Variabilidad de síntomas en pacientes ambulatorios con EPOC y validación del Instrumento colombiano de variabilidad de síntomas en EPOC (CoVaSy)

Introducción. Se considera que la variabilidad de los síntomas respiratorios de la enfermedad pulmonar obstructiva crónica (EPOC) es baja o inexistente. Sin embargo, algunos autores afirman que se pueden presentar fluctuaciones. Objetivos. Describir la variabilidad de síntomas en pacientes con EPOC a lo largo del día y la noche durante cuatro semanas mediante un diario de paciente y validar un cuestionario desarrollado para tal fin (el Instrumento Colombiano Autoadministrado de Variabilidad de Síntomas en EPOC - EPOC-CoVaSy) Materiales y métodos. Estudio de cohorte realizado en 96 pacientes con EPOC atendidos entre junio y diciembre de 2016 en el Centro de Atención Pulmonar - CAP, en Barranquilla, Colombia, quienes diligenciaron un diario de paciente durante cuatro semanas y, luego de este periodo, el instrumento auto administrado EPOC-CoVaSy. La independencia y comparación de frecuencias de las variables categóricas y continuas se establecieron mediante las pruebas χ² y exacta de Fisher y el coeficiente de correlación de Pearson, respectivamente. Se realizó un MANOVA, utilizando modelos de regresión lineal, para determinar las correlaciones entre los resultados del diario y el instrumento. Resultados. La edad promedio de los participantes fue 73.3±8.3 años y 71.87% eran hombres. Según el análisis de los diarios, los puntajes promedio (escala visual analógica) para todos los síntomas y desempeño de actividades diarias oscilaron entre 0.5 y 2.5 siendo más altos en la mañana (puntajes promedio entre 1.5 y 2.5) que en la tarde y noche (puntajes promedio entre 0.5 y 1.5), sin embargo esta variabilidad fue mínima, lo que coincidió con los resultados obtenidos en el EPOC-CoVaSy, evidenciándose una alta correlación entre ambos instrumentos, lo que permitió confirmar que la herramienta diseñada es útil para medir dicha variabilidad. Conclusiones. Con base en los hallazgos del presente estudio, se puede concluir que existe una leve variabilidad en los síntomas de EPOC a lo largo del día, la cual debe considerarse a la hora de establecer esquemas de tratamiento para esta enfermedad. Asimismo, se estableció que el EPOC-CoVaSy es válido para medir dicha variabilidad en la población colombiana con EPOC.

Support System for Early Diagnosis of Chronic Obstructive Pulmonary Disease Based on the Service-Oriented Architecture Paradigm and Business Process Management Strategy: Development and Usability Survey Among Patients and Health Care Providers

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with a high global prevalence. The main scientific societies dedicated to the management of this disease have published clinical practice guidelines for quality practice. However, at present, there are important weaknesses in COPD diagnosis criteria that often lead to underdiagnosis or misdiagnosis.

OBJECTIVE

We sought to develop a new support system for COPD diagnosis. The system was designed to overcome the weaknesses detected in current guidelines with the goals of enabling early diagnosis, and improving the diagnostic accuracy and quality of care provided.

METHODS

We first analyzed the main clinical guidelines for COPD to detect weaknesses that exist in the current diagnostic process, and then proposed a redesign based on a business process management (BPM) strategy for its optimization. The BPM system acts as a backbone throughout the process of COPD diagnosis in this proposed approach. The newly developed support system was integrated into a health information system for validation of its use in a hospital environment. The system was qualitatively evaluated by experts (n=12) and patients (n=36).

RESULTS

Among the 12 experts, 10 (83%) positively evaluated our system with respect to increasing the speed for making the diagnosis, helping in interpreting results, and encouraging opportunistic diagnosis. With an overall rating of 4.29 on a 5-point scale, 27/36 (75%) of patients considered that the system was very useful in providing a warning about possible cases of COPD. The overall assessment of the system was 4.53 on a 5-point Likert scale with agreement to extend its use to all primary care centers.

CONCLUSIONS

The proposed system provides a functional method to overcome the weaknesses detected in the current diagnostic process for COPD, which can help foster early diagnosis, while improving the diagnostic accuracy and quality of care provided.

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy and safety of an active strategy for the diagnosis and treatment of acute pulmonary embolism during exacerbations of chronic obstructive pulmonary disease

Introduction

Some previous studies have suggested a high prevalence of pulmonary embolism (PE) during exacerbations of chronic obstructive pulmonary disease (ECOPD). The SLICE trial aims to assess the efficacy and safety of an active strategy for the diagnosis and treatment of PE (vs usual care) in patients hospitalized because of ECOPD.

