Recuento de eosinófilos en sangre y eventos centrados en el paciente con enfermedad pulmonar obstructiva crónica en práctica asistencial real / Plasma Eosinophil Count and Patient-Centered Events in Chronic Obstructive Pulmonary Disease in Real-Life Clinical Practice

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Pacientes octogenarios con enfermedad pulmonar obstructiva crónica: características y utilidad de los índices pronósticos / Octogenarian patients with chronic obstructive pulmonary disease: Characteristics and usefulness of prognostic indexes

Antecedentes y objetivo: La mayoría de los estudios sobre enfermedad pulmonar obstructiva crónica (EPOC) excluyen a pacientes octogenarios, por lo que la enfermedad no está bien caracterizada en esta franja etaria. El objetivo de este trabajo es estudiar las características clínicas de los pacientes octogenarios con EPOC y la utilidad de los índices pronósticos más empleados en la enfermedad en esta edad. Pacientes y método: Estudio retrospectivo de pacientes consecutivos atendidos en una consulta entre 2009 y 2017. Se estudiaron parámetros de función pulmonar, distribución de fenotipos clínicos, historial de ingresos, mortalidad, comorbilidades y la utilidad de los índices de Charlson, BODEX, COTE y CODEX para predecir mortalidad. Resultados: La muestra constó de 698 sujetos, 82 (11,7%)≥80 años. El seguimiento medio fue de 47,9±21,8 meses. En los pacientes octogenarios la gravedad de la EPOC medida por el FEV1% o por el índice BODEX fue similar a la de sujetos más jóvenes, pero la disnea fue mayor. En estos pacientes fue más frecuente el fenotipo bronquitis crónica y el exacerbador frecuente, y menos prevalente el enfisema. Los octogenarios tenían más prevalencia de comorbilidad cardiovascular y de insuficiencia renal. Los ingresos hospitalarios y la mortalidad fueron mayores en los octogenarios. La mayoría de los índices pronósticos tuvieron utilidad para predecir mortalidad en los pacientes ancianos, y en ambos grupos etarios el índice CODEX fue el mejor a este respecto. Conclusión: Los pacientes octogenarios con EPOC tienen unas características diferenciales que podrían implicar un abordaje terapéutico diferente. Los índices pronósticos son útiles para predecir mortalidad en esta población

Background and objective: Most studies on chronic obstructive pulmonary disease (COPD) exclude octogenarian patients. Therefore, the disease is not well characterized in this age group. The objective of this study is to analyze the clinical characteristics of octogenarian patients with COPD and the usefulness of the prognostic indexes used most frequently in this age group. Patients and method: Retrospective study of consecutive patients seen at a clinic between 2009 and 2017. The following variables were analyzed: lung function parameters, distribution of clinical phenotypes, income history, mortality, comorbidities and usefulness of the Charlson, BODEX, COTE and CODEX indexes to predict mortality. Results: The sample comprised 698 patients, 82 aged (11.7%)≥80 years old. Mean follow-up time was 47.9±21.8 months. In octogenarian patients, the severity of the COPD, assessed by means of the FEV1% or BODEX index, was similar to that of younger patients, but dyspnea was worse in the elderly group. In these patients, the chronic bronchitis and frequent exacerbator phenotypes were the most frequent, whilst the emphysema phenotype was the least common. Octogenarians had a greater prevalence of cardiovascular comorbidities and renal diseases. Moreover, hospital admissions were more frequent and mortality was higher in these elderly patients. Most prognostic indexes were useful in predicting mortality in elderly patients. CODEX was the most useful index to predict mortality, both in octogenarian and younger patients. Conclusion: Octogenarian patients with COPD have differential characteristics which could imply the need for different therapeutic approaches. Prognostic indexes are useful for predicting mortality in this population

Mortality in COPD patients according to clinical phenotypes.

