Chronic Obstructive Lung Disease: Treatment Guidelines and Recommendations for Referral and Multidisciplinary Continuity of Care.

Chronic Obstructive Pulmonary Disease (COPD) constitutes a major public health problem, and it is anticipated that its prevalence will continue to increase in the future. Its progressive nature requires a continuous and well-coordinated care approach. The follow-up for COPD should primarily focus on disease screening and control, which includes monitoring of pulmonary function, prevention of exacerbations, identification of aggravating factors and comorbidities, as well as ensuring treatment adequacy and adherence. However, existing clinical practice guidelines and consensus documents offer limited recommendations for the follow-up. In this context, we undertake a review of COPD treatment and the continuity of care recommendations endorsed by several scientific societies. Moreover, we underscore the importance of the involvement of nursing and community pharmacy in this process, as well as the utilization of quality indicators in the provision of care for the disease.

GEMA 5.3. Spanish Guideline on the Management of Asthma.

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.Su objetivo es prevenir y mejorar la situación clínica de las personas con asma, aumentando el conocimiento de los profesionales sanitarios involucrados en su cuidado. Su propósito es convertir la evidencia científica en recomendaciones prácticas sencillas y fáciles de seguir. Por lo tanto, no se trata de una monografía que reúna todo el conocimiento científico sobre la enfermedad, sino más bien de un documento conciso con lo esencial, diseñado para ser aplicado rápidamente en la práctica clínica de rutina. Las recomendaciones son necesariamente multidisciplinares, están desarrolladas para ser útiles y una herramienta indispensable para médicos de diferentes especialidades, así como para profesionales de enfermería y farmacia.Seguramente, los aspectos más destacados de la guía son las recomendaciones para: establecer el diagnóstico del asma utilizando un algoritmo secuencial basado en pruebas diagnósticas objetivas; el seguimiento de los pacientes, preferentemente basado en la estrategia de lograr y mantener el control de la enfermedad; el tratamiento según el nivel de gravedad del asma utilizando seis escalones, desde la menor hasta la mayor necesidad de medicamentos, y el algoritmo de tratamiento basado en fenotipos para la indicación de biológicos en pacientes con asma grave no controlada. A esto se suma ahora una novedad para su fácil uso y seguimiento a través de una aplicación informática basada en la inteligencia artificial conversacional de tipo chatbot (ia-GEMA).

Current expert opinion and attitudes to optimize telemedicine and achieve control in patients with asthma in post-pandemic era: The COMETA consensus.

OBJECTIVE: To collect perspectives and explore consensus for expert recommendations related to asthma control and the use of telemedicine among professionals who manage patients with asthma. DESIGN: A Delphi-like questionnaire was designed to analyse the level of agreement about several recommendations formulated by an expert scientific committee about asthma control and the use of telemedicine with this purpose. A dedicated scientific committee validated the questionnaire, which included questions about the participants' profile and the use of technological tools at a personal level or in clinical practice. The experts expressed their agreement with a Likert-scale of 9 values: 1-3 was considered no agreement, 4-6 neutral, and 7-9 agreement. A rate ≥70% with the same answer was considered consensus. SITE: The questionnaire was programmed and distributed as an internet-based survey. PARTICIPANTS: A pre-selected sample of 75 experts with experience in telemedicine (pulmonology, allergology, family medicine, nursing and community pharmacy) responded to a Delphi-like questionnaire composed by six questions and 52 items. INTERVENTIONS: Consultation was performed in two consecutive waves: the first wave was carried out from 12th of July to 8th of September of 2021; the second wave, from 25th of October to 12th of November of 2021. MAIN MEASUREMENTS: Three questions about asthma control (actions for achieving or maintaining control of asthma at every visit, current problems that affect asthma control, and potential solutions to offset such problems), and three questions about the impact of telemedicine in asthma control (potential benefits of telemedicine, and potential reticence about telemedicine among both patients and healthcare professionals) were included. RESULTS: From the 52 items inquired, 35 were agreed by consensus. The actions for achieving or maintaining control of asthma, the problems that affect asthma control, and their potential solutions were agreed by consensus. The potential benefits of telemedicine were validated by consensus. None of the potential reservations of patients about telemedicine were validated, while five out of 14 potential reservations of healthcare professionals were agreed by consensus. CONCLUSIONS: The COMETA consensus provides a current picture of the main problems for achieving asthma control, the benefits and the reservations about the use of telemedicine in the Spanish setting, and offers solutions. A wide interest in implementing telemedicine has been observed, although current limitations need to be overcome.