Methods

SLICE is a phase III, prospective, international, multicenter, randomized, open‐label, and parallel‐group trial. A total of 746 patients hospitalized because of ECOPD will be randomized in a 1:1 fashion to receive either an active strategy for the diagnosis and anticoagulant treatment of PE or usual care (ie, standard care without any diagnostic test for diagnosing PE). The primary outcome is a composite of all‐cause death, non‐fatal (recurrent) venous thromboembolism (VTE), or readmission for ECOPD within 90 days after enrollment. Secondary outcomes are (a) death from any cause within 90 days after enrollment, (b) non‐fatal (recurrent) VTE within 90 days after enrollment, (c) readmission within 90 days after enrollment, and (d) length of hospital stay.

Results

Enrollment started in September 2014 and is expected to proceed until 2020. Median age of the first 443 patients was 71 years (interquartile range, 64‐78), and 26% were female.

Conclusions

This multicenter trial will determine the value of detecting PEs in patients with ECOPD. This has implications for COPD patient morbidity and mortality.

Trial registration number: NCT02238639.

Costos medicos directos en pacientes con enfermedad pulmonar obstructiva Crónica en Mexico

INTRODUCTION

chronic obstructive pulmonary disease (COPD) is a progressive, incurable and potentially mortal. COPD generates a high burden of illness and decreased quality of life in patients. The aim of this study was to determine the direct medical cost of COPD and the primary variables associated.

METHODOLOGY

We conducted a multicenter clinical study, based in a retrospective cohort as base of a partial economic evaluation in patients diagnosed with moderate to severe COPD. It was considered an institutional point of view to determine medical costs, with an annual time horizon. For analysis of associations between explanatory and end point variables, a generalized lineal regression model was developed.

RESULTS

We analyzed data from 283 patients, Fifty-nine percent were women, the average age was 72 years ± 11, Sixty-five percent of patients had a history of smoking and 57.6 % were exposed to wood smoke. The annual direct medical costs (MXN 2016) was 20,754 and 41,887 for patients with moderate and severe COPD, respectively, this difference is mainly due to the use of oxygen as well as longer hospital stay (12.9 vs. 24.7 days) of patients with severe COPD.

CONCLUSIONS

Although the severity level is associated with greater health care costs, the quality of life of the patients should be considered carefully because it is inversely associated with the cost of care for patients with COPD.

[The changing sex differences in life expectancy in Spain (1980-2012): decomposition by age and cause]

OBJECTIVE

To calculate and analyse the contributions of changes in mortality by age groups and selected causes of death to sex differences in life expectancy at birth in Spain from 1980 to 2012.

METHODS

Cross-sectional study with three time points (1980, 1995, and 2012). We used data from Human Cause-of-Death Database and Human Mortality Database. We use a decomposition method of the differences in life expectancy and gender differences in life expectancy from changes in mortality by 5-year age groups and causes of death between women and men.

RESULTS

From 1980 to 1995, the lower mortality of women from 25 years old, and the differences in mortality by HIV/AIDS, lung cancer, and chronic obstructive pulmonary diseases contributed to the gap increase. From 1995 to 2012, greatest improvement in mortality of males under 74 years of age, and in improving male mortality from HIV/AIDS, acute myocardial infarction and traffic accidents contributed to the narrowing.

CONCLUSIONS

The difference in life expectancy at birth between men and women has decreased since 1995 due to a greater improvement in mortality from causes of death associated with risky behaviours and habits of the working age male population.

Spirometry and Bronchodilator Test

Spirometry is a physiological test for assessing the functional aspect of the lungs using an objective indicator to measure the maximum amount of air that a patient can inhale and exhale. Acceptable spirometry testing needs to be conducted three times by an acceptable and reproducible method for determining forced vital capacity (FVC). Until the results of three tests meet the criteria of reproducibility, the test should be repeated up to eight times. Interpretation of spirometry should be clear, concise, and informative. Additionally, spirometry should guarantee optimal quality prior to the interpreting spirometry results. Our guideline adopts a fixed normal predictive value instead of the lower limit of normal as the reference value because fixed value is more convenient and also accepts FVC instead of vital capacity (VC) because measurement of VC using a spirometer is impossible. The bronchodilator test is a method for measuring the changes in lung capacity after inhaling a short-acting β-agonist that dilates the airway. When an obstructive ventilatory defect is observed, this test helps to diagnose and evaluate asthma and chronic obstructive pulmonary disease by measuring reversibility with the use of an inhaled bronchodilator. A positive response to a bronchodilator is generally defined as an increase of ≥12% and ≥200 mL as an absolute value compared with a baseline in either forced expiratory volume at 1 second or FVC.

