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Brockway K, Ahmed S. Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management. Respir Med 2024; 224:107553. [PMID: 38350512 DOI: 10.1016/j.rmed.2024.107553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/15/2024]
Abstract
CONTEXT Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs). OBJECTIVES Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD. METHODS PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present. RESULTS Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing. CONCLUSIONS Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.
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Affiliation(s)
- Kaelee Brockway
- University of St. Augustine for Health Sciences, 901 W. Walnut Hill Ln, Ste 210, Irving, TX, USA.
| | - Shakeel Ahmed
- University of Florida, College of Public Health & Health Professions, Department of Physical Therapy, Box 100154, UFHSC, Gainesville, FL, 32610-0154, USA.
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2
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Miravitlles M, Kawayama T, Dreher M. LABA/LAMA as First-Line Therapy for COPD: A Summary of the Evidence and Guideline Recommendations. J Clin Med 2022; 11:jcm11226623. [PMID: 36431099 PMCID: PMC9692772 DOI: 10.3390/jcm11226623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/27/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022] Open
Abstract
Inhaled bronchodilators (alone or in combination) are the cornerstone of treatment for symptomatic patients with COPD, either as initial/first-line treatment or for second-line/treatment escalation in patients who experience persistent symptoms or exacerbations on monotherapy. The Global Initiative for Chronic Obstructive Lung Disease 2022 report recommends initial pharmacological treatment with a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA) as monotherapy for most patients, or dual bronchodilator therapy (LABA/LAMA) in patients with more severe symptoms, regardless of exacerbation history. The recommendations for LABA/LAMA are broader in the American Thoracic Society treatment guidelines, which strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance. However, despite consistent guideline recommendations, real-world prescribing data indicate that LAMA and/or LABA without an inhaled corticosteroid are not the most widely prescribed therapies in COPD. This article reviews global and regional/national guideline recommendations for the use of LABA/LAMA in COPD, examines the evidence for the effectiveness and safety of LABA/LAMA versus other therapies and offers a practical guide for clinicians to help ensure appropriate use of LABA/LAMA therapy.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d′Hebron, Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Correspondence: ; Tel.: +34-(93)-274-6157
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, 52074 Aachen, Germany
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3
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Abstract
More than one-third of patients with chronic obstructive pulmonary disease (COPD) continue to smoke cigarettes despite knowing they have the disease. This behavior has a negative impact on prognosis and progression, as repeated injury enhances the pathobiological mechanisms responsible for the disease. A combination of counseling plus pharmacotherapy is the most effective cessation treatment of smokers with COPD, and varenicline seems to be the most effective pharmacologic intervention. Preventing exacerbations in patients with COPD is a major goal of treatment, and vaccination against influenza and pneumococcus is an effective preventive strategy to achieve this goal.
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Affiliation(s)
- Maria Montes de Oca
- Servicio de Neumonología, Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Centro Médico de Caracas, Av. Los Erasos, Edf. Anexo B, Piso 4, Consultorio 4B, San Bernardino, Caracas, Venezuela.
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Naranjo L, Torres-Duque CA, Colodenco D, Lopardo G, Rodriguez P, Agra de Albuquerque-Neto A, Hernandez-Zenteno RJ, Septien L, Chandler R, Ortega-Barria E, Juliao P, Guzman-Holst A. Highlights of an Expert Advisory Board on Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AE-COPD) in Latin America. Int J Chron Obstruct Pulmon Dis 2020; 15:1919-1929. [PMID: 32821094 PMCID: PMC7418149 DOI: 10.2147/copd.s261258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a preventable and usually progressive lung disease that affects millions of people worldwide and is the sixth leading cause of death in the Americas. Viral and bacterial respiratory tract infections and air pollution may cause acute exacerbations of COPD (AE-COPD) ranging from mild, moderate to severe. The greatest proportion of the overall COPD burden on the health system is due to disease exacerbations. There is limited evidence regarding the etiology and burden of AE-COPD in Latin America (LATAM). Methods To respond to this gap in evidence, an Advisory Board with regional pneumologists and infectious disease experts was convened in September 2018 in Panama City, Panama, to: 1) review the burden of AE-COPD in LATAM; 2) evaluate the etiology of AE-COPD in LATAM; and 3) assess and compare the local/regional guidelines to confirm the etiology, characterize, and manage AE-COPD. Results The results of the meeting showed that there is a high prevalence of AE-COPD in LATAM countries, limited evidence on etiology data, and discrepancies in the case definitions and symptomology (ie, severity) classifications used in LATAM. Conclusion The Advisory Board discussions further resulted in recommendations for future research on the impact on the epidemiology and burden of disease, on establishing standardized AE-COPD case definition guidelines, and on studying the etiology of both moderate and severe AE-COPD cases.
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Affiliation(s)
| | | | - Daniel Colodenco
- Director of Pneumology Specialization Course, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Pablo Rodriguez
- Pulmonary and Critical Care Medicine, CEMIC, Buenos Aires, Argentina
| | | | | | - Luis Septien
- Pulmonary and Critical Care Division, National Institute of Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Reynaldo Chandler
- Education and Investigation Coordination Unit, San Miguel Arcangel Hospital, Ministry of Health, Panama City, Panama
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Torres-Duque CA, Casas A, Zabert G, Jardim JR, Celli B, Rodríguez-Roisin R. The Latin American Thoracic Association (ALAT): 30 Years of History. Arch Bronconeumol 2020; 56:413-415. [PMID: 32245542 DOI: 10.1016/j.arbres.2020.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Carlos A Torres-Duque
- Fundación Neumológica Colombiana, Bogotá, Colombia; Universidad de La Sabana, Bogotá, Colombia.
