[Available resources for the management of chronic obstructive pulmonary disease exacerbations in Spain]. / Recursos disponibles para el manejo de la agudización de la enfermedad pulmonar obstructiva crónica en España.

OBJECTIVE: Chronic obstructive pulmonary disease exacerbations (COPDE) lead to a high use of healthcare resources. This study assesses the healthcare and organisational resources of Spanish health care centres for the management of COPDE at different care levels (Primary Care (PC), Respiratory Diseases, Internal Medicine, and Emergency Departments), and compare with current recommendations. MATERIAL AND METHODS: An observational study was carried out through telephone interviews to General Practitioners, Chest Diseases, Internal Medicine, and Emergency Department doctors. RESULTS: A total of 284 doctors were interviewed. According to their responses, at PC centres there is a high availability of pulse oximetry (98.9%) and electrocardiograph (100%), and a low availability of Chest X-Ray (19.1%), or urgent laboratory tests (17.0%) in sites. In hospital wards, non-invasive mechanical ventilation (NIV) availability was 76.1%, with only a 69.7% of nursing staff properly trained in its use. Respiratory intermediate care units (RICUs) were available in 18.3% of public hospitals versus 41.7% of private hospitals. Specific training for COPDE management was received by 47.9% of Emergency Department doctors in the previous year. Only 31.9% of PC centres had specific protocols for referring patients to specialists. More than 35% of PC centres and hospitals do not have their electronic medical records integrated with other healthcare levels. CONCLUSIONS: In general terms, there are sufficient resources available in Spanish healthcare centres. However, several areas of improvement were identified, such as an insufficient level of electronic medical record integration between healthcare levels, limited implementation of RICUs in public hospitals, and deficiencies related to specific training in NIV management.

Guía española de la enfermedad pulmonar obstructiva crónica (GesEPOC) 2017: tratamiento farmacológico en fase estable / Spanish guidelines for management of chronic obstructive pulmonary disease (GesEPOC) 2017: pharmacological treatment of stable phase

La enfermedad pulmonar obstructiva crónica (EPOC) presenta una gran heterogeneidad clínica, por lo que su tratamiento se debe individualizar según el nivel de riesgo y el fenotipo. La Guía española de la EPOC (GesEPOC) estableció por primera vez en 2012 unas pautas de tratamiento farmacológico basadas en fenotipos clínicos. Estas pautas han sido adoptadas posteriormente por otras normativas nacionales, y han sido respaldadas por nuevas evidencias publicadas desde entonces. En esta actualización 2017 se ha sustituido la clasificación de gravedad inicial por una clasificación de riesgo mucho más sencilla (bajo o alto riesgo), basándose en la función pulmonar, el grado de disnea y la historia de agudizaciones, y se recomienda la determinación del fenotipo clínico únicamente en pacientes de alto riesgo. Se mantienen los mismos fenotipos clínicos: no agudizador, EPOC-asma (ACO), agudizador con enfisema y agudizador con bronquitis crónica. La base del tratamiento farmacológico de la EPOC es la broncodilatación, y también es el único tratamiento recomendado en pacientes de bajo riesgo. En los pacientes con alto riesgo se añadirán diversos fármacos a los broncodilatadores según el fenotipo clínico. GesEPOC supone una aproximación al tratamiento de la EPOC más individualizado según las características clínicas de los pacientes y su nivel de riesgo o de complejidad.(AU)

The clinical presentation of chronic obstructive pulmonary disease (COPD) varies widely, so treatment must be tailored according to the level of risk and phenotype. In 2012, the Spanish COPD Guidelines (GesEPOC) first established pharmacological treatment regimens based on clinical phenotypes. These regimens were subsequently adopted by other national guidelines, and since then, have been backed up by new evidence. In this 2017 update, the original severity classification has been replaced by a much simpler risk classification (low or high risk), on the basis of lung function, dyspnea grade, and history of exacerbations, while determination of clinical phenotype is recommended only in high-risk patients. The same clinical phenotypes have been maintained: non-exacerbator, asthma-COPD overlap (ACO), exacerbator with emphysema, and exacerbator with bronchitis. Pharmacological treatment of COPD is based on bronchodilators, the only treatment recommended in low-risk patients. High-risk patients will receive different drugs in addition to bronchodilators, depending on their clinical phenotype. GesEPOC reflects a more individualized approach to COPD treatment, according to patient clinical characteristics and level of risk or complexity.(AU)

Does the COPD assessment test (CAT(TM)) questionnaire produce similar results when self- or interviewer administered?

