COPD as an independent risk factor for osteoporosis and fractures.

Fractures are common in individuals with COPD and occur at higher bone mass values than expected. COPD appears to be an important risk factor for bone fragility. INTRODUCTION: Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of osteoporosis and fractures, but screening and prophylactic measures to prevent both disorders are often neglected in this population. This case-control study assessed the prevalence of osteopenia, osteoporosis, and fractures in patients with COPD, and identified potential risk factors for fractures in this population. METHODS: Overall, 91 patients with COPD (COPD group; COPDG) and 81 age- and sex-matched controls (control group; CG) were assessed with bone mineral density (BMD), thoracic/lumbar spine radiographs, and serum PTH and 25-hydroxyvitamin D (25[OH]D) levels. The occurrence of prior fractures was retrieved from clinical history. RESULTS: The prevalence of total fractures in the COPDG was 57.1% (odds of fracture 4.7 times greater compared with the CG), and the femoral neck T-score emerged as the best predictor of fractures. Compared with the CG, the COPDG had lower spine and femoral BMD (p ≤ 0.01) and 25(OH)D levels (p = 0.01) and 2.6 times greater odds of osteoporosis. Among men, vertebral fractures were more prevalent in the COPDG versus CG (25.9% vs. 6.5%, respectively, p = 0.01). The odds of fracture increased with femoral neck T-scores ≤ - 2.7 in the CG and ≤ - 0.6 in the COPDG. CONCLUSION: These results add robust evidence to an increased odds of osteoporosis and fractures in COPD. Fractures in the COPDG occurred at higher BMD values than expected, suggesting that COPD may be an independent marker of fracture risk, reinforcing a need for regular osteoporosis screening with BMD measurement and prophylaxis of fractures in patients with this disorder.

Respiratory medication use in primary care among COPD subjects in four Latin American countries.

OBJECTIVES: To assess respiratory medications used, factors predicting treatment and patterns of corticosteroid (CS) use in primary care in Latin America among chronic obstructive pulmonary disease (COPD) patients. METHODS: COPD was defined as post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) < 0.70 or previous medical diagnosis. To determine factors associated with respiratory medication use, crude and adjusted Poisson regression models were performed. RESULTS: Of 1743 patients interviewed, 1540 completed spirometry, 309 had COPD (FEV1/FVC<0.70) and 102 had a prior diagnosis of COPD. Among spirometry-defined COPD patients, 36.6% used respiratory medications: bronchodilators (BD) 24.9%, CS 13.3%, BD+CS 15.2%. In those with a previous diagnosis, 79.4% used respiratory medications: BD 64.7%, CS 37.6%, BD+CS 25.6%. A total of 81/102 (79%) patients with prior diagnosis were using CS despite not having airway obstruction or exacerbation. In spirometry-defined COPD, dyspnoea (OR 2.09, 95%CI 1.13-3.87), severe airway obstruction (OR 3.36, 95%CI 1.40-8.03) and exacerbation in the past year (OR 5.52, 95%CI 2.19-13.89) were associated with increased respiratory medication use. Among those with a previous diagnosis, use of respiratory medications was associated with cough (OR 5.31, 95%CI 1.28-22.12), severe airway obstruction (OR 29.50, 95%CI 3.18-273.30) and fewer years of schooling (OR 0.12, 95%CI 0.03-0.52). CONCLUSIONS: In the primary care setting, undertreatment is frequent in spirometry-defined COPD patients, and there is increased use of CS (overtreatment) in patients with a previous diagnosis of COPD.

Postural control in chronic obstructive pulmonary disease: a systematic review.

