Myriam Calle

Spanish guideline for COPD (GesEPOC). Update 2014.

aServicio de Neumologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain bCIBER de Enfermedades Respiratorias (CIBERES), Spain cUnidad de Neumologia, Servicio de Medicina Interna, Hospital de Requena, Valencia, Spain dServicio de Neumologia, Hospital Clinico San Carlos, Madrid, Spain eCentro de Salud Francia, Direccion Asistencial Oeste, Madrid, Spain fServicio de Medicina Interna, Hospital Universitari Mutua de Terrassa, Terrasa, Barcelona, Spain gCentro de Salud Lucena I, Lucena, Cordoba, Spain hServicio de Neumologia, Hospital San Pedro de Alcantara, Caceres, Spain iCentro de Salud Menasalbas, Toledo, Spain jServicio de Urgencias, Hospital General Universitario Reina Sofia, Murcia, Spain kServicio de Urgencias, Hospital General Yague, Burgos, Spain lMedicina Fisica y Rehabilitacion, Parc de Salut Mar, Grupo de Investigacion en Rehabilitacion, Institut Hospital del Mar d’Investigacions Mediques, Universitat Autonoma de Barcelona, Universitat Internacional de Catalunya, Barcelona, Spain mUnidad de Fisioterapia Respiratoria, Hospital Universitario de Gran Canaria Dr. Negrin, Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Spain nServicio de Medicina Fisica y Rehabilitacion, Hospital Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Barcelona, Spain nServicio de Medicina Fisica y Rehabilitacion, Hospital Parc Tauli, Universitat Autonoma de Barcelona, Sabadell, Barcelona, Spain oCentro de Salud Gandhi, Madrid, Spain pServicio de Medicina Interna, Hospital Royo Vilanova, Zaragoza, Spain qFundacion Caubet-Cimera FISIB Illes Balears, Bunyola, Baleares, Spain rServicio de Neumologia, Hospital Universitario de la Princesa, Instituto de Investigacion Sanitaria Princesa (IP), Madrid, Spain

Treatment of COPD by clinical phenotypes: putting old evidence into clinical practice

The new Global Initiative for Chronic Obstructive Lung Disease update has moved the principles of treatment of stable chronic obstructive pulmonary disease (COPD) forward by including the concepts of symptoms and risks into the decision of therapy. However, no mention of the concept of clinical phenotypes is included. It is recognised that COPD is a very heterogeneous disease and not all patients respond to all drugs available for treatment. The identification of responders to therapies is crucial in chronic diseases to provide the most appropriate treatment and avoid unnecessary medications. The classically defined phenotypes of chronic bronchitis and emphysema, together with the newly described phenotypes of overlap COPD-asthma and frequent exacerbator, allow a simple classification of patients that share clinical characteristics and outcomes and, more importantly, similar responses to existing treatments. These clinical phenotypes can help clinicians identify patients that respond to specific pharmacological interventions. For example, frequent exacerbators are the only subjects with an indication for anti-inflammatory treatment in COPD. Among them, those with chronic bronchitis are the only candidates to receive phosphodiesterase-4 inhibitors. Patients with overlap COPD-asthma phenotype show an enhanced response to inhaled corticosteroids and infrequent exacerbators should only receive bronchodilators. These well-defined clinical phenotypes could potentially be incorporated into treatment guidelines.

A new approach to grading and treating COPD based on clinical phenotypes: summary of the Spanish COPD guidelines (GesEPOC).

After the development of the COPD Strategy of the National Health Service in Spain, all scientific societies, patient organisations, and central and regional governments formed a partnership to enhance care and research in COPD. At the same time, the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) took the initiative to convene the various scientific societies involved in the National COPD Strategy and invited them to participate in the development of the new Spanish guidelines for COPD (Guía Española de la EPOC; GesEPOC). Probably the more innovative approach of GesEPOC is to base treatment of stable COPD on clinical phenotypes, a term which has become increasingly used in recent years to refer to the different clinical forms of COPD with different prognostic implications. The proposed phenotypes are: (A) infrequent exacerbators with either chronic bronchitis or emphysema; (B) overlap COPD-asthma; (C) frequent exacerbators with emphysema predominant; and (D) frequent exacerbators with chronic bronchitis predominant. The assessment of severity has also been updated with the incorporation of multidimensional indices. The severity of the obstruction, as measured by forced expiratory volume in 1 second, is essential but not sufficient. Multidimensional indices such as the BODE index have shown excellent prognostic value. If the 6-minute walking test is not performed routinely, its substitution by the frequency of exacerbations (BODEx index) provides similar prognostic properties. This proposal aims to achieve a more personalised management of COPD according to the clinical characteristics and multidimensional assessment of severity.