Treatment patterns in COPD patients newly diagnosed in primary care. A population-based study

INTRODUCTION

Treatment for COPD is tailored based on clinical characteristics and severity. However, prescription patterns in COPD patients newly diagnosed in primary care may differ from guideline recommendations.

METHOD

We performed an epidemiological study with data obtained from the Information System for the Development in Research in Primary Care (SIDIAP), a population database that contains information of 5.8 million inhabitants (80% of the population of Catalonia). Patients newly diagnosed with COPD from 2007 to 2012 were identified and information about the initial treatment patterns was collected. The initial treatment was also described by phenotype and severity.

RESULTS

During the study period 41,492 patients were newly diagnosed with COPD. Patients were classified as non exacerbators (28,552 patients, 69%), asthma-COPD overlap syndrome (ACOS) (2152 patients, 5.2%) and frequent exacerbators (10,888 patients, 27.6%). Among the patients in whom FEV1 was available, 13.9% were GOLD stage 1, 55.2% stage 2, 26% stage 3 and 4.8% stage 4. Globally, the most frequently prescribed treatment patterns were short-acting bronchodilators (SABD) in monotherapy (17.7%), long-acting β-2 agonists (LABA) + inhaled corticosteroids (ICS) (17.3%) and triple therapy (12.2%). The frequency of patients treated with a SABD increased from 15.9% to 19.5% during the study period, while the number of untreated patients decreased from 24.4% to 15.1%. Up to 45.2% of patients were initially treated with ICS, which were frequently prescribed in the ACOS (69.2%) and in the exacerbator phenotype patients (52.4%) while ICS use has decreased from 43.8% in 2007 to 35.8% in 2012 in non exacerbator patients. Up to 13.6% and 14.8% of GOLD 4 patients received no treatment or only SABD after diagnosis.

CONCLUSIONS

Initial treatment patterns in newly diagnosed COPD patients often do no comply with guidelines. The use of ICS is excessive but has decreased mainly in non exacerbator patients. Many COPD patients still remain untreated after diagnosis, although this has decreased. Some GOLD 4 patients are still receiving SABD or no treatment at all after diagnosis.

Appropriateness of diagnostic effort in hospital emergency room attention for episodes of COPD exacerbation

RATIONALE, AIMS AND OBJECTIVES

To assess the adequacy of diagnostic effort in the emergency departments of Spanish hospitals with respect to episodes of exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

A descriptive cross-sectional study, conducted between 2007 and 2010 in 15 hospitals in Andalusia, Catalonia, Madrid and the Basque Country. The study population included cases of COPD exacerbation attended at the emergency departments of the participating hospitals. Diagnostic efforts were considered sufficient and appropriate when the emergency room conducted a clinical evaluation including electrocardiogram, chest X-ray, arterial blood gas analysis and spirometry.

RESULTS

2852 episodes of COPD exacerbation attended in hospital emergency departments were assessed. 91.4% of the patients were male, with a mean age of 72.8 (SD 9.5) years, and 45.6% had had a previous emergency admission. The diagnostic effort was considered adequate in 60.1% of the episodes (95% CI: 58.3-61.9). The inter-hospital range of variation(25-75) was 1.67 and the coefficient of variation was 28.3%. In multivariate analysis, adjusting for hospital, date of admission and previous hospitalization, among the male patients, the OR for adequate diagnostic effort was 1.38 (95% CI: 1.04-1.84) CONCLUSION: With respect to diagnostic effort, inequities were observed in our assessment of episodes of COPD exacerbation attended in the emergency departments of Spanish public hospitals. In a high percentage of cases (40%), proper assessment was not conducted. Moreover, inter-individual and inter-hospital differences were observed.

Pharmacotherapy for lower respiratory tract infections

INTRODUCTION

Bacterial infections play an important role as etiological agents in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and exacerbations of non-cystic fibrosis (CF) bronchiectasis. In acute bronchitis and asthma exacerbations their role is less well defined than with patients with COPD. The clinical features, causative pathogens and therapies of common acute respiratory tract infections are detailed in this review.

