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.

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.

Standards for quality care in respiratory rehabilitation in patients with chronic pulmonary disease. Quality Healthcare Committee. Spanish Society of Pneumology and Thoracic Surgery (SEPAR).

Respiratory rehabilitation (RR) has been shown to be effective with a high level of evidence in terms of improving symptoms, exertion capacity and health-related quality of life (HRQL) in patients with COPD and in some patients with diseases other than COPD. According to international guidelines, RR is basically indicated in all patients with chronic respiratory symptoms, and the type of program offered depends on the symptoms themselves. As requested by the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), we have created this document with the aim to unify the criteria for quality care in RR. The document is organized into sections: indications for RR, evaluation of candidates, program components, characteristics of RR programs and the role of the administration in the implementation of RR. In each section, we have distinguished 5 large disease groups: COPD, chronic respiratory diseases other than COPD with limiting dyspnea, hypersecretory diseases, neuromuscular diseases with respiratory symptoms and patients who are candidates for thoracic surgery for lung resection.

[Modifications of diaphragmatic activity induced by midline laparotomy and changes in abdominal wall compliance]. / Modificaciones en la actividad del diafragma inducidas por laparotomía media y cambios en la rigidez de la pared abdominal.

INTRODUCTION AND OBJECTIVE: Diaphragmatic activity varies with the initial length of the muscle. Our objective was to evaluate the influence of surgery and changes in abdominal wall compliance on diaphragmatic activity. METHODS: Both phrenic nerves in 7 mongrel dogs were stimulated electrically with single supramaximal pulses (twitch). The gastric (Pga) and transdiaphragmatic (Pdi) pressures generated and muscle shortening (sonomicrometry) were used to evaluate diaphragmatic activity, which was determined at baseline, after midline laparotomy, with an elastic abdominal bandage, and with a rigid circular cast. Abdominal pressure was then gradually increased in order to induce progressive lengthening of the diaphragm. RESULTS: After laparotomy, the pressures were somewhat lower (by 12%) than at baseline. The elastic bandage produced a slight increase in the pressure generated by the diaphragm (mean [SE] values: Pga, from 4.2 [0.3]cm H(2)O to 6.3 [0.9]cm H(2)O, P<.01; Pdi(tw), from 12.1 [2.0]cm H(2)O to 15.4 [1.8]cm H(2)O, P<.05]), and these values increased even further with the rigid cast (Pga, to 12.6 [1.5]cm H(2)O; Pdi, to 20.2 [2.3]cm H(2)O; P<.01 for both comparisons); this occurred despite smaller degrees of muscle shortening: by 57% [5%] of the initial length at functional residual capacity at baseline, by 49% [5%] with the bandage (P<.05), and by 39% [6%] with the cast (P<.01). With progressive lengthening of the muscle, its contractile efficacy increased up to a certain point (105% of the length at functional residual capacity), after which it began to decline. CONCLUSIONS: Abdominal wall compliance plays an important role in the diaphragmatic response to stimulation. This appears to be due mainly to changes in its length at rest.

Modificaciones en la actividad del diafragma inducidas por laparotomía media y cambios en la rigidez de la pared abdominal / Modifications of Diaphragmatic Activity Induced by Midline Laparotomy and Changes in Abdominal Wall Compliance

Introducción y objetivos la actividad del diafragma puede verse modificada por su longitud inicial. Nuestro objetivo ha sido evaluar la influencia de la cirugía y los cambios en la rigidez de la pared abdominal sobre la actividad del músculo.Métodoen 7 perros mestizos se estimularon eléctricamente ambos nervios frénicos con pulsos únicos supramáximos (twitch). Para evaluar la actividad del diafragma se determinaron las presiones generadas —gástrica (Pgatw) y transdiafragmática (Pditw)— y el acortamiento muscular (sonomicrometría). La respuesta diafragmática se obtuvo en situación basal, tras laparotomía media, con venda abdominal elástica y con prótesis rígida circular. A continuación se incrementó ligera y progresivamente la presión abdominal para conseguir el alargamiento sucesivo del diafragma.Resultadostras la laparotomía, las presiones fueron algo inferiores a las basales (12%). La banda elástica provocó un leve aumento de la presión generada por el diafragma (valores medios±error estándar. Pgatw: 4,2±0,3 a 6,3±0,9cmH2O, p<0,01; Pditw: 12,1±2,0 a 15,4±1,8cmH2O, p<0,05), que se incrementó aún más con la prótesis rígida (Pgatw: 12,6±1,5cmH2O; Pditw: 20,2±2,3cmH2O; p<0,01 para ambas), a pesar de valores de acortamiento inferiores —un 57±5% de la longitud inicial a capacidad funcional residual en situación basal, un 49±5% con banda (p<0,05) y un 39±6% con prótesis (p<0,01)—. Al alargar progresivamente el músculo, su efectividad contráctil aumentó hasta un punto (un 105% de la longitud a capacidad funcional residual) a partir del cual comenzó a declinar.Conclusiónla rigidez de la pared abdominal desempeña un papel importante en la respuesta del diafragma a la estimulación. Esto parece deberse fundamentalmente a cambios en su longitud de reposo(AU)

