Pseudomonas aeruginosa in Chronic Obstructive Pulmonary Disease Patients with Frequent Hospitalized Exacerbations: A Prospective Multicentre Study.

BACKGROUND: Pseudomonas aeruginosa (PA) is a common microorganism related to severe exacerbations in Chronic Obstructive Pulmonary Disease (COPD). However, their role in COPD patients with frequent hospitalized exacerbations (FHE) is not well described. OBJECTIVES: We aimed to determine prevalence, risk factors, susceptibility patterns and impact on outcomes of PA in COPD patients with FHE. METHODS: Prospective observational multicentre study that included COPD patients with FHE. The cohort was stratified in 2 groups according to the presence or absence of PA isolation in sputum. Patients were followed up for 12 months. RESULTS: We enrolled 207 COPD patients with FHE. In 119 patients (57%), a valid sputum culture was collected. Of them, PA was isolated in 21 patients (18%). The risk factors associated with PA were prior use of systemic corticosteroids (OR 3.3, 95% CI 1.2-9.7, p = 0.01) and prior isolation of PA (OR 4.36, 95% CI 1.4-13.4, p < 0.01). Patients with PA had an increased risk of having ≥3 readmissions (OR 4.1, 95% CI 1.3-12.8, p = 0.01) and higher PA isolation rate (OR 7.7, 95% CI 2.4-24.6, p < 0.001) during the follow-up period. In 14 patients (67%), PA was resistant to at least one antibiotic tested. PA persisted in the sputum in 70% of patients. CONCLUSIONS: The presence of PA was related to 3 or more readmissions during the 1-year follow-up and PA persisted in the sputum despite an appropriate antibiotic treatment. This finding suggested an important role of PA in the course of the disease of COPD patients with FHE.

¿Es útil la implantación de programas de gestión clínica de los pacientes con enfermedad pulmonar obstructiva crónica? Comparación de la efectividad de dos intervenciones sobre la evolución clínica y la atención recibida / Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received

Objetivo: Evaluar la efectividad de dos programas de gestión en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Diseño: Estudio de diseño cuasi-experimental para evaluar la efectividad de dos intervenciones (I1, I2) para la asistencia de pacientes con EPOC, tras un seguimiento medio de 31,2 meses. Emplazamiento: Centros de atención primaria de dos áreas sanitarias de Barcelona y sus hospitales de referencia. Participantes: Pacientes EPOC seleccionados por muestreo aleatorio simple en los que constara algún código correspondiente a EPOC. Intervenciones: I1: Programa de gestión integral que optimizaba y coordinaba los recursos. Se hizo formación y control de calidad de la espirometría. I2: Intervenciones aisladas, como el call-center. Compartían circuitos asistenciales y la historia clínica informatizada. Mediciones principales: variables de función pulmonar, gravedad, uso de inhaladores, estilos de vida, calidad de vida y exacerbaciones. Resultados: De los 393 pacientes evaluados al inicio, 120 y 104 (I1 e I2, respectivamente) realizaron la evaluación final. Con la I1 hubo una reducción de los pacientes fumadores (p = 0,034). En ambos grupos, la función pulmonar y la calidad de vida se mantuvieron y la disnea mostró un leve empeoramiento. El correcto uso de inhaladores aumentó, aunque solo alcanzó el 48 y el 61% con la I1 e I2, respectivamente. El porcentaje de pacientes exacerbados disminuyó con la I1 (respecto I2 [p < 0,001]) y el de ingresos hospitalarios por exacerbación disminuyó con la I2 (respecto I1 [p < 0,003]). Conclusiones: Ambas intervenciones consiguieron mejoras relevantes y el no empeoramiento global de una enfermedad crónica y progresiva como es la EPOC (AU)