UNLABELLED: Patients with chronic obstructive pulmonary disease (COPD) fall frequently, although the risk of falls may seem less important than the respiratory consequences of the disease. Nevertheless, falls are associated to increased mortality, decreased independence and physical activity levels, and worsening of quality of life. The aims of this systematic review was to evaluate information in the literature with regard to whether impaired postural control is more prevalent in COPD patients than in healthy age-matched subjects, and to assess the main characteristics these patients present that contribute to impaired postural control. METHODS: Five databases were searched with no dates or language limits. The MEDLINE, PubMed, EMBASE, Web of Science, and PEDro databases were searched using "balance", "postural control", and "COPD" as keywords. The search strategies were oriented and guided by a health science librarian and were performed on March 27, 2014. The studies included were those that evaluated postural control in COPD patients as their main outcome and scored more than five points on the PEDro scale. Studies supplied by the database search strategy were assessed independently by two blinded researchers. RESULTS: A total of 484 manuscripts were found using the "balance in COPD or postural control in COPD" keywords. Forty-three manuscripts appeared more than once, and 397 did not evaluate postural control in COPD patients as the primary outcome. Thus, only 14 studies had postural control as their primary outcome. Our study examiners found only seven studies that had a PEDro score higher than five points. The examiners' interrater agreement was 76.4%. Six of those studies were accomplished with a control group and one study used their patients as their own controls. The studies were published between 2004 and 2013. CONCLUSION: Patients with COPD present postural control impairment when compared with age-matched healthy controls. Associated factors contributing to impaired postural control were muscle weakness, physical inactivity, elderly age, need for supplemental oxygen, and limited mobility.

[Transport of mucoid mucus in healthy individuals and patients with chronic obstructive pulmonary disease and bronchiectasis]. / Transporte de secreções mucóides de indivíduos saudáveis e pacientes com doença pulmonar obstrutiva crónica e bronquiectasias.

OBJECTIVE: To characterise and compare the in vitro transport properties of respiratory mucoid secretion in individuals with no lung disease and in stable patients with chronic obstructive pulmonary disease (COPD) and bronchiectasis. METHODOLOGY: Samples of mucus were collected, from 21 volunteers presenting no lung disease who had undergone surgery, from 10 patients presenting chronic COPD, and from 16 patients with bronchiectasis. Mucociliary transport (MCT), transport by cough (SCM), and contact angle (CAM) were evaluated. RESULTS: MCT was found to be greater in healthy individuals (1.0±0.19) than in COPD (0.91±0.17) and bronchiectasis (0.76±0.23) patients (p<0.05), whereas SCM was greater in COPD patients (16.31±7.35 cm) than in patients with bronchiectasis (12.16±6.64 cm) and healthy individuals (10.50±25.8 cm) (p<0.05). No significant differences were observed between the groups regarding CAM. CONCLUSION: Mucus from healthy individuals allows better mucociliary transport compared to that from patients with lung diseases. However, the mucus from COPD patients allows a better transport by coughing, demonstrating that these individuals have adapted to a defence mechanism compared to patients with bronchiectasis, who have impairment in their ciliary and cough transport mechanisms.

Evaluation of immediate impact of cane use on energy expenditure during gait in patients with knee osteoarthritis.

PURPOSE: The aim of the present study was to assess the immediate impact of cane use on energy expenditure during gait in patients with knee OA analyzing VO(2). METHODS: An observational, cross-sectional study was carried out on 64 symptomatic patients with a diagnosis of knee OA. The assessment of energy expenditure was performed through an analysis of expired gases using the portable K4 apparatus (Cosmed, Model K4 b2, Italy) during the six-min walk test (6MWT). Two tests were performed with a cane and two without a cane on two different days within a seven-day period. RESULTS: The patients walked farther on the test without the cane (p<0.001). Oxygen expenditure (VO(2)) and the O(2) cost of walking at the end of the 6MWT increased approximately 50% and 80% during cane-assisted gait when compared to gait without the use of a cane (p<0.001). Pain (Borg scale) decreased approximately 20% at the end of the 6MWT with cane-assisted gait in comparison to gait without a cane (p<0.001). CONCLUSION: Cane use causes an immediate increase in energy expenditure (VO(2)) during gait and O(2) cost of walking and an immediate decrease of pain during gait. It is necessary to do a more prolonged follow up in order to assess the impact of daily cane use on energy expenditure among these patients and determine whether adaptation occurs. Furthermore, it is necessary to study whether daily cane use has a positive impact on important parameters in these patients, such as pain, function and quality of life.

Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial.

OBJECTIVE: To assess the impact of daily cane use during gait in relation to pain, function, general health and energy expenditure among patients with knee osteoarthritis. METHOD: Sixty-four patients were randomly assigned to an experimental group (EG) or control group (CG). The EG used a cane every day for 2 months, whereas the CG did not use a cane in this period. The first outcome was pain and the second were function (Lequesne and WOMAC), general health (SF-36) and energy expenditure (gas analysis during the 6-minute walk test (6MWT) with and without a cane). Evaluations were performed at baseline, 30 and 60 days. RESULTS: The groups were homogeneous for all parameters at baseline. Compared with the CG, the EG significantly improved pain (ES 0.18), function - Lequesne (ES 0.13), some domains of SF-36 (role physical, ES 0.07 and bodily pain, ES 0.08) and distance on the 6MWT with the cane (ES 0.16). At the end of the 6MWT with the cane, the EG significantly improved energy expenditure (ES 0.21), carbon dioxide production (ES 0.12) and metabolic equivalents (ES 0.15) compared with the CG. CONCLUSION: A cane can be used to diminish pain, improve function and some aspects of quality of life in patients with knee osteoarthritis. The prescription of a cane should take into account the substantial increase in energy expenditure in the first month of use, whereas energy expenditure is no longer a factor for concern by the end of the second month due to adaptation to cane use. The trial was registered in clinicaltrials.gov (NCT00698412).

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

Patients undergoing neurosurgery are predisposed to a variety of complications related to mechanical ventilation (MV). There is an increased incidence of extubation failure, pneumonia, and prolonged MV among such patients. The aim of the present study was to assess the influence of extubation failure and prolonged MV on the following variables: postoperative pulmonary complications (PPC), mortality, reoperation, tracheostomy, and duration of postoperative hospitalization following elective intra-cranial surgery. The study involved a prospective observational cohort of 317 patients submitted to elective intracranial surgery for tumors, aneurysms and arteriovenous malformation. Preoperative assessment was performed and patients were followed up for the determination of extubation failure and prolonged MV (>48 h) until discharge from the hospital or death. The occurrence of PPC, incidence of death, the need for reoperation and tracheostomy, and the length of hospitalization were assessed during the postoperative period. Twenty-six patients (8.2 percent) experienced extubation failure and 30 (9.5 percent) needed prolonged MV after surgery. Multivariate analysis showed that extubation failure was significant for the occurrence of death (OR = 8.05 [1.88; 34.36]), PPC (OR = 11.18 [2.27; 55.02]) and tracheostomy (OR = 7.8 [1.12; 55.07]). Prolonged MV was significant only for the occurrence of PPC (OR = 4.87 [1.3; 18.18]). Elective intracranial surgery patients who experienced extubation failure or required prolonged MV had a higher incidence of PPC, reoperation and tracheostomy and required a longer period of time in the ICU. Level of consciousness and extubation failure were associated with death and PPC. Patients who required prolonged MV had a higher incidence of extubation failure.

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery.

