Comment
(panel).4 However, these factors should not be viewed as circumstances that are beyond control. Hospice care is clearly defined (less than 6 months to live, as established by a physician) and understood by most adults, but palliative care, which has no time constraints, is often misunderstood and presumed by many to be synonymous with hospice care. When patients correlate hospice with death, and presume hospice and palliative care are the same or similar, they might be resistant to finding out what palliative care services have to offer. Therefore, the difference needs to be better explained to patients. Both hospice and palliative care are integral to care of the dying patient. Even though palliative care is associated with improved outcomes for patients and families,5 it is underused. Early palliative care improves quality of life and extends survival in patients with non-small-cell lung cancer,6 yet has not become a standard of care for patients with endstage pulmonary disease. Early palliative interventions can make a great difference in quality of life, when quantity of life is going to be shortened by disease. Pistoria7 outlined the results of research into end-oflife decisions made by physicians. In a survey of almost 800 physicians, nearly 90% would not want to receive cardiopulmonary resuscitation if they were in a chronic coma, compared with only 25% of members of the public who would not desire so-called heroic measures.7 Physicians know about the likelihood of success and outcomes of various resuscitative interventions, but patients and families do not fully understand the potential results of decisions that they make about end-of-life care. Given accurate information about the expected course of disease and options for care in a timely manner, patients with pulmonary disease might respond unexpectedly. They might choose comfort over pain, rehabilitation over the sofa, and home over the intensive care unit.
Panel: Perceived barriers to palliative care in chronic obstructive pulmonary disorder4 Patient factors • Unwillingness to discuss end of life • Poor understanding of palliative-care principles • Communication issues or language barriers Physician factors • Uncertainty about prognosis • Scarce resources or time constraints • Poor understanding of palliative-care principles • Commitment to preserve life at all costs Therapist factors • Poor understanding of palliative-care principles • No palliative care order in chart • Fear of reprisal by physician or supervisor
Health-care professionals need to start educating about the goals of palliative care early at the same time as providing appropriate curative care, to give patients with lung disease the very best that can be offered. Helen M Sorenson University of Texas Health Science Center, San Antonio, TX 78229–3900, USA [email protected] I declare that I have no conflicts of interest. 1 2 3 4 5 6 7
Clark D. From margins to centre: a review of the history of palliative care in cancer. Lancet Oncol 2007; 8: 430–38. Byock I. The best care possible: a physician’s quest to transform care through the end of life. New York, NY: Penguin, 2012. Carlucci A, Guerrieri A, Nava S. Palliative care in COPD patients: is it only an end-of-life issue? Eur Respir Rev 2012; 21: 346–54. Spence A, Hasson F, Waldron M, et al. Professionals delivering palliative care to people with COPD: a qualitative study. Palliat Med 2009; 23: 126–31. Litrivis E, Smith CB. Palliative care: a primer. Mt Sinai J Med 2011; 78: 627–31. Temel JS, Greer JA, Muzikansky MA, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med 2010; 363: 733–42. Pistoria MJ. Why should doctors die differently? March, 2013. http://www. nxtbook.com/nxtbooks/elsevier/chest_201303/index.php?startid=4 (accessed May 3, 2013).
