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Sivapalan P, Rømer V, Wirenfeldt Klausen T, Dyrby Johansen N, Pareek M, Modin D, Mathioudakis A, Vestbo J, Eklöf J, Jordan A, Hurst JR, Biering-Sørensen T, Jensen JU. AM/PM dosing of LAMA for COPD: a randomized controlled trial protocol using digital recruitment and registries. Front Med (Lausanne) 2024; 11:1430169. [PMID: 39165373 PMCID: PMC11334606 DOI: 10.3389/fmed.2024.1430169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/15/2024] [Indexed: 08/22/2024] Open
Abstract
Rationale Long-acting muscarinic antagonists (LAMAs) reduce the risk of acute exacerbations of chronic obstructive pulmonary disease (AECOPD), usually taken once daily in the morning. However, the circadian activity of autonomic regulation suggests that the highest need for anticholinergic therapy may be in the late night/early morning. This is supported by evidence that AECOPD most often begins in the morning. Furthermore, the trough spirometry effect of LAMA is lower than the peak effect, which further argues that evening dosing may be more optimal than morning dosing. This trial aims to determine whether evening administration of LAMA reduces hospitalization-requiring AECOPD or death from all causes within 1 year as compared to morning administration of the same LAMA. Methods Randomized controlled open-label trial. Persons aged 30 years or older with a once-daily LAMA prescription and a confirmed COPD diagnosis were recruited. Participants were randomized in a 1:1 ratio to either morning or evening LAMA administration. Complete follow-up for the primary outcome, hospitalization-requiring AECOPD, or death from all causes within 1 year was captured from the Danish National Health Register, as were patient-reported outcome assessments at 6 and 12 months. Results A total of 10,013 participants were randomized, and the recruitment process started on 9 March 2023. Secondary outcomes include (i) moderate COPD exacerbations; (ii) all-cause hospitalization; (iii) ICU admission; (iv) need for non-invasive ventilation; and (v) all-cause mortality, among others. All outcomes will be evaluated 12 months after recruitment.Clinical trial registration:ClinicalTrials.gov, NCT05563675.
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Affiliation(s)
- Pradeesh Sivapalan
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Valdemar Rømer
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Tobias Wirenfeldt Klausen
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Alexander Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jørgen Vestbo
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Josefin Eklöf
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Alexander Jordan
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Hellerup, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Jens-Ulrik Jensen
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Tsiligianni I, Kocks JWH. Daytime symptoms of chronic obstructive pulmonary disease: a systematic review. NPJ Prim Care Respir Med 2020; 30:6. [PMID: 32081967 PMCID: PMC7035364 DOI: 10.1038/s41533-020-0163-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/24/2020] [Indexed: 02/06/2023] Open
Abstract
There is no single source of compiled data on symptoms experienced by patients with chronic obstructive pulmonary disease (COPD) when awake and active throughout the day. The aim of this systematic review was to evaluate the prevalence, variability, and burden (i.e., bothersomeness and/or intensity), and the impact of daytime COPD symptoms on other outcomes. The review also evaluated the impact of interventions and the measures/tools used to assess daytime COPD symptoms in patients. A systematic literature search was conducted using the primary search terms "COPD", "symptoms", and "daytime" in EMBASE®, MEDLINE®, MEDLINE® In-Process, and CENTRAL in 2016, followed by an additional search in 2018 to capture any new literature that was published since the last search. Fifty-six articles were included in the review. The accumulated evidence indicated that the symptomatic burden of COPD appears greatest in the morning, particularly upon waking, and that these morning symptoms have a substantial impact on patients' ability to function normally through the day; they also worsen quality of life. A wide variety of tools were used to evaluate symptoms across the studies. The literature also confirmed the importance of pharmacotherapy in the management of daytime COPD symptoms, and in helping normalize daily functioning. More research is needed to better understand how COPD symptoms impact daily functioning and to evaluate COPD symptoms at well-defined periods throughout the day, using validated and uniform measures/tools. This will help clinicians to better define patients' needs and take appropriate action.
