Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey

Introduction

Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD.

Methods

A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal.

Results

A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction.

Conclusion

In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.

Air pollution and health prevention: A document of reflection

Ambient air quality, pollution and its implication on health is a topic of enormous importance that is normally dealt with by major specialists in their particular areas of interest. In general, it is not discussed from multidisciplinary approaches or with a language that can reach everyone. For this reason, the Health Sciences Foundation, from its prevention area, has formulated a series of questions to people with very varied competences in the area of ambient air quality in order to obtain a global panorama of the problem and its elements of measurement and control. The answers have been produced by specialists in each subject and have been subjected to a general discussion that has allowed conclusions to be reached on each point. The subject was divided into three main blocks: external ambient air, internal ambient air, mainly in the work-place, and hospital ambient air and the consequences of its poor control. Along with the definitions of each area and the indicators of good and bad quality, some necessary solutions have been pointed out. We have tried to know the current legislation on this problem and the competences of the different administrations on it. Despite its enormous importance, ambient air quality and health is not usually a topic of frequent presence in the general media and we have asked about the causes of this. Finally, the paper addresses a series of reflections from the perspective of ethics and very particularly in the light of the events that the present pandemic raises. This work aims to provide objective data and opinions that will enable non-specialists in the field to gain a better understanding of this worrying reality.

Use of Antivirals in SARS-CoV-2 Infection. Critical Review of the Role of Remdesivir

The aim of this report is to review the literature and shed light on the uncertainties surrounding the use of antiviral agents in general and remdesivir in COVID-19 patients. This review evaluated a battery of antiviral compounds and their effectiveness in the treatment of COVID-19 since the beginning of the pandemic. Remdesivir is the only antiviral approved by the EMA and FDA for the treatment of SARS-CoV-2 infection. This work extensively reviews remdesivir data generated from clinical trials and observational studies, paying attention to the most recent data, and focusing on outcomes to give readers a more comprehensive understanding of the results. This review also discusses the recommendations issued by official bodies during the pandemic in the light of the current knowledge. The use of remdesivir in the treatment of SARS-CoV-2 infection is justified because a virus is the causative agent that triggers the inflammatory responses and its consequences. More trials are needed to improve the management of this disease.

[Telephone Support for Copd Patients During COVID-19]

The state of alarm declared by the Spanish government as the main measure for preventing contagion has involved a change in the clinical management of chronic patients. Although new communication technologies offer us many ways to establish direct but remote contact, the peculiarities of the COPD patient often mean that their healthcare is reduced to telephone calls. The challenge of caring for COPD patients is made even more complex when it has to be delivered over the phone. The interview must be conducted without examining the patient, without performing additional tests, and without checking their inhalation technique. Therefore, healthcare providers who conduct these interviews must be trained to perform them properly in order to make the right decisions. This document is aimed at healthcare professionals who need to provide some form of telephone care to COPD patients during the SARS-CoV-2 pandemic and is based on the authors' experience in telephone interviews conducted during this period. It summarizes essential aspects of how this interview should be approached, how to conduct it, what factors should be kept in mind, how to organize the interview, and how to keep patients informed. It is very likely that from now on this type of interview will be common practice in the care of our patients, so we need to learn how to structure a new model of healthcare for many of the clinical visits that have until now been conducted face-to-face.

Blood Eosinophil Counts and Their Variability and Risk of Exacerbations in COPD: A Population-Based Study

BACKGROUND

There is controversy regarding the role of blood eosinophil levels as a biomarker of exacerbation risk in chronic obstructive pulmonary disease (COPD). Our aim was to quantify blood eosinophil levels and determine the risk of exacerbations associated with these levels and their variability.

METHODS

Observational, retrospective, population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical record database in Catalonia, Spain, covering 80% of the general population. Patients were classified into 4 groups using the following cut-offs: (a) <150cells/μl; (b) ≥150 and <300cells/μl; (c) ≥300 and <500cells/μl; (d) ≥500cells/μl.

RESULTS

A total of 57,209 patients were identified with a mean age of 70.2 years, a mean FEV1(% predicted) of 64.1% and 51.6% had at least one exacerbation the previous year. The number of exacerbations in the previous year was higher in patients with the lowest and the highest eosinophil levels compared with the intermediate groups. During follow-up the number of exacerbations was slightly higher in the group with the lowest blood eosinophil levels and in those with higher variability in eosinophil counts, but ROC curves did not identify a reliable threshold of blood eosinophilia to discriminate an increased risk of exacerbations.