Purpose: Grouping COPD subjects into clinical phenotypes might be useful for the management of the disease, but the clinical implications of such classification are still not totally clear, especially regarding prognosis. The primary objective of this study was to assess whether the mortality rates were different between four predefined clinical phenotypes. Patients and methods: This is a retrospective, observational study carried out at the COPD clinic of a University Hospital. A total of 891 COPD patients were classified, according to the Spanish COPD guidelines, into the following four phenotypes: asthma-COPD overlap (ACO; 75 subjects), nonexacerbator (NONEX; 531 subjects), exacerbator with chronic bronchitis (EXCB; 194 subjects), and exacerbator with emphysema (EXEMPH; 91 subjects). We compared the mortality outcomes between the phenotypes. Results: After a follow-up of 48.4±25.2 months, there were 194 deaths (21.8%). There were significant differences in all-cause mortality between phenotypes. The ACO phenotype had the best long-term prognosis, whereas EXEMPH had the highest risk of death. NONEX and EXCB mortality figures were in between the other two groups. We also found some differences in the causes of death, and patients with EXEMPH were at a higher risk of dying because of COPD itself. The differences in mortality did not seem related to the classification into phenotypes in itself but to disparities in COPD severity and comorbidity load between groups. Conclusion: Classifying COPD patients according to several predefined clinical phenotypes can identify clusters of subjects with different mortality outcomes. Some phenotypes are associated with a specific cause of death. The mechanisms that underlie these differences seem to be related to COPD severity and comorbidities.

Cardiovascular Studies in Patients with Chronic Obstructive Pulmonary Disease Due to Biomass Smoke or Tobacco.

BACKGROUND AND OBJECTIVE: The cardiovascular effects of biomass smoke exposure in patients with chronic obstructive pulmonary disease are not well characterized, and few studies have assessed the possible differences between patients with disease caused by biomass smoke and tobacco. The aim of this study was to search for differences in cardiovascular variables between both types of the disease. METHODS: Twenty subjects (15 men, 5 women) with chronic obstructive pulmonary disease caused by tobacco were matched one to one for sex, age, and forced expiratory volume in 1 s to 20 patients with biomass-related disease. Echocardiography and carotid ultrasound studies were performed. Flow-mediated endothelium-dependent vasodilatation and endothelium-independent vasodilatation were also measured. RESULTS: There were no significant differences between groups in any of the echocardiographic variables, nor in the intima-media carotid thickness, the number of carotid plaques, or the percentage of endothelium-dependent or endothelium-independent vasodilation. A high percentage of patients in both groups showed an abnormal flow-mediated endothelium-dependent vasodilatation pattern. CONCLUSION: The study does not support the hypothesis of a different cardiovascular effect of biomass or tobacco smoke exposure in patients with chronic obstructive pulmonary disease. Cardiovascular comorbidity should be assessed in patients with biomass-associated disease, similarly to subjects with tobacco-related disease.

Octogenarian patients with chronic obstructive pulmonary disease: Characteristics and usefulness of prognostic indexes. / Pacientes octogenarios con enfermedad pulmonar obstructiva crónica: características y utilidad de los índices pronósticos.

BACKGROUND AND OBJECTIVE: Most studies on chronic obstructive pulmonary disease (COPD) exclude octogenarian patients. Therefore, the disease is not well characterized in this age group. The objective of this study is to analyze the clinical characteristics of octogenarian patients with COPD and the usefulness of the prognostic indexes used most frequently in this age group. PATIENTS AND METHOD: Retrospective study of consecutive patients seen at a clinic between 2009 and 2017. The following variables were analyzed: lung function parameters, distribution of clinical phenotypes, income history, mortality, comorbidities and usefulness of the Charlson, BODEX, COTE and CODEX indexes to predict mortality. RESULTS: The sample comprised 698 patients, 82 aged (11.7%)≥80 years old. Mean follow-up time was 47.9±21.8 months. In octogenarian patients, the severity of the COPD, assessed by means of the FEV1% or BODEX index, was similar to that of younger patients, but dyspnea was worse in the elderly group. In these patients, the chronic bronchitis and frequent exacerbator phenotypes were the most frequent, whilst the emphysema phenotype was the least common. Octogenarians had a greater prevalence of cardiovascular comorbidities and renal diseases. Moreover, hospital admissions were more frequent and mortality was higher in these elderly patients. Most prognostic indexes were useful in predicting mortality in elderly patients. CODEX was the most useful index to predict mortality, both in octogenarian and younger patients. CONCLUSION: Octogenarian patients with COPD have differential characteristics which could imply the need for different therapeutic approaches. Prognostic indexes are useful for predicting mortality in this population.

