Julio Pertuzé

Tuberculosis and airflow obstruction: evidence from the PLATINO study in Latin America

The aim of the present study was to evaluate the association between history of tuberculosis and airflow obstruction. A population-based, multicentre study was carried out and included 5,571 subjects aged ≥40 yrs living in one of five Latin American metropolitan areas: Sao Paulo (Brazil); Montevideo (Uruguay); Mexico City (Mexico); Santiago (Chile); and Caracas (Venezuela). Subjects performed pre- and post-bronchodilator spirometry and were asked whether they had ever been diagnosed with tuberculosis by a physician. The overall prevalence of airflow obstruction (forced expiratory volume in one second/forced vital capacity post-bronchodilator <0.7) was 30.7% among those with a history of tuberculosis, compared with 13.9% among those without a history. Males with a medical history of tuberculosis were 4.1 times more likely to present airflow obstruction than those without such a diagnosis. This remained unchanged after adjustment for confounding by age, sex, schooling, ethnicity, smoking, exposure to dust and smoke, respiratory morbidity in childhood and current morbidity. Among females, the unadjusted and adjusted odds ratios were 2.3 and 1.7, respectively. In conclusion, history of tuberculosis is associated with airflow obstruction in Latin American middle-aged and older adults.

The chronic bronchitis phenotype in subjects with and without COPD: the PLATINO study

Little information exists regarding the epidemiology of the chronic bronchitis phenotype in unselected chronic obstructive pulmonary disease (COPD) populations. We examined the prevalence of the chronic bronchitis phenotype in COPD and non-COPD subjects from the PLATINO study, and investigated how it is associated with important outcomes. Post-bronchodilator forced expiratory volume in 1 s/forced vital capacity <0.70 was used to define COPD. Chronic bronchitis was defined as phlegm on most days, at least 3 months per year for ≥2 yrs. We also analysed another definition: cough and phlegm on most days, at least 3 months per year for ≥2 yrs. Spirometry was performed in 5,314 subjects (759 with and 4,554 without COPD). The proportion of subjects with and without COPD with chronic bronchitis defined as phlegm on most days, at least 3 months per year for ≥2 yrs was 14.4 and 6.2%, respectively. Using the other definition the prevalence was lower: 7.4% with and 2.5% without COPD. Among subjects with COPD, those with chronic bronchitis had worse lung function and general health status, and had more respiratory symptoms, physical activity limitation and exacerbations. Our study helps to understand the prevalence of the chronic bronchitis phenotype in an unselected COPD population at a particular time-point and suggests that chronic bronchitis in COPD is possibly associated with worse outcomes.

Impact of Bronchodilator Use on the Prevalence of COPD in Population-Based Samples

The aim of this study was to describe the impact of using bronchodilators on the prevalence of Chronic Obstructive Pulmonary Disease in a population-based survey (Platino study). A cluster sampling of subjects 40 years of age or older, representative of the metropolitan areas of 5 Latin American cities (Sao Paulo, Mexico, Montevideo, Santiago and Caracas) was chosen. Spirometry according to ATS standards was done before and after inhalation of 200 micrograms of salbutamol in 5183 subjects. Prevalences of airflow obstruction were estimated using different criteria, in tests done before and after bronchodilator use, and with reference values for pre- or post-bronchodilator use. Bronchodilator testing reduced the overall prevalence of FEV1/FVC% < 0.70 from 21.7% to 14% (35%). In the group with FEV1/FVC < 0.70 after bronchodilator use, 21% were asymptomatic from the respiratory point of view, and lacked significant adverse exposures. Subjects below the 5th percentile for FEV1/FVC and FEV1/FEV6 were fewer than those with FEV1/FVC < 0.70, especially among the elderly. More subjects are below the 5th percentile of FEV1/FVC and FEV1/FEV6 using reference values for tests after bronchodilator use than using the reference values determined without bronchodilator testing. Testing after bronchodilator use reduces the prevalence of airflow obstruction from 32 to 39% depending on the definition used. In addition, the subjects who were still obstructed after bronchodilator use were the ones who showed more respiratory symptoms and exposure to tobacco and other smokes and dusts, than subjects with reversible obstruction, suggesting an increased specificity for COPD.