Neonatal respiratory care: not how, but where and when See News page 288
280
In 1963, US President John F Kennedy’s son Patrick was born at 34 weeks’ gestation with a birth weight of 2100 g. He died 3 days later from complications of hyaline membrane disease. At the time, treatment of newborn babies with respiratory distress was limited to supplemental oxygen. In the next 30 years, neonatology was revolutionised by the introduction of antenatal
corticosteroids to enhance fetal lung maturation, continuous positive airway pressure, invasive mechanical ventilation, and surfactant replacement therapy. By the early 1990s, survival had become the expected outcome for most infants with hyaline membrane disease, and the limit of viability had reached 24 weeks. Although mortality of premature infants was decreasing, www.thelancet.com/respiratory Vol 1 June 2013
bronchopulmonary dysplasia was still the most common complication in survivors of extreme prematurity. When volutrauma, atelectrauma (ie, alveolar damage due to repeated closure and opening of alveoli), and oxygen toxicity began to be recognised as important factors contributing to ventilator-induced lung injury, lung-protective ventilation strategies and increasingly advanced ventilators were developed to decrease the incidence and severity of bronchopulmonary dysplasia. In the past decade, many large-scale randomised trials (eg, the SUPPORT1 and UKOS2 trials) have investigated the lung-protective roles of high-frequency ventilation, non-invasive respiratory support, inhaled nitric oxide treatment, and alternative methods of surfactant administration. The results of these studies were less than spectacular: none showed a significant reduction in death or bronchopulmonary dysplasia. Further refinements of present technologies will probably not result in major breakthroughs for newborn babies in high-income countries. By contrast, there is huge potential for improvements in low-income and middle-income countries. According to estimates from the Child Health Epidemiology Reference Group of WHO and UNICEF, 7·6 million children worldwide died in 2010 before reaching their fifth birthday, and 3·072 million (40%) were newborn babies (aged 0–27 days).3 Of these neonatal deaths, 1·078 million (35%) were caused by preterm birth complications, 0·717 million (23%) by intrapartumrelated complications (formerly called perinatal asphyxia), 0·393 million (13%) by neonatal sepsis, and 0·325 million (11%) by pneumonia.3 A staggering 99% of the global burden of neonatal mortality occurs in low-income and middle-income countries.4 In 2000, the UN Millennium Declaration, which included eight millennium development goals (MDGs), was adopted by 191 countries. The aim of MDG 4 is to reduce child mortality by two-thirds of the 1990 level by 2015. In 2012, I was invited to visit the Hôpital Méthodiste de Dabou in Côte d’Ivoire, and witnessed the challenges faced by medical staff providing neonatal care in lowincome countries. At the time of its independence in 1960, Côte d’Ivoire was the most prosperous nation in French West Africa. Unfortunately, civil wars in 2002, and 2011, and continuing political unrest have since ravaged the country and led to enormous poverty. By 2012, the health-care system had virtually collapsed www.thelancet.com/respiratory Vol 1 June 2013
Mauro Fermariello/Science Photo Library
Comment
and the country’s universities in Abidjan and Bouaké had only recently reopened. Infant mortality is 89 per 1000 livebirths and under-five mortality 127 per 1000 livebirths (MDG 4 sets the target for under-five mortality of 52 per 1000 livebirths).5 The estimated neonatal mortality is 41 per 1000 live births.6 A review of the neonatology unit admission book at the Hôpital Méthodiste de Dabou in 2012 established that mortality was 41%. The leading causes of death were disorders that are frequently associated with respiratory failure: prematurity, asphyxia, early-onset sepsis, and pneumonia. Most of these patients were near-term or term infants. Because of the poor infrastructure of hospitals such as the Hôpital Méthodiste de Dabou, both assessment and treatment of newborn babies presenting with respiratory distress are seriously restricted. Poor laboratory and radiography facilities mean that diagnoses are based solely on the patient’s history and clinical examinations. The only treatment option for newborn infants with respiratory distress is often supplemental oxygen, and its dosing is based on clinical assessment of the infant’s colour. The diagnostic and therapeutic possibilities are therefore comparable with what was available in the USA and Europe in the 1950s. Although basic resuscitation has been shown to be beneficial in low-income and middle-income countries,7 transfer of knowledge and technology to implement other straightforward pharmacological interventions and basic respiratory support strategies could have a large effect on the prognosis of newborn babies with respiratory failure. Widespread use of antenatal corticosteroids for women at risk of preterm birth could save up to 500 000 neonatal lives annually.8 Infants of low birthweight would probably benefit from caffeine for prevention of apnoea of prematurity. On the basis of the experience of high-income countries between 1960 and 1980, Kamath and colleagues have estimated that the introduction of supplemental oxygen and continuous positive airway pressure alone could increase survival of newborn babies with respiratory distress syndrome in low-income countries from close to 0% to 70%.9 Paul and Singh have proposed a stepwise approach to neonatal health-care strategies in developing countries on the basis of reported national neonatal mortality.10 For countries with neonatal mortality of more than 25 per 1000 livebirths, the focus should be on community-based care.11 Once neonatal mortality is less than 25 per 1000 281
Comment
livebirths, perinatal care should be provided by a network of facilities close to the community that is managed by midwives, nurses, and physicians, and is coupled with an effective outreach programme. At this stage, widespread implementation of low-cost, robust respiratory technologies (eg, oxygen concentrators, oxygen saturation monitoring, bubble continuous positive airway pressure) would assume increased importance and undoubtedly save the lives of many newborn infants admitted to the facilities.7,12–14 It is deplorable that international neonatal research continues to focus on expensive multicentre trials that address health issues that are relevant only to a small number of newborn babies worldwide, whereas questions about successful implementation of effective interventions and low-cost technologies in low-income and middle-income countries remain unanswered.15
1 2
3
4 5 6
7
8
9
10 11
Thomas M Berger Neonatal and Paediatric Intensive Care Unit, Children’s Hospital of Lucerne, CH-6000 Lucerne, Switzerland [email protected] I declare that I have no conflicts of interest. I thank Sabine Meier, paediatric nurse and member of a Swiss medical team who visited the Hôpital Méthodiste de Dabou in December 2012, for extracting statistical data from the neonatology unit admission book; and the local medical staff for their hospitality and the chance to get an impression of the immense challenges physicians and nurses face in their daily work.
