Cardiopulmonary exercise testing in clinical practice: Principles, applications, and basic interpretation.

Cardiopulmonary exercise testing (CPET) provides a noninvasive and integrated assessment of the response of the respiratory, cardiovascular, and musculoskeletal systems to exercise. This information improves the diagnosis, risk stratification, and therapeutic management of several clinical conditions. Additionally, CPET is the gold standard test for cardiorespiratory fitness quantification and exercise prescription, both in patients with cardiopulmonary disease undergoing cardiac or pulmonary rehabilitation programs and in healthy individuals, such as high-level athletes. In this setting, the relevance of practical knowledge about this exam is useful and of interest to several medical specialties other than cardiology. However, despite its multiple established advantages, CPET remains underused. This article aims to increase awareness of the value of CPET in clinical practice and to inform clinicians about its main indications, applications, and basic interpretation.

Performance of risk scores in patients with acute exacerbations of COPD.

OBJECTIVE: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. METHODS: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. RESULTS: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. CONCLUSIONS: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

Performance of risk scores in patients with acute exacerbations of COPD / Desempenho de escores de risco em pacientes com exacerbações agudas da DPOC

ABSTRACT Objective: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. Methods: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. Results: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. Conclusions: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

RESUMO Objetivo: As exacerbações agudas da DPOC (EADPOC) são causas comuns de hospitalização. Vários escores foram propostos para classificar o risco de deterioração clínica ou mortalidade em pacientes hospitalizados com EADPOC. Buscamos investigar se escores de deterioração clínica e mortalidade no momento da admissão podem prever eventos adversos durante a hospitalização e após a alta de pacientes com EADPOC. Métodos: Realizamos um estudo retrospectivo a respeito de pacientes admitidos com EADPOC. O National Early Warning Score 2 (NEWS2), o NEWS288-92%, o escore Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF, Dispneia, Eosinopenia, Consolidação, Acidemia e Fibrilação atrial) e o escore DECAF modificado (DECAFm) foram calculados no momento da admissão. Avaliamos a sensibilidade, a especificidade e o desempenho geral dos escores quanto aos seguintes desfechos: mortalidade hospitalar; necessidade de ventilação mecânica invasiva ou ventilação não invasiva (VNI); longas internações hospitalares; readmissões hospitalares e futuras AECOPD. Resultados: Incluímos 119 pacientes admitidos com EADPOC. A mediana da idade foi de 75 anos, e 87,9% eram do sexo masculino. O NEWS288-92% associou-se a uma redução de 8,9% no número de indivíduos classificados em pacientes com necessidade de observação atenta e contínua, sem aumento do risco de morte no grupo de indivíduos classificados em pacientes de baixo risco. O NEWS288-92% e o NEWS2 foram considerados adequados para prever a necessidade de VNI aguda e internações hospitalares mais longas. O DECAF e o DECAFm foram considerados melhores em prever a mortalidade hospitalar do que o NEWS2 e o NEWS288-92%. Conclusões: Em comparação com o NEWS2, o NEWS288-92% reduz com segurança a necessidade de monitoramento clínico em pacientes com EADPOC. O NEWS2 e o NEWS288-92% aparentemente são bons preditores do tempo de internação hospitalar e da necessidade de VNI, mas não substituem o DECAF e o DECAFm como preditores de mortalidade.

Lung cancer screening in clinical practice: identification of high-risk chronic obstructive pulmonary disease patients.

