Ingrid Solanes

Factores de riesgo de mortalidad en la EPOC

Objetivo Aunque los factores que predicen la supervivencia en pacientes con enfermedad pulmonar obstructive cronica (EPOC) han sido ampliamente estudiados, no disponemos de un consenso establecido. El objetivo de este estudio ha sido contribuir a clarificar el papel que desempenan los parametros de funcion pulmonar, tolerancia al esfuerzo y calidad de vida en la supervivencia en la EPOC. Pacientes y metodos Se diseno un estudio prospectivo en el que se incluyo a 60 pacientes diagnosticados de EPOC. Al inicio del estudio realizaron pruebas funcionales respiratorias, prueba de esfuerzo maximo y prueba de la marcha de 6 min, y respondieron un cuestionario de enfermedad respiratoria cronica para determinar la calidad de vida relacionada con la salud. El seguimiento de los pacientes fue de 7 anos. Resultados Se retiraron del estudio 5 de los 60 pacientes. De los 55 restantes, 26 (47%) murieron durante el estudio. El analisis univariante con regresion de Cox mostro que existia relacion entre la supervivencia y la edad, el grado de obstruccion, la capacidad inspiratoria, la capacidad de difusion del monoxido de carbono y la tolerancia al ejercicio maximo; no se observo dicha relacion entre la supervivencia y el indice de masa corporal, la presion arterial de oxigeno y anhidrido carbonico, la capacidad pulmonar total, el volumen residual, las presiones maximas respiratorias, la prueba de la marcha de 6 min ni la calidad de vida relacionada con la salud. En el analisis multivariante con regresion de Cox con pasos hacia adelante, en el que se introdujeron la edad, el grado de obstruccion (medido con la relacion volumen espiratorio forzado en el primer segundo/capacidad vital forzada tras la administracion de broncodilatador) y la ventilacion minuto maxima en la prueba de esfuerzo, solo esta ultima entro en el modelo final (riesgo relativo = 0,926; p Conclusiones Nuestros hallazgos demuestran que la tolerancia al ejercicio maximo es el mejor predictor de supervivencia en los pacientes con EPOC.

Distribution and Outcomes of a Phenotype-Based Approach to Guide COPD Management: Results from the CHAIN Cohort

Rationale The Spanish guideline for COPD (GesEPOC) recommends COPD treatment according to four clinical phenotypes: non-exacerbator phenotype with either chronic bronchitis or emphysema (NE), asthma-COPD overlap syndrome (ACOS), frequent exacerbator phenotype with emphysema (FEE) or frequent exacerbator phenotype with chronic bronchitis (FECB). However, little is known on the distribution and outcomes of the four suggested phenotypes. Objective We aimed to determine the distribution of these COPD phenotypes, and their relation with one-year clinical outcomes. Methods We followed a cohort of well-characterized patients with COPD up to one-year. Baseline characteristics, health status (CAT), BODE index, rate of exacerbations and mortality up to one year of follow-up were compared between the four phenotypes. Results Overall, 831 stable COPD patients were evaluated. They were distributed as NE, 550 (66.2%); ACOS, 125 (15.0%); FEE, 38 (4.6%); and FECB, 99 (11.9%); additionally 19 (2.3%) COPD patients with frequent exacerbations did not fulfill the criteria for neither FEE nor FECB. At baseline, there were significant differences in symptoms, FEV1 and BODE index (all p<0.05). The FECB phenotype had the highest CAT score (17.1±8.2, p<0.05 compared to the other phenotypes). Frequent exacerbator groups (FEE and FECB) were receiving more pharmacological treatment at baseline, and also experienced more exacerbations the year after (all p<0.05) with no differences in one-year mortality. Most of NE (93%) and half of exacerbators were stable after one year. Conclusions There is an uneven distribution of COPD phenotypes in stable COPD patients, with significant differences in demographics, patient-centered outcomes and health care resources use.

Identification of airway bacterial colonization by an electronic nose in Chronic Obstructive Pulmonary Disease

BACKGROUND Airway bacterial colonization by potentially pathogenic microorganisms occurs in a proportion of patients with Chronic Obstructive Pulmonary Disease (COPD). It increases airway inflammation and influences outcomes negatively. Yet, its diagnosis in clinical practice is not straightforward. The electronic nose is a new non-invasive technology capable of distinguishing volatile organic compound (VOC) breath-prints in exhaled breath. We aim to explore if an electronic nose can reliably discriminate COPD patients with and without airway bacterial colonization. METHODS We studied 37 clinically stable COPD patients (67.8 ± 5.2 yrs, FEV1 41 ± 10% ref.) and 13 healthy controls (62.8 ± 5.2 yrs, FEV1 99 ± 10% ref.). The presence of potentially pathogenic microorganisms in the airways of COPD patients (n = 10, 27%) was determined using quantitative bacterial cultures of protected specimen brush. VOCs breath-prints were analyzed by discriminant analysis on principal component reduction, resulting in cross-validated accuracy values. Area Under Receiver Operating Characteristics (AUROC) was calculated using multiple logistic regression. RESULTS Demographic, functional and clinical characteristics were similar in colonized and non-colonized COPD patients but their VOC breath-prints were different (accuracy 89%, AUROC 0.92, p > 0.0001). Likewise, VOCs breath-prints from colonized (accuracy 88%, AUROC 0.98, p < 0.0001) and non-colonized COPD patients (accuracy 83%, AUROC 0.93, p < 0.0001) were also different from controls. CONCLUSIONS An electronic nose can identify the presence of airway bacterial colonization in clinically stable patients with COPD.

