As transformações demográficas e epidemiológicas do século anterior trouxeram significativas modificações sociodemográficas e de saúde, em todo o mundo, com o aumento de idosos na população. Ao processo de envelhecimento pode estar associado às doenças crônicas não transmissíveis, dentre elas a doença pulmonar obstrutiva crônica (DPOC), um problema de saúde pública, parcialmente reversível, progressivo e incapacitante. Assim, os objetivos do estudo foram caracterizar os idosos com diagnóstico de DPOC nos estádios I a IV, atendidos no Ambulatório de Pneumologia Geral do HCFMRP/USP, segundo as variáveis sociodemográficas, história de tabagismo e condição de saúde; identificar o grau de independência funcional; identificar a presença de sintomas de depressão; analisar a correlação entre o grau de independência funcional, idade, número de morbidades, tempo e grau de DPOC e a associação entre a presença de sintomas de depressão, as variáveis sociodemográficas, o grau de DPOC e as comorbidades. Trata-se de um estudo descritivo, transversal e correlacional. A coleta dos dados ocorreu no período de março a maio de 2010. Utilizou-se um instrumento para caracterização da amostra, a Medida da Independência Funcional (MIF) e a Escala de rastreamento de sintomas depressivos (CES-D). Foram estudados 84 idosos, média de idade 70,4 anos (s=7,3); 61,9% homens; 51,2% casados; 36,9% viúvos; 36,9% sabiam ler e escrever informalmente/analfabetos; 82,8% eram aposentados; 73,2% recebiam um salário mínimo; 54,8% moravam com a família; 75% deixaram de fumar, 20,2% ainda fumavam e 4,8% nunca fumaram; a carga tabágica foi superior para os homens, sendo a diferença significativa (p<000,1); 100% tinham DPOC, 51,2% pressão alta, 39,3% problemas para dormir e 33,3 problemas cardíacos; a média de morbidades foi de 3,4(s=2,4); 41,7% referiram internação nos últimos 12 meses; 34,5% por exacerbação da DPOC e 34,3% por pneumonia. Houve predomínio da DPOC nos estádios III (40,5%) e II (35,7%), verificou-se prevalência de homens (79,5%) no estádio III e de mulheres (56,7%) no II; os homens apresentaram níveis de DPOC mais elevados que as mulheres, sendo a diferença estatisticamente significativa (p=0,05); tempo médio de DPOC foi 8,3 anos (s=6,4). O escore médio da MIF total foi 117,0 pontos; 96,4% com nível de Independência completa/modificada; a correlação de Pearson entre número de morbidade e MIF (total e motora) foi inversa e significativa (p=0,02). A CES-D classificou 71,4% com sintomas de depressão. Houve diferenças significativas entre presença de sintomas de depressão e as variáveis, sexo (p=0,01), estado conjugal (p=0,02) e problemas para dormir (p=0,01). O estudo revelou que a maioria dos idosos apresentava independência completa/modificada e presença de sintomas de depressão. Apesar de não ter encontrado diferenças significativas na correlação entre os escores da MIF e as variáveis, idade, tempo e grau de DPOC, bem como entre a associação de sintomas depressivos com idade, grau de DPOC e comorbidades, os resultados são relevantes para discussões entre os profissionais da área da saúde, uma vez que a identificação correta de fatores que podem influenciar no tratamento, reabilitação e qualidade de vida do idoso com DPOC torna efetiva as praticas assistenciais voltadas para as necessidades dos mesmos. / The demographic and epidemiological transformations of the previous century brought significant sociodemographic and health changes, globally, with an increase of the elderly population. The aging process can be associated to non transmissible chronic diseases, among them the chronic obstructive pulmonary disease (COPD), which is a partially reversible, progressive and debilitating public health problem. Thus, this descriptive, cross-sectional and correlational study aimed to characterize the elderly with diagnosis of COPD at stages I to IV, who receive care at the Outpatient Clinic of General Pneumology of the Hospital das Clínicas of the University of São Paulo at Ribeirão Preto Medical School (HCFMRP/USP), according to sociodemographic variables, history of smoking and health conditions; to identify the degree of functional independence; to identify the presence of symptoms of depression; to analyze the correlation among the degree of functional independence, age, number of morbidities, time and stage of COPD and the association between the presence of symptoms of depression, the sociodemographic variables, the stage of COPD and the comorbidities. Data collection was carried out between March and May 2010. An instrument was used for the characterization of the sample, as well as the Measure of Functional Independence (MFI) and the Center for Epidemiologic Studies Depression Scale (CES-D). In total, 84 elderly adults were studied, with average age of 70.4 years (sd=7,3); 61.9% men; 51.2% married; 36.9% widower; 36.9% could read and write and were informally