Talk:Chronic obstructive pulmonary disease/Archive 1

Archive 1

Archive 2

This

This page could use some epidemilogy statistical information. — Preceding unsigned comment added by StudentNurse (talk • contribs) 23:01, 26 January 2006 (UTC)

This page is in an abysmal state, you are right. But the topic is huge and needs a WP:MCOTW. JFW | T@lk 23:57, 28 January 2006 (UTC)

Asthma

Is asthma a form of C.O.P.D.?

Is C.O.P.D. a form of asthma? — Preceding unsigned comment added by Alec - U.K. (talk • contribs) 17:10, 20 October 2006 (UTC)

Not strictly speaking. COPD is the combination of at least 2 chronic conditions, ones which don't allow much relief. Although asthma is somewhat chronic, a patient with asthma who developed Emphysema would not be classified as having COPD. The most common combination is Chronic Bronchitis and Emphysema. MattVickers 10:12, 18 January 2007 (UTC)

Estrogen and lung disease

Removed the following misleading paragraph and reference that violates WP:NOR:

Among people over 70 who have never smoked, women make up 85 percent of those with COPD. This appears to be tied to decreases in estrogen as women age. Female mice that had their ovaries removed to deprive them of estrogen lost 45 percent of their working alveoli from their lungs. Upon receiving estrogen, the mice recovered full lung function. Two proteins that are activated by estrogen play distinct roles in breathing. One protein builds new alveoli, the other stimulates the alveoli to expel carbon dioxide. Loss of estrogen hampered both functions in the test mice. (Massaro & Massaro, 2004).

Massaro D, Massaro GD (2004). Estrogen regulates pulmonary alveolar formation, loss, and regeneration in mice. Am J Physiol Lung Cell Mol Physiol. Dec; 287(6):L1154-9. PMID 15298854

Study of 16 mice. Says "about 85% of aged never smokers with COPD are women" citing:

Birring SS, Brightling CE, Bradding P, Entwisle JJ, Vara DD, Grigg J, Wardlaw AJ, Pavord ID. (2002) Clinical, radiologic, and induced sputum features of chronic obstructive pulmonary disease in nonsmokers: a descriptive study. Am J Respir Crit Care Med. Oct 15; 166(8):1078-83. PMID 12379551

Of 441 adults with airflow obstruction seen over 2 years in an outpatient respiratory clinic in Leicester, England, 101 were nonsmokers, of whom 44 had no bronchodilator reversibility, of whom 25 had no explainable cause and no response to a corticosteroid trial, of whom 22 were not found to have another lung disease--their ages ranged from 40 to 82, with a mean age of 70, and 19 (86%) of the 22 were women.

This is misleading. More women than men under and over 70 have never smoked, but:

Behrendt CE (2005). Mild and moderate-to-severe COPD in nonsmokers: distinct demographic profiles. Chest. Sep; 128(3):1239-44. PMID 16162712

NHANES III survey of 16,238 adults age 18-80, of whom 13,995 underwent spirometry, of whom 7,526 (63% female) were nonsmokers, of whom 464 had COPD (403 mild COPD, 61 moderate COPD, 31 severe COPD).

Results: Mild COPD is more prevalent among women nonsmokers under 60, but less prevalent among women nonsmokers over 70. Moderate-severe COPD is less prevalent among women nonsmokers of all ages.

Since there is no reliable source that says decreased estrogen causes COPD, including speculation about the possible clinical revelance of one study of 16 mice violates WP:NOR. 68.253.222.118 07:15, 21 October 2006 (UTC)

I agree that the COPD connection is spurious, but I reinserted the results of the Massaro mouse study into the estrogen article. Unless the study is not reproducible, we should report on it. AxelBoldt 15:41, 21 October 2006 (UTC)

Move to chronic obstructive pulmonary disease?

I don't think chronic obstructive pulmonary disease is "... almost exclusively known only by its acronym". Therefore, per WP:NAME#Prefer_spelled-out_phrases_to_acronyms and WP:NCA, I think the article ought to be named chronic obstructive pulmonary disease.

• Support as per above. Nephron  T|C 07:17, 18 January 2007 (UTC)

Rewrite

I've spent a bit of time rewriting this article (mainly from scratch) here. I think this is a big improvement on the current article, but let me know (or edit it) if I've missed anything major. --Scot^t 19:30, 4 February 2007 (UTC)

Overall I like it, far cleaner. I touched up a couple of sentences in your sandbox so that they're more readable in my opinion. The parts I think are missing are pulmonary rehabilitation, which needs at least a mention, and the 0 to IV classifications of severity which I think clarifies the diagnosis a little better. Edit: Mentioning some of the other conditions which fall under the COPD umbrella would be a good idea also. I don't have the information around at the moment, so can't do it myself. MattVickers 04:45, 5 February 2007 (UTC)

Thanks for reading it. I've added in the table for diagnosis and a bit (enough?) on rehab. Was struggling to find something on the other conditions which is why it's not there, would appreciate it if you could add in anything I've missed. --Scot^t 20:03, 5 February 2007 (UTC)

I like the additions. I know I have the information regarding other conditions of COPD around, I just need to dig it up. I'll add it in as soon as I can, along with anything that might be appropriate for the rehab part (I have references for that too), without going into inappropriate detail. MattVickers 07:22, 7 February 2007 (UTC)

Excellent! Do you think it's suitable to move over to replace the main article without those additions? --Scot^t 08:00, 7 February 2007 (UTC)

Article Comments

Hi,

I a live with COPD and I just want to correct yuo on one thing. The GOLD standard you refer to has changed and no longer has a stage 0 classification. See the GOLD site for reference.—Preceding unsigned comment added by 213.202.148.1 (talk • contribs) 22:05, 8 February 2007 (UTC)

Second rewrite

I have spent over 100 hours completely overhauling this article to be more comprehensive and be of use to a GP who needs a crash course in COPD with links to everything. It is also of use to laymen who want to know more about the risks of occupational exposure to a range of toxins. --Veganfanatic —Preceding undated comment added 21:51, 10 March 2007 (UTC).

Cured meats

Someone clearly read the BBC news item that cured meats vastly increase the COPD risk. This is based on PMID 17255565. While interesting, this should not be in the intro until confirmed in larger cohorts; it distracts from the simple message that most COPD is due to smoking. JFW | T@lk 11:45, 17 April 2007 (UTC)

URLs

Could whoever added all those references change them from PubMed URLs to real nice academic citations? The most effective way is with Dave Iberri's template filler. JFW | T@lk 18:50, 20 April 2007 (UTC)

I rewrote this article a while back (see above) and since then have sort of lost track of the large edits that have taken place. Perhaps I'm wrong, but it looks to my like a lot of the added information is not really related to COPD (at least, not by any definition I've ever found). If others agree, maybe it should be trimmed as well as fixing the refs? --Scot^t 20:19, 20 April 2007 (UTC)

Trim, trim, trim, and don't stop until sentences like this "Occupationally exposed workers to hazardous materials frequently develop lung disease(s)." have been erased! Mmoneypenny 08:53, 28 April 2007 (UTC)

I've made a start, not sure whether I've been a bit over-trimming. Will move onto the treatment section later, I think it just needs a restructure as most of it is pretty good. --Scot^t 16:17, 28 April 2007 (UTC)

Off-topic material should be removed. If you are not sure, just copy it to the talkpage and we will offer our comments. We should rely as much as possible on published guidelines (e.g. the GOLDCOPD 2006 guidelines, British Thoracic Society etc). All the rest is extra. JFW | T@lk 11:59, 1 May 2007 (UTC)

Pharmacotherapy

"Cromones are mast cell stabilizers that are thought to act on a chloride channel found on mast cells that help reduce the production of histamine and other inflammatory factors. Chromones are also thought to act on IgE-regulated calcium channels on mast cells. Cromoglicate and Nedocromil, which has a longer half-life, are two chromones available.[12]"

Sorry folks, Cromones have NO place in COPD therapy. They are strictly used for allergic conjunctivitis (opthalmic), asthma, and brochospasm prophylaxis (ie asthma attack). This section should be removed.

The person that posted that there is no Stage 0 is correct. There is no longer an "at risk" classification, and I altered the Very Severe to what the current classifications say. I did not delete the at-risk section yet.

We should also add flu shots and pneumovax to the treatment algorithm.

