Physical Activity Levels and Associated Factors in a Latin American COPD Population of Patients. The LASSYC Study.

Reduced physical activity (PA) is an independent risk factor for lung function decline, hospitalization and mortality in chronic obstructive pulmonary disease (COPD) and affects a large proportion of patients from Europe and the United States. However, little is known of the level of PA of COPD patients in Latin America. The aim of this study was to provide information of the level of PA and its determinants in COPD patients in Latin America. This is an observational, cross-sectional study on patients with COPD in seven Latin American countries. PA level was evaluated with the short version of the International Physical Activity Questionnaire (IPAQ) and the association between PA and other variables was investigated. Complete information of PA level was obtained in 734 COPD patients consecutively recruited from specialized outpatient clinics; 448 (61%) were men, with a mean age of 69.6 years (standard deviation [SD] = 8.7) and a mean FEV1 (% predicted) = 49.1% (17.5%). In 37.9% the level of PA was low, and the average sitting time was 36.1 h per week. Patients with low levels of PA were older, with higher levels of dyspnea and higher CAT scores. Additionally, we found that patients with low level of PA presented more symptoms during the day. Low levels of PA have been observed in a large proportion of COPD patients of Latin America, which is higher in women and older patients and it is related with worse functional and clinical characteristics.

Bronchodilator treatment for COPD in primary care of four Latin America countries: The multinational, cross-sectional, non-interventional PUMA study.

BACKGROUND AND OBJECTIVE: Bronchodilators (BDs) are the cornerstone of COPD treatment. However, their underuse has been reported in real-life studies. PUMA is a primary-care study from Argentina, Colombia, Venezuela and Uruguay that could help understand the BD use in terms of frequency for long-acting (LA-BD) and short-acting (SA-BD) BDs alone or associated with corticosteroids (CS), and the use as-needed or on regular basis. METHODS: This is a multicentre, multinational, cross-sectional, non-interventional study including no randomised primary-care centres from each country (total 57 centres) without connection with respiratory specialists. Subjects attending routine visits, at-risk for COPD (≥40 years, current or former smokers or exposed to biomass) completed a questionnaire and performed spirometry. COPD was defined as post-BD FEV1/FVC<0.70 and by the lower limit of normal (LLN). Prior physician diagnosis of emphysema, chronic bronchitis or COPD was also determined. RESULTS: 1743 patients were interviewed, 1540 completed spirometry, 309 had COPD by post-BD FEV1/FVC<0.70, 226 by LLN, and 102 had prior medical diagnosis. A total of 77/309 COPD patients by spirometry (24.9%) used BD (3.6% LA-BDs), 15.2% used BD + CS (13.6% LA-BD + CS). Among these patients, SA-BDs (monotherapy) were the most commonly used medication both as-needed (4.5%) and on a regular basis (17.5%). Similar findings were observed using the LLN criteria. In those with prior medical diagnosis, 66/102 (64.7%) used BDs (9.8% LA-BD), and 25.6% used BD + CS (13.6% LA-BD + CS); among them SA-BDs were the most commonly medication used as-needed (9%) and on a regular basis (48.1%). Having health insurance with medication coverage increased the use of BDs. CONCLUSIONS: Up to 60% of COPD patients by spirometry and 10% of those with prior medical diagnosis attending a primary care sample of four Latin American countries did not use BDs. LA-BDs are widely underused on a regular-basis (2.6% and 8.3% of patients with spirometric and medical-diagnosis, respectively) This represents a considerable gap between guideline recommendations and BD prescribing pattern in these centres.

Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study.

BACKGROUND AND OBJECTIVE: Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD. METHODS: Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) < 0.70 and the lower limit of normal of FEV1 /FVC. RESULTS: A total of 1743 subjects completed the interview; 1540 performed acceptable spirometry. COPD prevalence was 20.1% (n = 309; ranging from 11.0% in Venezuela to 29.6% in Argentina) when defined using post-BD FEV1 /FVC < 0.70, and 14.7% (n = 226; ranging from 8.3% in Venezuela to 21.8% in Colombia) using the lower limit of normal. Logistic regression analysis for both definitions showed that the risk of COPD was significantly higher for persons >50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC < 0.70) of 76% and 79% for the simple and weighted scores, respectively. CONCLUSION: This simple seven-item score is an accurate screening tool to select subjects for spirometry in primary care.