Objective: To evaluate the effectiveness of two management programs on patients with chronic obstructive pulmonary disease (COPD). Design: A study with a quasi-experimental design was used to evaluate the effectiveness of two interventions (I1, I2) for the care of patients with COPD after a mean follow-up of 31.2 months. Setting: Primary Care Centres in two Barcelona Health Areas and their referral hospitals. Participants: Patients with COPD selected by simple random sampling using any disease code corresponding to COPD. Interventions: I1: Integrated management program that was optimised and coordinated the resources. Training was given, as well as quality control of spirometry. I2: Isolated interventions like a call-centre. Care circuits and computerised clinical notes were shared. Main measurements: Variables were recorded as regards lung function, severity, use of inhalers, lifestyles, quality of life, and exacerbations. Results: Of the 393 patients evaluated at the beginning, 120 and 104 (I1 and I2, respectively) received the final evaluation. With I1, there was a reduction in patients who smoked (P=.034). Lung function and quality of life did not change significantly in either group, but shortness of breath was slightly worse. There was an increase in the correct use of inhalers, although it only reached 48% and 61% with interventions I1 and I2, respectively. The percentage of patients with exacerbations decreased with I1 compared to that of I2 (P<.001), and there were less hospital admissions due to exacerbations with I2 compared to I1 (P<.003]). Conclusions: Both interventions achieved significant improvements, and no overall worsening of a chronic and progressive disease as is COPD (AU)

[Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received]. / ¿Es útil la implantación de programas de gestión clínica de los pacientes con enfermedad pulmonar obstructiva crónica? Comparación de la efectividad de dos intervenciones sobre la evolución clínica y la atención recibida.

OBJECTIVE: To evaluate the effectiveness of two management programs on patients with chronic obstructive pulmonary disease (COPD). DESIGN: A study with a quasi-experimental design was used to evaluate the effectiveness of two interventions (I1, I2) for the care of patients with COPD after a mean follow-up of 31.2months. SETTING: Primary Care Centres in two Barcelona Health Areas and their referral hospitals. PARTICIPANTS: Patients with COPD selected by simple random sampling using any disease code corresponding to COPD. INTERVENTIONS: I1: Integrated management program that was optimised and coordinated the resources. Training was given, as well as quality control of spirometry. I2: Isolated interventions like a call-centre. Care circuits and computerised clinical notes were shared. MAIN MEASUREMENTS: Variables were recorded as regards lung function, severity, use of inhalers, lifestyles, quality of life, and exacerbations. RESULTS: Of the 393 patients evaluated at the beginning, 120 and 104 (I1 and I2, respectively) received the final evaluation. With I1, there was a reduction in patients who smoked (P=.034). Lung function and quality of life did not change significantly in either group, but shortness of breath was slightly worse. There was an increase in the correct use of inhalers, although it only reached 48% and 61% with interventions I1 and I2, respectively. The percentage of patients with exacerbations decreased with I1 compared to that of I2 (P<.001), and there were less hospital admissions due to exacerbations with I2 compared to I1 (P<.003]). CONCLUSIONS: Both interventions achieved significant improvements, and no overall worsening of a chronic and progressive disease as is COPD.

Pseudomonas aeruginosa resistance patterns and clinical outcomes in hospitalized exacerbations of COPD.

BACKGROUND AND OBJECTIVE: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) due to Pseudomonas aeruginosa (PA) are associated with worse outcomes. PA antibiotic resistance is important to determine treatment and may influence clinical outcomes. The aim was to study clinical characteristics and outcomes in patients with AECOPD associated with PA based on their antibiotic resistance. METHODS: This was a prospective observational study including all patients with AECOPD and positive PA sputum culture admitted in a respiratory ward in a tertiary hospital in Barcelona during 2013-2014. PA was defined as resistant (PA-R) when the antibiogram showed ≥1 resistance. RESULTS: Four hundred one patients with AECOPD were evaluated. Of them, 54 (13%) had a positive PA sputum culture. Eighty-two per cent were men, median age was 77 (SD 7) years old and FEV1 was less than 36% (SD 17) of predicted value. PA-R was isolated in 35 patients (66%), and PA-sensitive (PA-S) was isolated in 18 (34%) patients. No differences were found in demographics, lung function and comorbidities among groups. PA-R patients were more likely exposed to prior oral corticosteroids (77% vs 44%, P = 0.03) and antibiotics (77% vs 31%, P = 0.01), respectively. AECOPD patients associated with PA-S were more likely to die at 30 days (odds ratio 13.53, 95% confidence interval: 1.14-69.56, P = 0.03) and 90 days (odds ratio 7.09, 95% confidence interval: 1.33-37.89, P = 0.02), respectively. CONCLUSION: Pseudomonas aeruginosa-resistant affects patients with severe AECOPD and previous use of corticosteroids and antibiotics. The presence of PA-S is associated with higher mortality. These results may suggest increased virulence in PA-S strains causing acute infections.

