ASSESS THE CLINICAL USAGE OF NEBULIZATION THERAPY AND ANTIBIOTICS IN IN-PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE: A RANDOMIZED PROSPECTIVE STUDY AT A TERTIARY CARE TEACHING HOSPITAL
Table 12: Changes in O2 Saturation Before and After Nebulization therapy in COPD (%)
Figure 11: Line Presentation Of Changes In O2 Saturation Before And After Nebulization In COPD (%)
Table 13: One-Sample Statistics of SpO2 with O2
Table 14: One-Sample Statistics of SpO2 with out O2
Among the study population, 94 individuals had effect on SpO2 levels whereas 8 individuals had no effect on SpO2 levels. 92% of individuals responde in a positive way after the nebulization therapy with oxygen therapy provided to them, as their SpO2 levels with oxygen therapy changed to normal range.
The rationality of prescription was evaluated by using the WHO core drug Prescribing indicators which was developed and published by WHO and INRUD (Quick JD et al., 1997). It resulted as the average number of drugs per encounter were found to be 11 drugs.
• Percentage encounters with an Antibiotic was 25.2%.
• Percentage of encounters with an Injection was 30.3%.
• Percentage of encounters with Nebulizers was 17.7%.
Thus, it was found to be irrational use of the drugs as two drugs per encounter is the rational use of drugs as per Prescription studies.
The age group between 21-90 years were admitted during the period of study. The age group between 21-30 years were found to be 4% where as in the study conducted previously only above 40 years of age were admitted during their period of study. The majority of patients were between 71-80 years age group (30%).
The sex wise distribution resulted that majority of the patients was of male sex which was as high as 84%. The females accounted for around 16%. Male to female ratio observed in our study is 5:1. This confirms the finding of the previous study conducted that males accounted for the majority of the disease burden which was as high as 87.5% (Sajesh Kalkandi Veettil et al., 2014).
The Alcoholic status distribution resulted that majority of the patients were Non-Alcoholic 73% and Alcoholics accounted for around 27%.
As per the survey done in the previous study, the common risk factors into focus were smoking, alcoholism and tobacco consumption. It was seen that 37% of the patients had smoking status (Maryam Mahmoodan et al., 2017). Where as In present study, the smokers accounted for around 41% and non-smokers accounted for 59% making smoking as a potential risk hazard for COPD patients.
In present study, the culture sensitivity test was performed in COPD patients. Among the study population, 24% were positive towards culuture sensitivity test, Out of which Candida Albicans was found in 6 patients (25%) and Klbesiella Pneumonia was found in 18 patients (75%). Whereas Candida albicans (16%) and Pseudomonas aeruginosa (4.6%) were the most common microorganisms isolated from sputum samples in previous study (Aswathy Unni et al., 2015).
Since, COPD requires extensive treatment, different classes of drugs used in the treatment were also assessed in the present study. Among them, Bronchodilators were mostly prescribed (96%). When compared to the study conducted by Maryam Mahmoodan et.al, our results were not in accordance, as the use of Corticosteroids was higher in that study (21.9%). Deriphylline was the most prescribed methylxanthine (13.9%).
Among the combination therapies, salbutamol with ipratropium bromide was the most preferred combination (96%). Where in previous studies salbutamol with ipratropium bromide combination was used in 54% of the cases. Salbutamol with ipratropium bromide was mostly preferred in older patients as it prevents cardiovascular complications and also one can avoid high doses of β2-agonist drugs (Maryam Mahmoodan et al., 2017).
Antibiotics were used in 92.1% of patients which may be an indicator of the prevalence of infections among the patients admitted with acute exacerbation of COPD in different demographic areas (Sajesh Kalkandi Veettil et al., 2014). The most commonly used antibiotic is Magnex Forte accounting for about 41.1%.
