Juan Luis Rodríguez Hermosa

Factors Associated With the Control of Severe Asthma

Introduction. Control is a priority treatment objective in asthma, and classification based on control is recommended in the follow-up of asthmatic patients. Different factors affect this control, and there are several regional differences, both in terms of prevalence and in terms of management and degree of control. Objective. To evaluate the factors associated with control of severe asthma in routine clinical practice. Material and Methods. This was a prospective, cross-sectional, observational study of patients with severe asthma who were receiving treatment with a fixed combination of a corticosteroid (at least 800 μg/day of budesonide or equivalent) and an inhaled β2-adrenergic agonist in respiratory medicine and allergology clinics throughout Spain. The authors collected demographic and socioeconomic data, as well as clinical data on asthma. The patients also completed a self-administered validated questionnaire—the Asthma Control Questionnaire (ACQ)—about the control of their asthma. Results. The authors included 1471 patients, of whom 1224 (83%) were valid for the final analysis. Women accounted for 61%. Mean age was 51 ± 16 years. The mean number of exacerbations during the previous year was 2.0 ± 2.0. The global score on the ACQ was 1.8 ± 1.1 (0 = no symptoms; 6 = maximum number of symptoms). Only 20.4% of patients were well controlled (ACQ < 0.75), and 55.7% of patients were poorly controlled (ACQ > 1.5). The multivariate analysis revealed that the variable with the greatest effect on control of asthma was the number of exacerbations during the previous year: when the number of exacerbations increased from 0 to 1 or more, the ACQ score increased by 0.56 points. Employed patients had a mean of 0.23 points less (better control) than unemployed and retired patients. Control of asthma was also significantly affected by adherence to treatment, patient knowledge of the disease, body mass index, gender, and number of visits to a physician in the previous 3 months. Conclusions. Many patients with severe asthma have poor control of their disease. The number of exacerbations is the variable with the greatest effect on control of asthma. Knowledge of the disease and adherence to treatment are associated with better control.

Exacerbación de la EPOC

Resumen 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. Abstract Exacerbations of chronic obstructive pulmonary disease (COPD) are considered to be episodes of instability that favor disease progression, reduce quality of life, increase the risk of death and cause substantial healthcare resource use. These exacerbations are due to bacterial and viral infections and environmental stressors. However, other concomitant diseases such as heart disease, other lung diseases (e.g. pulmonary embolism, aspiration or pneumothorax) and other systemic processes can trigger or complicate these exacerbations. The two factors with the greatest influence on the physiopathology of exacerbations are dynamic overinflation and local and systemic inflammation. In most patients, drug treatment includes short-acting bronchodilators, systemic corticosteroids and antibiotics. Hypoxemic respiratory failure requires controlled oxygen therapy. In hypercapnic respiratory failure, non-invasive positive pressure ventilation may allow time to be gained until other treatments begin to take effect and can thus avoid endotracheal intubation. The use of non-invasive mechanical ventilation should never delay intubation, if indicated. Hospital discharge criteria are based on both clinical and gasometric stabilization and on the patients ability to manage his or her disease at home. Hospitalization at home can be a treatment option in COPD exacerbations and is as effective as conventional hospitalization.

EPOC en individuos no fumadores

The association of chronic obstructive pulmonary disease (COPD) and smoking is well established. However, an increasing number of studies have reported a not inconsiderable prevalence of COPD among nonsmokers. Therefore, other factors, both endogenous and exogenous, may influence the development of this disease. The present article reviews the influence of possible genetic factors, gender and other respiratory diseases (such as chronic asthma and tuberculosis), as well as environmental pollution and occupational exposure in the development of COPD.

Estudio de la prevalencia y actitudes sobre tabaquismo en pacientes sometidos a oxigenoterapia crónica domiciliaria. Estudio toma

INTRODUCTION The objective of this study is to analyse the prevalence, attitudes and characteristics of smoking in the population of patients subjected to Long Term Domiciliary Oxygen Therapy (LTDOT) in the Community of Madrid. PATIENT AND METHODS A representative sample of 845 subjects (of which 461 (46%) were male) was obtained from a total of 11,174 who fulfilled the inclusion criteria. The mean age was 78.25 years (95% Confidence Interval (CI): 77.55-78.95; SD=10.36). A descriptive cross-sectional study was conducted based on questionnaires as well as cooximetry. RESULTS Forty-eight subjects (5.7%; 95%CI: 4.3%-7.5%) were smokers and 438 (51.8%; 95%CI: 48.5%-55.2%) were ex-smokers. The percentage of active smokers was higher in the 60 years or less subject group (χ(2); P<0.001). The large majority (75%) of smokers were men, their proportion being significantly higher than that of current non-smokers (χ(2); P<0.003). The mean score in the Fagerström Test was 3.6. More than 65% of smokers had their first cigarette up to 30 min from getting up in the morning, and 45% of these were in a preparation phase. Seventeen percent of these subjects said that they had not received advice on quitting smoking. CONCLUSIONS There is a high rate of smoking in patients on LTDOT, with a higher probability of males and younger subjects continuing to smoke. There is a high level of physical dependency for nicotine.