PURPOSE: The COPD assessment test (CAT) is a questionnaire that assesses the impact of chronic obstructive pulmonary disease (COPD) on health status, but some patients have difficulties filling it up by themselves. We examined whether the mode of administration of the Spanish version of CAT (self vs. interviewer) influences its scores and/or psychometric properties. METHODS: Observational, prospective study in 49 Spanish centers that includes clinically stable COPD patients (n = 153) and patients hospitalized because of an exacerbation (ECOPD; n = 224). The CAT was self-administered (CAT-SA) or administered by an interviewer (CAT-IA) based on the investigator judgment of the patient's capacity. To assess convergent validity, the Saint George's Respiratory Disease Questionnaire (SGRQ) and the London Chest Activity of Daily Living (LCADL) instrument were also administered. Psychometric properties were compared across modes of administration. RESULTS: A total of 118 patients (31 %) completed the CAT-SA and 259 (69 %) CAT-IA. Multiple regression analysis showed that mode of administration did not affect CAT scores. The CAT showed excellent psychometric properties in both modes of administration. Internal consistency coefficients (Cronbach's alpha) were high (0.86 for CAT-SA and 0.85 for CAT-IA) as was test-retest reliability (intraclass correlation coefficients of 0.83 for CAT-SA and CAT-IA). Correlations with SGRQ and LCADL were moderate to strong both in CAT-SA and CAT-IA, indicating good convergent validity. Similar results were observed when testing longitudinal validity. CONCLUSIONS: The mode of administration does not influence CAT scores or its psychometric properties. Hence, both modes of administration can be used in clinical practice depending on the physician judgment of patient's capacity.

Previous outpatient antibiotic use in patients admitted to hospital for COPD exacerbations: room for improvement.

PURPOSE: Several studies have analyzed factors associated to hospitalization in chronic obstructive pulmonary disease (COPD) patients. However, data are lacking on the quality of treatment received by patients prior to hospital admission. The present study analyzed how often patients requiring hospitalization for a COPD exacerbation had received previous treatment for the exacerbation, particularly antibiotics. METHODS: This was a multicenter, cross-sectional, observational study conducted in 30 Spanish hospitals among COPD patients aged >40 years who were hospitalized for an acute exacerbation. Patients were grouped according to whether or not they had received treatment prior to admission and, subsequently, according to whether or not they had received antibiotics. Patient eligibility for antibiotic therapy was assessed using both national and European guidelines. RESULTS: The study population consisted of 298 patients, of which 277 (93 %) were men, with a mean [standard deviation (SD)] age of 69.1 (9.5) years. One hundred and thirty-three patients (45 %) had received treatment prior to admission; among these, 76/133 (57 %) had received antibiotic therapy. However, 81-91 % of these patients fulfilled criteria for this therapy. Antibiotic use was significantly associated with yellow or green-yellow sputum prior to the exacerbation, a higher number of exacerbations in the previous year, more visits to emergency departments, and bronchiectasis. On the other hand, 10-20 % of patients who did receive antibiotics were not eligible for this therapy according to guidelines. CONCLUSIONS: This study demonstrates a low rate of previous outpatient treatment and antibiotic use among patients with a COPD exacerbation requiring hospital admission.

Increased incidence of nonfatal cardiovascular events in stroke patients with sleep apnoea: effect of CPAP treatment.

Obstructive sleep apnoea (OSA) is a risk factor for stroke, but little is known about the effect of OSA and continuous positive airway pressure (CPAP) on the incidence of long-term, nonfatal cardiovascular events (CVE) in stroke patients. A prospective observational study was made in 223 patients consecutively admitted for stroke. A sleep study was performed on 166 of them. 31 had an apnoea/hypopnoea index (AHI) <10 events · h(-1); 39 had an AHI between 10 and 19 events · h(-1) and 96 had an AHI ≥ 20 events · h(-1). CPAP treatment was offered when AHI was ≥ 20 events · h(-1). Patients were followed up for 7 yrs and incident CVE data were recorded. The mean ± SD age of the subjects was 73.3 ± 11 yrs; mean AHI was 26 ± 16.7 events · h(-1). Patients with moderate-to-severe OSA who could not tolerate CPAP (AHI ≥ 20 events · h(-1); n = 68) showed an increased adjusted incidence of nonfatal CVE, especially new ischaemic strokes (hazard ratio 2.87, 95% CI 1.11-7.71; p = 0.03), compared with patients with moderate-to-severe OSA who tolerated CPAP (n = 28), patients with mild disease (AHI 10-19 events · h(-1); n = 36) and patients without OSA (AHI <10 events · h(-1); n = 31). Our results suggest that the presence of moderate-to-severe OSA is associated with an increased long-term incidence of nonfatal CVE in stroke patients and that CPAP reduces the excess of incidence seen in these patients.