Incorporating New Evidence on Inhaled Medications in COPD. The Latin American Chest Association (ALAT) 2019. / Incorporando nuevas evidencias sobre medicamentos inhalados en la EPOC. Asociación Latinoamericana de Tórax (ALAT) 2019.

This document on COPD from the Latin American Chest Association (ALAT-2019) uses PICO methodology to analyze new evidence on inhaled medication and answer clinical questions. The following key points emerged from this analysis: 1) evidence is lacking on the comparison of short-acting vs. long-acting bronchodilators in patients with mild COPD; patients with moderate-to-severe COPD obtain greater benefit from long-acting bronchodilators; 2) the benefits of monotherapy with long-acting antimuscarinic agents (LAMA) and combined therapy with long-acting ß2-agonists and inhaled corticosteroids (LABA/ICS) are similar, although the latter is associated with a greater risk of pneumonia; 3) LABA/LAMA offer greater benefits in terms of lung function and risk of exacerbation than LABA/ICS (the latter involve an increased risk of pneumonia), 4) LAMA/LABA/ICS have greater therapeutic benefits than LABA/LAMA on the risk of moderate-severe exacerbations. With regard to the role of eosinophils in guiding the use of ICS, ICS withdrawal must be considered when the initial indication was wrong or no response is elicited, in patients with side effects such as pneumonia, and in patients with a low risk of exacerbation and an eosinophil blood count of <300 cells/µl. All this evidence, categorized according to the severity of the obstruction, symptoms, and risk of exacerbations, has been used to generate an algorithm for the use of inhaled medication in COPD.

External validation of the PUMA COPD diagnostic questionnaire in a general practice sample and the PLATINO study population.

Background: A seven-item prescreening questionnaire (gender, age, pack-years smoking, dyspnea, sputum, cough, previous spirometry data) was developed for COPD detection in the primary care setting (PUMA Study) of four Latin America countries. Objectives: To validate the PUMA prescreening COPD questionnaire externally in two different populations (primary care and general). Methods: The PUMA prescreening COPD questionnaire score was applied to subjects from the Hospital Maciel, Montevideo (primary care), case-finding program and the PLATINO population (general) using PUMA study inclusion criteria. Post-bronchodilator FEV1/FVC <0.70 and lower limit of normal (LLN) criteria were used to define COPD. Area under the received operator curve (ROCAUC), sensitivity, specificity, predictive positive and negative values (PNV), number needed to treat (NNT), and best cut-points of the score were calculated. Results: 974 individuals from Hospital Maciel and 2512 from the PLATINO population were eligible, using post-bronchodilator FEV1/FVC <0.70, 45.1% and 18.7% had COPD, respectively, and using LLN 38.4% and 15.4% had COPD, respectively. From Hospital Maciel (post-bronchodilator FEV1/FVC <0.70), the best cut-point of ≥6 had moderate discriminatory power (ROCAUC 0.70), sensitivity 69.9%, specificity 62.1%, PNV 70.9%, and NNT of 3. The discriminatory power was 0.73 (ROCAUC) in the PLATINO population with three potential cut-points (Youden's index): ≥3 (sensitivity 85.4%, specificity 46.9%), ≥4 (sensitivity 66.7%, specificity 66.5%), and ≥5 (sensitivity 51.5%, specificity 81.6%); the PNV at each cut-point was 93.3%, 89.9%, and 88.0%, respectively. The NNT was 5 for scores ≥3 and ≥4, and 4 for ≥5. The mean accuracy using the LLN for Hospital Maciel and PLATINO was 0.67 and 0.70, respectively. Conclusion: External validation of the PUMA prescreening questionnaire in two Latin American populations (general and primary care) suggests moderate accuracy, similar to the original study in which the questionnaire was developed.

[Treatment of chronic obstructive pulmonary disease in 5 Latin American cities: the PLATINO study]. / Tratamiento de la EPOC en 5 ciudades de América Latina: estudio PLATINO.