CONCLUSIONS

Our results do not support the use of blood eosinophil count as a reliable biomarker of the risk of exacerbation in COPD in a predominantly non-exacerbating population. Of note was that the small group of patients with the highest variability in blood eosinophils more frequently presented exacerbations.

Evaluation of Changes in Control Status in COPD: An Opportunity for Early Intervention

BACKGROUND

Control has been proposed as a dynamic tool that can capture changes in the clinical status of patients with COPD.

METHODS

This prospective, multicenter, observational study aimed to compare changes in control over a 3-month period with changes in risk level, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, and clinical phenotype (nonexacerbator, asthma-COPD overlap, or exacerbator with emphysema or with chronic bronchitis). Control was defined as the presence of low clinical impact, assessed according to the degree of dyspnea, use of rescue medication, physical activity and sputum color, and clinical stability assessed by clinical changes and exacerbations in the last 3 months. Impact and stability were alternatively assessed with COPD Assessment Test (CAT) scores.

RESULTS

We included 354 patients, with a mean FEV₁ of 49.8% ± 16.9%. At 3 months, the proportion of controlled patients was 50.3% according to clinical evaluation and 47.8% according to CAT score. Eighty-seven patients (29.2%) changed their control status as assessed by clinical variables, and 85 patients (28.5%) changed their status according to CAT score. In contrast, the risk level only changed in 26 patients (8.7%) (P < .001), 27 patients (9.1%) experienced changes in their clinical phenotype (P < .001), and 59 patients (19.8%) experienced changes in their GOLD stage (P = .008). Patients who showed an improvement in control status had better CAT scores at the end of follow-up (P < .001).

CONCLUSIONS

In only 3 months, almost one-third of patients experienced changes in their control status. Changes in control status were significantly more frequent than changes in phenotype, risk level, and GOLD stage, and resulted in significant changes in health status.

Active smoking and COPD phenotype: distribution and impact on prognostic factors

PURPOSE

Smoking can affect both the phenotypic expression of COPD and factors such as disease severity, quality of life, and comorbidities. Our objective was to evaluate if the impact of active smoking on these factors varies according to the disease phenotype.

PATIENTS AND METHODS

This was a Spanish, observational, cross-sectional, multicenter study of patients with a diagnosis of COPD. Smoking rates were described among four different phenotypes (non-exacerbators, asthma-COPD overlap syndrome [ACOS], exacerbators with emphysema, and exacerbators with chronic bronchitis), and correlated with disease severity (body mass index, obstruction, dyspnea and exacerbations [BODEx] index and dyspnea grade), quality of life according to the COPD assessment test (CAT), and presence of comorbidities, according to phenotypic expression.

RESULTS

In total, 1,610 patients were recruited, of whom 46.70% were classified as non-exacerbators, 14.53% as ACOS, 16.37% as exacerbators with emphysema, and 22.40% as exacerbators with chronic bronchitis. Smokers were predominant in the latter 2 groups (58.91% and 57.67%, respectively, P=0.03). Active smoking was significantly associated with better quality of life and a higher dyspnea grade, although differences were observed depending on clinical phenotype.

CONCLUSION

Active smoking is more common among exacerbator phenotypes and appears to affect quality of life and dyspnea grade differently, depending on the clinical expression of the disease.

What pulmonologists think about the asthma-COPD overlap syndrome

BACKGROUND

Some patients with COPD may share characteristics of asthma; this is the so-called asthma-COPD overlap syndrome (ACOS). There are no universally accepted criteria for ACOS, and most treatments for asthma and COPD have not been adequately tested in this population.

MATERIALS AND METHODS

We performed a survey among pulmonology specialists in asthma and COPD aimed at collecting their opinions about ACOS and their attitudes in regard to some case scenarios of ACOS patients. The participants answered a structured questionnaire and attended a face-to-face meeting with the Metaplan methodology to discuss different aspects of ACOS.

RESULTS

A total of 26 pulmonologists with a mean age of 49.7 years participated in the survey (13 specialists in asthma and 13 in COPD). Among these, 84.6% recognized the existence of ACOS and stated that a mean of 12.6% of their patients might have this syndrome. In addition, 80.8% agreed that the diagnostic criteria for ACOS are not yet well defined. The most frequently mentioned characteristics of ACOS were a history of asthma (88.5%), significant smoking exposure (73.1%), and postbronchodilator forced expiratory volume in 1 second/forced vital capacity <0.7 (69.2%). The most accepted diagnostic criteria were eosinophilia in sputum (80.8%), a very positive bronchodilator test (69.2%), and a history of asthma before 40 years of age (65.4%). Up to 96.2% agreed that first-line treatment for ACOS was the combination of a long-acting β2-agonist and inhaled steroid, with a long-acting antimuscarinic agent (triple therapy) for severe ACOS.