Properties of the COPD assessment test in a cross-sectional European study.

A short, easy-to-use health status questionnaire is needed in the multidimensional assessment of chronic obstructive pulmonary disease (COPD) in routine practice. The performance of the eight-item COPD assessment test (CAT) was analysed in 1,817 patients from primary care in seven European countries. The CAT has a scoring range of 0-40 (high score representing poor health status). Mean CAT scores indicated significant health status impairment that was related to severity of airway obstruction, but within each Global Initiative for Obstructive Lung Disease stage (I to IV) there was a wide range of scores (I: 16.2 ± 8.8; II: 16.3 ± 7.9; III: 19.3 ± 8.2; and IV: 22.3 ± 8.7; I versus II, p = 0.88; II versus III, p<0.0001; III versus IV, p = 0.0001). CAT scores showed relatively little variability across countries (within ± 12% of the mean across all countries). Scores were significantly better in patients who were stable (17.2 ± 8.3) versus those suffering an exacerbation (21.3 ± 8.4) (p<0.0001); and in patients with no (17.3 ± 8.1) or one or two (16.6 ± 8.2) versus three or more (19.7 ± 8.5) comorbidities (p<0.0001 for both). The CAT distinguished between classes of other impairment measures and was strongly correlated with the St George's Respiratory Questionnaire (r = 0.8, p<0.0001). The CAT is a simple and easy-to-use questionnaire that distinguishes between patients of different degrees of COPD severity and appears to behave the same way across countries.

[Impact of exacerbations on the clinical course of chronic obstructive pulmonary disease]. / Impacto de las exacerbaciones en la evolución de la EPOC.

The clinical course of chronic obstructive pulmonary disease (COPD) is marked by frequent exacerbations. Not all patients suffer exacerbations and not all decompensations have the same consequences; however, in the last few years, these episodes of clinical instability - especially if recurrent - have come to be viewed as a major element in the natural history of the disease insofar as they generate heavy workload and high costs, síntonegatively affect patients' quality of life, contribute to the multidimensional progression of the disease and, finally, affect its prognosis. The present article reviews the current scientific evidence on the impact of exacerbations on the clinical course of COPD and analyzes this impact from a multidimensional perspective. The need to base the management of COPD on clinical phenotypes is discussed, emphasizing the importance of the exacerbation phenotype, a clinical phenotype characterized by frequent exacerbations. This phenotype is often associated with the presence of cough and chronic expectoration, latent bronchial infection and bronchiectasis and leads to higher morbidity and mortality.

Health-related quality of life in patients by COPD severity within primary care in Europe.

Pan-European data on health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD) are lacking. This cross-sectional epidemiological study evaluated health status in 1817 COPD patients from an 'all-comers' primary care population in seven European countries (87% stable disease; 13% with current exacerbation) using: St George's Respiratory Questionnaire-COPD specific (SGRQ-C), the short form health survey (SF-12) and the Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue scale. Mean total score for SGRQ was 44.7 ± 19.4 showing marked impairment of HRQL. Scores differed little between countries (range 39.2-50.1). Impairment was associated with the severity of airway obstruction, but within each GOLD stage the variation (SD) was wide [Stage I: 38.5 ± 19.3 (n = 223); Stage II: 40.4 ± 18.1 (n = 868); Stage III: 50.2 ± 18.6 (n = 551); Stage IV: 58.6 ± 17.7 (n = 144)]. Patients suffering an exacerbation had a worse SGRQ score (54.9 ± 19.3) than those with stable disease (43.3 ± 19.0). The presence of ≥3 co-morbidities (CM) was also associated with a significantly worse score (49.9 ± 19.1) vs. 1-2 CM (42.1 ± 19.1) or no CM (42.3 ± 18.6). Findings with the SF-12 and FACIT-F results were consistent with those from the SGRQ-C. This large observational primary care study shows that health status is significantly impaired in COPD patients of all severities, even in those with mild airway obstruction. Within each GOLD stage of severity there is considerable heterogeneity in HRQL impairment among patients. (Study number: 111749).