12
13 14
15
Finer NN, Carlo WA, Walsh MC, et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010; 362: 1970–79. Johnson AH, Peacock JL, Greenough A, et al, for the United Kingdom Oscillation Study Group. High-frequency oscillatory ventilation for the prevention of chronic lung disease of prematurity. N Engl J Med 2002; 347: 633–42. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 2012; 379: 2151–61. Lawn JE, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900. UNICEF. UNICEF: Côte d’Ivoire 2009–2013. http://www.unicef.org/cote divoire/UNICEF_Briefing_Pack_2009_2013_En.pdf (accessed April 18, 2013). Countdown to 2015. Countdown to 2015 profile: Côte d’Ivoire. 2012. http://www.countdown2015mnch.org/country-profiles/cote-d-ivoire (accessed May 10, 2013). Wall SN, Lee AC, Niermeyer S, et al. Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet 2009; 107 (suppl 1): S47–62. Mwansa-Kambafwile J, Cousens S, Hansen T, Lawn JE. Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth. Int J Epidemiol 2010; 39 (suppl 1): i122–33. Kamath BD, Macguire ER, McClure EM, Goldenberg RL, Jobe AH. Neonatal mortality from respiratory distress syndrome: lessons for low-resource countries. Pediatrics 2011; 127: 1139–46. Paul VK, Singh M. Regionalized perinatal care in developing countries. Semin Neonatol 2004; 9: 117–24. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999; 354: 1955–61. Koyamaibole L, Kado J, Qovu JD, Colquhoun S, Duke T. An evaluation of bubble-CPAP in a neonatal unit in a developing country: effective respiratory support that can be applied by nurses. J Trop Pediatr 2006; 52: 249–53. Wyatt J. Appropriate medical technology for perinatal care in low-resource countries. Ann Trop Pediatr 2008; 28: 243–51. Darmstadt GL, Bhutta ZA, Cousens S, et al. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365: 977–88. Lawn JE, Cousens SN, Darmstadt GL, et al. 1 year after The Lancet Neonatal Survival Series—was the call for action heard? Lancet 2006; 367: 1541–47.
Ian Boddy/Science Photo Library
Does COPD begin in childhood?
Published Online April 23, 2013 http://dx.doi.org/10.1016/ S2213-2600(13)70049-3
282
Chronic obstructive pulmonary disease (COPD) is strongly linked to behavioural and environmental exposures that occur mainly in adulthood. Almost exclusively diagnosed in adults, the disorder is characterised by symptoms and functional impairment that, in most cases, begin after the third decade of life. As such, COPD is an adult illness. However, growing attention is being given to the idea that factors and developmental processes that occur in childhood could predispose individuals to the disorder. Work by Burrows and colleagues1 in the 1970s showed that adults with COPD were more likely to recall respiratory illnesses in childhood than were individuals without COPD. In the past decade, prospective studies robust to recall bias have provided longitudinal evidence for this association, showing that active asthma is a strong and independent risk
factor for COPD, and that, in individuals with childhood asthma who develop persistent airflow limitation in adulthood, a large proportion of lung function deficits are already established by young adult life.2 These findings are in line with results from longitudinal paediatric studies: lung function deficits in children with persistent wheezing and asthma have been shown to continue up to mid-adulthood in the Dunedin3 and Melbourne4 cohorts. In the prospective Children’s Respiratory Study,5 airflow in 22-year-old adults was inversely related to poor airway function measured as early as 2 months after birth. Thus, prospective studies have established that lung function at birth is associated with that in childhood and young adulthood, and children with asthma and asthma-like symptoms have early lung function deficits that could put them at risk for COPD in later www.thelancet.com/respiratory Vol 1 June 2013
