BACKGROUND:Since the last guidance was published by the Canadian Thoracic Society, there have been several advances in the clinical management of severe asthma. To gain a better understanding of the current standards of care and treatment patterns of patients, the CASCADE practice reflective program was established to conduct a real-world analysis of severe asthma management among specialists in Canada with a goal of identifying areas of opportunity to enhance patient management and outcomes.METHODS:The CASCADE program was a two-part practice reflective and assessment program delivered through an on-line portal for selected specialists (Respirologists and Allergists) in Canada. The program consisted of a one-time overview survey of physician practice to establish overall practice parameters, followed by a review of at least 5 severe asthma patients to establish the current landscape of severe asthma management.RESULTS:The program collected practice overview surveys from 78 specialists (52 Respirologists, 24 Allergists, and 2 General practice physicians with an interest in respiratory disease) in 8 provinces. Practices included a variety of types in both large metropolitan centres and smaller regional settings. There were 503 patients reviewed and included in the program. Most (65%) patients were currently using a biologic treatment, 30% were biologic naive, and 5% had used a biologic treatment in the past. Most patients (53%) were reported to have mixed allergic and eosinophilic phenotypes, despite a perception that allergic, eosinophilic and mixed phenotypes were evenly balanced in the physician practice. Overall, patients currently treated with biologic agents had parameters suggesting higher control and were more satisfied with treatment. However, there was less than optimal treatment satisfaction for more than half of all patients, particularly for those patients not treated with a biologic agent.CONCLUSIONS:Phenotyping is hampered by poor availability for several assessments, and the full range of treatments are not currently fully utilized, partly due to physician familiarity with the agents and partly due to prescribing restrictions. Even when treated with biologic agents, patient satisfaction can still be improved.

Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective. Methods A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1-9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures-kappa coefficient (kappa) value > 0.61. Results After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease. Conclusion This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.

Abstract Background In Canada, severe asthma affects an estimated 5–10% of people with asthma and is associated with frequent exacerbations, poor symptom control and significant morbidity from the disease itself, as well as the high dose inhaled, and systemic steroids used to treat it. Significant heterogeneity exists in service structure and patient access to severe asthma care, including access to biologic treatments. There appears to be over-reliance on short-acting beta agonists and frequent oral corticosteroid use, two indicators of uncontrolled asthma which can indicate undiagnosed or suboptimally treated severe asthma. The objective of this modified Delphi consensus project was to define standards of care for severe asthma in Canada, in areas where the evidence is lacking through patient and healthcare professional consensus, to complement forthcoming guidelines. Methods The steering group of asthma experts identified 43 statements formed from eight key themes. An online 4-point Likert scale questionnaire was sent to healthcare professionals working in asthma across Canada to assess agreement (consensus) with these statements. Consensus was defined as high if ≥ 75% and very high if ≥ 90% of respondents agreed with a statement. Results A total of 150 responses were received from HCPs including certified respiratory educators, respirologists, allergists, general practitioners/family physicians, nurses, pharmacists, and respiratory therapists. Consensus amongst respondents was very high in 37 (86%) statements, high in 4 (9%) statements and was not achieved in 2 (5%) statements. Based on the consensus scores, ten key recommendations were proposed. These focus on referrals from primary and secondary care, accessing specialist asthma services, homecare provision for severe asthma patients and outcome measures. Conclusions Implementation of these recommendations across the severe asthma care pathway in Canada has the potential to improve outcomes for patients through earlier detection of undiagnosed severe asthma, reduction in time to severe asthma diagnosis, and initiation of advanced phenotype specific therapies.

