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Chronic Obstructive Pulmonary Disease (COPD) is defined by the Global initiative for chronic Obstructive Lung Disease (GOLD) as a common preventable and treatable disease, which is characterized by a persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response of the airways and lungs to noxious particles or gases. Since 2010, COPD is globally the third leading cause of death. Each year, approximately 200 000 to 300 000 people die in Europe because of COPD. The morbidity, economic and social impact of COPD is substantial and increasing.2 Among respiratory diseases, COPD is the leading cause of lost work days and it has an estimated cost of 3 to 4% (or 38.6 billion €) of the total health care budget in the European Union.

AIM OF DATABASE: The Danish Register of Chronic Obstructive Pulmonary Disease (DrCOPD) is a nationwide database aiming to describe the quality of treatment of all patients with chronic obstructive pulmonary disease (COPD) in Denmark. STUDY POPULATION: DrCOPD comprises data on all patients with a diagnosis of COPD. In the hospital setting, both in- and outpatients are included. In the setting of the general practice (GP), DrCOPD aims to include all patients with a COPD diagnosis who attend an annual control visit for COPD. MAIN VARIABLES: DrCOPD includes information on forced expiratory volume in 1 second, smoking status, body mass index, dyspnea, treatment modalities such as rehabilitation, smoking cessation, medical treatment, and the use of noninvasive ventilation during hospitalization due to exacerbations. The outcome variables include frequency of readmission and death 30 days after discharge from hospital. DESCRIPTIVE DATA: Since 2008, the registration in the Danish hospitals has gradually become more comprehensive. In 2014, ~90% of 16,106 eligible patients had complete data sets that showed an improvement in the processes describing quality of care, including increased offering of smoking cessation, rehabilitation, and correct treatment with inhaled medication. Data from GPs have been included since 2011, but are still incomplete and comprise only ~20% of all COPD patients seen. The collection of data from GP settings has recently been hampered due to legislative controversies. CONCLUSION: In relatively few years, DrCOPD has become increasingly comprehensive and has documented an improvement in the management of COPD in Danish hospitals.

AIM OF DATABASE: The Danish Register of Chronic Obstructive Pulmonary Disease (DrCOPD) is a nationwide database aiming to describe the quality of treatment of all patients with chronic obstructive pulmonary disease (COPD) in Denmark. STUDY POPULATION: DrCOPD comprises data on all patients with a diagnosis of COPD. In the hospital setting, both in- and outpatients are included. In the setting of the general practice (GP), DrCOPD aims to include all patients with a COPD diagnosis who attend an annual control visit for COPD. MAIN VARIABLES: DrCOPD includes information on forced expiratory volume in 1 second, smoking status, body mass index, dyspnea, treatment modalities such as rehabilitation, smoking cessation, medical treatment, and the use of noninvasive ventilation during hospitalization due to exacerbations. The outcome variables include frequency of readmission and death 30 days after discharge from hospital. DESCRIPTIVE DATA: Since 2008, the registration in the Danish hospitals has gradually become more comprehensive. In 2014, ~90% of 16,106 eligible patients had complete data sets that showed an improvement in the processes describing quality of care, including increased offering of smoking cessation, rehabilitation, and correct treatment with inhaled medication. Data from GPs have been included since 2011, but are still incomplete and comprise only ~20% of all COPD patients seen. The collection of data from GP settings has recently been hampered due to legislative controversies. CONCLUSION: In relatively few years, DrCOPD has become increasingly comprehensive and has documented an improvement in the management of COPD in Danish hospitals.

