Ífi^n÷]<;õÁ÷]45mmHg without any delay. NIV reduces the work of breathing by 60%; moreover, it obviates the need for mechanical ventilation, decreases treatment failure and short-term mortality by as much as 50%. Finally mechanical ventilation may be needed in very sick and unstable patients, or in those who either fail or are thought to be unsuitable candidates for NIV. Second National Update on Chronic Obstructive Pulmonary Disease (COPD) Oman Respiratory Society and Sultan Qaboos University 438 | SQU Medical Journal, August 2011, Volume 11, Issue 3 Systemic Effects and Mortality in COPD Yacoub Al-Mahrooqui Department of Medicine, Royal Hospital, Muscat, Oman. Email: yaqpal@yahoo.com. COPD is a systemic disease. In addition to causing pulmonary abnormalities, COPD is associated with systemic consequences outside the lungs. The comorbidities associated with this disease include skeletal muscle dysfunction, cardiovascular disease, osteoporosis, anaemia, metabolic abnormalities, depression and gastrointestinal diseases. Higher rates of hospitalisation are common among COPD patients who have comorbidities. Because these consequences can seriously affect quality of life and worsen prognosis, preventing and treating the systemic effects is important in COPD management. Persistent local and systemic inflammation and oxidative stress may contribute to these changes. Several studies had shown the elevation of various inflammatory markers in COPD like C reactive protein, tumor necrosis factor alpha, fibrinogen, leucocytes and vascular endothelial growth factor. Fat free mass is often low in COPD. Risk of developing ischaemic heart disease or stroke is higher among COPD patients. They are also at risk of developing osteoporosis. The prevalence of diabetes and metabolic syndromes is also higher among COPD patients. Respiratory failure is the leading cause of mortality followed by cardiovascular disease and lung cancer. Validated indices are often used to classify the severity of disease and predict the outcome or mortality. When, forced expiratory volume 1 (FEV1), the widely used prognostic indicator, is low it is associated with an increased risk of all-cause mortality. In summary, in COPD one should look for comorbidities, and in smokers with the above problems look for COPD as well. Non-Pharmacological Management of COPD Dimitrije Ponomarev Department of Medicine, Royal Hospital, Muscat, Oman. Email: dponomarevster@gmail.com. The components of non-pharmacological management of COPD are: 1) Rehabilitation; 2) Oxygen therapy; 3) Ventilatory support, and 4) Surgical management. The goals of rehabilitation include the reduction of symptoms, improvement of quality of life, increasing physical and emotional participation in everyday activities and reducing health care costs by stabilising or reversing the systemic manifestations of the disease. Non-pulmonary problems that cannot be treated by medicines are de-conditioning, relative social isolation, depression, muscle wasting, and weight loss. Rehabilitation programs can contribute to the improvement of exercise capacity, reduction of the perceived intensity of breathlessness, reduction of anxiety and depression, improvement of health-related quality of life, and reduction in the number of hospital admissions and length of hospital stay. Comprehensive pulmonary rehabilitation should involve a team of various medical specialists involved in exercise training, nutrition counselling, education and psychological support. The primary goal of oxygen therapy is to increase the baseline oxygen level to at least 8 kPa (60 mmHg) or to produce a SpO2 of at least 90% in the waking state. In the long term this brings a beneficial effect to haemodynamics, haematological characteristics, exercise capacity, lung mechanics and mental state. The benefits of non-invasive ventilatory support include the improvement of inspiratory flow rate, correction of hypoventilation, rest to respiratory muscles and resetting central respiratory drive. Non-invasive nocturnal positive pressure ventilation is indicated in hypercapnic patients with COPD who have recurrent oxygen desaturation during sleep despite the use of supplemental oxygen; moreover, it is useful in patients recovering from an acute exacerbation that required the use of mechanical ventilation. Surgical management of COPD includes bullectomy and lung volume reduction surgery. Bullectomy is indicated if the bulla occupies ≥50% of the hemithorax and produces definite displacement of the adjacent lung. Lung volume reduction is a recent surgical technique where parts of the lung are removed to reduce hyperinflation which in turn improves the mechanical efficiency of respiratory muscles leading to an improvement in the overall gas exchange. Lung transplantation can be considered in selected patients when forced expiratory volume 1 (FEV1) is less than 25% of the predicted value with features of respiratory failure Smoking Cessation Zahir A. M. Al-Anqoudi Control of Non-Communicable Diseases Section, Directorate General of Health Services - Dakhilyah Region, Nizwa, Oman. Email: alanqoudi@gmail.com. Statistics indicate that it will not be possible to reduce tobacco-related deaths over the next 50 years, unless adult smokers are encouraged to quit. The World Health Organization (WHO) emphasises the need to have a multiple approach strategy including taxation, legislation, a ban on pro-tobacco advocacy and encouraging tobacco cessation rogrammes. The addiction starts with nicotine use for pleasure, enhanced performance and mood regulation and slowly tolerance and physical dependence develop. The process of addiction has three main aspects: physiological, due to nicotine; behavioural, where it is linked to different day-to-day behaviours and psychological, which is seen mostly in patients with depression or anxiety. Unfortunately, although a good percentage of smokers are considering cessation, the medical team somehow fails to reach them. Physicians, especially the primary care providers, have a role in all aspects of care. The “5A” intervention approach serves as a guide: Ask about tobacco use on every visit—this could easily be practised by including this questions in the vital signs chart; Advice patients to quit; Assess willingness to make a quit attempt; Assist by helping the patient formulate a quit plan, and Arrange follow-up contact to prevent relapses. The main step at the level of primary care team is the (Ask) screening. The management of tobacco cessation is a behavioural approach for those with a low Fagerström addiction score and the use of pharmacological therapy in selected cases. The “5R’s” in the behavioural approach are: Relevance, motivational information being more effective if it is relevant to a patient's circumstances; Risks, emphasising the acute and long-term risks of smoking; Rewards, identifying potential benefits of smoking cessation; Roadblocks, detection of the barriers, and Repetition, repeating the motivational interventions at each visit. Drug therapy doubles the chance of long term cessation. This includes several forms of nicotine replacement therapy and Bupropion. The selective serotonin re-uptake inhibitors, Nortriptyline and Naltrexone, are not that effective. The Nizwa Healthy Lifestyle Project, a community based initiative with technical support from the Ministry of Health and the WHO, is running a tobacco cessation clinic staffed by family physicians, nurses, dietitians and dentists. Behavioural and motivational approaches, drug therapy and follow-up telephone calls are the tools employed. The preliminary data on a 5-month abstinence is encouraging, reaching an impressive 62%. We recommend extending our local experience so that tobacco cessation clinics are established throughout Oman with an initial focus on regions of high prevalence.