Asthma is a heterogenous respiratory disease, usually associated with chronic airway inflammation and hyper-responsiveness, which affects an estimated 339 million people worldwide. Severe asthma affects approximately 5-10% of patients with asthma, approximately 17-34 million people globally, more than half of whom have uncontrolled disease. Severe asthma carries a substantial burden of disease, including unpredictable symptoms and potentially life-threatening flare-ups. Furthermore, severe asthma has a substantial burden on health care systems and economies worldwide. In 2018, a group of experts from the clinical community, patient support groups, and professional organisations joined together to develop the Severe Asthma Patient Charter, which set out six principles to define what patients should expect for the management of their severe asthma and what should constitute a basic standard of care. Since the publication of that original Charter in 2018, several important changes have occurred, including an improved understanding of asthma and effective asthma management; several new therapies have become available; and finally, the COVID-19 pandemic has placed a spotlight on respiratory conditions, the workforces that treat them, and the fundamental importance of health care system resilience. With those developments in mind, we, representatives of the academic, clinical, and patient advocacy group communities, have updated the Charter to Improve Patient Care in Severe Asthma with a focus on six principles: (1) I deserve a timely, comprehensive assessment of my asthma and its severity; (2) I deserve a timely, straightforward referral to an appropriate specialist for my asthma when it is not well controlled; (3) I deserve to understand what makes my asthma worse; (4) I deserve access to treatment and care that reduces the impact of asthma on my daily life; (5) I deserve not to be reliant on systemic corticosteroids; (6) I deserve to be involved in decisions about my treatment and care.

BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4-month interval (October-December 2014) were eligible for inclusion. The primary outcome was the 30-day major complication rate (Clavien-Dindo grade III-V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital-level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (320 per cent) were of normal weight, 2673 (336 per cent) were overweight and 2747 (345 per cent) were obese. Overall, 4925 (618 per cent) underwent elective and 3038 (381 per cent) emergency operations. The 30-day major complication rate was 114 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 159, 95 per cent c.i. 112 to 229, P = 0008; obese: OR 191, 131 to 283, P = 0002; compared with normal weight) but not benign disease (overweight: OR 089, 071 to 112, P = 0329; obese: OR 084, 066 to 106, P = 0147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

Background The Physician Quality Improvement Initiative (PQII) uses a well-established multi-source feedback program, and incorporates an additional facilitated feedback review with their department chief. The purpose of this mixed methods study was to examine the value of the PQII by eliciting feedback from various stakeholders. Methods All participants and department chiefs ( n = 45) were invited to provide feedback on the project implementation and outcomes via survey and/or an interview. The survey consisted of 12 questions focused on the value of the PQII, it’s influence on practice and the promotion of quality improvement and accountability. Results A total of 5 chiefs and 12 physician participants completed semi structured interviews. Participants found the PQII process, report and review session helpful, self-affirming or an opportunity for self-reflection, and an opportunity to engage their leaders about their practice. Chiefs indicated the sessions strengthened their understanding, ability to communicate and engage physicians about their practice, best practices, quality improvement and accountability. Thirty participants (66.7 %) completed the survey; of the responders 75.9, 89.7, 86.7 % found patient, co-worker, and physician colleague feedback valuable, respectively. A total of 67.9 % valued their facilitated review with their chief and 55.2 % indicated they were contemplating change due to their feedback. Participants believed the PQII promoted quality improvement (27/30, 90.0 %), and accountability (28/30, 93.3 %). Conclusions The PQII provides an opportunity for physician development, affirmation and reflection, but also a structure to further departmental quality improvement, best practices, and finally, an opportunity to enhance communication, accountability and relationships between the organization, department chiefs and their staff.