Efficacy of Bromhexine versus Standard of Care in Reducing Viral Load in Patients with Mild-to-Moderate COVID-19 Disease Attended in Primary Care: A Randomized Open-Label Trial.

A 28-day randomized open-label multicenter study was conducted to assess the efficacy of bromhexine plus standard of care (SOC) (n = 98) vs. SOC alone (n = 93) in 191 outpatients with mild-to-moderate COVID-19 in the primary health care setting. Bromhexine three daily doses of 10 mL (48 mg/day) were administered for seven days. The primary efficacy endpoint was the reduction of viral load estimated as the cycle thresholds (Ct) to detect ORF1ab, N Protein, and S Protein genes by RT-qPCR in saliva samples on day 4 as compared with baseline. Ct values of the three genes increased from baseline throughout days 4 to 14 (p < 0.001) but significant differences between the study groups were not found. Differences in the percentages of patients with low, medium, and high viral loads at 4, 7, and 14 days were not found either. In summary, treatment with bromhexine plus SCO was associated with a viral load reduction of ORF1ab, N Protein, and S Protein genes at day 4, which was not significantly different than similar viral load reductions observed with SOC alone. The present findings do not seem to favor the use of bromhexine as an antiviral in patients with COVID-19.

A Survey of Physicians' Perception of the Use and Effectiveness of Diagnostic and Therapeutic Procedures in Chronic Cough Patients.

PURPOSE: The aim of this study was to understand the perception of family physicians, pulmonologists, and allergists with respect to diagnostic tests performed on patients with chronic cough and treatments prescribed to patients with refractory or unexplained chronic cough. We also assessed how these health professionals perceived the effectiveness of these treatments. METHODS: An anonymous survey was distributed by the scientific societies SEPAR, SEAIC, SEMERGEN, semFYC, and SEMG. Respondents were asked how often they perform diagnostic tests and prescribe treatments (responses from 1 = never to 10 = always) and how they perceived the effectiveness of the drugs used (from 1 = not at all to 10 = very effective). The correlation between perceived effectiveness and frequency of prescription was analyzed. RESULTS: The respondents comprised 620 family physicians, 92 pulmonologists, and 62 allergists. The most frequently performed diagnostic tests were chest x-ray and, among pulmonologists and allergists, simple spirometry and bronchodilator tests. The most frequently prescribed drugs were bronchodilators (percentages scoring 8-10 for each specialty: 43.2%, 42.4%, and 56.5%; p = 0.127), inhaled corticosteroids (36.9%, 55.4%, and 54.8%; p < 0.001), and antitussives (family physicians, 33.4%). Regarding perceived effectiveness, only bronchodilators, inhaled or oral corticosteroids, and opioids obtained a median effectiveness score > 5 (between 6 and 7). Correlation coefficients (ρ2) suggested that approximately 45% of prescription was related to perceived effectiveness. CONCLUSION: Although chronic cough is a common problem, diagnosis and treatment differ among specialists. The perceived effectiveness of drugs is generally low.

[Referral Criteria for Asthma: An Updated Consensus]. / Criterios de derivación en asma: Actualización documento de consenso.

Asthma is one of the most prevalent chronic diseases in Spain. In 2019, the Spanish Society of Allergology and Clinical Immunology (SEAIC), the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of General and Family Physicians (SEMG) and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) drafted a document laying down the criteria for referral and action guidelines in the diagnosis, control and monitoring of the asthmatic patient to facilitate ongoing care and improved attention in every setting. The new circumstances derived from the Covid-19 pandemic have demanded that some of the recommendations of the previous edition be updated and adapted to the new healthcare situation.

[Multidisciplinary Consensus for the Monitoring and Control of Asthma Through Telemedicine. The COMETA Project]. / Consenso multidisciplinar para el seguimiento y control del asma mediante la telemedicina. El proyecto COMETA.