OBJECTIVE: PLATINO project is a population-based study designed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in São Paulo, Brazil; Mexico City, Mexico; Montevideo, Uruguay; Santiago de Chile, Chile; and Caracas, Venezuela. The objective of this portion of PLATINO was to describe preventive and pharmacological treatment of COPD patients and factors associated with such treatment. PATIENTS AND METHODS: Eligible subjects completed a questionnaire and underwent postbronchodilator spirometry. RESULTS: Of the total of 5529 individuals who answered items referring to treatment, 758 had COPD (ratio of postbronchodilator forced expiratory volume in 1 second to forced vital capacity of <0.7), and 86 of them had been previously diagnosed by a physician. Among all COPD patients, only half of smokers or former smokers had been advised to quit and 24.7% had received some type of respiratory medication. Only 13.5% had used inhaled corticosteroids, and those were the patients with the most severe disease. In the group of patients who had a previous medical diagnosis of COPD, 69% of the smokers or former smokers had been advised to quit by a physician and 75.6% had received respiratory medication in the preceding year: 43% reported having used inhaled medication and 36% had used bronchodilators. Rates of vaccination against influenza and the use of mucolytic drugs and inhalers varied from one health care facility to another. All drug prescriptions were based on previous spirometry. CONCLUSIONS: Spirometry emerged not only as a diagnostic tool, but also as a factor associated with treatment, against a background of uneven use of available health care resources in these 5 Latin American cities.

Prevalence and impact of respiratory symptoms in a population of patients with COPD in Latin America: The LASSYC observational study.

BACKGROUND: To analyse the relationship between symptoms at different times during the 24-hour day and outcomes in COPD. METHODS: Observational cross-sectional study in a patients from 7 Latin American countries. The frequency of symptoms in the morning, at night and during the day was explored by means of standardised and validated questionnaires, and the relationship between symptoms and exacerbations and quality of life were investigated. RESULTS: 734 patients (59.6% male, mean age 69.5 years, mean FEV1 50% predicted normal) were recruited. The most frequent symptoms during the day were dyspnea (75% of patients, of which 94% mild-moderate) and cough (72.2%, of which 93.4% mild-moderate). Highly symptomatic patients had a greater impairment in FEV1, more exacerbations and worse scores in COPD assessment test (CAT) and Body Mass Index, Obstruction, Dyspnoea and Exacerbations (BODEx) index (all p < 0.001). Morning symptoms were more frequent than night-time symptoms, particularly cough and dyspnoea (morning: 50.1% and 45.7%; night-time: 33.2% and 24.4%, respectively), and mostly rated as mild or moderate. Patients with morning or night-time symptoms presented with worse severity of daytime symptoms. There was a strong correlation between intensity of daytime with morning or night-time symptoms, as well as with CAT score (r = 0.715; p < 0.001), but a weak correlation with FEV1 (r = -0.205; p < 0.001). CONCLUSION: Morning symptoms were more frequent than night-time symptoms, and having either morning and/or night-time symptoms was associated with worse severity of daytime symptoms. Increased symptoms were strongly associated with worse quality of life and more frequent exacerbations, but weakly associated with airflow limitation. CLINICAL TRIAL REGISTRATION: NCT02789540.

Respiratory medication used in COPD patients from seven Latin American countries: the LASSYC study.

Background: Limited information is available regarding medication use in COPD patients from Latin America. This study evaluated the type of medication used and the adherence to different inhaled treatments in stable COPD patients from the Latin American region. Methods: This was an observational, cross-sectional, multinational, and multicenter study in COPD patients attended by specialist doctors from seven Latin American countries. Adherence to inhaled therapy was assessed using the Test of Adherence to Inhalers (TAI) questionnaire. The type of medication was assessed as: short-acting ß-agonist (SABA) or short-acting muscarinic antagonist (SAMA) only, long-acting muscarinic antagonist (LAMA), long-acting ß-agonist (LABA), LABA/LAMA, inhaled corticosteroid (ICS), ICS/LABA, ICS/LAMA/LABA, or other. Results: In total, 795 patients were included (59.6% male), with a mean age of 69.5±8.7 years and post-bronchodilator FEV1 of 50.0%±18.6%. The ICS/LAMA/LABA (32.9%) and ICS/LABA (27.7%) combinations were the most common medications used, followed by LABA/LAMA (11.3%), SABA or SAMA (7.9%), LABA (6.4%), LAMA (5.8%), and ICS (4.3%). The types of medication most commonly used in each Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 category were ICS/LABA (A: 32.7%; B: 19.8%; C: 25.7%; D: 28.2%) and ICS/LAMA/LABA (A: 17.3%; B: 30.2%; C: 33%; D: 41.1%). The use of long-acting bronchodilators showed the highest adherence (good or high adherence >50%) according to the TAI questionnaire. Conclusion: COPD management in specialist practice in Latin America does not follow the current guideline recommendations and there is an overuse of ICSs in patients with COPD from this region. Treatment regimens including the use of long-acting bronchodilators are associated with the highest adherence.