Peter Lange,1,2 Sandra Søgaard Tøttenborg,1 Anne Dichmann Sorknæs,3 Jørgen Steen Andersen,4 Mette Søgaard,5 Henrik Nielsen,5 Reimar Wernich Thomsen,5 Katrine Abildtrup Nielsen6 1Section of Social Medicine, Department of Public Health, University of Copenhagen, 2Lung Diseases Department, Respiratory Medicine Section, Lung Diseases Department, Hvidovre Hospital, University of Copenhagen, Copenhagen, 3Medical Department, Odense Universitetshospital–Svendborg Hospital, Svendborg, 4Danish College of General Practitioners, Copenhagen, 5Department of Clinical Epidemiology, Aarhus University Hospital, 6Registry Support Centre of Clinical Quality and Health Informatics (West), Århus, Denmark Aim of database: The Danish Register of Chronic Obstructive Pulmonary Disease (DrCOPD) is a nationwide database aiming to describe the quality of treatment of all patients with chronic obstructive pulmonary disease (COPD) in Denmark. Study population: DrCOPD comprises data on all patients with a diagnosis of COPD. In the hospital setting, both in- and outpatients are included. In the setting of the general practice (GP), DrCOPD aims to include all patients with a COPD diagnosis who attend an annual control visit for COPD. Main variables: DrCOPD includes information on forced expiratory volume in 1 second, smoking status, body mass index, dyspnea, treatment modalities such as rehabilitation, smoking cessation, medical treatment, and the use of noninvasive ventilation during hospitalization due to exacerbations. The outcome variables include frequency of readmission and death 30 days after discharge from hospital. Descriptive data: Since 2008, the registration in the Danish hospitals has gradually become more comprehensive. In 2014, ~90% of 16,106 eligible patients had complete data sets that showed an improvement in the processes describing quality of care, including increased offering of smoking cessation, rehabilitation, and correct treatment with inhaled medication. Data from GPs have been included since 2011, but are still incomplete and comprise only ~20% of all COPD patients seen. The collection of data from GP settings has recently been hampered due to legislative controversies. Conclusion: In relatively few years, DrCOPD has become increasingly comprehensive and has documented an improvement in the management of COPD in Danish hospitals. Keywords: chronic obstructive pulmonary disease, quality of care, exacerbations, register

Chronic obstructive pulmonary disease (COPD) has a profound impact on people living with the disease and has a high global economic and social burden. Often, people with COPD are undiagnosed, while those diagnosed are undertreated and undereducated on different aspects of COPD care. Although there are many published evidence-based treatment guidelines from different expert groups and societies, they are frequently not adhered to, which results in significant gaps in care. In particular, 'flare-ups' (known as exacerbations of COPD), which accelerate disease progression, are often under-reported, despite guidelines recommending an escalation of maintenance treatment to prevent subsequent flare-ups. Management of COPD should be proactive to prevent worsening of symptoms and to reduce the risk of future flare-ups and premature death, rather than a secondary reaction to a worsening health status. Key to this is patient access to accurate diagnosis, effective treatment and specialist care, which can vary widely due to socioeconomic differences, geographical locations and poor guideline implementation. In addition, the stigma associated with COPD can act as a barrier, which can result in people being reluctant to access treatment or clinicians being nihilistic. As global patient advocates, we have co-developed this patient charter to set a standard of care that people living with COPD should expect, raising awareness and understanding of the causes and consequences of COPD as well as the potential to improve patient care. Patients with COPD should be empowered to live the highest quality of life possible with the least number of flare-ups. We set out six principles in line with current COPD guideline recommendations, that should be implemented by governments, healthcare providers, policymakers, lung health industry partners and patients/caregivers to drive meaningful change in COPD care.

Approximately 50% of the people with COPD are not aware of having the disease. However, the prevalence of COPD is increasing. COPD threatens to become the third leading cause of death in Europe by 2020. This dissertation focusses on a short questionnaire with the ability to detect COPD aimed at people over forty. That is important, as the reduction in lung capacity in patients diagnosed with COPD can be limited and health care costs will eventually be lower, as previously conducted research has shown. When the general practitioner offers active assistance, twice as many patients fill in this questionnaire. This also goes for disadvantaged areas. It was found that the percentage of patients who smoked was very high, and so was their motivation to stop smoking. Politicians and policymakers should be asked to financially support the infrastructure, allowing COPD patients to be detected earlier.