| | - Alejandro Casas
- Fundación Neumológica Colombiana, Bogotá, Colombia; Universidad de El Rosario, Bogotá, Colombia
| | - Gustavo Zabert
- Clínica Pasteur, Neuquén, Argentina; Universidad Nacional de Comahue, Neuquén, Argentina
| | | | | | - Roberto Rodríguez-Roisin
- Universitat de Barcelona, Institut d'Investigació Biomédica August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona, España
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6
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Ambrocio-Ortiz E, Pérez-Rubio G, Ramírez-Venegas A, Hernández-Zenteno R, Del Angel-Pablo AD, Pérez-Rodríguez ME, Salazar AM, Abarca-Rojano E, Falfán-Valencia R. Effect of SNPs in HSP Family Genes, Variation in the mRNA and Intracellular Hsp Levels in COPD Secondary to Tobacco Smoking and Biomass-Burning Smoke. Front Genet 2020; 10:1307. [PMID: 31993068 PMCID: PMC6962328 DOI: 10.3389/fgene.2019.01307] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/26/2019] [Indexed: 12/22/2022] Open
Abstract
Heat shock proteins (HSP) genes are a superfamily responsible for encoding highly conserved proteins that are important for antigen presentation, immune response regulation, and cellular housekeeping processes. These proteins can be increased by cellular stress related to pollution, for example, smoke from biomass burning and/or tobacco smoking. Single nucleotide polymorphisms (SNPs) in these genes could affect the levels of their proteins, as well as the susceptibility to developing lung diseases, such as chronic obstructive pulmonary disease (COPD), related to the exposure to environmental factors. Methods: The subjects included were organized into two comparison groups: 1,103 smokers (COPD patients, COPD-S = 360; smokers without COPD, SWOC = 743) and 442 never-smokers who were chronically exposed to biomass smoke (COPD patients, COPD-BS = 244; exposed without COPD, BBES = 198). Eight SNPs in three HSP genes were selected and genotyped: four in HSPA1A, two in HSPA1B, and two in HSPA1L. Sputum expectoration was induced to obtain pulmonary cells and relative quantification of mRNA expression. Subsequently, the intracellular protein levels of total Hsp27, phosphorylated Hsp27 (Hsp27p), Hsp60, and Hsp70 were measured in a sample of 148 individuals selected based on genotypes. Results: In the smokers’ group, by a dominant model analysis, we found associations between rs1008438 (CA+AA; p = 0.006, OR = 1.52), rs6457452 (CT+TT; p = 0.000015, OR = 1.99), and rs2763979 (CT+TT; p = 0.007, OR = 1.60) and the risk to COPD. Among those exposed to biomass-burning smoke, only rs1008438 (CA+AA; p < 0.01, OR = 2.84) was associated. Additionally, rs1008438 was associated with disease severity in the COPD-S group (AA; p = 0.02, OR = 2.09). An increase in the relative expression level of HSPA1A was found (12-fold change) in the COPD-BS over the BBES group. Differences in Hsp27 and Hsp60 proteins levels were found (p < 0.05) in the comparison of COPD-S vs. SWOC. Among biomass-burning smoke-exposed subjects, differences in the levels of all proteins (p < 0.05) were detected. Conclusion: SNPs in HSP genes are associated with the risk of COPD and severe forms of the disease. Differences in the intracellular Hsp levels are altered depending on the exposition source.
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Affiliation(s)
- Enrique Ambrocio-Ortiz
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Alejandra Ramírez-Venegas
- Tobacco Smoking and COPD Research Department, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Rafael Hernández-Zenteno
- Tobacco Smoking and COPD Research Department, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Alma D Del Angel-Pablo
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Martha E Pérez-Rodríguez
- Unit of Medical Research in Immunology CMN S-XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Ana M Salazar
- Department of Genomic Medicine and Environmental Toxicology, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Edgar Abarca-Rojano
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
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Zhukov M, Alekhin Y, Kalyuzhny I, Dorozhkin V, Stekolnikov A. Reasons for cattle retirement on feeding farms. BIO WEB OF CONFERENCES 2020. [DOI: 10.1051/bioconf/20201700098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The study has been carried out at two livestock complexes specializing in the production of beef to investigate the causes of non-productive retirement of animals. The structure of the causes of death or necessary slaughter of young cattle was determined by the results of pathological autopsy (n = 2816). Moreover, it was revealed that in 83.5 % of the animals, morphological changes in the respiratory organs prevailed, which in 40.2 % of the cases were thanatogenetically significant. The pathology of the digestive system was found in 29.6 % of animals, and in 14.9 % of cases they caused death. Pathology of the kidneys and urinary tract most often occurred at the age of 4–6 months and caused the retirement of 7.6–9.4 % of the animals. The role of cardiovascular pathology in the structure of the causes of retirement increases in young animals aged 8–11 months, while that of diseases of the joints and distal extremities rises at the final stage of their fattening. Clinical and expert evaluation of the activity of veterinary specialists (n = 12) showed that they correctly identified the underlying disease in 74 %, concomitant pathologies in 17.9 %, and complications in 5 % of diseased. Therefore, one of the problems of diagnosing diseases in young cattle during the period of growing and fattening is an incomplete diagnosis due to the low detection rate of concomitant pathologies and complications, some of which are of decisive thanatogenetic significance.
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Montes de Oca M, López Varela MV, Acuña A, Schiavi E, Casas A, Tokumoto A, Torres Duque CA, Ramírez-Venegas A, García G, Camelier A, Bergna M, Cohen M, Sanchez-Angarita E, Guzmán S, Czischke K, Barros M, Rey A. Incorporating New Evidence on Inhaled Medications in COPD. The Latin American Chest Association (ALAT) 2019. Arch Bronconeumol 2019; 56:106-113. [PMID: 31767208 DOI: 10.1016/j.arbres.2019.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 02/07/2023]
Abstract
This document on COPD from the Latin American Chest Association (ALAT-2019) uses PICO methodology to analyze new evidence on inhaled medication and answer clinical questions. The following key points emerged from this analysis: 1) evidence is lacking on the comparison of short-acting vs. long-acting bronchodilators in patients with mild COPD; patients with moderate-to-severe COPD obtain greater benefit from long-acting bronchodilators; 2) the benefits of monotherapy with long-acting antimuscarinic agents (LAMA) and combined therapy with long-acting β2-agonists and inhaled corticosteroids (LABA/ICS) are similar, although the latter is associated with a greater risk of pneumonia; 3) LABA/LAMA offer greater benefits in terms of lung function and risk of exacerbation than LABA/ICS (the latter involve an increased risk of pneumonia), 4) LAMA/LABA/ICS have greater therapeutic benefits than LABA/LAMA on the risk of moderate-severe exacerbations. With regard to the role of eosinophils in guiding the use of ICS, ICS withdrawal must be considered when the initial indication was wrong or no response is elicited, in patients with side effects such as pneumonia, and in patients with a low risk of exacerbation and an eosinophil blood count of <300 cells/μl. All this evidence, categorized according to the severity of the obstruction, symptoms, and risk of exacerbations, has been used to generate an algorithm for the use of inhaled medication in COPD.