Smoke, Biomass Exposure, and COPD Risk in the Primary Care Setting: The PUMA Study.

BACKGROUND: The evidence indicates that risk factors other than smoking are important in the development of COPD. It has been postulated that less traditional risk factors (eg, exposure to coal and/or biomass smoke) may interact with smoking to further increase COPD risk. This analysis evaluated the effect of exposure to biomass and smoking on COPD risk in a primary care setting in Latin America. METHODS: Subjects attending routine primary care visits, ≥40 y old, who were current or former smokers or were exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator FEV1/FVC < 0.70 and the lower limit of normal. Smoking was defined by pack-years (≤ 20, 20-30, or > 30), and biomass exposure was defined as an exposure to coal or wood (for heating, cooking, or both) for ≥ 10 y. RESULTS: One thousand seven hundred forty-three individuals completed the questionnaire, and 1,540 performed spirometry. Irrespective of COPD definition, approximately 40% of COPD subjects reported exposure to biomass versus 30% of those without COPD. A higher proportion of COPD subjects (post-bronchodilator FEV1/FVC < 0.70) than those without COPD smoked > 30 pack-years (66% vs 39%); similar results were found with the lower limit of normal definition. Analysis of exposure to biomass > 10 y plus smoking > 20 pack-years (reference was no exposure) found that tobacco smoking (crude odds ratio [OR] 4.50, 95% CI 2.73-7.41; adjusted OR 3.30, 95% CI 1.93-5.63) and biomass exposure (crude OR 3.66, 95% CI 2.00-6.73; adjusted OR 2.28, 95% CI 1.18-4.41) were risk factors for COPD, with smoking a possible confounder for the association between biomass and COPD (post-bronchodilator FEV1/FVC < 0.70); similar results were found with the lower limit of normal definition. CONCLUSIONS: Subjects with COPD from primary care had a higher exposure to biomass and smoking compared with non-COPD subjects. Smoking and biomass are both risk factors for COPD, but they do not appear to have an additive effect.

Lung function decline in subjects with and without COPD in a population-based cohort in Latin-America.

BACKGROUND: Lung-function decline is one of the possible mechanisms leading to Chronic Obstructive Pulmonary Disease (COPD). METHODS: We analyzed data obtained from two population-based surveys of adults (n = 2026) conducted in the same individuals 5-9 years (y) after their baseline examination in three Latin-American cities. Post BronchoDilator (postBD) FEV1 decline in mL/y, as %predicted/y (%P/y) and % of baseline/y (%B/y) was calculated and the influence of age, gender, BMI, baseline lung function, BD response, exacerbations rate evaluated using multivariate models. RESULTS: Expressed in ml/y, the mean annual postBD FEV1 decline was 27 mL (0.22%P, 1.32%B) in patients with baseline COPD and 36 (0.14%P, 1.36%B) in those without. Faster decline (in mL/y) was associated with higher baseline lung function, with significant response to bronchodilators, older age and smoking at baseline, also in women with chronic cough and phlegm, or ≥2 respiratory exacerbations in the previous year, and in men with asthma. CONCLUSIONS: Lung function decline in a population-based cohort did not differ in obstructed and non-obstructed individuals, it was proportional to baseline FEV1, and was higher in smokers, elderly, and women with respiratory symptoms.

Classification of patients with chronic obstructive pulmonary disease according to the Latin American Thoracic Association (ALAT) staging systems and the global initiative for chronic obstructive pulmonary disease (GOLD). / Clasificación de los pacientes con enfermedad pulmonar obstructiva crónica según los sistemas de estadificación de la Asociación Latinoamericana de Tórax (ALAT) y la iniciativa global para la enfermedad pulmonar obstructiva crónica (GOLD).