Background: Recent evidence has suggested an association between postoperative non-steroidal anti-inflammatory drugs (NSAIDs) and increased operation-specific complications. This study aimed to determine the safety profile following gastrointestinal surgery across a multicentre setting in the UK.Methods: This multicentre study was carried out during a 2-week interval in September-October 2013. Consecutive adults undergoing elective or emergency gastrointestinal resection were included. The study was powered to detect a 10 per cent increase in major complications (grade III-V according to the Dindo-Clavien classification). The effect of administration of NSAIDs on the day of surgery or the following 2 days was risk-adjusted using propensity score matching and multivariable logistic regression to produce adjusted odds ratios (ORs). The type of NSAID and the dose were registered.Results: Across 109 centres, early postoperative NSAIDs were administered to 242 (16.1 per cent) of 1503 patients. Complications occurred in 981 patients (65.3 per cent), which were major in 257 (17.1 per cent) and minor (Dindo-Clavien grade I-II) in 724 (48.2 per cent). Propensity score matching created well balanced groups. Treatment with NSAIDs was associated with a reduction in overall complications (OR 0.72, 95 per cent confidence interval 0.52 to 0.99; P = 0.041). This effect predominately comprised a reduction in minor complications with high-dose NSAIDs (OR 0.57, 0.39 to 0.89; P = 0.009).Conclusion: Early use of NSAIDs is associated with a reduction in postoperative adverse events following major gastrointestinal surgery.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. Optimal COPD management requires patients to participate in their care and physician knowledge of patients’ perceptions of their disease. METHODS: A prospective study in which respiratory specialist physicians completed a practice assessment questionnaire and patient assessments for 15 to 20 consecutive patients with COPD. Patients also completed a questionnaire regarding their perceptions of COPD and its management. RESULTS: A total of 58 respiratory specialist physicians from across Canada completed practice assessments and 931 patient assessments. A total of 640 patients with COPD (96% with moderate, severe or very severe disease) completed questionnaires. Symptom burden was high and most patients had experienced a recent exacerbation. Potential COPD care gaps were identified with respect to appropriate medication prescription, lack of an action plan, and access to COPD educators and pulmonary rehabilitation. Perceived knowledge needs and gaps differed between physicians and patients. CONCLUSIONS: Despite the dissemination of Canadian and international COPD clinical practice guidelines for more than a decade, potential care gaps remain among patients seen by respiratory specialist physicians. Differing perceptions regarding many aspects of COPD among physicians and patients may contribute to these care gaps.

COPD is progressive and typically begins many years before a definite diagnosis is made. As the rate of decline in lung function may be faster in the initial stages of the disease, early intervention could be beneficial to control symptoms and affect disease progression and outcomes. A systematic review of published literature relating to mild-to-moderate COPD (patients with FEV(1) ≥50% predicted) was performed to evaluate the level of impairment and natural history or disease progression over time, and impact of interventions on the outcomes of patients with early-stage disease. Of the 79 published articles included in this analysis, 31 reported randomized controlled trials; the remaining 48 articles reported studies of non-randomized and/or observational design. Nine of the randomized controlled trials were ≥6 months' duration, enabling assessment of outcomes over time. Most of the randomized controlled trials were in patients with moderate COPD (GOLD stage II); few included patients with the mildest stages of the disease (i.e., stage I). The results show that even patients with milder or moderate COPD can have substantial limitations and physical impairment, which worsen over time. Encouragement of smoking cessation, in conjunction with management of symptoms and treating activity limitation and exacerbations by appropriate non-pharmacologic and pharmacologic management at the earliest possible stage, could positively affect the impact and progression of the disease.

Background: Current gaps exist between heathcare professionals and COPD patients in effective communication & counselling on patient self management. Aim and objective: To develop a patient centred counselling tool, based on Canadian Clinical Practice Guidelines, for COPD self management that will meet the needs of family physicians, nurses, respiratory therapists, COPD educators & pharmacists responsible for COPD patient education. Methods: 7 national stakeholder organizations and 14 healthcare professionals from across Canada collaborated in the development of a patient centred COPD education/counselling tool. A core development board (3 COPD nurse educators, 1 pharmacist, 1 family physicians and 1 respirologist) developed the core materials. Input and direction was then provided by 3 regional committees (each comprised of 2-3 healthcare practitioners) to ensure regional nuances and national application of the tool. The national stakeholder organizations ensured that the tool meet the requirements of the respective organizations. The tool was tested with COPD patients to ensure usability and validity. Results: A tool with universal graphics and language in a paper format will be presented at the ERS. The tool contains self management strategies for preventing acute exacerbations, breathlessness, signs of worsening COPD and action plan. Conclusion: An effective patient education/counselling tool is required for successful communication between healthcare professionals and patients on COPD patient self-management. The utility and clinical impact of the tool will require HCP education and training.