illiterate; 82.8% were retired; 73.2% received one minimum wage monthly; 54.8% lived with the family; 75% quit smoking, 20.2% still smoked and 4.8% never smoked; the tobacco load was higher for men, with significant difference (p<0.001); 100% had COPD, 51.2% had high blood pressure, 39.3% problems to sleep and 33.3 heart problems; the average of reported morbidities was 3.4 (sd=2.4); 41.7% reported being hospitalized in the last 12 months; 34.5% for aggravation of COPD and 34.3% pneumonia. There was predominance of COPD at stages III (40.5%) and stage II (35.7%), with prevalence of men (79.5%) at stage III and women (56.7%) at stage II; men presented higher levels of COPD than women, with statistically significant difference (p=0.05); average time of COPD was 8.3 years (sd=6.4). The average score of total MIF was 117.0 points; 96.4% with level of complete/altered independence; Person correlation between number of morbidity and MIF (total and motor) was inverse and significant (p=0.02). CES-D classified 71.4% of the participants with symptoms of depression. There were significant differences between the presence of symptoms of depression and the variables gender (p=0.01), marital status (p=0.02) and problems to sleep (p=0.01). The study revealed that most elderly adults presented complete/altered independence and presence of symptoms of depression. Although there were no significant differences between the correlation of the scores of MIF and the variables age, time and stage of COPD, as well as the association of depressive symptoms with age, stage of COPD and comorbidities, results are relevant for discussions among health professionals, once the correct identification of factors that can influence on the treatment, rehabilitation and quality of life of the elderly with COPD make care practices targeting the needs of the elderly more effective.

Introdução: Medidas baseadas no relato dos pacientes vêm sendo incorporadas de forma crescente como parâmetros adicionais na avaliação das intervenções e na decisão por modalidades de tratamento. Um dessas medidas é a avaliação da Qualidade de Vida Relacionada à Saúde (QVRS). Nos diversos estudos de QVRS em DPOC constata-se a predominância daqueles que avaliaram a influência de fatores clínicos relacionados à função pulmonar. Objetivos: Avaliar a QVRS de pacientes com DPOC e analisar a influência de fatores clínicos e sóciodemográficos e de bem-estar espiritual, na QVRS desses pacientes. Método: Foram entrevistados 70 pacientes atendidos em um ambulatório de pneumologia. Os dados foram coletados utilizando-se três instrumentos: uma ficha de caracterização dos pacientes, a Escala de Bem Estar Espiritual (EBE), contendo um componente religioso (BER) e um existencial (BEE), e o Saint George Respiratory Questionnaire (SGRQ), composto pelos domínios Sintomas, Atividades e Impactos. A regressão linear múltipla, método backward, foi a estratégia utilizada para identificação dos fatores associados à QVRS. Resultados: Os pacientes eram homens, em sua maioria, tinham em média 64,24 anos (dp =10,22), baixo nível de escolaridade e de renda, católicos, ex-fumantes, com alta carga tabágica e com DPOC grave ou muito grave. Os escores do SGRQ indicaram má QVRS, principalmente em função das limitações na atividade física (média de 72%, dp=15). No domínio Sintomas, a média foi de 65% (dp= 18), de 57% (dp=19) no domínio Impactos e de 63% (dp=15) no escore total. A EBE mostrou um alto nível de bem-estar espiritual, com maior contribuição do componente religioso, o escore total foi de 94,87 (dp= 13,56), 51,50 (dp =8,68) para o domínio religioso e 43,37 (dp=6,76) para o existencial. Nas analises multivariadas, as variáveis de maior influência na QVRS foram: a escolaridade, presente nos modelos finais dos três domínios e no total do SGRQ (valores de -15,15 em sintomas, -10,75 em atividade, -19,33 em impactos e -44,20 no escore total) ; presença de comorbidades ( -9,00) , trabalho atual ( -12,22), BER ( 0,41) e BEE (-0,88) no domínio Atividade; tempo de DPOC ( 0,61) , no domínio Sintomas e carga tabágica ( -0,131) no domínio Impactos, para o escore total, trabalho atual ( -36,59), presença de comorbidades ( -17,88), BER ( 1,30) e BEE ( -1,94). Conclusão: Os resultados deste estudo reforçam a importância de considerar fatores como a escolaridade, o trabalho, a presença de comorbidades, a religiosidade e a espiritualidade na assistência integral aos pacientes com DPOC, visando proporcionar-lhes uma melhor qualidade de vida. / Introduction: Patient Report Outcomes are being increasingly incorporated as additional parameters in the evaluation of interventions and decision for treatment modalities. One of these measures is the evaluation of Health Related Quality of Life (HRQOL). In several studies of HRQOL in COPD patients there is a predominance of evaluating the influence of clinical factors related to