Despite the therapeutic advances currently available, asthma control is poor. Such control is based on assessing the patient, adjusting treatment, and reviewing the response to treatment. In normal situations, asthma is monitored and controlled by sequential face-to-face visits. However, due to biosecurity and distancing measures to avoid disease transmission during a pandemic, such monitoring and control is limited. This is how tele-assistance, which is available from extensive published evidence in asthma, has emerged. Even so, it should not be understood as a substitute for face-to-face consultations, but as a complementary alternative to them, in which patients can be monitored when a face-to-face consultation is not necessary or cannot be carried out. Through the COMETA project (COntrol como Meta en la Era de la Telemedicina en el Asma, Control as a Goal in the Age of Telemedicine in Asthma), a group of experts addressed in depth the asthmatic pathology, analyzing in detail the existing problems in order to achieve control and propose solutions to situations such as those we are currently experiencing with the COVID-19 pandemic.

[Healthcare resources for asthma management at primary care level: Asthmabarometer Project]. / Recursos asistenciales en atención primaria para manejo del asma: proyecto Asmabarómetro.

OBJECTIVE: The objective of this study was to describe the current provision of basic resources for asthma management in Primary Health Care (PHC). DESIGN: Cross-sectional study, with an ad hoc quantitative survey. LOCATION AND PARTICIPANTS: A total of 380 primary healthcare physicians in Spain. INTERVENTIONS AND MAIN MEASUREMENTS: Analysis of perceptions of management and use of basic human, organisational and material resources to ensure appropriate care provision to asthma patients. RESULTS: Survey respondents stated that their centre did not have a consultant doctor (64%) or nurse (62%) in respiratory disease. Almost all (92%) of the centres have spirometers, of which 70% have peak flow meters, and 93% have placebo inhalers. In the last year, respondents have received specific theoretical/practical training from the centre (46%), and by third parties (83%). More than three-quarters (78%) of the centres has educational material available for patients. There is no specific healthcare protocol in 36% of the centres, and 43% had no referral protocol. A clinical interview is conducted to monitor the patient (90%), but there are no validated questionnaires to measure therapeutic adherence (85%), or a checklist to check inhalation technique (83%). Differences are observed in the relevant variables in the analysis of each Spanish Autonomous Community. CONCLUSIONS: Access to certain resources in the care of patients with asthma is limited in aspects of coordination between levels, varied according to Spanish Autonomous Community, and improved in most health resources in Asthma.

Determinants of the Appearance and Progression of Early-Onset Chronic Obstructive Pulmonary Disease in Young Adults. A Case-Control Study with Follow-up. / EARLY COPD: determinantes de la aparición y progresión de la enfermedad pulmonar obstructiva crónica en adultos jóvenes. Protocolo de un estudio caso-control con seguimiento.

INTRODUCTION AND OBJECTIVES: Determinants of chronic obstructive pulmonary disease (COPD) in the early stages of its natural history are not well known. Improving our knowledge of these factors will help to design interventions that can modify prognosis. Study objectives are: a) to characterize a COPD population of young adults aged 35-50 years from a multidimensional point of view; b) to compare these patients with smokers with normal lung function; and c) to create a cohort of young adults aged 35-50 years (smokers or former smokers), with and without COPD, who will be followed in the future to improve understanding of the natural history of the disease. PARTICIPANTS AND METHOD: This is a case-control multicenter study aimed at establishing a well-characterized cohort of young adults, smokers or former-smokers, with and without COPD, for subsequent follow-up. A total of 311 participants (101 cases and 210 controls) were selected from approximately 30 primary care settings and 12 hospitals in 8 Spanish regions. Subjects were smokers or former smokers (>10 pack-years) aged 35-50 years. Diagnosis of COPD was based on a post-bronchodilator result of FEV1/FVC<70%. The main study variables were: questionnaires on health, symptoms, exacerbations and daily physical activity, lung function tests, blood and sputum samples, and low-dose computed tomography. In the statistical analysis, COPD patient characteristics will be described and compared with control subjects using a logistic regression analysis.

How can we define well-controlled chronic obstructive pulmonary disease?