Sex-related differences in COPD in five Latin American cities: the PLATINO study

There is evidence to suggest sex differences exists in chronic obstructive pulmonary disease (COPD) clinical expression. We investigated sex differences in health status perception, dyspnoea and physical activity, and factors that explain these differences using an epidemiological sample of subjects with and without COPD. PLATINO is a cross-sectional, population-based study. We defined COPD as post-bronchodilator forced expiratory volume in 1 s/forced vital capacity ratio <0.70, and evaluated health status perception (Short Form (SF)-12 questionnaire) and dyspnoea (Medical Research Council scale). Among 5,314 subjects, 759 (362 females) had COPD and 4,555 (2,850 females) did not. In general, females reported more dyspnoea and physical limitation than males. 54% of females without COPD reported a dyspnoea score ≥2 versus 35% of males. A similar trend was observed in females with COPD (63% versus 44%). In the entire study population, female sex was a factor explaining dyspnoea (OR 1.60, 95%CI 1.40–1.84) and SF-12 physical score (OR -1.13, 95%CI -1.56– -0.71). 40% of females versus 28% of males without COPD reported their general health status as fair-to-poor. Females with COPD showed a similar trend (41% versus 34%). Distribution of COPD severity was similar between sexes, but currently smoking females had more severe COPD than currently smoking males. There are important sex differences in the impact that COPD has on the perception of dyspnoea, health status and physical activity limitation.

Valores de referencia espirométrica en 5 grandes ciudades de Latinoamérica para sujetos de 40 o más años de edad

Objetivo La espirometria es una prueba de gran utilidad clinica, que requiere un estricto control de calidad, una estrategia de interpretacion y valores de referencia adecuados. El proposito del presente trabajo es comunicar los valores de referencia para la espirometria en 5 ciudades de Latinoamerica. Pacientes y metodos El estudio PLATINO se llevo a cabo en Caracas, Mexico, Santiago, Sao Paulo y Montevideo e incluyo a un total de 5.315 sujetos con espirometria realizada. De ellos, se estudio a 906 (17%) que tenian entre 40 y 90 anos de edad para crear valores de referencia, porque nunca habian fumado, estaban asintomaticos y no tenian enfermedad pulmonar diagnosticada ni obesidad. Se efectuaron modelos de regresion multiple con los valores espirometricos –volumen espiratorio forzado en el primer segundo (FEV 1 ) y en 6 s (FEV 6 ), flujo espiratorio maximo, capacidad vital forzada (FVC), FEV 1 /FEV 6 , FEV 1 /FVC y flujo mesoespiratorio forzado–, la talla, el sexo y la edad. Resultados Los sujetos estudiados presentaron en promedio valores similares a los de la poblacion norteamericana blanca y americana de origen mexicano del estudio NHANES III, pero superiores a los de la poblacion negra en un 20%. Conclusiones Los valores de referencia propuestos representan una ventaja sobre los disponibles en la actualidad en Latinoamerica, ya que se eligio a los participantes por metodos de muestreo poblacional y el metodo empleado es estandarizado y actualizado.

Chronic obstructive pulmonary disease and body mass index in five Latin America cities: The PLATINO study