Introduction and Objective Diaphragmatic activity varies with the initial length of the muscle. Our objective was to evaluate the influence of surgery and changes in abdominal wall compliance on diaphragmatic activity.MethodsBoth phrenic nerves in 7 mongrel dogs were stimulated electrically with single supramaximal pulses (twitch). The gastric (Pga) and transdiaphragmatic (Pdi) pressures generated and muscle shortening (sonomicrometry) were used to evaluate diaphragmatic activity, which was determined at baseline, after midline laparotomy, with an elastic abdominal bandage, and with a rigid circular cast. Abdominal pressure was then gradually increased in order to induce progressive lengthening of the diaphragm.ResultsAfter laparotomy, the pressures were somewhat lower (by 12%) than at baseline. The elastic bandage produced a slight increase in the pressure generated by the diaphragm (mean [SE] values: Pga, from 4.2 [0.3]cm H2O to 6.3 [0.9]cm H2O, P<.01; Pditw, from 12.1 [2.0]cm H2O to 15.4 [1.8]cm H2O, P<.05]), and these values increased even further with the rigid cast (Pga, to 12.6 [1.5]cm H2O; Pdi, to 20.2 [2.3]cm H2O; P<.01 for both comparisons); this occurred despite smaller degrees of muscle shortening: by 57% [5%] of the initial length at functional residual capacity at baseline, by 49% [5%] with the bandage (P<.05), and by 39% [6%] with the cast (P<.01). With progressive lengthening of the muscle, its contractile efficacy increased up to a certain point (105% of the length at functional residual capacity), after which it began to decline.ConclusionsAbdominal wall compliance plays an important role in the diaphragmatic response to stimulation. This appears to be due mainly to changes in its length at rest(AU)

[Home vs hospital-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a Spanish multicenter trial]. / Comparación de un programa de rehabilitación domiciliario con uno hospitalario en pacientes con EPOC: estudio multicéntrico español.

OBJECTIVE: To compare the effects of a simple home pulmonary rehabilitation program and an intensive hospital-based program in terms of the exercise tolerance and health-related quality of life (HRQL) of patients with severe chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Patients in this prospective, multicenter trial were randomized to 2 groups to receive hospital or home pulmonary rehabilitation. Patients in both groups attended 2 informative sessions about the disease and 4 physical therapy sessions. Patients in the hospital group then carried out a structured exercise program while home group patients performed low intensity exercises at home without supervision. RESULTS: Twenty-eight patients were randomized to the hospital rehabilitation group and 23 to the home group. Both groups showed a similar improvement on the 6-minute walk test (mean difference, 8.7 m; P=.61). HRQOL measured with the Chronic Respiratory Questionnaire also improved in both groups, but the change was greater on the emotional function domain in the hospital rehabilitation group (mean difference between groups, 0.58 on a scale for which the smallest clinically relevant difference is 0.5 points). The benefits were maintained in both groups 6 months after the programs ended. CONCLUSIONS: This study demonstrates that the improvement in exercise tolerance achieved by COPD patients with an unsupervised home pulmonary rehabilitation program is similar to the gains of patients in an intensive hospital-based program. However, the hospital program afforded greater benefit on the HRQOL emotional function domain.

Near-fatal asthma related to menstruation.

BACKGROUND: Menstruation has been suggested as a possible trigger of near-fatal asthma (NFA), but the evidence supporting this association remains weak. OBJECTIVE: We sought to assess the role of menstruation as a contributing factor in the development of NFA episodes in women of reproductive age. METHODS: Forty-four female patients of reproductive age with near-fatal attacks were enrolled in a multicenter study. Data on patient and clinical characteristics were collected. We also performed spirometric and allergy studies when the patients were in stable condition. RESULTS: Significantly more NFA episodes were observed on the first day of menstruation (11 [25%] patients) than on the remaining days (33 [75%] patients, P =.022), and patients who presented for care on the first day of menstruation used more inhaled salbutamol as rescue medication (9 [9.5] vs 1.8 [3.7] microg/d during the 7 days before the asthma exacerbation, P =.003). CONCLUSION: Menstruation might act as a contributing factor in the development of NFA episodes in patients with unstable asthma. Specific recommendations should be included in educational programs, and the self-management plans of asthmatic women of reproductive age should include the systematic recording of their asthma symptoms and pulmonary function in the perimenstrual phase.