Guía española de la EPOC (GesEPOC). Actualización 2014

Servicio de Neumología, Hospital Universitari Vall d’Hebron, Barcelona, Spain CIBER de Enfermedades Respiratorias (CIBERES), Spain Unidad de Neumología, Servicio de Medicina Interna, Hospital de Requena, Valencia, Spain Servicio de Neumología, Hospital Clínico San Carlos, Madrid, Spain Centro de Salud Francia, Dirección Asistencial Oeste, Madrid, Spain Servicio de Medicina Interna, Hospital Universitari Mútua de Terrassa, Terrasa, Barcelona, Spain Centro de Salud Lucena I, Lucena, Córdoba, Spain Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, Spain Centro de Salud Menasalbas, Toledo, Spain Servicio de Urgencias, Hospital General Universitario Reina Sofía, Murcia, Spain Servicio de Urgencias, Hospital General Yagüe, Burgos, Spain Medicina Física y Rehabilitación, Parc de Salut Mar, Grupo de Investigación en Rehabilitación, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autònoma de Barcelona, Universitat Internacional de Catalunya, Barcelona, Spain Unidad de Fisioterapia Respiratoria, Hospital Universitario de Gran Canaria Dr. Negrín, Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Spain Servicio de Medicina Física y Rehabilitación, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain Servicio de Medicina Física y Rehabilitación, Hospital Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain Centro de Salud Gandhi, Madrid, Spain Servicio de Medicina Interna, Hospital Royo Vilanova, Zaragoza, Spain Fundación Caubet-Cimera FISIB Illes Balears, Bunyola, Baleares, Spain Servicio de Neumología, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, SpainServicio de Neumología, Hospital Universitari Vall d’Hebron, Barcelona, España CIBER de Enfermedades Respiratorias (CIBERES), España Unidad de Neumología, Servicio de Medicina Interna, Hospital de Requena, Valencia, España Servicio de Neumología, Hospital Clínico San Carlos, Madrid, España Centro de Salud Francia, Dirección Asistencial Oeste, Madrid, España Servicio de Medicina Interna, Hospital Universitari Mútua de Terrassa, Terrasa, Barcelona, España Centro de Salud Lucena I, Lucena, Córdoba, España Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España Centro de Salud Menasalbas, Toledo, España Servicio de Urgencias, Hospital General Universitario Reina Sofía, Murcia, España Servicio de Urgencias, Hospital General Yagüe, Burgos, España Medicina Física y Rehabilitación, Parc de Salut Mar, Grupo de Investigación en Rehabilitación, Institut Hospital del Mar d’Investigacions Mèdiques, Universitat Autònoma de Barcelona, Universitat Internacional de Catalunya, Barcelona, España Unidad de Fisioterapia Respiratoria, Hospital Universitario de Gran Canaria Dr. Negrín, Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, España Servicio de Medicina Física y Rehabilitación, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, España Servicio de Medicina Física y Rehabilitación, Hospital Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España Centro de Salud Gandhi, Madrid, España Servicio de Medicina Interna, Hospital Royo Vilanova, Zaragoza, España Fundación Caubet-Cimera FISIB Illes Balears, Bunyola, Baleares, España Servicio de Neumología, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, España

Estándares de calidad asistencial en la EPOC

Although clinical practice guidelines have contributed to improving the quality of health care offered to patients with chronic obstructive pulmonary disease (COPD), the level of adherence to recommendations continues to be inadequate and variable. Standards of care in COPD are written after applying an evidence-based approach, with the aim of unifying health-care criteria, establishing levels of acceptable adherence, and providing a way to assess quality; the ultimate goal is to improve patient care. In this statement we propose a series of health-care quality criteria and related indicators that will facilitate the quantitative evaluation of adherence to recommendations. The level of adherence that should be required is stipulated. This statement is not intended to provide a detailed description of how COPD should be managed. The aim is rather to set out quality assurance criteria that will contribute to the improvement of health-care access and equity, guaranteeing application of the highest levels of scientific and technical quality possible within the constraints of available resources, with the final purpose of satisfying the patient with COPD. The quality criteria have been grouped in 3 categories: a) so-called key criteria, to which adherence is essential; b) a set of conventional quality standards; and c) health-care administrative standards. Finally, we propose a framework on which to base the eventual accreditation of health-care quality for COPD patients.

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.