Knowledge and Attitudes of Nurses in Spain about Inhaled Therapy: Results of a National Survey.

BACKGROUND: The main problem with inhalation therapy is incorrect use of inhalers. Nurses' limited knowledge may contribute to this situation. This study aimed to assess the level of knowledge and attitudes of respiratory nurses about inhaled therapy. METHODS: A 12-item multiple-choice questionnaire was sent to members in the Nursing Area of the Spanish Society of Pneumology and Thorax Surgery and to nurses working with respiratory patients using inhalers devices. The survey was voluntary, self-administered, and anonymous. It collected demographic characteristics, preferences, and knowledge and education about devices and inhalation technique. RESULTS: A total of 1496 nurses completed the questionnaire correctly. Results showed 65.4% preferred dry powder inhalers (DPI), 8.7% were familiar with all 12 devices listed, 59.6% identified "firing the device after beginning inspiration" as the most important step when using the pressurized metered dose inhaler (pMDI), 53.5% identified ''inhale deeply and forcefully'' as the most significant step using DPI, and 20.4% "always checked a patient's inhalation technique when a new inhaler was prescribed." A composite, variable, general inhaled therapy knowledge pooled the correct answers related to knowledge and showed only 14% of nurses had adequate knowledge of inhaled therapy. CONCLUSIONS: In spite of recent training activities, knowledge concerning use of inhaler devices among Spanish nurses managing patients with respiratory diseases continues to be poor. Improvements are also needed in patient education and follow-up of inhalation techniques. Undergraduate and postgraduate educational programs need to be further developed.

A repeated short educational intervention improves asthma control and quality of life.

We assessed the effectiveness of an asthma educational programme based on a repeated short intervention (AEP-RSI) to improve asthma control (symptom control and future risk) and quality of life. A total of 230 adults with mild-to-moderate persistent uncontrolled asthma participated in a 1-year cluster randomised controlled multicentre study. The AEP-RSI was given in four face-to-face sessions at 3-month intervals, and included administration of a written personalised action plan and training on inhaler technique. Centres were randomised to the AEP-RSI (intervention) group or usual clinical practice group. Specialised centres using a standard educational programme were the gold standard group. A significant improvement in the Asthma Control Test score was observed in all three groups (p<0.001), but improvements were higher in the intervention and gold standard groups than in the usual clinical practice group (p=0.042), which also showed fewer exacerbations (mean±sd; 1.20±2.02 and 0.56±1.5 versus 2.04±2.72, respectively) and greater increases in the Mini Asthma Quality of Life Questionnaire scores (0.95±1.04 and 0.89±0.84 versus 0.52±0.97, respectively). The AEP-RSI was effective in improving asthma symptom control, future risk and quality of life.

Características de la enfermedad pulmonar obstructiva crónica en fase estable relacionadas con la inflamación sistémica / Characteristics of stable chronic obstructive pulmonary disease related to systemic inflammation