Leukotriene antagonists also have no place in COPD therapy. This needs to be removed. The algorithm goes: SABA => LAAC => LABA => Theo => ICS (if freq hospitalizations) => O2 tx 15 hrs per day. I realize now that acronyms may not make sense: Short acting beta agonist (albuterol), Long acting anti cholinergic (tiotropium...NOT ipratropium-which is short acting), Long acting Beta Agonist, Theophylline, Inhaled Corticosteroid, Oxygen therapy. [[TheAngriestPharmacist]] 04:53, 3 May 2007 (UTC)

By all means feel free to fix the treatment bits up. I've started to remove a lot of the irrelevant information, just haven't had time to finished it yet. --Scot^t 07:32, 3 May 2007 (UTC)

Exacerbations

Should there be a section on exacerbations? They are staged by cardinal symptoms (increase sputum volume, increased sputum purulence, and shortness of breath). 1 sx is mild, 2 is moderate, 3 is severe. They are usually caused by infections of Haemophilus influenzae, haemophilus parainfluenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Moderate and severe are treated with 7-10 days of antibiotic therapy (augmentin usually). [[TheAngriestPharmacist]] 05:09, 3 May 2007 (UTC)

There should be a VERY comprehensive section on exacerbations and how best to recognise them early and also how to avoid them. Especially for those who are most at risk of an exacerbation causing any serious further lung damage. --Phil Wardle (talk) 11:53, 17 July 2008 (UTC)

CAL as synonym for COPD

I haven't heard of CAL being used as a synonym for COPD. I've changed it back to COPD. Andrew73 16:18, 8 July 2007 (UTC)

-Dear Andrew, my apologies, CAL (Chronic Airway Limitation) is one of those frustrating new acronyms that are used which has replaced COPD. They all mean the same thing and this may seem trivial, but it is actually quite important. These days most UK, Australian and increasingly many more U.S. hospitals are using this as the 'default' title in place of COPD (or others) haha... Sorry to be fussy but I think it is very important to use up to date terms so that the article is easy to find and so that it uses the "correct" title. Whatever that means haha... best wishes, Tom H. (see http://www.abacci.com/wikipedia/topic.aspx?cur_title=Chronic_obstructive_pulmonary_disease, and http://www.ncahs.nsw.gov.au/chronic-disease/index.php?pageid=576&siteid=182, http://www.erj.ersjournals.com/cgi/content/abstract/10/1/114) Tom H. 03:11, 10 July 2007 (UTC)

This may reflect an American bias, but I think COPD is by far, much more widely used than CAL, and this should be reflected in the article. I've yet to hear of someone referring to COPD as CAL. Andrew73 11:34, 10 July 2007 (UTC

Hm yeah this is fair enough, but I think it is still perfectly legit to add it to the synonym list at the top - how about that for now at least? Tom H. 27th Aug

COPD is generally more widely used amoungst Respiratory units and lung function units in Australia. CAL is used and it is used by Respiratory Physicians, but the Pathologists prefer COPD. Most undergraduate pathology and physiology courses use the term COPD with only a very few referring to CAL as an alternate name. Stephen. 13:13 25 July 2007

I am actually hearing CAL used in many hospitals in Sydney, including St George, Liverpool, Sutherland, Prince of Wales and St Vincents. Most patient notes written by recent graduates in health sciences inc. phys. med. are using this term at the moment. Maybe it's just a brief trend but it's what I'm reading at the moment :) Ciao for now, Tom H. 27th Aug

Dear all -- can we please put CAL in as the synonym. This is a bit silly really. Many many textbooks use this. One particular stock standard (Talley and O'Connor's Clinical Examination, A Systematic Guide to Physical Diagnosis) for medical education uses it frequently. Tom H. 6th Nov, 07

Put it in as a synonym but don't let CAL predominate/rename article. My gran died of COPD, which is a disease that's been gaining increased public awareness for decades. I don't know how many non-doctors have ever heard of CAL, and wikip doesn't use the 'most accurate name, esp for a title, it used the most commonly used name.Merkinsmum 23:44, 9 November 2007 (UTC)

Guidelines

There are already NICE guidelines (National Institute for Health and Clinical Excellence. Clinical guideline 12: COPD. London, 2004.), and the American College of Physicians has published their lot: http://www.annals.org/cgi/content/abstract/147/9/633 JFW | T@lk 22:19, 1 November 2007 (UTC)

Asbestosis

Asbestosis is a restrictive/interstitial/diffuse (not an obstructive) lung disease. It's characterized by a decrease in RV and FRC, which is diagnostic of a restrictive disease. An obstructive disease would have an increase in RV and FRC due to the increased compliance associated with this type of disease. As such, it would seem that asbestosis should not be part of this article.

The inclusion of asbestosis with other obstructive lung diseases is also contradicted by the inclusion of asbestosis with restrictive lung disease (as opposed to obstructive lung diseases - ie COPDs) in the article on Lung Disease.

Normally I would wait a bit before deleting this part of the article, but my class is covering this topic right now, and I know at least 'several' people tend to get info from wikipedia, so I would hope that they would be getting the right information.

Other things...

under occupational pollutants, the assertation is made that cadmium and silica are risk factors for COPD. Is this implying that silicosis is a type of COPD? b/c is again is a restrictive lung disease. In general, I think that this subsection needs to be a bit more clear as to whether it is saying that industrial irritants like asbestos, silica, etc. can cause COPD (they can cause restrictive disease), or are simply a risk factor for developing COPD. I do not know whether exposure to these is a risk for other obstructive diseases like emphysema, so I can't make an accurate edit on this section, unless I have a better idea of what point these original statements were trying to make.

reference - http://www.emedicine.com/MED/topic2012.htm - see section 4 for some subtypes of RLDs

If for some reason it turns out I am completely wrong on this one, feel free to reinstate the deletion, and be annoyed at me :P (but please provide some reference)

--corvus.ag (talk) 22:23, 23 February 2008 (UTC)

Blue Bloater, Pink Puffer

Blue Bloater, Pink Puffer, no mention of these terms at all in the article. Both commonly used in textbooks when explaining COPD
Justcop (talk) 02:14, 29 March 2008 (UTC)

I find them massively confusing and not really helpful in distinguishing improvement. JFW | T@lk 08:04, 5 May 2008 (UTC)

Agreed. WAY out of date and really something that my mother's generation used when dealing with end-stage patients as nurses/doctors. Not funny and clinically pretty useless (especially once the cyanosis is obvious).--Phil Wardle (talk) 11:56, 17 July 2008 (UTC)

I agree. These terms are prejorative and stereoptyping and have little explanatory value.

"The famous images of the "pink puffer" and the "blue bloater," though not part of our current clinical paradigms, refuse to disappear" New England Journal of Medicine volume350, page 965

Any objections to removing them from the article? Or should they be retained and their value as descriptions (for and against) be discussed in the article rather than here on the talk page?

Jtravers (talk) 23:16, 3 November 2008 (UTC)

Bronchitis

Why does this page say "Acute bronchitis usually resolves in 2-10 years" when Acute bronchitis gives the far more accurate prognosis of "several days or weeks"? See http://www.medicinenet.com/bronchitis/article.htm and http://familydoctor.org/online/famdocen/home/common/infections/common/mulitsource/677.html. I am, in fact, so flabbergasted that I'm not even sure what to do to fix it! Orinoco-w (talk) 17:24, 20 April 2008 (UTC)

By clicking "edit this page". JFW | T@lk 08:04, 5 May 2008 (UTC)

No to screening

US Preventive Services Taskforce discourages use of spirometry to screen - NNS is in the 100s. JFW | T@lk 08:04, 5 May 2008 (UTC)

NNT for screening intevention can be much greater than NNT for therapeutic intervention. I believe the NNT for abdominal aortic aneurysm in susceptible populations is around 350. I'll have to look at the USPS guidelines though. Nbauman (talk) 18:53, 17 July 2008 (UTC)

Third rewrite

I have rewritten the introduction and plan on rewriting the rest of the article over the next few weeks. I hope to clear up some of the confusion about what COPD actually is and to make the article a better read. I also plan to address the issues raised here on the talk pages.

Please leave feedback on the changes here near the top of the talk page Jtravers (talk) 14:24, 6 June 2008 (UTC)

This is what I have done so far. Assistance with this job is always much appreciated.