CONCLUSION

Most Spanish specialists in asthma and COPD agree that ACOS exists, but the diagnostic criteria are not yet well defined. A previous history of asthma, smoking, and not fully reversible airflow limitation are considered the main characteristics of ACOS, with the most accepted first-line treatment being long-acting β2-agonist/inhaled corticosteroids.

Generic utilities in chronic obstructive pulmonary disease patients stratified according to different staging systems

Background

To determine generic utilities for Spanish chronic obstructive pulmonary disease (COPD) patients stratified by different classifications: GOLD 2007, GOLD 2013, GesEPOC 2012 and BODEx index.

Methods

Multicentre, observational, cross-sectional study. Patients were aged ≥40 years, with spirometrically confirmed COPD. Utility values were derived from EQ-5D-3 L. Means, standard deviations (SD), medians and interquartile ranges (IQR) were computed based on the different classifications. Differences in median utilities between groups were assessed by non-parametric tests.

Results

346 patients were included, of which 85.5% were male with a mean age of 67.9 (SD = 9.7) years and a mean duration of COPD of 7.6 (SD = 5.8) years; 80.3% were ex-smokers and the mean smoking history was 54.2 (SD = 33.2) pack-years. Median utilities (IQR) by GOLD 2007 were 0.87 (0.22) for moderate; 0.80 (0.26) for severe and 0.67 (0.42) for very-severe patients (p < 0.001 for all comparisons). Median utilities by GOLD 2013 were group A: 1.0 (0.09); group B: 0.87 (0.13); group C: 1.0 (0.16); group D: 0.74 (0.29); comparisons were statistically significant (p < 0.001) except A vs C. Median utilities by GesEPOC phenotypes were 0.84 (0.33) for non exacerbator; 0.80 (0.26) for COPD-asthma overlap; 0.71 (0.62) for exacerbator with emphysema; 0.72 (0.57) for exacerbator with chronic bronchitis (p < 0.001). Comparisons between patients with or without exacerbations and between patients with COPD-asthma overlap and exacerbator with chronic bronchitis were statistically-significant (p < 0.001). Median utilities by BODEx index were: group 0–2: 0.89 (0.20); group 3–4: 0.80 (0.27); group 5–6: 0.67 (0.29); group 7–9: 0.41 (0.31). All comparisons were significant (p < 0.001) except between groups 3–4 and 5–6.

Conclusion

Irrespective of the classification used utilities were associated to disease severity. Some clinical phenotypes were associated with worse utilities, probably related to a higher frequency of exacerbations. GOLD 2007 guidelines and BODEx index better discriminated patients with a worse health status than GOLD 2013 guidelines, while GOLD 2013 guidelines were better able to identify a smaller group of patients with the best health.

Report of 38 cases of tracheobronchitis in non-immunocompromised patients with dual isolation of Aspergillus in lower respiratory tract samples

INTRODUCTION

Aspergillus tracheobronchitis is an uncommon manifestation of Aspergillus infection. This study retrospectively analysed patients presenting tracheobronchitis among non-neutropenic/non-transplant adult patients with at least two valuable cultures of respiratory samples yielding Aspergillus spp. in Spanish hospitals.

METHODS

Clinical records were retrospectively reviewed. Simple tracheobronchitis was considered when the bronchoscopy report described mucosal inflammation and mucus secretions and invasive tracheobronchitis when ulceration and pseudomembrane formation was reported. Cases were considered "proven" (histopathological confirmation) or "probable" aspergillar tracheobronchitis.

RESULTS

A total of 38 cases of tracheobronchitis (26 simple, 12 invasive) were identified, all considered probable aspergillar tracheobronchitis. Patients were elderly (89.5% patients were ≥ 65 years), males (76.3%), presented advanced COPD (GOLD III+IV in 81.3%) and heart insufficiency (55.3%), with higher APACHE II score in those with invasive tracheobronchitis (10.17 ± 7.38 vs. 4.32 ± 4.39, p=0.019). Up to 50% patients were taking steroids (accumulated doses >100 mg in 89.5% of them) and 34.2% antibiotics pre-admission. Antifungals were administered to 60.5% patients (57.7% with simple and 66.6% with invasive tracheobronchitis). Voriconazole was the most frequent antifungal (alone or in combination): 69.6% in the 23 treated patients (60.0% simple and 87.5% invasive tracheobronchitis). Mortality was 23.7% (15.4% in simple and 41.7% in invasive tracheobronchitis).

