Introduction Mechanisms and materials to support the delivery of the education component of pulmonary rehabilitation are not widely available. The aim of this study was to adapt the Living Well with COPD (LWWCOPD) programme for embedding in pulmonary rehabilitation and to conduct a process and outcome evaluation. Methods Adaptation: Modifications to the LWWCOPD programme were informed by focus groups, current practice, relevant research and guidelines, and in collaboration with the authors of the LWWCOPD programme. The study used a cohort before-after design which incorporated the principles of a process evaluation. Evaluation: Sites administered their usual pulmonary rehabilitation programme with the exception of the LWWCOPD programme for pulmonary rehabilitation to deliver the education component. Health professionals and patients completed evaluation questionnaires to assess their acceptance. Patients completed the Understanding COPD (UCOPD) questionnaire and the Bristol COPD Knowledge Questionnaire before and after pulmonary rehabilitation. Analysis: Feedback and comments on the programme were collated and categorised. Changes in the UCOPD questionnaire and BCKQ were examined using paired t-tests. Results Adaptation: Amendments to the LWWCOPD programme included reducing the number and length of education sessions, incorporating additional information/techniques, materials to link the education and exercise sessions and a COPD action plan. Evaluation: 25 health professionals and 57 patients with COPD from eleven pulmonary rehabilitation programmes evaluated the LWWCOPD for pulmonary rehabilitation. The mean (SD) duration of the education sessions was 41 (9) min. The health professionals felt that the education sessions were either excellent (n=16/65, 25%) or good (n=40/65, 62%), and that they were comprehensive, evidence-based and utilised a good combination of teaching strategies for example, “Easy to follow and deliver”. They reported that the programme would require modification for non-COPD patients. Patients commented on improved knowledge and self-efficacy, peer support and relevant content for example, “Better understanding of action to be taken”. They requested supplementary information for family members. The UCOPD questionnaire and the BCKQ improved significantly: mean change (95% CI): UCOPD questionnaire: 26.8 (21.7 to 31.8)%, BCKQ: 10.6 (6.9 to 14.4)%. Conclusion The LWWCOPD programme for pulmonary rehabilitation is a feasible, effective and versatile way to deliver the education component of COPD pulmonary rehabilitation.

Cough reflex hypersensitization is a key feature in patients with troublesome cough. The clinical consequence of this hypersensitive state is typified by bouts of coughing often triggered by low threshold stimuli encountered by the patient during normal daily activities including exposure to aerosols, scents and odours, a change in air temperature and when talking or laughing. These features are often perceived by cough patients to be the most disruptive aspect of their condition and undoubtedly contribute to impaired quality of life. Patients with troublesome cough may describe a range of additional symptoms and sensations including an ‘urge to cough’ or the feeling of an ‘itch’ at the back of the throat, or a choking sensation and occasionally chest pain or breathlessness. It is uncertain if these features arise due to the processes responsible for cough reflex sensitization or as a direct consequence of the underlying cough aetiology. In an attempt to understand the clinical features of a sensitized cough reflex, the spectrum of symptoms typically described by cough patients will be reviewed and possible underlying mechanisms considered. Since an intact cough reflex is crucial to airway protection, anti-tussive treatment that attenuates the hypersensitive cough state rather than abolishing the cough reflex completely would be preferable. Identifying such agents remains a clinical, scientific and pharmacological challenge.

There should be a clear pathway through pulmonary rehabilitation and follow-on services. The aim of this survey was to determine the characteristics of the different components of the patient pathway, that is, pulmonary rehabilitation programs, ongoing exercise facilities, and support networks in Northern Ireland. Questionnaires were sent to current providers of pulmonary rehabilitation, providers of ongoing exercise, and support groups in Northern Ireland. Findings relating to the current status of pulmonary rehabilitation in Northern Ireland up to January 2007 are reported. There are currently 23 pulmonary rehabilitation programs in Northern Ireland. There appears to be a pathway through the short-term pulmonary rehabilitation program (6–8 weeks). Programs met standards for structure and format, except for the frequency of supervised exercise. Not all programs have links for the provision of ongoing exercise, but a range of exercise programs are available in leisure centers in Northern Ireland that include people with respiratory disease. There are 13 support groups for patients with respiratory disease in Northern Ireland and their function is diverse. Pulmonary rehabilitation is established in Northern Ireland, although not all patients are able to access these. Facilities for ongoing exercise and support groups are less developed. Improvements could be facilitated by better communication within the patient pathway and a strategic coordinated approach.