lung function. Objectives: This study aimed to evaluate the HRQOL of COPD patients and analyze the influence of sociodemographic, clinical and spiritual well being factors, on patients HRQOL. Method: We interviewed 70 patients treated on a pulmonology outpatient. Data were collected using three instruments: a form of patients characterization, the Saint George Respiratory Questionnaire (SGRQ), comprising Symptoms, Activities and Impacts domains, and Spiritual Well-Being Scale (SWBS), which includes a religious component (RWB) and an existential (EWB). Multiple linear regression, backward method, was the strategy chose to identify associated factors with HRQOL. Results: The patients were majority men, had an average of 64.24 years (SD = 10.22), low education and income, Catholics, former smokers, with high smoking load and severe or very severe COPD. The SGRQ scores indicated poor HRQOL, mainly due to limitations in physical activity (average of 72%, sd = 15). In the Symptoms domain the average was 65% (sd = 18), 57% (sd = 19) in the Impacts domain and of 63% (sd = 15) in the total score. The SWBS showed a high level of spiritual well-being (total score of 94.87, sd = 13.56), with major contribution of religious component, the 51.50 (sd = 8.68) for the religious domain and 43.37 (sd = 6.76) to the existential one. In multivariate analysis, the variables that influenced HRQOL were: schooling, present in the final model of the three domains and SGRQ total (values of -15.15 in Symptoms, -10.75 in Activities, -19 in Impacts, and -44.20 in total score); comorbidities presence ( -9.00), current job ( -12.22), RWB ( 0.41) and EWB (-0, 88) in Activities area; duration of COPD ( 0.61) in Symptoms; tobacco intake ( -0.131) in Impacts and current job ( -36.59), comorbidities presence ( -17.88 ), RWB ( 1.30) and EWB ( -1.94) in total score. Conclusion: The results of this study reinforce the importance of considering factors such as education, employment, presence of comorbidities, religion and spirituality in comprehensive care to patients with COPD in order to provide them a better quality of life.

Introdução. Em todo o mundo, a proporção de pessoas com 60 anos ou mais está crescendo mais rapidamente que a de qualquer outra faixa etária. Com o envelhecimento da população, as doenças crônicas passaram a representar uma expressiva e crescente demanda aos serviços de saúde no Brasil, evidenciando a necessidade de se conhecer sua prevalência. As doenças pulmonares crônicas (DPC) afetam as vias aéreas inferiores e outras estruturas pulmonares, comprometendo milhões de pessoas. Algumas destas doenças são progressivamente incapacitantes, provocam vários sintomas e freqüentes exacerbações que interferem na qualidade de vida de seus portadores. Considerando que são esperados aumentos na prevalência e mortalidade da doença nas próximas décadas, o estudo de sua prevalência entre idosos na realidade brasileira se faz necessário Objetivo. Esta pesquisa é parte do Estudo SABE (Saúde, Bem-estar e Envelhecimento) e tem por objetivo de verificar a prevalência de DPC entre os idosos residentes no Município de São Paulo e investigar a sua associação com capacidade funcional/ mobilidade, tabagismo e óbito. Metodologia. O presente estudo baseou-se na amostra de idosos portadores e não-portadores de DPC em 2000 (n = 2.137) e re-entrevistados em 2006 (n = 1.113), correspondendo a uma amostra expandida de 834.287 em 2000 e de 473.764 idosos em 2006. Resultados. A prevalência das DPC foi de 42,55por cento ., maior percentual de idosos do sexo masculino, em faixas etárias mais avançadas (75 anos e mais), com baixa escolaridade, sem renda suficiente para manutenção das necessidades diárias mínimas e que moravam acompanhados. As condições gerais de saúde dos idosos portadores de DPC revelam que: ocorrência de idosos com baixo peso (IMC<25), mais predominante entre os homens; pior avaliação do próprio estado de saúde; maior redução de atividades básicas e instrumentais de vida diária, mais evidente entre as mulheres. Homens e mulheres portadores de DPC estiveram mais vezes internados quando comparados a idosos nãoportadores da doença. Além do maior número de internações, o tempo de permanência no hospital também foi maior entre portadores de DPC. Idosos portadores mais velhos (75 e mais) relataram maior número de consultas médicas. Finalmente em relação aos óbitos, portadores de DPC apresentaram razão de chance de óbito de 1,88 (OR ajustado, IC: 1,23 2,88) e 2,29 (OR, IC: 1,65 3,18) vezes maior quando comparado a nãoportadores da doença, independente dos demais fatores analisados (tabagismo, sexo, faixa etária, renda suficiente, presença de co-morbidades). Conclusão. Os dados indicam que a DPC aumenta com a idade, sendo mais alta nos homens do que nas mulheres. Idosos portadores de DPC tiveram mais internações e maior período de permanência em hospitais. Na análise