Impacto de la exacerbaciones en la evolución de la EPOC / Impact of the exacerbations in the evolution of COPD

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Obstructive sleep apnea has little impact on quality of life in the elderly.

STUDY OBJECTIVE: To analyze the impact of the number of respiratory sleep disorders or clinically related conditions (especially excessive daytime sleepiness [EDS]), on health related quality of life (HRQoL) in subjects over 65 years of age, as compared to younger subjects and the general population. METHODS: Two hundred and twelve adult patients with obstructive sleep apnea (OSA, AHI> or =10) divided into two age groups, over 65 (n=109, mean age 74.6 [6,8] years, and 65 or under (n=103, mean age 51.7, [6,5] years). General, anthropometric and clinical data related to OSA (epworth sleepiness score [ESS]), comorbidities (Charlson comorbidity index [CCI]), HRQoL (SF-36 questionnaire), use of psychotropic medications and habitual polygraphic/polysomnographic parameters were recorded and compared between the two age groups. The HRQoL values in each age group were compared with the values in the general population, adjusted for age and gender. RESULTS: In patients 65 and under, both the presence of OSA as well as the presence of EDS (ESS>11) were associated with an important deterioration in HRQoL as compared to normal reference values. The principal determinants of HRQoL were the presence of EDS (p<0.04), body mass index (p<0.03) and the apnea-hypopnea index (AHI) (p<0.04). Nevertheless, in subjects over 65 years of age, the presence of OSA or EDS had only a slight impact on HRQoL, relative to normal values. In this age group, the principal determinants of HRQoL were the presence of comorbidities (CCI, p<0.01), age (p<0.01), oxygen desaturation parameters (p<0.04) and the use of psychotropic medications (p<0.04). CONCLUSION: In elders, the presence of OSA with or without EDS has little impact on HRQoL measures.

Factores pronósticos de la EPOC / Prognostic factors of COPD

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Dissociation of lung function, dyspnea ratings and pulmonary extension in bronchiectasis.

UNLABELLED: Bronchiectasis is a heterogeneous disease in terms of its clinical and functional presentation. Some isolated parameters have been used to assess the severity of bronchiectasis or its response to treatment. A study was undertaken to evaluate whether lung function, dyspnea and extension of the disease are separate entities in the impact of bronchiectasis upon patients using factor analysis. Patients with bronchiectasis diagnosed by high-resolution computed tomography (HRCT) and airflow obstruction defined by FEV1/FVC<70% were included. Data were collected relating to clinical history, three different clinical ratings of dyspnea (Medical Research Council (MRC), Borg scale and Basal Dyspnea Index), the extent of bronchiectasis and functional variables. A total of 81 patients (mean age (SD): 69.5 (8.7)) years were included. The degree of dyspnea (MRC) was 1.9 (0.8). Mean FEV1 was 1301 ml (56.9% pred.). Four factors were found that accounted for 84.1% of the total data variance. Factor 1 (45.6% of the data variance) included the three measurements of dyspnea. Factor 2 (16% variance) comprised airflow obstruction parameters (FEV1, FEV1/FVC and PEF). Factor 3 (13.8% variance) included RV/TLC and RV (lung hyperinflation). Factor 4 (8.6% variance) included bronchiectasis extent. Dyspnea was more closely correlated with lung hyperinflation (r:0.33-0.54) than with airflow obstruction parameters (r:0.17-0.26). CONCLUSIONS: Airflow obstruction, dyspnea, lung hyperinflation and the lung extent of the bronchiectasis are four independent entities in the impact of bronchiectasis upon patients.

Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission.

OBJECTIVE: To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP). METHODS: A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days. RESULTS: Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics. CONCLUSIONS: A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.

Positive effect of CPAP treatment on the control of difficult-to-treat hypertension.