Chronic cough is a common and disabling symptom. Recent guidelines have attempted to provide direction in the clinical management of cough in both primary and secondary care. They have also provided a critical review of the available literature and identified gaps in current knowledge. Despite this they have been criticized for a reliance on a low quality evidence base. In this review, we summarize the current consensus on the clinical management of chronic cough and attempt to rationalize this based on recent evidence. We have also provided an overview of the likely pathophysiological mechanisms responsible for cough and highlighted areas, where knowledge deficits exist and suggest directions for future research. Such progress will be critical in the search for new and effective treatments for cough.

Chronic cough is a common and disabling symptom. Recent guidelines have attempted to provide direction in the clinical management of cough in both primary and secondary care. They have also provided a critical review of the available literature and identified gaps in current knowledge. Despite this they have been criticized for a reliance on a low quality evidence base. In this review, we summarize the current consensus on the clinical management of chronic cough and attempt to rationalize this based on recent evidence. We have also provided an overview of the likely pathophysiological mechanisms responsible for cough and highlighted areas, where knowledge deficits exist and suggest directions for future research. Such progress will be critical in the search for new and effective treatments for cough. Chronic Respiratory Disease 2007; 4: 215—223

The aim of this study was to determine whether patients (n = 40) with chronic obstructive pulmonary disease (COPD) currently receiving short-burst oxygen therapy meet existing criteria for ambulatory oxygen. A prospective randomised balanced double-blind crossover design was used. Criterion (i) for ambulatory oxygen (desaturation by 4% to below 90% on the practice walk) was met in 21 patients; 15 of these 21 patients also met criterion (ii) (10% improvement in distance and/or breathlessness score with oxygen). Despite no evidence of desaturation in 19/40 patients, 9/19 improved their distance and/or breathlessness score with oxygen. This study has shown that many patients on short-burst oxygen meet existing criteria for ambulatory oxygen and may have been receiving suboptimal therapy. It supports recent proposals for the development of comprehensive assessment services which incorporate assessment for all categories of oxygen.

The prescription of home oxygen cylinders is substantial. This study aimed to establish patient's current use of short burst oxygen therapy in chronic obstructive pulmonary disease (COPD) and to examine potential cost savings if cylinder use had been replaced by a concentrator. An interviewer-administered questionnaire was completed by 100 patients currently receiving short burst oxygen therapy. Patients reported that they used their oxygen before exercise/activity (26%), during exercise (19%), after exercise/activity (87%) and at rest (46%) and mostly for the relief of symptomatic breathlessness. The length of time [mean (SD)] patients had oxygen at home was 27.42 (29.31) months. Of those patients using cylinders, savings could have been made by transferring from cylinders to concentrators. While withdrawal of oxygen may be difficult, an oxygen assessment service could ensure that future prescription is aimed at those who benefit and is delivered by the most cost-effective method.

The objectives of this study were to obtain information about the use and subjective benefits of inhaled therapies in patients with bronchiectasis and to determine if these benefits were related to the presence of airflow obstruction. One hundred and twenty patients completed a questionnaire on inhaled therapies and performed spirometry. Inhalers were used daily by 85/120 patients with bronchiectasis and 42/120 patients had a nebuliser. Inhaled therapies were used extensively in patients with (FEV1 < 80%) and without (FEV1 > 80%) evidence of airflow obstruction. The majority of patients reported subjective benefits from their inhaled therapies. Chi2 analysis showed that there was no association between perceived benefits of short acting bronchodilators (SAB), long acting bronchodilators (LAB), corticosteroids or nebulisers and degree of airflow obstruction. This study provides information about the subjective benefits of inhaled therapies which could facilitate a more comprehensive assessment of the net benefit of inhaled therapies in patients with bronchiectasis with and without airflow obstruction.

Introduction:UK figures show that the prescription of home oxygen cylinders for intermittent use is substantial. Aim: To examine GP assessment criteria and prescribing practice for intermittent oxygen therapy in patients with a diagnosis of chronic obstructive pulmonary disease (COPD) in Northern Ireland. Methods:A postal questionnaire was sent to all GPs (n = 534) in two health boards who had prescribed cylinder oxygen in a six month period prior to the study. The questionnaire was piloted to establish reliability and validity. Results:Completed questionnaires were returned by 52% (280/534) of GPs. GPs ‘most frequently’ used advice from hospital specialists [82% (230/280)] to determine the need for intermittent oxygen. Criteria such as breathlessness score on exercise (e.g., BORG), oximetry on exercise, local guidelines or national guidelines were used less frequently or never. Conclusions:Most patients are likely to have been prescribed intermittent oxygen without any objective assessment. Implementation of evidence-based guidelines and a formal oxygen assessment service, would rationalize the use of intermittent oxygen therapy and enable better targeting of this expensive resource.