• Reduced the prominence of the term COAD in the introduction because it is in less common use in the scientific literature (2000 vs 28000 hits on Google scholar for example) and the major societies promoting respiratory health and awareness to the public use the term COPD.
• Rewritten the Symptoms and Signs section.
  • Removed mention of hemoptysis because I think it is very uncommon in COPD except if there is also a lung infection.
  • Removed mention of spirometry because I think this belongs in the diagnosis sectiion.Jtravers (talk) 16:00, 10 June 2008 (UTC)
• Rewritten the Etiology section and clarified the role of silica. I agree with Corvus.ag that asbestos does not cause COPD and have removed this section.Jtravers (talk) 21:27, 24 June 2008 (UTC)
• Rewritten the pathophysiology section and renamed it "disease process" as it encomapssed both pathology and pathophysiology. Pathophysiology links will now link to the relevant subsection of "disease process"Jtravers (talk) 14:55, 8 July 2008 (UTC)
• Rewritten Diganosis section.Jtravers (talk) 13:58, 22 July 2008 (UTC)

Cannabis Smoking and Other Causes

Way too little mention of other, increasingly common causes of COPD in this article. Mainly (in addition to tobacco smoking) cannabis smoking, as well as other less well known home/industrial precursors. For a poorly understood and recognised disease (by the average layperson) this and related articles should be classified as TOP PRIORITY for raising to exceptional article quality. This disease not only kills nearly as many people as malaria, but it is very poorly understood by the average Joe Smoker and Jane Pothead, it kills slowly and with the sufferers full awareness. It is a major cause of poor quality of life and chronic depression in those afflicted (and by Jesus I should know...I've got it bad enough myself, as have many in the music industry). We have a duty here folks to make this issue (COPD in general) stand out. --Phil Wardle (talk) 12:08, 17 July 2008 (UTC)

The British Lung Association published a study, which I read, on COPD, and they concluded that there was no evidence that cannabis contributed to COPD. I also heard this discussed at a conference in New York City, and none of the experts there knew any evidence that cannabis caused COPD. Unless someone can find a reliable source, we can't make that claim. Nbauman (talk) 18:50, 17 July 2008 (UTC)

There is now some evidence that smoking cannabis is linked to COPD. I have added a citation from a reasonably reliable source. Jtravers (talk) 01:44, 18 July 2008 (UTC)

That article doesn't say anything about COPD. It doesn't support your claims. It merely says:

CONCLUSIONS: Smoking cannabis was associated with a dose-related impairment of large airways function resulting in airflow obstruction and hyperinflation. In contrast, cannabis smoking was seldom associated with macroscopic emphysema.

"Airflow obstruction" is not COPD. For you to draw that conclusion would violate WP:OR.

How does that support your claim that cannabis is linked to COPD? Nbauman (talk) 14:59, 18 July 2008 (UTC)

BTW, when you read the Taylor abstract [PMID 12144608] on Pubmed, didn't you see this in the "Related articles"?

http://www.ncbi.nlm.nih.gov/pubmed/9001303

Heavy habitual marijuana smoking does not cause an accelerated decline in FEV1 with age.

Tashkin DP, Simmons MS, Sherrill DL, Coulson AH.

Am J Respir Crit Care Med. 1997 Jan;155(1):141-8.

Although men showed a significant effect of tobacco on FEV1 decline (p < 0.05), in neither men nor women was marijuana smoking associated with greater declines in FEV1 than was nonsmoking, nor was an additive effect of marijuana and tobacco noted, or a significant relationship found between the number of marijuana cigarettes smoked per day and the rate of decline in FEV1. We conclude that regular tobacco, but not marijuana, smoking is associated with greater annual rates of decline in lung function than is nonsmoking. These findings do not support an association between regular marijuana smoking and chronic COPD but do not exclude the possibility of other adverse respiratory effects.

[PMID 9001303]

It's not good science (and it violates WP:NPOV) to pick only the peer-reviewed studies that agree with your position. Nbauman (talk) 15:16, 18 July 2008 (UTC)

Thank you, a NPOV is especially important here as cannabis always seems to be a controversial topic. As cannabis smoke is very similar to tobacco smoke in composition, it seems very plausible that smoking enough cannabis could cause COPD. Both studies discussed above used pulmonary function testing as a surrogate measure of COPD and came to different conclusions. Without arguing about the relative merits of the studies, perhaps some neutral statement like "...altough the scientific evidence for this is conflicting." is best. Jtravers (talk) 14:36, 21 July 2008 (UTC)

Regarding cannabis smoking (and unfiltered vaporization of cannabis). Cannabis smoke often contains irritants and pollutants that are extra to the cannabis itself. Prime among these are mould spores which CAN cause exacerbations and flare ups of bronchitis (I know; again, because I have had them...try vomiting up a pint of jet black sputum filled with mould....I did that some years ago and ended up in hospital...bad weed grown in a wet late season...result? Accelerated loss of lung function). In regards to COPD of the smaller airways and emphysemia damage to the alveoli, I have not found any papers that confirm this personally. However I have read a papers that cites cannabis as more likely to produce large bullae (basically large empty air sacs)in the lungs which obviously impair lung function and make any fine airway COPD that much worse. http://www.ctsnet.org/sections/clinicalresources/clinicalcases/article-1.html In addition a suspected autoimmune component of COPD in some sufferers (especially those with concomitant asthma) suggests that the highly irritant nature of cannabis smoke for some could be a cause of fine airway inflammation. --Phil Wardle (talk) 03:35, 19 July 2008 (UTC)

That is your personal interpretation and opinion, which you can't include in Wikipedia because it violates WP:OR among other rules. Unless you can find a [[WP:RS] source that specifically says that cannabis causes COPD, it will be deleted. There are many sources, like the one I cited above, that say that cannabis was not associated with COPD. Nbauman (talk)

Which is why I mentioned my inability to find a reliable paper on the subject. At present I can only state that for someone who already has COPD, smoking cannabis is perhaps not in their best interests and in my personal case has made my condition worse (a fact that I would not us for the actual article of course). I'm as much against personal POV as the next contributor. :-) --Phil Wardle (talk) 04:12, 20 July 2008 (UTC)

Additions without sources

You're adding a lot of material that doesn't have sources. Please read WP:RS. All unsourced material must be removed. (There's a lot of unsourced material in the entry right now that should also be sourced or removed.)

Please also read WP:MEDMOS. Wikipedia doesn't give medical advice to patients. WP doesn't tell people when to see a doctor, or how to care for their disease. Nbauman (talk) 05:11, 19 July 2008 (UTC)

OK, then I suggest we revert to before I made any contributions...though I would hope that someone else could clean up the mess that is the bronchitis section. :-) Sorry to cause any problems here, or goof on Wiki guidelines (I admit it gets a bit personal when you have the disease yourself.....and it's a real bastard of a disease). --Phil Wardle (talk) 05:03, 20 July 2008 (UTC)

COPD

CAN YOU CATCH THIS DISEASE. —Preceding unsigned comment added by 67.140.230.143 (talk) 01:39, 17 September 2008 (UTC)

You cannot catch COPD from another person because it is not caused by a germ. It is caused by breathing in noxious particles and gassess (such as tobacco smoke)over a long period of time. Jtravers (talk) 23:08, 28 October 2008 (UTC)

Removed diet

I removed the part about mediterranian diets helping COPD in the management section. The basic premise of COPD is that it is irreversible. This diet I am sure is a great thing, but it would only prevent the onset of COPD. It would do nothing to significantly affect the prognosis.

Maybe it should be worked into a more unified section on 'prevention.' PS, I bet the french would get less COPD if they stoped smoking... although I am sure they have a wonderful diet. —Preceding unsigned comment added by 140.254.204.185 (talk) 16:36, 21 October 2008 (UTC)

Management

Section rewritten. I've been bold, so welcome comments. I've reorganised several sections, removed mention of dust mite allergen as this relates to asthma and not COPD. I have removed some of the jargon used in describing medication. Much of the former prognosis and epidemiology section was irrelevant to COPD or repeated elesewhere so I have removed it. Jtravers (talk) 23:08, 28 October 2008 (UTC)

Section edited, Cold Weather Protection. I have taken out all references - I am new to Wiki and I don't completely understand the formatting rules. The submission is not copyrighted, but I do not know how to remove the copyright template now that I have edited the submission (as the template box indicates for me to do.) —Preceding unsigned comment added by Nonna Kate (talk • contribs) 15:23, 8 July 2009 (UTC)

Support groups removed

I have removed this:

====Support groups==== Joining a support group where members share common experiences and problems can help reduce the stress of illness. Regular social interactions and exercise can avoid a vicious cycle of inactivity, isolation, getting “out of shape” and depression that is common in COPD.

because the application of the second sentence to the first amounts to original research. The listed ref doesn't say a single word about support groups. It does say that limited social/family support is associated with worse prognosis, but social/family support is not the same thing as a support group. Social support includes things like being able to find someone to drive you to the doctor's office, to buy your groceries, to help you pay your bills, or to advocate for you; it goes well beyond having someone to talk to. Also, support groups frequently don't involve any sort of exercise. WhatamIdoing (talk) 18:48, 29 October 2008 (UTC)

I know that it is now February, and this was a long time ago (October). I just thought I would let you know that I agree with this change because I took a look at the listed reference and, like you said, It does not mention support groups. Thank you for improving the article with this change. Have you removed this source from the reference section of the article if it was not used for anything else? Tyrol5 [Talk] 17:31, 9 February 2009 (UTC)

Yes, inline refs are easily removed in the same step (since the ref is kept with the text instead of being listed at the bottom of the page). WhatamIdoing (talk) 20:14, 10 February 2009 (UTC)

Thank you for letting me know, as I merely wanted to be sure that you did so. Tyrol5 [Talk] 22:08, 10 February 2009 (UTC)

