Consensus document on asthma and smoking of the Regional Asthma Forum of SEPAR. / Documento de consenso sobre asma y tabaquismo del Foro Autonómico de Asma de la SEPAR.

The prevalence of active smoking in adults with asthma is similar in the total population. Smoking is associated with worse clinical control of the disease, a rapid reduction of lung function and a variable response to corticoids. Tobacco consumption negatively affects the quality of life of asthmatic patients as well as increasing the number of medical visits and hospital admissions due to exacerbations. Moreover, smoking entails a higher risk of developing lung cancer, cardiovascular comorbidities and death in asthmatic patients. Nevertheless, current asthma guidelines do not include specific recommendations on the management of smoking asthmatic patients and the treatment of the smoking habit in this subpopulation. For this reason, a narrative review of the literature was carried out for consensus using a nominal group methodology developed throughout 2019 to extract practical recommendations that would allow the diagnosis and treatment of asthma in smokers, as well as the treatment of smoking in asthmatics, to be improved. The conclusions and recommendations were validated at the SEPAR national congress of the same year. Among the most relevant, the need to address smoking in people with asthma through health advice, pharmacological treatment and behavioral therapy was emphasized, as this is a factor that negatively impacts the symptoms, prognosis and response to asthma treatment. In smokers with suspected asthma, the presence of emphysema and the differential diagnosis of other diseases should be evaluated and the impact of smoking on the result of diagnostic tests should be considered. It is also concluded that smoking reduces the response to treatment with inhaled corticosteroids, which is why combined therapy with bronchodilators is recommended.

La prevalencia de tabaquismo activo en adultos con asma es similar a la de la población general. El tabaquismo se asocia con un peor control clínico de la enfermedad, una disminución acelerada de la función pulmonar y una respuesta irregular a la terapia con glucocorticoides. El consumo de tabaco impacta negativamente en la calidad de vida de los pacientes asmáticos y provoca un incremento en el número de visitas y de hospitalizaciones por exacerbaciones. Además, el tabaquismo aumenta el riesgo de cáncer de pulmón, comorbilidades cardiovasculares y muerte en pacientes asmáticos. A pesar de todo ello, las guías actuales del manejo del asma no incluyen recomendaciones específicas para el manejo de los pacientes asmáticos fumadores. Por este motivo, se procedió a una revisión narrativa de la literatura para un consenso mediante metodología de grupo nominal desarrollada a lo largo del año 2019 para extraer recomendaciones prácticas que permitieran mejorar el diagnóstico y el tratamiento del asma en fumadores, así como el tratamiento del tabaquismo en asmáticos. Las conclusiones y recomendaciones fueron validadas en el congreso nacional de la SEPAR del mismo año. Entre las más relevantes, se incidió en la necesidad de abordar el tabaquismo en las personas con asma mediante consejo sanitario, tratamiento farmacológico y terapia conductual, al ser un factor que impacta negativamente en la sintomatología, el pronóstico y la respuesta al tratamiento del asma. En el fumador con sospecha de asma, se debe evaluar la presencia de enfisema y el diagnóstico diferencial de otras enfermedades y considerar el impacto del tabaquismo en el resultado de las pruebas diagnósticas. También se concluye que el hábito tabáquico reduce la respuesta al tratamiento con corticoides inhalados, por lo que se recomienda terapia combinada con broncodilatadores.

Persistently elevated exhaled nitric oxide fraction is associated with increased risk of exacerbation in COPD.

Preventing the occurrence of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is a major therapeutic goal. We hypothesise that persistently increased levels of exhaled nitric oxide (FeNO) during follow-up can identify a group of COPD patients at higher risk of AECOPD.To test this hypothesis, we measured FeNO levels (HypAir FeNO®, Medisoft; Sorinnes, Belgium) prospectively in 226 clinically stable COPD outpatients at recruitment and during follow-up (at 6 and 12 months). Patients were stratified according to the number of visits with FeNO ≥20 ppb.FeNO was <20 ppb in all three visits in 44.2% of patients, 29.6% in visit 1 and 26.1% in visit 2 or 3. These three groups suffered progressively higher AECOPD rates during follow-up (0.67, 0.91 and 1.42, respectively, p<0.001). After adjusting for potential confounding variables (log-rank test), the hazard ratio for AECOPD was higher in the latter group (1.579 (95% CI 1.049-2.378), p=0.029). Likewise, time to first moderate and severe AECOPD was shorter in these patients. Finally, there was no relationship between FeNO levels and circulating eosinophils.Persistent FeNO levels ≥20 ppb in clinically stable COPD outpatients are associated with a significantly higher risk of AECOPD.

