prednisone for exacerbated chronic obstructive pulmonary disease (COPD).
Prospective observational study.
Patients presenting to the emergency department were randomized to receive 40 mg prednisone daily for 5 or 14 days in a placebo-controlled manner. The HPA axis was longitudinally assessed with the 1 μg corticotropin test and a clinical hypocortisolism score at baseline, on day 6 prior to blinded treatment, at hospital discharge, and for up to 180 days of follow-up. Prednisone was stopped abruptly, irrespective of test results. Patients discharged with pathological test results received instructions about emergency hydrocortisone treatment.
A total of 311 patients were included in the analysis. Mean basal and stimulated serum total cortisol levels were highest on admission (496 ± 398 and 816 ± 413 nmol/l, respectively) and lowest on day 6 (235 ± 174 and 453 ± 178 nmol/l, respectively). Pathological stimulation tests were found in 63%, 38%, 9%, 3% and 2% of patients on day 6, at discharge, and on days 30, 90 and 180, respectively; without significant difference between treatment groups. Clinical indicators of hypocortisolism did not correlate with stimulation test results, but cortisol levels were inversely associated with reexacerbation risk. There were no hospitalizations or deaths due to adrenal crisis.
Dynamic changes in the HPA axis occur during and after treatment of acute exacerbations of COPD. In hypocortisolemic patients, provided with instructions about stress prophylaxis, abrupt termination of prednisone appeared safe.
European Journal of Endocrinology 04/2015; 173(1). DOI:10.1530/EJE-15-0182 · 4.07 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and objectiveBoth comorbidities and physical inactivity have been shown to impair quality of life and contribute to hospital admissions and mortality in chronic obstructive pulmonary disease (COPD) patients. We hypothesized that the comorbid status predicts the level of daily physical activity (PA) in COPD.Methods
In 228 patients with COPD (76% men; median (quartiles) age: 64 (59/69) years; percentage of predicted forced expiratory volume in 1 s (FEV1% pred): 44 (31/63)), comorbidities were assessed by medical history, clinical interviews, examination and blood analysis. PA level (PAL) was measured by an activity monitor (SenseWear Pro, Bodymedia Inc., Pittsburgh, PA, USA). The association between PAL and comorbidities was investigated by univariate and multivariate regression analysis.ResultsSeventy-nine per cent of the COPD patients had at least one additional chronic comorbidity, 56% had two or more comorbidities and 35% had three or more comorbidities. In univariate analysis body mass index, the number of pack years and having at least one additional comorbidity was negatively associated with PAL while there was a positive nonlinear association between FEV1 and PAL. The presence of at least one additional comorbidity was independently associated with PAL irrespective of airflow limitation.Conclusions
In this cohort, almost 80% of COPD patients had at least one additional chronic comorbidity. The level of daily PA seems to be significantly impaired by the presence of comorbidities irrespective of the type of comorbidity and independent of the degree of airflow limitation.Clinical Trial RegistrationNCT01527773 at http://www.clinicalTrials.gov.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: Acute exacerbations (AE) in patients with COPD are associated with a decline in lung function, increased risk of hospitalization, and mortality. In this cross-sectional study we tested whether the level of objectively measured daily physical activity and exercise capacity are associated with the number of COPD exacerbations.
METHODS: In 210 patients with COPD (67 % men; mean (SD) age: 63 (8) years) enrolled in The Obstructive Pulmonary Disease Outcomes Cohort of Switzerland (TOPDOCS) physical activity (PA) (steps per day, physical activity level, (PAL)), exercise capacity (6-min walking distance, (6MWD)), comorbidities, lung function, and medication were assessed. Differences between COPD patients with frequent (≥2 year) and infrequent (0-1 year) exacerbations were assessed. Univariate and multivariate analyses were performed to investigate whether the level of objectively measured daily physical activity and exercise capacity are associated with the number of COPD exacerbations.
