Monitoring and Diagnosis of Exacerbation
Patients with significant respiratory disease other than COPD, such as bronchiectasis, were excluded. The study had ethics approval from the Royal Free Hospital National Health Service Trust (09/H0720/8), and patients provided written informed consent.
Recruitment and Generic Viagra
At recruitment, a history was taken of smoking habits (pack years of smoking and current smoking status), and patients were asked if they produced sputum for > 3 months per year. Measurements were made of FEV: and FVC using a routinely calibrated rolling seal spirometer (Sensor Medics Corp) or volumetric storage spirometer (Vitalograph 2160; Maids Moreton).
Monitoring and Diagnosis of Exacerbation
Patients were instructed to record each morning on daily diary cards any increase over normal levels in their respiratory symptoms. Major symptoms were dyspnea, sputum purulence, or sputum volume, and minor symptoms were coryza (nasal dis-charge/congestion), wheeze, sore throat, and cough. From March 1996, the patients also recorded hours spent outside the home.
Onset of exacerbation was identified as the first of >2 consecutive days with an increase in either two major symptoms or one major and one minor symptom. Exacerbations were treated according to the prevailing guidelines and clinical judgment, and records were kept of whether the exacerbation involved admission to the hospital. Treatment delay was defined as the time between exacerbation onset and physician consultation, and hospital delay as the time between onset and admission.
Exacerbation Recovery, Frequency, and Symptoms
Exacerbation recovery was defined as the number of days after onset that symptoms persisted. If no symptoms were recorded on a single day but the day with no symptoms was bracketed by days when symptoms were present, the exacerbation was considered to be continuing throughout. Thus, 2 symptom-free days defined the end of the exacerbation. To examine whether prolonged exacerbation recovery was due only to prolonged minor symptoms, recovery was additionally defined as the duration for which major symptoms were present. The maximum duration of an exacerbation was capped at 100 days.