Corticosteroids remain a standard of care for Acute exacerbation of COPD, secondary to their documented efficacy in improving air flow and gas exchange (increasing FEV1 and PaO2) as well as improving dyspnea, hasten recovery, and reducing length of hospitalization and rate of relapse at 30 days. In the previous study, the Systemic Corticosteroids are efficacious in the treatment of COPD and is considered as the standard care for COPD patients (Woods JA et al., 2014). The Corticosteroids accounted for about 66.6% which included the IV injection of Hydrocortisone and relatively the same percentage of Prednisolone. Therefore in our study, the use of Systemic Corticosteroid is used as an additional therapy to treat COPD along with different medications.
The majority of the drugs are taken as Orals than the Inhalers, Nebulizers and Injections which accounted for 53%, 2%, 12% and 33% respectively. In the previous study the most preffered Route of Administration is Injections, and they state that, the possible reason for the use of high amount of injectables could be beliefs and attitudes of patients and physicians about the high efficacy of injections as compared to oral medications (Dr. R. Kothai et al., 2017). The use of Nebulization therapy was preferred over Inhalational therapy as the formulation of Nebulizers account around 12% and Inhalers around 2%. Despite several known drawbacks associated with Nebulized therapy it is recommended that maintenance therapy with Nebulizers should employed in elderly patients and those with physical (or) cognitive limitations (Dhand R et al., 2012) as it is easy to use and results in a positive manner than Inhalational therapy.
Majority of the patients in the study had co-morbid conditions accounting for about 67% and patients without co-morbid conditions accounted for 33% where in the previous study 55% of the patients presented with COPD alone and 45% of patients presented COPD along with certain co-morbidities (Maryam Mahmoodan et al., 2017). The most commonly observed co-morbid condition was Hypertension. The other co-morbid conditions found were Diabetes Mellitus, Congestive Cardiac Failure, Alcoholic Hepatitis, Acute Renal Failure etc.
In the previous study, there was no significant change in the SpO2 levels before and after the ODN was given (Wu WW et al., 2014). In the present study, there was a significant difference between the value of SpO2 with O2 and SpO2 without O2. The levels of SpO2 with the oxygenation were changed in the normal range after the Nebulization therapy was given.
In our present study we performed a Randomized, Prospective and Observational study on patient cohort in Gleneagles Global Hospital to evaluate the following:
• The Observational study was conducted in 102 patients to assess the efficacy of Nebulization and Antibiotic therapy in COPD patients. During the study, the SpO2 levels were monitored and recorded as the parameter to assess the efficacy of the Nebulization therapy. After the study, it was founded that 92% of individuals showed a positive response to the Nebulization therapy as their SpO2 levels recovered in the normal ranges.
• During study, the culture sensitivity test was performed in COPD patients. Among the study population, 24% were positive towards culture sensitivity test, Out of which Candida Albicans was found in 6 patients (25%) and Klbesiella Pneumonia was found in 18 patients (75%).
• Poverty and illiteracy lead to increase number of COPD patients as they use OTC and Non-Pharmacological methods to avoid the economic burden of hospitals. During the study, we counseled the patients and provided some knowledge about the disease so as to avoid irrational use of drugs and increase risk of COPD.
• Further study can be done using Spirometry as a diagnostic tool. The study related to adverse effects, associated with prescribed drugs, for treating COPD can be done for optimization of the therapy.
• Duolin belonging to the class of Bronchodilator was found to be the most commonly used Nebulizer in COPD patients. Magnex Forte which is a combinational antibiotic was most commonly used Antibiotic in In-patients with COPD.
• The Alcoholic status distribution resulted that majority of the patients were Non-Alcoholic 73% and Alcoholics accounted for around 27% smokers accounted for around 41% and non-smokers accounted for 59% making smoking as a potential risk hazard for COPD patients.
Thus from our study we have concluded that the Nebulization therapy had more clinical improvements. The addition of corticosteroids had decreased the patient stay in hospital. Antibiotics added to the treatment decreased the frequency of exacerbations. The patient should be educated about the rational use of the drug to decrease risk of COPD.
1. Albert RK., Connett J., Bailey WC., Casaburi R., Cooper JA Jr., Criner GJ., Curtis JL., Dransfield MT., Han MK., Lazarus SC., Make B., Marchetti N., Martinez FJ., Madinger NE., McEvoy C., Niewoehner DE., Porsasz J., Price CS., Reilly J., Scanlon PD., Sciurba FC,. Scharf SM., Washko GR., Woodruff PG. and Anthonisen NR (2011); Azithromycin for prevention of exacerbations of COPD; N Engl J Med; 365(8); 689-98.