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Affiliation(s)
- Ioanna Tsiligianni
- Department of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete, Greece.
| | - Janwillem W H Kocks
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
- General Practitioners Research Institute, Groningen, The Netherlands
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Rebelo P, Oliveira A, Paixão C, Valente C, Andrade L, Marques A. Minimal Clinically Important Differences for Patient-Reported Outcome Measures of Cough and Sputum in Patients with COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:201-212. [PMID: 32099345 PMCID: PMC6996113 DOI: 10.2147/copd.s219480] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/31/2019] [Indexed: 11/23/2022] Open
Abstract
Background Cough and sputum are highly prevalent in patients with chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation (PR) has shown to be effective in managing these symptoms. However, the interpretation of the magnitude of PR effects is hindered by the lack of minimal clinically important differences (MCIDs). Purpose This study established MCIDs for the Leicester cough questionnaire (LCQ) and the cough and sputum assessment questionnaire (CASA-Q), in patients with COPD after PR. Patients and Methods An observational prospective study was conducted in patients with COPD who participated in a 12-weeks community-based PR program. Anchor- (mean change, receiver operating characteristic curves and linear regression analysis) and distribution-based methods [0.5*standard deviation; standard error of measurement (SEM); 1.96*SEM; minimal detectable change and effect size] were used to compute the MCIDs. The anchors used were: i) patients and physiotherapists global rating of change scale, ii) COPD assessment test, iii) St. George's respiratory questionnaire and iv) occurrence of an exacerbation during PR. Pooled MCIDs were computed using the arithmetic weighted mean (2/3 for anchor- and 1/3 for distribution-based methods). Results Forty-nine patients with COPD (81.6% male, 69.8±7.4years, FEV150.4±19.4%predicted) were used in the analysis. The pooled MCIDs were 1.3 for LCQ and for CASA-Q domains were: 10.6 - cough symptoms; 10.1 - cough impact; 9.5 - sputum symptoms and 7.8 - sputum impact. Conclusion The MCIDs found in this study are potential estimates to interpret PR effects on cough and sputum, and may contribute to guide interventions.
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Affiliation(s)
- Patrícia Rebelo
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal
- Institute of Biomedicine, School of Health Sciences (iBiMED), University of Aveiro (ESSUA), Aveiro, Portugal
| | - Ana Oliveira
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal
- Institute of Biomedicine, School of Health Sciences (iBiMED), University of Aveiro (ESSUA), Aveiro, Portugal
| | - Cátia Paixão
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal
- Institute of Biomedicine, School of Health Sciences (iBiMED), University of Aveiro (ESSUA), Aveiro, Portugal
| | - Carla Valente
- Pulmonology Department, Centro Hospitalar Do Baixo Vouga (CHBV), Aveiro, Portugal
| | - Lília Andrade
- Pulmonology Department, Centro Hospitalar Do Baixo Vouga (CHBV), Aveiro, Portugal
| | - Alda Marques
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal
- Institute of Biomedicine, School of Health Sciences (iBiMED), University of Aveiro (ESSUA), Aveiro, Portugal
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Kokturk N, Abuharbid W, Albanna AS, Gunen H, Gurgun A, Khadadah M, Malvolti E, Soliman M, van Zyl-Smit R, Zidouni N, Alzaabi A. A Cross-Sectional Study in Patients with Severe COPD to Assess the Perception of Symptom Variability (COPVAR) in the Middle East and Africa. Int J Chron Obstruct Pulmon Dis 2020; 14:2959-2970. [PMID: 31908444 PMCID: PMC6929940 DOI: 10.2147/copd.s215859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/11/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose This study was performed to assess symptom variability and its impact on morning activities in stable patients with severe COPD in the Middle East and Africa (MEA) countries. Patients and methods Non-interventional, cross-sectional study (NCT03425760) in patients with severe COPD (GOLD 2015, C, or D categories). Symptom variability was assessed directly by interviewing the patient and using the Global Chest Symptoms Questionnaire (GCSQ). The impact on morning activities was assessed using the Capacity of Daily Living during the Morning (CDLM) and the Morning Activities and Symptoms Questionnaire (MASQ). Results A total of 3253 patients (mean±SD age: 64.1±9.5 years, 90.3% males) were enrolled. Overall, 81.6% and 83.4% of patients reported weekly and daily symptom variability, respectively. The number of exacerbations in the previous year, smoking cessation, and COPD GOLD D were the most consistent factors associated with symptom variability. The GCSQ score was significantly higher (p<0.001) in GOLD D than in GOLD C patients at each time during the day. In GOLD D, the mean (±SD) GCSQ score was higher at night (1.6±1.2, p<0.001) and in the morning (1.5±1.0, p<0.001) than in the afternoon (1.3±0.9), suggesting daytime variability of breathlessness and chest tightness. Overall, 60.0% of GOLD D patients (versus 13.6% GOLD C, p<0.0001) had difficulty getting out of bed due to COPD. Patients with symptom variability had significantly more difficulty to get out of bed, especially patients with chest tightness variability (p<0.0001) and wheezing variability (p<0.0001). The CDLM global score was significantly lower (p<0.0001) in GOLD D than in GOLD C patients (3.5±1.1 and 4.6 ± 3.5, respectively). Daily variability in chest tightness and wheezing was also significantly associated with CDLM scores (p<0.0001). Conclusion In MEA countries, patients with severe stable COPD reported significant daily and weekly symptom variability which affects morning activities, particularly in GOLD D patients.
