Evolution of the Use of Noninvasive Mechanical Ventilation in Chronic Obstructive Pulmonary Disease in a Spanish Region, 1997–2010

IntroductionNoninvasive mechanical ventilation (NIV) appeared in the 1980s as an alternative to invasive mechanical ventilation (IMV) in patients with acute respiratory failure. We evaluated the introduction of NIV and the results in patients with acute exacerbation of chronic obstructive pulmonary disease in the Region of Murcia (Spain).Subjects and methodsA retrospective observational study based on the minimum basic hospital discharge data of all patients hospitalised for this pathology in all public hospitals in the region between 1997 and 2010. We performed a time trend analysis on hospital attendance, the use of each ventilatory intervention and hospital mortality through JoinPoint regression.ResultsWe identified 30 027 hospital discharges. JoinPoint analysis: downward trend in attendance (annual percentage change [APC]=?3.4, 95% CI: ?4.8 to ?2.0, P<.05) and in the group without ventilatory intervention (APC=?4.2%, ?5.6 to ?2.8, P<.05); upward trend in the use of NIV (APC=16.4, 12.0–20.9, P<.05), and downward trend that was not statistically significant in IMV (APC=?4.5%, ?10.3 to 1.7). We observed an upward trend without statistical significance in overall mortality (APC=0.5, ?1.3 to 2.4) and in the group without intervention (APC=0.1, ?1.6 to 1.9); downward trend with statistical significance in the NIV group (APC=?7.1, ?11.7 to ?2.2, P<.05) and not statistically significant in the IMV group (APC=?0.8, ?6, 1–4.8). The mean stay did not change substantially.ConclusionsThe introduction of NIV has reduced the group of patients not receiving assisted ventilation. No improvement in results was found in terms of mortality or length of stay.     

Inflammatory Cytokines and Repair Factors in the Intercostal Muscles of Patients With Severe COPD

ObjectiveThere is disagreement regarding the local action of cytokines in the respiratory muscles of patients with chronic obstructive pulmonary disease (COPD). The objective of this study was to analyze the relationships between cytokine expression and genetic activation of the mechanisms of muscle repair.Patients and MethodsTwenty-five patients with severe COPD and in stable condition were enrolled in the study. We performed a biopsy of the external intercostal muscle of the patients and analyzed the specimen for signs of muscle lesion (morphometry), infiltration of inflammatory cells (immunohistochemistry), and expression of selected genes (real-time polymerase chain reaction technique) corresponding to the cytokines (tumor necrosis factor α [TNF-α] and its type 1 and 2 receptors [TNFR1 and TNFR2], and interleukin [IL] 1β, IL-6, and IL-10), a pan-leukocyte marker (CD18), and key molecules in the repairmyogenesis pathways (Pax7, M-cadherin, and MyoD).ResultsExpression of TNFR2 is directly related to inspiratory muscle function (represented by maximum sustainable inspiratory pressure; r=0.496; P<.05), whereas expression of CD18 is inversely related (r=0.462; P<.05). Moreover, expression of the 2 TNF-α receptors was directly related to that of the key molecules of the repair pathways analyzed (TNFR1 to Pax7 [r=0.650; P<.001] and M-cadherin [r=0.678; P<.001]; TNFR2 to Pax7 [r=0.395; P<.05], M-cadherin [r=0.409; P<.05], and MyoD [r=0.418; P<.05]).ConclusionsExpression of TNF-α receptors bears a close relationship both to activation of the myogenesis programs and to inspiratory muscle function. This reinforces our hypothesis that some local cytokines take part in the repair of respiratory muscles in patients with COPD.     

Geriatric Assessment and Prognostic Factors of Mortality in Very Elderly Patients With Community-Acquired Pneumonia