INTRODUCTION: Several classification systems use different criteria when assessing COPD stages. The objective of this study was to compare the prevalence and distribution of COPD stagesusing Global initiative for chronic Obstructive Lung Disease (GOLD) recommendationsand Latin American Thoracic Association (ALAT) guidelinesin a primary-care population. METHODS: Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator FEV1/FVC<0.70 and categorised according to GOLD-2013 criteria and ALAT-2014 guideline. The BODEx index was used to assess the prognostic value of the stratification systems. RESULTS: A total of 1743 subjects completed the interview, 1540 performed acceptable spirometry. COPD prevalence according GOLD-2013 was 20.1% and had a U-shaped stage distribution (group A: 9.3%, B: 4.3%, C: 2.0%, D: 4.6%). According to ALAT, prevalence was 19.7% with a bell-shaped stage distribution (mild: 2.9%, moderate: 9%, severe: 5.4%, very-severe: 2.7%). Approximately 73% of patients were stratified as moderate (45.4%) or severe (27.3%) by ALAT guidelines, whereas using GOLD-2013 criteria the majority of subjects (approximately 69%) were in group A (46.3%) or group B (22.7%). BODE index score increased as COPD worsened according to ALAT stratification. This is not observed with GOLD2013 criteria (similar values for B and C groups). CONCLUSIONS: Disease stages differ under ALAT and GOLD-2013 criteria. ALAT identified a greater proportion of COPD subjects in the moderate and severe categories compared with GOLD-2013, where the majority were categorised in group A. Future evaluation of the ALAT classification should address its predictive ability in terms of hospitalizations and mortality.

Adherence to inhaled therapies of COPD patients from seven Latin American countries: The LASSYC study.

BACKGROUND: This study assessed the adherence profiles to inhaled therapies and the agreement between two patient self-report adherence methods in stable COPD lpatients from seven Latin American countries. METHODS: This observational, cross-sectional, multinational, multicenter study involved 795 COPD patients (post-bronchodilator forced expiratory volume in 1 second/forced vital capacity [FEV1/FVC] <0.70). Adherence to inhaled therapy was assessed using the specific Test of Adherence to Inhalers (10-item TAI) and the generic 8-item Morisky Medication Adherence Scale (MMAS-8) questionnaires. The percentage agreement and the kappa index were used to compare findings. RESULTS: 59.6% of patients were male (69.5±8.7 years); post-bronchodilator FEV1 percent predicted was 50.0±18.6%. Mean values for 10-item TAI and MMAS-8 questionnaires were 47.4±4.9 and 6.8±1.6, respectively. Based on the TAI questionnaire, 54.1% of patients had good, 26.5% intermediate, and 19.4% poor adherence. Using the MMAS-8 questionnaire, 51% had high, 29.1% medium, and 19.9% low adherence. According to both questionnaires, patients with poor adherence had lower smoking history, schooling but higher COPD Assessment Test score, exacerbations in the past-year and post-bronchodilator FEV1. The agreement between 10-item TAI and MMAS-8 questionnaires was moderate (Kappa index: 0.42; agreement: 64.7%). CONCLUSION: Suboptimal adherence to medication was frequent in COPD patients from Latin America. Low adherence was associated with worse health status impairment and more exacerbations. There was inadequate agreement between the two questionnaires. Greater effort should be made to improve COPD patients' adherence to treatment, and assessment of adherence with more specific instruments, such as the TAI questionnaire, would be more convenient in these patients. CLINICAL TRIAL REGISTRATION: NCT02789540.

[Functional status and survival in patients with chronic obstructive pulmonary disease following pulmonary rehabilitation]. / Estado funcional y supervivencia de los pacientes con EPOC tras rehabilitación respiratoria.