The main objectives in the management of chronic disorders such as chronic obstructive pulmonary disease (COPD) are: to suppress or minimize symptoms; to prevent and reduce exacerbations; to avoid limitations in activities of daily living, and thus to enable the patient to lead a normal, or nearly normal, life. COPD has become a serious public-health concern. The disease, which may be life-threatening if not properly managed, often goes undiagnosed. COPD accounts for significant healthcare, social and personal costs, as it can cause disability and lead to marked impairment in patients' quality of life. The primary goal in the management of COPD should be to maintain patients' clinical stability so as to lessen the impact of the disease. This implies achieving an adequate patient control with as few limitations of everyday activities as possible. In an attempt to optimize their quality of life, patients should be symptom-free or virtually symptom-free. In addition, exacerbations, which involve a high consumption of both healthcare and personal resources, must be prevented. COPD is the fourth leading cause of death among men in Europe. As its prevalence is expected to increase, it might become the third cause of mortality by 2030. In Spain, COPD management has recently been reviewed in the Spanish COPD Guidelines (GesEPOC). The COPD National Health System Strategy, developed by the Spanish Ministry of Health, Social Policy and Equality under the Quality Plan, aims at implementing a set of measures to improve both the efficacy and the quality of healthcare services for patients with COPD.

[External assessment of the GEMA2009 recommendations by a multidisciplinary expert panel on asthma]. / Valoración externa de las recomendaciones de la GEMA2009 por un panel multiprofesional de expertos en asma.

OBJECTIVES: To assess the level of agreement on the GEMA 2009 clinical recommendations by a Spanish expert panel on asthma. MATERIALS AND METHODS: The study was divided into four stages: 1) establishment of a 9 member scientific committee (GEMA authors) for selection of GEMA recommendations to use in the survey; 2) formation of a panel of 74 professionals with expertise in this field (pulmonologists, allergists, family doctors, ear, nose and throat and paediatric specialists); 3) Delphi survey in two rounds, sent by mail, with intermediate processing of opinions and a report to the panel members; and 4) analysis and discussion of results for the Scientific Committee. RESULTS: Seventy four participants completed the two rounds of survey. During the first round, a consensus was reached in 49 out of 56 questions analysed. Following discussion by the panel, the consensus was increased to a total of 53 items in the survey. With respect to the remaining questions, Insufficient consensus was obtained on the rest of the questions, due to differing views between sub-specialists, or lack of criteria by most of the experts. CONCLUSIONS: The external analysis by asthma experts from different specialities showed a high level of professional agreement with the GEMA 2009 recommendations in Spain (96.5%). The disagreement shown in three recommendations reflect the lack of a high level evidence. These issues represent areas of interest for future research.

[Cardiovascular risk factors in chronic obstructive pulmonary disease: results of the ARCE study]. / Asociación de factores de riesgo cardiovascular y EPOC. Resultados de un estudio epidemiológico (estudio ARCE).

OBJECTIVE: Cardiovascular disease is a common cause of death in patients with chronic obstructive pulmonary disease (COPD). It is not clear whether the high cardiovascular comorbidity is due to an increase in traditional risk factors or whether, in contrast, COPD can be considered an independent risk factor. The aim of this study was to analyze the prevalence of risk factors and cardiovascular comorbidity in a community-based population treated for COPD. PATIENTS AND METHODS: This was a concurrent multicenter, cross-sectional study that included 572 patients with confirmed diagnosis of COPD. Information on cardiovascular risk factors and comorbidity was collected by extracting data from the medical records of the participating center. RESULTS: The mean (SD) forced expiratory volume in 1 second (FEV1) was 53.7% (16.85%) of predicted and the ratio of FEV1 to forced vital capacity was 57.9% (10.9%). Hypertension was reported in 53%, obesity in 27%, dyslipidemia in 26%, and diabetes in 23% of the patients. The prevalence of risk factors was not related to disease severity, but there was a trend towards an association with age. In the study group, 16.4% had ischemic heart disease, 7% cerebrovascular disease, and 17% peripheral vascular disease. Cardiovascular disease was not associated with COPD severity, but such an association was reported for age and traditional risk factors. CONCLUSIONS: Cardiovascular risk factors are highly prevalent in patients with COPD. The prevalence of cardiovascular and cerebrovascular disease exceeds that reported in the general population. No relationship was found between the severity of airflow obstruction and the presence of cardiovascular comorbidity.