2. Anthonisen NR., Connett JE., Kiley JP., Altose MD., Bailey WC., Buist AS., Conway WA Jr., Enright PL., Kanner RE. and O'Hara P (1994); Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study; JAMA; 272(19); 1497-505.
3. Anthonisen NR., Manfreda J., Warren CP., Hershfield ES., Harding GK. and Nelson NA (1987); Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease; Ann Intern Med;106(2); 196-204.
4. Aswathy Unni., Akshaya K Jayaprakash., Yadukrishnan Mc. and Uma Devi P (2015); Drug Utilization Pattern In Chronic Obstructive Pulmonary Disease Inpatients At A Tertiary Care Hospital; International Journal of Pharmacy and Pharmaceutical Sciences; 7(11); 389-391.
5. Barbara G. Wells., Joseph T. DiPiro., Terry L. Schwinghammer. and Cecily V. DiPiro (2009), “Chronic Obstructive Pulmonary Disease”, in Dennis M. Williams and Sharya V. Bourdet, Handbook of Pharmacotherapy-A Pathophysiologic Approach, McGraw-Hill, New York, pp. 924-928.
6. Barbera JA., Reyes A., Roca J., Montserrat JM., Wagner PD. and Rodriguez-Roisin R (1992); Effect of intravenously administered aminophylline on ventilation/perfusion inequality during recovery from exacerbations of chronic obstructive pulmonary disease; Am Rev Respir Dis; 145(6); 1328-33.
7. Barnes PJ (2010); Chronic obstructive pulmonary disease: effects beyond the lungs; PLOS Med; 7(3); e1000220.
8. Barnes PJ (2014); Preface. Chronic obstructive pulmonary disease; Clin Chest Med; 35; xiii.
9. Behrendt CE (2005); Mild and moderate-to-severe COPD in nonsmokers. Distinct demographic profiles; Chest; 128; 1239-44.
10. Bianchi R., Gigliotti F., Romagnoli I., Lanini B., Castellani C., Grazzini M. and Scano G (2004); Chest wall kinematics and breathlessness during pursed-lip breathing in patients with COPD; Chest; 125(2); 459-65.
11. Bousquet J., Kiley J., Bateman ED., Viegi G., Cruz AA., Khaltaev N., Ait Khaled N., Baena-Cagnani CE., Barreto ML., Billo N., Canonica GW., Carlsen KH., Chavannes N., Chuchalin A., Drazen J., Fabbri LM., Gerbase MW., Humbert M., Joos G., Masjedi MR., Makino S., Rabe K., To T. and Zhi L (2010); Prioritised research agenda for prevention and control of chronic respiratory diseases; Eur Respir J; 36(5); 995–1001.
12. Boutin-Forzano S., Moreau D., Kalaboka S., Gay E., Bonnefoy X., Carrozzi L., Viegi G., Charpin D. and Annesi-Maesano I (2007); Reported prevalence and co-morbidity of asthma, chronic bronchitis and emphysema: a pan-European estimation; Int J Tuberc Lung Dis; 11(6); 695–702.
13. Burge S. and Wedzicha JA (2003); COPD exacerbations: definitions and classifications; Eur Respir J Suppl; 21(41s); 46s-53s.
14. Burrows B., Knudson RJ., Cline MG. and Lebowitz MD (1977); Quantitative relationships between cigarette smoking and ventilatory function; Am Rev Respir Dis; 115(2); 195-205.
15. Cazzola M. and Matera MG (2014); Bronchodilators: current and future; Clin Chest Med; 35(1); 191–201.
16. Cazzola M. and Page C (2014); Long-acting bronchodilators in COPD: where are we now and where are we going?; Breathe; 10; 110 20.
17. Celli BR. and MacNee W (2004); Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper; Eur Respir J; 23(6); 932-46.
18. Celli BR., Halbert RJ., Isonaka S. and Schau B (2003); Population impact of different definitions of airway obstruction; Eur Respir J; 22(2); 268-73.