Prevalence of persistent blood eosinophilia: relation to outcomes in patients with COPD

The impact of blood eosinophilia in chronic obstructive pulmonary disease (COPD) remains controversial. To evaluate the prevalence and stability of a high level of blood eosinophils (≥300 cells·μL–1) and its relationship to outcomes, we determined blood eosinophils at baseline and over 2 years in 424 COPD patients (forced expiratory volume in 1 s (FEV1) 60% predicted) and 67 smokers without COPD from the CHAIN cohort, and in 308 COPD patients (FEV1 60% predicted) in the BODE cohort. We related eosinophil levels to exacerbations and survival using Cox hazard analysis. In COPD patients, 15.8% in the CHAIN cohort and 12.3% in the BODE cohort had persistently elevated blood eosinophils at all three visits. A significant proportion (43.8%) of patients had counts that oscillated above and below the cut-off points, while the rest had persistent eosinophil levels <300 cells·μL–1. A similar eosinophil blood pattern was observed in controls. Exacerbation rates did not differ in patients with and without eosinophilia. All-cause mortality was lower in patients with high eosinophils compared with those with values <300 cells·μL–1 (15.8% versus 33.7%; p=0.026). In patients with COPD, blood eosinophils ≥300 cells·μL–1 persisting over 2 years was not a risk factor for COPD exacerbations. High eosinophil count was associated with better survival. The stability of blood eosinophils ≥300 cells per μL is low in COPD patients and it does not confer a poor prognosis http://ow.ly/TwGX30etVIy

Treatment of patients with COPD and recurrent exacerbations: the role of infection and inflammation.

Exacerbations of COPD represent an important medical and health care problem. Certain susceptible patients suffer recurrent exacerbations and as a consequence have a poorer prognosis. The effects of bronchial infection, either acute or chronic, and of the inflammation characteristic of the disease itself raise the question of the possible role of antibiotics and anti-inflammatory agents in modulating the course of the disease. However, clinical guidelines base their recommendations on clinical trials that usually exclude more severe patients and patients with more comorbidities, and thus often fail to reflect the reality of clinicians attending more severe patients. In order to discuss aspects of clinical practice of relevance to pulmonologists in the treatment and prevention of recurrent exacerbations in patients with severe COPD, a panel discussion was organized involving expert pulmonologists who devote most of their professional activity to day hospital care. This article summarizes the scientific evidence currently available and the debate generated in relation to the following aspects: bacterial and viral infections, chronic bronchial infection and its treatment with cyclic oral or inhaled antibiotics, inflammatory mechanisms and their treatment, and the role of computerized tomography as a diagnostic tool in patients with severe COPD and frequent exacerbations.

Duration of pulmonary rehabilitation to achieve a plateau in quality of life and walk test in COPD

OBJECTIVE To address the minimum duration of pulmonary rehabilitation necessary for patients with chronic obstructive pulmonary disease (COPD) to achieve a plateau in Health-Related Quality of Life (HRQL) and exercise tolerance. METHODS COPD patients with a dyspnea rating of at least 2 on the Medical Research Council scale participated in an outpatient rehabilitation program of 3 weekly sessions for 12 weeks. Measurements included HRQL and exercise tolerance 2 weeks before the program started and every 2 weeks thereafter. Patients were considered to have reached a plateau if they showed no improvement beyond 20% of the minimal important difference between 2 consecutive evaluations on HRQL score or walk tests. RESULTS Twenty-eight patients participated. The number of patients achieving stability after 8 weeks, showing continued improvement after 8 weeks, and demonstrating an erratic pattern of change was as follows: for physical function 16 (56%), 10 (37%) and 2 (7%) patients; for emotional function 22 (79%), 5 (18%) and 1 (4%); and for 6-min walk test 21 (75%), 5 (18%) and 2 (7%). More severe patients demonstrated a greater likelihood (76%) of achieving stability in physical function at 12 weeks than did less severe patients (27%; p on difference=0.003). The likelihood of stability at 12 weeks in emotional function and the 6-min walk test did not differ by severity. CONCLUSIONS A program of 3 weekly 3-h sessions of outpatient pulmonary rehabilitation program should last at least 8 weeks in order to achieve optimal HRQL and exercise tolerance for most patients.