OBJECTIVE: The NELSON study demonstrated a positive association between computed tomography scanning and reduced mortality associated with lung cancer. The COPD-LUCSS-DLCO is a tool designed to improve screening selection criteria of lung cancer for chronic obstructive pulmonary disease patients. The aim of this study was to examine and compare the discriminating value of both scores in a community-based cohort of chronic obstructive pulmonary disease patients. METHODS: A retrospective study of chronic obstructive pulmonary disease patients followed in pulmonology consultation for a period of 10 years (2009-2019) was conducted. The NELSON criteria and COPD-LUCSS-DLCO score were calculated for each patient at the time of the study inclusion. The lung cancer incidence was calculated for each of the subgroups during the follow-up period. RESULTS: A total of 103 patients were included in the study (mean age 64.7±9.2 years, 88.3% male). Applying the COPD-LUCSS-DLCO score, high-risk patients have a 5.9-fold greater risk of developing lung cancer versus the low risk. In contrast, there was no significant association between NELSON selection criteria and lung cancer incidence. The area under the curve was 0.69 for COPD-LUCSS-DLCO and 0.59 for NELSON criteria. Comparing test results showed no differences. CONCLUSIONS: The use of the COPD-LUCSS-DLCO score in clinical practice can help to detect chronic obstructive pulmonary disease patients in greater risk of developing lung cancer with better performance than NELSON criteria. Therefore, models that include a risk biomarker strategy can improve selection criteria and consequently can enhance a better lung cancer prediction.

European Portuguese Language and Cultural Validation of the Chronic Obstructive Pulmonary Disease Assessment Test.

INTRODUCTION: The chronic obstructive pulmonary disease assessment test (CAT) is a self-administered questionnaire that measures health-related quality of life. GOLD proposes using this questionnaire, since it provides thorough coverage of the impact of chronic obstructive pulmonary disease (COPD) on well-being. This questionnaire has been widely used in daily clinical practice in Portugal, but it lacks validation for European Portuguese. The aim of this study was to carry out the cultural adaptation and validation of the CAT questionnaire so that the most appropriate version can be made available to Portuguese researchers and clinicians. MATERIAL AND METHODS: A cross-sectional descriptive study was performed involving 65 patients with COPD aged 40 years or older. CAT and the previously validated Portuguese-language version of the Clinical Questionnaire for COPD were applied between January 2019 and June 2019. The agreement between the two questionnaires was determined with Kappa agreement with a 95% confidence interval. Spearman correlation was used to find the correlation between two scores. RESULTS: The 65 patients included in the study were observed in a hospital-based pulmonology clinic [aged 68 ± 7 years; forced expiratory volume in 1 sec (FEV1) 49.86% ± 16.5% predicted]. CAT correlated significantly with all the domains and the overall score of the CCQ (0.47 < r < 0.75; p < 0.001). The bilingual patient interclass correlation coefficient was 0.922; Pearson's r = 0.928; p < 0.001. The Cronbach's alpha coefficient was 0.96 (p < 0.001). CONCLUSION: The European Portuguese version of the COPD Assessment Test is a valid instrument for measurement of health-related quality of life in COPD patients. The use of validated questionnaires is of great importance since it generates reliable and reproducible evidence for use either in research or clinical practice.

Introdução: O teste de avaliação da doença pulmonar obstrutiva crónica (CAT) é um questionário autoaplicável que mede a qualidade de vida relacionada com a saúde. As normas internacionais GOLD propõem o uso deste questionário, uma vez que traduz o impacto da doença pulmonar obstrutiva crónica (DPOC) no bem-estar. Este questionário tem sido amplamente utilizado na prática clínica diária em Portugal, mas carece de validação para o português europeu. Assim, o objetivo deste estudo foi realizar a adaptação cultural e validação do questionário CAT para que a sua versão mais adequada possa ser disponibilizada a investigadores e clínicos portugueses. Material e Métodos: Foi realizado um estudo transversal descritivo com 65 doentes com DPOC com 40 anos ou mais. O CAT e a versão em português previamente validada do questionário clínico para DPOC foram aplicados entre janeiro de 2019 e junho de 2019. A concordância entre os dois questionários foi determinada com o teste de concordância de Kappa com intervalo de confiança de 95%. A correlação de Spearman foi usada para avaliar a presença de uma correlação entre os dois scores. Resultados: Os 65 doentes incluídos no estudo foram observados em consulta de pneumologia hospitalar [idade 68 ± 7 anos; volume expiratório máximo no 1º segundo (FEV1) 49,86% ± 16,5% do previsto]. O CAT correlacionou-se significativamente com todos os domínios e com a pontuação geral do CCQ (0,47 < r < 0,75; p < 0,001). O coeficiente de correlação interclasse de doentes bilíngues foi de 0,922; R de Pearson = 0,928; p < 0,001. O coeficiente alfa de Cronbach foi de 0,96 (p < 0,001). Conclusão: A versão em português europeu do CAT é um instrumento válido para medir a qualidade de vida relacionada com a saúde em doentes com DPOC. A aplicação de questionários validados é fundamental, visto que gera evidência confiável e reprodutível para uso em ensaios clínicos ou na prática clínica.