IntroductionTo assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit.MethodsFour hundred fifty-six patients (≥75 years). Variables: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin).ResultsA hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6±6.4 vs 85.1±6.4, P<.04), had more comorbidity (ChI 2.35±1.61 vs 2.08±1.38; P<.083), worse functional impairment [(LI: 0.49±1.15 vs 1.45±2.32, P<.001) (BIp: 34.6±32.9 vs 54.0±34.1, P<.001) (BIa: 5.79±12.5 vs 20.5±22.9, P<.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4±28.6; P<.0001), worse cognitive impairment (PT: 7.20±3.73 vs 5.10±3.69, P<.001) and malnutrition (albumin 2.67±0.54 vs 2.99±0.49, P<.001). Mortality was higher with impaired consciousness [49.2% (P<.01)], tachypnea [33.3% (P<.01)], tachycardia [44.4% (P<.002), high urea levels [31.8 (P<.001)], anemia [44.7% (P<.02)], pleural effusion [42.9% (P<.002)], and multilobar infiltrates [43.2% (P<.001)]. In the multivariate analysis, variables associated with mortality were: age≥90 years [OR: 3.11 (95% CI: 1.31–7.36)], impaired consciousness [3.19 (1.66–6.15)], hematocrit<30% [2.87 (1.19–6.94)], pleural effusion [3.77 (1.69–8.39)] and multilobar infiltrates [2.76 (1.48–5.16)]. Female sex and a preserved functional status prior (LI≥5) and during admission (BIa≥40) were protective of mortality [0.40 (0.22–0.70), 0.09 (0.01–0.81) and 0.11 (0.02–0.51)].ConclusionsGeriatric assessment parameters and routine clinical variables were associated with mortality.     

Implementation of an Integrated Care Model for Frequent-Exacerbator COPD Patients: A Controlled Prospective Study

IntroductionFrequent-exacerbator COPD (fe-COPD) associated with frequent hospital admissions have high morbidity, mortality and use of health resources. These patients should be managed in personalized integrated care models (ICM). Accordingly, we aimed to evaluate the long-term effectiveness of a fe-COPD ICM on emergency room (ER) visits, hospital admissions, days of hospitalization, mortality and improvement of health status.MethodsProspective-controlled study with analysis of a cohort of fe-COPD patients assigned to ICM and followed-up for maximally 7 years that were compared to a parallel cohort who received standard care. All patients had a confirmed diagnosis of COPD with a history of ≥2 hospital admissions due to exacerbations in the year before enrollment. The change in CAT score and mMRC dyspnea scale, hospital admissions, ER visits, days of hospitalization, and mortality were analyzed.Results141 patients included in the ICM were compared to 132 patients who received standard care. The ICM reduced hospitalizations by 38.2% and ER visits by 69.7%, with reduction of hospitalizations for COPD exacerbation, ER visits and days of hospitalization (p < 0.05) compared to standard care. Further, health status improved among the ICM group after 1 year of follow-up (p = 0.001), effect sustained over 3 years. However, mortality was not different between groups (p = 0.117). Last follow-up CAT score > 17 was the strongest independent risk factor for mortality and hospitalization among ICM patients.ConclusionsAn ICM for fe-COPD patients effectively decreases ER and hospital admissions and improves health status, but not mortality.     

Muscle Glucose Metabolism in Chronic Obstructive Pulmonary Disease Patients

IntroductionMuscle dysfunction is one of the most extensively studied manifestations of COPD. Metabolic changes in muscle are difficult to study in vivo, due to the lack of non-invasive techniques. Our aim was to evaluate metabolic activity simultaneously in various muscle groups in COPD patients.MethodsThirty-nine COPD patients and 21 controls with normal lung function, due to undergo computed axial and positron emission tomography for staging of localized lung lesions were included. After administration of 18-fluordeoxyglucose, images of 2 respiratory muscles (costal and crural diaphragm, and rectus abdominus) and 2 peripheral muscles (brachial biceps and quadriceps) were obtained, using the standard uptake value as the glucose metabolism index.ResultsStandard uptake value was higher in both portions of the diaphragm than in the other muscles of all subjects. Moreover, the crural diaphragm and rectus abdominus showed greater activity in COPD patients than in the controls (1.8±0.7 vs 1.4±0.8; and 0.78±0.2 vs 0.58±0.1; respectively, P<.05). A similar trend was observed with the quadriceps. In COPD patients, uptake in the two respiratory muscles and the quadriceps correlated directly with air trapping (r=0.388, 0.427 and 0.361, respectively, P<.05).ConclusionsThere is greater glucose uptake and metabolism in the human diaphragm compared to other muscles when the subject is at rest. Increased glucose metabolism in the respiratory muscles (with a similar trend in their quadriceps) of COPD patients is confirmed quantitatively, and is directly related to the mechanical loads confronted.     