CONCLUSIONS

The results of the present study suggest that aspergillar tacheobronchitis should be considered in the differential diagnosis of non-immunocompromised patients with deteriorating chronic airway limitation.

Multicentric study on the beta-blocker use and relation with exacerbations in COPD

Chronic obstructive pulmonary disease (COPD) is frequently associated with chronic heart failure (CHF) or coronary artery disease (CAD). In spite of the recommendation to use beta-blockers (BB) they are likely under-prescribed to patients with concurrent COPD and heart diseases. To find out the prevalence of use of BB, 256 COPD patients were consecutively recruited by pulmonary physicians from 14 hospitals in 7 regions of Spain in their outpatient offices if they had a diagnosis of COPD, were not on long-term oxygen therapy, had CHF or CAD, and met the criteria for BB treatment. In patients with indication 58% (95%CI, 52-64%) of the COPD patients and 97% of the non-COPD patients were on BB (p < 0.001). In patients with COPD, several factors were independently related to at least one visit to the emergency room in the previous year such as use of BB, adjusted OR = 0.27 (95% CI 0.15-0.50), GOLD stage D, OR = 2.52 (1.40-4.53), baseline heart rate >70, OR 2.19 (1.24-3.86) use of long-acting beta2-agonists OR = 2.18 (1.29-3.68), previous episodes of left ventricular failure OR 2.27 (1.19-4.33) and diabetes, OR = 1.82 (1.08-3.38). We conclude that, according to what is recommended by current guidelines, BB are still under-prescribed in COPD patients. COPD patients with CHF or CAD using BB suffer fewer exacerbations and visits to the ER. GOLD stage, use of long-acting beta2-agonists, baseline heart rate and comorbidities are also risk factors for exacerbations in this population.

Factors associated with hospital admission for exacerbation of chronic obstructive pulmonary disease

INTRODUCTION

Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) that require hospital admission have a major impact on the progression of disease and generate high health costs.

METHOD

A multi-center, cross-sectional, observational, study was conducted with the aim to identify factors associated with hospital admission in patients with COPD. We obtained data of socio-demographic and anthropometric characteristics, quality of life, respiratory symptoms, anxiety and depression, physical activity and pulmonary function tests. We analyzed their association with hospital admission with a multivariate analysis using a logistic regression model.

RESULTS

We analyzed 127 patients, 50 (39%) of whom had been hospitalized. 93.7% were men, mean age 67 years (SD=9) and a FEV1 of 41.9% (SD=15.3). In the first model obtained, the baseline SpO(2), the BODE index and emergency room (ER) visits were associated with hospital admission and the area under the ROC curve (AUC) was 0.809. In a second model we included only variables readily available (without the 6 minutes walking test) and only the SpO(2) and previous visits to the ER were significant with an AUC ROC 0.783.

CONCLUSIONS

hospital admission for exacerbation of COPD is associated with poor SpO(2), higher BODE index score and a greater number of visits to the ER. In case you do not have the 6 minutes walking test, the other two variables offer a similar discriminative ability.

Neuropsychological Functioning Associated with High-Altitude Exposure

This article focuses on neuropsychological functioning at moderate, high, and extreme altitude. This article summarizes the available literature on respiratory, circulatory, and brain determinants on adaptation to hypoxia that are hypothesized to be responsible for neuropsychological impairment due to altitude. Effects on sleep are also described. At central level, periventricular focal damages (leuko-araiosis) and cortical atrophy have been observed. Frontal lobe and middle temporal lobe alterations are also presumed. A review is provided regarding the effects on psychomotor performance, perception, learning, memory, language, cognitive flexibility, and metamemory. Increase of reaction time and latency of P300 are observed. Reduced thresholds of tact, smell, pain, and taste, together with somesthetic illusions and visual hallucinations have been reported. Impairment in codification and short-term memory are especially noticeable above 6,000 m. Alterations in accuracy and motor speed are identified at lower altitudes. Deficits in verbal fluency, language production, cognitive fluency, and metamemory are also detected. The moderating effects of personality variables over the above-mentioned processes are discussed. Finally, methodological flaws found in the literature are detailed and some applied proposals are suggested.