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Marc Miravitlles, Juan José Soler-Cataluña,
Myriam Calle,
Jesús Molina,
Pere Almagro,
José Antonio Quintano,
Juan Antonio Trigueros,
Pascual Piñera,
Adolfo Simón,
Juan Antonio Riesco,
Julio Ancochea,
Joan B Soriano
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ABSTRACT: 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.
Primary care respiratory journal: journal of the General Practice Airways Group 03/2013; 22(1):117-21.
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ABSTRACT: The new GOLD update has moved forward the principles of treatment of stable COPD by including the concepts of symptoms and risks into the decision of therapy; however, no mention of the concept of clinical phenotypes was included. It is recognized that COPD is a very heterogeneous disease and not all patients respond to all the 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 pharmacologic interventions. As an 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 PDE4 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.
European Respiratory Journal 10/2012; · 5.89 Impact Factor
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ABSTRACT: RATIONALE: Obstructive sleep apnoea (OSA) is a risk factor for cardiovascular death in middle-age subjects, but it is not known whether it is also a risk factor in the elderly. OBJECTIVES: To investigate whether OSA is a risk factor for cardiovascular death and assess whether continuous positive airway pressure (CPAP) treatment is associated with a change in risk in the elderly. METHODS: Prospective, observational study of a consecutive cohort of elderly patients (≥65 years) studied for suspicion of OSA between 1998 and 2007. Patients with an apnoea-hypopnea index (AHI)<15 were the control group. OSA was defined as mild to moderate (AHI of 15 to 29) or severe (AHI≥30). Patients with OSA were classified as CPAP-treated (adherence≥4 hours per day) or untreated (adherence<4 hours per day or not prescribed). Participants were followed up until December 2009. The endpoint was cardiovascular death. A multivariate Cox survival analysis was used to determine the independent impact of OSA and CPAP treatment on cardiovascular mortality. MAIN RESULTS: 939 elderly were studied (median follow-up, 69 months). Compared with the control group, the fully adjusted hazard ratios for cardiovascular mortality were 2.25 (CI,1.41 to 3.61) for the untreated severe OSA group, 0.93 (CI, 0.46 to 1.89) for the CPAP-treated group; and 1.38 (CI, 0.73 to 2.64) for the untreated mild to moderate OSA group. CONCLUSIONS: Severe OSA not treated with CPAP is associated with cardiovascular death in the elderly, and adequate CPAP treatment may reduce this risk.
American Journal of Respiratory and Critical Care Medicine 09/2012; · 11.08 Impact Factor
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Marc Miravitlles, Juan José Soler-Cataluña,
Myriam Calle,
Jesús Molina,
Pere Almagro,
José Antonio Quintano,
Juan Antonio Riesco,
Juan Antonio Trigueros,
Pascual Piñera,
Adolfo Simón,
José Luis López-Campos,
Joan B Soriano,
Julio Ancochea
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ABSTRACT: Recognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.
Atención Primaria 06/2012; 44(7):425-37. · 0.63 Impact Factor
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ABSTRACT: The term phenotype in the field of COPD is defined as "a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes". Among all phenotypes described, there are three that are associated with prognosis and especially are associated with a different response to currently available therapies. There phenotypes are: the exacerbator, the overlap COPD-asthma and the emphysema-hyperinflation. The exacerbator is characterised by the presence of, at least, two exacerbations the previous year, and on top of long-acting bronchodilators, may require the use of antiinflammatory drugs. The overlap phenotype presents symptoms of increased variability of airflow and incompletely reversible airflow obstruction. Due to the underlying inflammatory profile, it uses to have a good therapeutic response to inhaled corticosteroids in addition to bronchodilators. Lastly, the emphysema phenotype presents a poor therapeutic response to the existing antiinflammatory drugs and long-acting bronchodilators together with rehabilitation are the treatments of choice. Identifying the peculiarities of the different phenotypes of COPD will allow us to implement a more personalised treatment, in which the characteristics of the patients, together with their severity will be key to choose the best treatment option.