BACKGROUND The body mass index (BMI) is a prognostic factor for chronic obstructive pulmonary disease (COPD). Despite its importance, little information is available regarding BMI alteration in COPD from a population-based study. We examined characteristics by BMI categories in the total and COPD populations in five Latin-American cities, and explored the factors influencing BMI in COPD. METHODS COPD was defined as a postbronchodilator forced expiratory volume in the first second/forced vital capacity (FEV(1)/FVC) <0.70. BMI was categorized as underweight (< 20 kg/m(2)), normal weight (20-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (> or = 30.0 kg/m(2)). RESULTS Interviews were completed in 5571 subjects from 6711 eligible individuals, and spirometry was performed in 5314 subjects. There were 759 subjects with COPD and 4555 without COPD. Compared with the non-COPD group, there was a higher proportion of COPD subjects in the underweight and normal weight categories, and a lower proportion in the obese category. Over one-half COPD subjects had BMI over 25 kg/m(2). No differences in BMI strata among countries were found in COPD subjects. Factors associated with lower BMI in males with COPD were aging, current smoking, and global initiative for chronic obstructive lung disease (GOLD) stages III-IV, whereas wheeze and residing in Santiago and Montevideo were associated with higher BMI. In females with COPD, current smoking, lower education, and GOLD stages II-IV were associated with lower BMI, while dyspnea and wheeze were associated with higher BMI. CONCLUSIONS BMI alterations are common in COPD with no significant differences among countries. Current smoking, age, GOLD stages, education level, residing in Santiago and Montevideo, dyspnea and wheeze were independently associated with BMI in COPD.

Prevalence of smoking and incidence of initiation in the Latin American adult population: the PLATINO study

BackgroundThe PLATINO project was launched in 2002 in order to study the prevalence of chronic obstructive pulmonary disease (COPD) in Latin America. Because smoking is the main risk factor for COPD, detailed data on it were obtained. The aim of this paper was to evaluate the prevalence of smoking and incidence of initiation among middle-aged and older adults (40 years or older). Special emphasis was given to the association between smoking and schooling.MethodsPLATINO is a multicenter study comprising five cross-sectional population-based surveys of approximately 1,000 individuals per site in Sao Paulo (Brazil), Santiago (Chile), Mexico City (Mexico), Montevideo (Uruguay) and Caracas (Venezuela). The outcome variable was smoking status (never, former or current). Current smokers were those who reported to smoke within the previous 30 days. Former smokers were those who reported to quit smoking more than 30 days before the survey. Using information on year of birth and age of smoking onset and quitting, a retrospective cohort analysis was carried out. Smoking prevalence at each period was defined as the number of subjects who started to smoke during the period plus those who were already smokers at the beginning of the period, divided by the total number of subjects. Incidence of smoking initiation was calculated as the number of subjects who started to smoke during the period divided by the number of non-smokers at its beginning. The independent variables included were sex, age and schooling.ResultsNon-response rates ranged from 11.1% to 26.8%. The prevalence of smoking ranged from 23.9% (95%CI 21.3; 26.6) in Sao Paulo to 38.5% (95%CI 35.7; 41.2) in Santiago. Males and middle-aged adults were more likely to smoke in all sites. After adjustment for age, schooling was not associated with smoking. Using retrospective cohort analysis, it was possible to detect that the highest prevalence of smoking is found between 20–29 years, while the highest incidence is found between 10–19 years. Age of smoking onset tended to decline over time among females.ConclusionThe prevalence of smoking varied considerably across sites, but was lower among countries with national anti-smoking campaigns.

Frequency of Self-Reported COPD Exacerbation and Airflow Obstruction in Five Latin American Cities: The Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar (PLATINO) Study

BACKGROUND Recurrent exacerbations are common in COPD patients. Limited information exists regarding exacerbation frequency in COPD patients from epidemiologic studies. We examined the frequency of self-reported exacerbations and the factors influencing exacerbation frequency among COPD patients in a population-based study conducted in Latin America. METHODS We used a post-bronchodilator FEV(1)/FVC ratio of < 0.70 to define COPD. Exacerbation was self-reported and defined by symptoms (deterioration of breathing symptoms that affected usual daily activities or caused missed work). RESULTS Spirometry was performed in 5,314 subjects. There were 759 subjects with airflow limitation; of these, 18.2% reported ever having had an exacerbation, 7.9% reported having an exacerbation, and 6.2% reported having an exacerbation requiring at least a doctor visit within the past year. The proportion of individuals with an exacerbation significantly increased by Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages, from 4.2% in stage 1 to 28.9% in stages 3 and 4. The self-reported exacerbation rate was 0.58 exacerbations per year. The rate of exacerbations requiring at least a doctor visit and length of stay in hospital due to exacerbations also increased as COPD severity progressed. The factors associated with having an exacerbation in the past year were dyspnea, prior asthma diagnosis, receiving any respiratory therapy, and disease severity of GOLD stages 3 and 4. CONCLUSIONS The proportion of individuals with airflow limitation and self-reported exacerbation increases as the disease severity progresses. Dyspnea, prior asthma diagnosis, receiving any respiratory therapy, and more severe obstruction were significantly associated with having an exacerbation in the past year.

