Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

Global strategy for asthma management and prevention

The discovery that mammalian cells generate nitric oxide, a gas previously considered to be merely an atmospheric pollutant, is providing important information about many biologic processes. Nitric oxide is synthesized from the amino acid L-arginine by a family of enzymes, the nitric oxide synthases, through a hitherto unrecognized metabolic route -- namely, the L-arginine-nitric oxide pathway1–8. The synthesis of nitric oxide by vascular endothelium is responsible for the vasodilator tone that is essential for the regulation of blood pressure. In the central nervous system nitric oxide is a neurotransmitter that underpins several functions, including the formation of memory. . . .

The L-Arginine-Nitric Oxide Pathway

Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

/pdf/allergic-rhinitis-and-its-impact-on-asthma-aria-2008-update-13eqfzaw4u.pdf

Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Resveratrol, a constituent of red wine, has long been suspected to have cardioprotective effects. Interest in this compound has been renewed in recent years, first from its identification as a chemopreventive agent for skin cancer, and subsequently from reports that it activates sirtuin deacetylases and extends the lifespans of lower organisms. Despite scepticism concerning its bioavailability, a growing body of in vivo evidence indicates that resveratrol has protective effects in rodent models of stress and disease. Here, we provide a comprehensive and critical review of the in vivo data on resveratrol, and consider its potential as a therapeutic for humans.

Therapeutic potential of resveratrol: the in vivo evidence.

### Cough

1) All basic scientific articles should refer to cough as a three-phase motor act. For the purposes of acoustic recordings in clinical studies, however, cough should be described as a forced expulsive manoeuvre or manoeuvres against a closed glottis that are associated with a characteristic sound or sounds.

2) All scientific articles should include a clear definition of what the authors have used as their definition of cough.

### Capsaicin and citric acid inhalation cough challenge

1) The methodology for the performance of inhalation cough challenge should be standardised so as to facilitate universal interpretation and comparison of data generated by different laboratories.

2) Comprehensive normal ranges need to be developed using the standardised methodology advocated in the present document.

3) The single-breath concentration–response method using a flow-limited dosimeter is recommended for most experimental protocols.

4) Both C2 and C5 should be recorded.

5) Since there is wide inter-individual variation, cough challenge data have no intrinsic significance, but may usefully be used to follow change in cough reflex sensitivity in an individual.

### Cough induced by inhalation of aqueous solutions

1) Aerosolised aqueous solutions represent a useful experimental tool in cough research.

2) The cough challenge with ultrasonic distilled water (fog) is difficult to standardise since it is highly dependent upon nebuliser output.

3) Consideration should be given to potential adverse events, such as bronchoconstriction and cross-infection.

### Cough monitors

1) No cough monitor is currently the gold standard.

2) Monitors should be developed that are ambulatory, are capable of being digitally processed and permit prolonged (24-h) recording.

3) There is little to commend any particular method of quantifying cough over any other.

### Assessment of quality of life of patients with chronic cough

1) Cough can have profound effects on health status, which can be assessed by cough-specific health status questionnaires.

2) Cough visual analogue scale (VAS, 0–100 mm) should be used to assess cough severity in patients with chronic cough.

3) Patients with chronic cough should be assessed with cough-specific quality-of-life questionnaires in clinical studies.

### Animal models of cough

1) The most useful animal model of cough is …

/pdf/ers-guidelines-on-the-assessment-of-cough-3gr3n85c88.pdf

ERS guidelines on the assessment of cough

Fig. 1.— 
Overview of the evaluation of chronic cough in an adult. ACE-I: angiotensin converting enzyme inhibitor; PEF: peak expiratory flow; PNDS: post-nasal drip syndrome; GORD: gastro-oesophageal reflux disease.





Fig. 2.— 
Therapeutic algorithm. ACE: angiotensin-converting enzyme; GORD: gastro-oesophageal reflux disease.





Fig. 3.— 
Investigational algorithm. CT: computed tomography.





Fig. 4.— 
Diagnostic algorithm for the approach to children with chronic cough. ENT: ear, nose and throat; PFT: pulmonary function testing; BAL: bronchoalveolar lavage; CT: computed tomography; tbc: total blood count; CMV: cytomegalovirus; PCR: polymerase chain reaction; MRI: magnetic resonance imaging; NO: nitric oxide; BHR: bronchial hyperresponsiveness.





CONTENTS



Chronic cough, here defined as a cough of >8 weeks duration, is a common and frequently debilitating symptom 1, 2 that is often viewed as an intractable problem. However, theexperience of specialist cough clinics is that a very high success rate, in the order of 90%, can be achieved (table 1⇓) 3–15. The key to successful management is to establish a diagnosis and to treat the cause of cough. Truly idiopathic cough is rare and misdiagnosis common, particularly because of the failure to recognise that cough is often provoked from sites outside the airway. These guidelines aim to distil the lessons from these reports and provide a framework for a logical care pathway for patients with this highly disabling symptom.

View this table:

Table 1— 
Commonest causes of chronic cough in patients investigated in specialist clinics



There are three common causes of chronic cough that arise from three different anatomical areas. This varied presentation explains the major reason for the success of multidisciplinary cough clinics compared with general clinics 16. As asthma, reflux and rhinitis are the realms of different specialists who have little experience in the diagnosis of conditions outside their expertise, a patient with chronic cough may not undergo full evaluation. This problem is exacerbated by the frequently atypical presentation of …

https://erj.ersjournals.com/content/erj/24/3/481.full.pdf

The diagnosis and management of chronic cough

Neuropeptides in the Respiratory Tract: Part I

Even five years ago few could have realised that the simple gas nitric oxide (NO) would be involved in the regulation of so many physiological functions and pathophysiological processes. There has been an explosion of information about nitric oxide which appears to be involved in an extraordinary range of functions including vascular regulation, neurotransmission, host defence, and cytotoxicity.1 2 An increasing volume of literature has shown the importance of nitric oxide in the regulation of various pulmonary functions and suggested its involvement in several pulmonary diseases.34 The purpose of this review is to highlight some of the recent advances in this rapidly moving field. For over 20 years it has been recognised that the vasodilator responses to many agents are mediated by the release of a vasodilator substance from endothelial cells.5 The identity of endothelium derived relaxant factor (EDRF) remained elusive, largely because of its short half life, until 1987 when two groups independently suggested EDRF had the characteristics of nitric oxide.67 Many were surprised that such a simple molecule could account for all of the actions of EDRF, but extensive investigations in many species have now provided compelling supportive evidence.' Parallel investigations established that nitric oxide was also important in macrophage mediated cytotoxicity.89

https://thorax.bmj.com/content/thoraxjnl/48/10/1034.full.pdf

Maria G. Belvisi

Papers

ERS guidelines on the assessment of cough

The diagnosis and management of chronic cough

Neuropeptides in the Respiratory Tract: Part I

Nitric oxide and lung disease.

Nitric oxide is the endogenous neurotransmitter of bronchodilator nerves in humans.