Differences in systemic inflammation between cigarette and biomass smoke-induced COPD.

BACKGROUND AND OBJECTIVE: It is known that biomarkers of systemic inflammation are raised in COPD caused by tobacco (T-COPD) compared with healthy controls, but there is less information on the inflammatory status of subjects with COPD caused by biomass smoke (B-COPD). In addition, the possible (if any) differences in inflammation between both types of the disease are still not well known. The aim of this study was to assess the inflammatory profile in B-COPD and T-COPD. METHODS: A total of 20 subjects (15 men and five women) with T-COPD were matched one to one for sex, age and forced expiratory volume in 1 s (FEV1) to 20 B-COPD patients. In all, 20 sex-matched healthy subjects with normal lung function without smoking history or biomass exposure were included as controls. The following biomarkers were measured: exhaled nitric oxide, serum IL-6, IL-8, IL-5, IL-13, periostin, surfactant protein-P, TNF-α, IgE, erythrocyte sedimentation rate, C-reactive protein and fibrinogen. Complete blood count was also obtained. RESULTS: The age of the subjects was 70.2±7.9 years and FEV1% was 56.2%±14.6%. Most inflammatory biomarkers were higher in both types of COPD than in healthy controls. IL-6, IL-8 and IL-5 were significantly higher in T-COPD than in B-COPD, without other significant differences. CONCLUSION: Both types of COPD are associated with high levels of systemic inflammation biomarkers. T-COPD patients have a higher systemic inflammatory status than the patients with B-COPD.

Prevalence of Major Comorbidities in Chronic Obstructive Pulmonary Disease Caused by Biomass Smoke or Tobacco.

BACKGROUND: Comorbidities are very common in chronic obstructive pulmonary disease (COPD), contributing to the overall severity of the disease. The relative prevalence of comorbidities in COPD caused by biomass smoke (B-COPD), compared with COPD related to tobacco (T-COPD), is not well known. OBJECTIVES: To establish if both types of COPD are associated with a different risk for several major comorbidities. METHOD: The prevalence of comorbidities was compared in 863 subjects with B-COPD (n = 179, 20.7%) or T-COPD (n = 684, 79.2%). Multivariate analysis was carried out to explore the independent relationship between comorbidities and type of exposure. RESULTS: Three comorbidities were more frequent in T-COPD than in B-COPD: ischemic heart disease (11.5 vs. 5.0%, respectively, p = 0.01), peripheral vascular disease (9.2 vs. 2.7%, p = 0.006), and peptic ulcer disease (4.8% vs. 0, p = 0.005). After correcting for potential confounding variables, the risk of ischemic heart disease was lower in B-COPD than in T-COPD (OR: 0.33, 95% CI: 0.16-0.69, p = 0.003). CONCLUSIONS: The prevalence of ischemic heart disease is significantly lower in B-COPD than in T-COPD, suggesting a different systemic effect of both types of smoke in COPD patients.

Combustión de biomasa como factor de riesgo para enfermedad pulmonar obstructiva crónica en España / Biomass Burning as a Risk Factor for Chronic Obstructive Pulmonary Disease in Spain

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Corticoides inhalados, eosinófilos y exacerbaciones de la enfermedad pulmonar obstructiva crónica / Inhaled corticosteroids, eosinophils and chronic obstructive pulmonary disease exacerbations

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Prognostic Indices and Mortality Prediction in COPD Caused by Biomass Smoke Exposure.