19. Celli BR., Halbert RJ., Nordyke RJ. and Schan B (2005); Airway obstruction in never smokers: results from the Third National Health and Nutrition Examination Survey; Am J Med; 118(2); 1364-72.
20. Chapman KR (2004); Chronic obstructive pulmonary disease: are women more susceptible than men?; Clin Chest Med; 25(2); 331-41.
21. Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation; Chest 1999; 116(2); 521-34.
22. Davies L., Angus RM. and Calverley PM (1999); Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial; Lancet; 354(9177); 456-60.
23. Definition and classification of chronic bronchitis for clinical and epidemiological purposes. A report to the Medical Research Council by their Committee on the Aetiology of Chronic Bronchitis; (1965); Lancet; 1(7389); 775-779.
24. deKoning HW., Smith KR. and Last JM (1985); Biomass fuel combustion and health; Bull World Health Organ; 63(1); 11-26.
25. Dhand R., Dolovich M., Chipps B., Myers TR., Restrepo R. and Farrar JR (2012); The role of nebulized therapy in the management of COPD: evidence and recommendations COPD; 9(1); 58-72.
26. Diaz-Guzman E. and Mannino DM (2014); Epidemiology and prevalence of chronic obstructive pulmonary disease; Clin Chest Med; 35(1); 7–16.
27. Dr. R. Kothai., Dr. Rangabashayan., Dr. B. Arul., Punniya Mariam Sunny., Reshma R. Nair. and Rinku Eliza Mathew (2017); Analysis Of Prescribing Pattern Of COPD Patients In A Tertiary Care Hospital Salem; World Journal Of Pharmacy And Pharmaceutical Sciences; Issue 6(10);1111-1117.
28. Elliott MW., Adams L., Cockcroft A., MacRae KD., Murphy K. and Guz A (1991); The language of breathlessness. Use of verbal descriptors by patients with cardiopulmonary disease; Am Rev Respir Dis; 144(4); 826-32.
29. Fein A. and Fein AM (2000); Management of acute exacerbations in chronic obstructive pulmonary disease; Curr Opin Pulm Med; 6(2); 122–126.
30. Fishman A., Martinez F., Naunheim K., Piantadosi S., Wise R., Ries A., Weinmann G. and Wood DE (2003); A randomized trial comparing lung-volume reduction surgery with medical therapy for severe emphysema; N Engl J Med; 348(21); 2059-2073.
31. Georgopoulas D. and Anthonisen NR (1991); Symptoms and signs of COPD. In: Cherniack NS, ed. Chronic obstructive pulmonary disease. Toronto; WB Saunders Co; 357-63.
32. Halbert RJ., Isonaka S., George D. and Iqbal A (2003); Interpreting COPD prevalence estimates: what is the true burden of disease?; Chest; 123(5); 1684-1692.
33. Halbert RJ., Natoli JL., Gano A., Badamgarav E., Buist AS. and Mannino DM (2006); Global burden of COPD: systematic review and meta-analysis; Eur Respir J; 28(3); 523-32.
34. Hill AT., Bayley D. and Stockley RA (1999); The interrelationship of sputum inflammatory markers in patients with chronic bronchitis; Am J Respir Crit Care Med; 160(3); 893-8.
35. Hnizdo E., Glindmeyer HW., Petsonk EL., Enright P. and Buist AS (2006); Case Definitions for Chronic Obstructive Pulmonary Disease; J COPD; 3(2); 95-100.
36. International Institute of Population Sciences (IIPS) and Macro International (2007); National Family Health Survey NFHS-3, 2005-2006: India: Volume II, Mumbai: IIPS 2007.
37. Jarvis S., Ind PW. and Shiner RJ (2007); Inhaled therapy in elderly COPD patients: time for re-evaluation?; Age Ageing; 36(2); 213-218.
38. Jemal A., Ward E., Hao Y. and Thun M (2005); Trends in the leading causes of death in the United States, 1970-2002; JAMA; 294(10); 1255-1259.
