Background: Pulmonary rehabilitation (PR) is an essential part of the treatment for patients with COPD, but there are few adapted services in the primary health service in Norway. Objective: To test whether a Danish model for PR for COPD is transferable to the Norwegian primary health care system. Design: Simple observational study. Method: In nursing homes in two municipalities, a low threshold PR program led by local GPs, two physiotherapists and a nurse was established. Patients were recruited by their own GPs. Patients were examined before, immediately after and three months post intervention. Training outcome measures were physical capacity (Incremental Shuttle Walk Test; ISWT), burden of symptoms and quality of life; Clinical COPD Questionnaire (CCQ), COPD Assessement Test (CAT). Material: 36 patients (average age 70.5 years; 17 women) of whom 72% had very severe COPD. Results: After eight weeks, ISWT results were improved in 74.3% of participants. Corrected for cluster effects of repeated measurements at patient level, participants scored significantly better after eight weeks on all measurements. Three months later, most training effects had subsided. Conclusion: The Danish model was transferable to primary health care service in Norway. Most patients had benefits from the program, but the effects were short-lived. To maintain achieved improvements, follow up with continued training is needed after PR.

Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and management vary depending on where children live in the world and how their community can care for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by government support, changes in policy, access to diagnosis and effective therapy for all children, with research to improve implementation. We propose a worldwide charter for all children with asthma, a roadmap to better education and training which can be adapted for local use. It includes access to effective basic asthma medications. It is not about new expensive medications and biologics as much can be achieved without these. If implemented carefully, the overall cost of care is likely to fall and the global future health and life chance of children with asthma will greatly improve. The key to success will be community involvement together with the local and national development of asthma champions. We call on governments, institutions, and healthcare services to support its implementation.