Ansiedad y EPOC

Symptoms of anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD) but are underdiagnosed and data on this association are scarce. The prevalence of anxiety and depression in COPD varies considerably among studies and is probably greater than is currently known. Only a third of these patients receives appropriate treatment. Certain drugs, behavioral therapy and a multidisciplinary approach can improve the management of these patients, a good example being respiratory rehabilitation.

Variability in adherence to clinical practice guidelines and recommendations in COPD outpatients: a multi-level, cross-sectional analysis of the EPOCONSUL study

BackgroundClinical audits have reported considerable variability in COPD medical care and frequent inconsistencies with recommendations. The objectives of this study were to identify factors associated with a better adherence to clinical practice guidelines and to explore determinants of this variability at the the hospital level.MethodsEPOCONSUL is a Spanish nationwide clinical audit that evaluates the outpatient management of COPD. Multilevel logistic regression with two levels was performed to assess the relationships between individual and disease-related factors, as well as hospital characteristics.ResultsA total of 4508 clinical records of COPD patients from 59 Spanish hospitals were evaluated. High variability was observed among hospitals in terms of medical care. Some of the patient’s characteristics (airflow obstruction, degree of dyspnea, exacerbation risk, presence of comorbidities), the hospital factors (size and respiratory nurses available) and treatment at a specialized COPD outpatient clinic were identified as factors associated with a better adherence to recommendations, although this only explains a small proportion of the total variance.ConclusionTo be treated at a specialized COPD outpatient clinic and some intrinsic patient characteristics were factors associated with a better adherence to guideline recommendations, although these variables were only explaining part of the high variability observed among hospitals in terms of COPD medical care.

Tratamiento farmacológico de la EPOC. ¿Dónde nos encontramos?

Current clinical guidelines recommend a step-wise approach to the pharmacological treatment of chronic obstructive pulmonary disease (COPD), with drugs being added according to the severity of airflow obstruction, symptoms, and the number of acute exacerbations in patients with severe disease. However, greater knowledge of the physiopathogenesis of this disease has led to COPD being considered a heterogeneous process in which therapeutic decisions should not be based exclusively on the results of spirometry. Treatment is increasingly individualized according to the patients characteristics. The present article reviews the scientific evidence on the aims of treatment in COPD and the benefits achieved by the various pharmacological options available.Resumen En la actualidad, las guias clinicas recomiendan la terapia escalonada y progresiva para el tratamiento de la enfermedad pulmonar obstructiva cronica (EPOC), que consiste en ir anadiendo farmacos en funcion de la gravedad de la obstruccion al flujo aereo, de los sintomas y del numero de agudizaciones en los pacientes graves. Sin embargo, a medida que avanza el conocimiento de la fisiopatogenia de esta enfermedad, se considera que la EPOC es un proceso heterogeneo en el cual la decision terapeutica no debe basarse exclusivamente en un valor espirometrico. Nos inclinamos cada vez mas a establecer un tratamiento personalizado, en funcion de las caracteristicas del paciente. En el presente articulo se repasan las evidencias cientificas existentes sobre los objetivos en el tratamiento de la EPOC y los beneficios alcanzados por las diferentes intervenciones farmacologicas disponibles.Current clinical guidelines recommend a step-wise approach to the pharmacological treatment of chronic obstructive pulmonary disease (COPD), with drugs being added according to the severity of airflow obstruction, symptoms, and the number of acute exacerbations in patients with severe disease. However, greater knowledge of the physiopathogenesis of this disease has led to COPD being considered a heterogeneous process in which therapeutic decisions should not be based exclusively on the results of spirometry. Treatment is increasingly individualized according to the patients characteristics. The present article reviews the scientific evidence on the aims of treatment in COPD and the benefits achieved by the various pharmacological options available.