AREAS COVERED

This article covers medical literature published in any language from 2000 to 2014, on 'lower respiratory tract infections', identified using PubMed, MEDLINE and ClinicalTrial.gov. The search terms used were 'COPD exacerbations', 'bronchiectasis', 'macrolides' and 'inhaled antibiotics'.

EXPERT OPINION

Given that almost half of AECOPD are caused by bacteria, administration of antibacterial agents is recommended for patients with severe exacerbations or severe underlying COPD. Chronic prophylactic use of macrolides seems to be of benefit, particularly in patients with bronchiectasis and chronic mucous hypersecretion. In an effort to manage chronic airway infection non-CF bronchiectasis due to drug-resistant pathogens, aerosolized antibiotics may be of value, and the data from recent studies are examined to demonstrate the potential value of this therapy, which is often used as an adjunctive measure to systemic antimicrobial therapy.

Efficacy of a multifactorial intervention on therapeutic adherence in patients with chronic obstructive pulmonary disease (COPD): a randomized controlled trial

BACKGROUND

Therapeutic adherence of patients with chronic obstructive pulmonary disease (COPD) is poor. This study evaluated the effectiveness of a multifactorial intervention on improving the therapeutic adherence in chronic obstructive pulmonary disease (COPD) patients with scheduled inhalation therapy.

METHODS

The study design consisted of a randomised controlled trial in a primary care setting. 146 patients diagnosed with COPD were randomly allocated into two groups using the block randomisation technique. One-year follow-ups with three visits were performed. The intervention consisted of motivational aspects related to adherence (beliefs and behaviour) in the form of group and individual interviews, cognitive aspects in the form of information about the illness and skills in the form of training in inhalation techniques. Cognitive-emotional aspects and training in inhalation techniques were reinforced during all visits of the intervention group. The main outcome measure was adherence to the medication regimen. Therapeutic adherence was determined by the percentage of patients classified as good adherent as evaluated by dose or pill count.

RESULTS

Of the 146 participants (mean age 69.8 years, 91.8% males), 41.1% reported adherence (41.9% of the control group and 40.3% of the intervention group). When multifactorial intervention was applied, the reported adherence was 32.4% for the control group and 48.6% for the intervention group, which showed a statistically significant difference (p = 0.046). Number needed to treat is 6.37. In the intervention group, cognitive aspects increased by 23.7% and skilled performance of inhalation techniques increased by 66.4%. The factors related to adherence when multifactorial intervention was applied were the number of exacerbations (OR = 0.66), visits to health centre (OR = 0.93) and devices (OR = 2.4); illness severity (OR = 0.67), beta-2-adrenergic (OR = 0.16) and xantine (OR = 0.19) treatment; activity (OR = 1.03) and impact (OR = 1.03) scales of the Saint George Respiratory Questionnaire.

CONCLUSION

Application of the multifactorial intervention designed for this study (COPD information, dose reminders, audio-visual material, motivational aspects and training in inhalation techniques) resulted in an improvement in therapeutic adherence in COPD patients with scheduled inhalation therapy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18841601.

Recommendations for fitness for work medical evaluations in chronic respiratory patients. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)

Chronic respiratory diseases often cause impairment in the functions and/or structure of the respiratory system, and impose limitations on different activities in the lives of persons who suffer them. In younger patients with an active working life, these limitations can cause problems in carrying out their normal work. Article 41 of the Spanish Constitution states that «the public authorities shall maintain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship». Within this framework is the assessment of fitness for work, as a dual-nature process (medico-legal) that aims to determine whether it is appropriate or not to recognise a person's right to receive benefits which replace the income that they no longer receive as they cannot carry out their work, due to loss of health. The role of the pulmonologist is essential in evaluating the diagnosis, treatment, prognosis and functional capacity of respiratory patients. These recommendations seek to bring the complex setting of fitness for work evaluation to pulmonologists and thoracic surgeons, providing action guidelines that allow them to advise their own patients about their incorporation into working life.