Archivos de Bronconeumología 12/2011; 48(3):86-98. · 2.17 Impact Factor
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ABSTRACT: The aim of this study is to evaluate the efficacy and safety of medium-dose formoterol-budesonide combined inhaled treatment in a single inhaler compared with high-dose budesonide treatment in patients with non-cystic fibrosis (non-CF) bronchiectasis.
This is a 12-month randomized, double-blind, parallel-groups clinical trial, to run in 40 patients with non-CF bronchiectasis diagnosed by high-resolution CT scan of the chest, receiving formoterol-budesonide combined treatment (18/640 μg daily) or budesonide treatment (1,600 μg daily). Variables concerning clinical condition, health-related quality of life (HRQL), lung function, β(2)-adrenergic agonist use, potentially pathogenic microorganism (PPM) isolates, and medication side effects were analyzed by intention-to-treat analysis.
The study group receiving a formoterol-budesonide combined treatment showed a significant improvement, both clinically and statistically, of symptoms (dyspnea, number of coughs, and rescue β(2)-adrenergic agonist-free days). Furthermore, we observed an HRQL improvement, with no changes in functional parameters or in PPM isolates, together with an important reduction in overall side effects, especially for those related to inhaled steroids, compared with the high-dose budesonide treatment group.
Inhaled medium-dose formoterol-budesonide combined treatment in a single inhaler is more effective and safe compared with high-dose budesonide treatment in patients with non-CF bronchiectasis.
ClinicalTrials.gov; No.: NCT00728715; URL: www.clinicaltrials.gov.
Chest 07/2011; 141(2):461-8. · 5.25 Impact Factor
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ABSTRACT: Previous studies have shown that physical activity (PA) in COPD is associated with a better quality of life and less morbidity and mortality. Our aim was to study the daily PA in the lives of stable COPD patients, outside the setting of a pulmonary rehabilitation program.
Observational, descriptive and transversal multi-center study in patients with stable COPD controlled in an outpatient clinic by pneumologists. In order to determine the Physical Activity Index (PAI), the Minnesota Leisure Time Physical Activity Questionnaire (MLTPAQ) was used to differentiate the following groups according to the energy expenditure: inactive (less than 1,000 kilocalories per week), moderately active (between 1,000 and 3,000 kilocalories per week) and very active (more than 3,000 kilocalories per week). We analyzed the relationship between PAI and disease severity, health level and socioeconomic variables of the patients.
A total of 132 patients (121 men) were included in the study. Mean age was 66; mean FEV1 was 45%. Regarding PA, 32.6% had energy expenditures of less than 1,000 kilocalories/week, 38.6% between 1,000 and 3,000 and 28.8% more than 3,000. The most inactive COPD patients had more bronchial obstruction, more severe disease, more dyspnea and walked fewer meters in the 6MWT.
Stable COPD patients perform low levels of PA. Lower PA is associated with poorer health and with more severe disease.
Archivos de Bronconeumología 07/2011; 47(7):335-42. · 2.17 Impact Factor
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ABSTRACT: Inhaled antibiotics are increasingly used in patients with non-cystic fibrosis (CF) bronchiectasis. Currently, there is no formal indication for the use of this therapy in these patients as inhaled antibiotics are currently only indicated in patients with CF. Therefore, prescription in patients with non-CF bronchiectasis will continue to be based on compassionate use until scientific evidence from ongoing clinical trials becomes available. However, the studies performed to date have shown several positive effects on some key parameters such as a reduction in the number of colonies and the quantity and purulence of sputum, improved quality of life and fewer exacerbations, although this therapy has little impact on accelerated loss of pulmonary function. The percentage of eradication varies, with a low rate of resistance. The clearest use of inhaled antibiotics in patients with non-CF bronchiectasis is probably colonization, especially chronic infection with Pseudomonas aeruginosa. Adverse effects are usually mild and consist of local irritation of the airway, although their frequency is greater than that in patients with CF. Currently, various clinical trials are being carried out that aim to establish the indications for inhaled antibiotic therapy in these patients. Due to its special characteristics (high local concentrations of the drug with scarce systemic adverse effects), inhaled antibiotic therapy will undoubtedly be an excellent future option for the management of bronchiectasis, as well as of many other diseases of the airways.