Comorbidities and Health Status in Individuals With and Without COPD in Five Latin American Cities: The PLATINO Study

IntroductionComorbidities are common in patients with chronic obstructive pulmonary disease (COPD), and have a significant impact on health status and prognosis. The PLATINO study provides data on self-reported comorbidities and perceived health status in COPD subjects.MethodsPLATINO is a population-based study on COPD prevalence in five Latin American cities. COPD diagnosis was defined by GOLD criteria (FEV₁/FVC<.70 post-bronchodilator). Information was collected on the following comorbidities: heart disease, hypertension, diabetes, cerebrovascular disease, peptic ulcer and asthma. Health status was evaluated using the SF-12 questionnaire, derived from the question: “In general, would you say your health is excellent, very good, good, fair or poor?” A simple comorbidity score was calculated by adding the total number of comorbid conditions.ResultsOf a total population of 5314 individuals, 759 had COPD. Reported comorbidities by decreasing frequency were: any cardiovascular disease, hypertension, peptic ulcer, heart disease, diabetes, cerebrovascular disease, asthma and lung cancer. COPD patients had a higher comorbidity score and prevalence of lung cancer (P<.0001) and asthma (P<.0001), as well as a higher tendency to have hypertension (P=.0652) and cerebrovascular disease (P=.0750). Factors associated with comorbidities were age, body mass index (BMI) and female gender. The number of comorbidities increased as the health status deteriorated.ConclusionsIn the PLATINO population-based study, COPD individuals had an increased number of comorbidities. Age, female gender and higher BMI were the factors associated with comorbidity in these patients. Comorbid conditions were associated with impaired health status, independently of the COPD status.     

Acute Exacerbation According to GOLD 2017 Categories in Patients with Chronic Obstructive Pulmonary Disease

IntroductionThe association between GOLD categorizations and future exacerbations has not been fully investigated. This study elucidates whether the GOLD 2017 classification is associated with different future exacerbation risk in patients with chronic obstructive pulmonary disease (COPD) compared with the previous GOLD categorization. Another objective was to investigate the impacts of the symptoms and FEV1 on the predicted future exacerbation independently of previous exacerbation history.MethodsWe analyzed patients from three prospective COPD cohorts (SNUH, KOCOSS, and KOLD) and evaluated the risk of moderate to severe exacerbation among different models, including GOLD grade (FEV1), GOLD 2011, and GOLD 2017.ResultsIn total, 611 COPD patients were included (36 from SNUH, 257 from KOCOSS, and 318 from KOLD). GOLD 2017 classification, excluding FEV1% for categorization criteria, showed no differences in future exacerbation risk compared with GOLD grade and GOLD 2011 based on c-statistics. Among those with no frequent exacerbation history and FEV1 ≥50%, the group with more symptoms was significantly associated with future exacerbations than the group with less symptoms. A lower FEV1 (FEV1 <50%) was not associated with a higher future exacerbation risk than a higher FEV1 (FEV1 ≥50%), regardless of prior exacerbation history and symptom group.ConclusionThe GOLD 2017 classification was not different from GOLD grade and GOLD 2011 regarding the association with future exacerbation risk, and there were no significant differences in exacerbation risk according to FEV1%. This suggests that FEV1 might not be an important factor in future exacerbation risk. These results partly support the GOLD 2017 assessment tool.     

Underdiagnosis of Chronic Obstructive Pulmonary Disease in Women: Quantification of the Problem,Determinants and Proposed Actions

IntroductionThe distribution of chronic obstructive pulmonary disease (COPD) in women, and its underdiagnosis and determinants in the general population, have not been well described. The EPI-SCAN study is an epidemiologic, observational study conducted at 11 Spanish centers on the general population aged 40–80.Patients and methodThis paper describes the rates and extrapolates the population burden from the 3802 participants of the EPI-SCAN study.ResultsWith 2005 female and 1797 male participants, there was a lower prevalence of COPD in women (5.7%; 95% CI, 4.7–6.7) than in men (15.1%; 95% CI, 13.5–16.8; P<.05). Among the 386 participants with COPD, 114 (29.5%) were women, who were younger, currently smoked less and had lower tobacco smoke exposure, while reporting a lower level of education (P<.05). As for the respiratory symptoms, there were no differences between sexes for cough, dyspnea or wheezing, but the women with COPD reported sputum less frequently (P<.05). There were no differences in the spirometric severity of COPD between women and men. Overall, 73% of the patients with spirometric COPD criteria were underdiagnosed, and this percentage is unevenly distributed by sex, being 1.27 times more frequent in women (86.0%) than in men (67.6%) (P<.05). By extrapolating the rates of prevalence and underdiagnosis of COPD to the general population, we estimate that there are 628 102 Spanish women between the ages of 40 and 80 with COPD, 540 168 of whom still have not been diagnosed.ConclusionsThere is a greater underdiagnosis of COPD in women than in men in Spain.     