COPD is under diagnosed and undertreated. Physicians and patients may have significantly different perceptions of disease severity, educational needs and treatment options. Purpose: To identify areas of COPD care that could be improved, a practice review was completed. Method: 58 respirologists from across Canada participated from June to October 2010; each completed a practice profile and patient assessments (n=931) during COPD patient visits. Patients also completed a questionnaire (n=640). Similar questions were asked of both groups to determine if perceptual differences existed. Data was evaluated for important comparisons of patient and physician demographics and practice characteristics. Results: Physicians and patients both recognized that symptoms are bothersome throughout the day, but morning was reported as the most troublesome time, 33% versus 18% for afternoon or evening. Perceptual differences were identified including treatment compliance and educational needs. 88% of patients felt they never or rarely miss taking their COPD medication while 80% of physicians perceived that patients missed their medication several times per week/month. For education and resources, patients emphasized disease understanding and progression, while physicians prioritized symptom management and smoking cessation. Only 51% of patients were taught to recognize signs of exacerbation by their physicians yet 78% of patients identified the physician as their greatest source of information. Conclusions: Patients and physicians provided different insight about COPD. Identifying these differences may allow for improved patient assessment, education and management leading to improved communication and outcomes.

Study ObjectivesTo report the clinical, imaging, and pathologic manifestations of case series of patients in whom the only systemic expression of relapsing polychondritis (RP) was their airway complications. DesignRetrospective review of the medical records of all patients with respiratory complications of RP between 1995 and 2007. SettingTertiary care, university-affiliated hospital. ResultsThree patients with RP had just lower airway manifestations as the only sign of their RP. All 3 were women, aged 44, 49, and 54 years. All had an abnormal chest computed tomography scan, although 2 had a completely normal chest x-ray. All had positive tracheal biopsy, which was consistent with the diagnosis of respiratory chondritis. Pulmonary function tests showed severe reduction in forced expiratory volume in 1 second in all patients. Bronchoscopy revealed tracheal narrowing with variable degrees of inflammation and collapsibility in all patients. Two of the 3 patients underwent tracheal and bronchial stent insertion. Pharmacotherapy included prednisone, methotrexate, cyclophosphamide, and leflunomide. The overall outcome was poor. Two patients died as a result of respiratory complications, 25 and 30 months from diagnoses, and 1 is still alive with follow-up of 85 months after presentation. ConclusionsLower airway manifestations of RP can be the only sign of the disease. RP has to be considered in the differential diagnosis of patients with recent onset of progressive dyspnea and severe airflow limitation even without other systemic signs of cartilage damage.

When rising rates of occurrence are reported for a particular disease, clinicians often cannot determine whether the disease has increased in actual occurrence or in the improved detection provided by better diagnostic technology and expanded access to medical care. The epidemiologic use of necropsy data, which might help answer these questions, has been inhibited by fears of bias in demographic and clinical selection of patients for necropsy. The demographic problem can be managed by suitable adjustment and standardization of the disease rates found at necropsy, and the clinical problem can be reduced or avoided by studying the rates with which the disease is found unexpectedly in necropsies performed for other, unrelated clinical reasons. The results, obtained in population groups "screened" via necropsy, can suggest the magnitude of the "undetected reservoir" that coexists and supplements the rates of reported occurrence for a disease. In a study of necropsies at Yale\p=m-\NewHaven (Conn) Hospital from 1972 to 1981, the necropsy detection rates for lung cancer were slightly higher for women than for men, and were substantially higher for both genders than the customarily reported rates in the general population. The results suggest that the reported rates may continue to rise in both genders until they become essentially equal at a size approximating that of the currently undetected reservoir. The "epidemiologic necropsy" offers a potentially valuable method to help distinguish the true occurrence rates of disease from the changes attributable to improved diagnostic detection with modern technology. (JAMA 1987;258:331-338)

Bronchiolitis obliterans (BO) is a serious complication of hematopoietic SCT (HSCT). The condition is believed to be the result of an inflammatory part of the GVHD. Although many BO patients receive immunosuppressive therapy, there is no clear evidence that therapeutic interventions have a positive impact. In the last 20 years, it has been recognized that macrolides have immunomodulatory effects beyond their antibiotic effect. Recent data suggest also that the use of macrolides in BO post HSCT may halt disease progression. Our objectives are to give the readers information on the background of BO post HSCT, to review the immunomodulatory properties of macrolides in general and specifically in pulmonary diseases, and to summarize the current knowledge of macrolide benefits in BO therapy. Research into macrolide immunomodulation for chronic pulmonary disorders, such as diffuse panbronchiolitis and cystic fibrosis, shows consistent positive effects. The use of macrolides for other types of pulmonary inflammatory complications is yet to be proved. The benefit for BO post HSCT was shown only in a small non-randomized trial. Additional in vivo research is needed before developing any firm conclusions.