Archivos de Bronconeumología 06/2011; 47 Suppl 6:19-23. · 2.17 Impact Factor
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ABSTRACT: Previous studies have shown a high prevalence of bronchiectasis in patients with moderate to severe COPD. However, the factors associated with bronchiectasis remain unknown in these patients. The objective of this study is to identify the factors associated with bronchiectasis in patients with moderate to severe COPD.
Consecutive patients with moderate (50% < FEV(1) ≤ 70%) or severe (FEV(1) ≤ 50%) COPD were included prospectively. All subjects filled out a clinical questionnaire, including information about exacerbations. Peripheral blood samples were obtained, and lung function tests were performed in all patients. Sputum samples were provided for monthly microbiologic analysis for 6 months. All the tests were performed in a stable phase for at least 6 weeks. High-resolution CT scans of the chest were used to diagnose bronchiectasis.
Ninety-two patients, 51 with severe COPD, were included. Bronchiectasis was present in 53 patients (57.6%). The variables independently associated with the presence of bronchiectasis were severe airflow obstruction (OR, 3.87; 95% CI, 1.38-10.5; P = .001), isolation of a potentially pathogenic microorganism (PPM) (OR, 3.59; 95% CI, 1.3-9.9; P = .014), and at least one hospital admission due to COPD exacerbations in the previous year (OR, 3.07; 95% CI, 1.07-8.77; P = .037).
We found an elevated prevalence of bronchiectasis in patients with moderate to severe COPD, and this was associated with severe airflow obstruction, isolation of a PPM from sputum, and at least one hospital admission for exacerbations in the previous year.
Chest 05/2011; 140(5):1130-7. · 5.25 Impact Factor
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Joan B Soriano,
Marc Miravitlles,
Luis Borderías,
Enric Duran-Tauleria,
Francisco García Río,
Jaime Martínez,
Teodoro Montemayor,
Luis Muñoz,
Luis Piñeiro,
Guadalupe Sánchez,
Joan Serra, Juan José Soler-Cataluña,
Antoni Torres,
Jose Luis Viejo,
Víctor Sobradillo-Peña,
Julio Ancochea
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ABSTRACT: The EPI-SCAN study (Epidemiologic Study of COPD in Spain), conducted from May 2006 to July 2007, determined that the prevalence of COPD in Spain according to the GOLD criteria was 10.2% of the 40 to 80 years population. Little is known about the current geographical variation of COPD in Spain.
We studied the prevalence of COPD, its under-diagnosis and under-treatment, smoking and mortality in the eleven areas participating in EPI-SCAN. COPD was defined as a post-bronchodilator FEV₁/FVC ratio <0.70 or as the lower limit of normal (LLN).
The ratio of prevalences of COPD among the EPI-SCAN areas was 2.7-fold, with a peak in Asturias (16.9%) and a minimum in Burgos (6.2 %) (P<0.05). The prevalence of COPD according to LLN was 5.6% (95% CI 4.9-6.4) and the ratio of COPD prevalence using LLN was 3.1-fold, but with a peak in Madrid-La Princesa (10.1%) and a minimum in Burgos (3.2%) (P<0.05). The ranking of prevalences of COPD was not maintained in both sexes or age groups in each area. Variations in under-diagnosis (58.6% to 72.8%) and under-treatment by areas (24.1% to 72.5%) were substantial (P<0.05). The prevalence of smokers and former smokers, and cumulative exposure as measured by pack-years, and the age structure of each of the areas did not explain much of the variability by geographic areas. Nor is there any relation with mortality rates published by Autonomous Communities.
There are significant variations in the distribution of COPD in Spain, either in prevalence or in under-diagnosis and under-treatment.