How should we define and classify exacerbations in chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a chronic disorder whose clinical course may be punctuated by exacerbations characterized by a sudden symptom worsening beyond the expected daily variations. Exacerbations bear clinical and prognostic relevance, and may result in marked functional and clinical deterioration. The varying presentations of COPD mean that exacerbations, although more frequent in patients with severe or very severe disease, may occur regardless of the degree of functional impairment. The new Spanish COPD Guideline (GesEPOC) has provided new insights into the management of the disease. The GesEPOC defines various disease phenotypes with different clinical, prognostic and therapeutic implications. One of these phenotypes is the so-called 'exacerbator', characterized by the incidence of an increased number of exacerbations (two or more moderate-severe exacerbations in the last year). An exacerbation must be defined by: an increase in symptom intensity occurring after a certain period of time since the last exacerbation (so that treatment failure can be excluded as the cause of the event); and the contribution of social criteria or reasons concerning the choice of therapy. The availability of certain tools to detect exacerbations would enable establishment of a homogeneous definition of exacerbation, and improved diagnosis, a suitable treatment choice and a more appropriate patient selection for clinical studies. Validated clinical questionnaires and biomarkers are the most helpful instruments to reach the above objectives. Following the clinical diagnosis of a COPD exacerbation, associated comorbidities must be evaluated and an etiologic diagnosis must be made, all of which will partially drive the choice of treatment. Once a diagnosis has been made, the severity of the exacerbation should be established in order to define where and how the patient should be treated. Based on the patient's clinical history, clinical examination and diagnostic tests, the severity will be classified in one of these four degrees: very severe, severe, moderate and mild.

How and when to use inhaled corticosteroids in chronic obstructive pulmonary disease?

Inhaled corticosteroids (ICSs) are widely used in chronic obstructive pulmonary disease (COPD). Since inflammatory processes play a key role in the pathogenesis of the disease and ICSs have been shown to be very effective in controlling asthma, their use in COPD patients has become widespread. However, their efficacy in COPD is more limited than in asthma, since the type of inflammation in COPD is predominantly neutrophilic and resistant to corticosteroids. ICSs have not been shown to prevent disease progression or reduce mortality in clinical trials. By contrast, these agents reduce exacerbations and improve both symptoms and quality of life in selected patients, particularly those with bronchial reversibility. Since ICSs are not harmless drugs, clinicians should make every effort to distinguish patients who will benefit from ICS treatment from those who will not. Side effects of ICSs may be both local and systemic, with most of them being dose dependent. A potential increase in the risk of pneumonia, diabetes, dysphonia or candiadiasis, among other complications, should be considered when prescribing these drugs in patients who usually have several comorbidities. Hence, it is important to identify those patients in whom the best risk-to-benefit ratio can be achieved and to use the most appropriate ICS dose with the least incidence of side effects.

Efficacy of pulmonary rehabilitation in patients with moderate chronic obstructive pulmonary disease: a randomized controlled trial

BACKGROUND

Pulmonary Rehabilitation for moderate Chronic Obstructive Pulmonary Disease in primary care could improve patients' quality of life.

METHODS

This study aimed to assess the efficacy of a 3-month Pulmonary Rehabilitation (PR) program with a further 9 months of maintenance (RHBM group) compared with both PR for 3 months without further maintenance (RHB group) and usual care in improving the quality of life of patients with moderate COPD.We conducted a parallel-group, randomized clinical trial in Majorca primary health care in which 97 patients with moderate COPD were assigned to the 3 groups. Health outcomes were quality of life, exercise capacity, pulmonary function and exacerbations.

RESULTS

We found statistically and clinically significant differences in the three groups at 3 months in the emotion dimension (0.53; 95%CI0.06-1.01) in the usual care group, (0.72; 95%CI0.26-1.18) the RHB group (0.87; 95%CI 0.44-1.30) and the RHBM group as well as in fatigue (0.47; 95%CI 0.17-0.78) in the RHBM group. After 1 year, these differences favored the long-term rehabilitation group in the domains of fatigue (0.56; 95%CI 0.22-0.91), mastery (0.79; 95%CI 0.03-1.55) and emotion (0.75; 95%CI 0.17-1.33). Between-group analysis only showed statistically and clinically significant differences between the RHB group and control group in the dyspnea dimension (0.79 95%CI 0.05-1.52). No differences were found for exacerbations, pulmonary function or exercise capacity.

CONCLUSIONS

We found that patients with moderate COPD and low level of impairment did not show meaningful changes in QoL, exercise tolerance, pulmonary function or exacerbation after a one-year, community based rehabilitation program. However, long-term improvements in the emotional, fatigue and mastery dimensions (within intervention groups) were identified.

TRIAL REGISTRATION

ISRCTN94514482.

Chronic obstructive pulmonary disease: a worldwide problem

Respiratory diseases receive little attention and funding in comparison with other major causes of global morbidity and mortality. Chronic obstructive pulmonary disease (COPD) has been a major public health problem and will remain a challenge for clinicians within the twenty-first century. Worldwide, COPD is in the spotlight because of its high prevalence, morbidity, and mortality, and creates formidable challenges for health care systems. This review summarizes the magnitude of the COPD problem at the population and individual levels.