Management: Oxygen

I removed the recent addition by PantherAragorn because it is off the topic and is probably incorrect that high flows of oxygen are needed to treat heart attack and angina. See for example page 7 of http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Emergency%20Oxygen/Emergency%20oxygen%20guideline/Appendix%201%20Summary%20of%20recommendations.pdf

Jtravers (talk) 04:08, 25 November 2008 (UTC)

staphylococcus epidermidis

Had a lung biopsy and it came back positive. Can you tell me any information on this subject. I have a rare lung disease called Bronchilitis Obliterans Organizing Pneumonia. I would like to know how contagious this disease is and what it looks like. —Preceding unsigned comment added by 65.190.122.21 (talk) 09:23, 31 December 2008 (UTC)

We don't give medical advice: please see your local healthcare provider. We do have an article called Bronchilitis Obliterans Organizing Pneumonia if you would like to read about it. --Steven Fruitsmaak (Reply) 19:17, 9 February 2009 (UTC)

GERD

You might want to add something about how gastro-esophageal reflux disease can cause breathing difficulties and ashtma which could lead to COPD. It produces phlegm that infiltrates the lungs, etc. I take both Nexium and Asmanex now in the early stages of GERD. —Preceding unsigned comment added by Reb2 (talk • contribs) 13:47, 9 April 2009 (UTC)

GERD/gastric aspirations would seem to lead to adult respiratory distress syndrome. And Asthma is not COPD as per this articles definition, though it is a type of obstructive pulmonary disease. -- Bubbachuck (talk) 21:38, 19 April 2009 (UTC)

"..is a group of diseases..."

Where is the listing for this group of diseases? I see only pathophysiology for emphysema and chronic bronchitis, which is what i've always considered to be the two diseases of COPD. But the name IS misleading, as both asthma and bronchiectasis (the other two obstructive PDs) are chronic in nature. Should there be a section clearing up the nomenclature? -- Bubbachuck (talk) 21:42, 19 April 2009 (UTC)

Some may find this confusing, although I don't believe that there should be a completely different section explaining this. However, if you and others find this to be a necessary measure, than please don't let me prevent you from improving this article. Tyrol5 [Talk] 14:27, 20 April 2009 (UTC)

OK I'm going to change it to say COPD refers to chronic bronchitis and emphysema, as described by the NIH http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html -- Bubbachuck (talk) 21:17, 21 April 2009 (UTC)

I agree that the term chronic obstructive pulmonary disease is misleading but we are stuck with it. I do not think that it is accurate to say that it “refers to chronic bronchitis and emphysema” for the reasons given below so I have edited the article again.

The pathologies of COPD (such as chronic bronchitis and empysema) are not explicitly referred to in current definitions which usually emphasize the importance of airflow obstruction rather than a specific pathology. The GOLD definition of COPD is "COPD is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gasses." Murray and Nadel's Textbook of Respiratory Medicine defines COPD as "a heterogeneous collection of conditions characterized by persistitent expiratory airflow limitation".The NIH reference says COPD is “a progressive disease that makes it hard to breathe.” Much further down the page it says “In the United States, the term "COPD" includes two main conditions—emphysema (em-fi-SE-ma) and chronic obstructive bronchitis (bron-KI-tis).” Chronic bronchitis, emphysema, small airways inflammation and, perhaps, asthma-like inflammation are some of the pathologic processes or conditions that may cause the airflow obstruction of COPD. In the developing world, much of COPD is due to other conditions such as scarring from tuberculosis of the lung. Part of the confusion arises because the terms chronic bronchitis and emphysema were previously used as the names for this disease/group of diseases.-- Jtravers (talk) 22:22, 2 June 2009 (UTC)

Acute exacerbations of COPD

I have looked at this section in the article and I believe that it should be more comprehensive than it already is. I have read a few articles in well known medical publications and the exact definition of a COPD exacerbation is in fact very trivial. There are many different ways of explaining this process, and I believe that the section should be a little more explanatory. Please share your thoughts. Tyrol5 [Talk] 14:23, 20 April 2009 (UTC)

This topic deserves an article in its own right really: so go ahead! --Steven Fruitsmaak (Reply) 14:25, 20 April 2009 (UTC)

As there is quite a bit of information to cover relating to exacerbations of COPD, I do believe that an article relating to this topic could easily be created. However, are you absolutely sure that there should be an article relating to this solely instead of a section within this article? Tyrol5 [Talk] 14:38, 20 April 2009 (UTC)

Here are recommended guidelines [[1]] for article length and what constitutes a new article. -- Bubbachuck (talk) 21:15, 21 April 2009 (UTC)

I just created the article. Please help me with the proper citation format. Thanks, Tyrol5 [Talk] 01:44, 30 April 2009 (UTC)

Risks

I had cited risks in the prognosis that seem to have been removed, there is a 25% risk of emphysema and 10% risk of pulmonary neoplams in smokers. I would like that part restored as it makes the case for smoking cessation. --Veganfanatic —Preceding undated comment added 01:17, 16 June 2009 (UTC).

Cut and paste?

The section ====Cold Weather Protection==== is also found here under the heading "Trusted Web Resources" and is clearly a link back to this section of this article. Gordo (talk) 12:00, 17 August 2009 (UTC)

COPD treated with in-home BiPAP therapy

I did not see any mention of BiPAP therapy for COPD patients. As I have come to understand it from dealing with my mother's COPD, BiPAP for this is only four or five years old (according to my mother's respiratory therapist).

The BiPAP therapy has made a significant difference in my mother's health by reducing the amount of retained CO 2 in her blood.

Finding indepth information about this therapy has been very difficult. One of my mother's doctors did not even know there was in-home therapy with a BiPAP for COPD.

It would be very helpful to see this subject included and elaborated on in your Wikipedia COPD topic.

Thank you.

Cynthia Davis

email: calicojordan@aol.com —Preceding unsigned comment added by 71.222.52.189 (talk) 22:23, 25 October 2009 (UTC)

Can someone clarify this please

The article says "At the same time Tiotropium was shown to be effective in eliminating the risk of all cause mortality, cardiovascular mortality and cardiovascular events" and sites a reference which uses more or less identical wording, thats fine but...

What does 'all cause mortality' mean in plain speech - is that the same as 'overall mortality' rates, or does it mean something specific (above and beyond) mortality from all causes? EdwardLane (talk) 17:15, 3 April 2010 (UTC)

Asthma leading to asthmatic chronic bronchitis and COPD?

I can't find solid info in the medical literature, but there are quite a few mentions of asthmatic chronic bronchitis leading to a COPD-like state. But there's no mention of anything here but smoking and particulates as a caused of COPD. The asthma page does mention this possible progression of disease. Nor is it mentioned that other forms of lung disease (such as pneumonia) can lead to chronic bronchitis. This seems both incorrect, and a disservice to COPD/chronic bronchitis patients who have no history of smoking or particulate exposure.

Feyandstrange (talk) 10:59, 23 September 2010 (UTC)

Not always smokers

doi:10.1378/chest.10-1253 (primary study) - a substantial proportion of COPD occurs in never-smokers, particularly people with asthma, women and those from lower eductional background. JFW | T@lk 14:29, 26 May 2011 (UTC)

Possibly misleading definition

I believe that the definition of COPD as the "co-occurrence of chronic bronchitis and emphysema" is misleading as it implies that BOTH have to be present for the diagnosis, whereas in my knowledge only one has to be present (I.e. it should be: "the occurrence of either progressive chronic bronchitis or progressive emphysema. Typically both are present.") NS Feb 20, 2012 — Preceding unsigned comment added by 71.146.74.216 (talk) 01:37, 21 February 2012 (UTC)

Yes fixed. --Doc James (talk · contribs · email) 23:56, 11 April 2012 (UTC)

England?

What's the relevance of the England-specific statistic in the first paragraph? johnpseudo 16:19, 4 June 2012 (UTC)

It isn't relevant, and moreover it is based on a primary source. Are you aware of a study that covers the epidemiology of COPD worldwide? I'm sure the GOLD consensus documentation has something on that. JFW | T@lk 18:54, 4 June 2012 (UTC)

A new review of AE

• The Lancet, not long ago, with a general review: doi:10.1016/S0140-6736(11)60968-9.JFW | T@lk 00:07, 12 April 2012 (UTC)
• Mackay, AJ (2013 Feb). "COPD exacerbations: causes, prevention, and treatment". Immunology and allergy clinics of North America. 33 (1): 95–115. PMID 23337067. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Brulotte, CA (2012 May). "Acute exacerbations of chronic obstructive pulmonary disease in the emergency department". Emergency medicine clinics of North America. 30 (2): 223–47. PMID 22487106. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
• [2]
• NICE 2010 review [3] Doc James (talk · contribs · email) 22:58, 7 June 2012 (UTC)

Rewrite for 3.3 Cause: Air Pollution?

