Chest
Volume 133, Issue 1, January 2008, Pages 34-41
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Original Research
COPD
Reported and Unreported Exacerbations of COPD: Analysis by Diary Cards

https://doi.org/10.1378/chest.07-1692Get rights and content

Background

Exacerbations of COPD are a major cause of morbidity and mortality; however, it has been reported that nearly half of such episodes based on symptoms are classified as “unreported” (no change in treatment), although the reasons are unknown.

Method

We used a symptom-based diary card to study 155 symptom-defined episodes (74 episodes in which treatment was not changed) in 19 patients with α1-antitrypsin deficiency.

Results

The average length for the untreated episodes (time to resolution of all symptoms) was shorter than treated episodes (mean ± SE, 8.3 ± 1.0 days vs 16.1 ± 1.6 days; p < 0.001). Of most importance, the patients documented feeling less well than usual for an average of only 1.9 ± 0.4 days for untreated episodes, vs 11.7 ± 1.7 days for treated episodes (p < 0.001). We developed a scoring system based on the symptoms of breathlessness, well-being, sputum color, and volume to quantify the episodes. The scores were higher for the first day of the treated episodes than untreated episodes (33.5 ± 0.6 vs 28.4 ± 0.5, respectively; p < 0.001), and the treated episodes had total scores that exceeded the baseline more than the untreated episodes (160.5 ± 20.0 vs 43.4 ± 6.6; p < 0.001). Antibiotics or steroids were started 4.4 ± 0.5 days and 4.9 ± 1.8 days on average, respectively, after symptoms changed, suggesting that the early return of well-being to normal is central to the episodes described as unreported (untreated) by others.

Conclusion

The diary card analysis described here provides a tool to document therapies that influence health-care–dependent exacerbations of COPD.

Section snippets

Materials and Methods

Patients attending the α1-Antitrypsin Deficiency Assessment Program and Treatment Research Unit at Queen Elizabeth Hospital, Birmingham, UK, who matched the selection criteria were enrolled into the α1 augmentation “EXACTLE” trial. Ethical approval for this study was obtained from University Hospital Birmingham NHS trust research and ethics committee. All patients provided written informed consents before recruitment into the study and filled in daily diary cards. During the run-in period, the

Baseline Characteristics

A total of 19 patients who completed the study maintained daily diary cards for 2 years. All had α1-antitrypsin deficiency of the PiZ type confirmed by isoelectric focusing. These patients (6 female, 13 male) had a mean age of 52.5 years (SE 2.2), an average (± SE) postbronchodilator FEV1 of 1.19 ± 0.1 L (FEV1 percentage of predicted, 39.09 ± 3.5%), and gas transfer corrected for alveolar volume of 0.9 ± 0.1 mmol/min/kPa/L (gas transfer corrected for alveolar volume percentage of predicted,

Discussion

The current study describes a novel approach to the monitoring of exacerbations relevant to COPD. Uniquely, it develops a scoring system to quantify the symptomatology related to the classical criteria described by Anthonisen and colleagues.17 The analysis identifies a sustained change in symptomatology that indicates to the start of the episode and the converse to define the end of the episode. Using this approach, we have identified that the resolution of symptom varies, with changes in

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    Dr. Vijayasaratha has no conflict of interest to disclose. Dr. Stockley is a member of the Alpha One International Registry.

    This work was funded by an unrestricted grant from Talecris Biotherapeutics, Research Triangle Park, NC.

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