39. Jindal SK., Aggarwal AN., Chaudhry K., Chhabra SK., D'Souza GA., Gupta D., Katiyar SK., Kumar R., Shah B. and Vijayan VK (2006); A multicentric study on epidemiology of chronic obstructive pulmonary disease and its relationship with tobacco smoking and environmental tobacco smoke exposure; Indian J Chest Dis Allied Sci; 48(1); 23-29.
40. Lightowler JV., Wedzicha JA., Elliott M. and Ram FS (2003); Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis; BMJ; 326(7382); 185.
41. Liu S., Zhou Y., Wang X., Wang D., Lu J., Zheng J., Zhong N. and Ran P (2007); Biomass fuels are the probable risk factor for chronic obstructive pulmonary disease in rural South China; Thorax; 62(10); 889–897.
42. Lopez AD., Shibuya K., Rao C., Mathers CD., Hansell AL., Held LS., Schmid V. and Buist S (2006); Chronic obstructive pulmonary disease; current burden and future projections; Eur Respir J; 27(2):397-412.
43. Loveridge B., West P., Kryger MH. and Anthonisen NR (1986); Alteration in breathing pattern with progression of chronic obstructive pulmonary disease; Am Rev Respir Dis; 134(5); 930-4.
44. Lozano R., Naghavi M., Foreman K, et al. (2012); Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010; Lancet; 380 (9859): 2095-128.
45. MacNee W (2005); Pulmonary and systemic oxidant/antioxidant imbalance in chronic obstructive pulmonary disease; Proc Am Thorac Soc; 2(1); 50-60.
46. Mannino DM. and AS Buist (2007); Global burden of COPD: risk factors, prevalence, and future trends; Lancet; 370(9589); 765–773.
47. Mary Anne Koda-Kimble., Lloyd Yee Young., Brian K. Alldredge., Robin L. Corelli., B. Joseph Guglielmo., Wayne A. Kradjan. and Bradley R. Williams (2005), “Chronic Obstructive Pulmonary Disease”, in Philip T. Diaz and Daren L. Knoell, Textbook of Applied Therapeutics-The Clinical Use of Drugs, Lippincott Williams & Wilkins, Maryland, USA, pp. 23-1.
48. Mary Anne Koda-Kimble., Lloyd Yee Young., Brian K. Alldredge., Robin L. Corelli., B. Joseph Guglielmo., Wayne A. Kradjan. and Bradley R. Williams (2005), “Chronic Obstructive Pulmonary Disease”, in Philip T. Diaz and Daren L. Knoell, Textbook of Applied Therapeutics-The Clinical Use of Drugs, Lippincott Williams & Wilkins, Maryland, USA, pp. 23-1, 23-2.
49. Mary Anne Koda-Kimble., Lloyd Yee Young., Brian K. Alldredge., Robin L. Corelli., B. Joseph Guglielmo., Wayne A. Kradjan. and Bradley R. Williams (2005), “Chronic Obstructive Pulmonary Disease”, in Philip T. Diaz and Daren L. Knoell, Textbook of Applied Therapeutics-The Clinical Use of Drugs, Lippincott Williams & Wilkins, Maryland, USA, pp. 23-2 to 23-6.
50. Maryam Mahmoodan., N. M. Mahesh. and Bandenawaz Ramdurga (2017); Drug Utilization Evaluation In Chronic Obstructive Pulmonary Disease Patients; Der Pharmacia Lettre; 9(6]; 142-151.
51. McCloskey SC., Patel BD., Hinchliffe SJ., Reid ED., Wareham NJ. and Lomas DA (2001); Siblings of patients with severe chronic obstructive pulmonary disease have a significant risk of airflow obstruction; Am J Respir Crit Care Med; 164 (8 Pt 1); 1419-24.
52. Menezes AM., Perez-Padilla R., Jardim JR., Muino A., Lopez MV., Valdivia G., Montes de Oca M., Talamo C., Hallal PC. and Victora CG (2005); Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): a prevalence study; Lancet; 366(9500); 1875-81.
53. Morbidity & Mortality: Chart book on Cardiovascular, Lung, and Blood Diseases. Bethesda, MD: US Department. of Health and Human Services, Public Health Service, National Institutes of Health; (1998).