Archivos de Bronconeumología 10/2010; 46(10):522-30. · 2.17 Impact Factor
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ABSTRACT: Exacerbations are important events in the natural history of chronic obstructive pulmonary disease (COPD). The higher the number of COPD exacerbations, the worse are the clinical and economical consequences. The distribution of COPD exacerbations is however highly variable. Some patients do not exhibit exacerbations at all whereas others suffer frequent events (i.e., "frequent COPD exacerbators"). We review the scientific evidence regarding the impact of COPD exacerbation frequency and assess whether or not these frequent exacerbators represent a unique population of COPD patients with higher morbidity and mortality risks. A definition of "frequent COPD exacerbators" is suggested to differentiate it from other related terms, such as "treatment failure" and "recurrence." The standardization of this terminology seems to be necessary to further identify COPD phenotypes in patients who have an individual susceptibility to develop frequent exacerbations. It can also be of help to refine the most appropriate therapeutic and preventative measures.
COPD Journal of Chronic Obstructive Pulmonary Disease 08/2010; 7(4):276-84. · 1.79 Impact Factor
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ABSTRACT: Chronic obstructive pulmonary disease (COPD) and bronchiectasias are two of the most frequent and underdiagnosed diseases of the airways. The association between these two entities can be established from different points of view. On the one hand, because of their high prevalence, the co-occurrence of COPD and bronchiectasias in the same patient is not unusual. On the other hand, recent studies have observed an association between COPD and bronchiectasias, given that more than 50% of patients with moderate-severe COPD show bronchiectasias unexplained by other causes that could provoke an excess of bronchial inflammation, as well as a higher number of exacerbations, possibly mediated by an increase in bronchial colonization-infection by potentially pathogenic microorganisms. Lastly, some physiopathologic hypotheses that remain to be demonstrated suggest a causal relation between the two diseases in which COPD, especially severe forms, would constitute a risk factor for the formation of bronchiectasias.
Archivos de Bronconeumología 01/2010; 46 Suppl 3:11-7. · 2.17 Impact Factor
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ABSTRACT: One of the inherent characteristics of chronic obstructive pulmonary disease (COPD) is the occurrence of exacerbations. These episodes of clinical decompensation, which used to be considered epiphenomena of the disease, are now viewed as key elements in the natural history of COPD. Exacerbations generate huge clinical workload and enormous costs, impair patients' quality of life, make a decisive contribution to the multidimensional progression of the disease and affect prognosis. The present article reviews the current scientific evidence on the multifaceted impact of COPD exacerbations. However, the effects of exacerbations are not homogeneous. Not all patients suffer exacerbations and not all exacerbations have the same repercussions. This review highlights the need to standardize the definition of exacerbation, as well as that of concepts such as the frequency, severity, and duration of the episode. These factors influence the effect of the exacerbation itself and introduce variables that may affect treatment. Indeed, there is an increasing need to identify specific clinical phenotypes and personalize treatment. Consequently, an "exacerbating" phenotype is postulated as a therapeutic target of special importance.
Archivos de Bronconeumología 01/2010; 46 Suppl 11:12-9. · 2.17 Impact Factor
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ABSTRACT: To examine the quality of COPD diagnosis in hospitalised patients.
Retrospective multicentre cross-sectional audit review of the clinical histories of patients discharged with a diagnosis of COPD. The diagnosis of COPD was considered correct (DxC) in cases where the combination of a bronchial obstruction (FEV1/FVC<70%) and smoking (>10 packets/year) could be documented. In the rest of the cases the diagnosis was considered deficient (DxD). A DxC in at least 60% of patients was required to be considered an acceptable quality health care diagnosis. Demographic data such as, smoking, spirometry, the specialist who discharged the patient (P: Pneumologist; MS: Medical Specialty; CS: Surgical Specialty), and health care level (hospital complexity; low (H1), intermediate (H2) and high (H3)).
A total of 840 cases were analysed (718 males, 122 females); mean age (SD) 73 (10), from 10 hospitals (3 H1, 4 H2, 3 H3). A DxD was obtained in 597 (71.1%), due to either lack of spirometry (538, 64%) or smoking criteria (319, 38%), (P<0.001). Only two of the ten hospitals complied with the criteria of an acceptable quality health care diagnosis. Significant differences (P<0.0001) were seen on comparing DxC and DxD by health care level (DxC: 56.2% in H1, 29.9% in H2, 20.9% in H3), and by specialist (DxC: 47.6% en P, 24.6% in SP, 17.4% in MS). A multivariate analysis associated DxC with the male sex, H1 and pneumology reports.