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Affiliation(s)
- María Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela.
| | | | - Agustín Acuña
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela; Departamento de Investigación y Estadística, ITSalud/Medsolid, Caracas, Venezuela
| | - Eduardo Schiavi
- SubSecretaría de Planificación Sanitaria, Ministerio de Salud, Gobierno de la Ciudad Autónoma de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | | | | | - Aquiles Camelier
- Universidade do Estado da Bahia e Escola Bahiana de Medicina, Salvador, Brasil
| | - Miguel Bergna
- Hospital Dr. Antonio Cetrángolo, Vicente López, Buenos Aires, Argentina
| | - Mark Cohen
- Hospital Centro Médico, Guatemala, Guatemala
| | - Efraín Sanchez-Angarita
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela; Departamento de Investigación y Estadística, ITSalud/Medsolid, Caracas, Venezuela
| | | | - Karen Czischke
- Clínica Alemana de Santiago, Hospital Padre Hurtado, Universidad del Desarrollo, San Ramón, Región Metropolitana, Chile
| | - Manuel Barros
- Escuela de Medicina, Universidad de Valparaíso, Hospital C. Van Buren, Valparaíso, Región de Valparaíso, Chile
| | - Alejandra Rey
- Universidad de la República, Hospital Maciel, Montevideo, Uruguay
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Ramírez-Venegas A, Velázquez-Uncal M, Aranda-Chávez A, Guzmán-Bouilloud NE, Mayar-Maya ME, Pérez Lara-Albisua JL, Hernández-Zenteno RDJ, Flores-Trujillo F, Sansores RH. Bronchodilators for hyperinflation in COPD associated with biomass smoke: clinical trial. Int J Chron Obstruct Pulmon Dis 2019; 14:1753-1762. [PMID: 31496674 PMCID: PMC6689558 DOI: 10.2147/copd.s201314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/12/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction The efficacy of long-acting bronchodilators for COPD associated with biomass (BE-COPD) has not been properly evaluated. Objective To determine the acute effect of indacaterol (IND) 150 μg q.d and tiotropium (TIO) 18 μg q.d. on lung hyperinflation, walking distance (WD) and dyspnea during the six-minute walking test (6MWT) in moderate BE-COPD at 30, 60 and 240 mins post-drug administration. Design Randomized, controlled, open-level, crossover noninferiority clinical trial. Forty-two women with BE-COPD were randomly assigned to a bronchodilator sequence: IND–TIO or vice versa. Results There were statistically significant changes over time in inspiratory capacity (IC) (p<0.0001), FEV1 (p<0.0001) and FVC (p<0.0001) when IND was used. When TIO was administered, an increase over all time periods was observed only for FEV1 (p<0.0001) and FVC (p<0.0001), whereas for IC an increase was observed only at 30 mins and 24 hrs after TIO administration. We did not find clinically significant increases in WD and dyspnea after the administration of both bronchodilators. Conclusion Both IND and TIO showed significant and fast onset improvement in hyperinflation. Therefore, either of them may be recommended as a first line of treatment for COPD associated with BE-COPD.
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Affiliation(s)
- Alejandra Ramírez-Venegas
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Mónica Velázquez-Uncal
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Adrián Aranda-Chávez
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Nicolás Eduardo Guzmán-Bouilloud
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - María Eugenia Mayar-Maya
- Department of Medical Attention, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - José Luis Pérez Lara-Albisua
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Rafael de Jesus Hernández-Zenteno
- Obstructive Disease Ward, Pulmonary Obstructive Diseases Clinical Service, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Fernando Flores-Trujillo
- Obstructive Disease Ward, Pulmonary Obstructive Diseases Clinical Service, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Raúl H Sansores
- Department of Respiratory Medicine, Medica Sur Clinic & Foundation , Mexico City, Mexico
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10
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Lewthwaite H, Williams G, Baldock KL, Williams MT. Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain? Healthcare (Basel) 2019; 7:healthcare7010015. [PMID: 30678205 PMCID: PMC6473434 DOI: 10.3390/healthcare7010015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/10/2019] [Accepted: 01/19/2019] [Indexed: 12/11/2022] Open
Abstract
Chronic pain is highly prevalent and more common in people with chronic obstructive pulmonary disease (COPD) than people of similar age/sex in the general population. This systematic review aimed to describe how frequently and in which contexts pain is considered in the clinical practice guidelines (CPGs) for the broad management of COPD. Databases (Medline, Scopus, CiNAHL, EMbase, and clinical guideline) and websites were searched to identify current versions of COPD CPGs published in any language since 2006. Data on the frequency, context, and specific recommendations or strategies for the assessment or management of pain were extracted, collated, and reported descriptively. Of the 41 CPGs (English n = 20) reviewed, 16 (39%) did not mention pain. Within the remaining 25 CPGs, pain was mentioned 67 times (ranging from 1 to 10 mentions in a single CPG). The most frequent contexts for mentioning pain were as a potential side effect of specific pharmacotherapies (22 mentions in 13 CPGs), as part of differential diagnosis (14 mentions in 10 CPGs), and end of life or palliative care management (7 mentions in 6 CPGs). In people with COPD, chronic pain is common; adversely impacts quality of life, mood, breathlessness, and participation in activities of daily living; and warrants consideration within CPGs for COPD.
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Affiliation(s)
- Hayley Lewthwaite
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
| | - Georgia Williams
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
| | - Katherine L Baldock
- Australian Centre for Precision Health, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
| | - Marie T Williams
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
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Abstract
The PLATINO and PREPOCOL population-based studies documented the prevalence of chronic obstructive pulmonary disease (COPD) in several Latin American (Mexico City, Sao Paulo, Montevideo, Santiago and Caracas) and Colombian (Medellin, Bogota, Barranquilla, Bucaramanga and Cali) cities. COPD ranged between 6.2 and 19.6% in individuals ≥40 years of age, with substantial rates of underdiagnosis (up to 89%) but also overdiagnosis, mostly due to the lack of spirometric confirmation. The main risk factor was tobacco smoking, but male gender and age were also associated with COPD. COPD in never smokers represented about one third of the cases and was associated with previous history of tuberculosis or a diagnosis of asthma. COPD associated with biomass smoke exposure was a common clinical phenotype in Latin America, found as a risk factor in PREPOCOL and other observational studies in the region. Smoking has been decreasing in Latin America and efforts have been made to implement cleaner biomass stoves. Unfortunately, treatment of COPD in Latin America remains highly variable with low rates of smoking cessation counselling, low use of inhaled bronchodilators and influenza vaccination. A primary-care approach to COPD, particularly in the form of integrated programs is lacking but would be critical to improving rates of diagnosis and treatment of COPD.
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12
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Rabe KF, Hurst JR, Suissa S. Cardiovascular disease and COPD: dangerous liaisons? Eur Respir Rev 2018; 27:27/149/180057. [PMID: 30282634 DOI: 10.1183/16000617.0057-2018] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β2-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.
