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Respiratory medicine for the coming decade

Prof Marc Decramer

Chief of the Respiratory Division and Professor of Medicine, University 
Hospital, Katholieke 
Universiteit Leuven, and head of its Laboratory of Pneumology.
ERS President 2010–2011

Fresh from celebrating its 20th anniversary at its most successful Annual Congress ever – 22,220 participants to be precise – the European Respiratory Society (ERS) is now in the process of focusing squarely on the future of respiratory medicine and how this vast network of respiratory professionals can best pursue their common goal of improving patient care and preventing, managing and treating respiratory disease.

The ERS Annual Congress in Barcelona in September proved to be not only a unifier of all players in respiratory medicine but also a once-a-year occasion for members of ERS assemblies to meet, debate and thrash out new approaches. These assemblies will be instrumental in combining the expertise of current and new members to develop the recommendations and action plans that together make up the projected ERS Respiratory Roadmap, a strategic document, currently in early draft stages. The results of preliminary consultations with over 140 leading respiratory professionals have already been published and the structure of the final document already defined.

The Roadmap will focus on four specific areas. The first of these is prevention because today respiratory disease is on the increase everywhere, is often chronic thus costly in terms of long-term care, and is a major cause of premature death. In most cases this is largely preventable. The second area is research because, as American health activist Mary Woodard Lasker once said, ‘if you think research is expensive, try disease’ and because, given current trends of respiratory disease chronic care and mortality, European funding in the field is in dire need of consolidation.

Third is clinical care, an area where professionally led innovative approaches will be needed to respond to an increased demand for long-term treatment of chronic illness. Finally, education will be a major issue in a world where respiratory medicine, its practitioners and educators are constantly challenged to stay ahead of technological developments.

A brief series of preliminary recommendations are now available on the ERS website ( However, the Respiratory Roadmap is conceived as an ongoing project that ERS assembly leaders and members can update and modify in the light of new knowledge and experience.

The plan is to hold a respiratory summit in Leuven, Belgium, in March 2011 to take stock of input, further discuss content, resolve outstanding issues and in general finalise contents of the final Roadmap, which, it is anticipated, will be published in advance of the ERS Annual Congress in Amsterdam, 24–28 September 2011.

In the meantime, 19 and 20 October were key dates in the drive to put chronic respiratory disease in its rightful place, at the top of Europe’s public health agenda. An ERS pre-ministerial Congress on the first day, bringing together respiratory experts, patient groups and other interested parties, established a list of recommendations in the field of prevention, innovative models of care and research funding.

These I communicated to a ministerial event the following day, organised by the Belgian presidency of the EU, where they were integrated into a series of conclusions to be presented at a December Council meeting of the EU Ministers of Health.  
Applying expertise

Another glimpse of the future ERS strategic development is from its recent priority projects and its plans for the next 12 months. These include applying its expertise in the service of EU networks of respiratory health; consolidating existing and identifying new subjects and geographic horizons; reinforcing commitment to continuing medical education (CME) and expanding the scope of some educational products; and bringing its expert knowledge to the attention of decision-makers on specific areas of policy related to respiratory health.

One of these projects is chronic obstructive pulmonary disease (COPD), which affects 4%–10% of adults in Europe. ERS was recently one of a coalition of organisations to sign a Call to Action to make the disease a political priority, increase awareness, prioritise its early diagnosis, improve its care, management and prevention, and increase support for research.

It has just launched the first Europe-wide COPD audit with the overall aim of raising the standards of care to a level consistent with European management guidelines. Data collection has already begun, with the aim of publishing reports and analyses by mid-2011. This pilot phase will, it is hoped, subsequently provide the basis for an EU-commissioned wider global study.

The audit will collect information about the service models used in each responding hospital and compare them with clinical outcomes. It is hoped that innovative services will be identified and associations between service models and outcomes correlated. In time, different service designs can be shared between participating hospitals to provide new ideas to those who seek to improve their COPD care.

In the field of tuberculosis, ERS is pursuing its lead role in TB PAN-NET, a network funded by the EU Commission under the 7th Framework Programme for Research, and implemented by ERS over a period of five years. The aim is to focus attention and resources on the new threat of multi-drug-resistant TB to better understand, prevent and treat the disease, with special emphasis on Eastern Europe. ERS spends part of the funding on network activities and disseminating information.

The other part goes towards education and organising school courses where registration fees are deliberately accessible to participants from Eastern Europe and, in certain cases, bursaries are offered to cover registration, travel and accommodation or just the cost of registration and meals. The ultimate goal is to provide practical help to practitioners in their working environment and the tools to improve patient care.

ERS held two TB PAN-NET events in 2010, a seminar ‘Tuberculosis at times emerging drug resistance’ in Borstel (Germany) in May and a ‘Train the Trainer’ course during the Annual Congress. Another event is scheduled for 2012 in Bucharest, Romania.