Section, 3.3 Cause: Air Pollution, may need a rewrite. There are a few uncited statements throughout. Also, regarding the lichens, a species should be cited if possible; xanthoria are typically yellow or orange, not blue as the current version reads. Also, Kennedy et al (cited for series of statements related to gender differences) doesn't support the statements in Section 3.3. Specifically, the section states, "In many developing countries, indoor air pollution from cooking fire smoke (often using biomass fuels such as wood and animal dung) is a common cause of COPD, especially in women." However, Kennedy et al do not discuss "many" developing countries. The literature review names two articles on cooking fires in developing countries, one on Mexico and one on China; only the China reference (which involves coal, not biomass) supports the assertion of gender differences from cooking fires. — Precedingunsigned comment added by 205.254.147.8 (talk) 17:43, 4 February 2013 (UTC)

Have removed

We have better sources and this does not really make sense. " As a pure mechanical responce to the this break down of the alveolar septa the lung elastic recoil automatically rearranges the parenchyma to a lower expansion; in fact due to lacking of the stabilizing action of the broken septum the resulting new air space is larger than the sum of the two alveoli put in communication, necessarily at the expenses of the confining alveoli expansion (video)" Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:34, 14 September 2013 (UTC)

GA Review

This review is transcluded from Talk:Chronic obstructive pulmonary disease/GA1. The edit link for this section can be used to add comments to the review.

Reviewer: Jfdwolff (talk · contribs) 21:25, 25 November 2013 (UTC)

• I intend to review the article. Seeing that my editing time occurs in short stretches, I will probably review sections at a time. All going well, this shouldn't take longer than a week. If I forget, please nudge me on my talkpage. JFW | T@lk 21:25, 25 November 2013 (UTC)

Thanks for taking this on. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:46, 25 November 2013 (UTC)

I have finished the review. Looking forward to helping with the finishing touches. JFW | T@lk 16:26, 4 December 2013 (UTC)

Introduction

Comments on the introduction JFW | T@lk 21:25, 25 November 2013 (UTC)

• All sections from the article are represented.
•  Done The terms "chronic airflow limitation" (CAL) and "chronic obstructive respiratory disease" (CORD) are unfamiliar to me. Do they require the prominence that we're giving them, or can the terminology be moved to a subsection?

Agree and will move to the history section. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:46, 25 November 2013 (UTC)

•  Done Emphysema redirects here, but the term is not mentioned in the introduction and not bolded anywhere in the article.

Mentioned. Not sure if it needs bolding though. It is a lot less emphasized now. Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:05, 26 November 2013 (UTC)

I would, if only for the reason that some people might primarily search for "emphysema" and find themselves on the page about COPD. Here in the UK, many older people have not heard of COPD but state that they have "emphysemia" (sic). JFW | T@lk 15:17, 26 November 2013 (UTC)

Okay bolded both emphysema and chronic bronchitis as they were historically considered the two main subtypes. Doc James (talk · contribs ·email) (if I write on your page reply on mine) 10:59, 27 November 2013 (UTC)

•  Done I would not want the intro to omit indoor cooking on open fire, which in countries such as India is a major cause of COPD in women. I realise that it is subsumed under the broader term of "air quality", but this is already too abstract. The GOLD consensus guideline place substantial emphasis on this.

Agree and I give a fair bit of coverage both in the cause and the prevention section to this. Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:10, 26 November 2013 (UTC)

•  Done "The definition includes most cases of chronic bronchitis" - which cases would it not include? Not sure what this sentence adds.

Supposedly there is something called "chronic bronchitis without airflow limitation" I had never heard about it before either. Have merged chronic bronchitis into this article. Will comment on this is the differential diagnosis section.Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:49, 25 November 2013 (UTC)

•  Done "In contrast to asthma, this poor airflow is not as significantly improvable" - I presume this is a reference to reversibility. How about: "In contrast to asthma, the airflow reduction does not improve significantly with the administration of medication."

Sounds good. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:49, 25 November 2013 (UTC)

Signs and symptoms

Comments on "signs and symptoms": JFW | T@lk 21:58, 25 November 2013 (UTC)

•  Done The section does not seem to separate signs from symptoms. This is not a large problem, but might be tricky for readers who struggle with the terminology. Is wheeze required for the diagnosis, or is it heard by stethoscope?

Yes I sort of divided it around the two main symptoms. Than have a section for the other stuff and tired to touch on exacerbations. Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:21, 26 November 2013 (UTC)

I have made it a bit more specific which features are found on physical examination. JFW | T@lk 15:17, 26 November 2013 (UTC)

•  Done Exertional dyspnoea is an important omission. Many people in the early stages of COPD are comfortable at rest but find their exercise limited. The NICE guideline places emphasis on using MRC breathlessness grade as a marker of severity (rather than spirometric parameters)

Already state "Typically the shortness of breath is of a prolonged duration, worsens over time, and is worse with exercise" Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:21, 26 November 2013 (UTC)

I felt it might benefit from a bit more prominence, as many people with milder stage COPD appear to be fine at rest but can't make it to the bus stop without pausing several times for breath. JFW | T@lk 15:17, 26 November 2013 (UTC)

•  Done In "Other", the mechanism for cor pulmonale is stated to be pressure-related. What is the role of hypoxic pulmonary artery vasoconstriction? (Or is this best mentioned elsewhere?)

From my understanding hypoxia causes pulmonary artery vasconstriction which causes rt heart strain which causes cor pulmonal / right sided heart failure secondary to pulmonary causes. I could add it to the patho section? Or it could simply be left to cor pulmonal. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:50, 27 November 2013 (UTC)

I agree that this is potentially better left for the "pathophysiology" section. I suspect that the pathogenesis of cor pulmonale might be more complex than just chronic hypoxia. JFW | T@lk 15:19, 27 November 2013 (UTC)

•  Done In "Exacerbations", might there be good cause to mention decreased level of consciousness due to severe acute hypercapnia and type 2 respiratory failure? Do the sources cover this?

Mention "confusion" is there. Have added that they are combative. Typically described as an "altered level of consciousness" Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:46, 27 November 2013 (UTC)

Cause

Overall a strong section. Some small comments: JFW | T@lk 15:17, 26 November 2013 (UTC)

•  DoneThe URL for the "Ward2012" source generates a search result rather than an individual page in the book.

This one was tough but fixed Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:17, 27 November 2013 (UTC)

•  Done The percentages, all added up, exceed 100% - depending on which percentages are included. Not sure how this could be improved.

Yes physicians are generally not good at math. This is however what the sources say. Every source like to over emphasis a bit their particular issue. Check out Talk:Common cold for another example. I am happy for suggestions. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:17, 27 November 2013 (UTC)

• Who isn't sure whether COPD is more prevalent in poor because they're poor or because environmental conditions? I've never heard of any disease being more prevalent simply because of someone's socioeconomic status. If there is a higher rate of any disease in those in poverty, it's due to diet or environmental causes. I'm gonna change that, revert if it makes sense to anyone else. — Preceding unsigned comment added by 76.113.38.98 (talk) 10:04, 4 March 2014 (UTC)

Pathophysiology

This is generally a strong section. I fixed some typos ("degree of airway hyperresponsiveness" rather than "decrease"). Just this: JFW | T@lk 16:10, 28 November 2013 (UTC)

•  Done At the moment the article suggests that hypercapnia is caused by destruction of alveolar surface. Physiologically this might not be sufficient explanation; alveolar hypoventilation (probably due to air trapping). Does the discussion about hypercapnia need to be moved to the paragraph about dynamic hyperinflation?

Yes hypercapnia is due to a number of different mechanisms. Have clarified and moved. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:36, 2 December 2013 (UTC)

•  Done Do we need a short paragraph about the pathogenesis of cor pulmonale? (See discussion above.)

Done Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:51, 2 December 2013 (UTC)

•  Done We don't talk much about the role of infection in the progression of COPD. Is there a good source that outlines the direct effect of infection (usually as part of exacerbations) on the "downward spiral" of COPD?

Okay added some to the section on causes under exacerbations. The role of infections in stable COPD is less clear. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:51, 2 December 2013 (UTC)

Diagnosis

This is all for this section: JFW | T@lk 16:10, 28 November 2013 (UTC)

•  Done Do we need to explain what "bronchodilator" in the opening paragraph refers to? For the lay reader this might imply something mechanical... Similarly, we have not fully introduced the concept of "spirometry", and perhaps an image of a handheld spirometer might help here.

Have added a picture of a spirometry machine. Have added a link to bronchodilator. Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:04, 29 November 2013 (UTC)

•  Done The paragraph starting with "It is unclear" could conceivably be moved to "signs and symptoms", where it seems relevant, or another relevant section.