RESULTS: Patients with frequent AE had a significantly lower FEV1 and 6MWD compared to patients with infrequent AE. In univariate analysis, the number of exacerbations was inversely associated with FEV1, 6MWD, BMI, and smoking status while there was a positive association with RV/TLC and combined inhaled medication. However, there was no significant association with PAL and steps per day. In multivariate analysis, FEV1 and the use of combined inhaled medication were independently associated with the number of AE, after correction for covariates.
CONCLUSIONS: The findings of this study imply that FEV1, independent of inhaled medication, is significantly associated with COPD exacerbations. Neither physical activity nor exercise capacity was independently associated with COPD exacerbations.
Beiträge zur Klinik der Tuberkulose 12/2014; 193(1). DOI:10.1007/s00408-014-9673-7 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Psychological morbidity is common in chronic respiratory diseases. The diagnostic accuracy of the Hospital Anxiety and Depression Scale (HADS) and risk factors for comorbid depression in chronic obstructive pulmonary disease (COPD) are addressed. Consecutive COPD patients (GOLD stage I–IV, 40–75 years old) were enrolled in a multicentre, cross-sectional cohort study. Diagnosis of depression was ascertained through clinical records. Lung function, HADS score, 6-minute walking test (6-MWT), MRC dyspnoea score, and COPD Assessment Test (CAT) were evaluated. Two hundred fifty-nine COPD patients (mean age 62.5 years; 32% female; mean FEV1 48% predicted) were included. Patients diagnosed with depression (29/259; 11.2%) had significantly higher HADS-D and HADS-Total scores than nondepressed patients (median (quartiles) HADS-D 6 [4; 9] versus 4 [2; 7], median HADS-Total 14 [10; 20] versus 8 [5; 14]). Receiver-operating characteristic plots showed moderate accuracy for HADS-D, AUC 0.662 (95%CI 0.601–0.719), and HADS-Total, AUC 0.681 (95%CI 0.620–0.737), with optimal cut-off scores of >5 and >9, respectively. Sensitivity and specificity were 62.1% and 62.6% for HADS-D compared to 75.9% and 55.2% for HADS-Total. Age, comorbidities, sex, and lower airflow limitation predicted depression. The HADS exhibits low diagnostic accuracy for depression in COPD patients. Younger men with comorbidities are at increased risk for Depression.
Pulmonary Medicine 12/2014; 2014. DOI:10.1155/2014/973858
[Show abstract][Hide abstract] ABSTRACT: Objective:
With respect to the overweight epidemic, this study aimed to investigate the association between domain-specific physical activity and body composition measures in Swiss male employees.
A total of 192 healthy male adults in full-time employment were investigated. Height, weight, and waist circumference were measured and body mass index was calculated. Relative fat mass and relative muscle mass were determined by bioelectric impedance analysis. Physical activity was assessed by the validated International Physical Activity Questionnaire.
In multiple linear regressions, leisure-time activity showed an inverse association with waist circumference and relative fat mass and a positive correlation with relative muscle mass. Work activity was positively related to waist circumference and body mass index.
This study shows that leisure-time activity may be the most effective physical activity domain for body composition. Work activity does not seem to be protective against overweight.
Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 10/2014; 56(10):1074-1081. DOI:10.1097/JOM.0000000000000224 · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The Global Initiative for Chronic Obstructive Lung Disease proposed in 2011 a new system to classify chronic obstructive pulmonary disease (COPD) patients into risk groups A-D, which considers symptoms and future exacerbation risk to grade disease severity. The aim of this study was to investigate the agreement between COPD risk group classifications using COPD assessment test (CAT) or modified Medical Research Council (mMRC) and severity grades or past-year exacerbations. Furthermore, physical activity across risk groups was examined.
87 patients with stable COPD were classified into risk groups A-D. CAT and mMRC were completed. Severity grades I-IV were determined using spirometry and the number of past-year exacerbations was recorded. To test the interrater agreement, Cohen’s Kappa was calculated. Daily physical activity was measured by the SenseWear Mini armband.