Patients undergoing neurosurgery are predisposed to a variety of complications related to mechanical ventilation (MV). There is an increased incidence of extubation failure, pneumonia, and prolonged MV among such patients. The aim of the present study was to assess the influence of extubation failure and prolonged MV on the following variables: postoperative pulmonary complications (PPC), mortality, reoperation, tracheostomy, and duration of postoperative hospitalization following elective intra-cranial surgery. The study involved a prospective observational cohort of 317 patients submitted to elective intracranial surgery for tumors, aneurysms and arteriovenous malformation. Preoperative assessment was performed and patients were followed up for the determination of extubation failure and prolonged MV (>48 h) until discharge from the hospital or death. The occurrence of PPC, incidence of death, the need for reoperation and tracheostomy, and the length of hospitalization were assessed during the postoperative period. Twenty-six patients (8.2%) experienced extubation failure and 30 (9.5%) needed prolonged MV after surgery. Multivariate analysis showed that extubation failure was significant for the occurrence of death (OR = 8.05 [1.88; 34.36]), PPC (OR = 11.18 [2.27; 55.02]) and tracheostomy (OR = 7.8 [1.12; 55.07]). Prolonged MV was significant only for the occurrence of PPC (OR = 4.87 [1.3; 18.18]). Elective intracranial surgery patients who experienced extubation failure or required prolonged MV had a higher incidence of PPC, reoperation and tracheostomy and required a longer period of time in the ICU. Level of consciousness and extubation failure were associated with death and PPC. Patients who required prolonged MV had a higher incidence of extubation failure.

Paid employment in subjects with and without chronic obstructive pulmonary disease in five Latin American cities: the PLATINO study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a costly condition that frequently causes permanent work disabilities. Little information exists regarding the impact of COPD on work force participation and the indirect costs of the disease in developing countries. OBJECTIVE: To examine the frequency of paid employment and factors influencing it in a Latin-American population-based study. METHODS: Post-bronchodilator FEV(1)/FVC < 0.70 (forced expiratory volume in 1 s/forced vital capacity) was used to define COPD. Information regarding paid work was assessed by the question 'At any time in the past year, have you worked for payment?' RESULTS: Interviews were conducted with 5571 subjects; 5314 (759 COPD and 4554 non-COPD) subjects underwent spirometry. Among the COPD subjects, 41.8% reported having paid work vs. 57.1% of non-COPD (P < 0.0001). The number of months with paid work was reduced in COPD patients (10.5 ± 0.17 vs. 10.9 ± 0.06, P < 0.05). The main factors associated with having paid work in COPD patients were male sex (OR 0.33, 95%CI 0.23-0.47), higher education level (OR 1.05, 95%CI 1.01-1.09) and younger age (OR 0.90, 95%CI 0.88-0.92). COPD was not a significant contributor to employment (OR 0.83, 95%CI 0.69-1.00, P = 0.054) in the entire population. CONCLUSIONS: Although the proportion of persons with paid work is lower in COPD, having COPD appears not to have a significant impact on obtaining paid employment in the overall population of developing countries.

Association of oxidative stress markers and C-reactive protein with multidimensional indexes in COPD.

To evaluate the oxidative stress and the C-reactive protein (CRP) in chronic obstructive pulmonary disease (COPD) patients and their correlation between the severity of the disease according to GOLD criteria and multidimensional indexes such as BODE index. A blood sample was collected for thiobarbituric acid reactive substances (TBARS), superoxide dismutase (SOD), catalase, glutathione (GSH), homocysteine (HCY) and CRP analysis from 45 stable COPD patients. Lung function, body nutritional status, dyspnea and 6-min walk test (6MWT) were evaluated. Patients with GOLD stage IV presented a higher value for the TBARS than stage I patients (4.47 + 1.58 versus 2.27 + 1.04 nmol/mL, p < 0.05). CRP was higher for GOLD IV (2.46 + 3.68 mg/dL) than other stages (GOLD I: 0.39 + 0.25, GOLD II: 0.39 + 0.18 and GOLD III: 0.48 + 0.36 mg/dL, p < 0.05). Oxidative stress markers measured as TBARS presented a negative correlation between forced expiratory volume in the first second (FEV(1)) post bronchodilatador (% predicted; r = -0.39, p = 0.01) and positive correlations with Modified Medical Research Council Scale (MMRC) dyspnea index (r = 0.40, p = 0.01), multidimensional index (r = 0.49, p = 0.001) and BODE index (r = 0.51, p = 0.001).