INTRODUCTION: Little is known about survival and prognostic factors in chronic obstructive pulmonary disease (COPD) due to biomass smoke exposure (BS-COPD). OBJECTIVES: (1) To determine the value of two indices of COPD severity: BODEx (body mass index, obstruction, dyspnea, and previous severe exacerbations) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) categories system (ABCD) to predict all-cause mortality in BS-COPD, compared with COPD due to tobacco (T-COPD); (2) to verify the usefulness of 2 comorbidity indices, Charlson index and COTE (COPD comorbidity index); and (3) to put side by side the value of these indices. METHODS: 612 consecutive COPD patients were retrospectively studied. Prognostic factors were evaluated taking into account the exposure to biomass or tobacco smoke. The relative predictive values of the prognostic indices were compared using receiver-operating characteristic analysis. RESULTS: Mortality in the BS-COPD and T-COPD groups was not significantly different, when sex was taken into account. BODEx, Charlson and COTE indices-but not type of exposure-predicted mortality in multivariate analysis. The value of the C-statistic for the BODEx index was not different than that of GOLD ABCD for BS-COPD, but was higher for T-COPD. The discriminatory value of the Charlson index was higher than that of COTE for BS-COPD, but no significant differences were found for T-COPD. CONCLUSIONS: Multidimensional indices of COPD severity and comorbidity predict all-cause mortality in BS-COPD. The behavior of the different indices is different for BS-COPD and T-COPD.

Esclerosis lateral amiotrófica: impacto del seguimiento neumológico y ventilación mecánica en la supervivencia. Experiencia en 114 casos / Amyotrophic Lateral Sclerosis: Impact of Pulmonary Follow-Up and Mechanical Ventilation on Survival. A Study of 114 Cases

Objetivo: Conocer el impacto en la supervivencia del manejo y tratamiento ventilatorio de enfermos con esclerosis lateral amiotrófica (ELA). Método: Análisis retrospectivo de 114 pacientes con ingreso consecutivo en un hospital general, evaluandodatos demográficos, tipo de presentación, manejo clínico, tratamiento con ventilación mecánica y supervivencia. Estadística: descriptiva y análisis de Kaplan-Meier. Resultados: Sesenta y cuatro pacientes tenían afectación bulbar inicial. La supervivencia media global tras el diagnóstico fue 28,0 meses (IC 95%, 21,1-34,8). Setenta pacientes fueron derivados al neumólogo (61,4%) y 43 recibieron ventilación no invasiva (VMNI) a los 12,7 meses (mediana) del diagnóstico. Se mantuvieron con VMNI sin posterior ventilación invasiva 37 pacientes, cuya supervivencia media fue de 23,3 meses (IC 95%, 16,7-28,8), superior en los no bulbares, aunque en rango no significativo. En 26 en los que la VMNI se indicó de manera programada la supervivencia fue mayor que en 11 en que se indicó sin evaluación neumológica previa (considerando tras el diagnóstico, p < 0,012, y en función del comienzo de la ventilación, p < 0,004). Se trataron en modalidad invasiva 7 pacientes cuya supervivencia fue de 72 meses (IC 95%, 14,36-129,6), mediana de 49,6 ± 17,5 (IC 95%, 15,3-83,8), y pese a las dificultades de laatención en domicilio, la aceptación y la tolerancia fueron aceptables. Conclusiones: La ventilación mecánica prolonga la supervivencia de la ELA. La evaluación neumológica programada tiene un impacto favorable en la supervivencia de los pacientes con ELA y constituye un elemento esencial en el manejo multidisciplinario de esta enfermedad