Using CAT, 65.5% of patients were in high-symptom groups (B and D). With mMRC, only 37.9% were in B and D. Using severity grades, 20.7% of patients were in high-exacerbation risk groups (C and D). With past-year exacerbations, 9.2% were in C and D. Interrater agreement between CAT and mMRC (κ = 0.21) and between severity grades and past-year exacerbations (κ = 0.31) was fair. Daily steps were reduced in risk groups B and C + D compared to A (p < 0.01), using either classification.
When classifying COPD patients into risk groups A-D, the use of CAT or mMRC and severity grades or past-year exacerbations does not provide equal results. Daily steps decreased with increasing COPD risk groups.
BMC Research Notes 08/2014; 7(1):562. DOI:10.1186/1756-0500-7-562
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Existing prediction models for mortality in chronic obstructive pulmonary disease (COPD) patients have not yet been validated in primary care, which is where the majority of patients receive care.
OBJECTIVES: Our aim was to validate the ADO (age, dyspnoea, airflow obstruction) index as a predictor of 2-year mortality in 2 general practice-based COPD cohorts.
METHODS: Six hundred and forty-six patients with COPD with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages I-IV were enrolled by their general practitioners and followed for 2 years. The ADO regression equation was used to predict a 2-year risk of all-cause mortality in each patient and this risk was compared with the observed 2-year mortality. Discrimination and calibration were assessed as well as the strength of association between the 15-point ADO score and the observed 2-year all-cause mortality.
RESULTS: Fifty-two (8.1%) patients died during the 2-year follow-up period. Discrimination with the ADO index was excellent with an area under the curve of 0.78 [95% confidence interval (CI) 0.71-0.84]. Overall, the predicted and observed risks matched well and visual inspection revealed no important differences between them across 10 risk classes (p = 0.68). The odds ratio for death per point increase according to the ADO index was 1.50 (95% CI 1.31-1.71).
CONCLUSIONS: The ADO index showed excellent prediction properties in an out-of-population validation carried out in COPD patients from primary care settings.
[Show abstract][Hide abstract] ABSTRACT: Background
Mannitol- and exercise bronchial provocation tests are both used to diagnose exercise-induced bronchoconstriction. The study aim was to compare the short-term treatment response to budesonide and montelukast on airway hyperresponsiveness to mannitol challenge test and to exercise challenge test in children and adolescents with exercise-induced bronchoconstriction.
Patients were recruited from a paediatric asthma rehabilitation clinic located in the Swiss Alps. Individuals with exercise-induced bronchoconstriction and a positive result in the exercise challenge test underwent mannitol challenge test on day 0. All subjects then received a treatment with 400 μg budesonide and bronchodilators as needed for 7 days, after which exercise- and mannitol-challenge tests were repeated (day 7). Montelukast was then added to the previous treatment and both tests were repeated again after 7 days (day 14).
Of 26 children and adolescents with exercise-induced bronchoconstriction, 14 had a positive exercise challenge test at baseline and were included in the intervention study. Seven of 14 (50%) also had a positive mannitol challenge test. There was a strong correlation between airway responsiveness to exercise and to mannitol at baseline (r = 0.560, p = 0.037). Treatment with budesonide and montelukast decreased airway hyperresponsiveness to exercise challenge test and to a lesser degree to mannitol challenge test. The fall in forced expiratory volume in one second during exercise challenge test was 21.7% on day 0 compared to 6.7% on day 14 (p = 0.001) and the mannitol challenge test dose response ratio was 0.036%/mg on day 0 compared to 0.013%/mg on day 14 (p = 0.067).
Short-term treatment with an inhaled corticosteroid and an additional leukotriene receptor antagonist in children and adolescents with exercise-induced bronchoconstriction decreases airway hyperresponsiveness to exercise and to mannitol.
[Show abstract][Hide abstract] ABSTRACT: Introduction:
In the therapy of chronic obstructive pulmonary disease (COPD), it is a major goal to improve health-related quality of life (HRQOL). Patients with COPD often suffer from exertional dyspnea and adopt a sedentary lifestyle, which could be associated with poorer HRQOL. The aim of this study was to investigate the independent association of objectively measured daily physical activity and functional capacity with HRQOL in patients with COPD.