OBJECTIVES: To study functional status and survival in patients with chronic obstructive pulmonary disease (COPD) following a pulmonary rehabilitation program. PATIENTS AND METHODS: We assessed lung function, 6-minute walk distance, Borg score for dyspnea upon completion of the 6-minute walk, workload in watts on a cycle ergometer, quality of life using the St George's Respiratory Questionnaire (SGRQ); the body-mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index; and survival. RESULTS: One hundred five patients participated in the pulmonary rehabilitation program. The patients had a mean (SD) age of 63.9 (9.3) years, body mass index of 24.5 (4.56) kg/m2, and forced expiratory volume in 1 second (FEV1) of 0.91 (0.46) L. The mean distances walked in 6 minutes were 412.8 (79.4) m before the pulmonary rehabilitation program and 443.46 (81.57) m after rehabilitation. The mean workloads on the cycle ergometer before and after rehabilitation, respectively, were 47.9 (29.6) W and 77.76 (20.88) W. The mean Borg scores were 2.2 (1.37) before and 1.47 (1.37) after rehabilitation, and the SGRQ scores at the same times were 27.63 (16.02) and 25.45 (15.12). Mortality due to respiratory disease (105 months) was 19%. Cumulative survival rates at 1 year, 3 years, and 6 years were 91%, 86.7%, and 6.75%, respectively. Survival was related to an FEV1 greater than 1.02 L (P = .05), a 6-minute walk distance over 448 m before rehabilitation (P = .04) and 454 m after rehabilitation (P = .05), and a workload on the cycle ergometer of over 54 W before rehabilitation (P = .01) and 72 W (P = .02) afterwards. The correlations between survival and both SGRQ and BODE scores were weaker. CONCLUSIONS: We observed improved exercise capacity, dyspnea ratings, and, to a lesser extent, better SGRQ scores in our COPD patients following pulmonary rehabilitation. The best predictors of survival were FEV1, the 6-minute walk distance, and the cycle ergometer workloads.

COPD Underdiagnosis and Misdiagnosis in a High-Risk Primary Care Population in Four Latin American Countries. A Key to Enhance Disease Diagnosis: The PUMA Study.

BACKGROUND: Acknowledgement of COPD underdiagnosis and misdiagnosis in primary care can contribute to improved disease diagnosis. PUMA is an international primary care study in Argentina, Colombia, Venezuela and Uruguay. OBJECTIVES: To assess COPD underdiagnosis and misdiagnosis in primary care and identify factors associated with COPD underdiagnosis in this setting. METHODS: COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <0.70 and the lower limit of normal (LLN). Prior diagnosis was self-reported physician diagnosis of emphysema, chronic bronchitis, or COPD. Those patients with spirometric COPD were considered to have correct prior diagnosis, while those without spirometric criteria had misdiagnosis. Individuals with spirometric criteria without previous diagnosis were considered as underdiagnosed. RESULTS: 1,743 patients were interviewed, 1,540 completed spirometry, 309 (post-BD FEV1/FVC <0.70) and 226 (LLN) had COPD. Underdiagnosis using post-BD FEV1/FVC <0.70 was 77% and 73% by LLN. Overall, 102 patients had a prior COPD diagnosis, 71/102 patients (69.6%) had a prior correct diagnosis and 31/102 (30.4%) had a misdiagnosis defined by post-BD FEV1/FVC ≥0.70. Underdiagnosis was associated with higher body mass index (≥30 kg/m2), milder airway obstruction (GOLD I-II), black skin color, absence of dyspnea, wheezing, no history of exacerbations or hospitalizations in the past-year. Those not visiting a doctor in the last year or only visiting a GP had more risk of underdiagnosis. COPD underdiagnosis (65.8%) and misdiagnosis (26.4%) were less prevalent in those with previous spirometry. CONCLUSIONS: COPD underdiagnosis is a major problem in primary care. Availability of spirometry should be a priority in this setting.

Exacerbations and health care resource utilization in patients with airflow limitation diseases attending a primary care setting: the PUMA study.

