Differential Effect of Modified Medical Research Council Dyspnea, COPD Assessment Test, and Clinical COPD Questionnaire for Symptoms Evaluation Within the New GOLD Staging and Mortality in COPD.

OBJECTIVE: The modified Medical Research Council (mMRC) dyspnea, the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ) have been interchangeably proposed by GOLD (Global Initiative for Chronic Obstructive Lung Disease) for assessing symptoms in patients with COPD. However, there are no data on the prognostic value of these tools in terms of mortality. We endeavored to evaluate the prognostic value of the CAT and CCQ scores and compare them with mMRC dyspnea. METHODS: We analyzed the ability of these tests to predict mortality in an observational cohort of 768 patients with COPD (82% men; FEV1, 60%) from the COPD History Assessment in Spain (CHAIN) study, a multicenter observational Spanish cohort, who were monitored annually for a mean follow-up time of 38 months. RESULTS: Subjects who died (n = 73; 9.5%) had higher CAT (14 vs 11, P = .022), CCQ (1.6 vs 1.3, P = .033), and mMRC dyspnea scores (2 vs 1, P < .001) than survivors. Receiver operating characteristic analysis showed that higher CAT, CCQ, and mMRC dyspnea scores were associated with higher mortality (area under the curve: 0.589, 0.588, and 0.649, respectively). CAT scores ≥ 17 and CCQ scores > 2.5 provided a similar sensitivity than mMRC dyspnea scores ≥ 2 to predict all-cause mortality. CONCLUSIONS: The CAT and the CCQ have similar ability for predicting all-cause mortality in patients with COPD, but were inferior to mMRC dyspnea scores. We suggest new thresholds for CAT and CCQ scores based on mortality risk that could be useful for the new GOLD grading classification. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov.

Clinical application of the COPD assessment test: longitudinal data from the COPD History Assessment in Spain (CHAIN) cohort.

OBJECTIVE: The COPD Assessment Test (CAT) has been proposed for assessing health status in COPD, but little is known about its longitudinal changes. The objective of this study was to evaluate 1-year CAT variability in patients with stable COPD and to relate its variations to changes in other disease markers. METHODS: We evaluated the following variables in smokers with and without COPD at baseline and after 1 year: CAT score, age, sex, smoking status, pack-year history, BMI, modified Medical Research Council (mMRC) scale, 6-min walk distance (6MWD), lung function, BODE (BMI, obstruction, dyspnea, exercise capacity) index, hospital admissions, Hospital and Depression Scale, and the Charlson comorbidity index. In patients with COPD, we explored the association of CAT scores and 1-year changes in the studied parameters. RESULTS: A total of 824 smokers with COPD and 126 without COPD were evaluated at baseline and 441 smokers with COPD and 66 without COPD 1 year later. At 1 year, CAT scores for patients with COPD were similar (± 4 points) in 56%, higher in 27%, and lower in 17%. Of note, mMRC scale scores were similar (± 1 point) in 46% of patients, worse in 36%, and better in 18% at 1 year. One-year CAT changes were best predicted by changes in mMRC scale scores (ß-coefficient, 0.47; P < .001). Similar results were found for CAT and mMRC scale score in smokers without COPD. CONCLUSIONS: One-year longitudinal data show variability in CAT scores among patients with stable COPD similar to mMRC scale score, which is the best predictor of 1-year CAT changes. Further longitudinal studies should confirm long-term CAT variability and its clinical applicability. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov.

New GOLD classification: longitudinal data on group assignment.

RATIONALE: Little is known about the longitudinal changes associated with using the 2013 update of the multidimensional GOLD strategy for chronic obstructive pulmonary disease (COPD). OBJECTIVE: To determine the COPD patient distribution of the new GOLD proposal and evaluate how this classification changes over one year compared with the previous GOLD staging based on spirometry only. METHODS: We analyzed data from the CHAIN study, a multicenter observational Spanish cohort of COPD patients who are monitored annually. Categories were defined according to the proposed GOLD: FEV1%, mMRC dyspnea, COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and exacerbations-hospitalizations. One-year follow-up information was available for all variables except CCQ data. RESULTS: At baseline, 828 stable COPD patients were evaluated. On the basis of mMRC dyspnea versus CAT, the patients were distributed as follows: 38.2% vs. 27.2% in group A, 17.6% vs. 28.3% in group B, 15.8% vs. 12.9% in group C, and 28.4% vs. 31.6% in group D. Information was available for 526 patients at one year: 64.2% of patients remained in the same group but groups C and D show different degrees of variability. The annual progression by group was mainly associated with one-year changes in CAT scores (RR, 1.138; 95%CI: 1.074-1.206) and BODE index values (RR, 2.012; 95%CI: 1.487-2.722). CONCLUSIONS: In the new GOLD grading classification, the type of tool used to determine the level of symptoms can substantially alter the group assignment. A change in category after one year was associated with longitudinal changes in the CAT and BODE index.

[Therapeutic approach to the distal airways in asthma]. / Abordaje terapéutico de la vía aérea pequeña en el asma.