Lung cancer screening in clinical practice: identification of high-risk chronic obstructive pulmonary disease patients

SUMMARY OBJECTIVE: The NELSON study demonstrated a positive association between computed tomography scanning and reduced mortality associated with lung cancer. The COPD-LUCSS-DLCO is a tool designed to improve screening selection criteria of lung cancer for chronic obstructive pulmonary disease patients. The aim of this study was to examine and compare the discriminating value of both scores in a community-based cohort of chronic obstructive pulmonary disease patients. METHODS: A retrospective study of chronic obstructive pulmonary disease patients followed in pulmonology consultation for a period of 10 years (2009-2019) was conducted. The NELSON criteria and COPD-LUCSS-DLCO score were calculated for each patient at the time of the study inclusion. The lung cancer incidence was calculated for each of the subgroups during the follow-up period. RESULTS: A total of 103 patients were included in the study (mean age 64.7±9.2 years, 88.3% male). Applying the COPD-LUCSS-DLCO score, high-risk patients have a 5.9-fold greater risk of developing lung cancer versus the low risk. In contrast, there was no significant association between NELSON selection criteria and lung cancer incidence. The area under the curve was 0.69 for COPD-LUCSS-DLCO and 0.59 for NELSON criteria. Comparing test results showed no differences. CONCLUSIONS: The use of the COPD-LUCSS-DLCO score in clinical practice can help to detect chronic obstructive pulmonary disease patients in greater risk of developing lung cancer with better performance than NELSON criteria. Therefore, models that include a risk biomarker strategy can improve selection criteria and consequently can enhance a better lung cancer prediction.

Confirmatory Evaluation of the Modified Medical Research Council Questionnaire for Assessment of Dyspnea in Patients with Chronic Obstructive Pulmonary Disease in Portugal.

INTRODUCTION: The Modified British Medical Research Council Questionnaire is considered an adequate and simple measure of breathlessness in chronic obstructive pulmonary disease. It is widely used in clinical practice in Portugal, but it still lacks confirmatory evaluation for the Portuguese setting. The aim of this study was to perform a cultural adaptation and validation of the Modified British Medical Research Council Questionnaire so that its most suitable version can be made available to researchers and clinicians in Portugal. MATERIAL AND METHODS: We performed a cross-sectional descriptive study involving patients with chronic obstructive pulmonary disease aged 40 years or older. We applied the Modified British Medical Research Council Questionnaire and the previously validated Portuguese-language version of the clinical questionnaire for chronic obstructive pulmonary disease between January and June 2019. We determined the agreement between the two questionnaires with kappa agreement, with a 95% confidence interval, and we used Spearman correlation to find a correlation between two scores. RESULTS: The study included 65 patients managed in a hospital pulmonology clinic (aged 68 ± 7 years; with predicted FEV1 of 49.86% ± 16.5%). The Modified British Medical Research Council scale correlated significantly with all the domains and the overall score of the clinical questionnaire for chronic obstructive pulmonary disease (0.46 < r < 0.68; p < 0.001). In bilingual patients, interclass correlation coefficient was 0.912 (p < 0.001). DISCUSSION: Our study showed that the Portuguese-language version of the Modified British Medical Research Council Questionnaire is feasible and externally valid when compared with a traditional and previously validated instrument. CONCLUSION: The Portuguese version of the Modified British Medical Research Council Questionnaire is a valid instrument for measurement of breathlessness in chronic obstructive pulmonary disease.