BACKGROUND: COPD, asthma, and asthma-COPD overlap increase health care resource consumption, predominantly because of hospitalization for exacerbations and also increased visits to general practitioners (GPs) or specialists. Little information is available regarding this in the primary care setting. OBJECTIVES: To describe the prevalence and number of GP and specialist visits for any cause or due to exacerbations in patients with COPD, asthma, and asthma-COPD overlap. METHODS: COPD was defined as post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio <0.70; asthma was defined as prior medical diagnosis, wheezing in the last 12 months, or wheezing plus reversibility (post-bronchodilator FEV1 or FVC increase ≥200 mL and ≥12%); asthma-COPD overlap was defined as post-bronchodilator FEV1/FVC <0.70 plus prior asthma diagnosis. Health care utilization was evaluated as GP and/or specialist visits in the previous year. RESULTS: Among the 1,743 individuals who completed the questionnaire, 1,540 performed acceptable spirometry. COPD patients had a higher prevalence of any medical visits to any physician versus those without COPD (37.2% vs 21.8%, respectively) and exacerbations doubled the number of visits. The prevalence of any medical visits to any physician was also higher in asthma patients versus those without asthma (wheezing: 47.2% vs 22.7%; medical diagnosis: 54.6% vs 21.6%; wheezing plus reversibility: 46.2% vs 23.8%, respectively). Asthma patients with exacerbations had twice the number of visits versus those without an exacerbation. The number of visits was higher (2.8 times) in asthma-COPD overlap, asthma (1.9 times), or COPD (1.4 times) patients versus those without these respiratory diseases; the number of visits due to exacerbation was also higher (4.9 times) in asthma-COPD overlap, asthma (3.5 times), and COPD (3.8 times) patients. CONCLUSION: COPD, asthma, and asthma-COPD overlap increase the prevalence of medical visits and, therefore, health care resource utilization. Attempts to reduce health care resource use in these patients require interventions aimed at preventing exacerbations.

ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: questions and answers.

ALAT-2014 COPD Clinical Practice Guidelines used clinical questions in PICO format to compile evidence related to risk factors, COPD screening, disease prognosis, treatment and exacerbations. Evidence reveals the existence of risk factors for COPD other than tobacco, as well as gender differences in disease presentation. It shows the benefit of screening in an at-risk population, and the predictive value use of multidimensional prognostic indexes. In stable COPD, similar benefits in dyspnea, pulmonary function and quality of life are achieved with LAMA or LABA long-acting bronchodilators, whereas LAMA is more effective in preventing exacerbations. Dual bronchodilator therapy has more benefits than monotherapy. LAMA and combination LABA/IC are similarly effective, but there is an increased risk of pneumonia with LABA/IC. Data on the efficacy and safety of triple therapy are scarce. Evidence supports influenza vaccination in all patients and anti-pneumococcal vaccination in patients <65years of age and/or with severe airflow limitation. Antibiotic prophylaxis may decrease exacerbation frequency in patients at risk. The use of systemic corticosteroids and antibiotics are justified in exacerbations requiring hospitalization and in some patients managed in an outpatient setting.

A population-based cohort study on chronic obstructive pulmonary disease in Latin America: methods and preliminary results. The PLATINO Study Phase II.

BACKGROUND: The PLATINO baseline study, conducted from 2003-2005 in five Latin American cities (São Paulo, Mexico City, Montevideo, Santiago, Caracas), showed a high prevalence of chronic obstructive pulmonary disease (COPD). METHODS/DESIGN: A follow-up study was conducted in three out of the five centers (Montevideo, Santiago, and São Paulo) after a period of 5, 6 and 9years, respectively, aimed at verifying the stability of the COPD diagnosis over time, the evolution of the disease in terms of survival, morbidity and respiratory function, and the analyses of inflammatory and genetic biomarkers in the blood. Some questions were added to the original questionnaire and death certificates were obtained from the national official registries. RESULTS: The fieldwork has been concluded in the three centers. From the original samples in the PLATINO study phasei, we were able to locate and interview 85.6% of patients in Montevideo, 84.7% in Santiago and 77.7% in São Paulo. Individuals who could not be located had higher education levels in Brazil, and were more likely to be current smokers in Santiago and São Paulo than in Montevideo. The overall quality of spirometries was ≥80% according to American Thoracic Society criteria. The number of deaths was 71 (Montevideo), 95 (Santiago) and 135 (São Paulo), with death certificates obtained from the national mortality registries for 76.1%, 88.3% and 91.8% of cases in Montevideo, Santiago and São Paulo, respectively. CONCLUSIONS: This study shows that is possible to perform population-based longitudinal studies in Latin American with high follow-up rates and high-quality spirometry data. The adequacy of national mortality registries varies among centers in Latin America.