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

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

Comprehensive exercise training improves ventilatory muscle function and reduces dyspnea perception in patients with COPD.

BACKGROUND: Comprehensive exercise training (CET) is an efficient strategy to decrease dyspnea perception in chronic obstructive pulmonary disease (COPD) and may result in significant improvement in ventilatory muscles function. Our aim was to evaluate the effects of general exercise training on dyspnea perception and on respiratory muscles strength in COPD patients. METHODS: Consecutive COPD patients were enrolled to complete a CET programme. The patients underwent a routine that included a global warm up, upper and lower limbs endurance exercise as well as stretching and relaxation. Before and after the CET programme, patients completed maximal inspiratory (PImax) and expiratory (PEmax) pressures measurements, maximal incremental test, endurance test, and 6-min walk distance (6MWD). RESULTS: 71 patients (52 male). Mean age 67.6 +/- 8.6 years, FEV1 (%) 44.2 +/- 16.2 and Mahler dyspnea scale 6.4 +/- 1.8. The results before and after the exercise programme were: PImax 64.7 +/- 22.9 vs. 75.5 +/- 23.7 cmH2O (p=0.001), PEmax 110.8 +/- 28.1 vs. 120.4 +/- 28.1 cmH2O (p=0.004), 6MWD 510.6 +/- 90.3 vs. 528.2 +/- 99.7 metres (p=0.88), time of incremental test 672 +/- 135 vs. 856 +/- 226 sec (p<0.0001). Compared with the pre exercise programme, we observed a significant reduction on Borg dyspnea scale (6.1 +/- 2.8 to 3.6 +/- 2.3, p<0.0001) as well as a longer test time (504 +/- 218 to 1.038 +/- 841, p<0.0001) at the end of the endurance test after CET programme. Improvement of PImax correlated negatively with dyspnea perception at iso-time during the endurance test (r = -0.33, p=0.03). CONCLUSIONS: Our results confirm that CET is associated with significant improvement in PImax, PEmax and provide evidence demonstrating that CET reduces dyspnea perception in patients with COPD.

Exercises using the upper limbs hyperinflate COPD patients more than exercises using the lower limbs at the same metabolic demand.

BACKGROUND: Lower and upper body exercise are mandatory constituents of a rehabilitation programme for patients with COPD. However, it is not known how much these exercises may induce pulmonary dynamic hyperinflation (DH). OBJECTIVE: To evaluate the DH in patients with COPD exercising the upper and lower parts of the body at the same metabolic demand. METHODS: Sixteen patients aged 63 +/- 13 years and with a FEV1 of 1.5 +/- 0.7 L (41 +/- 11% pred) were studied. Patients initially performed a maximal exercise test with the arms using the diagonal movement technique. The lower limbs were exercised on a treadmill at the same metabolic demand. RESULTS: Inspiratory capacity decreased 222 +/- 158 ml (9.8%) after the upper body exercise (p < 0.0001) and 148 +/- 161 ml (7%) after exercise with the lower body (p = 0.0028) and a difference between the two groups was found (p < 0.05). There was no difference between resting IC before upper and lower limbs exercises (p = 0.8); increase in minute ventilation and in pulmonary ventilation in percentage of maximum voluntary ventilation and reduction of expiratory time were larger in the upper limbs exercise (p < 0.05). Dyspnea as measured by the Borg Scale was higher in the upper body (3.9 +/- 2.2) than in the lower body (2.3 +/- 1.3) at the end of the exercise (p = 0.033). Pulmonary ventilation and inspiratory capacity were correlated (p = 0.0001; r = 0.82). CONCLUSION: Exercise with the upper part of the body causes more DH and dyspnea than exercise with the lower part of the body at the same metabolic demand.

[Vital capacity reduction in postoperative of elective craniotomy]. / Disminución de la capacidad vital en el período postoperatorio de la craneotomía electiva.