(panel).4 However, these factors should not be viewed as circumstances that are beyond control. Hospice care is clearly defined (less than 6 months to live, as established by a physician) and understood by most adults, but palliative care, which has no time constraints, is often misunderstood and presumed by many to be synonymous with hospice care. When patients correlate hospice with death, and presume hospice and palliative care are the same or similar, they might be resistant to finding out what palliative care services have to offer. Therefore, the difference needs to be better explained to patients. Both hospice and palliative care are integral to care of the dying patient. Even though palliative care is associated with improved outcomes for patients and families,5 it is underused. Early palliative care improves quality of life and extends survival in patients with non-small-cell lung cancer,6 yet has not become a standard of care for patients with endstage pulmonary disease. Early palliative interventions can make a great difference in quality of life, when quantity of life is going to be shortened by disease. Pistoria7 outlined the results of research into end-oflife decisions made by physicians. In a survey of almost 800 physicians, nearly 90% would not want to receive cardiopulmonary resuscitation if they were in a chronic coma, compared with only 25% of members of the public who would not desire so-called heroic measures.7 Physicians know about the likelihood of success and outcomes of various resuscitative interventions, but patients and families do not fully understand the potential results of decisions that they make about end-of-life care. Given accurate information about the expected course of disease and options for care in a timely manner, patients with pulmonary disease might respond unexpectedly. They might choose comfort over pain, rehabilitation over the sofa, and home over the intensive care unit.
Panel: Perceived barriers to palliative care in chronic obstructive pulmonary disorder4 Patient factors • Unwillingness to discuss end of life • Poor understanding of palliative-care principles • Communication issues or language barriers Physician factors • Uncertainty about prognosis • Scarce resources or time constraints • Poor understanding of palliative-care principles • Commitment to preserve life at all costs Therapist factors • Poor understanding of palliative-care principles • No palliative care order in chart • Fear of reprisal by physician or supervisor
Health-care professionals need to start educating about the goals of palliative care early at the same time as providing appropriate curative care, to give patients with lung disease the very best that can be offered. Helen M Sorenson University of Texas Health Science Center, San Antonio, TX 78229–3900, USA [email protected] I declare that I have no conflicts of interest. 1 2 3 4 5 6 7
Clark D. From margins to centre: a review of the history of palliative care in cancer. Lancet Oncol 2007; 8: 430–38. Byock I. The best care possible: a physician’s quest to transform care through the end of life. New York, NY: Penguin, 2012. Carlucci A, Guerrieri A, Nava S. Palliative care in COPD patients: is it only an end-of-life issue? Eur Respir Rev 2012; 21: 346–54. Spence A, Hasson F, Waldron M, et al. Professionals delivering palliative care to people with COPD: a qualitative study. Palliat Med 2009; 23: 126–31. Litrivis E, Smith CB. Palliative care: a primer. Mt Sinai J Med 2011; 78: 627–31. Temel JS, Greer JA, Muzikansky MA, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med 2010; 363: 733–42. Pistoria MJ. Why should doctors die differently? March, 2013. http://www. nxtbook.com/nxtbooks/elsevier/chest_201303/index.php?startid=4 (accessed May 3, 2013).