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Affiliation(s)
- Klaus F Rabe
- Dept of Medicine, University of Kiel, Kiel, Germany .,Lung Clinic Großhansdorf, Airway Research Center North (ARCN), Groβhansdorf, Germany
| | - John R Hurst
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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13
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Abad-Arranz M, Moran-Rodríguez A, Mascarós Balaguer E, Quintana Velasco C, Abad Polo L, Núñez Palomo S, Gonzálvez Rey J, Fernández Vargas AM, Hidalgo Requena A, Helguera Quevedo JM, García Pardo M, Lopez-Campos JL. Community Assessment of COPD Health Care (COACH) study: a clinical audit on primary care performance variability in COPD care. BMC Med Res Methodol 2018; 18:68. [PMID: 29970023 PMCID: PMC6029063 DOI: 10.1186/s12874-018-0528-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 06/20/2018] [Indexed: 12/01/2022] Open
Abstract
Background A thorough evaluation of the adequacy of clinical practice in a designated health care setting and temporal context is key for clinical care improvement. This study aimed to perform a clinical audit of primary care to evaluate clinical care delivered to patients with COPD in routine clinical practice. Methods The Community Assessment of COPD Health Care (COACH) study was an observational, multicenter, nationwide, non-interventional, retrospective, clinical audit of randomly selected primary care centers in Spain. Two different databases were built: the resources and organization database and the clinical database. From January 1, 2015 to December 31, 2016 consecutive clinical cases of COPD in each participating primary care center (PCC) were audited. For descriptive purposes, we collected data regarding the age at diagnosis of COPD and the age at audit, gender, the setting of the PCC (rural/urban), and comorbidities for each patient. Two guidelines widely and uniformly used in Spain were carefully reviewed to establish a benchmark of adequacy for the audited cases. Clinical performance was analyzed at the patient, center, and regional levels. The degree of adequacy was categorized as excellent (> 80%), good (60–80%), adequate (40–59%), inadequate (20–39%), and highly inadequate (< 20%). Results During the study 4307 cases from 63 primary care centers in 6 regions of the country were audited. Most evaluated parameters were judged to fall in the inadequate performance category. A correct diagnosis based on previous exposure plus spirometric obstruction was made in an average of 17.6% of cases, ranging from 9.8 to 23.3% depending on the region. During the audited visit, only 67 (1.6%) patients had current post-bronchodilator obstructive spirometry; 184 (4.3%) patients had current post-bronchodilator obstructive spirometry during either the audited or initial diagnostic visit. Evaluation of dyspnea was performed in 11.1% of cases. Regarding treatment, 33.6% received no maintenance inhaled therapies (ranging from 31.3% in GOLD A to 7.0% in GOLD D). The two most frequently registered items were exacerbations in the previous year (81.4%) and influenza vaccination (87.7%). Conclusions The results of this audit revealed a large variability in clinical performance across centers, which was not fully attributable to the severity of the disease.
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Affiliation(s)
- María Abad-Arranz
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Avda. Manuel Siurot, s/n, 41013, Seville, Spain
| | | | | | | | | | | | | | | | | | | | | | - Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Avda. Manuel Siurot, s/n, 41013, Seville, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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Casas A, Montes de Oca M, Menezes AM, Wehrmeister FC, Lopez Varela MV, Mendoza L, Ramírez L, Miravitlles M. Respiratory medication used in COPD patients from seven Latin American countries: the LASSYC study. Int J Chron Obstruct Pulmon Dis 2018; 13:1545-1556. [PMID: 29785104 PMCID: PMC5955011 DOI: 10.2147/copd.s154097] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Limited information is available regarding medication use in COPD patients from Latin America. This study evaluated the type of medication used and the adherence to different inhaled treatments in stable COPD patients from the Latin American region. Methods This was an observational, cross-sectional, multinational, and multicenter study in COPD patients attended by specialist doctors from seven Latin American countries. Adherence to inhaled therapy was assessed using the Test of Adherence to Inhalers (TAI) questionnaire. The type of medication was assessed as: short-acting β-agonist (SABA) or short-acting muscarinic antagonist (SAMA) only, long-acting muscarinic antagonist (LAMA), long-acting β-agonist (LABA), LABA/LAMA, inhaled corticosteroid (ICS), ICS/LABA, ICS/LAMA/LABA, or other. Results In total, 795 patients were included (59.6% male), with a mean age of 69.5±8.7 years and post-bronchodilator FEV1 of 50.0%±18.6%. The ICS/LAMA/LABA (32.9%) and ICS/LABA (27.7%) combinations were the most common medications used, followed by LABA/LAMA (11.3%), SABA or SAMA (7.9%), LABA (6.4%), LAMA (5.8%), and ICS (4.3%). The types of medication most commonly used in each Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 category were ICS/LABA (A: 32.7%; B: 19.8%; C: 25.7%; D: 28.2%) and ICS/LAMA/LABA (A: 17.3%; B: 30.2%; C: 33%; D: 41.1%). The use of long-acting bronchodilators showed the highest adherence (good or high adherence >50%) according to the TAI questionnaire. Conclusion COPD management in specialist practice in Latin America does not follow the current guideline recommendations and there is an overuse of ICSs in patients with COPD from this region. Treatment regimens including the use of long-acting bronchodilators are associated with the highest adherence.
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Affiliation(s)
- Alejandro Casas
- Fundación Neumológica Colombiana, Universidad del Rosario, Bogotá, Colombia
| | | | | | | | | | - Laura Mendoza
- Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | | | - Marc Miravitlles
- Department of Pneumology, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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15
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Affiliation(s)
- Evgenios I. Metaxas
- Department of Pulmonary Medicine, Evaggelismos General Hospital, Athens, Greece
- Department of Pulmonary Medicine, Polyclinic Ygia Hospital, Limassol, Cyprus
| | - Evangelos Balis
- Department of Pulmonary Medicine, Evaggelismos General Hospital, Athens, Greece
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Capparelli I, Fernandez M, Saadia Otero M, Steimberg J, Brassesco M, Campobasso A, Palacios S, Caro F, Alberti ML, Rabinovich RA, Paulin F. Traducción al español y validación del cuestionario Saint George específico para fibrosis pulmonar idiopática. Arch Bronconeumol 2018; 54:68-73. [DOI: 10.1016/j.arbres.2017.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/12/2017] [Accepted: 09/18/2017] [Indexed: 01/17/2023]
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Luis López-Campos J, Fernández-Villar A, Represas Represas C, Marín Barrera L, Botana Rial M, López Ramírez C, Casamor R. Evaluation of clinical variables according to follow-up times in COPD: results from ON-SINT cohort. Eur Clin Respir J 2017; 4:1394132. [PMID: 29201289 PMCID: PMC5700532 DOI: 10.1080/20018525.2017.1394132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 10/02/2017] [Indexed: 02/07/2023] Open
Abstract
Background: COPD is a chronic disease traditionally associated with increased symptoms as lung function deteriorates. Follow-up times in previous cohort studies were limited to a few years. Interestingly, newer longer observational studies show a more comprehensive picture on disease progression over time. Therefore, the question on the relevancy of the follow-up time in cohort studies remains open. Methods: The ON-SINT study is an observational, retrospective, nationwide, real-life cohort study, in which patients diagnosed with COPD were recruited between December 2011 and April 2013 by primary care (PC) and secondary care (SC) physicians. Patients were evaluated at the inclusion visit and at the initial visit when the diagnosis of COPD was first established. Distribution of lung function decline over the years was studied comparing those cases with longer follow-up times, with the median of the distribution as the cutoff point. Results: The sample included 1214 patients of which 857 (70.6%) were recruited by PC and 357 (29.4%) by SC physicians. Median follow-up time was 6.26 years. Mean annual change in the complete cohort were –4.5 (222) ml year–1 for FVC and 5.5 (134) ml year–1 for FEV1. We confirm the variable distribution of FEV1 decline and found that longer follow-up periods reduce this variability. Of note, FEV1 decline was different between groups (shorter: 19.7 [180.4] vs longer: –9.7 [46.9]; p = 0.018). Further, our data revealed differences in the clinical presentation according to follow-up times, with special emphasis on dyspnea (OR: 1.035; 95%CI: 1.014–1.056), exacerbations (OR 1.172; 95%CI 1.045–1.315) and CAT scores (OR 1.047; 95%CI 1.019–1.075) being associated with longer follow-up times. Conclusions: This study describes the impact of follow-up periods on lung function variability, and reveals differences in clinical presentation according to follow-up times, with special emphasis on dyspnea, exacerbations and CAT scores.