54. Murray CJ. and Lopez AD (1997); Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study; Lancet; 349(9064); 1498-504.
55. Murray CJL. and Lopez AD (1996); The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA; Harvard University Press.
56. National Institute for Clinical Excellence (NICE) (2004); Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care; Thorax; 59 Suppl 1; 1-232.
57. Niewoehner DE., Erbland ML., Deupree RH., Collins D., Gross NJ., Light RW., Anderson P. and Morgan NA (1999); Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group; N Engl J Med; 340(25); 1941-7.
58. O'Driscoll BR., Kay EA., Taylor RJ., Weatherby H., Chetty MC. and Bernstein A (1992); A long-term prospective assessment of home nebulizer treatment; Respir Med; 86(4); 317–25.
59. O'Driscoll R (1991); Home nebulized therapy: is it effective?; Respir Med; 85(1); 1–3.
60. P Moayyedi., J Congleton., R L Page., S B Pearson. and M F Muers (1995); Comparison of nebulised salbutamol and ipratropium bromide with salbutamol alone in the treatment of chronic obstructive pulmonary disease; Thorax; 50(8); 834-837.
61. Paolo Montuschi (2006); Pharmacological treatment of chronic obstructive pulmonary disease; Int J Chron Obstruct Pulmon Dis; 1(4); 409–423.
62. Pauwels RA., Buist AS., Calverley PM., Jenkins CR. and Hurd SS (2001); GOLD Scientific Committee. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary; Am. J. Respir. Crit. Care Med; 163(5); 1256–76.
63. Pellegrino R., Viegi G., Brusasco V., Crapo RO., Burgos F., Casaburi R., Coates A., van der Grinten CP., Gustafsson P., Hankinson J., Jensen R., Johnson DC., MacIntyre N., McKay R., Miller MR., Navajas D., Pedersen OF. and Wanger J (2005); Interpretative strategies for lung function tests; Eur Respir J; 26(5); 948-68.
64. Postma DS. and Siafakas N (1998); Epidemiology of chronic obstructive pulmonary disease. Management of Chronic Obstructive Pulmonary Disease; Eur Respir; 7; 41–73.
65. Prasad R., Singh A., Garg R. and Giridhar GB (2012); Biomass fuel and respiratory disease in India; Biosci Trends; 6(5); 219-228.
66. Quick JD., Rankin JR., Laing RO., O’Connor RW., Hogerzeil HV., Dukes MNG. and Garnett A (1997); Managing drug supply. 2nd ed; West Hartford, CT, Kumarian Press.
67. Reddy KS., Shah B., Varghese C. and Ramadoss A (2005); Responding to the threat of chronic diseases in India; Lancet; 366(9498); 1744-1749.
68. Robert L. Talbert., Gary C. Yee., Gary R. Matzke., Joseph T. Dipiro., Cecily V. Dipiro., Barbara G. Wells. and L. Michael Posey (2008), “Chronic Obstructive Pulmonary Disease”, in Dennis M. Williams and Sharya V. Bourdet, Textbook of Pharmacotherapy-A Pathophysiologic Approach, McGraw-Hill, New York, pp. 502-513.
69. Roberts CM., Bugler JR., Melchor R., Hetzel MR. and Spiro SG (1993); Value of pulse oximetry in screening for long-term oxygen therapy requirement; Eur Respir J; 6(4); 559-62.
70. Roberts SD., Farber MO., Knox KS., Phillips GS., Bhatt NY., Mastronarde JG. and Wood KL(2006); FEV1/FVC ratio of 70% misclassifies patients with obstruction at the extremes of age; Chest; 130(1); 200-206.
71. Rodriguez-Roisin R (2000); Toward a consensus definition for COPD exacerbations; Chest; 117(5 Suppl 2); 398S-401S.
72. Saint S., Bent S., Vittinghoff E. and Grady D (1995); Antibiotics in chronic obstructive pulmonary disease exacerbations. A meta-analysis; JAMA; 273(12); 957–960.