Hyeon-Kyoung Koo,1 Sung-Woo Park,2 Jeong-Woong Park,3 Hye Sook Choi,4 Tae-Hyung Kim,5 Hyoung Kyu Yoon,6 Kwang Ha Yoo,7 Ki-Suck Jung,8 Deog Kyeom Kim9 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Republic of Korea; 2Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, Bucheon, Republic of Korea; 3Department of Pulmonary and Critical Care Medicine, Gachon University, Gil Medical Center, Incheon, Republic of Korea; 4Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea; 5Division of Pulmonary and Critical Care Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea; 6Department of Internal Medicine, The Catholic University of Korea, Yeouido St Mary's Hospital, Seoul, Republic of Korea; 7Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea; 8Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea; 9Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea Background and purpose: Chronic cough can be a dominant symptom of chronic obstructive pulmonary disease (COPD), although its clinical impact remains unclear. The aim of our study was to identify phenotypic differences according to the presence of chronic cough or sputum and evaluate the impact of chronic cough on the risk of acute exacerbation of COPD (AECOPD). Methods: In a nationwide COPD cohort including 1,613 COPD patients, patients with chronic cough only, those with sputum only, those with chronic bronchitis (CB), and those without cough and sputum were compared with regard to dyspnea, lung function, quality of life (QoL), and risk of AECOPD. Results: The rates of chronic cough, chronic sputum, and both were 23.4%, 32.4%, and 18.2%, respectively. Compared with patients without chronic cough, those with chronic cough exhibited a lower forced expiratory volume in 1 second (% predicted) and diffusing capacity of the lungs for carbon monoxide (% predicted), more frequent AECOPD, more severe dyspnea, and worse QoL. Pulmonary function, dyspnea severity, and QoL worsened in the following order: without cough or sputum, with sputum only, with cough only, and with CB. Multivariate analyses revealed chronic cough as an independent risk factor for a lower lung function, more severe dyspnea, and a poor QoL. Moreover, the risk of future AECOPD was significantly associated with chronic cough (odds ratio 1.56, 95% CI 1.08–2.24), but not with chronic sputum. Conclusion: Our results suggest that chronic cough should be considered as an important phenotype during the determination of high-risk groups of COPD patients. Keywords: pulmonary disease, chronic obstructive, cough, exacerbation, severity

"In diesem Beitrag beschäftigen wir uns mit einem innovativen Mixed-Methods-Ansatz zur Bewertung der positiven und problematischen Effekte eines Rehabilitationsprogramms, das eine verbesserte Lebensqualität von Patient/innen mit chronisch obstruktiver Lungenerkrankung zum Ziel hatte. Hierzu führten wir 2012 drei Konsultationsworkshops in West-Wales durch mit Patient/innen, die an einem solchen Programm teilgenommen hatten, deren Angehörigen und mit Professionellen, die in dem Programm tätig gewesen waren. Die Resonanz war vergleichsweise enthusiastisch, sowohl was Inhalte und was den Impact des Programms angeht, und zwar vor allem mit Blick auf eine vermehrte Aktivität der Patient/innen, auf deren Kontrollgefühl, Zuversicht und Bereitschaft einer verbesserten Selbstfürsorge sowie ein erhöhtes Zusammengehörigkeitsgefühl. Sieben Schlüsselthemen konnten als besonders relevant für die Untersuchungsteilnehmer/innen herausgearbeitet werden: die Patient/innen, physische Gesundheit, psychische Gesundheit, das Programm, Professionale und Angehörige, Wissen und Bildung sowie die Zukunft. Ausgehend hiervon entwickelten wir einen Best-Practice-Vorschlag für die Konzeption und Durchführung von Folgeprogrammen und -Dienstleistungen." (Autorenreferat)

Tina Riegels-Jakobsen1, Malene Skouboe1, Jens Dollerup2, Christian Buus Andersen2, Louise Barkan Staal1, Rolf BH Jakobsen1, Peter Bo Poulsen21Department of Health Prevention and Promotion, Municipality of Esbjerg, Esbjerg, 2Medical and Access, Pfizer Denmark, Ballerup, DenmarkAbstract: Up to 436,000 adult Danes suffer from chronic obstructive pulmonary disease (COPD), with only one third diagnosed at this time. The Danish National Board of Health recommends early detection of COPD, focusing on smokers/ex-smokers over 35 years of age with at least one lung symptom. A governmental prevention committee has suggested that the municipalities, in addition to general practice, should be a potential arena responsible for early detection of COPD. We undertook a pilot study to investigate the feasibility and effectiveness of early detection of COPD in municipalities following the recommendations of the Danish National Board of Health.Methods: The Municipality of Esbjerg offered spirometry to Danish citizens at risk of COPD without a previous diagnosis of the disease, following the National Board of Health's recommendations. Citizens with evidence of airway obstruction (forced expiratory volume in one second [FEV1]/forced vital capacity [FVC] <70%) were advised to visit their general practitioner for diagnosis. These citizens were followed up by telephone interview 3 months later.Results: Of 152 citizens sampled (50% females, mean age 58 years, 51% smokers) 51.3% had evidence of airway obstruction, with 87% being mild to moderate in terms of severity. Seven of ten citizens (71%) then visited their general practitioner, with 85% of these being diagnosed with COPD. The number of smokers embarking on smoking cessation or quitting smoking increased following COPD screening, with the highest frequency in participants with evidence of airway obstruction.Conclusion: In addition to early detection of COPD in general practice, early detection of airway obstruction in defined risk populations in Danish municipalities seems feasible and effective for identifying new patients with COPD. However, additional research is needed in larger samples to confirm the results of the present study.Keywords: chronic obstructive pulmonary disease, screening, spirometry, smoking cessation