Xerostomia relates to the degree of asthma control.

Few studies have assessed the relationships between xerostomia and the use of inhaled corticosteroids (ICS). The main objective of this study was to investigate the prevalence of xerostomia in a respiratory outpatient clinic and its relationship with bronchial asthma and ICS use. A cross-sectional observational study of patients recruited in an outpatient setting divided them according to previous diagnoses of bronchial asthma. Data about pulmonary function, concomitant medication, medical comorbidities, Xerostomia Inventory test (XI test), and the degree of asthma control by ACT (asthma control test) were collected for each patient. A linear regression model was applied, using the XI score as dependent variable and the ACT score as independent variable. The 57 patients were divided into asthmatics (40 patients, 70.2%) and control group without asthma (17, 29.8%). The prevalence of xerostomia was 87.7% (50 patients), with no differences between the study groups or current dose of ICS. In the asthmatic group, patients with uncontrolled asthma had worse XI scores than those with partially or totally controlled asthma (30.43 ± 8.71 vs. 24.92 ± 8.08; P < 0.05). In a logistic regression model, the XI test was significantly associated to ACT scores with a moderately strong correlation (r = 0.55; P = 0.005) after adjusting for the current daily dose of ICS. Xerostomia is a common symptom in the ambulatory setting. There is a moderate relationship between the degree of asthma control and the severity of xerostomia.

Chronic obstructive pulmonary disease mortality in Spain between 1999 and 2019.

INTRODUCTION: Mortality from COPD has decreased in Spain in recent years, but it is unknown whether this decline has been homogeneous among the different regions. METHODS: From the Statistical Portal of the Ministry of Health of Spain we obtained the age-adjusted mortality rates/100,000 inhabitants for men and women in Spain and the Autonomous Communities for the years 1999-2019, using the coding of the International Classification of Diseases (ICD 10, sections J40-J44). With the adjusted rates we performed a jointpoint regression analysis to estimate an annual percentage change (APC), as well as identify possible points of trend change. Statistical significance was considered for a value of p<0.05. RESULTS: During the study period, COPD mortality rates adjusted in Spain decreased from 28.77 deaths/100,000 inhabitants in 1999 to 12.14 deaths/100,000 inhabitants in 2019. We observed a linear decline in COPD mortality in men at national level of -3.67% per year (95% CI -4.1 to -3.4; p<0.001), with differences between the Autonomous Communities. Mortality in women also experienced a decrease in mortality in two phases, with a first period from 1999 to 2006 with a fall of -6.8% per year (95% CI -8.6 to -5.0; p<0.001) and a second period from 2006 to 2019 with a decrease in mortality of -2.1% (95% CI -2.8 to -1.3; p<0.001), with again differences between the Autonomous Communities. CONCLUSION: Mortality rates from COPD have decreased heterogeneously among the different Autonomous Communities in both men and women.

T2 Biomarkers as Predictors of Exacerbations of Chronic Obstructive Pulmonary Disease.

INTRODUCTION: Type 2 (T2) biomarkers such as blood eosinophil count (BEC) and FeNO have been related to a higher risk of exacerbations in COPD. It is unknown whether combining these biomarkers could be useful in forecasting COPD exacerbations. METHODS: COPD patients were enrolled in this prospective, multicenter, observational study and followed up for 1 year, during which BEC were analysed at baseline (V0) while FeNO analyses were performed at baseline (V0), 6 months (V1) and 12 months (V2). The risk of moderate or severe exacerbation during follow up was assessed by Cox regression analysis, and the predictive capacity of both measurements was assessed by ROC curves and the DeLong test. Statistical significance was assumed at P<.05. RESULTS: Of the 322 COPD patients initially recruited, 287 were followed up. At baseline, 28.0% were active smokers, and experienced moderate airflow limitation (mean FEV1 56.4%±17.0% predicted). Patients with at least one elevated T2 biomarker (n=125, 42.5%) were at increased risk of COPD exacerbation (HR 1.75, 95% CI 1.25-2.45, P=.001) and of shorter time to first COPD exacerbation. There was no difference between BEC and FeNO regarding the predictive capacity for moderate to severe exacerbation (AUC 0.584 vs 0.576, P=.183) but FeNO predicted severe episodes more accurately than BEC (AUC 0.607 vs 0.539, P<.05). Combining the two biomarkers enhanced the detection of moderate and severe COPD exacerbations. CONCLUSIONS: Both eosinophil count and FeNO have limited utility for predicting COPD exacerbations. Combining these T2 biomarkers could enhance the detection of future COPD exacerbations.