BACKGROUND Oropharyngeal (OP) symptoms are common in asthma patients using inhaled corticosteroids (ICSs) alone and in combination with a long-acting beta(2)-agonist (LABA). Patterns of medication use, level of asthma control and association with OP symptoms are not often reported in a nonstudy setting. OBJECTIVES To determine the prevalence of OP symptoms among adult asthma patients using ICSs alone and an ICS plus a LABA; to investigate the relationships between medication use, asthma control and OP symptoms; and to assess family physicians' (FPs') perceptions of the prevalence and management of OP symptoms. METHODS A random telephone survey of 1003 asthma patients and 250 FPs treating asthma patients was conducted from February to March 2005 across Canada. RESULTS Twenty-four per cent of patients experienced OP symptoms; 67% of them spoke to their FPs about the OP symptoms. Thirty-one per cent of patients who experienced OP symptoms stopped or reduced their dose of medication. OP symptoms were reported by 25% of patients using ICSs and 22% using an ICS plus a LABA. The incidence of OP symptoms was not affected by the choice of inhalation device (metered-dose inhaler versus dry powder inhaler) or the use of a spacer. Fifty-eight per cent of patients had uncontrolled asthma; patients achieving a lower level of general education were more likely to have poor control. Patients with uncontrolled asthma were more likely than those with controlled asthma to report OP symptoms (28% versus 18%, respectively; P<0.05). Eighty-nine per cent of FPs had patients who had reported OP symptoms to them. FPs estimated that 15% of their patients experienced OP symptoms and that compliance to treatment worsened in approximately 20% of them. CONCLUSIONS The prevalence of OP symptoms in asthma patients using ICSs and an ICS plus a LABA is significant. OP symptoms were found to be associated with a reduced patient education level, with a likelihood of reducing or stopping medication, and with a less well-controlled asthma patient. While FPs recognized that a significant proportion of their asthma patients experience OP symptoms and that OP symptoms may affect compliance, they underestimated the prevalence of this problem.

BACKGROUND: Oropharyngeal (OP) symptoms are common in asthma patients using inhaled corticosteroids (ICSs) alone and in combination with a long-acting beta(2)-agonist (LABA). Patterns of medication use, level of asthma control and association with OP symptoms are not often reported in a nonstudy setting. OBJECTIVES: To determine the prevalence of OP symptoms among adult asthma patients using ICSs alone and an ICS Plus a LABA; to investigate the relationships between medication use, asthma control and OP symptoms; and to assess family physicians' (FPs') perceptions of the prevalence and management of OP symptoms. METHODS: A random telephone survey of 1003 asthma patients and 250 FPs treating asthma patients was conducted from February to March 2005 across Canada. RESULTS: Twenty-four per cent of patients experienced OP symptoms; 67% of them spoke to their FPs about the OP symptoms. Thirty-one per cent of patients who experienced OP symptoms stopped or reduced their dose of medication. OP symptoms were reported by 25% of patients using ICSs and 22% using an ICS Plus a LABA. The incidence of OP symptoms was not affected by the choice of inhalation device (metered-dose inhaler versus dry powder inhaler) or the use of a spacer. Fifty-eight per cent of patients had uncontrolled asthma; patients achieving a lower level of general education were more likely to have poor control. Patients with uncontrolled asthma were more likely than those with controlled asthma to report OP symptoms (28% versus 18%, respectively; P<0.05). Eighty-nine per cent of FPs had patients who had reported OP symptoms to them. FPs estimated that 15% of their patients experienced OP symptoms and that compliance to treatment worsened in approximately 20% of them. CONCLUSIONS: The prevalence of OP symptoms in asthma patients using ICSs and an ICS plus a LABA is significant. OP symptoms were found to be associated with a reduced patient education level, with a likelihood of reducing or stopping medication, and with a less well-controlled asthma patient. While FPs recognized that a significant proportion of their asthma patients experience OP symptoms and that OP symptoms may affect compliance, they underestimated the prevalence of this problem.