In this cross-sectional study conducted at the University Hospital Basel, Switzerland, 87 stable patients (58.6% male, mean age: 67.3 ± 9.6 yrs) with COPD in GOLD grades I (n = 23), II (n = 46), III (n = 12) and IV (n = 6) were investigated. To assess HRQOL, the COPD assessment test (CAT) was completed. Patients performed spirometry and 6-min walk test. Physical activity was measured by the SenseWear Mini Armband on 7 consecutive days. By performing a multiple linear regression analysis, independent predictors of CAT score were identified.
Age (β = -0.39, p = 0.001), average daily steps (β = -0.31, p = 0.033) and 6-min walk distance (β = -0.32, p = 0.019) were found to be independent predictors of CAT score, whereas physical activity duration above 3 METs (p = 0.498) and forced expiratory volume in 1 s in% of predicted (p = 0.364) showed no significant association.
This study showed that average daily steps and functional capacity are independent determinants of HRQOL in patients with COPD. This emphasizes the importance to remain active and mobile, which is associated with better HRQOL.
[Show abstract][Hide abstract] ABSTRACT: Sleep problems are a well-known risk factor for work injuries, but less is known about which vulnerable populations are most at risk. The aims of this study were to investigate the association between sleep quality and the risk of work injury and to identify factors that may modify the association. A case-control study including 180 cases and 551 controls was conducted at the University Hospital in Basel, Switzerland, from 1 December 2009 to 30 June 2011. Data on work injuries and sleep quality were collected. Adjusted odds ratios and 95% confidence intervals of the association between sleep quality and work injury were estimated in multivariable logistic regression analyses and were stratified by hypothesized effect modifiers (age, gender, job risk, shift work, sleep duration and working hours). Poor sleep quality was associated significantly with work injury of any type (P < 0.05) and with being caught in particular (P < 0.05). The association between poor sleep quality and work injury was significantly higher for workers older than 30 years (odds ratio>30 1.30 versus odds ratio≤30 0.91, P < 0.01), sleeping 7 h or less per night (odds ratio≤7 1.17 versus odds ratio>7 0.79, P < 0.05) and working 50 h or more per week (odds ratio≥50 1.79 versus odd ratio<50 1.10, P < 0.01). Work injury risk increased with increasing severity of sleep problems (P < 0.05). Prior work injury frequency increased with decreasing sleep quality (P < 0.05). Older age, short sleep duration and long working hours may enhance the risk of work injuries associated with sleep quality.
Journal of Sleep Research 06/2014; 23(5). DOI:10.1111/jsr.12146 · 3.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sleep problems present a risk for work injuries and are a major occupational health concern worldwide. Knowledge about the influence of sleep problems on work injury patterns is limited. Therefore, the aim of this study was to identify potential associations between different types of work injuries and sleep quality, sleep duration, and daytime sleepiness.
In this hospital-based study, 180 male and female patients with work injuries were recruited at the Emergency Department of the University Hospital Basel, Switzerland, from December 1st 2009 to June 30th 2011. The data on work injury characteristics, sleep problems, and potential confounders, such as demographic, health, lifestyle, occupational and environmental factors, were collected. Multivariable logistic regression analyses were performed to investigate the relationship between sleep problems and various types of work injury.
Each dimension of sleep problems - sleep quality, sleep duration and daytime sleepiness - was a significant risk factor for at least one type of work injury. The strongest association was found for musculoskeletal injuries and falls with short sleep duration (odds ratio [OR] 5.41, 95% confidence interval [CI] 1.81-16.22). The standardised scores of the Pittsburgh sleep quality index (PSQI) and the Epworth sleepiness scale (ESS) did not discriminate between injury types.
Employees with sleep problems were more likely to suffer from certain types of work injuries. This should be considered by employers monitoring work injuries and implementing prevention measures in the company's health and safety management.
[Show abstract][Hide abstract] ABSTRACT: This review describes different bronchoprovocation tests and their merits in diagnosing asthma.
A new indirect challenge test using dry powder mannitol has been made available and has been systematically validated and tested in different populations.
Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, and its measurement using direct inhalation challenges, particularly with inhaled methacholine or histamine, or indirect challenges using stimuli such as exercise, dry air hyperpnea, distilled water, hypertonic saline and mannitol, and the pharmacological agent adenosine monophosphate is important in establishing a correct diagnosis. Direct challenge tests are sensitive and have a high negative predictive value to exclude asthma. This is particularly true in excluding asthma as a diagnosis in patients with symptoms that suggest asthma, but are caused by another condition. Indirect AHR correlates better with eosinophilic airway inflammation. Therefore, indirect challenge tests are seen as more specific. A newer indirect challenge test that uses a kit containing prepacked capsules of dry powder mannitol in different doses is safe and efficient to use. Indirect challenge tests are superior to direct challenge tests to confirm the presence of asthma.
Current opinion in pulmonary medicine 11/2013; 20(1). DOI:10.1097/MCP.0000000000000009 · 2.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IMPORTANCE International guidelines advocate a 7- to 14-day course of systemic glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the optimal dose and duration are unknown. OBJECTIVE To investigate whether a short-term (5 days) systemic glucocorticoid treatment in patients with COPD exacerbation is noninferior to conventional (14 days) treatment in clinical outcome and whether it decreases the exposure to steroids. DESIGN, SETTING, AND PATIENTS REDUCE (Reduction in the Use of Corticosteroids in Exacerbated COPD), a randomized, noninferiority multicenter trial in 5 Swiss teaching hospitals, enrolling 314 patients presenting to the emergency department with acute COPD exacerbation, past or present smokers (≥20 pack-years) without a history of asthma, from March 2006 through February 2011. INTERVENTIONS Treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled, double-blind fashion. The predefined noninferiority criterion was an absolute increase in exacerbations of at most 15%, translating to a critical hazard ratio of 1.515 for a reference event rate of 50%. MAIN OUTCOME AND MEASURE Time to next exacerbation within 180 days. RESULTS Of 314 randomized patients, 289 (92%) of whom were admitted to the hospital, 311 were included in the intention-to-treat analysis and 296 in the per-protocol analysis. Hazard ratios for the short-term vs conventional treatment group were 0.95 (90% CI, 0.70 to 1.29; P = .006 for noninferiority) in the intention-to-treat analysis and 0.93 (90% CI, 0.68 to 1.26; P = .005 for noninferiority) in the per-protocol analysis, meeting our noninferiority criterion. In the short-term group, 56 patients (35.9%) reached the primary end point; 57 (36.8%) in the conventional group. Estimates of reexacerbation rates within 180 days were 37.2% (95% CI, 29.5% to 44.9%) in the short-term; 38.4% (95% CI, 30.6% to 46.3%) in the conventional, with a difference of -1.2% (95% CI, -12.2% to 9.8%) between the short-term and the conventional. Among patients with a reexacerbation, the median time to event was 43.5 days (interquartile range [IQR], 13 to 118) in the short-term and 29 days (IQR, 16 to 85) in the conventional. There was no difference between groups in time to death, the combined end point of exacerbation, death, or both and recovery of lung function. In the conventional group, mean cumulative prednisone dose was significantly higher (793 mg [95% CI, 710 to 876 mg] vs 379 mg [95% CI, 311 to 446 mg], P < .001), but treatment-associated adverse reactions, including hyperglycemia and hypertension, did not occur more frequently. CONCLUSIONS AND RELEVANCE In patients presenting to the emergency department with acute exacerbations of COPD, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD. TRIAL REGISTRATION isrctn.org Identifier:ISRCTN19646069.
JAMA The Journal of the American Medical Association 05/2013; 309(21):1-9. DOI:10.1001/jama.2013.5023 · 35.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Sleep problems are a potential risk factor for work injuries but the extent of the risk is unclear. We conducted a systematic review and meta-analysis to quantify the effect of sleep problems on work injuries.
A systematic literature search using several databases was performed. Sleep problems of any duration or frequency as well as work injuries of any severity were of interest. The effect estimates of the individual studies were pooled and relative risks (RR) and 95% confidence intervals (CI) were calculated through random effects models. Additionally, the population attributable risk was estimated.
