Editorial
A recent report in Thorax of a 12 month audit at the Hillingdon Hospital in the UK showed the disappointing result that only about 10% of patients hospitalised with COPD exacerbations undertook a pulmonary rehabilitation programme upon discharge, despite a fully commissioned service being available. Another study published in Respirology on Feb 2, 2014, showed ambulatory patients with COPD, who had a low level of physical activity, or whose activity level decreased over time, were more likely to be hospitalised for COPD exacerbations. Much effort is rightly expended in tackling earlier diagnosis, defining patient groups, and in the assessment of new treatments for patients with COPD. However, the importance of simple and cheap interventions as part of a rehabilitation programme—such as exercise, symptommanagement, and patient education—should not be underestimated. With the application of increasingly sophisticated methods to improve patient management and add to our understanding of the pathogenesis and progression of COPD, the potential easy wins and lowhanging fruit of increased exercise and better symptommanagement might be overlooked. It seems obvious that increased exercise, for example, will be of benefit in terms of reducing the number of exacerbations and slowing the disease trajectory. But this idea presumes that this objective is straightforward to meet, and ignores the fact that patients with COPD can have extensive comorbidities, dyspnoea, and muscle weakness, all of which can limit the effectiveness of such interventions, and the inclination for patients to participate in rehabilitation programmes. So how can the uptake and effectiveness of these programmes be improved? The ATS/ERS statement, published in October, 2013, updated the definition of pulmonary rehabilitation to “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviours”. Several general recommendations were made in this statement, including refinement of programmes, increasing their applicability and accessibility, and effecting behavioural change. Getting traction with www.thelancet.com/respiratory Vol 2 March 2014
these factors might be a first step in improvement of patient uptake and the effectiveness of rehabilitation programmes, and the increasing published evidence in this area suggests doctors are focusing their attention on increasing patient compliance and developing such programmes as a priority. Effecting behavioural change is perhaps one of the most difficult factors to tackle—for example, it is unsurprising that it is difficult to encourage patients to exercise when they are struggling to breathe in their daily life activities. Organisations can play a part in helping to change attitudes, with initiatives such as the American Lung Association’s Fight for Air Climb proving valuable in promoting the importance of lung health in the general community. Importantly, the ATS/ ERS statement highlighted that evidence shows not only the sickest patients can benefit from rehabilitation— those with less airflow limitation can also have symptomatic benefit. Nevertheless, patients with severe COPD are perhaps the most challenging group to enroll into, and ensure completion of, pulmonary rehabilitation programmes, and the trajectory of COPD is such that by the time many patients are diagnosed they are already in the later GOLD stages of disease. In this context, the study reported online in The Lancet Respiratory Medicine on Feb 13, 2014, by Rupert Jones and colleagues, that assessed the timing of diagnosis of COPD in relation to the patient’s previous history of presentations to doctors is noteworthy; the authors showed that 85% of patients had the opportunity to be identified earlier in the 5 years preceding diagnosis, when their lung function and prognosis might have been better. The Lancet Respiratory Medicine celebrates its 1 year anniversary with the publication of this issue. Content over the past year has described many of the problems faced by patients with COPD and their caregivers, and these challenges are further illustrated by several papers on COPD described in this issue. Our Editorial in the launch issue last year declared that a juggernaut of respiratory diseases had arrived, with COPD marked as a major player. Although some progress has been made in 2013, we should ask ourselves whether there are any low-hanging fruit for us to pick, or is it a case of tackling every area of disease that could act synergistically and bend the branches of the tree to within our reach. ■ The Lancet Respiratory Medicine
Science Photo Library
The low-hanging fruits—are they out of reach?