Fundamento y objetivo: La enfermedad pulmonar obstructiva crónica (EPOC) es un proceso que cursa con inflamación sistémica. El objetivo del estudio fue evaluar la asociación entre la inflamación sistémica, medida con la concentración de proteína C reactiva (PCR) en sangre capilar, y distintos parámetros clínico-funcionales de la enfermedad. Pacientes y método: Se evaluó una muestra aleatoria de 413 pacientes con EPOC atendidos en 31 centros de salud de Barcelona. Se registraron antecedentes, variables antropométricas, hábitos tóxicos, tratamientos, Chronic Respiratory Questionnaire (CRQ, «Cuestionario de Enfermedades Respiratorias Crónicas») y escala de disnea. Se realizó una espirometría y se determinó la concentración de CO en aire espirado y de la PCR en sangre capilar. Resultados: La media (desviación estándar) de edad fue 72 (8,4) años y la del volumen espirado en el primer segundo (FEV1) posbroncodilatador de 1,65 (0,65) l. La correlación fue negativa entre PCR y FEV1 posbroncodilatador (r=-0,25, p<0,001), así como entre PCR y puntuación en el CRQ (r=-0,098, p=0,048), y fue positiva entre PCR y CO en aire espirado (r=0,1, p=0,039). La proporción de pacientes con PCR elevada fue superior en los estadios GOLD más avanzados (p<0,001), en aquellos con más disnea (p=0,042), en los tratados con glucocorticoides inhalados (p=0,018) y en aquellos que habían ingresado por agudización en el último año (p=0,026). El análisis multivariante indicó como determinantes independientes de la PCR el FEV1 posbroncodilatador y la concentración de CO en aire espirado. Conclusión: En los pacientes con EPOC, el tabaquismo activo y el grado de la obstrucción al flujo aéreo se asocian a una mayor intensidad de la respuesta inflamatoria sistémica medida por la PCR (AU)

Background and objetive: Chronic obstructive pulmonary disease (COPD) is characterized by a systemic inflammation. The aim of this study was to evaluate the association between systemic inflammation, measured with C reactive protein (CRP), and clinical and functional outcomes of the disease. Patients and methods: A randomized sample of 413 COPD patients from 31 primary health care centers of Barcelona was evaluated. Medical history, anthropometric measurements, toxic habits, treatments, Chronic Respiratory Questionnaire (CRQ) and dyspnea were registered. Spirometry, exhaled CO concentration and CRP in capillary blood were performed. Results: Median (standard deviation) of the age was 72 (8.4) years and forced expiratory volume in one second (FEV1) postbronchodilatador 1.65 (0.65) l. The correlation was negative between CRP and FEV1 postbronchodilatador(r=-0.25, P<0.001) and between CRP and CRQ scores (r=-0.098, P=0.048) and positive between CRP and CO (r=0.1, P=0.039). The ratio of patients with elevated CRP was higher in advanced GOLD stage (P<0.001), worst dyspnea (P=0.042), patients treated with inhaled corticosteroids (P=0.018) and if they had been hospitalized during the last year (P=0.026). The multivariant analysis showed, as independent factors of elevated CRP, FEV1 postbronchodilator and CO concentration. Conclusion: In COPD patients, active smoking habit and the airway's obstruction degree are associated with a greater intensity of the inflammatory systemic response measured by the CRP (AU)

[Characteristics of stable chronic obstructive pulmonary disease related to systemic inflammation]. / Características de la enfermedad pulmonar obstructiva crónica en fase estable relacionadas con la inflamación sistémica.

BACKGROUND AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is characterized by a systemic inflammation. The aim of this study was to evaluate the association between systemic inflammation, measured with C reactive protein (CRP), and clinical and functional outcomes of the disease. PATIENTS AND METHODS: A randomized sample of 413 COPD patients from 31 primary health care centers of Barcelona was evaluated. Medical history, anthropometric measurements, toxic habits, treatments, Chronic Respiratory Questionnaire (CRQ) and dyspnea were registered. Spirometry, exhaled CO concentration and CRP in capillary blood were performed. RESULTS: Median (standard deviation) of the age was 72 (8.4) years and forced expiratory volume in one second (FEV(1)) postbronchodilatador 1.65 (0.65) l. The correlation was negative between CRP and FEV(1) postbronchodilatador(r=-0.25, P<0.001) and between CRP and CRQ scores (r=-0.098, P=0.048) and positive between CRP and CO (r=0.1, P=0.039). The ratio of patients with elevated CRP was higher in advanced GOLD stage (P<0.001), worst dyspnea (P=0.042), patients treated with inhaled corticosteroids (P=0.018) and if they had been hospitalized during the last year (P=0.026). The multivariant analysis showed, as independent factors of elevated CRP, FEV(1) postbronchodilator and CO concentration. CONCLUSION: In COPD patients, active smoking habit and the airway's obstruction degree are associated with a greater intensity of the inflammatory systemic response measured by the CRP.

Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease.

BACKGROUND: The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients. METHODS/DESIGN: A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts. DISCUSSION: The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.