AIMS: To assess the vital capacity (VC), tidal volume, minute volume and respiratory rate during the first four postoperative days of elective craniotomy and how they are correlated with smoking, associated diseases and respiratory symptoms. PATIENTS AND METHODS: Ninety-four patients were initially evaluated for elective craniotomy and they were included in this study only if they presented normal consciousness level and spontaneous breathing at the first postoperative. The preoperative and postoperative evaluations comprised physical examination and ventilometry up to the fourth postoperative. The repeated measures analysis of variance was used to the ventilation measurements. The significance level adopted for all the statistical tests was p = 0.05. RESULTS: Sixty-two patients were included in this study. There was a 20% fall in the VC from the first to the third postoperative (p = 0.001). Patients with systemic arterial hypertension presented in the preoperative period a lower mean VC (2.59 L) than the patients without (3.28 L) (p = 0.045). Smokers presented a lower mean VC (2.65 and 1.95 L) than the nonsmokers (3.13 and 2.43 L), both in the preoperative and in the postoperative, but with no statistic significance (p = 0.090). CONCLUSION: After elective craniotomy, there is a significant decrease in VC immediately after surgery, improving gradually thereafter; there was no difference in VC between the smoking and nonsmoking patients in the pre- and postoperative as well.

Worldwide burden of COPD in high- and low-income countries. Part II. Burden of chronic obstructive lung disease in Latin America: the PLATINO study.

SETTING: Five Latin American cities: São Paulo, Brazil; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; Caracas, Venezuela. OBJECTIVE: To describe the burden of chronic obstructive pulmonary disease (COPD) in Latin America. DESIGN: This is a multicentre study. Post-bronchodilator spirometry was used and the main outcome measure was FEV(1)/FVC < 0.7 (fixed ratio criterion). Global Obstructive Lung Disease (GOLD) stages were also analysed. RESULTS: The combined population aged > or =40 years in the five countries included in the study was approximately 85.3 million. Of these, it was estimated that 12.2 million have airflow obstruction, which corresponds to our prevalence estimate of 14.3%. The proportion of subjects in Stages II-IV of the GOLD classification was 5.6%. Risk factors presenting the highest aetiological fractions for COPD were age, current smoking, indoor exposure to coal and exposure to dust in the workplace. Smoking, the modifiable factor with the strongest aetiological fraction for COPD, affects 29.2% of adults aged > or =40 years in these cities, corresponding to approximately 25 million smokers in this age group. CONCLUSION: Prevention of smoking and exposure to pollutants, such as coal and dust, are the interventions most likely to succeed against COPD in Latin America. The information obtained by a collaborative study has been vast and encouraging for other similar studies.

Efficacy of the FEV1/FEV6 ratio compared to the FEV1/FVC ratio for the diagnosis of airway obstruction in subjects aged 40 years or over

The present cross-sectional, population-based study was designed to evaluate the performance of the FEV1/FEV6 ratio for the detection of airway-obstructed subjects compared to the FEV1/FVC <0.70 fixed ratio test, as well as the lower limit of normality (LLN) for 1000 subjects ³40 years of age in the metropolitan area of São Paulo, SP, Brazil. After the exclusion of 37 (3.7 percent) spirometries, a total of 963 pre-bronchodilator (BD) and 918 post-BD curves were constructed. The majority of the post-BD curves (93.1 percent) were of very good quality and achieved grade A (762 curves) or B (93 curves). The FEV1/FEV6 and FEV1/FVC ratios were highly correlated (r² = 0.92, P < 0.000). Two receiver operator characteristic curves were constructed in order to express the imbalance between the sensitivity and specificity of the FEV1/FEV6 ratio compared to two FEV1/FVC cut-off points for airway obstruction: equal to 70 (area under the curve = 0.98, P < 0.0001) and the LLN (area under the curve = 0.97, P < 0.0001), in the post-BD curves. According to an FEV1/FVC <0.70, the cut-off point for the FEV1/FEV6 ratio with the highest sum for sensitivity and specificity was 0.75. The FEV1/FEV6 ratio can be considered to be a good alternative to the FEV1/FVC ratio for the diagnosis of airway obstruction, both using a fixed cut-off point or below the LLN as reference. The FEV1/FEV6 ratio has the additional advantage of being an easier maneuver for the subjects and for the lung function technicians, providing a higher reproducibility than traditional spirometry maneuvers.

