Pulmonary rehabilitation (PR) is an important component of chronic obstructive pulmonary disease (COPD) management. Physician use of PR for patients with COPD lags behind national and international guideline recommendations.

In this article, we discuss the important components of PR, including exercise training, self-management education, and psychosocial and nutritional interventions, as based on the American Thoracic Society/European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We also discuss the potential benefits of PR, including reduction of respiratory symptoms, decreased disability, and increased participation in physical and social activities. Increased activity promotes independence, improves quality of life, and reduces the number of COPD exacerbations and hospitalizations. In all stages of COPD, PR has been shown to result in improved exercise tolerance, with reduced dyspnea and fatigue, although the greatest improvement has been seen in patients with GOLD stages II to IV. Pulmonary rehabilitation is now a well-recognized therapy that should be available to all patients with symptomatic COPD.

To facilitate inclusion of PR in COPD management, primary care physicians need to recognize and diagnose COPD, and regularly decide when PR best fits in an individual's COPD treatment program.

The rate of forced expiratory volume in 1 second (FEV1) decline ("beta") is a marker of chronic obstructive pulmonary disease risk. The reduction in beta after quitting smoking is an upper limit for the reduction achievable from switching to novel nicotine delivery products. We review available evidence to estimate this reduction and quantify the relationship of smoking to beta.

METHODS: Studies were identified, in healthy individuals or patients with respiratory disease, that provided data on beta over at least 2 years of follow-up, separately for those who gave up smoking and other smoking groups. Publications to June 2010 were considered. Independent beta estimates were derived for four main smoking groups: never smokers, ex-smokers (before baseline), quitters (during follow-up) and continuing smokers. Unweighted and inverse variance-weighted regression analyses compared betas in the smoking groups, and in continuing smokers by amount smoked, and estimated whether beta or beta differences between smoking groups varied by age, sex and other factors.

RESULTS: Forty-seven studies had relevant data, 28 for both sexes and 19 for males. Sixteen studies started before 1970. Mean follow-up was 11 years. On the basis of weighted analysis of 303 betas for the four smoking groups, never smokers had a beta 10.8 mL/yr (95% confidence interval (CI), 8.9 to 12.8) less than continuing smokers. Betas for ex-smokers were 12.4 mL/yr (95% CI, 10.1 to 14.7) less than for continuing smokers, and for quitters, 8.5 mL/yr (95% CI, 5.6 to 11.4) less. These betas were similar to that for never smokers. In continuing smokers, beta increased 0.33 mL/yr per cigarette/day. Beta differences between continuing smokers and those who gave up were greater in patients with respiratory disease or with reduced baseline lung function, but were not clearly related to age or sex.

CONCLUSION: The available data have numerous limitations, but clearly show that continuing smokers have a beta that is dose-related and over 10 mL/yr greater than in never smokers, ex-smokers or quitters. The greater decline in those with respiratory disease or reduced lung function is consistent with some smokers having a more rapid rate of FEV1 decline. These results help in designing studies comparing continuing smokers of conventional cigarettes and switchers to novel products.

During the 2009-2010 winter season, the new pandemic influenza A/H1N1 virus (S-OIV) was responsible for 1,334 hospitalized severe infection cases including 312 (23.4%) deaths in metropolitan France. In the Champagne-Ardenne area (north eastern) this new epidemic strain was detected in the respiratory samples of 14 severe S-OIV infection cases resulting in 5 deaths.

Here we report two of these 14 cases who were suffering from a bilateral pneumonia related to S-OIV infection and who were hospitalized in the Intensive Care Unit (ICU) of the Reims University Medical Centre during December 2009. These two patients were male with at least one known risk factor for severe S-OIV infection (chronic obstructive pulmonary disease (COPD) and morbid obesity, respectively); the COPD patient developed an acute respiratory distress syndrome. The etiological diagnosis of S-OIV infection was performed by use of a real time RT-PCR (rRT-PCR) assay allowing the detection of all the known human influenza A viruses (rRT-PCR targeting the influenza gene M) and of the new influenza A/H1N1 pandemic strain. This rRT-PCR assay was positive in bronchoalveolar lavage samples taken from the two patients, whereas the nasal swab (using Virocult® collection system) appeared to be positive for only one of them. For both patients, a presumptive treatment combining oseltamivir and broad-spectrum antibiotics was started at the time of hospital admission, 24 hours at least before obtaining the results of the virological and bacteriological analyses.

These two patients did not develop any secondary bacterial pneumonia and their clinical outcome was good after one and six weeks of hospitalization in ICU, respectively.

A combination of chronic obstructive pulmonary disease (COPD) and heart failure (HF) is common yet it is inadequately and rarely recognized. Because of the similar clinical manifestations, comorbidity is frequently not considered and appropriate diagnostic tests are not performed. It is very important that a combination of COPD and HF is recognized as these patients have a worse prognosis than patients with an individual disease.

When present, COPD should not prevent the use of life-saving therapy in patients with HF, particularly β-blockers. Despite clear evidence of the safety and tolerability of cardioselective β-blockers in COPD patients, these drugs remain grossly underprescribed and underdosed.

Routine spirometry and echocardiography in HF and COPD patients, respectively, is therefore warranted to improve current clinical practice.