1. The quality health care for the diagnosis of COPD is deficient. 2. The lack of spirometry is the most common cause of DxD.
Archivos de Bronconeumología 12/2009; 46(2):64-9. · 2.17 Impact Factor
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ABSTRACT: 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.
Archivos de Bronconeumología 04/2009; 45(4):196-203. · 2.17 Impact Factor
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ABSTRACT: Obstructive sleep apnea (OSA) is an independent risk factor for stroke, but little is known about the role of continuous positive airway pressure (CPAP) on mortality in patients with stroke.
To analyze the independent impact of long-term CPAP treatment on mortality in patients with ischemic stroke.
Prospective observational study in 166 patients with ischemic stroke. Sleep study was performed in all of them and CPAP treatment was offered in the case of moderate to severe cases. Patients were followed-up for 5 years to analyze the risk of mortality.
Of 223 patients consecutively admitted for stroke, a sleep study was performed on 166 of them (2 mo after the acute event). Thirty-one had an apnea-hypopnea index (AHI) of less than 10; 39 had an AHI between 10 and 19, and 96 had an AHI of 20 or greater. CPAP treatment was offered when AHI was 20 or greater. Patients were followed up in our outpatient clinic at 1, 3, and 6 months, and for every 6 months thereafter for 5 years (prospective observational study). Mortality data were recorded from our computer database and official death certificates. The mean age of subjects was 73.3 +/- 11 years (59% males), and the mean AHI was 26 (for all patients with a predominance of obstructive events). Patients with an AHI of 20 or greater who did not tolerate CPAP (n = 68) showed an increase adjusted risk of mortality (hazards ratio [HR], 2.69; 95% confidence interval [CI], 1.32-5.61) compared with patients with an AHI of less than 20 (n = 70), and an increased adjusted risk of mortality (HR, 1.58; 95% CI, 1.01-2.49; P = 0.04) compared with patients with moderate to severe OSA who tolerated CPAP (n = 28). There were no differences in mortality among patients without OSA, patients with mild disease, and patients who tolerated CPAP.
Our results suggest that long-term CPAP treatment in moderate to severe OSA and ischemic stroke is associated with a reduction in excess risk of mortality.
American Journal of Respiratory and Critical Care Medicine 04/2009; 180(1):36-41. · 11.08 Impact Factor
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ABSTRACT: 1) To determine whether severe exacerbation of COPD is a BODE index independent risk factor for death; 2) whether the combined application of exacerbations and BODE (e-BODE index), offers greater predictive capacity than BODE alone or can simplify the model, by replacing the exercise capacity (BODEx index).
A prospective study was made of a cohort of COPD patients. In addition to calculation of the BODE index we register frequency of exacerbations. An analysis was made of all-cause mortality, evaluating the predictive capacity of the exacerbations after adjusting for the BODE. These variables were also used to construct two new indexes: e-BODE and BODEx.
The study included 185 patients with a mean age of 71+/-9 years, and FEV(1)% 47+/-17%. Severe exacerbation appeared as an independent adverse prognostic variable of BODE index. For each new exacerbation the adjusted mortality risk increased 1.14-fold (95% CI: 1.04-1.25). However, the e-BODE index (C statistic: 0.77, 95% CI: 0.67-0.86) didn't improve prognostic capacity of BODE index (C statistic: 0.75, 95% CI: 0.66-0.84) (p=NS). An interesting finding was that BODEx index (C statistic: 0.74, 95% CI: 0.65-0.83) had similar prognostic capacity than BODE index.
Severe exacerbations of COPD imply an increased mortality risk that is independent of baseline severity of the disease as measured by the BODE index. The combined application of both parameters (e-BODE index) didn't improve the predictive capacity, but on replacing exacerbation with exercise capacity the multidimensional grading system is simplified without loss of predictive capacity.