For the audit from Hillingdon hospital see Thorax 2014; 69: 181–82 For the paper on physical activity and hospitalisation, see Respirology 2014; published online Feb 2. DOI:10.1111/ resp.12239 For the ATS/ERS statement, see Am J Respir Crit Care Med 2013; 188: e13–e64 For the study by Jones and colleagues, see Lancet Respir Med 2014; published online Feb 13. http://dx.doi.org/10.1016/ S2213-2600(14)70008-6
165
A recent report in Thorax of a 12 month audit at the Hillingdon Hospital in the UK showed the disappointing result that only about 10% of patients hospitalised with COPD exacerbations undertook a pulmonary rehabilitation programme upon discharge, despite a fully commissioned service being available. Another study published in Respirology on Feb 2, 2014, showed ambulatory patients with COPD, who had a low level of physical activity, or whose activity level decreased over time, were more likely to be hospitalised for COPD exacerbations. Much effort is rightly expended in tackling earlier diagnosis, defining patient groups, and in the assessment of new treatments for patients with COPD. However, the importance of simple and cheap interventions as part of a rehabilitation programme—such as exercise, symptommanagement, and patient education—should not be underestimated. With the application of increasingly sophisticated methods to improve patient management and add to our understanding of the pathogenesis and progression of COPD, the potential easy wins and lowhanging fruit of increased exercise and better symptommanagement might be overlooked. It seems obvious that increased exercise, for example, will be of benefit in terms of reducing the number of exacerbations and slowing the disease trajectory. But this idea presumes that this objective is straightforward to meet, and ignores the fact that patients with COPD can have extensive comorbidities, dyspnoea, and muscle weakness, all of which can limit the effectiveness of such interventions, and the inclination for patients to participate in rehabilitation programmes. So how can the uptake and effectiveness of these programmes be improved? The ATS/ERS statement, published in October, 2013, updated the definition of pulmonary rehabilitation to “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviours”. Several general recommendations were made in this statement, including refinement of programmes, increasing their applicability and accessibility, and effecting behavioural change. Getting traction with www.thelancet.com/respiratory Vol 2 March 2014
these factors might be a first step in improvement of patient uptake and the effectiveness of rehabilitation programmes, and the increasing published evidence in this area suggests doctors are focusing their attention on increasing patient compliance and developing such programmes as a priority. Effecting behavioural change is perhaps one of the most difficult factors to tackle—for example, it is unsurprising that it is difficult to encourage patients to exercise when they are struggling to breathe in their daily life activities. Organisations can play a part in helping to change attitudes, with initiatives such as the American Lung Association’s Fight for Air Climb proving valuable in promoting the importance of lung health in the general community. Importantly, the ATS/ ERS statement highlighted that evidence shows not only the sickest patients can benefit from rehabilitation— those with less airflow limitation can also have symptomatic benefit. Nevertheless, patients with severe COPD are perhaps the most challenging group to enroll into, and ensure completion of, pulmonary rehabilitation programmes, and the trajectory of COPD is such that by the time many patients are diagnosed they are already in the later GOLD stages of disease. In this context, the study reported online in The Lancet Respiratory Medicine on Feb 13, 2014, by Rupert Jones and colleagues, that assessed the timing of diagnosis of COPD in relation to the patient’s previous history of presentations to doctors is noteworthy; the authors showed that 85% of patients had the opportunity to be identified earlier in the 5 years preceding diagnosis, when their lung function and prognosis might have been better. The Lancet Respiratory Medicine celebrates its 1 year anniversary with the publication of this issue. Content over the past year has described many of the problems faced by patients with COPD and their caregivers, and these challenges are further illustrated by several papers on COPD described in this issue. Our Editorial in the launch issue last year declared that a juggernaut of respiratory diseases had arrived, with COPD marked as a major player. Although some progress has been made in 2013, we should ask ourselves whether there are any low-hanging fruit for us to pick, or is it a case of tackling every area of disease that could act synergistically and bend the branches of the tree to within our reach. ■ The Lancet Respiratory Medicine
Science Photo Library
The low-hanging fruits—are they out of reach?
For the audit from Hillingdon hospital see Thorax 2014; 69: 181–82 For the paper on physical activity and hospitalisation, see Respirology 2014; published online Feb 2. DOI:10.1111/ resp.12239 For the ATS/ERS statement, see Am J Respir Crit Care Med 2013; 188: e13–e64 For the study by Jones and colleagues, see Lancet Respir Med 2014; published online Feb 13. http://dx.doi.org/10.1016/ S2213-2600(14)70008-6
165