[Spanish COPD Guidelines (GesEPOC): Pharmacological treatment of stable COPD]

Recognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.

Efficacy of two educational interventions about inhalation techniques in patients with chronic obstructive pulmonary disease (COPD). TECEPOC: study protocol for a partially randomized controlled trial (preference trial)

BACKGROUND

Drugs for inhalation are the cornerstone of therapy in obstructive lung disease. We have observed that up to 75 % of patients do not perform a correct inhalation technique. The inability of patients to correctly use their inhaler device may be a direct consequence of insufficient or poor inhaler technique instruction. The objective of this study is to test the efficacy of two educational interventions to improve the inhalation techniques in patients with Chronic Obstructive Pulmonary Disease (COPD).

METHODS

This study uses both a multicenter patients´ preference trial and a comprehensive cohort design with 495 COPD-diagnosed patients selected by a non-probabilistic method of sampling from seven Primary Care Centers. The participants will be divided into two groups and five arms. The two groups are: 1) the patients´ preference group with two arms and 2) the randomized group with three arms. In the preference group, the two arms correspond to the two educational interventions (Intervention A and Intervention B) designed for this study. In the randomized group the three arms comprise: intervention A, intervention B and a control arm. Intervention A is written information (a leaflet describing the correct inhalation techniques). Intervention B is written information about inhalation techniques plus training by an instructor. Every patient in each group will be visited six times during the year of the study at health care center.

DISCUSSION

Our hypothesis is that the application of two educational interventions in patients with COPD who are treated with inhaled therapy will increase the number of patients who perform a correct inhalation technique by at least 25 %. We will evaluate the effectiveness of these interventions on patient inhalation technique improvement, considering that it will be adequate and feasible within the context of clinical practice.

TRIAL REGISTRATION

Current Controlled Trials ISRTCTN15106246.

Spanish COPD Guidelines (GesEPOC): pharmacological treatment of stable COPD. Spanish Society of Pulmonology and Thoracic Surgery

Recognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.

The use of the lower limit of normal as a criterion for COPD excludes patients with increased morbidity and high consumption of health-care resources

The objective of this study is to analyze the clinical characteristics of two COPD patient populations: one diagnosed using the lower limit of normal (LLN) and another diagnosed by the GOLD criteria. We also compared the population excluded by the LLN criterion with a non-COPD control population. The COPD patients determined with the LLN criterion presented significantly lower levels of FEV1/FVC at 0.55 (0.8) vs. 0.66 (0.2), P=.000; FEV1 44.9% (14) vs. 53.8% (13), P=.000, and FVC 64.7% (17) vs. 70.4% p 0.04. The two COPD groups presented more frequent ER visits in the last year (57% and 52% of the patients, respectively, compared with 11.9% of the control group), without any statistically significant differences between the two. This same pattern was observed in the number of ER visits in the last year: 1.98 (1.6), 1.84 (1.5) and 1.18 (0.7), respectively. When we analyzed the prevalence of the comorbidities that are most frequently associated COPD, there was a clear increase in the percentage of patients who presented associated disorders compared with the control group. Nevertheless, these differences were not very relevant between the two COPD groups. The differences also were not relevant between both COPD groups in the pharmacological prescription profile. In conclusion, the use of the LLN as a criterion for establishing the diagnosis of COPD, compared with the GOLD criteria, excludes a population with important clinical manifestations and with a high consumption of health-care resources. Before its implementation, the relevance of applying this criterion in clinical practice should be analyzed.

Issues in pulmonary function testing for the screening and diagnosis of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

The purpose of this review article is to provide an up-to-date summary on the current evidence for or against the use of lung function tests as screening and diagnostic tools for airflow obstruction in chronic obstructive pulmonary disease (COPD), and to consider the relevant issues in context.

RECENT FINDINGS

COPD is characterized by chronic respiratory symptoms and airflow limitation with only partial reversibility on lung function testing. However, screening on a population basis or of an enriched 'at-risk' subset like chronic smokers is not supported by findings from previous epidemiological studies, screening trials or in currently published clinical management guidelines by professional societies and review bodies. The definition of airflow obstruction and the classification of disease severity of COPD also differ slightly between guidelines and statements from different professional societies.

SUMMARY

Given the experience from previous screening trials and controversial classification of airflow obstruction by severity, it is impossible to have accurate screening results for COPD based on lung function tests alone. Clinical respiratory symptoms should be taken into consideration in terms of the diagnosis and management of COPD, as well as in any screening trial or programme that is to be attempted or implemented.