In total, 27 observational studies (n = 268,332 participants) that provided 54 relative risk estimates were included. The findings of the meta-analysis suggested that workers with sleep problems had a 1.62 times higher risk of being injured than workers without sleep problems (RR: 1.62, 95% CI: 1.43-1.84). Approximately 13% of work injuries could be attributed to sleep problems.
This systematic review confirmed the association between sleep problems and work injuries and, for the first time, quantified its magnitude. As sleep problems are of growing concern in the population, these findings are of interest for both sleep researchers and occupational physicians.
Sleep Medicine Reviews 05/2013; 18(1). DOI:10.1016/j.smrv.2013.01.004 · 8.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to assess airway hyperresponsiveness to eucapnic voluntary hyperventilation and dry powder mannitol challenge in athletes aiming to participate at the Paralympic Games 2008 in Beijing, especially in athletes with spinal cord injury.
Forty-four athletes with a disability (27 with paraplegia (group 1), 3 with tetraplegia (group 2) and 14 with other disabilities such as blindness or single limb amputations (group 3) performed spirometry, skin prick testing, measurement of exhaled nitric oxide, eucapnic voluntary hyperventilation challenge test (EVH) and mannitol challenge test (MCT). A fall in FEV1 of >=10% in either challenge test was deemed positive for exercise-induced bronchoconstriction.
Fourteen (32%) athletes were atopic and 7 (16%) had a history of physician-diagnosed asthma. Absolute lung function values were significantly lower in patients of group 1 and 2 compared to group 3. Nine (20%) athletes were positive to EVH (8 paraplegics, 1 tetraplegic), and 8 (18%) athletes were positive to MCT (7 paraplegics, 1 tetraplegic). Fourteen (22.7%) subjects were positive to at least one challenge; only three athletes were positive to both tests. None of the athletes in group 3 had a positive test. Both challenge tests showed a significant association with physician-diagnosed asthma status (p = 0.0001). The positive and negative predictive value to diagnose physician-diagnosed asthma was 89% and 91% for EHV, and 75% and 86% for MCT, respectively.
EVH and MCT can be used to identify, but especially exclude asthma in Paralympic athletes.
[Show abstract][Hide abstract] ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a global health challenge and a leading cause of death worldwide. Several risk factors have been identified, with cigarette smoking being the most important. Diagnostic assessment is based on symptoms, risk of exacerbations and results of lung function testing. A fixed post-bronchodilator ratio for forced expiratory volume in one second to forced expiratory volume (FEV1/FVC) of <0.7 is required to make the diagnosis, and the severity of airflow obstruction defines the grade according to GOLD (Global Strategy for the Diagnosis, Management, and Prevention of COPD). The GOLD strategy makes therapeutic recommendations taking into account the grade, symptomatic assessment and future risk of exacerbations. This review focuses on the therapeutic options for COPD, in accordance with the GOLD strategy. Smoking cessation is the most effective treatment option in all COPD stages. Bronchodilators, namely long-acting antimuscarinic drugs and long-acting beta-agonists, form the mainstay of treatment in COPD. Patients with frequent exacerbations also benefited from the addition of inhaled corticosteroids. Roflumilast is an add-on option for patients with severe COPD. Several controversies are the subject of discussion: (1.) whether pharmacotherapy can modify the natural history of COPD; (2.) whether pharmacotherapy should be started in the early stages of COPD; (3.) the impact of therapy on comorbidities; (4.) whether patients benefit from a combination therapy with a long-acting beta-agonist, a long-acting antimuscarinic drug and an inhaled corticosteroid; (5.) step-down therapy. This overview also reviews the evidence for recommended vaccines in COPD, as well as nonpharmacological therapies. Rehabilitation is an essential part of COPD treatment. Oxygen therapy, noninvasive nocturnal ventilation and surgical treatment options only apply to a highly selected group of patients. Disease management programmes and guideline adherence are briefly discussed. In conclusion, although there is debate as to the extent with which pharmacological therapies influence mortality, adherence to the GOLD strategy is recommended.