de sobrevida verificou-se que portadores de DPC têm menor sobrevida independentemente de sexo, faixa etária e presença de multimorbidades. Os dados obtidos neste estudo sugerem a necessidade de aprofundamento no estudo das DPC / Introduction. Worldwide, the amount of people aged 60 or over is growing faster than any other age group. With the aging of the population chronic diseases now represent a significant and growing demand for health services in Brazil, highlighting the need to know its prevalence. Chronic pulmonary diseases (DPC) affect millions of peoples lower airways and other lung structures. Bronchial asthma and chronic pulmonary obstructive disease are chronic lung diseases that affect thousands of people. Some of these diseases are progressively debilitating, causing various symptoms and frequent exacerbations that worsen the quality of life of the patients. Whereas are expected increases in the prevalence and mortality from this disease in the coming decades, as well, the study of its prevalence among elderly in Brazilian reality is necessary. Goal. This survey is part of the study SABE (Health, well-being and aging) to verify the prevalence of CPD among elderly residents in the municipality of São Paulo and investigate the association with functional capacity/mobility, smoking, deaths. Methodology. This study was based on the sample of elderly people and non-carriers of CPD in 2000 (n = 2,137) and re-interviewed in 2006 (n = 1,113), corresponding to an expanded sample of 834,287 elderly in 2000 and of 473,764 in 2006. Results. The prevalence of CPD was 42.55per cent ; the greatest percentage in male, over 75 years old, low schooling, enough income to maintain the minimum daily needs and who lived together. General health of the elderly people with CPD reveal that: predominance of underweight elderly (BMI < 25) more prevalent among men; worst assessment of own State of health; further reduction of basic and instrumental activities of daily living, most evident among women. Women and men holders of CPD were hospitalized more often compared to elderly non-carriers of the disease. As well as the largest number of admissions, the residence time in the hospital was also higher among people with CPD. Oldest patients (75 and more) reported a greater number of medical consultations. Finally in relation to deaths, persons with CPD in the present study showed odds ratio of death of 1.88 (OR adjusted, CI: 1,23 2,88) e 2,29 (OR, CI: 1,65 3,18) times higher when compared to non-carriers of the disease, regardless of other factors analyzed (smoking, sex, age, sufficient income, presence of comorbidity). Conclusion. The data indicate that the CPD increases with age, being higher in men than in women, Elderly people with DPC had more hospitalizations and longer period of stay in hospitals. Analysis of survival were bearers of DPC have lower survival, and regardless of sex, age and the presence of multimorbidity. The data obtained in this study suggest the need for deeper study of DPC

A characteristic feature of Chronic Obstructive Pulmonary Disease (COPD) is an abnormal inflammatory response in the lungs to inhaled particles or gases. The ability to assess and monitor this response in the lungs of COPD patients is important for understanding the pathogenic mechanisms, but also provides a measure of the activity of the disease. Disease activity is more likely to relate to lung inflammation rather than the degree of airflow limitation as measured by the FEV1. Preliminary studies have shown the 18F fluorodeoxyglucose positron emission tomography (18F FDG-PET) signal, as a measure of lung inflammation, is quantifiable in the lungs and is increased in COPD patients compared to controls. However, the methodology requires standardisation and any further enhancement of the methodology would improve its application to assess inflammation in the lungs. I investigated various methods of assessing FDG uptake in the lungs and assessed the reproducibility of these methods, and particularly evaluated whether the data was reproducible or not in the COPD patients (smokers and ex-smokers). This data was then compared with a group of healthy controls to assess the role of dynamic 18F FDG-PET scanning as a surrogate marker of lung inflammation. My data showed a good reproducibility of all methods of assessing FDG lung uptake. However, using conventional Patlak analysis, the uptake was not statistically different between COPD and the control group. Encouraging results in favour of COPD patients were nonetheless shown using compartmental methods of assessing the FDG lung uptake, suggesting the need to correct for the effect of air and blood (tissue fraction effect) when assessing this in a highly vascular organ like the lungs. A prospective study analysis involving a bigger cohort of COPD patients would be desirable to investigate this further.