Most children with asthma should be easy to manage and achieve good disease control. However, the global quality of asthma diagnosis and its management in children is extremely variable, with consistently high numbers of hospital admissions, avoidable asthma deaths, poor engagement in care by families, and very high financial burdens accrued by health-care systems. There is little evidence that asthma management is improving as the years progress. Great global inequalities continue in both diagnosis and management, with a disproportionate number of children in low-income and middle-income countries with no access to or unable to receive appropriate care. The Lancet Clinical Commission, After asthma: redefining airways diseases, states that asthma is an umbrella term with differing presentations across the world. In 2017, the GSK Children's Asthma Project was initiated to better understand the global issues around this disease. An independent advisory board was established to determine what improvements were needed. An independent scientific committee selected experts in children's asthma from all world regions, which comprised primary, secondary, and tertiary care specialists, teachers and trainers, patient representatives and colleagues working in international health organisations. The group has debated and agreed what main obstacles continue to prevent improvement in the global care of children with asthma. By addressing these issues, we believe families, health-care workers, researchers, policy makers, and governments can, together, improve asthma care through better education and training. The plan does not involve newer or more expensive medicines and could well result in substantial cost savings. We call on governments to affirm that every child with asthma, irrespective of where he or she lives, receives the essential standards of care as outlined below (panel).PanelGlobal asthma diagnosis and management in children—six essential requirements•Early and accurate diagnosis for all•Internationally acceptable standards of asthma management in every country•Knowledge and skills to understand how to control symptoms•A professional trained in asthma and in child health to monitor progress in each defined health area•Clean air in every child's home and in their external environment•The availability of specialist asthma care when needed •Early and accurate diagnosis for all•Internationally acceptable standards of asthma management in every country•Knowledge and skills to understand how to control symptoms•A professional trained in asthma and in child health to monitor progress in each defined health area•Clean air in every child's home and in their external environment•The availability of specialist asthma care when needed The quality of asthma diagnosis in children is poor globally, particularly in young children. Overdiagnosis is common in Europe, Australasia, and North America. Elsewhere, under-diagnosis is common. Children have the right to accurate diagnosis by use of objective tests wherever possible, to ensure they can benefit from the available treatment. All children with asthma need access to an inhaled short-acting β-agonist, an inhaled corticosteroid, oral prednisolone, a simple spacer device, and supplemental oxygen. These medications should be of low cost, of high quality, and easily accessible. Besides in low-income and middle-income countries, there are low-income and middle-income regions in high-income countries. Every child should have access to effective treatment for acute asthma attacks and for chronic symptom prevention for continued asthma control. We must ensure appropriate engagement, collaboration, and training of children and families in their asthma care. All children and families have the right to receive developmentally appropriate information to understand their asthma and to know what triggers it and how to avoid those triggers. They need an asthma plan to manage their symptoms, if necessary. School teachers should be included in such training. All countries must have a plan to train primary-care health workers in asthma diagnosis and protocol-driven management pathways. Asthma attack risk assessments need to be regularly undertaken. The height and weight of each child needs to be regularly recorded on a growth chart. Full immunisation, especially against influenza, should be recommended. Indoor and outdoor pollution threatens lung development and future lung health, with serious long-term consequences, including worsening asthma. Every child should be protected from tobacco, e-cigarettes, biomass fuel, and excessive exposure to traffic and industrial pollutants. We call on all governments to take measures to prevent air pollution and to strengthen smoking cessation programmes especially those targeting women of childbearing age. Airway damage in childhood greatly increases the risk of chronic lung disease in adult life. Non-response to prescribed treatment mandates referral to an asthma specialist. We call on all countries to implement training programmes to ensure sufficient numbers of trained asthma specialists. The International Primary Care Respiratory Group is developing a programme, to be piloted in four countries during 2019, which will train selected primary-care professionals. They will then cascade their training to colleagues within each pilot country, with the aim of training and educating whole communities. Such training must be culturally appropriate. It must encompass schools, schoolteachers, and non-medical community workers. The programme will be monitored and audited. The plan is then to extend the programme to other countries worldwide. The high financial burden of asthma care can be substantially reduced by taking the above steps. We call for a global collaborative effort, including national governments and international organisations to recognise these needs and opportunities, which can improve care of children with asthma wherever they live in the world. WL reports being a GSK employee and a GSK shareholder. YA reports grants from Astellas, GSK, and Pfizer and personal fees from Merck Sharp & Dohme, GSK, and Kyorin Pharmaceuticals. SP reports personal fees from AstraZeneca, ALK, Thermo Fisher Scientific, and Phadia. SJS reports acting as a consultant for and research with Boehringer Ingleheim, Genentech, GSK, Aerocrine, AstraZeneca, Roche, Teva, Daiichi Sankyo, and Sanofi and grants from GSK and Propeller Health. HJZ reports grants from The Allergy Society of South Africa, South Africa Medical Research Council and personal fees from GSK, outside of the submitted work. All authors attended the Washington DC Forum meeting on October 31, 2018, and report their travel and accommodation expenses being met by GSK. All other authors declare no other competing interests. The GSK Global Children's Asthma Group Yuichi Adachi, Lara J Akinbami, Kathryn V Blake, Andrew Bush, Michael Cabana, Lisa C Cicutto, Adnan Custovic, Iolo Doull, Gilberto B Fischer, Dominic A Fitzgerald, Monica Fletcher, Jonathan Grigg, Jianguo Hong, Rod Hughes, Christina Keen, David A Leather, Rob F Lemanske, Warren Lenney, Louis Garcia-Marcos, Donna J Mazyck, Anders Ostrem, Soren Pedersen, Bruce K Rubin, Aziz Sheikh, Kunling Shen, Peter Sly, Renato T Stein, James W Stout, Padmaja Subbarao, Stanley J Szefler, Raj Tilak, Tonya Winders, Sian Williams, Heather J Zar.

Purpose: Describe the experiences of an interprofessional low-threshold model for pulmonary rehabilitation in the municipal health service, seen from COPD patients and health providers’ perspective. Design and method: Qualitative design with focus group interviews. Material: 20 patients, 10 women and 10 men, average age 71. Results: There is a need for more knowledge about COPD in the municipal health service. Follow- up and referral routines from the GPs’ are insufficient. The project has helped to develop patient expertise through enhanced experience of control and self-management, as well as given the patients more tools to deal with their symptoms. New experiences with the body have changed the patients’ attitudes toward their disease and contributed to a better everyday life and a brighter outlook. However, it is still a challenge for many to continue to exercise on their own. The implementation has not posed major challenges. Conclusion: Interprofessional, low-threshold rehabilitation organized by the municipal health service show promising results, both with regard to feasibility and benefits for participants. The program has improved the participants’ performance in everyday activities. The solidarity with peers and the knowledge and attitudes of the professionals have contributed to the feeling of ease and security. It’s challenging for people with COPD to maintain the benefits without follow-up.