Done Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:58, 2 December 2013 (UTC)

•  Done In the "differential diagnosis" subsection, I would recommend a degree of rephrasing. Clearly, jugular distention and pedal oedema occur in cor pulmonale (unless the COPD is otherwise mild); I would want additional evidence of left ventricular dysfunction before considering pulmonary oedema as the cause of dyspnoea. Similarly, leg oedema is often asymmetrical to some degree, and I would want to consider pulmonary embolism only in the face of additional evidence. Perhaps the secret of this section is not to attempt to say too much about the clinical considerations made by doctors at the time of assessment, but focus on the possible causes of dyspnoea.

Agree and adjusted. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:15, 2 December 2013 (UTC)

Prevention

Limited comments on this strong section: JFW | T@lk 17:01, 2 December 2013 (UTC)

•  Done Smoking cessation: this is quite detailed content that is covered elsewhere to a large extent.

It is three short paragraphs and such a key aspect of COPD. The refs in question are also commenting on smoking cessation in relation to COPD. What do you recommend removing / condensing? Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:37, 4 December 2013 (UTC)

Fair enough. The sources do focus on COPD. JFW | T@lk 20:32, 4 December 2013 (UTC)

•  Done Occupational health: the sentence "If a worker develops COPD" has no reference. This may be found in occupational health manuals/textbooks.

Added ref. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:46, 4 December 2013 (UTC)

Management

Comments on this section: JFW | T@lk 16:26, 4 December 2013 (UTC)

•  Done In the "bronchodilators" subsection, the terms "short acting" and "long acting" are not hyphenated. Almost all sourced that I've seen use hyphenated terms.

Done Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:50, 4 December 2013 (UTC)

•  Done I am unsure if there might be a secondary source available to replace the primary source reference for the TORCH trial

Hum yes the secondary sources are not as positive. Need to read further. Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:19, 4 December 2013 (UTC)

•  Done Karner2012 is cited as suggesting mortality differences between the tiotropium preparations. This has been displaced by doi:10.1056/NEJMoa1303342, so I wonder if it might be better to omit this sentences altogether.

Hum. So does this mean both formulations are associated with a risk of death or neither formulation? Have reworded. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:39, 4 December 2013 (UTC)

•  Done With regards to macrolides for prophylaxis, doi:10.1016/j.rmed.2012.12.019 suggests a cost benefit, and might be cited in addition or indeed instead of the current source.

Added. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:48, 4 December 2013 (UTC)

•  Done With regards to harms from excessive oxygen, I wonder if you might consider the Jindal source with doi:10.1136/thx.2008.102947 (the BTS emergency oxygen guideline) which covers the problem well. Unfortunately doi:10.1136/bmj.c5462, which provides excellent proof, is a primary source.

Added some more. Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:20, 5 December 2013 (UTC)

•  Done With regards to acute exacerbations, there is no mention on the delivery of bronchodilators; while using spacer devices might be sufficient, those admitted to hospital will typically require nebulised therapy.

Done Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:27, 5 December 2013 (UTC)

Prognosis

No comments on this section. JFW | T@lk 16:26, 4 December 2013 (UTC)

Epidemiology

Comments on this section: JFW | T@lk 16:26, 4 December 2013 (UTC)

•  Done The fivefold increase in prevalence (from 64 to 329 million) over 6 years really probably does require a better explanation. Does this reflect screening and increased awareness? Or more effective treatment and hence better prognosis and thus longer time between diagnosis and death?

Have tried to discuss this. I am unable to find a clear explanation. I guess we could simply remove the 2004 estimate. It is here [4] and mentions that it is only symptomatic? But all COPD has to sort of be symptomatic for the diagnosis. There is good evidence it is increasing in prevalence though. Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:51, 5 December 2013 (UTC)

•  Done The sentence "Some developing countries have seen increased rates [...]" might be more informative if it was made clear whether the factors the influence these rates are recognised.

Should have read "some developed countries" Fixed Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:34, 5 December 2013 (UTC)

History

No comments on this section. Well researched and presented. JFW | T@lk 16:26, 4 December 2013 (UTC)

Society and culture

Comments: JFW | T@lk 16:26, 4 December 2013 (UTC)

•  Done I wonder if the distinction "blue bloaters and pink puffers" is better suited for the "signs and symptoms" section. The phenotypes were (up until recently) propagated in medical school tutorials.

This has really fallen out of favor. The 2013 GOLD guidelines do not mention it. Thus why I put it in the section on society and culture. Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:50, 4 December 2013 (UTC)

Okay, seems reasonable. JFW | T@lk 13:35, 5 December 2013 (UTC)

•  Done In "economics", is it possible to give a breakdown as to whether the costs reflect medical care or loss of productivity? I notice that one figure is broken down as mostly reflecting hospital care, but not the others.

Added breakdown for the total. Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:13, 5 December 2013 (UTC)

Research

I think the discussion of infliximab should be removed unless there are secondary sources discussing the evidence base; the current reference is a primary source. JFW | T@lk 16:26, 4 December 2013 (UTC)

•  Done Secondary source now present. There might be scope for expanding this paragraph, but that's not crucial for GA. JFW | T@lk 20:32, 4 December 2013 (UTC)

Other animals

I wonder if there are veterinary substrates of poor air quality-related COPD. Do the sources mention anything about this? JFW | T@lk 16:26, 4 December 2013 (UTC)

 Done I have been able to find very little regarding COPD in animals other than horses. This ref is not good but talks about it [5] and we have this [6] Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:23, 5 December 2013 (UTC)

Okay have found a couple of more papers. Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:30, 5 December 2013 (UTC)

General comments

Some general comments JFW | T@lk 15:17, 26 November 2013 (UTC)

•  Done Some references have capitalised titles, while others do not. Consistency would be welcomed.

There must be a bot to do this no? Have asked User:Chris Capoccia who does lots of ref work. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:47, 27 November 2013 (UTC)

some works are published with capital letters in the titles and some are not. Is there any standard about recapitalizing titles? Or should they only be cited with the capitalization as published?  —Chris Capoccia ^T⁄_C 18:58, 27 November 2013 (UTC)

My personal preference has always been to use consistency within each article, but this is not a breaking point for GA as long as the relevant parameters all follow the same style. JFW | T@lk 23:06, 27 November 2013 (UTC)

•  Done Some references (e.g. GOLD references) quote chapters rather than pages, and yet this parameter is prefaced with "p."

Can put in page numbers. For some e-book now there are no page numbers just chapters and they change the number of pages depending on what size you view it at. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:26, 27 November 2013 (UTC)

so the request would be to cite the whole page range of the chapter? Or should the citation be reformatted without a chapter if the intent is to only cite one page?  —Chris Capoccia ^T⁄_C 19:00, 27 November 2013 (UTC)

Page range for the whole chapter. I have used all the chapters a number of times.Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:58, 27 November 2013 (UTC)

Another option would be to use GOLD as a reference, the same way we organised the citations to WHO in the dengue fever article. JFW | T@lk 23:06, 27 November 2013 (UTC)

•  Done For some web-based references, the citation templates might still be populated a bit more (particularly the accessdate= parameter).

I think this has been done. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:16, 2 December 2013 (UTC)

Finishing points

Just a few things. I have cleaned up a couple of links to redirects and rephrased some stuff in places. The following remains: JFW | T@lk 23:31, 7 December 2013 (UTC)

• The Kissell source (2003) is cited as a reference for occupational measures in dusty environments. There's currently a {{page needed}} tag that I cannot resolve (I managed two other ones). This should be sorted before GA.

Not the greatest ref. Replaced with two better ones. Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:40, 8 December 2013 (UTC)

• We speak little of the role of hospital admission, and "hospital at home schemes" and admission prevention programmes (run by "community matrons") currently very popular. Do the sources say anything about this?

Have added some info. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:38, 9 December 2013 (UTC)

• Is Vestbo the only author of the GOLD document, or do we need to list other authors?

There are a bunch per page ii and iii. The person listed is the chair. How do you propose we ref this guideline? Doc James (talk · contribs · email) (if I write on your page reply on mine) 20:39, 9 December 2013 (UTC)

I'm not entirely sure how to attribute authorship of this resource, considering it is a consensus document. I don't know how medical journals refer to it. Does Rodriguez-Roisin (second signatory of the introduction) need attribution? I am happy to pass for GA without this being addressed. JFW | T@lk 21:43, 9 December 2013 (UTC)

Have all 50 names is simply too much IMO. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:55, 9 December 2013 (UTC)

Agree. Perhaps the first three and "et al", as we do with articles that have >5 authors in many articles? JFW | T@lk 22:13, 9 December 2013 (UTC)

• In "society and culture", one of the sources has a {{page needed}} tag

Fixed sort of. Did not add this bit. Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:52, 8 December 2013 (UTC)

Not sure why this bit was removed?

This is typically based on the FEV₁ expressed as a percentage of the predicted "normal" for the person's age, gender, height and weight.

Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:48, 5 December 2013 (UTC)

It struck me as redundant with everything that was already discussed in the previous section (about spirometry). Perhaps it needs to be moved. JFW | T@lk 21:03, 7 December 2013 (UTC)

From my understanding the FEV1 percentage of normal is used to determine severity while the diagnosis is FEV1/FVC<0.7. Slightly different. Doc James (talk · contribs · email) (if I write on your page reply on mine) 00:30, 8 December 2013 (UTC)

I had a closer look, and I agree that the sentence is needed for the rest to make sense. I've put it back. JFW | T@lk 07:21, 8 December 2013 (UTC)

Bullous emphysema

I have come across bullous emphysema in an accident report of 1952 (see Easington_Colliery#Men) which is (apparently) "distension of the air sacs to blister like formations on the surface of the lungs". In the case I am researching a man suffered a rupture of a bulla leading to a partial collapse of the lung. [[emphysema]] leads here, and yet as a non-medical reader (WP:RF) I can find no mention of this form. If the old bullous emphysema is a form of COPD perhaps a sentence or two could be added. If it is classified differently today then could someone add an appropriate hat note please. Thanks, Martin of Sheffield (talk) 21:02, 4 May 2014 (UTC)

This is simply emphysema with bullae. We mention in the article and have pictures. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:04, 4 May 2014 (UTC)

September 11 attacks aftermath

I'm a casual Wikipedia user, so forgive me if this is way off base. The article quotes "The number of deaths is projected to increase due to higher smoking rates and an aging population in many countries", should we also mention the increasing amounts of COPD due to surviving the 9/11 attacks? I just feel like it could be a good addition.

2605:A601:287:B301:99CA:9B8D:51CC:704B (talk) 17:23, 7 May 2014 (UTC)

To include this, we would need a very strong secondary source. It bears remembering that "only" at most 100,000 people were exposed to the fumes, which pales in comparison to those exposed to cigarette smoke and smoke from indoor domestic fires. JFW | T@lk 18:03, 7 May 2014 (UTC)

Refs

Need page number for the book

"In 1953, Dr. George L. Waldbott, an American allergist, first described a new disease he named "Smoker's Respiratory Syndrome" in the 1953 Journal of the American Medical Association. This was the first association between tobacco smoking and chronic respiratory disease. "

Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:35, 20 September 2014 (UTC)

Page 6.-gadfium 03:10, 20 September 2014 (UTC)

Types

Centriacinar vs panacinar COPD doesn't seem to be mentioned. Should it be? WhatamIdoing (talk) 00:57, 25 November 2015 (UTC)

Stem cells

Have reverted to [7] as stem cell therapy is not supported for human use at this point in time. Doc James (talk · contribs · email) 14:36, 14 December 2015 (UTC)

agree (could add [8])--Ozzie10aaaa (talk) 18:10, 14 December 2015 (UTC)

Yes thanks User:Ozzie10aaaa another really good review. Have added it. Doc James (talk · contribs · email) 03:34, 15 December 2015 (UTC)

What do I need to do in order to add information on stem cell therapy to the research section? Ckennerly — Preceding unsigned comment added by Ckennerly (talk • contribs) 14:36, 15 December 2015 (UTC)

You need to use recent high quality sources that are actually about the subject in question. We can than discuss what is a fair summary. Doc James (talk · contribs · email) 18:04, 15 December 2015 (UTC)

What is considered recent? ckennerly — Preceding unsigned comment added by Ckennerly (talk • contribs) 19:28, 15 December 2015 (UTC)

Last 3 to 5 years. Than you need to accurately reflect the sources in question. Doc James (talk · contribs · email) 14:12, 16 December 2015 (UTC)

Alright, so for clarification a source between 2010 and 2015 would be acceptable? ckennerly

So Doc James , I just want to be clear, as you've previously stated, I need to use "high quality sources" within the last "3 to 5 years" meaning the oldest source I can use should be no older than 2010.ckennerly

We use the best available sources. There are some rough guidelines on what counts as good.

We than discuss how to summarize these with appropriate weight. Doc James (talk · contribs · email) 16:09, 16 December 2015 (UTC)

Doc James can you provide the link for those rough guidelines? User: ckennerly

Wikipedia:Identifying_reliable_sources_(medicine)--Ozzie10aaaa (talk) 16:28, 16 December 2015 (UTC)

Hyperinflation

We discuss it under pathophysiology. Not sure this duplicate content in the section on exacerbation supported by a "letter" is needed.

"Additionally some patients suffer from hyperinflation. These patients are dyspnoeic, with hyperinflated lungs, and without an infectious or eosinophilic pattern. These patients can be treated differently, for instance with longacting bronchodilators. " Using long acting bronchodilators for acute exacerbations of COPD is controversial. Doc James (talk · contribs · email) 21:27, 18 January 2016 (UTC)

Have removed this again as COPD exacerbations are not typically treated with LABAs and the source is a commentary not a review article "although there is reason for longacting bronchodilators as well. " Doc James (talk · contribs · email) 13:36, 19 January 2016 (UTC)

Ref is not saying that long acting agents are appropriate for acute exacerbations but that their long term use can prevent hyperinflation which is somewhat different. Adjusted to reflect [9] Doc James (talk · contribs · email) 00:57, 20 January 2016 (UTC)

References

Decent 2015 review on managing with drugs

PMID 26244017 and has a free PMC version. Authors disclose connections to pharma, just fyi Jytdog (talk) 18:29, 2 March 2016 (UTC)

Emphysema & Chronic Bronchitis

The terms emphysema and chronic bronchitis continue to be used, despite what the current version of the article implies at one point. It's a bit confusing, but COPD is a distinct functionally defined disease that occurs when airway function is impeded to a certain degree and cannot be corrected by bronchodilators. Emphysema and chronic bronchitis, on the other hand, are more specific disease processes that can (but do not always) cause COPD. It's understating it to say that they merely co-occur with COPD. The point that is correct, is that medicine is still trying to figure out if there are different effective treatments, and different prognostics for COPD, depending on the subtype. This hasn't really been figured out much yet (from what I understand). Still, it's important that the article makes it clear: (1) what emphysema is, (2) what chronic bronchitis is, (3) that COPD is defined in terms of airway obstruction uncorrectable with bronchodilators, regardless of the underlying disease process, and (4) that either emphysema or chronic bronchitis can cause COPD.

An added wrinkle is that smoking and other risk factors can contribute either to emphysema or chronic bronchitis, even though the disease processes are different.

Verazzano (talk) 05:04, 6 April 2016 (UTC)

The WHO says "The more familiar terms of chronic bronchitis and emphysema are no longer used; they are now included within the COPD diagnosis."[10] Doc James (talk · contribs · email) 16:19, 6 April 2016 (UTC)

Thank you for the reply. That is just one source, however, and the New England Journal of Medicine -- for example -- continues to publish articles that refer to emphysema, chronic bronchitis, and co-occuring emphysema with chronic bronchitis as different phenotypes of COPD. COPD, as I understand it, is defined in terms of FEV1/FVC, and does not refer to the disease process. Terms like emphysema and chronic bronchitis seek to offer some characterization of the disease process that results in this change in airway function. Given that the terms emphysema and chronic bronchitis continue to be used in the literature in connection with COPD, some fuller explanation of what these terms mean and how they relate to COPD would improve this article, in my view -- especially since there is no separate wikipedia page for emphysema, whether as a current disease classification, or (at the very least) to explain its significance in the history of seeking to understand lung disease.

For example -- "COPD is also an inflammatory airway disease, one that affects the small airways in particular.2 In chronic bronchitis, there are inflammatory infiltrates in the airways, especially the mucus secretory apparatus, whereas in emphysema, there are clusters of inflammatory cells near areas of alveolar-tissue breakdown (Figure 1). Chronic bronchitis and emphysema often coexist, although there are patients in whom one phenotype predominates. COPD usually becomes symptomatic with breathlessness in persons older than 40 to 45 years of age and is frequently associated with chronic cough, phlegm, wheezing, or a combination of these."

From: The Asthma-COPD Overlap Syndrome Drazen, Jeffrey MView Profile; Postma, Dirkje S; Rabe, Klaus F. The New England Journal of Medicine373.13 (Sep 24, 2015): 1241-1249.

Verazzano (talk) 02:20, 7 April 2016 (UTC)

Both condition are included within the diagnosis of COPD now. In the body we state "It is unclear if different types of COPD exist.[3] While previously divided into emphysema and chronic bronchitis, emphysema is only a description of lung changes rather than a disease itself, and chronic bronchitis is simply a descriptor of symptoms that may or may not occur with COPD.[1]" based on http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf#18

We discuss emphysema further in the pathopysiology section. The NEJM piece is basically presenting them as two types of COPD, which is a controversial position which I guess could be discuss further in the body of the text. Doc James (talk · contribs · email) 12:49, 7 April 2016 (UTC)

Thank you for the reply. It sounds like we now agree that it is worth having the page explain the way the terms were once used -- and continue to be used by some doctors and researchers -- even while acknowledging that they are now controversial. This seems like a good compromise as an approach to editing the page.