Asthma is a chronic lung inflammatory disease that causes inflammation and narrowing of the airways. Swelling of the airways can be caused by the activation of cytokines that lead to an inflammatory or allergenic-like response. Environmental factors, both indoors and outdoors, have been found to increase the likelihood of asthma in children. Among those found to impact disease are air pollutants such as ozone, nitric dioxide, and particulate matter, as well as home exposures, like cockroaches and rodents. Those who have multiple or increased exposure to these pollutants are more likely to experience exacerbated symptoms and uncontrolled asthma. There currently is no cure for asthma, but effective therapies have been found to treat the symptoms associated with asthmatic episodes. During an asthma attack, due to narrowing of the airways, individuals experience wheezing, chest tightness, and even shortness of breath. To combat these occurrences, physicians use inhaled corticosteroids (ICS), Beta-agonist, or a combination of both to relieve symptoms. In the United States asthma affects 25.8 million people. This number is projected to increase as the US continuously becomes more industrialized and as environmental conditions deteriorate. Research conducted by the Center for Disease Control concluded that the prevalence of asthma increased amongst the general population, however, once the data were disaggregated by race, age, gender, and SES significant increases were noted amongst some groups but not others. Most notably, on average, children, women, Puerto Ricans, and people living in poverty as defined by federal guidelines had the highest asthma prevalence. Chronic diseases like asthma also produce substantial burdens on the healthcare system. Asthmatics on average require three-times as many prescriptions, twice as many emergency room visits and four-times as many hospitalizations as individuals without asthma in the same demographic population. Additionally, when an expenditure analysis was carried out, it revealed that children with asthma cost approximately three-times more per capita per child than adolescents without asthma. Chronic disease occurs over the duration of individual lives. Thus, poorly managed, they will cause preventable increases in disability-adjusted-life years, premature death, and health care expenditure for both the individual and the broader healthcare system. The observed increases will predominantly impact the indicated high-risk populations. The prevalence of asthma in urban settings was anticipated by researchers based on known environmental influences. However, the discovery of a higher prevalence and mortality rate of asthma within impoverished communities, in comparison to other urban communities, is not yet fully understood. Through this research an association between high-risk populations with uncontrolled asthma and a lack of patient education, low socioeconomic status, and utilization of Medicaid insurance was found, which indicates the influence of these factors on asthma control. Improving current asthma interventions by remodeling them to take a broader stance on asthma prevention, treatment and maintenance and through acknowledgement of the impact disparities, asthma will likely be better controlled for all individuals in the Unites States.

The purpose of this dissertation was to evaluate the biological, behavioral, and psychosocial attributes of individuals diagnosed with chronic obstructive pulmonary disease (COPD). Specific aims were to: 1) explore the predictive power of spirometry measures for event-free survival in patients with heart failure and suspected COPD, focusing on the differences in survival between those with and without airflow limitation; 2) examine the psychometric properties of the Multidimensional Scale of Perceived Social Support (MSPSS) in patients with concomitant COPD and heart failure; and 3) test the efficacy of a theory-based, multidimensional, self-care educational intervention using an eHealth platform on measures of symptom severity and variability, anxiety and depressive symptoms, perceived self-care ability, perceived self-care adherence, and selfcare information needs (knowledge) in a sample of adult patients with stable COPD. Specific aim one was addressed by evaluation of the predictive power of spirometry measures (forced expiratory volume/second [FEV1], forced vital capacity [FVC], and the ratio of FEV1/FVC) for event-free time to combined hospitalization/mortality after controlling for clinical and sociodemographic variables. This analysis revealed that those patients with airflow limitation were 2.2 times more likely to experience hospitalization/mortality compared to those without airflow limitation. The second specific aim was addressed with a psychometric evaluation of the Multidimensional Scale of Perceived Social support (MSPSS) which included determination of internal consistency reliability, the factor structure and construct validity by hypothesis testing in participants with comorbid COPD and heart failure. The MSPSS was a valid and reliable instrument to measure perceived social support in patients with comorbid COPD and heart failure. The third specific aim was addressed by a trial of an eHealth educational intervention in participants with COPD (N = 20). This intervention resulted in significant change in symptom severity evaluation in patients categorized as having medium symptom severity for the following symptoms: distress due to cough, chest tightness, dyspnea with activity and fatigue; these symptoms were perceived as more severe in the intervention period. Anxiety, depressive symptoms and perceived self-care ability were unchanged; however, perceived self-care adherence scores improved, and knowledge needs were significantly reduced after the intervention.