Documento de consenso sobre asma y tabaquismo del Foro Autonómico de Asma de la SEPAR / Consensus document on asthma and smoking of the Regional Asthma Forum of SEPAR

La prevalencia de tabaquismo activo en adultos con asma es similar ala de la población general. El tabaquismo se asocia con un peor control clínico de la enfermedad, una disminución acelerada de la función pulmonar y una respuesta irregular a la terapia con glucocorticoides. El consumo de tabaco impacta negativamente en la calidad devida de los pacientes asmáticos y provoca un incremento en el númerode visitas y de hospitalizaciones por exacerbaciones. Además, el tabaquismo aumenta el riesgo de cáncer de pulmón, comorbilidades cardiovasculares y muerte en pacientes asmáticos. A pesar de todo ello,las guías actuales del manejo del asma no incluyen recomendacionesespecíficas para el manejo de los pacientes asmáticos fumadores. Poreste motivo, se procedió a una revisión narrativa de la literatura paraun consenso mediante metodología de grupo nominal desarrolladaa lo largo del año 2019 para extraer recomendaciones prácticas quepermitieran mejorar el diagnóstico y el tratamiento del asma en fumadores, así como el tratamiento del tabaquismo en asmáticos. Lasconclusiones y recomendaciones fueron validadas en el congreso nacional de la SEPAR del mismo año. Entre las más relevantes, se incidió en la necesidad de abordar el tabaquismo en las personas conasma mediante consejo sanitario, tratamiento farmacológico y terapiaconductual, al ser un factor que impacta negativamente en la sintomatología, el pronóstico y la respuesta al tratamiento del asma. En elfumador con sospecha de asma, se debe evaluar la presencia de enfisema y el diagnóstico diferencial de otras enfermedades y considerarel impacto del tabaquismo en el resultado de las pruebas diagnósticas.También se concluye que el hábito tabáquico reduce la respuesta altratamiento con corticoides inhalados, por lo que se recomienda terapia combinada con broncodilatadores. (AU)

The prevalence of active smoking in adults with asthma is similar inthe total population. Smoking is associated with worse clinical control of the disease, a rapid reduction of lung function and a variableresponse to corticoids. Tobacco consumption negatively affects thequality of life of asthmatic patients as well as increasing the numberof medical visits and hospital admissions due to exacerbations. Moreover, smoking entails a higher risk of developing lung cancer, cardiovascular comorbidities and death in asthmatic patients. Nevertheless,current asthma guidelines do not include specific recommendationson the management of smoking asthmatic patients and the treatmentof the smoking habit in this subpopulation. For this reason, a narrativereview of the literature was carried out for consensus using a nominalgroup methodology developed throughout 2019 to extract practicalrecommendations that would allow the diagnosis and treatment ofasthma in smokers, as well as the treatment of smoking in asthmatics,to be improved. The conclusions and recommendations were validated at the SEPAR national congress of the same year. Among the mostrelevant, the need to address smoking in people with asthma throughhealth advice, pharmacological treatment and behavioral therapy wasemphasized, as this is a factor that negatively impacts the symptoms,prognosis and response to asthma treatment. In smokers with suspected asthma, the presence of emphysema and the differential diagnosisof other diseases should be evaluated and the impact of smoking onthe result of diagnostic tests should be considered. It is also concluded that smoking reduces the response to treatment with inhaled corticosteroids, which is why combined therapy with bronchodilators isrecommended (AU)

T2 Biomarkers as Predictors of Exacerbations of Chronic Obstructive Pulmonary Disease