A Comprehensive, National Survey of Spirometry in Spain: Current Bottlenecks and Future Directions in Primary and Secondary Care

BACKGROUND We aimed to evaluate the availability and practice of spirometry, training of technicians, and spirometer features and maintenance in Spain in both primary care (PC) and secondary care (SC) centers. METHODS We used a nationwide, cross-sectional, 36-item telephone survey of health-care centers in Spain to target the technician in charge of conducting spirometries in PC and SC centers where outpatient respiratory patients are routinely evaluated. The questions surveyed for resources, training, spirometer use, bronchodilator tests, and spirometer features and maintenance. RESULTS Of a total of 1,259 centers screened, 605 PC centers (21.2% of the PC centers in Spain) and 200 SC centers (24.9% of the SC centers in Spain) were surveyed. The response rate was 85.4% for PC centers and 75.1% for SC centers. All together, 19% of screened centers did not have a spirometer or were not using it. The number of spirometers per center and spirometries conducted per week was higher in SC centers than in PC centers (P < .001). Most centers received training for conducting spirometries, but this was periodically done in < 40%. Most centers used two inhalations of salbutamol for the bronchodilator test, but the international criteria of a positive test was considered only in 55.8% of PC and 52.8% of SC centers. Calibration of the spirometer was never done in 10.5% of PC and 3.1% of SC centers. CONCLUSIONS This survey maps for the first time, to our knowledge, the current situation of spirometry in Spain, identifying bottlenecks and suggesting future directions applicable in both PC and SC centers and elsewhere.

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.

The General Public's Knowledge of Chronic Obstructive Pulmonary Disease and Its Determinants: Current Situation and Recent Changes

BACKGROUND The objective of this study was to determine the level of knowledge about chronic obstructive pulmonary disease (COPD) and its determinants in the general population of Spain, and to compare it with a similar survey conducted in 2002. METHODS We conducted a cross-sectional, observational, epidemiological study in September 2011 by means of a telephone interview with a representative sample of individuals aged 40-80 years living in all 17 regions of Spain. RESULTS A total of 6,528 responses were obtained (response rate of 13.1%), 53% of respondents were females with a mean age of 59.8 years. Regarding tobacco use, 19.4% were current smokers while 27.9% reported being former smokers. Only 17.0% spontaneously recognized the term «COPD». Valencia was the region with the highest degree of ignorance regarding COPD (91%), while Aragon had the lowest (73.7%). Nevertheless, COPD is considered a severe disease, following angina pectoris in severity. Upon comparing these results with the previous survey from 2002, we observed significant improvements in the knowledge and understanding of COPD (8.6% vs. 17.0%), with a marked variability between the regions (P<.05). Currently, only 4.7% of the Spanish population knows that there is a National Strategy for COPD, although 86.0% have a favorable or very favorable opinion about the new Anti-tobacco Law. CONCLUSION The lack of knowledge about COPD and its determinants in the general population remains high compared to 2002; thus, more and better educational and awareness programs are necessary.

Algorithm for identification of asthma–COPD overlap: consensus between the Spanish COPD and asthma guidelines

It was as early as 1959 that the report of the CIBA Symposium described the possible coexistence of different obstructive airway diseases, such as asthma, chronic bronchitis and/or emphysema, in the same individual. However, because there were no specific therapies for all these different expressions of lung disease, these overlaps were largely ignored by guidelines. In 1995, the American Thoracic Society chronic obstructive pulmonary disease (COPD) statement included a Venn diagram with the different possible overlaps of clinical presentation of obstructive lung diseases [1], but no specific recommendations of treatment were provided for them. It was not until 2007 that the Canadian COPD guidelines specified that: “if the asthma component (in COPD) is prominent, earlier introduction of inhaled corticosteroids (ICS) may be justified” [2]. Later, in 2010, the Japanese guidelines for COPD dedicated a chapter to “Treatment of COPD complicated by asthma” [3]. To the best of our knowledge, the Spanish guidelines for COPD (GesEPOC) in 2012 were the first to propose specific criteria for the identification of the so-called asthma–COPD overlap (ACO) [4, 5]. Because there was no internationally accepted definition of ACO, a group of experts proposed diagnostic criteria for ACO in COPD [6] and these were adopted in the document. The major criteria were as follows: a very positive bronchodilator response (>400 mL and >15% increase in forced expiratory volume in 1 s (FEV1)), sputum eosinophilia or a previous diagnosis of asthma. Minor criteria were an increased total serum IgE, previous history of atopy or a positive bronchodilator test (>200 mL and >12% in FEV1) on at least two occasions [6]. To be diagnosed with ACO, a patient must fulfil two major or one major and two minor criteria. Other national guidelines for COPD, such as the Finnish [7] and the Czech guidelines [8], followed this approach and proposed similar criteria for ACO. An algorithm to identify patients with ACO rather than asthma or COPD alone http://ow.ly/Viyy308Ehdk