Distribution of Clinical Phenotypes in Patients With Chronic Obstructive Pulmonary Disease Caused by Biomass and Tobacco Smoke

IntroductionExposure to biomass smoke is a risk factor for chronic obstructive pulmonary disease (COPD). It is unknown whether COPD caused by biomass smoke has different characteristics to COPD caused by tobacco smoke.ObjectiveTo determine clinical differences between these two types of the disease.MethodsRetrospective observational study of 499 patients with a diagnosis of COPD due to biomass or tobacco smoke. The clinical variables of both groups were compared.ResultsThere were 122 subjects (24.4%) in the biomass smoke group and 377 (75.5%) in the tobacco smoke group. In the tobacco group, the percentage of males was higher (91.2% vs 41.8%, P<.0001) and the age was lower (70.6 vs 76.2 years, P<.0001). Body mass index and FEV₁% values were higher in the biomass group (29.4±5.7 vs 28.0±5.1, P=.01, and 55.6±15.6 vs 47.1±17.1, P<.0001, respectively). The mixed COPD-asthma phenotype was more common in the biomass group (21.3% vs 5%, P<.0001), although this difference disappeared when corrected for gender. The emphysema phenotype was more common in the tobacco group (45.9% vs 31.9%, P=.009). The prevalence of chronic bronchitis, exacerbator phenotypes, the comorbidity burden and the rate of hospital admissions were the same in both groups.ConclusionDifferences were observed between COPD caused by biomass and COPD caused by tobacco smoke, although these may be attributed in part to uneven gender distribution between the groups.     

A Study of the Effect of Proinflammatory Cytokines on the Epithelial Cells of Smokers,With or Without COPD

IntroductionCigarette smoke is the main cause of inflammation in COPD. The mechanisms that differentiate smokers who develop COPD are diverse. In this study, we analyzed the presence of cytokines in the respiratory secretions of smokers with or without COPD and the secretory properties of the differentiated bronchial epithelium obtained from the individuals themselves after exposure to tobacco smoke.Material and methodsTwenty-seven smokers were studied, 12 of whom had COPD that had not been previously treated with steroids. In 11, samples were obtained by means of induced sputum, and the remaining samples were collected from bronchial aspiration after bronchoscopy. Concentrations of IL8, IL13, and TNFα in the supernatant were determined. The results obtained were compared between individuals with and without COPD, and we studied their relationship with the severity of COPD as expressed by the degree of obstruction, dyspnea, presence of hypersecretion and intensity of smoking. Bronchial epithelial cell cultures were obtained by air–liquid interface in 4 smokers. The samples were exposed to increasing concentrations of cigarette smoke (5%–20%) and the epithelial mRNA expressions of Muc5AC, IL8, and TNFα were determined.ResultsCOPD patients had significantly higher values of IL8 than healthy smokers (41 [22] pM vs 21 [12] pM). The values of IL8 correlated significantly with the severity of the obstruction (r=0.6; P<.05), dyspnea (r=0.45; P<.05) and the presence of hypersecretion. There was no relationship between cytokines and the intensity or duration of the tobacco habit. Cigarette smoke produced a dose-dependent increase in the expression of RNAm for Muc5AC, IL8, and TNFα.ConclusionsThere are differences in cytokine production (fundamentally IL8) between smokers and smokers with COPD which could be explained by the direct action of cigarette smoke on epithelial cells.     

Classification of Chronic Obstructive Pulmonary Disease Severity According to the New Global Initiative for Chronic Obstructive Lung Disease 2011 Guidelines: COPD Assessment Test Versus Modified Medical Research Council Scale