Asthma is the most common chronic condition in children worldwide. It affects daytime activities, sleep and school attendance and causes anxiety to parents, families and other carers. The quality of asthma diagnosis and management globally still needs substantial improvement. From infancy to the teenage years, there are age-specific challenges, including both underdiagnosis and overdiagnosis with stigma-related barriers to treatment in some cultures and in adolescents. Guidelines are increasingly evidence based, but their impact on improving outcomes has been negligible in many parts of the world, often due to lack of implementation. New thinking is needed to enable substantial improvements in outcomes. The disease varies globally and plans will need to differ for individual countries or places where region-specific barriers prevent optimal care. A wide selection of educational activities is needed, including community-targeted initiatives, to engage with families. The Paediatric Asthma Project Plan has been initiated to strengthen diagnosis and management of asthma. This encompasses a vision for the next 10–15 years, building on the knowledge and experience from previous educational projects. It will take into account the educational needs of patients, carers and healthcare professionals as well as the accessibility and affordability of medication, particularly in low and middle-income countries where the prevalence of asthma is rising more rapidly. This overview presents a first step for those involved in the diagnosis and management of childhood asthma to strengthen care for children globally.

A correction to this article has been published and is linked from the HTML version of this article.

Several fixed-dose combinations (FDCs) of long-acting bronchodilators (a long-acting muscarinic antagonist [LAMA] plus a long-acting β2-agonist [LABA]) are available for the treatment of COPD. Studies of these FDCs have demonstrated substantial improvements in lung function (forced expiratory volume in 1 second) in comparison with their respective constituent monocomponents. Improvements in patient-reported outcomes (PROs), such as symptoms and health status, as well as exacerbation rates, have been reported compared with a LABA or LAMA alone, but results are less consistent. The inconsistencies may in part be owing to differences in study design, methods used to assess study end points, and patient populations. Nevertheless, these observations tend to support an association between improvements in forced expiratory volume in 1 second and improvements in symptom-based outcomes. In order to assess the effects of FDCs on PROs and evaluate relationships between PROs and changes in lung function, we performed a systematic literature search of publications reporting randomized controlled trials of FDCs. Results of this literature search were independently assessed by two reviewers, with a third reviewer resolving any conflicting results. In total, 22 Phase III randomized controlled trials of FDC bronchodilators in COPD were identified, with an additional study including a post-literature search (ten for indacaterol-glycopyrronium once daily, eight for umeclidinium-vilanterol once daily, three for tiotropium-olodaterol once daily, and two for aclidinium-formoterol twice daily). Results from these studies demonstrated that the LAMA-LABA FDCs significantly improved lung function compared with their component monotherapies or other single-agent treatments. Furthermore, LABA-LAMA combinations also generally improved symptoms and health status versus monotherapies, although some discrepancies between lung function and PROs were observed. Overall, the safety profiles of the FDCs were similar to placebo. Further research is required to examine more closely any relationship between lung function and PROs in patients receiving LABA-LAMA combinations.

The effective self-management of obstructive lung disease is dependent upon the patient achieving good inhaler technique. However, many current inhalers are complicated to use, which may lead to handling difficulties. These difficulties can cause clinically relevant errors, whereby pharmacotherapy fails to achieve adequate lung deposition and therapeutic effect. In this report, the potential of novel inhaler devices to overcome unmet needs in the management of obstructive lung disease is considered by a panel of Nordic experts. The panel concludes that innovative inhalers can contribute to good disease management and better use of healthcare resources.