Neonatal respiratory care: not how, but where and when See News page 288
280
In 1963, US President John F Kennedy’s son Patrick was born at 34 weeks’ gestation with a birth weight of 2100 g. He died 3 days later from complications of hyaline membrane disease. At the time, treatment of newborn babies with respiratory distress was limited to supplemental oxygen. In the next 30 years, neonatology was revolutionised by the introduction of antenatal
corticosteroids to enhance fetal lung maturation, continuous positive airway pressure, invasive mechanical ventilation, and surfactant replacement therapy. By the early 1990s, survival had become the expected outcome for most infants with hyaline membrane disease, and the limit of viability had reached 24 weeks. Although mortality of premature infants was decreasing, www.thelancet.com/respiratory Vol 1 June 2013
bronchopulmonary dysplasia was still the most common complication in survivors of extreme prematurity. When volutrauma, atelectrauma (ie, alveolar damage due to repeated closure and opening of alveoli), and oxygen toxicity began to be recognised as important factors contributing to ventilator-induced lung injury, lung-protective ventilation strategies and increasingly advanced ventilators were developed to decrease the incidence and severity of bronchopulmonary dysplasia. In the past decade, many large-scale randomised trials (eg, the SUPPORT1 and UKOS2 trials) have investigated the lung-protective roles of high-frequency ventilation, non-invasive respiratory support, inhaled nitric oxide treatment, and alternative methods of surfactant administration. The results of these studies were less than spectacular: none showed a significant reduction in death or bronchopulmonary dysplasia. Further refinements of present technologies will probably not result in major breakthroughs for newborn babies in high-income countries. By contrast, there is huge potential for improvements in low-income and middle-income countries. According to estimates from the Child Health Epidemiology Reference Group of WHO and UNICEF, 7·6 million children worldwide died in 2010 before reaching their fifth birthday, and 3·072 million (40%) were newborn babies (aged 0–27 days).3 Of these neonatal deaths, 1·078 million (35%) were caused by preterm birth complications, 0·717 million (23%) by intrapartumrelated complications (formerly called perinatal asphyxia), 0·393 million (13%) by neonatal sepsis, and 0·325 million (11%) by pneumonia.3 A staggering 99% of the global burden of neonatal mortality occurs in low-income and middle-income countries.4 In 2000, the UN Millennium Declaration, which included eight millennium development goals (MDGs), was adopted by 191 countries. The aim of MDG 4 is to reduce child mortality by two-thirds of the 1990 level by 2015. In 2012, I was invited to visit the Hôpital Méthodiste de Dabou in Côte d’Ivoire, and witnessed the challenges faced by medical staff providing neonatal care in lowincome countries. At the time of its independence in 1960, Côte d’Ivoire was the most prosperous nation in French West Africa. Unfortunately, civil wars in 2002, and 2011, and continuing political unrest have since ravaged the country and led to enormous poverty. By 2012, the health-care system had virtually collapsed www.thelancet.com/respiratory Vol 1 June 2013
Mauro Fermariello/Science Photo Library
Comment
and the country’s universities in Abidjan and Bouaké had only recently reopened. Infant mortality is 89 per 1000 livebirths and under-five mortality 127 per 1000 livebirths (MDG 4 sets the target for under-five mortality of 52 per 1000 livebirths).5 The estimated neonatal mortality is 41 per 1000 live births.6 A review of the neonatology unit admission book at the Hôpital Méthodiste de Dabou in 2012 established that mortality was 41%. The leading causes of death were disorders that are frequently associated with respiratory failure: prematurity, asphyxia, early-onset sepsis, and pneumonia. Most of these patients were near-term or term infants. Because of the poor infrastructure of hospitals such as the Hôpital Méthodiste de Dabou, both assessment and treatment of newborn babies presenting with respiratory distress are seriously restricted. Poor laboratory and radiography facilities mean that diagnoses are based solely on the patient’s history and clinical examinations. The only treatment option for newborn infants with respiratory distress is often supplemental oxygen, and its dosing is based on clinical assessment of the infant’s colour. The diagnostic and therapeutic possibilities are therefore comparable with what was available in the USA and Europe in the 1950s. Although basic resuscitation has been shown to be beneficial in low-income and middle-income countries,7 transfer of knowledge and technology to implement other straightforward pharmacological interventions and basic respiratory support strategies could have a large effect on the prognosis of newborn babies with respiratory failure. Widespread use of antenatal corticosteroids for women at risk of preterm birth could save up to 500 000 neonatal lives annually.8 Infants of low birthweight would probably benefit from caffeine for prevention of apnoea of prematurity. On the basis of the experience of high-income countries between 1960 and 1980, Kamath and colleagues have estimated that the introduction of supplemental oxygen and continuous positive airway pressure alone could increase survival of newborn babies with respiratory distress syndrome in low-income countries from close to 0% to 70%.9 Paul and Singh have proposed a stepwise approach to neonatal health-care strategies in developing countries on the basis of reported national neonatal mortality.10 For countries with neonatal mortality of more than 25 per 1000 livebirths, the focus should be on community-based care.11 Once neonatal mortality is less than 25 per 1000 281
Comment
livebirths, perinatal care should be provided by a network of facilities close to the community that is managed by midwives, nurses, and physicians, and is coupled with an effective outreach programme. At this stage, widespread implementation of low-cost, robust respiratory technologies (eg, oxygen concentrators, oxygen saturation monitoring, bubble continuous positive airway pressure) would assume increased importance and undoubtedly save the lives of many newborn infants admitted to the facilities.7,12–14 It is deplorable that international neonatal research continues to focus on expensive multicentre trials that address health issues that are relevant only to a small number of newborn babies worldwide, whereas questions about successful implementation of effective interventions and low-cost technologies in low-income and middle-income countries remain unanswered.15
1 2
3
4 5 6
7
8
9
10 11
Thomas M Berger Neonatal and Paediatric Intensive Care Unit, Children’s Hospital of Lucerne, CH-6000 Lucerne, Switzerland [email protected] I declare that I have no conflicts of interest. I thank Sabine Meier, paediatric nurse and member of a Swiss medical team who visited the Hôpital Méthodiste de Dabou in December 2012, for extracting statistical data from the neonatology unit admission book; and the local medical staff for their hospitality and the chance to get an impression of the immense challenges physicians and nurses face in their daily work.