Consensus document on the overlap phenotype COPD-asthma in COPD

INTRODUCTION

Although asthma and COPD are different pathologies, many patients share characteristics from both entities. These cases can have different evolutions and responses to treatment. Nevertheless, the evidence available is limited, and it is necessary to evaluate whether they represent a differential phenotype and provide recommendations about diagnosis and treatment, in addition to identifying possible gaps in our understanding of asthma and COPD.

METHODS

A nation-wide consensus of experts in COPD in two stages: 1) during an initial meeting, the topics to be dealt with were established and a first draft of statements was elaborated with a structured "brainstorming" method; 2) consensus was reached with two rounds of e-mails, using a Likert-type scale.

RESULTS

Consensus was reached about the existence of a differential clinical phenotype known as"Overlap Phenotype COPD-Asthma", whose diagnosis is made when 2 major criteria and 2 minor criteria are met. The major criteria include very positive bronchodilator test (increase in FEV(1) ≥ 15% and ≥ 400ml), eosinophilia in sputum and personal history of asthma. Minor criteria include high total IgE, personal history of atopy and positive bronchodilator test (increase in FEV(1) ≥ 12% and ≥ 200ml) on two or more occasions. The early use of individually-adjusted inhaled corticosteroids is recommended, and caution must be taken with their abrupt withdrawal. Meanwhile, in severe cases the use of triple therapy should be evaluated. Finally, there is an obvious lack of specific studies about the natural history and the treatment of these patients.

CONCLUSIONS

It is necessary to expand our knowledge about this phenotype in order to establish adequate guidelines and recommendations for its diagnosis and treatment.

Difficulties in differential diagnosis of COPD and asthma in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and asthma treatment must be based on appropriate diagnosis. However, patients receiving inhaled therapy in primary care may not be accurately diagnosed according to current guidelines.

AIM

To analyse the characteristics of patients treated with inhaled medication, the concordance of tools for differential diagnosis, and the adequacy of prescription of inhaled corticosteroids (ICs) in primary care.

DESIGN AND SETTING

Cross-sectional, multicentre, non-interventional study conducted in 10 primary care centres in Barcelona, Spain.

METHOD

Patients with chronic respiratory disease, aged >40 years were treated with ICs. They provided sociodemographic and clinical information and performed forced spirometry with a bronchodilator test (BDT). The diagnostic accuracy of asthma and COPD diagnoses were tested using two differential diagnosis questionnaires.

RESULTS

A total of 328 patients were initially classified as having COPD (64.8%), asthma (15.4%), or indeterminate (19.8%) by their GPs. After spirometry, 40% of patients had moderate-severe airflow obstruction according to the GOLD classification; mean reversibility of forced expiratory volume in 1 second (FEV1) was 8.4%; 18.6% had a positive BDT; and 39.8% had post-bronchodilator FEV1/forced vital capacity >0.7. Concordance of the differential diagnosis tools was moderate (clinical diagnosis versus spirometry and between the two questionnaires), low (clinical diagnosis versus questionnaires), and very low (spirometry versus differential diagnosis). Of the patients diagnosed with COPD, 71.4% were treated with ICs, and 12% of those classified as having asthma were not receiving ICs.

CONCLUSION

Most patients can be classified as having COPD or asthma by primary care physicians. The use of the two questionnaires did not provide a better differential diagnostic compared with symptoms and spirometry with a BDT. Misdiagnosis may lead to inadequate treatment.

Clinical phenotypes of COPD: identification, definition and implications for guidelines

The term phenotype in the field of COPD is defined as "a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes". Among all phenotypes described, there are three that are associated with prognosis and especially are associated with a different response to currently available therapies. There phenotypes are: the exacerbator, the overlap COPD-asthma and the emphysema-hyperinflation. The exacerbator is characterised by the presence of, at least, two exacerbations the previous year, and on top of long-acting bronchodilators, may require the use of antiinflammatory drugs. The overlap phenotype presents symptoms of increased variability of airflow and incompletely reversible airflow obstruction. Due to the underlying inflammatory profile, it uses to have a good therapeutic response to inhaled corticosteroids in addition to bronchodilators. Lastly, the emphysema phenotype presents a poor therapeutic response to the existing antiinflammatory drugs and long-acting bronchodilators together with rehabilitation are the treatments of choice. Identifying the peculiarities of the different phenotypes of COPD will allow us to implement a more personalised treatment, in which the characteristics of the patients, together with their severity will be key to choose the best treatment option.