There is notable heterogeneity in clinical presentation of patients with chronic obstructive pulmonary disease (COPD). Classification of COPD is usually based on the severity of airflow limitation (pre- and post- bronchodilator FEV1), which may not sensitively differentiate subpopulations with distinct phenotypes. A recent advance of quantitative medical imaging and data analysis techniques allows for deriving quantitative computed tomography (QCT) imaging-based metrics. These imaging-based metrics can be used to link structural and functional alterations at multiscale levels of human lung. We acquired QCT images of 800 former and current smokers from Subpopulations and Intermediate Outcomes in COPD Study (SPIROMICS). A GPU-based symmetric non-rigid image registration method was applied at expiration and inspiration to derived QCT-based imaging metrics at multiscale levels. With these imaging-based variables, we employed a machine learning method (an unsupervised clustering technique (K-means)) to identify imaging-based clusters. Four clusters were identified for both current and former smokers. Four clusters were identified for both current and former smokers with meaningful associations with clinical and biomarker measures. Results demonstrated that QCT imaging-based variables in patients with COPD can derive statistically stable and clinically meaningful clusters. This sub-grouping can help better categorize the disease phenotypes, ultimately leading to a development of an efficient therapy.

Previous researchers have identified that participation in a pulmonary rehabilitation program improves health outcomes yet, continuation in a weekly maintenance program yielded mixed results. Self-management programs have had reported use in chronic obstructive pulmonary disease (COPD). A meta analysis has identified that no self-management program had evaluated the effect of this type of intervention on the functional status of the participant with COPD. Reduced functional status is well reported as an indicator of disease progression in COPD. Adjuvant therapies for people with COPD need to demonstrate an effect in this domain. The Stanford model chronic disease self-management program (CDSMP) had been reported as a program that may optimise the health of people with chronic health conditions. However, its utility has not been formally evaluated for people with COPD. There have not been any reports of a comparison of the Stanford model CDSMP with pulmonary rehabilitation via a randomised controlled study in COPD. Aim: To compare and evaluate the health outcomes from participation in nurse ledwellness-promoting interventions conducted in the ambulatory care setting of a metropolitan hospital. Participants were randomised to either a six-week behavioural intervention: the Stanford model CDSMP or, a six-week pulmonary rehabilitation program and results compared to usual care (a historical control group). The efficacy of the interventions was measured at week seven and repeated at week 26 and 52. Following the week seven evaluation, the pulmonary rehabilitation program participants were rerandomised to usual care or, weekly maintenance pulmonary rehabilitation for 18 weeks and, followed up until the study completion at week 52.Little is reported about the costs of care for people with COPD in Australia. This study prospectively evaluated the costs of the interventions and health resource for the 52 weeks and undertook a cost utility analysis. Methods: Walking tests (The Incremental Shuttle Walking Test) and questionnaires asking participants about their health related quality of life, mood status, dyspnoea and self efficacy were assessed prior to randomisation to either six week intervention and repeated at weeks 7, 26 and 52. The implementation of these adjuvant therapies enabled all costs associated with the interventions to be prospectively examined and compared. Results: During the two years of recruitment 252 people (54% males) with a mean age 71 years (SD 11, range 39-93 years) were referred to the study. Student’s ttests identified that there were no statistically significant differences (P=0.16) between all those referred by age and gender as compared to all those admitted to Hospital A with an exacerbation of COPD. Ninety-seven people (51% male) with a mean age of 68 years (SD 9, range 39-87 years) agreed to participate in the study. Follow up in the study continued for 12 months following enrolment with only a modest level of attrition by week seven (3%) and week 52 (25%). Following the six-week interventions, both the pulmonary rehabilitation and CDSMP groups recorded statistically significant increases in functional