Bronchial asthma is a chronic inflammatory disease that affects both the large-caliber airways and the smaller-caliber bronchioles. In the last few years, a major therapeutic advance has been made with the development of new systems of inhalation solutions, which produce extra-fine particles, achieving better lung deposition throughout the airways and reducing oropharyngeal deposition. These formulations have improved the effectiveness of bronchodilation and particularly the antiinflammatory effect. The use of long-acting b2-adrenergic steroids in extra-fine formulation, whether alone or in combinations of fixed doses, improves drug distribution throughout the bronchial tree, enhancing the therapeutic effect with lower doses of drugs. Leukotriene receptor antagonists have shown their effect on the small airways in asthmatic patients, both in studies of pulmonary resistance and pulmonary volumes and in imaging studies.

[Inflammation markers in the exhaled air of patients with bronchiectasis unassociated with cystic fibrosis]. / Estudio de marcadores de inflamación en el aire exhalado de pacientes con bronquiectasias no asociadas a fibrosis quística.

INTRODUCTION: The aim of the study was to analyse the relationship between the intensity of the respiratory tract inflammation, expressed by oxidative stress markers, and the severity of the disease in patients with bronchiectasis unassociated with cystic fibrosis. PATIENTS AND METHODS: The study included 25 patients with stable bronchiectasis (15 females and 10 males). As determining factors of severity, the following parameters were collected: degree of dyspnoea, number of exacerbations/admissions in the last year, mean daily sputum volume, sputum colour (graduated colour scale), bacterial colonisation, respiratory function tests, quality of life (St. George questionnaire) and radiological extension of the lesions (Bhalla scale). Inflammation was analysed using the measurement of nitric oxide, pH and concentration of nitrites, nitrates and isoprostane in the exhaled air condensate. The C reactive protein and erythrocyte sedimentation rate were also determined in peripheral blood. RESULTS: There were no significant relationships between the markers in the exhaled air condensate and the clinical, radiological and functional involvement or the quality of life of the patients. Only bacterial colonisation (16 cases) was associated with higher values of nitrates in exhaled air (mean+/-standard deviation: 18+/-4 compared to 7+/-2microM; r(2)=0.6) and a higher number of exacerbations (3.1+/-1.9 compared to 1.7+/-1.9; r(2)=0.3). CONCLUSIONS: In our study, the measurement of inflammation markers in exhaled air is only associated with some parameters of severity in patients with bacterial bronchiectasis.

Analysis of the stability of stored adenosine 5'-monophosphate used for bronchoprovocation.

Adenosine 5'-monophosphate (AMP) bronchial challenge has been shown to be very useful tool in the diagnosis of asthma. Freshly test solutions are prepared just prior to each test in most of the studies. The objective of this study was to assess the stability of AMP solutions at different temperatures using a reversed-phase high-performance liquid chromatography assay. Sodium salt AMP solutions in concentrations of 0.03 mg/ml and 400 mg/ml were analyzed. One aliquot was kept at room temperature (20-25 degrees C) and the others were refrigerated at 4 degrees C. Room temperature stored samples were analyzed daily. Refrigerated stored samples were analyzed daily for first 15 days and then weekly. The duration of the study was 25 weeks. Samples were injected into the chromatograph column in quadruplicate and quantification was based on the arithmetic mean and standard deviation (+/-SD) of four measurements. Room temperature stored samples at concentrations of 0.03 mg/ml showed a mean percent variation greater than 10% at day 9 and greater than 75% at day 14. Samples at concentrations of 400 mg/ml maintained almost the initial concentration during the first 10 days, but decomposition occurred thereafter. In contrast, there was no significant degradation of refrigerated stored samples throughout the study period. We conclude the exposure to room temperature of AMP solutions results in a substantial loss of the initial concentration, but the shelf life of adequately prepared stock AMP solutions stored at 4 degrees C is at least 25 weeks.

[Respiratory changes during ascension to 8,000 meters mountain]. / Cambios respiratorios durante la ascensión a una montaña de más de 8.000 metros.

BACKGROUND: Our goal was to determine whether spirometric alterations occur during expeditions to 8,000-metre peaks, and whether these are modified by acclimatization or are related to acute mountain sickness, to arterial oxygen saturation (SaO2) or to muscular deterioration due to chronic hypoxic exposure. SUBJECTS AND METHOD: Forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), inspiratory (MIP) and expiratory (MEP) maximal static pressures, grip strength in both hands, and SaO2 at rest and exercise were measured in eight subjects during an expedition to Gasherbrum II (8,035 m). RESULTS: Upon arrival at the base camp (5,200 m), both FVC and FEV1 decreased, with no changes in the FEV1/FVC ratio. FVC did not improve after a brief pressurisation in a portable hyperbaric chamber. A month later, FVC in the base camp returned to normal values. FVC fall correlated with both the severity of acute mountain sickness and weight loss. Resting SaO2 improved with acclimatisation and correlated with the previous hypoxic ventilatory response, both before and after acclimatisation. Acclimatisation led to a decrease in the exercise-induced SaO2 fall. Stay at a high altitude lowered body weight and grip strength, although MIP and MEP remained unchanged. CONCLUSIONS: We observed a restrictive alteration was corrected by with acclimatisation. This phenomenon seems to be related to a subclinical high-altitude pulmonary oedema rather than to an increase in the pulmonary vascular volume. Despite the high-altitude muscular deterioration, respiratory muscle weakness was not