Book Review

Chronic Obstructive Pulmonary Disease

N Engl J Med 1995; 333:1430-1431November 23, 1995

Article

Chronic Obstructive Pulmonary Disease
Edited by P.M.A. Calverley and N.B. Pride. 579 pp., illustrated. New York, Chapman & Hall, 1995. $135. ISBN: 0-412-46450-0

As the editors point out in their preface, the prevalence of chronic obstructive pulmonary disease among adults is similar to that of asthma — and the associated mortality rate is some 25 times higher — yet it is accorded much less attention by funding agencies, textbook writers, and many clinicians. Admittedly, chronic obstructive pulmonary disease is less glamorous than asthma, and there remain strong beliefs not only that the illness is mainly the patient's own doing (through years of cigarette smoking) but also that there is little the practitioner can do to help. This excellent, comprehensive textbook should go a long way toward dispelling these impressions, particularly the latter.

Two thirds of the book consists of state-of-the-art reviews of the scientific underpinnings of chronic obstructive pulmonary disease; these chapters address the epidemiologic, structural, and physiologic aspects of the disorder and include all the important facets of chronic obstructive pulmonary disease. The reviews are sufficiently comprehensive (with extensive references) to serve as a resource for the academic specialist preparing a seminar, yet they do not dwell on technical details or primary data to a degree that would discourage the primary care giver seeking a greater understanding of an individual patient's condition. The focus in these chapters is on current knowledge of the mechanisms or effects under discussion; the authors do not discuss direct clinical applications. This omission would be a distinct drawback from the clinician's perspective were it not for the remaining chapters, which offer practical guidance in the care of patients, often including the author's own approach.

The chapter on clinical and laboratory assessment is comprehensive and practical. Included are not only discussions of individual symptoms and signs in chronic obstructive pulmonary disease but also good descriptions of the various clinical presentations of the disorder and the relation between clinical and physiologic manifestations. The tables clarifying the definitions and implications of the individual measurements obtained during spirometry and cycle ergometry are especially helpful. Useful diagrams show how to confirm adequate effort by the patient and common patterns of technically inadequate tracings on spirograms and flow–volume loops. Included in the chapter are a guide to differential diagnosis, an approach to the general clinical assessment of patients with chronic obstructive pulmonary disease, and a brief discussion of preoperative assessment for thoracic and nonthoracic surgery.

Bronchodilator therapy, the keystone of management in chronic obstructive pulmonary disease, is discussed in two chapters, the first on basic pharmacology and the second on symptomatic bronchodilator treatment. Both are excellent, and the latter offers a reasonable, practical approach to the use of the various classes of bronchodilators in patients. The chapter on corticosteroid therapy presents a comprehensive review of the available clinical data but unfortunately stops short of offering practical guidance on this crucial aspect of management. Other chapters that are especially well done from both the scientific and the practical perspectives are those on sleep in chronic obstructive pulmonary disease, smoking cessation, and bullous lung disease.

The chapter on acute respiratory failure is more didactic than the others, perhaps reflecting the inconclusive data base on which management rests. There are good discussions of inspiratory muscle fatigue and dynamic hyperinflation, including guidance in managing these important but still underappreciated phenomena. The discussion of mechanical ventilation is sound but seems dated in its reference to pressure-support ventilation as a “new mode,” one that lacks a backup rate for patients with uncertain ventilatory drive. There is no mention of pressure-control ventilation, which is also well established and can readily circumvent this problem.

The editors of this book and two thirds of its contributors are British but both the editors and the publisher have taken great care to make it user-friendly and applicable to practice on this side of the Atlantic. This effort has generally succeeded. Most of the writing has the clarity and elegance typical of British textbooks, but with American spelling, abbreviations, and usage. Only occasionally does “TLCO” creep in instead of “DLCO” for diffusing capacity, “t.d.s.” for “t.i.d.,” and such slips pose no obstacle to the reader.

In terms of content and clinical approach, it was gratifying to see how rarely I thought interpretations or advice would probably be different in the United States. One exception is the chapter on domiciliary oxygen therapy, in which the listed indications include “short-burst oxygen therapy for palliation and temporary relief of symptoms,” and the options for in-home administration include tight-fitting masks requiring a minimal oxygen-flow rate of 4 to 6 liters per minute. This application of oxygen therapy in the home must be restricted to the United Kingdom. A discussion of the economic aspects of long-term oxygen therapy also focuses on British practice, giving all costs in pounds sterling and referring only briefly to the U.S. “Medi-Care programme.” In fact, Medicare exerts a profound influence on the costs and clinical administration of in-home oxygen therapy both in this country and abroad.

This very well done book should be valuable to all clinicians who care for patients with chronic obstructive pulmonary disease. Although the editors state in the preface that they have made no attempt to cover all aspects of this complex disorder, they add, “we hope that the reader will find insights into the scientific basis of this illness and some guidance on the practical care of these patients.” In this aim they have succeeded very well.

David Pierson, M.D.
Harborview Medical Center, Seattle, WA 98104