Objective: To study the impact of ventilatory management and treatment on the survival of patients with amyotrophic lateral sclerosis (ALS). Method: Retrospective analysis of 114 consecutive patients admitted to a general hospital, evaluating demographic data, type of presentation, clinical management, treatment with mechanical ventilation and survival. Statistics: descriptive and Kaplan-Meier estimator. Results: Sixty four patients presented initial bulbar involvement. Overall mean survival after diagnosis was 28.0 months (95% CI, 21.1-34.8). Seventy patients were referred to the pulmonary specialist (61.4%) and 43 received non-invasive ventilation (NIV) at 12.7 months (median) after diagnosis. Thirty seven patients continued to receive NIV with no subsequent invasive ventilation. The mean survival of these patients was 23.3 months (95% CI, 16.7-28.8), higher in those without bulbar involvement, although below the range of significance. Survival in the 26 patients receiving programmed NIV was higher than in the 11 patients in whom this was indicated without prior pulmonary assessment (considered following diagnosis, P < .012, and in accordance with the start of ventilation, P < .004). A total of 7 patients were treated invasively; mean survival in this group was 72 months (95% CI, 14.36-129.6), median 49.6 ± 17.5 (95% CI, 15.3-83.8), and despite the difficulties involved in home care, acceptance and tolerance was acceptable. Conclusions: Long-term mechanical ventilation prolongs survival in ALS. Programmed pulmonary assessment has a positive impact on survival of ALS patients and is key to the multidisciplinary management of this disease

Distribución de fenotipos clínicos en pacientes con enfermedad pulmonar obstructiva crónica por humo de biomasa y por tabaco / Distribution of Clinical Phenotypes in Patients With Chronic Obstructive Pulmonary Disease Caused by Biomass and Tobacco Smoke

Introducción: La exposición al humo de biomasa es un factor de riesgo para enfermedad pulmonar obstructiva crónica (EPOC). Se ignora si la EPOC por biomasa y por tabaco tienen características diferentes. Objetivo: Buscar diferencias clínicas entre ambos tipos de enfermedad. Métodos: Estudio observacional retrospectivo de 499 pacientes diagnosticados de EPOC por biomasa o por tabaco. Se compararon ambos grupos respecto a variables clínicas. Resultados: Ciento veintidós sujetos (24,4%) fueron clasificados en el grupo de biomasa y 377 (75,5%) en el de tabaco. El porcentaje de varones fue más alto en el grupo de tabaco (91,2% vs 41,8%, p < 0,0001) y la edad resultó inferior en este grupo (70,6 vs 76,2 años, p < 0,0001). Los valores del índice de masa corporal y del FEV1% fueron superiores en el grupo de biomasa (29,4 ± 5,7 vs 28,0 ± 5,1; p = 0,01 y 55,6 ± 15,6 vs 47,1 ± 17,1; p < 0,0001, respectivamente). El fenotipo mixto EPOC-asma fue más prevalente en el grupo biomasa (21,3% vs 5%, p < 0,0001), aunque esta diferencia desapareció al hacer una corrección por sexo. El fenotipo enfisema fue más frecuente en el grupo tabaco (45,9% vs 31,9%, p = 0,009). La prevalencia de los fenotipos bronquitis crónica y exacerbador, el peso de las comorbilidades y la tasa de ingresos hospitalarios fueron equivalentes entre los 2 grupos. Conclusión: Existen diferencias clínicas entre la EPOC por humo de biomasa y por tabaco, aunque podrían ser atribuibles en parte a desigualdades de sexo entre ambos grupos