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Affiliation(s)
- José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Lucía Marín Barrera
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Maribel Botana Rial
- Servicio de Neumología, Complexo Hospitalario de Vigo, Sevilla, Spain.,Instituto de Investigación biomédica de Vigo (IBIV), Vigo, Spain
| | - Cecilia López Ramírez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Ricard Casamor
- Departamento Médico de Novartis Farmacéutica, Novartis España, Barcelona, Spain
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Miravitlles M, Menezes A, López Varela MV, Casas A, Ugalde L, Ramirez-Venegas A, Mendoza L, López A, Wehrmeister FC, Surmont F, Montes de Oca M. Prevalence and impact of respiratory symptoms in a population of patients with COPD in Latin America: The LASSYC observational study. Respir Med 2017; 134:62-69. [PMID: 29413510 DOI: 10.1016/j.rmed.2017.11.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 11/26/2017] [Accepted: 11/27/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND To analyse the relationship between symptoms at different times during the 24-hour day and outcomes in COPD. METHODS Observational cross-sectional study in a patients from 7 Latin American countries. The frequency of symptoms in the morning, at night and during the day was explored by means of standardised and validated questionnaires, and the relationship between symptoms and exacerbations and quality of life were investigated. RESULTS 734 patients (59.6% male, mean age 69.5 years, mean FEV1 50% predicted normal) were recruited. The most frequent symptoms during the day were dyspnea (75% of patients, of which 94% mild-moderate) and cough (72.2%, of which 93.4% mild-moderate). Highly symptomatic patients had a greater impairment in FEV1, more exacerbations and worse scores in COPD assessment test (CAT) and Body Mass Index, Obstruction, Dyspnoea and Exacerbations (BODEx) index (all p < 0.001). Morning symptoms were more frequent than night-time symptoms, particularly cough and dyspnoea (morning: 50.1% and 45.7%; night-time: 33.2% and 24.4%, respectively), and mostly rated as mild or moderate. Patients with morning or night-time symptoms presented with worse severity of daytime symptoms. There was a strong correlation between intensity of daytime with morning or night-time symptoms, as well as with CAT score (r = 0.715; p < 0.001), but a weak correlation with FEV1 (r = -0.205; p < 0.001). CONCLUSION Morning symptoms were more frequent than night-time symptoms, and having either morning and/or night-time symptoms was associated with worse severity of daytime symptoms. Increased symptoms were strongly associated with worse quality of life and more frequent exacerbations, but weakly associated with airflow limitation. CLINICAL TRIAL REGISTRATION NCT02789540.
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Affiliation(s)
- Marc Miravitlles
- Department of Pneumology, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
| | - Ana Menezes
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Alejandro Casas
- Fundación Neumológica Colombiana, Universidad del Rosario, Bogotá, Colombia
| | | | | | - Laura Mendoza
- Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - Ana López
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | | | | | - Maria Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela
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Cazzola M, Rogliani P. Comparative effectiveness of indacaterol/glycopyrronium in the treatment of chronic obstructive pulmonary disease. J Comp Eff Res 2017; 6:627-636. [PMID: 28840753 DOI: 10.2217/cer-2017-0037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Indacaterol/glycopyrronium has been the first long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combination to be approved as a maintenance treatment in chronic obstructive pulmonary disease patients. Comparative effectiveness studies indicate that it is constantly superior to a LAMA or a LABA alone or even a LABA/inhaled corticosteroid combination, regardless of the drugs used. However, definitive data documenting the benefit of indacaterol/glycopyrronium fixed-dose combination over these consolidated therapies are still absent in a real-world setting, although the results of pivotal randomized controlled trials show that this is the case. Therefore, in addition to the large body of evidence already available supporting the use of indacaterol/glycopyrronium, pragmatic observational studies or ad hoc designed trials should be planned to collect data that could confirm the high effectiveness of indacaterol/glycopyrronium even in the real-life clinical practice.