Nocardiosis pulmonar en pacientes con EPOC: características y factores pronósticos

INTRODUCTION Pulmonary nocardiosis (PN) is a severe infection with a high morbidity and mortality that mainly affects immunocompromised patients. In recent years, an increase in PN cases has been detected among patients with chronic obstructive pulmonary disease (COPD). The factors that are associated with its presence and determine its prognosis remain unknown. METHODS Retrospective study of COPD patients diagnosed with PN over the period from 1997-2009 at the Hospital de la Santa Creu i Sant Pau, in Barcelona (Spain). Demographic, clinical, microbiological and evolution data were evaluated in all cases RESULTS Thirty patients were identified with PN and COPD. Mean age (standard deviation) was 76 (7) years and the mean FEV(1) was 40 (14)%. Chronic respiratory failure was observed in 56,7% patients and 51,7% had received systemic corticosteroid therapy previous to the PN diagnosis. The most common symptoms were cough and dyspnea (90%). Alveolar infiltrates were observed in 60% of the cases. The most frequently isolated Nocardia species was N. cyriacigeorgica (68%). The one-month mortality rate was 17%, while the one-year mortality rate was 33%. The factors associated with mortality within the first year included previous systemic corticosteroid treatment, less than three months of specific antibiotic therapy and active associated neoplasm. CONCLUSIONS PN affects patients with moderate-severe COPD and has high short- and mid-term mortality rates. Previous corticosteroid treatment, specific antibiotic therapy for less than 3 months and active neoplasia were factors associated with mortality.

Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease

BackgroundThe diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients.Methods/DesignA quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts.DiscussionThe COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.

Airway Mucin 2 Is Decreased in Patients with Severe Chronic Obstructive Pulmonary Disease with Bacterial Colonization

RATIONALE Mucins are essential for airway defense against bacteria. We hypothesized that abnormal secreted airway mucin levels would be associated with bacterial colonization in patients with severe chronic obstructive pulmonary disease (COPD) Objectives: To investigate the relationship between mucin levels and the presence of potentially pathogenic micro-organisms in the airways of stable patients with severe COPD Methods: Clinically stable patients with severe COPD were examined prospectively. All patients underwent a computerized tomography scan, lung function tests, induced sputum collection, and bronchoscopy with bronchoalveolar lavage (BAL) and protected specimen brush. Patients with bronchiectasis were excluded. Secreted mucins (MUC2, MUC5AC, and MUC5B) and inflammatory markers were assessed in BAL and sputum by ELISA. MEASUREMENTS AND MAIN RESULTS We enrolled 45 patients, with mean age (±SD) of 67 (±8) years and mean FEV1 of 41 (±10) % predicted. A total of 31% (n = 14) of patients had potentially pathogenic micro-organisms in quantitative bacterial cultures of samples obtained by protected specimen brush. Patients with COPD with positive cultures had lower levels of MUC2 both in BAL (P = 0.02) and in sputum (P = 0.01). No differences in MUC5B or MUC5AC levels were observed among the groups. Lower MUC2 levels were correlated with lower FEV1 (r = 0.32, P = 0.04) and higher sputum IL-6 (r = -0.40, P = 0.01). CONCLUSIONS Airway MUC2 levels are decreased in patients with severe COPD colonized by potentially pathogenic micro-organisms. These findings may indicate one of the mechanisms underlying airway colonization in patients with severe COPD. Clinical trial registered with www.clinicaltrials.gov (NCT01976117).

Características de la enfermedad pulmonar obstructiva crónica en fase estable relacionadas con la inflamación sistémica

BACKGROUND AND OBJECTIVE Chronic obstructive pulmonary disease (COPD) is characterized by a systemic inflammation. The aim of this study was to evaluate the association between systemic inflammation, measured with C reactive protein (CRP), and clinical and functional outcomes of the disease. PATIENTS AND METHODS A randomized sample of 413 COPD patients from 31 primary health care centers of Barcelona was evaluated. Medical history, anthropometric measurements, toxic habits, treatments, Chronic Respiratory Questionnaire (CRQ) and dyspnea were registered. Spirometry, exhaled CO concentration and CRP in capillary blood were performed. RESULTS Median (standard deviation) of the age was 72 (8.4) years and forced expiratory volume in one second (FEV(1)) postbronchodilatador 1.65 (0.65) l. The correlation was negative between CRP and FEV(1) postbronchodilatador(r=-0.25, P<0.001) and between CRP and CRQ scores (r=-0.098, P=0.048) and positive between CRP and CO (r=0.1, P=0.039). The ratio of patients with elevated CRP was higher in advanced GOLD stage (P<0.001), worst dyspnea (P=0.042), patients treated with inhaled corticosteroids (P=0.018) and if they had been hospitalized during the last year (P=0.026). The multivariant analysis showed, as independent factors of elevated CRP, FEV(1) postbronchodilator and CO concentration. CONCLUSION In COPD patients, active smoking habit and the airways obstruction degree are associated with a greater intensity of the inflammatory systemic response measured by the CRP.