The aim of the present study was to analyse the role of continuous positive airway pressure (CPAP) treatment in patients with difficult-to-control hypertension (DC-HT) and sleep apnoea. An Autoset (ResMed, Sydney, Australia) study was performed in 60 patients diagnosed with DC-HT based on two 24-h ambulatory blood pressure monitorisation (ABPM) studies. CPAP was offered to patients with an apnoea/hypopnoea index (AHI) > or =15 events.h(-1). After 3 months of treatment, repeat ABPM was performed to evaluate the effect of CPAP upon the blood pressure values. A total of 39 (65%) patients received CPAP treatment, but only 33 completed the study. The mean+/-sd systolic and diastolic blood pressures (SBP and DBP, respectively) were 154.8+/-14 and 90+/-8.8 mmHg. Patients had a mean+/-sd AHI of 37.7+/-18.2 events.h(-1). Only three patients presented a dipper nocturnal pressure pattern. CPAP treatment significantly reduced SBP (-5.2 mmHg), and particularly the nocturnal values (-6.1 mmHg), but not DBP. Considering only those patients who tolerated CPAP, the decrease in SBP was greater (-7.3 mmHg). Furthermore, CPAP treatment significantly increased the percentage of patients who recovered the dipper pattern (three (9.1%) out of 33 versus 12 (36.4%) out of 33). Continuous positive airway pressure treatment significantly reduces systolic blood pressure, particularly at night, and normalises the nocturnal pressure pattern in patients with difficult-to-control hypertension and sleep apnoea.

EPOC ¿Una enfermedad inflamatoria? / No disponible

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Ictus isquémico y apnea del sueño. Relación entre transtornos respiratorios durante el sueño y estenosis carotídea. Respuesta / Ischemic stroke and sleep apnea. Relationship between sleep breathing disorders and carotid stenosis. Response

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[Sleep-disordered breathing in patients with difficult-to-control hypertension]. / Trastornos respiratorios durante el sueño en pacientes con hipertensión arterial de difícil control.

OBJECTIVE: To analyze the relationship between sleep-disordered breathing and difficult-to-control arterial hyper-tension. PATIENTS AND METHODS: Patients were considered to have difficult-to-control hypertension when mean systolic blood pressure was 125 mm Hg or higher and/or mean diastolic blood pressure was more than or equal to 80 mm Hg (as recorded during 2 24-hour ambulatory monitoring studies) despite the use of 3 or more antihypertensive drugs. Respiratory polygraphy using the AutoSet device (ResMed Corp, Sydney, Australia) was then performed to study sleep-disordered breathing in all patients. RESULTS: Forty-nine patients with a mean (SD) age of 68.1 (9.1) years, mean systolic and diastolic pressures of 152.5 (13)/89.2 (8.5) mm Hg, and an average of 3.5 prescribed drugs were included in the study. The mean apnea-hypopnea index (AHI) was 26.2 (19.5) and events were predominantly obstructive. Patients with severe sleep apnea-hypopnea syndrome (SAHS) (AHI > or = 30; 40.8%) showed more uncontrolled daytime (P = .017) and nighttime (P = .033) systolic pressure than the rest, as well as higher daytime diastolic pressure (P = .035) and a greater consumption of drugs than those without severe SAHS (AHI < 10; 28.6%) (P = .041). The study population as a whole showed a significant correlation between blood pressure and obesity. There was a significant correlation (adjusted for age and sex) with AHI only in patients with SAHS. AHI was found to be the independent predictor with the greatest effect on blood pressure in these patients. CONCLUSIONS: Prevalence of SAHS was very high in patients with difficult-to-control hypertension. In patients with SAHS, AHI was found to be the independent predictor with the greatest affect on arterial blood pressure.

Trastornos respiratorios durante el sueño en pacientes con hipertensión arterial de difícil control / Sleep-disordered breathing in patients with difficult-to-control hypertension