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Affiliation(s)
- Nurdan Kokturk
- Department of Chest Diseases, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Amr S Albanna
- King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Hakan Gunen
- Clinic of Chest Diseases, Sureyyapasa Chest Diseases and Chest Surgery Training and Research Hospital, Istanbul, Turkey
| | - Alev Gurgun
- Department of Chest Diseases, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mousa Khadadah
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
| | | | - Medhat Soliman
- Kasr El Aini Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Richard van Zyl-Smit
- University of Cape Town Lung Institute, Department of Medicine and Division of Pulmonology, Groote Schuur Hospital, Cape Town, South Africa
| | - Noureddine Zidouni
- Department of Pulmonology, University Hospital Issad Hassani, Béni Messous, Alger, Algeria
| | - Ashraf Alzaabi
- Respiratory Medicine Division, Zayed Military Hospital, Abu Dhabi, UAE
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Ohar JA, Bowling A, Goodin T, Price B, Ozol-Godfrey A, Sharma S, Sanjar S. Efficacy and safety of glycopyrrolate in patients with COPD by reversibility: pooled analysis of GEM1 and GEM2 12-week studies. Int J Chron Obstruct Pulmon Dis 2019; 14:461-470. [PMID: 30863047 PMCID: PMC6388797 DOI: 10.2147/copd.s194102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Bronchodilator reversibility has been reported in patients with COPD, although correlations between reversibility and treatment response are unclear. The effect of reversibility on lung function, health status, and dyspnea was assessed in patients with moderate-to-severe COPD receiving glycopyrrolate (GLY) 15.6 µg twice daily vs placebo in the Glycopyrrolate Effect on syMptoms and lung function 1 and 2 (GEM1 and GEM2) replicate, 12-week, placebo-controlled studies. Patients and methods Reversibility was defined as a post-bronchodilator increase of ≥12% and ≥0.200 L in FEV1. FEV1 area under the curve from 0 to 12 hours (AUC0-12 h), trough FEV1, St George's Respiratory Questionnaire (SGRQ) total score, COPD Assessment Test (CAT™) score, Transition Dyspnea Index (TDI) focal score, daily symptom scores, and rescue medication use were assessed by reversibility status. Incidences of adverse events and serious adverse events were also assessed. Results Data from 846 patients enrolled in GEM1 and GEM2 with known reversibility status were pooled for post hoc analysis. GLY significantly improved FEV1 AUC0-12 h, trough FEV1, SGRQ and CAT total scores, and rescue medication use compared with placebo in reversible and nonreversible patients. Significant improvements in TDI focal score and daily symptom scores with GLY over placebo were observed only among reversible patients. Improvements in FEV1 AUC0-12 h (0.165 vs 0.078 L; P<0.001) and trough FEV1 (0.173 vs 0.070 L; P<0.001) were clinically relevant (based on minimal clinically important differences) and significantly greater in reversible compared with nonreversible patients receiving GLY. The safety profile of GLY was not affected by reversibility status. Conclusion In this post hoc analysis, GLY was associated with significant improvements in lung function and patient-reported outcomes compared with placebo, mostly independent of reversibility status. In patients receiving GLY, improvements in lung function were greater in reversible compared with nonreversible patients. Reversibility status did not meaningfully impact the safety profile of GLY.