Hematopoietic stem cell transplantation (HSCT) has been employed clinically for the therapy of a wide variety of acquired neoplastic and nonmalignant disorders. However, these immunocompromised patients remain at high risk of developing many serious and often life threatening complications. Occurring in up to 70% of allogeneic HSCT patients, respiratory complications are a leading cause of morbidity and mortality in this population. A rapid identification of the cause and institution of specific therapy is critical to achieve a good outcome. Unfortunately, early recognition and definitive diagnosis of such complications are difficult. In the presence of a modest immune response and neutropenia, the changes on a chest radiograph corresponding to early infectious and non-infectious processes are subtle, nonspecific and may not be recognized. Due to its greater sensitivity, thoracic computed tomography (CT) scan has been proposed to replace the plain chest radiograph (CXR) in the primary evaluation of immunocompromised patients.In the last five years in our institution, thoracic low dose CT (LDCT) scan has become the standard of care and has replaced the CXR in evaluating fever or respiratory symptoms in this group of patients. The published data concerning the use of LDCT scan of the chest as the primary tool for evaluation of this group of patients is limited. Our aim is to summarize the current knowledge in this matter and to add some new perspective from our experience.

BACKGROUNDPatients with chronic obstructive pulmonary disease (COPD) who smoke have a greater annual rate of decline in forced expiratory volume in 1 s (FEV(1)) than those patients who have stopped smoking.OBJECTIVESTo assess the effect of tiotropium on pre-dose (trough) FEV(1) in patients with COPD followed in Canada.METHODSA total of 913 patients were randomly assigned to receive either tiotropium 18 mug once daily (n=608) or placebo (usual care minus inhaled anticholinergics) (n=305) for 48 weeks in the present randomized, double-blind, parallel-group study. The effect of tiotropium on measurements of lung function (FEV(1), FEV(6) and forced vital capacity), symptoms, health-related quality of life (St George's Respiratory Questionnaire) and exacerbations were examined.RESULTSTiotropium improved trough FEV(1) in both current and ex-smokers compared with placebo. Baseline FEV(1) in smokers and ex-smokers was 1.03 L and 0.93 L, respectively (P<0.001). At week 48, the mean difference between the tiotropium and placebo groups was 0.14+/-0.04 L (P<0.001) in the smoker group and 0.08+/-0.02 L (P<0.0001) in the ex-smoker group. Tiotropium also significantly improved trough forced vital capacity and FEV(6) compared with placebo throughout the treatment period (P<0.05, for all). Furthermore, tiotropium significantly improved the St George's Respiratory Questionnaire total score compared with placebo at week 48 (40.9 versus 43.7 units, P<0.005).CONCLUSIONSCompared with the placebo group, tiotropium provides sustained improvements in lung function in patients with COPD, with improvements for smokers and ex-smokers.

Idiopathic pulmonary fibrosis (IPF) is a disease with limited therapeutic options. Corticosteroids and immunouppressive agents have been the mainstays of treatment, primarily due to their anti-inflammatory properties. However, they have demonstrated minimal efficacy and significant toxicity. Recent efforts have sought to target other aspects of the pathophysiology of this condition. Several investigators have hypothesized that imbalances of coagulation and fibrinolysis play a role in the pathophysiology of IPF. Thrombin has been identified as a possible trigger of fibroblast proliferation in IPF, suggesting a role for thrombin inhibition in modifying the course of disease. Furthermore, anticoagulation may have a role in preventing thrombotic complications in IPF patients with secondary pulmonary hypertension.This review will discuss the potential role for anticoagulation in the treatment of IPF. One randomised control trial has demonstrated a significant survival benefit associated with anticoagulation of IPF patients. We will review the evidence supporting this treatment strategy, as well as its possible mechanisms of action.