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EDITORIALS: William MacNee Guidelines for chronic obstructive pulmonary disease BMJ 2004; 329: 361-363 [Full text]

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Guidelines for Respiratory diseases and the developing countries

Parvaiz A Koul   (15 August 2004)

Coagulation, Complement and Calcification - Innate Immunity in COPD.

Friedrich Flachsbart   (15 August 2004)

Problem of early diagnosis of COPD

Vasiliy Vlassov   (18 August 2004)

The voice of scientific reason is quiet compared with the jingoism of a “war on tobacco”

Andrew J Ashworth   (19 August 2004)

The controversy surrounding bronchodilator reversibility in defining chronic obstructive pulmonary disease

Daniel K C Lee   (20 October 2004)

COPD and Intensive Care

Scott R Price, James Watts   (29 November 2004)

Guidelines for Respiratory diseases and the developing countries 15 August 2004
Parvaiz A Koul, Additional Professor of Internal and Pulmonary Medicine SKIMS, Soura, Srinagar 190011, Kashmir Send response to journal: Re: Guidelines for Respiratory diseases and the developing countries	The guidelines for COPD and other respiratory diseases published off and on have concentrated on the ideal or near ideal management of a particular disease. The realities of management in the developing countries with their vastly illetrate masses are indeed different. Poverty, illiteracy, obstinacy and false religious and cultural beliefs make the ideal management impossible. Poverty is a big impediment to their procuring inhalation medications and their delivery devices. It results in underutilization of the devices and supplemenation or substitution by oral formulations. The generally illiterate masses fall an easy prey to the false cultural beliefs and taboos. Steroids are dispensed in the form of sachets and wierd medications like herbs, tattooing, fish therapy etc are prescribed for management of these disorders. False beliefs that the inhalation devices mean the end-of-the-road for the patient also makes prescription of the inhalational therapies that much more difficult. It would be worthwhile if the guidelines address some of these issues and recommend alternate research for evidence for or against such therapies. At the end of such studies more concrete evidence based guidelines for the developing countries could be forthcoming. Competing interests: None declared
Coagulation, Complement and Calcification - Innate Immunity in COPD. 15 August 2004
Friedrich Flachsbart, General Medicine Praxis 37085 Göttingen Send response to journal: Re: Coagulation, Complement and Calcification - Innate Immunity in COPD.	Dear Sir, since 1977 I try to understand COPD. Chronic Obstructive Pulmonary Disease is Chronic Obstructive Pulmonary Artery Disease. Airway inflammation is associated with artery inflammation. Vascular inflammation is associated with coagulation, activation of complement and calcification inside the vascular system. Since 1978 I try to induce anticoagulation into the treatment of COPD. Heparin and coumarin should be tested in cases of recurrent exacerbations. Even very low dosis (INR = 1,1) do help! Symptoms vanish. Breathlessness and exercise limitations vanish. Leg edema vanishes. A possible explanation of these observations is: Group A Streptococci and Pneumococci invade by evading coagulation and complement. To survive, man has to have a hypercoagulatory state! Sincerily Yours Friedrich Flachsbart McCullough PA, Sandberg KR, Dumler F, Yanez JE: Determinants of coronary vascular calcification in patients with chronic kidney disease and end-stage renal disease: a systematic review. J Nephrol 2004;17:205-15 Competing interests: None declared
Problem of early diagnosis of COPD 18 August 2004
Vasiliy Vlassov, Director, Russian Branch of the Nordic Cochrane Centre Moscow 109451, POB 13 Send response to journal: Re: Problem of early diagnosis of COPD	The NICE gideline as well as other guides of the recent time have the door open for the early diagnosis of COPD in suspected cases after the FEV testing. It is in a some contradiction with the description of the condition (clunical signs, breathlessness etc.). As in many other prevalent conditions this lead to the further increase in prevalence because of the early diagnosis to the subjects who may be not diagnosed as COPD without practising the orthodox and unproved approach "early diagnosis leads to beter outcome". This approach is misused by some producers of beta-adrenomimetics and combination drugs who place the ads calling for early diagnosis. There is no good evidence that early diagnosis lead to better outcomes in these subjects, and it must be clearly stated in guidelines. Competing interests: None declared
The voice of scientific reason is quiet compared with the jingoism of a “war on tobacco” 19 August 2004
Andrew J Ashworth, General Practice Principal Davidson's Mains Medical Centre, 5 Quality St, EDINBURGH, EH4 5BP Send response to journal: Re: The voice of scientific reason is quiet compared with the jingoism of a “war on tobacco”	Addiction to Nicotine (a medical condition) and smoking (a behaviour)are presently confused as being the same thing, unlike addiction to opiates and injecting Heroin where guidelines(1)encourage long-term substitution of a drug to reduce the behaviour. When I prescribe Methadone, National guidelines encourage me to give enough to maintain behavioural change for as long as the patient feels it necessary; with Nicotine, my local guideline encourages me to give only three months of a reducing dose based on an arbitrary limit set, in effect, by the manufacturer of the product (neither drugs supplied by dealers nor Nicotine supplied by the Tobacco industry is the subject of dose limitation). In COPD it seems blindingly obvious that effective interventions to stop smoking would have even greater community benefit than those used to stop blood borne virus transmission but they are inhibited by confusion between a medical condition that causes cardiovascular disease and a related behaviour that exacerbates respiratory disease. As a General Practitioner I need evidence based answers to my breathless patients’ questions on the value of cutting down a behaviour they need (and often enjoy) and my own questions on the risks and benefits of long- term combination nicotine substitution for those with COPD who are otherwise unable to stop smoking. (1) Drug Misuse and Dependence – Guidelines on clinical Management. Department of Health, The Scottish Office Department of Health, Welsh Office, Department of Health and Social Services Northern Ireland HMSO 1999. Competing interests: I am Medical Director of ControlMySmoking, a web-based intervention embracing harm reduction, cessation and relapse prevention strategies in nicotine addiction.
