Issue 2 - "Update on adverse respiratory effects of indoor air pollution". Part 2): Indoor air pollution and respiratory diseases: Perspectives from Italy and some other GARD countries.

OBJECTIVE: to synthesize the Italian epidemiological contribution to knowledge on indoor pollution respiratory impact, and to analyze the perspective of some GARD countries on the health effects of indoor air pollution. RESULTS: Italian epidemiological analytical studies confirmed a strong relationship between indoor air pollution and health in general population. Environmental tobacco smoke, biomass (wood/coal) fuel for cooking/heating and indoor allergens (house dust mites, cat and dog dander, mold/damp) are the most relevant indoor pollution sources and are related to respiratory and allergic symptoms/diseases in Italy and in other GARD countries such as Mexico, Brazil, Vietnam, India, Nepal and Kyrgyzstan. Community-based global health collaborations are working to improve prevention, diagnosis and care of respiratory diseases around the world, specially in low- and middle-income countries, through research and education. CONCLUSIONS: in the last thirty years, the scientific evidence produced on respiratory health effects of indoor air pollution has been extensive, but the necessity to empower the synergies between scientific community and local administrations remains a challenge to address in order to implement effective interventions. Based on abundant evidence of indoor pollution health effect, WHO, scientific societies, patient organizations and other members of the health community should work together to pursue the GARD vision of "a world where all people breathe freely" and encourage policy makers to increase their engagement in advocacy for clean air.

Identification of chronic obstructive pulmonary disease subgroups in 13 Asian cities.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition that can differ in its clinical manifestation, structural changes and response to treatment. OBJECTIVE: To identify subgroups of COPD with distinct phenotypes, evaluate the distribution of phenotypes in four related regions and calculate the 1-year change in lung function and quality of life according to subgroup. METHODS: Using clinical characteristics, we performed factor analysis and hierarchical cluster analysis in a cohort of 1676 COPD patients from 13 Asian cities. We compared the 1-year change in forced expiratory volume in one second (FEV1), modified Medical Research Council dyspnoea scale score, St George's Respiratory Questionnaire (SGRQ) score and exacerbations according to subgroup derived from cluster analysis. RESULTS: Factor analysis revealed that body mass index, Charlson comorbidity index, SGRQ total score and FEV1 were principal factors. Using these four factors, cluster analysis identified three distinct subgroups with differing disease severity and symptoms. Among the three subgroups, patients in subgroup 2 (severe disease and more symptoms) had the most frequent exacerbations, most rapid FEV1 decline and greatest decline in SGRQ total score. CONCLUSION: Three subgroups with differing severities and symptoms were identified in Asian COPD subjects.

Nutritional status of Vietnamese outpatients with chronic obstructive pulmonary disease.

BACKGROUND: Nutritional screening and assessment is not currently part of routine clinical practice in Vietnam. Therefore, the present study aimed to investigate the utility of the commonly used methods for identifying malnutrition in outpatients with chronic obstructive pulmonary disease (COPD). METHODS: A cross-sectional pilot study and a larger retrospective study were carried out in outpatients with COPD who were attending a respiratory clinic in Ho Chi Minh City, Vietnam. Routine clinical data were collected [body mass index (BMI), forced expiratory volume in 1 s (FEV1 )]. Nutritional screening and assessment were performed using the Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA) as the gold standard to diagnose malnutrition. RESULTS: In total, 393 outpatients had documented BMI and 29 were prospectively assessed using SGA: males, n = 25; females, n = 4; mean (SD) age 69.7 (9.6) years; mean (SD) BMI 21.0 (3.4) kg m-2 ; mean (SD) FEV1 percentage predicted 57.0% (19.7%). Malnutrition risk was identified in 20.7% (n = 6) of patients using the MST (38% sensitivity; 94% specificity). However, 45% (n = 13) were diagnosed as malnourished using the SGA (31% mild/moderate; 14% severe). All malnourished patients not identified by the MST had evidence of muscle wasting. BMI had a strong negative correlation with muscle wasting as assessed using the SGA (r = -0.857, n = 28; P < 0.001) and all malnourished patients had a BMI <21 kg m-2 (range 14.6-20.8 kg m-2 , nourished range 20.0-27.6 kg m-2 ). CONCLUSIONS: Malnutrition is common in Vietnamese outpatients with COPD. A BMI threshold of <21 kg m-2 appears to represent a useful and pragmatic cut-off point for identifying outpatients requiring comprehensive nutritional assessment and support.

Implementation of GINA guidelines in Ho Chi Minh City: a model for Viet Nam.

SETTING: The Global Initiative for Asthma (GINA) guidelines have not been implemented effectively in primary care settings in Viet Nam. OBJECTIVES: To estimate the proportion of patients with controlled asthma and the direct health care costs of managing asthma according to GINA guidelines at four out-patient clinics in Ho Chi Minh City (HCMC), Viet Nam. METHODS: One hundred and six patients with asthma were treated and followed up according to GINA guidelines for 12 months. Clinical and pulmonary function responses and direct health care costs were evaluated every 3 months during the study. RESULTS: The proportion of patients with controlled asthma rose from 1.0% at the start of the study to 36.8% by the end of the study (P < 0.0001). The proportion of patients who had at least one hospitalisation per year decreased significantly, from 32.1% to 5.7% (P < 0.0001). The annual per patient median direct health care cost was US$169. Using asthma controllers continuously gave better asthma control than using them intermittently (OR 12.9, 95%CI 4.7-35.7). CONCLUSIONS: The implementation of GINA guidelines at out-patient clinics in HCMC, Viet Nam, improved asthma control with modest direct health care costs.