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Affiliation(s)
- Mario Cazzola
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paola Rogliani
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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Berton DC, Santos ÁHD, Bohn I, Lima RQD, Breda V, Teixeira PJZ. Effects of indacaterol versus tiotropium on exercise tolerance in patients with moderate COPD: a pilot randomized crossover study. J Bras Pneumol 2017; 42:367-373. [PMID: 27812637 PMCID: PMC5094874 DOI: 10.1590/s1806-37562015000000334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/31/2016] [Indexed: 12/19/2022] Open
Abstract
Objective: To compare a once-daily long-acting β2 agonist (indacaterol 150 µg) with a once-daily long-acting anticholinergic (tiotropium 5 µg) in terms of their effects on exercise endurance (limit of tolerance, Tlim) in patients with moderate COPD. Secondary endpoints were their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Methods: This was a randomized, single-blind, crossover pilot study involving 20 patients (mean age, 60.9 ± 10.0 years; mean FEV1, 69 ± 7% of predicted). Spirometric parameters, Transition Dyspnea Index scores, Tlim, and exertional dyspnea were compared after three weeks of each treatment (with a one-week washout period between treatments). Results: Nineteen patients completed the study (one having been excluded because of COPD exacerbation). Improvement in Tlim from baseline tended to be greater after treatment with tiotropium than after treatment with indacaterol (96 ± 163 s vs. 8 ± 82 s; p = 0.06). Tlim significantly improved from baseline after treatment with tiotropium (having increased from 396 ± 319 s to 493 ± 347 s; p = 0.010) but not after treatment with indacaterol (having increased from 393 ± 246 to 401 ± 254 s; p = 0.678). There were no differences between the two treatments regarding improvements in Borg dyspnea scores and lung hyperinflation at "isotime" and peak exercise. There were also no significant differences between treatments regarding Transition Dyspnea Index scores (1.5 ± 2.1 vs. 0.9 ± 2.3; p = 0.39). Conclusions: In patients with moderate COPD, tiotropium tends to improve Tlim in comparison with indacaterol. No significant differences were observed between the two treatments regarding their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Future studies, including a larger number of patients, are required in order to confirm our findings and explore mechanistic explanations. (ClinicalTrials.gov identifier: NCT01693003 [http://www.clinicaltrials.gov/])
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Affiliation(s)
- Danilo Cortozi Berton
- . Programa de Pós-Graduação em Pneumologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Álvaro Huber Dos Santos
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil
| | - Ivo Bohn
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil
| | - Rodrigo Quevedo de Lima
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil
| | - Vanderléia Breda
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil
| | - Paulo José Zimermann Teixeira
- . Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS) Brasil.,. Universidade Feevale, Novo Hamburgo (RS) Brasil.,. Pavilhão Pereira Filho, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
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Miravitlles M, Anzueto A, Jardim JR. Optimizing bronchodilation in the prevention of COPD exacerbations. Respir Res 2017; 18:125. [PMID: 28633665 PMCID: PMC5477752 DOI: 10.1186/s12931-017-0601-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/29/2017] [Indexed: 02/03/2023] Open
Abstract
The natural disease course of chronic obstructive pulmonary disease (COPD) is often punctuated by exacerbations: acute events of symptom worsening associated with significant morbidity and healthcare resource utilization; reduced quality of life; and increased risk of hospitalization and death. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend that patients at risk of exacerbations (GOLD Groups C and D) receive a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA)/LAMA combination, respectively, as preferred initial treatments. The latter recommendation is based on recent trial evidence demonstrating the superior efficacy of a fixed-dose LABA/LAMA over an inhaled corticosteroid (ICS)/LABA in exacerbation prevention. ICS in combination with a LABA is also indicated for prevention of exacerbations, but the use of ICS is associated with an increased risk of adverse events such as pneumonia, and offers limited benefits beyond those provided by LABA or LAMA monotherapy. In this review, we examine evidence from a number of pivotal studies of LABAs and LAMAs, administered as monotherapy or as part of dual or triple combination therapy, with a specific focus on their effect on exacerbations. We also discuss a new proposed treatment paradigm for the management of COPD that takes into account this recent evidence and adopts a more cautious approach to the use of ICS. In alignment with GOLD 2017, we suggest that ICS should be reserved for patients with concomitant asthma or in whom exacerbations persist despite treatment with LABA/LAMA.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, TX USA
| | - José R. Jardim
- Respiratory Division, Escola Paulista de Medicina / Federal University de São Paulo, São Paulo, Brazil
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Ortega Ruiz F, Márquez Martín E, López-Campos JL. Enfermedad pulmonar obstructiva crónica: en busca de la clasificación ideal. Arch Bronconeumol 2017; 53:91-92. [DOI: 10.1016/j.arbres.2016.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/25/2016] [Accepted: 11/25/2016] [Indexed: 10/20/2022]
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Cazzola M, Ora J, Puxeddu E, Rogliani P. Indacaterol/Glycopyrronium Combination for COPD. Pulm Ther 2017. [DOI: 10.1007/s41030-016-0024-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Montes de Oca M, López Varela MV, Laucho-Contreras ME, Casas A, Schiavi E, Rey A, Silva A. Classification of patients with chronic obstructive pulmonary disease according to the Latin American Thoracic Association (ALAT) staging systems and the global initiative for chronic obstructive pulmonary disease (GOLD). Arch Bronconeumol 2016; 53:98-106. [PMID: 27956034 DOI: 10.1016/j.arbres.2016.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Several classification systems use different criteria when assessing COPD stages. The objective of this study was to compare the prevalence and distribution of COPD stagesusing Global initiative for chronic Obstructive Lung Disease (GOLD) recommendationsand Latin American Thoracic Association (ALAT) guidelinesin a primary-care population. METHODS Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator FEV1/FVC<0.70 and categorised according to GOLD-2013 criteria and ALAT-2014 guideline. The BODEx index was used to assess the prognostic value of the stratification systems. RESULTS A total of 1743 subjects completed the interview, 1540 performed acceptable spirometry. COPD prevalence according GOLD-2013 was 20.1% and had a U-shaped stage distribution (group A: 9.3%, B: 4.3%, C: 2.0%, D: 4.6%). According to ALAT, prevalence was 19.7% with a bell-shaped stage distribution (mild: 2.9%, moderate: 9%, severe: 5.4%, very-severe: 2.7%). Approximately 73% of patients were stratified as moderate (45.4%) or severe (27.3%) by ALAT guidelines, whereas using GOLD-2013 criteria the majority of subjects (approximately 69%) were in group A (46.3%) or group B (22.7%). BODE index score increased as COPD worsened according to ALAT stratification. This is not observed with GOLD2013 criteria (similar values for B and C groups). CONCLUSIONS Disease stages differ under ALAT and GOLD-2013 criteria. ALAT identified a greater proportion of COPD subjects in the moderate and severe categories compared with GOLD-2013, where the majority were categorised in group A. Future evaluation of the ALAT classification should address its predictive ability in terms of hospitalizations and mortality.
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Affiliation(s)
- Maria Montes de Oca
- Servicio de Neumología, Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela.
| | | | - María Eugenia Laucho-Contreras
- Servicio de Neumología, Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela
| | | | - Eduardo Schiavi
- Hospital de Rehabilitación Respiratoria María Ferrer, Buenos Aires, Argentina
| | - Alejandra Rey
- Universidad de la República, Facultad de Medicina, Hospital Maciel, Montevideo, Uruguay
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Gea J, Casadevall C, Pascual S, Orozco-Levi M, Barreiro E. Clinical management of chronic obstructive pulmonary disease patients with muscle dysfunction. J Thorac Dis 2016; 8:3379-3400. [PMID: 28066619 DOI: 10.21037/jtd.2016.11.105] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Muscle dysfunction is frequently observed in chronic obstructive pulmonary disease (COPD) patients, contributing to their exercise limitation and a worsening prognosis. The main factor leading to limb muscle dysfunction is deconditioning, whereas respiratory muscle dysfunction is mostly the result of pulmonary hyperinflation. However, both limb and respiratory muscles are also influenced by other negative factors, including smoking, systemic inflammation, nutritional abnormalities, exacerbations and some drugs. Limb muscle weakness is generally diagnosed through voluntary isometric maneuvers such as handgrip or quadriceps muscle contraction (dynamometry); while respiratory muscle loss of strength is usually recognized through a decrease in maximal static pressures measured at the mouth. Both types of measurements have validated reference values. Respiratory muscle strength can also be evaluated determining esophageal, gastric and transdiaphragmatic maximal pressures although there is a lack of widely accepted reference equations. Non-volitional maneuvers, obtained through electrical or magnetic stimulation, can be employed in patients unable to cooperate. Muscle endurance can also be assessed, generally using repeated submaximal maneuvers until exhaustion, but no validated reference values are available yet. The treatment of muscle dysfunction is multidimensional and includes improvement in lifestyle habits (smoking abstinence, healthy diet and a good level of physical activity, preferably outside), nutritional measures (diet supplements and occasionally, anabolic drugs), and different modalities of general and muscle training.