Objetivo: Analizar la relación existente entre los trastornos respiratorios durante el sueño y la hipertensión arterial de difícil control (HTAr). Pacientes y métodos: Se consideró HTAr cuando las cifras medias de la presión arterial sistólica (PAS) eran mayores o iguales a 125 mmHg y/o la diastólica (PAD) era igual o superior a 80 mmHg según el registro de 2 estudios de monitorización ambulatoria durante 24 h a pesar de la utilización de 3 o más fármacos antihipertensivos. Se realizó posteriormente una poligrafía respiratoria (Autoset) para el estudio de los trastornos respiratorios durante el sueño en todos los pacientes. Resultados: Se incluyó en el estudio a 49 pacientes con una media (± desviación estándar) de edad de 68,1 ± 9,1 años, PAS/PAD media de 152,5 ±13/89,2 ±8,5 mmHg y una media de 3,5 fármacos prescritos. El índice de apneas-hipopneas (IAH) fue de 26,2 ± 19,5, de predominio obstructivo. Los pacientes con síndrome de apneas-hipopneas durante el sueño (SAHS) grave (IAH ≥ 30; 40,8%) presentaron mayor descontrol de la PAS tanto diurna (p = 0,017) como nocturna (p = 0,033) que el resto de pacientes, así como mayor PAD diurna (p = 0,035) y toma de un mayor número de fármacos que quienes no lo presentaban (IAH < 10; 28,6%) (p = 0,041). Tomados en su conjunto, los pacientes presentaron una correlación significativa entre las cifras de la presión arterial y la obesidad, además de existir una correlación ajustada significativa con el IAH sólo en los pacientes con SAHS. El IAH se mostró como el predictor independiente que más influyó en las cifras de la presión arterial de estos pacientes. Conclusiones: En pacientes con HTAr la prevalencia de SAHS fue muy elevada. En los pacientes con SAHS, el IAH se mostró como el factor predictivo independiente más importante de las cifras de presión arterial

Objective: To analyze the relationship between sleep-disordered breathing and difficult-to-control arterial hyper-tension. Patients and methods: Patients were considered to have difficult-to-control hypertension when mean systolic blood pressure was 125 mm Hg or higher and/or mean diastolic blood pressure was more than or equal to 80 mm Hg (as recorded during 2 24-hour ambulatory monitoring studies) despite the use of 3 or more antihypertensive drugs. Respiratory polygraphy using the AutoSet device (ResMed Corp, Sydney, Australia) was then performed to study sleep-disordered breathing in all patients. Results: Forty-nine patients with a mean (SD) age of 68.1 (9.1) years, mean systolic and diastolic pressures of 152.5 (13)/89.2 (8.5) mm Hg, and an average of 3.5 prescribed drugs were included in the study. The mean apnea-hypopnea index (AHI) was 26.2 (19.5) and events were predominantly obstructive. Patients with severe sleep apnea-hypopnea syndrome (SAHS) (AHI ≥ 30; 40.8%) showed more uncontrolled daytime (P=.017) and nighttime (P=.033) systolic pressure than the rest, as well as higher daytime diastolic pressure (P=.035) and a greater consumption of drugs than those without severe SAHS (AHI < 10; 28.6%) (P=.041). The study population as a whole showed a significant correlation between blood pressure and obesity. There was a significant correlation (adjusted for age and sex) with AHI only in patients with SAHS. AHI was found to be the independent predictor with the greatest effect on blood pressure in these patients. Conclusions: Prevalence of SAHS was very high in patients with difficult-to-control hypertension. In patients with SAHS, AHI was found to be the independent predictor with the greatest affect on arterial blood pressure

Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often present with severe acute exacerbations requiring hospital treatment. However, little is known about the prognostic consequences of these exacerbations. A study was undertaken to investigate whether severe acute exacerbations of COPD exert a direct effect on mortality. METHODS: Multivariate techniques were used to analyse the prognostic influence of acute exacerbations of COPD treated in hospital (visits to the emergency service and admissions), patient age, smoking, body mass index, co-morbidity, long term oxygen therapy, forced spirometric parameters, and arterial blood gas tensions in a prospective cohort of 304 men with COPD followed up for 5 years. The mean (SD) age of the patients was 71 (9) years and forced expiratory volume in 1 second was 46 (17)%. RESULTS: Only older age (hazard ratio (HR) 5.28, 95% CI 1.75 to 15.93), arterial carbon dioxide tension (HR 1.07, 95% CI 1.02 to 1.12), and acute exacerbations of COPD were found to be independent indicators of a poor prognosis. The patients with the greatest mortality risk were those with three or more acute COPD exacerbations (HR 4.13, 95% CI 1.80 to 9.41). CONCLUSIONS: This study shows for the first time that severe acute exacerbations of COPD have an independent negative impact on patient prognosis. Mortality increases with the frequency of severe exacerbations, particularly if these require admission to hospital.