stockley.qxp 11/8/09 2:42 pm Page 36
Chronic Obstructive Pulmonary Disease
those with type II respiratory failure who have had their ABGs health status, increased risk of exacerbation,
60
reduced lung function,
normalised. This can largely be circumvented by ventilating only to a mortality and hospitalisation.
61,62
However, CRP levels can also be
normal pH but not to a normal PaCO
2
. altered by age, gender, medication and other co-morbidities, so it
lacks specificity. In reality, the causes of exacerbations are diverse and
Relapse and Prevention it is unlikely that a single biomarker will be useful for all. Perhaps
Recurrence of an exacerbation is a common problem, and one study CRP,
63,64
sputum purulence
44
and procalcitonin
65,66
are the most likely to
found that 34% of patients were readmitted within three months indicate a bacterial cause.
following an exacerbation.
14
Patients with an increased CRP at 50 days
post-exacerbation had a 22% chance of recurrence.
55
Preventing Potential New Treatments
recurrences is important as they lead to increased mortality and are Finding new therapies for the treatment of COPD is essential in view
associated with worse quality of life.
8
of consistently high mortality rates. This is hampered by the lack of a
sensitive biomarker to assist in phase II clinical trials. In addition,
Several inhaled therapies have been proved to reduce exacerbation COPD patients have co-morbidities that usually exclude them from
rates, including inhaled corticosteroids,
56
long acting β
2
-agonists trials,
67
and hence even positive studies may not be generalisable.
(LABAs),
57
anticholinergics
58
and combination inhaled therapy (LABA Many different therapies are being developed, including macrolides,
and inhaled corticosteroid).
59
which have anti-inflammatory activity that may explain their efficacy
in cystic fibrosis.
68
The development of other anti-inflammatory
Discharge therapies may also prove of benefit in the future management of
The mean length of hospital stay of patients with acute COPD COPD and at least some exacerbations. ■
exacerbations is nine days (range: five to 15 days).
7
Before discharge
from hospital it is important that patients are clinically stable,
Helen Ward is a Clinical Research Fellow in the
including stable ABGs and appropriate social arrangements, and out-
Department of Respiratory Medicine at Queen
of-hospital management plans have been scheduled. If the patient Elizabeth Hospital, University Hospitals Birmingham.
continues to have low oxygen saturations (<90%), supplemental
She reviews patients from the UK alpha-1-antitrypsin
deficiency registry annually. She has been co-
oxygen can be prescribed for discharge, but this should be reviewed
investigator in several clinical phase II drug trials and
at the first clinic visit after four to six weeks. has had several oral presentations and posters at
international conferences.
The Future
Biomarkers
Robert A Stockley is a Professor of Medicine in the
Department of Respiratory Medicine at Queen Elizabeth
Exacerbations have a significant impact on quality of life and
Hospital, University Hospitals Birmingham, and Director
prognosis in COPD patients. There has been a range of definitions
of Research and Development for the Trust. He has a
(symptom- and treatment-based) used for exacerbations, so it is
long-standing interest in chronic obstructive pulmonary
disease (COPD), with particular reference to airway
important that a marker is found that is reproducible, sensitive and
inflammation, proteinases and antiproteinases,
specific for diagnosing these episodes. Much work has investigated
especially the role of the neutrophils, bacteria and
sputum, induced sputum, bronchial biopsies and exhaled breath
exacerbations; he lectures widely on these subjects.
Professor Stockley acts as an advisor to many pharmaceutical companies on the
condensate as possible biomarkers, but they are invasive and poorly
design and delivery of phase II and III clinical trials and has been the principal
reproducible and may lack sensitivity. Blood biomarkers have been
investigator for several large multinational COPD trials.
investigated more recently, especially CRP, which relates to poor
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36 EUROPEAN RESPIRATORY DISEASE
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