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Affiliation(s)
- Joaquim Gea
- Servei de Pneumologia, Hospital del Mar - IMIM, Experimental Sciences and Health Department (DCEXS), Universitat Pompeu Fabra, CIBERES, ISC III, Barcelona, Catalonia, Spain
| | - Carme Casadevall
- Servei de Pneumologia, Hospital del Mar - IMIM, Experimental Sciences and Health Department (DCEXS), Universitat Pompeu Fabra, CIBERES, ISC III, Barcelona, Catalonia, Spain
| | - Sergi Pascual
- Servei de Pneumologia, Hospital del Mar - IMIM, Experimental Sciences and Health Department (DCEXS), Universitat Pompeu Fabra, CIBERES, ISC III, Barcelona, Catalonia, Spain
| | - Mauricio Orozco-Levi
- Department of Respiratory, Cardiovascular Foundation from Colombia Floridablanca, Santander, Colombia, CIBERES, ISC III, Barcelona, Catalonia, Spain
| | - Esther Barreiro
- Servei de Pneumologia, Hospital del Mar - IMIM, Experimental Sciences and Health Department (DCEXS), Universitat Pompeu Fabra, CIBERES, ISC III, Barcelona, Catalonia, Spain
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López Varela MV, Montes de Oca M, Rey A, Casas A, Stirbulov R, Di Boscio V. Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study. Respirology 2016; 21:1227-34. [PMID: 27319305 DOI: 10.1111/resp.12834] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD. METHODS Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) < 0.70 and the lower limit of normal of FEV1 /FVC. RESULTS A total of 1743 subjects completed the interview; 1540 performed acceptable spirometry. COPD prevalence was 20.1% (n = 309; ranging from 11.0% in Venezuela to 29.6% in Argentina) when defined using post-BD FEV1 /FVC < 0.70, and 14.7% (n = 226; ranging from 8.3% in Venezuela to 21.8% in Colombia) using the lower limit of normal. Logistic regression analysis for both definitions showed that the risk of COPD was significantly higher for persons >50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC < 0.70) of 76% and 79% for the simple and weighted scores, respectively. CONCLUSION This simple seven-item score is an accurate screening tool to select subjects for spirometry in primary care.
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Affiliation(s)
| | - Maria Montes de Oca
- Faculty of Medicine, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela
| | - Alejandra Rey
- Faculty of Medicine, University of the Republic, Montevideo, Uruguay
| | | | - Roberto Stirbulov
- Faculty of Medical Science of Santa Casa de São Paulo, Sao Paulo, Brazil
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Callejas González FJ, Genovés Crespo M, Cruz Ruiz J, Godoy Mayoral R, Agustín Martínez FJ, Martínez García AJ, Tárraga López PJ. UPLIFTstudy -understanding potential long-term impacts on function with tiotropium - and sub-analyses. Bibliographic resume of the obtained results. Expert Rev Respir Med 2016; 10:1023-33. [DOI: 10.1080/17476348.2016.1188693] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bronchodilator treatment for COPD in primary care of four Latin America countries: The multinational, cross-sectional, non-interventional PUMA study. Pulm Pharmacol Ther 2016; 38:10-6. [PMID: 27113029 DOI: 10.1016/j.pupt.2016.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/14/2016] [Accepted: 04/21/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Bronchodilators (BDs) are the cornerstone of COPD treatment. However, their underuse has been reported in real-life studies. PUMA is a primary-care study from Argentina, Colombia, Venezuela and Uruguay that could help understand the BD use in terms of frequency for long-acting (LA-BD) and short-acting (SA-BD) BDs alone or associated with corticosteroids (CS), and the use as-needed or on regular basis. METHODS This is a multicentre, multinational, cross-sectional, non-interventional study including no randomised primary-care centres from each country (total 57 centres) without connection with respiratory specialists. Subjects attending routine visits, at-risk for COPD (≥40 years, current or former smokers or exposed to biomass) completed a questionnaire and performed spirometry. COPD was defined as post-BD FEV1/FVC<0.70 and by the lower limit of normal (LLN). Prior physician diagnosis of emphysema, chronic bronchitis or COPD was also determined. RESULTS 1743 patients were interviewed, 1540 completed spirometry, 309 had COPD by post-BD FEV1/FVC<0.70, 226 by LLN, and 102 had prior medical diagnosis. A total of 77/309 COPD patients by spirometry (24.9%) used BD (3.6% LA-BDs), 15.2% used BD + CS (13.6% LA-BD + CS). Among these patients, SA-BDs (monotherapy) were the most commonly used medication both as-needed (4.5%) and on a regular basis (17.5%). Similar findings were observed using the LLN criteria. In those with prior medical diagnosis, 66/102 (64.7%) used BDs (9.8% LA-BD), and 25.6% used BD + CS (13.6% LA-BD + CS); among them SA-BDs were the most commonly medication used as-needed (9%) and on a regular basis (48.1%). Having health insurance with medication coverage increased the use of BDs. CONCLUSIONS Up to 60% of COPD patients by spirometry and 10% of those with prior medical diagnosis attending a primary care sample of four Latin American countries did not use BDs. LA-BDs are widely underused on a regular-basis (2.6% and 8.3% of patients with spirometric and medical-diagnosis, respectively) This represents a considerable gap between guideline recommendations and BD prescribing pattern in these centres.
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Araújo A. COPD and physical activity. REVISTA PORTUGUESA DE PNEUMOLOGIA 2016; 22:299-301. [PMID: 27094119 DOI: 10.1016/j.rppnen.2016.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- A Araújo
- Respiratory Department, H. Sª Oliveira, Guimarães, Portugal.
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Cazzola M, Rogliani P, Ora J, Matera MG. Treatment options for moderate-to-very severe chronic obstructive pulmonary disease. Expert Opin Pharmacother 2016; 17:977-88. [PMID: 26894516 DOI: 10.1517/14656566.2016.1155555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The appropriate drug management of COPD is still based on the use of bronchodilators, possibly associated with an anti-inflammatory agent. However, there are still fundamental questions that require clarification to optimise their use and major unmet clinical needs that must be addressed. AREAS COVERED The advances obtained with the pharmacological options currently consolidated and the different approaches that are often used in an attempt to respond to unmet therapeutic needs are reviewed Expert opinion: In view of the unsatisfactory status of current treatments for COPD, there is an urgent need for alternative and more effective therapeutic approaches that will help to relieve patient symptoms and affect the natural course of COPD, inhibiting chronic inflammation and reversing the disease process or preventing its progression. However, new pharmacologic options have proved difficult to develop. Therefore, it is mandatory to optimize the use of the treatment options at our disposal. However, there are still fundamental questions regarding their use, including the step-up and step-down pharmacological approach, that require clarification to optimise the use of these drugs. It is likely that phenotyping COPD patients would help in identifying the right treatment for each COPD patient and improve the effectiveness of therapies.