capacity, self-efficacy and health related quality of life.Functional performance was additionally evaluated in the intervention arms with participants wearing pedometers for the six-week period of the interventions. There were no statistically significant differences between steps per week (P=0.15) and kilometres per week (P=0.17) walked between these two groups in functional performance. The Spearman rho statistic identified no statistically significant relationship between functional performance and the severity of COPD (rs (33) = 0.19, P = 0.26). No significant correlation between functional capacity and functional performance was identified (rs (32) = 0.19, P = 0.29). This suggests that other factors contribute to daily functional performance. The largest cost of care for people with COPD has been reported to be unplanned admissions due to an exacerbation of COPD.In this study there were no statistically significant differences between the three intervention groups in the prospective measurement of ambulatory care visits, Emergency Department presentations and admissions to hospital. The calculation of costs illuminated the costs of care in COPD are greater than the population norm. In addition, maintenance pulmonary rehabilitation generated a greater quality adjusted life year (QALY) than a six-week program. Despite the strength of the participants preferences (as measured by the QALY) for maintenance PRP, there were no significant differences in use of hospital resources throughout the study period by the three intervention groups, which suggests some degree of equivalence.

The overall aim of this work was to examine the effects of depleted nutritional status on some aspects of Chronic Obstructive Pulmonary Disease (COPD). Morbidity. In paper І, we found that energy intake was lower than the calculated energy demand for all patients. A low body mass index (BMI) at inclusion and weight loss, during the one year follow-up period were independent risk factors for having a new exacerbation (p = 0.003 and 0.006, respectively). Mortality. Nineteen percent of the patients in paper ІІ, where underweight (BMI&lt;20). A significant positive correlation was found between BMI and FEV1, and this correlation remained significant after adjustment for age, sex and pack years (p&lt;0.0001). Being underweight was related to increased overall mortality and respiratory mortality but not to mortality of other causes, 19% of the patients had died within 2 years. The lowest mortality was found among the overweight patients (BMI 25-30 kg/m). Physical capacity and effect of training. In paper ІІІ we investigated baseline characteristics of patients that were starting physical training. We found that peak working capacity was positively related to BMI (r=0.35, p=0.02) and fat free mass index (FFMI) (r=0.49, p=0.004) and negatively related to S-Fibrinogen and serum C reactive protein (S-CRP). BMI and FFMI were significantly related to the 12 minutes walking distance when adjusted for body weight. Fifty to 76% of the variation in physical capacity was accounted for when age, gender, FEV1, FFMI and CRP were combined in a multiple regression model. In Paper ІV the median change in fat free mass (FFM), after 4 months of physical training was 0.5 kg. Old age, low FEV1 and high level of dyspnoea were independent negative predictors of FFM increase after the training period. In conclusion nutritional status is an important determinant of morbidity, mortality and physical capacity in COPD. Low FEV1 and high level of dyspnea are negative predictors for increased FFM after physical training.

Sammanfattning Bakgrund Kronisk obstruktiv lungsjukdom orsakas ofta av rökning, vilket anses av de flesta vara en självförvållad sjukdom. Konsekvenserna av detta blir att patienter med KOL ofta upplever skuld och skamkänslor. Syfte Syftet med denna litteraturstudie är att beskriva patienters erfarenhet av skuld och skam vid kronisk obstruktiv lungsjukdom. Metod I litteraturstudien granskades åtta vetenskapliga artiklar för att få en kunskap om patienternas känslor kring sin sjukdom. Innehållsanalys användes med ett deduktivt förhållningssätt där data bearbetades för att identifiera mönster och teman. Resultat Två huvudkategorier; skuld och skam var från början definierade och under analysen identifierades en tredje; stigmatisering. Dessa kunde senare delas in i tre olika nivåer; individ, familj/omgivning och sjukvård. Konklusion Denna studie ger sjuksköterskan en bättre förståelse för vilka känslor som kan uppstå vid en ofta självförvållad sjukdom som KOL. Den visar också vikten av att möta patienterna med empati, respekt och höja deras känsla av värdighet och moral.