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Affiliation(s)
- Jill A Ohar
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA,
| | | | | | - Barry Price
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA
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van Buul AR, Kasteleyn MJ, Chavannes NH, Taube C. The association between objectively measured physical activity and morning symptoms in COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:2831-2840. [PMID: 29042764 PMCID: PMC5633288 DOI: 10.2147/copd.s143387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The morning is the most bothersome period for COPD patients. Morning symptom severities in different Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages are not well studied. Furthermore, factors that are associated with morning symptoms, especially the associations with objectively measured physical activity, are also not well described. MATERIALS AND METHODS The aim of this cross-sectional observational study was to assess morning symptom severity in GOLD A, B, C and D patients, according to the definitions of the GOLD 2015 statement. Morning symptoms were assessed with the PRO-Morning COPD Symptoms Questionnaire. Differences in morning symptom severity between different COPD stages were assessed with a one-way analysis of variance followed by post hoc analyses. The association between dyspnea severity (assessed with the modified Medical Research Council scale), health status, airflow limitation, lung hyperinflation, anxiety and depression, inflammatory parameters, exacerbations, objectively measured physical activity parameters retrieved from accelerometry and morning symptom severity was evaluated using linear regression analysis. RESULTS Eighty patients were included (aged 65.6±8.7 years, forced expiratory volume in 1 second [FEV1] % predicted 55.1±16.9). Mean (±SD) morning symptom score was 19.7 (±11.7). Morning symptom severity was significantly different between COPD stages: mean (±SD) score in GOLD A was 9.7 (±7.2), in GOLD B 19.8 (±10.7), in GOLD C 8.6 (±9.3) and in GOLD D 23.8 (±11.2) (p<0.001). Lower health status, more symptoms, increased anxiety and depression, less physical activity (all p<0.001) and lower FEV1 (p=0.03) were associated with an increased morning symptom severity. CONCLUSION Patients with overall more symptomatic COPD have significant higher morning symptom scores. Morning symptom severity was associated with important clinical outcomes: lower health status, more symptoms, increased anxiety and depression, fewer steps a day, less time in moderate and vigorous physical activity with bouts of at least 10 minutes and lower FEV1. The data suggest that morning symptoms should be carefully assessed in addition to assessment by general COPD-specific questionnaires, especially in those with more symptomatic COPD. More research is needed on potential therapies to improve morning symptoms; this study shows potential targets for intervention.
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Affiliation(s)
| | - Marise J Kasteleyn
- Department of Pulmonology.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Christian Taube
- Department of Pulmonology.,Department of Pulmonary Medicine, West German Lung Center, Essen University Hospital, Ruhrlandklinik, University Duisburg-Essen, Essen, Germany
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Fernandes FLA, Cukier A, Camelier AA, Fritscher CC, da Costa CH, Pereira EDB, Godoy I, Cançado JED, Romaldini JG, Chatkin JM, Jardim JR, Rabahi MF, de Nucci MCNM, Sales MDPU, Castellano MVCDO, Aidé MA, Teixeira PJZ, Maciel R, Corrêa RDA, Stirbulov R, Athanazio RA, Russo R, Minamoto ST, Lundgren FLC. Recommendations for the pharmacological treatment of COPD: questions and answers. J Bras Pneumol 2017; 43:290-301. [PMID: 29365005 PMCID: PMC5687967 DOI: 10.1590/s1806-37562017000000153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/04/2017] [Indexed: 11/22/2022] Open
Abstract
The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.
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Affiliation(s)
- Frederico Leon Arrabal Fernandes
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Alberto Cukier
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Aquiles Assunção Camelier
- . Universidade do Estado da Bahia - UNEB - Salvador (BA) Brasil
- . Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil
| | - Carlos Cezar Fritscher
- . Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS− Porto Alegre (RS)Brasil
| | | | | | - Irma Godoy
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | | | - José Gustavo Romaldini
- . Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo,São Paulo (SP) Brasil
| | - Jose Miguel Chatkin
- . Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS− Porto Alegre (RS)Brasil
| | - José Roberto Jardim
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | | | | | | | | | - Miguel Abidon Aidé
- . Faculdade de Medicina, Universidade Federal Fluminense, Niterói (RJ) Brasil
| | - Paulo José Zimermann Teixeira
- . Departamento de Clínica Médica, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
- . Universidade FEEVALE, Campus II, Novo Hamburgo (RS) Brasil
| | - Renato Maciel
- . Disciplina de Pneumologia, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Ricardo de Amorim Corrêa
- . Faculdade de Medicina, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Roberto Stirbulov
- . Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo,São Paulo (SP) Brasil
| | - Rodrigo Abensur Athanazio
- . Divisão de Pneumologia, Instituto do Coração - InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rodrigo Russo
- . Departamento de Medicina, Universidade Federal de São João Del Rei - UFSJ − São João Del Rei (MG) Brasil
| | - Suzana Tanni Minamoto
- . Departamento de Medicina Interna, Área de Pneumologia, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
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