Introduction: Type 2 (T2) biomarkers such as blood eosinophil count (BEC) and FeNO have been related to a higher risk of exacerbations in COPD. It is unknown whether combining these biomarkers could be useful in forecasting COPD exacerbations. Methods: COPD patients were enrolled in this prospective, multicenter, observational study and followed up for 1 year, during which BEC were analysed at baseline (V0) while FeNO analyses were performed at baseline (V0), 6 months (V1) and 12 months (V2). The risk of moderate or severe exacerbation during follow up was assessed by Cox regression analysis, and the predictive capacity of both measurements was assessed by ROC curves and the DeLong test. Statistical significance was assumed at P<.05. Results: Of the 322 COPD patients initially recruited, 287 were followed up. At baseline, 28.0% were active smokers, and experienced moderate airflow limitation (mean FEV1 56.4%±17.0% predicted). Patients with at least one elevated T2 biomarker (n=125, 42.5%) were at increased risk of COPD exacerbation (HR 1.75, 95% CI 1.25–2.45, P=.001) and of shorter time to first COPD exacerbation. There was no difference between BEC and FeNO regarding the predictive capacity for moderate to severe exacerbation (AUC 0.584 vs 0.576, P=.183) but FeNO predicted severe episodes more accurately than BEC (AUC 0.607 vs 0.539, P<.05). Combining the two biomarkers enhanced the detection of moderate and severe COPD exacerbations. Conclusions: Both eosinophil count and FeNO have limited utility for predicting COPD exacerbations. Combining these T2 biomarkers could enhance the detection of future COPD exacerbations. (AU)

Chronic obstructive pulmonary disease mortality in Spain between 1999 and 2019 / Mortalidad por enfermedad pulmonar obstructiva crónica en España entre 1999 y 2019

Introduction Mortality from COPD has decreased in Spain in recent years, but it is unknown whether this decline has been homogeneous among the different regions. Methods From the Statistical Portal of the Ministry of Health of Spain we obtained the age-adjusted mortality rates/100,000 inhabitants for men and women in Spain and the Autonomous Communities for the years 1999–2019, using the coding of the International Classification of Diseases (ICD 10, sections J40–J44). With the adjusted rates we performed a jointpoint regression analysis to estimate an annual percentage change (APC), as well as identify possible points of trend change. Statistical significance was considered for a value of p<0.05. Results During the study period, COPD mortality rates adjusted in Spain decreased from 28.77 deaths/100,000 inhabitants in 1999 to 12.14 deaths/100,000 inhabitants in 2019. We observed a linear decline in COPD mortality in men at national level of −3.67% per year (95% CI −4.1 to −3.4; p<0.001), with differences between the Autonomous Communities. Mortality in women also experienced a decrease in mortality in two phases, with a first period from 1999 to 2006 with a fall of −6.8% per year (95% CI −8.6 to −5.0; p<0.001) and a second period from 2006 to 2019 with a decrease in mortality of −2.1% (95% CI −2.8 to −1.3; p<0.001), with again differences between the Autonomous Communities. Conclusion Mortality rates from COPD have decreased heterogeneously among the different Autonomous Communities in both men and women (AU)

Introducción La mortalidad por EPOC ha disminuido en España en los últimos años, pero se desconoce si esta caída ha sido homogénea entre las diferentes comunidades autónomas. Metodología consultando el Portal Estadístico del Ministerio de Sanidad de España obtuvimos las tasas ajustadas por edad/100.000 habitantes para hombres y mujeres de España y las CCAA para los años 1999 a 2019, utilizando la codificación de la Clasificación Internacional de Enfermedades (CIE 10, secciones J40 a J44). Con las tasas ajustadas realizamos un análisis de regresión de jointpoint con el objetivo de estimar un porcentaje anual de cambio (APC), así como identificar posibles puntos de cambio de tendencia. Se consideró la significación estadística para un valor de p<0.05. Resultados Durante el periodo de estudio, las tasas de mortalidad global ajustada por EPOC en España pasaron de 28.77 muertes/100.000 habitantes en 1999 a 12.14 muertes/100.000 habitantes en 2019. Observamos una caída de la mortalidad por EPOC en varones a nivel de España lineal del -3.67% anual (IC 95% -4.1 a -3.4; p<0.001), con diferencias entre las CCAA. La mortalidad en mujeres también experimentó una disminución de mortalidad en dos fases, con un primer periodo de 1999 a 2006 con caída del -6.8% anual (IC 95% -8.6 a -5.0; p<0.001) y un segundo periodo de 2006 a 2019 con un descenso de la mortalidad del -2.1% (IC 95% -2.8 a -1.3; p<0.001), encontrando diferencias entre las CCAA. Conclusiones Las tasas de mortalidad por EPOC han disminuido de forma heterogénea entre las diferentes CCAA (AU)