Effectiveness of a structured motivational intervention including smoking cessation advice and spirometry information in the primary care setting: the ESPITAP study

Background

There is current controversy about the efficacy of smoking cessation interventions that are based on information obtained by spirometry. The objective of this study is to evaluate the effectiveness in the primary care setting of structured motivational intervention to achieve smoking cessation, compared with usual clinical practice.

Methods

Discussion

Application of a motivational intervention based on structured information about spirometry results, improved abstinence rates among smokers seen in actual clinical practice conditions in primary care.

Trial registration

ClinicalTrial.gov, number NCT01194596.

[Treating COPD in chronic patients in a primary-care setting]

The aging of the populations in Western countries entails an increase in chronic diseases, which becomes evident with the triad of age, comorbidities and polymedication. chronic obstructive pulmonary disease represents one of the most important causes of morbidity and mortality, with a prevalence in Spain of 10.2% in the population aged 40 to 80. In recent years, it has come to be defined not only as an obstructive pulmonary disease, but also as a systemic disease. Some aspects stand out in its management: smoking, the main risk factor, even though avoidable, is an important health problem; very important levels of underdiagnosis and little diagnostic accuracy, with inadequate use of spirometry; chronic patient profile; exacerbations that affect survival and cause repeated hospitalizations; mobilization of numerous health-care resources; need to propose integral care (health-care education, rehabilitation, promotion of self-care and patient involvement in decision-making).

[Exacerbation of chronic obstructive pulmonary disease]

Las exacerbaciones de la enfermedad pulmonar obstructiva crónica (EPOC) se consideran episodios de inestabilidad que favorecen la progresión de la enfermedad, disminuyen la calidad de vida del paciente, aumentan el riesgo de defunción y son la causa de un consumo significativo de recursos sanitarios. Estas exacerbaciones se deben a infecciones bacterianas y virales, y a factores estresantes medioambientales, pero otras enfermedades concomitantes como las cardiopatías, otras enfermedades pulmonares (como la embolia pulmonar, la aspiración o el neumotórax) y otros procesos sistémicos, pueden desencadenar o complicar estas agudizaciones. En la fisiopatología de las exacerbaciones los dos factores que más influyen son la hiperinsuflación dinámica y la inflamación local y sistémica. El tratamiento farmacológico en la mayoría de los pacientes incluye broncodilatadores de acción corta, corticoides sistémicos y antibióticos. La insuficiencia respiratoria hipoxémica requiere oxigenoterapia controlada y en la insuficiencia respiratoria hipercápnica la ventilación con presión positiva no invasiva puede permitir ganar tiempo hasta que otros tratamientos empiecen a funcionar y, así, evitar la intubación endotraqueal. El uso de ventilación mecánica no invasiva nunca debe retrasar la intubación si ésta está indicada. Los criterios de alta hospitalaria se basan en la estabilización, tanto clínica como gasométrica, y en la capacidad del paciente para poder controlar la enfermedad en su domicilio. La hospitalización domiciliaria puede ser una opción de tratamiento de la exacerbación de la EPOC con eficacia equivalente a la hospitalización convencional.

[Importance of the distal airway in COPD]

Chronic obstructive pulmonary disease (COPD) is characterized by inflammation causing airflow obstruction. However, the initial histological lesion of COPD occurs in the respiratory bronchiole and spirometry is unable to detect involvement of this area until the disease is advanced. Major advances have been made in characterizing the inflammatory process in the small airways. However, in clinical practice, a non-invasive marker of small airways involvement, which would allow injury and the effect of treatment to be monitored, is lacking. To date, the combination of bronchodilators and inhaled corticosteroids is recommended for the most severe cases, although the effects of this therapeutic option on the small airways are not well known. New treatments that reach the distal airways and novel techniques to assess the small airways will allow a more complete approach to this disease.

[Chronic obstructive pulmonary disease and asthma]

Chronic obstructive pulmonary disease and asthma are both highly prevalent inflammatory diseases characterized by airway obstruction with distinct pathogenic mechanisms and different degrees of response to antiinflammatory therapy. However, forms of presentation that show overlap between both diseases and which are not clearly represented in clinical trials are frequently encountered in clinical practice. These patients may show accelerated loss of pulmonary function and have a worse prognosis. Therefore their early identification is essential. Biomarkers such as bronchial hyperreactivity or nitric oxide in exhaled air have yielded discrepant results. Phenotypic characterization will allow treatment with inhaled corticosteroids to be individually tailored and optimized.