Reflux-cough is a diagnosis based on demonstrating both gastro-oesophageal reflux and a positive response to anti-reflux therapy. The authors sought to determine early and long-term response to therapy in patients with a "positive" 24 h oesophageal pH study, and identify any features which might predict response. Patients with chronic cough were recruited from July 1998 to July 2002. Those with a positive pH study were given dietary advice and an 8-week trial of omeprazole (20 mg b.i.d.). Response was judged after 8 weeks (clinical follow-up), and at long-term follow-up (telephone questionnaire). A total of 146 patients underwent pH monitoring with 82 (56.2%) "positive" studies. Follow-up data was available in 60 patients, with 49 receiving anti-reflux therapy, of which 20 (40.8%) reported a positive treatment response. At long-term follow-up (median 30 months), there was a significantly lower response (14 out of 49, 28.5%), with no significant difference in either acid exposure times (distal/proximal) or symptom correlation between responders and nonresponders at early or long-term follow-up. In conclusion, despite "positive" pH studies, over half of the patients (55.1%) failed to respond to therapy. No features on pH monitoring accurately predicted response. Short-term response did not predict long-term response. The precise role for pH monitoring in the assessment of chronic cough remains to be defined.

Psychogenic cough occurs most commonly in patients under 18 years of age. Making the diagnosis on clinical features alone is problematic, and it is usually a diagnosis of exclusion after several negative clinical investigations. We report on the case of a 13‐year‐old schoolboy with a 3‐month history of persistent dry cough with no other associated symptoms. Clinical examination and investigations revealed no abnormality, and empirical trials of antiasthma and antacid medications proved unsuccessful. An objective assessment of his cough frequency was made using an ambulatory cough monitor. A large number of cough episodes were recorded during the day, but during the time he was in bed there were very few episodes recorded. This suggested a diagnosis of psychogenic cough, and he underwent behavior modification therapy under the guidance of a clinical psychologist, with good result. Objective cough monitoring may therefore improve the evaluation and management of chronic cough. Pediatr Pulmonol. 2003; 36:73–75. © 2003 Wiley‐Liss, Inc.

BACKGROUND:Environmental, cultural and health care differences may account for variation among countries in the prevalence of asthma and respiratory symptoms in teenagers.OBJECTIVE:To examine the prevalence of respiratory symptoms and the level of diagnosis, and to compare determinants of asthma and severe wheeze in two countries.METHODS:Self-completion questionnaires based on the International Study of Asthma and Allergies in Childhood (ISAAC) protocol were provided to school children in Ireland (Republic and Northern Ireland). In the Republic of Ireland, all children in classes largely aged 13-14 years from 30 post-primary schools were selected by random sampling stratified by school size, composition and Health Board in Spring 1995. In Northern Ireland, all children largely aged 13-14 years of age from 26 post-primary schools were selected by random sampling stratified by school type, composition and Education and Library Board in Spring 1996.RESULTS:Questionnaires were completed by 2,364 children from Northern Ireland and 2,671 from the Republic, about 90% of those eligible to participate. The prevalences of wheeze at various levels of severity, of diagnosed asthma and of treated wheeze were very similar in Northern Ireland and the Republic of Ireland. A significant proportion of those reporting more severe symptomatology (four or more attacks of wheeze in the past 12 months and/or one or more nights disturbed and/or moderate or greater disruption of daily activities and/or speech restriction due to wheeze) had been neither diagnosed nor treated for asthma (20-37%). To investigate the determinants of the more severe symptomatology of asthma or treated wheeze a series of stepwise multiple regression analyses was performed. A history of atopy, cigarette smoking, the possession of a furry pet other than a dog or cat and age were each independently associated with severe wheeze, whilst atopy, a furry pet (as above) and gender were each independently associated with asthma or treated wheeze.CONCLUSIONS:Cigarette smoking is closely associated with the reporting of significant respiratory symptoms together with atopy and exposure to furry pets. Some 20-37% of severe symptoms were neither diagnosed nor treated as asthma.

The purpose of this survey was to ascertain which physiotherapy techniques are currently used, how interventions are assessed and to determine the views of physiotherapists in the UK on the need for further research. Senior physiotherapists in 100 randomly selected hospitals providing respiratory care in the UK were sent a previously piloted questionnaire on their bronchiectasis practice. The response rate was 82%. A variety of physiotherapy treatment techniques and outcome measures are used, and there are no national guidelines on the physiotherapy management of patients with bronchiectasis. There is a clear need for research into the effectiveness of physiotherapy techniques in bronchiectasis including a cost-benefit analysis which would enable targeting of resources and the development of evidence-based practice guidelines.