Dear Sirs, The editorial by Mike Thomas and Eric Bateman1 focusses on a very important, clinical challenge—how to reduce asthma attacks. One of the issues discussed is the apparent lack of the patient's understanding of the information regarding self-management, which can lead to non-adherence. We agree with the authors that ‘persuading some patients that they need to take regular ICS (even as a combination inhaler) is an ongoing challenge’. We find it timely to emphasise the knowledge we have regarding how we can improve asthma control by understanding the patient’s perspective. Patients do not blindly follow the treatment advice but are strongly influenced by their ‘common-sense’ beliefs about their illness and treatment.2,3 Even if the advice comes from a trusted health-care worker the patient will evaluate whether it makes sense in the light of their understanding and beliefs. Adherence to medication is especially influenced by the patients’ beliefs about the prescribed medication, particularly how they judge their personal need for it relative to their concerns about the potential adverse consequences of taking it. A recent meta-analysis showed that this simple Necessity Concerns Framework was helpful in explaining non-adherence across 94 peer-reviewed publications from 18 countries involving over 25,000 patients, across 24 long-term conditions including asthma.4 Many patients with asthma doubt their personal need for daily doses of ICS or have concerns about them, even when they experience no ‘side-effects’.5–7 Doubts about the necessity of ICS often arise from the patient's beliefs about asthma.7 In order to perceive that we need treatment we have to see a close fit between our understanding of the problem (the illness) and the proposed solution (the treatment). Many patients with asthma simply don’t see a good fit. The medical model of asthma as a chronic condition that requires daily preventative medication may be at odds with their experience of asthma as an episodic condition in which symptoms come and go. Daily ICS may not make sense to them if their belief is ‘no symptoms, no asthma.’8 One could suspect that in many of the patients included in the linked paper by Patel et al.,9 the extreme overuse of SABA (short-acting β2-agonist) could be explained by the patient’s own beliefs about asthma and how best it can be treated. The challenge for the health-care worker, be it the GP, practice nurse, pharmacist or hospital specialist, is to understand the patient’s beliefs about asthma and its treatment. This is the starting point for tailoring the prescription and providing support to meet the needs of the individual. A three-point perceptions and practicalities approach2 might be a good start to tailor the support to enhance the patient’s motivation and ability to get the best from the appropriate treatment: Present a ‘common-sense’ rationale or ‘story’ explaining why daily treatment is necessary, even in the absence of symptoms. Elicit and address the concerns about medication. Make the regimen as easy and convenient as possible to check that the patient is able to use the treatment (including inhaler technique where appropriate). We agree with the authors of the editorial that we still have a long way to go before optimal, effective self-management is achieved, but we suggest that an understanding of the patient’s perspective about asthma and its treatment offers the gateway to this.

We applaud and totally agree with the concept expressed by A. Ostrem and colleagues that in order to win the battle against chronic obstructive pulmonary disease (COPD) we must all join forces. Indeed, the coincidence of important research questions related to COPD between the document generated by the International Primary Care Respiratory Group (IPCRG) in 2010 [1] and the recently published American Thoracic Society (ATS)/European Respiratory Society (ERS) statement on research questions in COPD [2] is evidence of the agreement that exists among everyone interested in this topic. ATS/ERS task force agrees coordinated action by all groups (including patients) aimed at combating COPD is beneficial

A combination of inhaled corticosteroid and long-acting beta2 agonist (ICS/LABA) is used frequently to treat chronic obstructive pulmonary disease (COPD) patients. The aim of the study was to determine whether prescribing ICS/LABA to COPD patients in primary care in 2009/10 was within the GOLD guidelines and whether and to what degree patient characteristics were associated with prescription of these drugs by GPs.

BACKGROUND:Community-based care, underpinned by relevant primary care research, is an important component of the global fight against non-communicable diseases. The International Primary Care Research Group's (IPCRG's) Research Needs Statement identified 145 research questions within five domains (asthma, rhinitis, chronic obstructive pulmonary disease (COPD), smoking, respiratory infections). AIMS:To use an e-mail Delphi process to prioritise the research questions. METHODS:An international panel of primary care clinicians scored the clinical importance, feasibility, and international relevance of each question on a scale of 1-5 (5 = most important). In subsequent rounds, informed by the Group's median scores, participants scored overall priority. Consensus was defined as 80% agreement for priority scores 4 or 5. RESULTS:Twenty-three experts from 21 countries completed all three rounds. Sixty-two questions were prioritised across the five domains. A recurring theme was for 'simple tools' (e.g. questionnaires) enabling diagnosis and assessment in community settings, often with limited access to investigations. Seven questions recorded 100% agreement: these involved pragmatic approaches to the diagnosis of COPD and rhinitis, assessment of asthma and respiratory infections, management of rhinitis, and implementing asthma self-management. CONCLUSIONS:Evidence to underpin the primary care approach to diagnosis and assessment and broad management strategies were overarching priorities. If primary care is to contribute to the global challenge of managing respiratory non-communicable diseases, policymakers, funders, and researchers need to prioritise these questions.