Introduction: Exposure to biomass smoke is a risk factor for chronic obstructive pulmonary disease (COPD). It is unknown whether COPD caused by biomass smoke has different characteristics to COPD caused by tobacco smoke. Objective: To determine clinical differences between these two types of the disease. Methods: Retrospective observational study of 499 patients with a diagnosis of COPD due to biomass or tobacco smoke. The clinical variables of both groups were compared. Results: There were 122 subjects (24.4%) in the biomass smoke group and 377 (75.5%) in the tobacco smoke group. In the tobacco group, the percentage of males was higher (91.2% vs 41.8%, P < 0.0001) and the age was lower (70.6 vs 76.2 years, P < 0.0001). Body mass index and FEV1% values were higher in the biomass group (29.4 ± 5.7 vs 28.0 ± 5.1, P = 0.01, and 55.6 ± 15.6 vs 47.1 ± 17.1, P < 0.0001, respectively). The mixed COPD-asthma phenotype was more common in the biomass group (21.3% vs 5%, P < 0.0001), although this difference disappeared when corrected for gender. The emphysema phenotype was more common in the tobacco group (45.9% vs 31.9%, P = 0.009). The prevalence of chronic bronchitis, exacerbator phenotypes, the comorbidity burden and the rate of hospital admissions were the same in both groups. Conclusion: Differences were observed between COPD caused by biomass and COPD caused by tobacco smoke, although these may be attributed in part to uneven gender distribution between the groups

Amyotrophic lateral sclerosis: impact of pulmonary follow-up and mechanical ventilation on survival. A study of 114 cases.

OBJECTIVE: To study the impact of ventilatory management and treatment on the survival of patients with amyotrophic lateral sclerosis (ALS). METHOD: Retrospective analysis of 114 consecutive patients admitted to a general hospital, evaluating demographic data, type of presentation, clinical management, treatment with mechanical ventilation and survival. STATISTICS: descriptive and Kaplan-Meier estimator. RESULTS: Sixty four patients presented initial bulbar involvement. Overall mean survival after diagnosis was 28.0 months (95%CI, 21.1-34.8). Seventy patients were referred to the pulmonary specialist (61.4%) and 43 received non-invasive ventilation (NIV) at 12.7 months (median) after diagnosis. Thirty seven patients continued to receive NIV with no subsequent invasive ventilation. The mean survival of these patients was 23.3 months (95%CI, 16.7-28.8), higher in those without bulbar involvement, although below the range of significance. Survival in the 26 patients receiving programmed NIV was higher than in the 11 patients in whom this was indicated without prior pulmonary assessment (considered following diagnosis, P<.012, and in accordance with the start of ventilation, P<.004). A total of 7 patients were treated invasively; mean survival in this group was 72 months (95%CI, 14.36-129.6), median 49.6±17.5 (95%CI, 15.3-83.8), and despite the difficulties involved in home care, acceptance and tolerance was acceptable. CONCLUSIONS: Long-term mechanical ventilation prolongs survival in ALS. Programmed pulmonary assessment has a positive impact on survival of ALS patients and is key to the multidisciplinary management of this disease.

Distribution of clinical phenotypes in patients with chronic obstructive pulmonary disease caused by biomass and tobacco smoke.

INTRODUCTION: Exposure to biomass smoke is a risk factor for chronic obstructive pulmonary disease (COPD). It is unknown whether COPD caused by biomass smoke has different characteristics to COPD caused by tobacco smoke. OBJECTIVE: To determine clinical differences between these two types of the disease. METHODS: Retrospective observational study of 499 patients with a diagnosis of COPD due to biomass or tobacco smoke. The clinical variables of both groups were compared. RESULTS: There were 122 subjects (24.4%) in the biomass smoke group and 377 (75.5%) in the tobacco smoke group. In the tobacco group, the percentage of males was higher (91.2% vs 41.8%, P<.0001) and the age was lower (70.6 vs 76.2 years, P<.0001). Body mass index and FEV1% values were higher in the biomass group (29.4±5.7 vs 28.0±5.1, P=.01, and 55.6±15.6 vs 47.1±17.1, P<.0001, respectively). The mixed COPD-asthma phenotype was more common in the biomass group (21.3% vs 5%, P<.0001), although this difference disappeared when corrected for gender. The emphysema phenotype was more common in the tobacco group (45.9% vs 31.9%, P=.009). The prevalence of the chronic bronchitis and exacerbator phenotypes, the comorbidity burden and the rate of hospital admissions were the same in both groups. CONCLUSION: Differences were observed between COPD caused by biomass and COPD caused by tobacco smoke, although these may be attributed in part to uneven gender distribution between the groups.