Introdução: O Questionário British Medical Research Council (mMRC) Modificado é considerado um instrumento adequado e simples para a medição da dispneia na doença pulmonar obstrutiva crónica (DPOC). Tem sido amplamente usado na prática clínica em Portugal, mas carece de avaliação confirmatória para o cenário português. O objetivo deste estudo é realizar a adaptação cultural e validação do Questionário British Medical Research Council Modificado para que a versão mais adequada possa estar disponível a investigadores e clínicos em Portugal. Material e Métodos: Realizamos um estudo descritivo e transversal com doentes com doença pulmonar obstrutiva crónica e idade ≥ 40 anos. Aplicamos o Questionário British Medical Research Council Modificado e o questionário clínico para a doença pulmonar obstrutiva crónica previamente validado para a língua portuguesa, entre janeiro e junho de 2019. Determinámos a concordância entre os dois questionários com kappa agreement, com 95% de intervalo de confiança, e usámos o coeficiente de correlação de Spearman para determinar a correlação entre os dois scores. Resultados: O estudo incluiu 65 doentes seguidos em consulta hospitalar de Pneumologia (idades de 68 ± 7 anos; com FEV1 49,86% ± 16,5% do predito). A Escala Modificada do British Medical Research Council correlacionou-se significativamente com todos os domínios e pontuação total do questionário clínico (0,46 < r < 0,68; p < 0,001). Nos doentes bilingues, o coeficiente de correlação interclasse foi 0,912 (p < 0,001). Discussão: O nosso estudo mostrou que a versão portuguesa do Questionário Modificado do British Medical Research Council apresenta exequibilidade e validade externa quando comparado com um instrumento tradicional e previamente validado. Conclusão: A versão portuguesa do Questionário Modificado do British Medical Research Council é um instrumento válido para a medição da dispneia na doença pulmonar obstrutiva crónica.

Mucosal bacterial vaccines in clinical practice - a novel approach to an old problem?

OBJECTIVES To evaluate the efficacy of mucosal bacterial vaccines (MBV) in reducing the number of exacerbations in patients with chronic respiratory disease. METHODS A prospective cohort study of patients followed at the Pneumology Unit of the University and Hospital Centre of Coimbra, with frequent infectious exacerbations (3 or more) despite the best therapeutic strategies employed. MBV was used as additional therapy. The number of exacerbations 1 year before therapy and 1 year after it were analyzed. RESULTS A sample of 11 individuals, 45.5% male, mean age 62.5 years. Eight patients had non-cystic fibrosis bronchiectasis, 2 COPD (1 on long-term oxygen therapy), and 1 patient with Mounier Kuhn's syndrome. Three patients were on azithromycin, 1 on inhaled colistin, and 2 on inhaled tobramycin. Out of the 11 patients, one presented complication (fever), which led to a suspension of therapy (excluded from results). Of the 10 patients who completed treatment, 5 had bacterial colonization and were submitted to a custom vaccine. The remaining 6 completed the standard composition. The average of infectious exacerbations in the previous year was 4.3 (0.7 with hospitalization). In the year after therapy, the mean number was 1.5 (0.5 with hospitalization). CONCLUSION The results obtained in this study favor the use of bacterial immunostimulation to reduce the frequency of RRIs in patients with chronic respiratory disease.

Mucosal bacterial vaccines in clinical practice - a novel approach to an old problem?