IntroductionThe GOLD 2011 revision proposes to stratify patients with chronic obstructive pulmonary disease (COPD) by measuring the impact of the disease using the modified Medical Research Council (mMRC) scale or COPD assessment test (CAT). Our aim was to determine whether both methods are equivalent.Patients and methodsObservational study on a cohort of 283 patients diagnosed with COPD. We analyzed the demographic and lung function results. Patients were assessed by CAT and mMRC on the same day by the same interviewer, and divided into GOLD 2011 categories according to the result of the evaluation. The degree of concordance and Spearman correlation were determined. We used ANOVA on the clinical and functional variables of the four GOLD 2011 categories.ResultsOn assessing the classification of patients according to the method used, an overall correlation of ρ = 0.613 and a degree of concordance of κ = 0.63 (moderate) were obtained. κ = 0.44 was obtained for the 152 patients in categories A and B (moderate-low), and at 0.38 for the 131 patients in categories C and D (low). Differences were observed between the categories in terms of functional parameters.ConclusionsThe classification of patients with COPD using the assessment proposed by GOLD 2011 varies according to the method used (CAT or mMRC); more than 25% of patients were reclassified into different categories, implying differences in the recommended therapeutic strategy. Longitudinal studies are needed to appraise which method does better classification of the patients, according to its prognostic ability.     

Blood Eosinophil Counts and Their Variability and Risk of Exacerbations in COPD: A Population-Based Study

BackgroundThere is controversy regarding the role of blood eosinophil levels as a biomarker of exacerbation risk in chronic obstructive pulmonary disease (COPD). Our aim was to quantify blood eosinophil levels and determine the risk of exacerbations associated with these levels and their variability.MethodsObservational, retrospective, population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical record database in Catalonia, Spain, covering 80% of the general population. Patients were classified into 4 groups using the following cut-offs: (a) <150 cells/μl; (b) ≥150 and <300 cells/μl; (c) ≥300 and <500 cells/μl; (d) ≥500 cells/μl.ResultsA total of 57,209 patients were identified with a mean age of 70.2 years, a mean FEV1(% predicted) of 64.1% and 51.6% had at least one exacerbation the previous year. The number of exacerbations in the previous year was higher in patients with the lowest and the highest eosinophil levels compared with the intermediate groups. During follow-up the number of exacerbations was slightly higher in the group with the lowest blood eosinophil levels and in those with higher variability in eosinophil counts, but ROC curves did not identify a reliable threshold of blood eosinophilia to discriminate an increased risk of exacerbations.ConclusionsOur results do not support the use of blood eosinophil count as a reliable biomarker of the risk of exacerbation in COPD in a predominantly non-exacerbating population. Of note was that the small group of patients with the highest variability in blood eosinophils more frequently presented exacerbations.     

The Roles of Bacteria and Viruses in Bronchiectasis Exacerbation: A Prospective Study

BackgroundExacerbations are crucial events during bronchiectasis progression.ObjectivesTo explore the associations between bacterial, viral, and bacterial plus viral isolations and bronchiectasis exacerbations.MethodsIn this prospective study, we enrolled 108 patients who were followed up every 3–6 months and at onset of exacerbations between March 2017 and November 2018. Spontaneous sputum was split for detection of bacteria (routine culture) and viruses (quantitative polymerase chain reaction). Symptoms and lung function were assessed during exacerbations.ResultsThe median exacerbation rate was 2.0 (interquartile range: 1.0–2.5) per patient-year. At any visit, viral isolations (V+) occurred more frequently during onset of exacerbations [odds ratio (OR): 3.28, 95% confidence interval (95%CI): 1.76–6.12], as did isolation of new bacteria (NB+) (OR: 2.52, 95%CI: 1.35–4.71) and bacterial plus viral isolations (OR: 2.24, 95%CI: 1.11–4.55). Whilst coryza appeared more common in exacerbations with V+ than in exacerbations with no pathogen isolations and those with NB+, lower airway symptoms were more severe in exacerbations with NB+ (P < .05). Sputum interleukin-1β levels were higher in exacerbations with NB+ than in exacerbations with no pathogen isolations and those with V+ (both P < .05). Significantly more coryza symptoms correlated with bacterial plus viral isolations at exacerbations (P = .019). Compared with V+ alone, bacterial with and without viral isolations tended to yield more severe lower airway symptoms, but not sputum cytokine levels at exacerbations.ConclusionsViral isolations, isolation of new bacteria and bacterial plus viral isolation are associated with bronchiectasis exacerbations. Symptoms at exacerbations might inform clinicians the possible culprit pathogens.     