12
13 14
15
Finer NN, Carlo WA, Walsh MC, et al. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010; 362: 1970–79. Johnson AH, Peacock JL, Greenough A, et al, for the United Kingdom Oscillation Study Group. High-frequency oscillatory ventilation for the prevention of chronic lung disease of prematurity. N Engl J Med 2002; 347: 633–42. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 2012; 379: 2151–61. Lawn JE, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900. UNICEF. UNICEF: Côte d’Ivoire 2009–2013. http://www.unicef.org/cote divoire/UNICEF_Briefing_Pack_2009_2013_En.pdf (accessed April 18, 2013). Countdown to 2015. Countdown to 2015 profile: Côte d’Ivoire. 2012. http://www.countdown2015mnch.org/country-profiles/cote-d-ivoire (accessed May 10, 2013). Wall SN, Lee AC, Niermeyer S, et al. Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet 2009; 107 (suppl 1): S47–62. Mwansa-Kambafwile J, Cousens S, Hansen T, Lawn JE. Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth. Int J Epidemiol 2010; 39 (suppl 1): i122–33. Kamath BD, Macguire ER, McClure EM, Goldenberg RL, Jobe AH. Neonatal mortality from respiratory distress syndrome: lessons for low-resource countries. Pediatrics 2011; 127: 1139–46. Paul VK, Singh M. Regionalized perinatal care in developing countries. Semin Neonatol 2004; 9: 117–24. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999; 354: 1955–61. Koyamaibole L, Kado J, Qovu JD, Colquhoun S, Duke T. An evaluation of bubble-CPAP in a neonatal unit in a developing country: effective respiratory support that can be applied by nurses. J Trop Pediatr 2006; 52: 249–53. Wyatt J. Appropriate medical technology for perinatal care in low-resource countries. Ann Trop Pediatr 2008; 28: 243–51. Darmstadt GL, Bhutta ZA, Cousens S, et al. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365: 977–88. Lawn JE, Cousens SN, Darmstadt GL, et al. 1 year after The Lancet Neonatal Survival Series—was the call for action heard? Lancet 2006; 367: 1541–47.
Ian Boddy/Science Photo Library
Does COPD begin in childhood?
Published Online April 23, 2013 http://dx.doi.org/10.1016/ S2213-2600(13)70049-3
282
Chronic obstructive pulmonary disease (COPD) is strongly linked to behavioural and environmental exposures that occur mainly in adulthood. Almost exclusively diagnosed in adults, the disorder is characterised by symptoms and functional impairment that, in most cases, begin after the third decade of life. As such, COPD is an adult illness. However, growing attention is being given to the idea that factors and developmental processes that occur in childhood could predispose individuals to the disorder. Work by Burrows and colleagues1 in the 1970s showed that adults with COPD were more likely to recall respiratory illnesses in childhood than were individuals without COPD. In the past decade, prospective studies robust to recall bias have provided longitudinal evidence for this association, showing that active asthma is a strong and independent risk
factor for COPD, and that, in individuals with childhood asthma who develop persistent airflow limitation in adulthood, a large proportion of lung function deficits are already established by young adult life.2 These findings are in line with results from longitudinal paediatric studies: lung function deficits in children with persistent wheezing and asthma have been shown to continue up to mid-adulthood in the Dunedin3 and Melbourne4 cohorts. In the prospective Children’s Respiratory Study,5 airflow in 22-year-old adults was inversely related to poor airway function measured as early as 2 months after birth. Thus, prospective studies have established that lung function at birth is associated with that in childhood and young adulthood, and children with asthma and asthma-like symptoms have early lung function deficits that could put them at risk for COPD in later www.thelancet.com/respiratory Vol 1 June 2013