SUMMARY OBJECTIVES To evaluate the efficacy of mucosal bacterial vaccines (MBV) in reducing the number of exacerbations in patients with chronic respiratory disease. METHODS A prospective cohort study of patients followed at the Pneumology Unit of the University and Hospital Centre of Coimbra, with frequent infectious exacerbations (3 or more) despite the best therapeutic strategies employed. MBV was used as additional therapy. The number of exacerbations 1 year before therapy and 1 year after it were analyzed. RESULTS A sample of 11 individuals, 45.5% male, mean age 62.5 years. Eight patients had non-cystic fibrosis bronchiectasis, 2 COPD (1 on long-term oxygen therapy), and 1 patient with Mounier Kuhn's syndrome. Three patients were on azithromycin, 1 on inhaled colistin, and 2 on inhaled tobramycin. Out of the 11 patients, one presented complication (fever), which led to a suspension of therapy (excluded from results). Of the 10 patients who completed treatment, 5 had bacterial colonization and were submitted to a custom vaccine. The remaining 6 completed the standard composition. The average of infectious exacerbations in the previous year was 4.3 (0.7 with hospitalization). In the year after therapy, the mean number was 1.5 (0.5 with hospitalization). CONCLUSION The results obtained in this study favor the use of bacterial immunostimulation to reduce the frequency of RRIs in patients with chronic respiratory disease.

RESUMO OBJETIVO Avaliar a eficácia de vacinas bacterianas de mucosa (MBV) na redução do número de exacerbações de pacientes com doença respiratória crônica. MÉTODOS Um estudo de coorte prospectivo incluindo pacientes da Unidade de Pneumologia da Universidade e Centro Hospitalar de Coimbra, com exacerbações infecciosas frequentes (3 ou mais), apesar do uso das melhores estratégias terapêuticas. MBVs foram usadas como terapia adicional. O número de exacerbações 1 ano antes da terapia e 1 ano após ela foram analisados. RESULTADOS Amostra incluiu 11 indivíduos, 45,5% do sexo masculino, com média de idade de 62,5 anos. Oito pacientes apresentaram bronquiectasia não relacionada à fibrose cística, 2 DPOC (1 em oxigenoterapia prolongada) e 1 paciente com síndrome de Mounier-Kuhn. Três pacientes estavam sendo medicados com azitromicina, 1 com colistina inalada e 2 com tobramicina inalada. Dos 11 pacientes, um apresentou complicação (febre), o que levou à suspensão da terapia (excluído dos resultados). Dos 10 pacientes que completaram o tratamento, 5 apresentaram colonização bacteriana e receberam uma vacina personalizada. Os 6 restantes foram tratados com a composição padrão. A média de exacerbações infecciosas no ano anterior foi de 4,3 (0,7 com hospitalização). No ano após a terapia, o número médio foi de 1,5 (0,5 com hospitalização). CONCLUSÃO Os resultados obtidos neste estudo favorecem o uso de imunoestimulação bacteriana para reduzir a frequência de infecções respiratórias recorrentes em pacientes com doença respiratória crônica.

[Thoracic nocardiosis]. / Nocardiose torácica.

Nocardiosis is an opportunistic infection which occurs mostly in immunocompromised individuals. Pulmonary presentation is the most frequent; however it can affect other parts of the body. Antibiotic treatment is usually prolonged to avoid relapses. The authors present a case report of a patient under prolonged immunosuppressive therapy for psoriatic arthritis, with complaints of right chest pain with one month of evolution.

[Allergic rhinitis and related diseases]. / Rinite alérgica e doenças associadas.

Allergic disease prevalence including allergic rhinitis has increased. It's relationship with other allergic diseases including asthma makes imperative it's diagnosis as well as co- -morbidity identification and associated complications. The most recent classification of the disease highlights the duration of symptoms and it's interference in the quality of life. The therapeutic strategy presented is based on eviction measures, pharmacological treatment, immunotherapy and, in selected cases, surgery. Pharmacological treatment should be done by "steps" according to the severity of the disease.