Assessment of Induced Sputum Cellularity in COPD Patients Belonging to Two Different Classes of Air Pollution Exposure

IntroductionSeveral studies have previously demonstrated that long-term exposure to outdoor pollution present airway inflammation in term of an increase of sputum neutrophils.Aim and methodsThe aim of our study was to evaluate the level of airway inflammation by induced sputum in a group of 15 non-professionally exposed population of well-characterized COPD patients, residing in urban areas with high rate of outdoor pollution, compared to a control group of 13 individuals with COPD, living in rural areas with a low pollution rate. All participants underwent spirometry and sputum induction.ResultsA statistically significant increase in the percentage of neutrophil cell count was found among the residents in urban areas compared to those living in rural regions (89.1 vs 79.0, p < 0.05)ConclusionsIn conclusion, we showed that non-professionally exposed patients with COPD residing in highly-polluted urban areas had greater airway inflammation in terms of sputum neutrophils compared to a population with very similar characteristics, living in rural areas with lower outdoor pollution. The results of this pilot study may be relevant for the long term effect of environmental outdoor pollution in vulnerable patients like those with COPD.     

Asynchrony and Hyperinflation in Patients With Chronic Obstructive Pulmonary Disease During Two Types of Upper Limbs Exercise

IntroductionOccurrence of dynamic hyperinflation during upper-limbs exercises in chronic obstructive pulmonary disease (COPD) patients is not well established. We hypothesized that dynamic hyperinflation and thoracoabdominal asynchrony occur in COPD patients accomplishing arms exercises. We assessed the occurrence and association of dynamic hyperinflation and thoracoabdominal asynchrony in COPD patients during the accomplishment of two arm exercises.Patients and methodsThis was a prospective study with 25 COPD patients. A maximal and a sub-maximal upper limbs exercise test with 50% load were performed with the diagonal technique and the arm cycle ergometer technique. Respiratory pattern, thoracoabdominal configuration and dynamic hyperinflation were assessed in the exercise tests.ResultsThirty per cent and 60% of patients hyperinflated at the end of the sub-maximum exercise tests with the diagonal and cycle ergometer techniques, respectively. Thoracoabdominal asynchrony occurred in 80% and 100% of patients who hyperinflated with the diagonal and cycle ergometer techniques, respectively. For both exercises we found enhancement of pulmonary ventilation, dyspnea, central respiratory drive and shortening of expiratory time (P<.05). Upper-limbs exercises with the diagonal technique presented less number of patients with these alterations.ConclusionsDynamic pulmonary hyperinflation and thoracoabdominal asynchrony association occurred in both upper-limbs exercises; however, the diagonal technique developed less dynamic hyperinflation and thoracoabdominal asynchrony in COPD patients than the arm cycle ergometer.     

Comparison of Intermittent Positive Pressure Breathing and Temporary Positive Expiratory Pressure in Patients With Severe Chronic Obstructive Pulmonary Disease

BackgroundResults supporting the use and the effectiveness of positive expiratory, pressure devices in chronic obstructive pulmonary disease (COPD) patients are still controversial. We have tested the hypothesis that adding TPEP or IPPB to standard pharmacological therapy may provide additional clinical benefit over, pharmacological therapy only in patients with severe COPD.MethodsForty-five patients were randomised in three groups: a group was treated with IPPB, a group was treated with TPEP and a group with pharmacological therapy alone (control group).Primary outcome measures included the measurement of scale, or questionnaire concerning dyspnoea (MRC scale); dyspnoea, cough, and sputum (BCSS) and quality of life (COPD assessment test) (CAT). Secondary outcome measures were respiratory function testing, arterial blood gas analysis and haematological examinations.ResultsPatients in both the IPPB group and the TPEP group showed a significant improvement in two of three tests (MRC, CAT) compared to the control group. However, in the group comparison analysis for the same variables between the IPPB group and the TPEP group, we observed a significant improvement in the IPPB group (P≤.05 for MRC and P≤.01 for CAT).The difference of action of the two techniques is evident in the results of pulmonary function testing: IPPB increases FVC, FEV1, and MIP; this reflects its capacity to increase lung volume. Also TPEP increases FVC and FEV1 (less than IPPB), and MEP, while decreasing total lung capacity and residual volume.ConclusionsThe two techniques (IPPB and TPEP) improve significantly dyspnoea, quality of life tools and lung function in patients with severe COPD. IPPB demonstrated a greater effectiveness in improving dyspnoea and quality of life tools (MRC, CAT) than TPEP.     