Acute bronchodilator responsiveness in subjects with and without airflow obstruction in five Latin American cities: The PLATINO study

BACKGROUND Acute bronchodilator responsiveness is an area of discussion in COPD. No information exists regarding this aspect of the disease from an unselected COPD population. We assessed acute bronchodilator responsiveness and factors influencing it in subjects with and without airway obstruction in an epidemiologic sample. METHODS COPD was defined by GOLD criteria (post-bronchodilator FEV(1)/FVC<0.70). In this analysis, subjects with pre-bronchodilator FEV(1)/FVC <0.70 but > or =0.70 post-bronchodilator were considered to have reversible obstruction. Bronchodilator responsiveness after albuterol 200microg was assessed using three definitions: a) FVC and/or FEV(1) increment > or =12% plus > or =200mL over baseline; b) FEV(1)> or =15% increase over baseline; and c) FEV(1) increase > or =10% of predicted value. RESULTS There were 756 healthy respiratory subjects, 481 subjects with reversible obstruction and 759 COPD subjects. Depending on the criterion used the proportion of person with acute bronchodilator responsiveness ranged between 15.0-28.2% in COPD, 11.4-21.6% in reversible obstructed and 2.7-7.2% in respiratory healthy. FEV(1) changes were lower (110.6+/-7.40 vs. 164.7+/-11.8mL) and FVC higher (146.5+/-14.2mL vs. -131.0+/-19.6mL) in COPD subjects compared with reversible obstructed. Substantial overlap in FEV(1) and FVC changes was observed among the groups. Acute bronchodilator responsiveness in COPD persons was associated with less obstruction and never smoking. CONCLUSIONS Over two-thirds of persons with COPD did not demonstrate acute bronchodilator responsiveness. The overall response was small and less than that considered as significant by ATS criteria. The overlap in FEV(1) and FVC changes after bronchodilator among the groups makes it difficult to determine a threshold for separating them.

Spirometry Reference Values After Inhalation of 200 μg of Salbutamol

Objective The criteria for disease severity established by the Global Initiative for Chronic Obstructive Lung Disease are based on forced expiratory volume in 1 second (FEV 1 ) expressed as a percentage of the predicted value after application of a bronchodilator. This study aims to determine postbronchodilator spirometry reference values. SUBJECTS AND METHODS A cluster sample of subjects aged 40 years or over was chosen to be representative of the metropolitan areas of 5 Latin American cities (Sao Paulo, Mexico City, Montevideo, Santiago, and Caracas). Spirometry was performed on 5183 subjects following the recommendations of the American Thoracic Society before and after inhalation of 200 μg of salbutamol. Multiple linear regression equations were fitted for the postbronchodilator spirometric values–FEV 1 , forced expiratory volume in 6 seconds (FEV 6 ), peak expiratory flow rate, forced vital capacity (FVC), FEV 1 /FEV 6 , FEV 1 /FVC and forced expiratory flow between 25% and 75% of vital capacity (FEF 25-75 ). These were adjusted for sex, age, and height in 887 asymptomatic subjects with no history of lung disease. RESULTS The postbronchodilator reference values for FEV 1 , FEV 1 /FVC, and FEV 1 /FEV 6 were on average 3% higher than those obtained before bronchodilation. This apparently small difference caused an upward shift in the 5th percentile (lower limit of normal) of the predicted values. When prebronchodilation instead of postbronchodilation reference values were used, 3.2% of the results for airflow obstruction in our population of over-40-year-olds were false negatives. CONCLUSIONS The reported reference values are more appropriate for postbronchodilator spirometry and make it possible to reduce the number of misclassifications.