The controversy surrounding bronchodilator reversibility in defining chronic obstructive pulmonary disease 20 October 2004
Daniel K C Lee, Respiratory Physician Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, Suffolk, England Send response to journal: Re: The controversy surrounding bronchodilator reversibility in defining chronic obstructive pulmonary disease	MacNee [1] is to be commended for providing a critical and unbiased appraisal of the current National Institute for Clinical Excellence (NICE) guideline on chronic obstructive pulmonary disease (COPD). However, the ongoing controversy at the heart of COPD definition with respect to bronchodilator reversibility deserves further mention. The decision by NICE to forego spirometric reversibility testing in the current guideline on COPD is out of alignment with Europe and the United States of America where the definition of COPD is based on airflow limitation that is not fully reversible as described by the World Health Organisation Global Obstructive Lung Disease initiative and is characterised by a ceiling of forced expiratory volume in one second (FEV1) and FEV1 to forced vital capacity ratio that remain decreased following bronchodilator therapy. Sterk [2] stresses the importance of the post-bronchodilator FEV1 but discourages the use of reversibility in defining COPD due to the varied subjective expression of reversibility whilst being very poorly reproducible. Nevertheless, Sterk and Jindal [3] draw attention to the importance of reversibility in pointing towards clinically and pathophysiologically relevant phenotypes of COPD where there exist a subgroup of COPD patients with eosinophilic inflammation who demonstrate significant reversibility and who are likely to respond to bronchodilator and anti-inflammatory therapy. On the other hand, there is also a subset of COPD patients who do not demonstrate reversibility where neutrophilic inflammation is predominant and whom Jindal refers to as “true COPD” patients, bearing in mind that one can never be too sure whether COPD patients who show reversibility are asthmatics as such patients with reversible airflow obstruction may have developed a degree of fixed obstruction through prolonged inhalational insults such as tobacco smoking. Finally, the discordance between national guidelines and expert opinions may simply be a reflection of the fundamental lack of knowledge about the cellular, molecular, and genetic causes of COPD as commented by Barnes and Kleinert [4] who have coined COPD – a neglected disease. Daniel K C Lee MB BCh MRCP MD, Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, Suffolk, England, United Kingdom References 1. MacNee W. Guidelines for chronic obstructive pulmonary disease: NICE guidelines are evidence based but will need regular updating. BMJ 2004; 329: 361–3. 2. Sterk PJ. Pre- and post-bronchodilator spirometric values and the degree of reversibility in patients with COPD. Eur Respir J 2004; 24: 332–3. 3. Jindal SK. Dutch hypothesis: revisited? Chest 2004; 126: 329–31. 4. Barnes PJ, Kleinert S. COPD – a neglected disease. Lancet 2004; 364: 564–5. Competing interests: None declared
COPD and Intensive Care 29 November 2004
Scott R Price, Consultant Anaesthetist Burnley General Hospital, BB10 2PQ, James Watts Send response to journal: Re: COPD and Intensive Care	Sir, The recent editorial by MacNee [1] directed us to the NICE guidelines for Chronic Obstructive Pulmonary Disease (COPD)[2]. As Intensivists, we were very interested in the section on 'Invasive Ventilation and Intensive Care'. Overall, we agree with the recommendations R174/R175, but disagree with the way the evidence has been quoted. Using the paper by Esteban et al [3], a comparison is made between COPD and Acute Respiratory Distress Syndrome. It is to be expected that there are different mortality rates, duration of ventilation for these two conditions as they have totally different aetiologies. Similarly, it is not surprising that the quoted mortality for COPD exacerbation of 22% is less than that of other conditions leading to acute respiratory failure (ARF). Exacerbation of COPD is a single organ failure, and ARF due to other conditions implies multiple organ failure, which has a higher mortality, either in conjunction with COPD or from other causes[4]. It is particularly confusing why coma was used as a comparator. Even within the Esteban paper, the mortality for pneumonia requiring ventilation - the main cause of COPD exacerbation - is 39%, and once the patient gets past 70 years old, the odds ratio for death is 2.11. From our own, unpublished figures, the odds ratio for death in the over 80s who are ventilated is 3.07, compared with our baseline mortality. We support the idea that therapeutic nihilism in COPD is not always warranted, but feel the guidelines have not presented the facts accurately, and have used dubious comparisons in trying to promote aggressive intensive care for COPD patients. Given these guidelines carry such weight, we feel it would have been prudent to include intensivists in the preparation of guidelines for intensive care. Dr J.C.Watts B.Sc. M.B. Ch.B F.R.C.A. Dr. S.R.Price, B.Sc. M.B. Ch.B. F.R.C.A. C.Med.Ed Consultants, Critical Care Unit, Burnley General Hospital, East Lancashire Hospitals NHS Trust, Casterton Avenue, Burnley, BB10 2PQ References. [1] MacNee W. Guidelines for chronic obstructive pulmonary disease. BMJ 2004;329: 361-363 [2[ National Collaborating Centre for Chronic Conditions. Chronic Obstructive Pulmonary Disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004; 59 (suppl 1):1-232 [3] Esteban A, Anzueto A, Frutos F et al Characteristics and outcomes in Adult Patients Receiving Mechanical Ventilation. JAMA 2002; 287: 345-355 [4] Afessa B, Morales IJ, Scanlon PD et al. Prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive acre unit for acute respiratory failure. Crit Care Med 2002; 30 : 1610-1615. Competing interests: None declared