Obesity-hypoventilation Syndrome: Baseline Hemodynamic Status and Impact of Non-invasive Ventilation

IntroductionObesity-hypoventilation syndrome (OHS) is a risk factor for heart failure (HF). Some studies associate the use of non-invasive ventilation (NIV) with changes in hemodynamic parameters. Our objective was to describe the hemodynamic status of a group of patients with OHS and to study the effect of NIV.Patients and methodsPatients with stable OHS treated with NIV were included in this cross-sectional repeated measurements study. Hemodynamics were measured by bioimpedance: 30 min at baseline and another 30 min on NIV. Cardiac output (CO), cardiac index, and systolic volume were measured. The CO calculated for each patient expressed as a percentage of the lower limit of normal (LLN) was taken as reference, and 2 groups were formed: patients without HF and normal CO (≥100% of LLN) and patients with HF and low CO (<100% of LLN). The Mann–Whitney U test was used to compare independent variables and the Wilcoxon test was used for paired variables, with significance set at P<.05.ResultsThe final sample comprised 36 patients, aged 66 (±8) years, 19 (52%) men. In 17 (46%) patients, HF was detected with a CO of 3.7 l/min (66%) compared to the group without HF, whose CO was 7 l/min (107%). After NIV, patients with HF showed improvement in CO 4.5 l/min (77%), P=.009, while the non-HF group remained unchanged, with CO 6.8 l/min (104%), P=.2.ConclusionA total of 46% of patients with stable OHS present HF; NIV improves hemodynamics and does not affect patients with normal CO.     

Prevalence of Alpha-1 antitrypsin deficiency in COPD patients in Argentina. The DAAT.AR study

IntroductionAlpha-1 antitrypsin deficiency (AATD) is still underdiagnosed, despite the recommendation to determine AAT in patients with chronic obstructive pulmonary disease (COPD).ObjectiveTo estimate the prevalence of AATD in COPD patients adjusted according to the population of the COPD prevalence study in Argentina (EPOC.AR).Material and methodsThis was a multicenter prospective cross-sectional study of a population aged ≥ 30 years of age diagnosed with COPD, involving AAT quantification in dry blood spot and subsequent genotyping in subjects with < 1.5 mg/dl AAT in dry blood spot (< 80 mg/dl in serum). AAT was defined as the detection of variants ZZ or SZ on genotyping. The EPOC.AR study population was used to calculate local adjusted prevalence.ResultsWe included 3254 patients (544 with AAT < 80 mg/dL) with a spirometric diagnosis of COPD. The prevalence of AATD in the total study population was 1.29% (95% CI 0.93–1.74), of which 0.92% (95% CI 0.62–1.31) were Pi*ZZ and 0.37% (95% CI 0.19−0.64) Pi*SZ. The adjusted prevalence of AATD in COPD patients ≥ 40 years of age was 0.83% (95% CI 0.23–2.08). We found that AATD was negatively associated with age (OR 0.94; 95% CI 0.90−0.98; P = .006), smoking habit (OR 0.98; 95% CI 0.96−0.99; P = .009), and FEV₁% (OR 0.95; 95% CI 0.91−0.99; P = .015).ConclusionsThe prevalence of AATD in the adult population with COPD in Argentina is estimated to be 0.83%, which could represent 17,000 cases in our country.     

Causes of Death and Risk Factors for Mortality in Patients With Severe Chronic Obstructive Pulmonary Disease

ObjectiveThe objective of this study was to assess the causes of death and risk factors for mortality in a cohort of patients with severe chronic obstructive pulmonary disease (COPD).Patients and methodsWe studied 203 patients with severe COPD (forced expiratory volume in 1 second [FEV₁] <50%), who were attended in our respiratory department day hospital (2001-2006). Clinical variables were recorded on inclusion, and clinical course and causes of death were retrospectively reviewed.ResultsThe mean (SD) age of patients was 69 (8) years and the mean FEV₁ was 30.8% (8.2%). One-hundred and nine patients died (53.7%); death was attributed to respiratory causes in 72 (80.9%), with COPD exacerbation being the most frequent specific cause within this category (48.3%). During follow-up, 18.7% required admission to the intensive care unit (ICU). Survival at 1, 3, and 5 years was 80%, 53%, and 26%, respectively. The multivariate analysis showed that mortality was associated with age, stage IV classification according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), cor pulmonale, and hospital admission during the year prior to inclusion. Need for admission to the ICU during follow-up was a factor independently associated with higher mortality.ConclusionsMortality in patients with severe COPD was high and exacerbation of the disease was one of the most frequent causes of death. Age, GOLD stage, cor pulmonale, prior admission to hospital, and need for admission to the ICU during follow-up were independent predictors of mortality.