Respiratory medicine 02/2009; 103(5):692-9. · 2.33 Impact Factor
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ABSTRACT: The presence of cardiovascular alterations in patients with chronic obstructive pulmonary disease (COPD) is no coincidence. Smoking, a risk factor for both entities, could partly explain the strength of the association; however, there are data that suggest that other determining factors such as systemic inflammation, oxidative stress, hypoxemia, endothelial dysfunction and even aging could also be involved. Prognosis is worse in patients with both entities. Cardiovascular disease (CVD) contributes to hospitalization in patients with COPD and to mortality. Approximately one out of every four patients with COPD dies from cardiovascular causes. Equally, COPD exacerbation also leads to a greater number of cardiovascular events and an increase in mortality has even been found among patients with CVD and COPD compared with controls without COPD. These determining factors underline the need to develop a comprehensive view for the early detection of at-risk individuals and use of appropriate therapeutic measures. Vasodilators, statins and beta-blockers may improve morbidity and mortality in patients with COPD, possibly because these drugs maximize control of the underlying CVD. Nevertheless, the antiinflammatory potential of statins could be of interest. Inhaled corticosteroids and even some bronchodilators could also decrease cardiovascular morbidity. These data are from observational studies and should be interpreted with caution but are nevertheless sufficiently interesting to warrant the enormous interest aroused by the interaction between the two most prevalent chronic diseases in the western world, COPD and CVD.
Archivos de Bronconeumología 01/2009; 45 Suppl 4:18-23. · 2.17 Impact Factor
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ABSTRACT: The TORCH and UPLIFT studies are probably the most ambitious clinical trials performed to date in chronic obstructive pulmonary disease (COPD). Unfortunately, the main objectives were not achieved. Compared with placebo, combination therapy with salmeterol and fluticasone did not significantly reduce all-cause mortality, nor did tiotropium slow lung function deterioration over 4 years. However, careful analysis of the results reduces the initial disappointment to a minimum and leads to moderate optimism, as both trials showed a decrease in the number of exacerbations, improvement in health-related quality of life (HRQoL) and, in general, a good safety profile throughout the studies. Moreover, some benefits on survival were noted. This latter observation opens new horizons as it suggests that, apart from lung function, there are other therapeutic targets with prognostic importance. When analyzed overall, the UPLIFT and TORCH studies confirm and highlight the key role of prolonged action bronchodilators in the management of COPD. Although inhaled corticosteroids, administered in monotherapy, reduce exacerbations and improve HRQoL, these drugs show no benefit on survival and increase the risk of adverse effects. Nevertheless, when inhaled corticosteroids are associated with bronchodilator treatment, their benefits seem to be enhanced.
Archivos de Bronconeumología 01/2009; 45 Suppl 5:14-20. · 2.17 Impact Factor
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ABSTRACT: The level of clinical suspicion of sleep apnea-hypopnea syndrome (SAHS) among primary care physicians is low. The aim of this study was to analyze the impact of a primary care training program on the quality and quantity of referrals made due to suspected SAHS.
A group of 16 primary care physicians were offered the option of participating in a training program consisting of 2 talks-workshops, the provision of up-to-date information on SAHS and a form for making referrals according to an established protocol, and the opportunity to contact the sleep department at our hospital directly. Twenty-one primary care physicians who did not receive training served as the control group. We gathered data on the quantity and quality of referrals made by both groups for the period January through June 2005 and 2006, and recorded the number of both SAHS diagnoses made and patients prescribed treatment with continuous positive airway pressure. Data were analyzed in function of the primary care population assigned to each group.
The training program was completed by 81.3% of the physicians. The number of referrals made by the training group increased 2.38-fold after the program (intergroup comparison, P=.0001). There was also a 2.36-fold increase in the percentage of cases of SAHS detected in the population (P=.0008), a 1.85-fold increase in the percentage of serious cases detected (P=.001), and a 2-fold increase in the number of patients prescribed continuous positive airway pressure (P=.009). Agreement between the data gathered by the physicians and the sleep specialist was significantly higher in the training group for all the items studied.
The implementation of a training program on SAHS aimed at primary care physicians improved both the quantity and quality of referrals made due to suspected SAHS.
Archivos de Bronconeumología 02/2008; 44(1):15-21. · 2.17 Impact Factor