Efficacy of the FEV1/FEV6 ratio compared to the FEV1/FVC ratio for the diagnosis of airway obstruction in subjects aged 40 years or over.

The present cross-sectional, population-based study was designed to evaluate the performance of the FEV1/FEV6 ratio for the detection of airway-obstructed subjects compared to the FEV1/FVC <0.70 fixed ratio test, as well as the lower limit of normality (LLN) for 1000 subjects (3)40 years of age in the metropolitan area of São Paulo, SP, Brazil. After the exclusion of 37 (3.7%) spirometries, a total of 963 pre-bronchodilator (BD) and 918 post-BD curves were constructed. The majority of the post-BD curves (93.1%) were of very good quality and achieved grade A (762 curves) or B (93 curves). The FEV1/FEV6 and FEV1/FVC ratios were highly correlated (r(2) = 0.92, P < 0.000). Two receiver operator characteristic curves were constructed in order to express the imbalance between the sensitivity and specificity of the FEV1/FEV6 ratio compared to two FEV1/FVC cut-off points for airway obstruction: equal to 70 (area under the curve = 0.98, P < 0.0001) and the LLN (area under the curve = 0.97, P < 0.0001), in the post-BD curves. According to an FEV1/FVC <0.70, the cut-off point for the FEV1/FEV6 ratio with the highest sum for sensitivity and specificity was 0.75. The FEV1/FEV6 ratio can be considered to be a good alternative to the FEV1/FVC ratio for the diagnosis of airway obstruction, both using a fixed cut-off point or below the LLN as reference. The FEV1/FEV6 ratio has the additional advantage of being an easier maneuver for the subjects and for the lung function technicians, providing a higher reproducibility than traditional spirometry maneuvers.

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

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

Chronic obstructive pulmonary disease is underdiagnosed and undertreated in São Paulo (Brazil): results of the PLATINO study.

Chronic obstructive pulmonary disease (COPD) is a common disease in adults over 40 years of age and has a great social and economic impact. It remains little recognized and undertreated even in developed countries. However, there are no data about its diagnosis and treatment in Brazil. The objectives of the present study were to evaluate the proportion of COPD patients who had never been diagnosed and to determine if the COPD patients who had been identified were receiving appropriate treatment. The Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) was a randomized epidemiological study of adults over 40 years living in five metropolitan areas, including São Paulo. The studied sample was randomly selected from the population after a division of the metropolitan area of São Paulo in clusters according to social characteristics. All subjects answered a standardized questionnaire on respiratory symptoms, history of smoking, previous diagnosis of lung disease, and treatments. All subjects performed spirometry. The criterion for the diagnosis of COPD was defined by a post-bronchodilator FEV1/FVC ratio lower than 0.7. A total of 918 subjects were evaluated and 144 (15.8%) met the diagnostic criterion for COPD. However, 126 individuals (87.5%) had never been diagnosed. This undiagnosed group of COPD patients had a lower proportion of subjects with respiratory symptoms than the previously diagnosed patients (88.9 vs 54.8%) and showed better lung function with greater FEV1 (86.8 +/- 20.8 vs 68.5 +/- 23.6% predicted) and FVC (106.6 +/- 22.4 vs 92.0 +/- 24.1% predicted). Among the COPD patients, only 57.3% were advised to stop smoking and 30.6% received the influenza vaccine. In addition, 82.3% did not receive any pharmacological treatment. In conclusion, COPD is underdiagnosed and a large number of COPD patients are not treated appropriately.