Aims: To describe symptoms and lung function in patients registered with asthma or chronic obstructive pulmonary disease (COPD) in primary care and to examine how spirometry findings fit with general practitioners' (GPs) diagnoses.Methods: Patients aged >= 40 years with a diagnosis of asthma or COPD registered in the electronic medical record during the previous 5 years were recruited at seven GP offices in Norway in 2009-2010. Registered diagnosis, spirometry results, comorbidity, and reported symptoms were compared.Results: Among 376 patients, 62% were women. Based on Global Initiative for Chronic Obstructive Lung Diseases criteria, a spirometry diagnosis of COPD could be made in 68.1% of the patients with a previous COPD diagnosis and in 17.1% of those diagnosed with asthma only (P < 0.001). The. agreement between last clinical diagnosis of COPD and COPD based on spirometry was 0.50. A restrictive spirometry pattern was found in 19.4% and more frequently in patients diagnosed with both asthma and COPD (23.9%) than in patients diagnosed with COPD only (6.8%, P = 0.003).Conclusion: The ability of GPs to differentiate between asthma and COPD seems to have considerably improved during the last decade, probably due to the dissemination of spirometry and guidelines for COPD diagnosis. A diagnosis of COPD that cannot be confirmed by spirometry represents a challenge in clinical practice, in particular when a restrictive pattern on spirometry is found.

AIM Respiratory diseases are a public health issue throughout the world, with high prevalence and morbidity. This Research Needs Statement from the International Primary Care Respiratory Group (IPCRG) aims to highlight unanswered questions on the management of respiratory diseases that are of importance to practising primary care clinicians. METHODS An informal but inclusive consultation process was instigated in 2009. Draft statements in asthma, rhinitis, COPD, tobacco dependence, and respiratory infections were circulated widely to IPCRG members, other recognised experts, and representatives from a range of economic and healthcare backgrounds. An iterative process was used to generate, prioritise and refine research questions in each section. RESULTS Two overarching themes emerged. Firstly, there is a real need for research to be undertaken within primary care, which recruits patients representative of primary care populations, evaluates interventions realistically delivered within primary care, and draws conclusions that will be meaningful to professionals working within primary care. Secondly, international and national guidelines exist, but there is little evidence on the best strategies for implementing recommendations. Disease-specific research questions focus on effective and cost-effective ways to prevent disease, confirm the diagnosis, assess control, manage treatment, and empower selfmanagement. Practical questions about how to deliver this comprehensive agenda in diverse primary care settings are highlighted. CONCLUSIONS We hope that this Research Needs Statement will be used by clinicians and patients campaigning for answers to relevant questions, by researchers seeking funding to provide answers to these questions, and by funding bodies to enable them to prioritise research agendas.

Chronic obstructive pulmonary disease (COPD) is a multi-faceted disease that is a major cause of morbidity and mortality worldwide, and is a significant burden in terms of healthcare resource utilisation and cost. Despite the availability of national and international guidelines, and effective, well-tolerated pharmacological treatments, COPD remains substantially under-diagnosed and under-treated within primary care. As COPD is both preventable and treatable there is an urgent need to raise the awareness and profile of the disease among primary care physicians and patients. Increasing evidence suggests that initiation of long-acting bronchodilator treatment at an early stage can significantly improve the patient's long-term health and quality of life (QoL). Recent large-scale trials in COPD have confirmed the long-term benefits of maintenance treatment with long-acting bronchodilators. A wide range of benefits have been shown in selected patient groups including improved lung function and QoL, reduced exacerbations and, in some studies, delayed disease progression and improved survival. In this review, we consider recent developments in our understanding of COPD, including current and emerging pharmacological treatment options, and identify steps for optimising early diagnosis and pharmacological treatment of COPD within the primary care environment.

Chronic obstructive pulmonary disease (COPD) is a smoking-related, progressive lung disease that represents a substantial individual, societal and economic burden. Primary care professionals have an important role in healthcare provision for patients with COPD. In this position paper we summarise the current knowledge about, and management of patients with COPD. Next, we describe the role general practitioners and other primary care disciplines (should) have to prevent, diagnose and treat COPD. Finally, we explore differences in the way particular aspects of primary care COPD disease management are available or organised in a number of European countries, in order to identify barriers and provide examples of 'best practices' for optimal primary care management of patients with COPD.