Young Ho Jung,1* Doh Young Lee,2* Dong Wook Kim,1 Sung Soo Park,3 Eun Young Heo,3 Hee Soon Chung,3 Deog Kyeom Kim3 1Department of Otorhinolaryngology-Head and Neck Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, 2Department of Otorhinolaryngology-Head and Neck Surgery, Anam Hospital, Korea University Medical Center, 3Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea *These authors contributed equally to this work Background: Although chronic obstructive pulmonary disease (COPD) is closely associated with gastroesophageal reflux disease (GERD), the clinical significance of laryngopharyngeal reflux (LPR) is not fully understood in COPD.Methods: Prospective cohorts were established among 118 patients with COPD from March 2013 to July 2014. Thirty-two age-matched and sex-matched normal controls, who had routine health check-ups during the study period, were included. Laryngopharyngeal reflux finding scores (RFS) and reflux symptom index (RSI) for LPR were subjected to association analysis with severity and acute exacerbation of COPD during the 1-year follow-up.Results: The mean age of patients enrolled in the study was 69.2±8.8 years, with 93.2% being male. Positive RFS (>7) and RSI (>13) were observed in 51 (42.5%) and six patients (5.0%), respectively. RFS and RSI were significantly higher in patients with COPD than in normal, healthy patients (P<0.001). RFS was significantly correlated with residual volume/total lung capacity (%, P=0.048). Scores for diffuse laryngeal edema, erythema, and hyperemia were significantly higher in the high-risk group (Global Initiative for Chronic Obstructive Lung Disease classification C and D; P=0.025 and P=0.049, respectively), while RSI was significantly higher in the more symptomatic group (Global Initiative for Chronic Obstructive Lung Disease classification B and D; P=0.047). RSI and RFS were significant predictors for severe acute exacerbation of COPD (P=0.03 and P=0.047, respectively), while only RSI was associated with severity of dyspnea.Conclusion: Laryngeal examination and evaluation of laryngeal reflux symptom could be a surrogate clinical indicator related to severe acute exacerbation of COPD. Further studies of LPR in COPD patients should be considered. Keywords: COPD, acute exacerbation, laryngopharyngeal reflux, reflux symptom index, reflux finding scoreA Letter to the Editor has been received and published for this article

Research on the etiology of chronic pulmonary disease (COPD), an irreversible degenerative lung disease affecting 15% to 20% of smokers, has blossomed over the past half‐century. Profound new insights have emerged from a combination of in vitro and –omics studies on affected lung cell populations (including cytotoxic CD8+ T lymphocytes, regulatory CD4+ helper T cells, dendritic cells, alveolar macrophages and neutrophils, alveolar and bronchiolar epithelial cells, goblet cells, and fibroblasts) and extracellular matrix components (especially, elastin and collagen fibers); in vivo studies on wild‐type and genetically engineered mice and other rodents; clinical investigation of cell‐ and molecular‐level changes in asymptomatic smokers and COPD patients; genetic studies of susceptible and rapidly‐progressing phenotypes (both human and animal); biomarker studies of enzyme and protein degradation products in induced sputum, bronchiolar lavage, urine, and blood; and epidemiological and clinical investigations of the time course of disease progression. To this rich mix of data, we add a relatively simple in silico computational model that incorporates recent insights into COPD disease causation and progression. Our model explains irreversible degeneration of lung tissue as resulting from a cascade of positive feedback loops: a macrophage inflammation loop, a neutrophil inflammation loop, and an alveolar epithelial cell apoptosis loop. Unrepaired damage results in clinical symptoms. The resulting model illustrates how to simplify and make more understandable the main aspects of the very complex dynamics of COPD initiation and progression, as well as how to predict the effects on risk of interventions that affect specific biological responses.