73. Sajesh Kalkandi Veettil., Kingston Rajiah. and Suresh Kumar (2014); Study of Drug Utilization Pattern for Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Patients Attending a Government Hospital in Kerala, India; J Family Med Prim Care; 3(3); 250–254.
74. Salvi S. and Agarwal A (2012); India needs a national COPD prevention and Control program; J Assoc Physicians India; 60Suppl; 5-7.
75. Salvi S. and Barnes PJ (2009); Chronic obstructive pulmonary disease in non smokers; Lancet; 374(9691); 733-743.
76. Salvi S. and Barnes PJ (2010); Is exposure to biomass smoke the biggest risk factor for COPD globally?; Chest; 138(1); 3-6.
77. Schellevis FG., Van de Lisdonk EH., Van der Velden J., Hoogbergen SH., Van Eijk JT. and Van Weel C (1994); Consultation rates and incidence of intercurrent morbidity among patients with chronic disease in general practice; Br J Gen Pract; 44(383); 259-62.
78. Schols AM., Soeters PB., Dingemans AM., Mostert R., Frantzen PJ. and Wouters EF (1993); Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation; Am Rev Respir Dis; 147(5); 1151-6.
79. Shohaimi S., Welch A., Bingham S., Luben R., Day N., Wareham N. and Khaw KT (2004); Area deprivation predicts lung function independently of education and social class; Eur Respir J; 24; 157–161.
80. Simon PM., Schwartzstein RM., Weiss JW., Fencl V., Teghtsoonian M. and Weinberger SE (1990); Distinguishable types of dyspnea in patients with shortness of breath; Am Rev Respir Dis; 142(5); 1009-14.
81. Soriano JB., Visick GT., Muellerova H., Payvandi N. and Hansell AL (2005); Patterns of comorbidities in newly diagnosed COPD and asthma in primary care; Chest; 128(4); 2099-107.
82. Soriano JR., Maier WC., Egger P., Visick G., Thakrar B., Sykes J. and Pride NB (2000); Recent trends in physician diagnosed COPD in women and men in the UK; Thorax; 55(9); 789-94.
83. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. American Thoracic Society; (1995); Am J Respir Crit Care Med; 152(5 pt 2); S77–121.
84. Sterk PJ (2004); Let's not forget: the GOLD criteria for COPD are based on post-bronchodilator FEV1; Eur Respir J; 23(4); 497-498.
85. Stoller JK. and Aboussouan LS (2005); Alpha1-antitrypsin deficiency; Lancet; 365(9478); 2225-36.
86. Tirimanna PR., van Schayck CP., den Otter JJ., van Weel C., van Herwaarden CL., van den Boom G., van Grunsven PM. and van den Bosch WJ (1996); Prevalence of asthma and COPD in general practice in 1992: has it changed since 1977?; Br J Gen Pract; 46(406); 277-81.
87. US Surgeon General. The health consequences of smoking: chronic obstructive pulmonary disease. Washington, D.C. US Department of Health and Human Services; (1984).
88. van den Boom G., van Schayck CP., van Mollen MP., Tirimanna PR., den Otter JJ., van Grunsven PM., Buitendijk MJ., van Herwaarden CL. and van Weel C (1998); Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program; Am J Respir Crit Care Med; 158(6); 1730-8.
89. Voelkel NF. and Tuder R (2000); COPD: exacerbation; Chest; 117(5 suppl 2); S376–379.
90. Woods JA., Wheeler JS., Finch CK. and Pinner NA (2014); Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease; Int J Chron Obstruct Pulmon Dis; 4(9); 421-430.
91. World Health Organization. (2008), “World Health Statistics”, available at: http://www.who.int/whosis/whostat/2008/en/index.html.
92. Wu WW., Hong HH., Shao XP., Rui L., Jing M. and Lu GD (2014); Effect of oxygen-driven nebulization at different oxygen flows in acute exacerbation of chronic obstructive pulmonary disease patients; Am J Med Sci; 347(5); 343-6.
93. Xu X., Weiss ST., Rijcken B. and Schouten JP (1994); Smoking, changes in smoking habits, and rate of decline in FEV1: new insight into gender differences; Eur Respir J; 7(6); 1056-61.
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