Verazzano (talk) 00:36, 8 April 2016 (UTC)

As a non-medic may I just add that including popular and historic terms in medical articles is essential. Wikipedia is not just a GP's reference manual! Feel free to disparage and update terms, but it is reasonable to ask what "bullous emphysema" or "general paralysis of the insane" (the lead on that is particularly bad) used to mean. If I may be bold, might I suggest an occasional review of WP:RF, lest a tendency to rush into "doctor-speak" means that ordinary people are denied the information. Martin of Sheffield (talk) 11:32, 8 April 2016 (UTC)

Yes I think we all agree these terms should not only be mentioned but discussed at least in the history section if not elsewhere aswell. Currently the term emphysema is used 25 times and chronic bronchitis 14 Doc James (talk · contribs · email) 15:49, 8 April 2016 (UTC)

Just to clarify -- it is not true (despite what the current version of the article states) that chronic bronchitis was an old term for Chronic Obstructive Pulmonary Disease, since it is possible to have chronic bronchitis without having COPD. It would be more accurate to say that chronic bronchitis has been used to try to isolate a specific phenotype of COPD, and to refer to a disease process that is sometimes (and sometimes not) associated with COPD. This should be stated more clearly in the text.

Verazzano (talk) 15:38, 9 April 2016 (UTC)

Please use references. For example this needs a reference "Chronic bronchitis refers to a specific physical disease process involving the inflammation of the airways, while COPD refers to a specific clinical picture involving persistent airway impairment that cannot be resolved with medications that open the airways. Thus chronic bronchitis can contribute to the airway impairment known as COPD, but it is nevertheless possible to have chronic bronchitis without having COPD, or COPD without having chronic bronchitis. Likewise, emphysema is a term that refers to a physical disease process that involves damage to the structures where gas exchange occurs (the alveoli). This specific pattern of physical changes may be observed on chest X-ray. But COPD may exist with or without emphysema. Asthma has also been associated with some cases of COPD, and may be part of the disease process that contributes to some forms of the disease. "

Also leads are generally kept to four paragraphs. And this is best dealt with in the body of the article IMO. Doc James (talk · contribs · email) 18:37, 9 April 2016 (UTC)

Quotes to support

What quotes from the ref provided supports this:

"COPD is a disorder which combines components of various other conditions such as asthma, chronic bronchitis, emphysema or airway obstruction, with each of these conditions being important when considering the final process of COPD. These components determine the presentation, treatment and management of the disease as a result."

Also why are we using a review from 2002. http://www.ncbi.nlm.nih.gov/pubmed/12010839

There are newer sources. Doc James (talk · contribs · email) 19:18, 11 April 2016 (UTC)

Quote

Added a quote to support from 2013 review.

Moved this here "Smoking tobacco out of a water pipe does not reduce risk of developing COPD compared to smoking cigarettes . The risk of developing COPD from marijuana smoke is less clear. A study of 878 adults in Vancouver found that smoking only marijuana was not associated with an increased risk of COPD . In an analysis of multiple studies evaluating pulmonary obstruction , there was no consistent association found between long term marijuana use and obstruction measures. There was an association found between long-term marijuana use and respiratory symptoms (e.g. cough, phlegm). Though it is important to note that the selected studies were "variable in their overall quality (e.g. controlling for confounders, including tobacco smoking).""

Doc James (talk · contribs · email) 00:04, 22 July 2016 (UTC)

As the original author of this quoted edit, I feel compelled to respond to the subsequent changes here. The Vestbo et al. journal article that was cited at the time and which is now again the main citation does indeed state "Other types of tobacco (e.g., pipe, cigar, water pipe (14)) and marijuana (15) are also risk factors for COPD (16, 17)."

But, this implies either that non-cigarette tobacco smoking and marijuana smoking confer the same risk (i.e. "other types of tobacco and marijuana are also risk factors"), or that the risks of non-cigarette tobacco smoking and marijuana smoking are undefined (i.e. "a risk" without quantification).

However, the articles cited in the original source to support this statement do not support either implication:

(14) The Raad, et al. study on water-pipe smoking does not discuss marijuana smoking, and finds no statistically significant difference in the risk factors compared to cigarette smoking (i.e. smoking tobacco from a water pipe is just as dangerous as smoking cigarettes, not an undefined or unspecified risk).

(15) The Tan, et al. study on marijuana smoking only found an increased risk in those who smoked marijuana and tobacco concurrently, whereas it found no increase in COPD risk among those study participants who reported smoking only marijuana.

(16) The WHO study focuses exclusively on smoking tobacco out of water-pipes and reaches the same conclusions as the Raad, et al. study mentioned above.

(17) The Tetrault, et al. citation is a review of multiple studies on the effects of marijuana smoking on pulmonary function and as such draws on a larger pool of marijuana users than the Tan, et al. study mentioned above. However, even though the 14 studies on long-term marijuana use all noted an association between long-term marijuana use and "respiratory symptoms", the authors also note that the studies under review varied in quality, specifically mentioning a failure to control for the confounding effects of concurrent tobacco smoke. This result would be entirely in-line with the speculation in the Tan, et al. study that the bronchodilation caused by marijuana smoking exacerbates the harmful effects of tobacco smoke.

In light of this information, I am at a loss to understand why the original quote and citation from Vestbo et al. was restored. I feel that, at the very least, my language indicating water-pipe tobacco smokers and cigarette smokers have statistically the same risk of developing COPD is more accurate than the Vestbo et al. quote which implies a vague and unspecified risk. Furthermore, in view of Tan, et al. and Tetrault, et al., I feel that my language stating that "the risk of developing COPD from marijuana smoking is less clear" is a more accurate representation of the findings cited by the Vestbo, et al. article.

216.254.255.219 (talk) 23:13, 29 July 2016 (UTC)

edited to conform to formatting guidelines 216.254.255.219 (talk) 00:13, 30 July 2016 (UTC)

That the review article cited supports it is sufficient. We do not typically try to figure out if the review article is correct or not.

It appears cannabis smoke and cigs is worse than cigs alone (so cannabis increases the risk).

And there is tentative evidence that "Long-term marijuana smoking is associated with increased respiratory symptoms suggestive of obstructive lung disease." Doc James (talk · contribs · email) 07:07, 30 July 2016 (UTC)

Have added "Problems from marijuana smoke may only be with heavy use." Thoughts? Doc James (talk · contribs · email) 08:37, 30 July 2016 (UTC)

I realize that calling foul on the citations of a citation is unusual; I never would have looked into the review article's citations if I had not been trying to quantify "are also risk factors" for my personal edification. It appears that the best way to describe the current understanding of the COPD risk of cannabis smoke is that it has a catalytic effect upon the COPD risk posed by tobacco smoke, rather than increasing the risk per se. Still, "may only be with heavy use" seems like a concise and accurate representation, though I lack the institutional and personal resources to view the full text of Joshi, et al.

I'm still concerned that the language quoted from the abstract of Vestbo, et al. implies that "other types of tobacco smoke" and "marijuana smoke" are both undefined risks. The Vestbo, et al. citation of Raad, et al. at "other types of tobacco smoke" in fact only addresses water-pipe tobacco smoking of the three types of tobacco smoking mentioned, and Raad, et al. quite clearly finds that water-pipe tobacco smoke is just as dangerous as cigarette tobacco smoke. And since the studies and reviews of marijuana smoke use language like "tentative" and "suggestive" and "did not control for tobacco smoke", it doesn't seem accurate to structure the sentence that way.

I would advocate something like the following, "Other methods of smoking tobacco (e.g. water-pipe) are no safer than cigarettes. Those smoking both marijuana and tobacco have an increased COPD risk relative to those who smoke tobacco alone. The COPD risk posed by smoking marijuana alone appears to be less than tobacco alone, but it is not as well-studied as the risk posed by tobacco. Habitual marijuana smoking is not harmless, however, and avoiding regular heavy use is wise." Reasonable?

216.254.255.219 (talk) 11:00, 30 July 2016 (UTC)

Have added "Water pipe smoke appears to be as harmful as smoking cigarettes."

Wording like "avoiding regular heavy use is wise" is a little to POV IMO.

Am inclined to stick with just the secondary sources. Doc James (talk · contribs · email) 11:10, 30 July 2016 (UTC)

Agree that my draft language is suggestive of POV. Was attempting to paraphrase the Joshi, et al. abstract. These most recent edits resolve all of my concerns. Thanks for your leadership here, and for being accommodating to this neophyte.

216.254.255.219 (talk) 22:29, 30 July 2016 (UTC)

Happy to have you here :-) Doc James (talk · contribs · email) 07:00, 31 July 2016 (UTC)