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Affiliation(s)
- Mario Cazzola
- a Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Paola Rogliani
- a Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
| | - Josuel Ora
- a Department of Systems Medicine , University of Rome Tor Vergata , Rome , Italy
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López-Campos JL, Abad Arranz M, Calero-Acuña C, Romero-Valero F, Ayerbe-García R, Hidalgo-Molina A, Aguilar-Pérez-Grovas RI, García-Gil F, Casas-Maldonado F, Caballero-Ballesteros L, Sánchez-Palop M, Pérez-Tejero D, Segado A, Calvo-Bonachera J, Hernández-Sierra B, Doménech A, Arroyo-Varela M, González-Vargas F, Cruz-Rueda JJ. Guideline Adherence in Outpatient Clinics for Chronic Obstructive Pulmonary Disease: Results from a Clinical Audit. PLoS One 2016; 11:e0151896. [PMID: 26985822 PMCID: PMC4795772 DOI: 10.1371/journal.pone.0151896] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/04/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Previous clinical audits of COPD have provided relevant information about medical intervention in exacerbation admissions. The present study aims to evaluate adherence to current guidelines in COPD through a clinical audit. METHODS This is a pilot clinical audit performed in hospital outpatient respiratory clinics in Andalusia, Spain (eight provinces with more than 8 million inhabitants), including 9 centers (20% of the public centers in the area) between 2013 and 2014. Cases with an established diagnosis of COPD based on risk factors, clinical symptoms, and a post-bronchodilator FEV1/FVC ratio of less than 0.70 were deemed eligible. The performance of the outpatient clinics was benchmarked against three guidance documents available at the time of the audit. The appropriateness of the performance was categorized as excellent (>80%), good (60-80%), adequate (40-59%), inadequate (20-39%), and highly inadequate (<20%). RESULTS During the audit, 621 clinical records were audited. Adherence to the different guidelines presented a considerable variability among the different participating hospitals, with an excellent or good adherence for symptom recording, MRC or CAT use, smoking status evaluation, spirometry, or bronchodilation therapy. The most outstanding areas for improvement were the use of the BODE index, the monitoring of treatments, the determination of alpha1-antitrypsin, the performance of exercise testing, and vaccination recommendations. CONCLUSIONS The present study reflects the situation of clinical care for COPD patients in specialized secondary care outpatient clinics. Adherence to clinical guidelines shows considerable variability in outpatient clinics managing COPD patients, and some aspects of the clinical care can clearly be improved.
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Affiliation(s)
- Jose L. López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- * E-mail:
| | - Maria Abad Arranz
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
| | - Carmen Calero-Acuña
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Sansores RH, Velázquez-Uncal M, Pérez-Bautista O, Villalba-Caloca J, Falfán-Valencia R, Ramírez-Venegas A. Prevalence of chronic obstructive pulmonary disease in asymptomatic smokers. Int J Chron Obstruct Pulmon Dis 2015; 10:2357-63. [PMID: 26586941 PMCID: PMC4636090 DOI: 10.2147/copd.s91742] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Physicians do not routinely recommend smokers to undergo spirometry unless they are symptomatic. Objective To test the hypothesis that there are a significant number of asymptomatic smokers with chronic obstructive pulmonary disease (COPD), we estimated the prevalence of COPD in a group of asymptomatic smokers. Methods Two thousand nine hundred and sixty-one smokers with a cumulative consumption history of at least 10 pack-years, either smokers with symptoms or smokers without symptoms (WOS) were invited to perform a spirometry and complete a symptom questionnaire. Results Six hundred and thirty-seven (21.5%) smokers had no symptoms, whereas 2,324 (78.5%) had at least one symptom. The prevalence of COPD in subjects WOS was 1.5% when considering the whole group of smokers (45/2,961) and 7% when considering only the group WOS (45/637). From 329 smokers with COPD, 13.7% were WOS. Subjects WOS were younger, had better lung function and lower cumulative consumption of cigarettes, estimated as both cigarettes per day and pack-years. According to severity of airflow limitation, 69% vs 87% of subjects were classified as Global Initiative for Chronic Obstructive Lung Disease stages I–II in the WOS and smokers with symptoms groups, respectively (P<0.001). A multivariate analysis showed that forced expiratory volume in 1 second (mL) was the only predictive factor for COPD in asymptomatic smokers. Conclusion Prevalence of COPD in asymptomatic smokers is 1.5%. This number of asymptomatic smokers may be excluded from the benefit of an “early” intervention, not just pharmacological but also from smoking cessation counseling. The higher forced expiratory volume in 1 second may contribute to prevent early diagnosis.
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Affiliation(s)
- Raúl H Sansores
- Tobacco Smoking and COPD Research Department, National Institute of Respiratory Diseases, Ismael Cosio Villegas, Mexico City, Mexico
| | - Mónica Velázquez-Uncal
- Tobacco Smoking and COPD Research Department, National Institute of Respiratory Diseases, Ismael Cosio Villegas, Mexico City, Mexico
| | - Oliver Pérez-Bautista
- Tobacco Smoking and COPD Research Department, National Institute of Respiratory Diseases, Ismael Cosio Villegas, Mexico City, Mexico
| | - Jaime Villalba-Caloca
- Tobacco Smoking and COPD Research Department, National Institute of Respiratory Diseases, Ismael Cosio Villegas, Mexico City, Mexico
| | - Ramcés Falfán-Valencia
- Tobacco Smoking and COPD Research Department, National Institute of Respiratory Diseases, Ismael Cosio Villegas, Mexico City, Mexico
| | - Alejandra Ramírez-Venegas
- Tobacco Smoking and COPD Research Department, National Institute of Respiratory Diseases, Ismael Cosio Villegas, Mexico City, Mexico
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López-Campos JL, Tan W, Soriano JB. Global burden of COPD. Respirology 2015; 21:14-23. [DOI: 10.1111/resp.12660] [Citation(s) in RCA: 480] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/12/2015] [Accepted: 07/23/2015] [Indexed: 12/23/2022]
Affiliation(s)
- José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS); Hospital Universitario Virgen del Rocío/Universidad de Sevilla; Sevilla Spain
- CIBER de Enfermedades Respiratorias (CIBERES); Instituto de Salud Carlos III; Madrid Spain
| | - Wan Tan
- James Hogg Research Laboratories; St Paul's Hospital, University of British Columbia Providence Heart and Lung Institute; Vancouver Canada
| | - Joan B. Soriano
- Cátedra UAM-Linde; Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid; Madrid Spain
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