Study of Prevalence and Attitudes on Smoking in Patients on Continuous Home Oxygen Therapy. Toma Study

Abstract Introduction The objective of this study was to analyse the prevalence, attitudes and characteristics of smoking in the population of patients subjected to Long Term Home Oxygen Therapy (LTOT) in the Community of Madrid. Patient and methods A representative sample of 845 subjects (461 male, 46%) was obtained from a total of 11 174 who fulfilled the inclusion criteria. The mean age was 78.25 years (95% Confidence Interval, CI, 77.55-78.95; SD=10.36). A descriptive cross-sectional study was conducted based on questionnaires as well as CO-oximetry. Results Forty-eight subjects were smokers (5.7%; 95% CI, 4.3-7.5) while 438 (51.8%; 95% CI, 48.5-55.2) were ex-smokers. The percentage of active smokers was higher in the 60 years or less subject group (χ 2 ; P 2 ; P Conclusions There is a high rate of smoking in patients on LTOT, with a higher probability of males and younger subjects continuing to smoke. There is a high level of physical dependence on nicotine.

Testing for alpha-1 antitrypsin in COPD in outpatient respiratory clinics in Spain: A multilevel, cross-sectional analysis of the EPOCONSUL study

Background Alpha-1 antitrypsin deficiency (AATD) is the most common hereditary disorder in adults, but is under-recognized. In Spain, the number of patients diagnosed with AATD is much lower than expected according to epidemiologic studies. The objectives of this study were to assess the frequency and determinants of testing serum α1-antitrypsin (AAT) levels in COPD patients, and to describe factors associated with testing. Methods EPOCONSUL is a cross-sectional clinical audit, recruiting consecutive COPD cases over one year. The study evaluated serum AAT level determination in COPD patients and associations between individual, disease-related, and hospital characteristics. Results A total of 4,405 clinical records for COPD patients from 57 Spanish hospitals were evaluated. Only 995 (22.5%) patients had serum AAT tested on some occasion. A number of patient characteristics (being male [OR 0.5, p < 0.001], ≤55 years old [OR 2.38, p<0.001], BMI≤21 kg/m2 [OR 1.71, p<0.001], FEV1(%)<50% [OR 1.35, p<0.001], chronic bronchitis [OR 0.79, p < 0.001], Charlson index ≥ 3 [OR 0.66, p < 0.001], or history or symptoms of asthma [OR 1.32, p<0.001]), and management at a specialized COPD outpatient clinic [OR 2.73,p<0.001] were identified as factors independently associated with ever testing COPD patients for AATD. Overall, 114 COPD patients (11.5% of those tested) had AATD. Of them, 26 (22.8%) patients had severe deficiency. Patients with AATD were younger, with a low pack-year index, and were more likely to have emphysema (p<0.05). Conclusion Testing of AAT blood levels in COPD patients treated at outpatient respiratory clinics in Spain is infrequent. However, when tested, AATD (based on the serum AAT levels ≤100 mg/dL) is detected in one in five COPD patients. Efforts to optimize AATD case detection in COPD are needed.

Tabaquismo en la enfermedad pulmonar obstructiva crónica

Resumen El tabaquismo es una enfermedad cronica adictiva recidivante, causante de multiples patologias y principal causa conocida de morbilidad y mortalidad evitables, y constituye un importante problema para la salud publica. En los paises desarrollados es la principal causa aislada de morbilidad y mortalidad prematuras prevenibles. La combustion del tabaco libera mas de 4.000 sustancias toxicas para la salud y mas de 50 con efectos cancerigenos comprobados; es un factor de riesgo para 6 de las 8 causas principales de muerte en el mundo. El tratamiento del tabaquismo es eficaz y coste-efectivo. Cualquier intervencion terapeutica que los profesionales realicemos sobre el tabaquismo de nuestros pacientes sera eficaz. Si dicha intervencion se adecua a las caracteristicas individuales de cada fumador, su eficacia y eficiencia seran mucho mayores. Todos los tratamientos son seguros, presentandose efectos secundarios generalmente leves y que raramente obligan a la suspension de la medicacion. Los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) tienen una mayor dependencia a la nicotina y aparentemente una mayor dificultad para dejar de fumar. En los pacientes con EPOC debe considerarse una prioridad, al ser la unica medida capaz de frenar el avance de la enfermedad.Smoking is a recurrent, chronic addictive disease that causes multiple diseases and is the main known cause of avoidable morbidity and mortality, constituting a major public health problem. In developed countries, smoking is the main single cause of premature preventable morbidity and mortality. Tobacco combustion releases more than 4,000 toxic substances and more than 50 substances with demonstrated carcinogenic effects; smoking is a risk factor for six of the eight main causes of death worldwide. The treatment of smoking is both effective and cost-effective. Any therapeutic intervention performed by health professions for smoking will have beneficial results. If such interventions are adapted to the individual characteristics of each patient, their efficacy and efficiency will be much greater. All treatments are safe, with generally mild adverse effects that rarely lead to treatment withdrawal. Patients with COPD show higher nicotine dependence and seem to have greater difficulty in quitting smoking. Nevertheless, smoking cessation should be a priority in these patients, as it constitutes the only measure able to halt progression of the disease.