New subjects and geographic horizons
ERS is also consolidating existing and developing new conference ‘products’ with a view to inviting in the experts to discuss and review knowledge in specific areas of respiratory medicine. The aim of the Lung Science Conference series is to present the very best of international lung science research, highlight new discoveries likely to impact on the future of respiratory medicine and encourage debate and interaction between young postdoctoral scientists and established investigators, The schedule is already fixed for the 9th edition, to be held 1–3 April 2011, once again in Estoril, Portugal; this time under   the theme of ‘Immune system dysregulation in chronic lung disease’.

Future plans include the first international ‘Sleep and Breathing’ conference, set to take place from 31 March to 2 April 2011 in Prague, Czech Republic. It is jointly organised by ERS and the European Sleep Research Society (ESRS). Conceived, designed and moderated by experts, the conference will focus on hands-on practical experience for practitioners and educate on diagnosis, treatment and patient referral.

For new geographical horizons, ERS is looking to India, already a significant consumer of ERS-accredited educational material, and where a growing proportion of physicians are registering to take the HERMES exam (see below) and an ‘Indian’ version of Breathe, the respiratory professional’s source for CME, is already being distributed.

In June, it conducted a six-day educational programme in three Indian cities – Bangalore, Kolkata and Jaipur – and provided training to an estimated 1,000 medical practitioners.

In education, ERS is also evolving; a recent example being its European Examination on Adult Respiratory Medicine and the resulting European Diploma, one of the crowning achievements of ERS and its HERMES programme (Harmonised Education in Respiratory Medicine for European Specialists).

Previously available only to registered medical practitioners who are nationally accredited (or equivalent) to practise as a specialist in adult respiratory medicine, ERS has this year opened up the examination to self-assessment and in-training assessment candidates. Although the exam will not, for them, result in the European Diploma, it nevertheless provides an opportunity to test their knowledge and performance against that of their peers, either in medical practice or in training.

This year’s examination took place during the Barcelona Annual Congress. Next year, HERMES is set to expand yet again, with the first European examination in paediatric respiratory medicine set to take place during the Amsterdam Congress.

Individual and collective responsibility
2010 has been designated ‘Year of the Lung’ to raise awareness of the importance of lung health as well as of the social and economic costs associated with chronic lung disease. Charged by the Forum of International Respiratory Societies (FIRS) with the Year of the Lung programme in Europe, ERS has been particularly active in targeting EU decision-makers in order to advocate policy on a number of issues of public concern.

On World No Tobacco Day 2010 (31 May), ERS joined with the Smoke Free Partnership, an advocacy group partially funded by ERS, in an event in the EU Parliament in Brussels. The subject was the merits of standardised packaging and pictorial warnings for tobacco products, and distinguished panellists discussed the impact of tobacco branding on consumers, especially vulnerable consumers such as teenagers.

ERS has also, since the beginning of the Year of the Lung, seized every occasion to advocate for more funds for lung and respiratory science research, notably within the context of the future eighth EU Framework Programme for Research (FP8) carried out within the ‘EU2020’ strategy.

ERS would particularly like to see more money allocated to urgently-needed investigations into children’s respiratory health. With this in mind, in June, it brought together decision-makers from national environment or health ministries for a symposium entitled ‘Protecting Children’s Health in a Changing Environment’ to present medical and scientific evidence and outline policy recommendations and responses.

In March, raising the issue of air pollution, ERS published its position paper on a draft EU Directive on Industrial Emissions. It cautioned that EU legislators must put human health at the forefront. Among ERS concerns is its contention that the new EU Common Position is regressive, offering considerably less public health protection than previous European Commission proposals.

It took up the issue of air pollution again in September at the Annual Congress in Barcelona, where it unveiled its new publication, Air Quality and Health, a comprehensive overview of air pollution and public health. This guide was commissioned by the ERS Environment and Health Committee with a view to empowering physicians and other health professionals to lobby for better air quality.

Air Quality and Health details the links between pollution and health and current sources and levels of pollution. It sums up the scientific evidence for specific health effects of pollution, and – equally important – the gains to be expected from cleaner air. It concludes with information on what regulators can do, how physicians can play a role in promoting the public health benefits of cleaner air and an outline of current rules.

World Spirometry Day
Targeting decision-makers requires one strategy, targeting the individual another, which is why ERS has also seized on the Year of the Lung campaign to highlight individual responsibility for lung health. It notes that, while the public are very aware of having a healthy heart and looking after it, they unfortunately don’t appreciate their lungs in the same way.

One responsibility the individual can take is to undergo a lung function test and, with this in mind, the European Lung Foundation, the ERS body that deals with respiratory issues in layman’s terms for patients and the general public, coordinated the first World Spirometry Day campaign, 14 October 2010. The aim was to heighten awareness of lung health and demonstrate the importance of early detection of chronic lung disease and thereby improve diagnosis. To date, nearly 300 events have been reported and a total of nearly 100,000 tests carried out.