Are Predictors for Overall Mortality in COPD Patients Robust over Time?

(1) Background: Mortality is a major outcome in research on chronic obstructive pulmonary disease (COPD) with various predictors described. However, the dynamic courses of important predictors over time are disregarded. This study evaluates if longitudinal assessment of predictors provides additional information on the mortality risk in COPD when compared with a cross-sectional analysis.; (2) In a longitudinal, prospective, non-interventional cohort study including mild to very severe COPD patients, mortality and its various possible predictors were annually assessed up to seven years.; (3) Results: 297 patients were analysed. Mean (SD) age was 62.5 (7.6) years and 66% males. Mean (SD) FEV1 was 48.8 (21.4)%. A total of 105 events (35.4%) happened with a median (95% CI) survival time of 8.2 (7.2/NA) years. No evidence for a difference between the raw variable and the variable history on the predictive value for all tested variables over each visit was found. There was no evidence for changing effect estimates (coefficients) across the study visits due to the longitudinal assessment; (4) Conclusions: We found no evidence that predictors of mortality in COPD are time dependent. This implies that cross-sectional measured predictors show robust effect estimates over time and multiple assessments seem not to change the predictive value of the measure

COPD – eine unterschätzte Erkrankung

COPD - An Underestimated Disease Abstract: Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition with a complex clinical picture. The diagnosis is not easy to make because COPD can develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in the early detection of the disease. Suspected COPD can be confirmed by special examinations in collaboration with pulmonologists. The new GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. A short- or long-acting bronchodilator (SAMA/SABA or LAMA/LABA) is recommended for group A, and a dual long-acting bronchodilator therapy (LABA+LAMA) is recommended for group B and E. In case of blood eosinophilia (≥300 cells/µl) and/or recent hospitalization for COPD exacerbation, triple therapy (LABA+LAMA+ICS) is recommended. General practitioners are important in implementing non-pharmacological measures (smoking cessation, regular exercise, vaccinations, patient selfmanagement education). However, this also underlines the high demands of the implementation of the GOLD guideline in daily practice.COPD ist eine heterogene Erkrankung mit komplexem Krankheitsbild. Die Diagnose ist nicht einfach zu stellen, denn COPD kann sich schleichend entwickeln und lange unbemerkt bleiben. Hausärztinnen und -ärzten kommt daher für die Früherkennung eine zentrale Rolle zu. Der COPD-Verdacht kann in Zusammenarbeit mit Pneumologen durch spezielle Untersuchungen abgesichert werden als Voraussetzung für das medikamentöse Therapiekonzept. Die neue GOLD-Guideline definiert drei COPD-Risikogruppen (A-B-E). Für Gruppe A wird ein kurz- oder langwirksamer Bronchodilatator (SAMA/SABA bzw. LAMA/LABA) empfohlen. Für Gruppe B und E wird eine Kombinationstherapie LABA+LAMA empfohlen. Bei Bluteosinophilie (≥ 300 Zellen/μl) und/oder kürzlicher Hospitalisierung aufgrund einer COPD-Exazerbation wird eine Dreifachtherapie (LABA+LAMA+ICS) empfohlen. Hausärztinnen und -ärzte sind wichtig bei der Umsetzung therapiebegleitender Massnahmen (Coaching von Patientinnen und Patienten, Impfungen, Rauchstopp, regelmässige Bewegung). Dies unterstreicht aber auch die hohen Anforderungen der Umsetzung der GOLD-Guideline in den Praxisalltag

Resting and Post Bronchial Challenge Testing Carbon Dioxide Partial Pressure in Individuals with and without Asthma

Objective: There is conflicting evidence about resting carbon dioxide levels in asthmatic individuals. We wanted to determine if transcutaneously measured carbon dioxide levels prior and during bronchial provocation testing differ according to asthma status reflecting dysfunctional breathing. Methods: We investigated active firefighters and policemen by means of a validated questionnaire on respiratory symptoms, spirometry, bronchial challenge testing with methacholine (MCT) and measurement of transcutaneous blood carbon dioxide partial pressure (PtcCO 2) at rest prior performing spirometry, one minute and five minutes after termination of MCT. A respiratory physician blinded to the PtcCO2 results assigned a diagnosis of asthma after reviewing the available study data and the files of the workers medical screening program. Results: The study sample consisted of 128 male and 10 female individuals. Fifteen individuals (11%) had physiciandiagnosed asthma. There was no clinically important difference in median PtcCO 2 at rest, one and five minutes after recovery from MCT in asthmatics compared to non-asthmatics (35.6 vs 35.7 mmHg, p = 0.466; 34.7 vs 33.4 mmHg, p = 0.245 and 37.4 vs 36.4 mmHg, p = 0.732). The median drop in PtcCO2 during MCT and the increase after MCT was lower in asthmatics compared to non-asthmatics (0.1 vs 3.2 mmHg, p = 0.014 and 1.9 vs 2.9 mmHg, p = 0.025). Conclusions: PtcCO2 levels at rest prior and during recovery after MCT do not differ in individuals with or without physicia

Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia

BACKGROUND: Community-acquired pneumonia (CAP) is the most frequent infection-related cause of death. The reference standard to diagnose CAP is a new infiltrate on chest radiograph in the presence of recently acquired respiratory signs and symptoms. This study aims to evaluate the diagnostic and prognostic accuracy of clinical signs and symptoms and laboratory biomarkers for CAP. METHODS: 545 patients with suspected lower respiratory tract infection, admitted to the emergency department of a university hospital were included in a pre-planned post-hoc analysis of two controlled intervention trials. Baseline assessment included history, clinical examination, radiography and measurements of procalcitonin (PCT), highly sensitive C-reactive protein (hsCRP) and leukocyte count. RESULTS: Of the 545 patients, 373 had CAP, 132 other respiratory tract infections, and 40 other final diagnoses. The AUC of a clinical model including standard clinical signs and symptoms (i.e. fever, cough, sputum production, abnormal chest auscultation and dyspnea) to diagnose CAP was 0.79 [95% CI, 0.75–0.83]. This AUC was significantly improved by including PCT and hsCRP (0.92 [0.89–0.94]; p < 0.001). PCT had a higher diagnostic accuracy (AUC, 0.88 [0.84–0.93]) in differentiating CAP from other diagnoses, as compared to hsCRP (AUC, 0.76 [0.69–0.83]; p < 0.001) and total leukocyte count (AUC, 0.69 [0.62–0.77]; p < 0.001). To predict bacteremia, PCT had a higher AUC (0.85 [0.80–0.91]) as compared to hsCRP (p = 0.01), leukocyte count (p = 0.002) and elevated body temperature (p < 0.001). PCT, in contrast to hsCRP and leukocyte count, increased with increasing severity of CAP, as assessed by the pneumonia severity index (p < 0.001). CONCLUSION: PCT, and to a lesser degree hsCRP, improve the accuracy of currently recommended approaches for the diagnosis of CAP, thereby complementing clinical signs and symptoms. PCT is useful in the severity assessment of CAP

Management of chronic obstructive pulmonary disease patients after hospitalization for acute exacerbation

The objective of this review is to sum up the literature regarding the management of patients with chronic obstructive pulmonary disease (COPD) after hospitalization for an acute exacerbation. Guidelines recommend a follow-up 4-6 weeks after hospitalization to assess coping strategies, inhaler technique, the need for long-term oxygen therapy and the measurement of FEV(1). This review discusses the follow-up of patients with exacerbations of COPD, the use and value of spirometry in their further management, the potential benefit of home monitoring, the value of long-term oxygen therapy, the value of self-management programs including the use of action plans, the potential benefit of noninvasive ventilation as well as the value of early rehabilitation. There is not enough literature to allow specific recommendations and to define components of a care plan after hospitalization for an acute exacerbation; however, early rehabilitation should be included

Management von Exazerbationen in Asthma und COPD

Asthma and chronic obstructive airways disease are chronic pulmonary diseases which have a high prevalence world-wide. Both conditions can deteriorate acutely and potentially put patients into life-threatening situations. Management of an acute exacerbation starts in the emergency consultation-setting and ends only once the longterm management has been thoroughly assessed and optimised in order to prevent future exacerbations. Exacerbation frequency is strongly associated with long-term morbidity and mortality in both diseases. Recent data have shown that short-course systemic steroids (5 days) for the treatment of an acute exacerbation of COPD are as successful as long-course treatments (14 days) in preventing exacerbations during the subsequent 6 months. Similarly the targeted use of antibiotics is discussed in this review.Asthma bronchiale und chronisch obstruktive Pneumopathie (COPD) sind chronische Atemwegserkrankungen mit einer hohen weltweiten Prävalenz. Beide Krankheiten können akut exazerbieren und dadurch Patienten in eine lebensbedrohliche Situation bringen. Das Management einer akuten Exazerbation fängt mit der akuten Situation an, hört aber erst nach sorgfältiger Überprüfung und Optimierung des Langzeitmanagements auf. Das Ziel ist, zukünftige Exazerbationen möglichst zu vermeiden, da die Exazerbation-Frequenz bei beiden Krankheiten stark mit der Langzeitprognose assoziiert ist. Neue Daten konnten zeigen, dass eine kürzere Behandlungsdauer mit systemischen Kortikosteroiden (5 Tage) bei einer akuten Exazerbation einer COPD die gleiche Erfolgschancen hat in den darauffolgenden 6 Monaten eine erneute Exazerbation zu verhindern wie eine Behandlungsdauer von 14 Tagen. Ebenfalls wird der gezielter Einsatz von Antibiotika in diesem Review diskutiert

The Early HOSPITAL Score to Predict 30-Day Readmission Soon After Hospitalization: a Prospective Multicenter Study.

BACKGROUND The simplified HOSPITAL score is an easy-to-use prediction model to identify patients at high risk of 30-day readmission before hospital discharge. An earlier stratification of this risk would allow more preparation time for transitional care interventions. OBJECTIVE To assess whether the simplified HOSPITAL score would perform similarly by using hemoglobin and sodium level at the time of admission instead of discharge. DESIGN Prospective national multicentric cohort study. PARTICIPANTS In total, 934 consecutively discharged medical inpatients from internal general services. MAIN MEASURES We measured the composite of the first unplanned readmission or death within 30 days after discharge of index admission and compared the performance of the simplified score with lab at discharge (simplified HOSPITAL score) and lab at admission (early HOSPITAL score) according to their discriminatory power (Area Under the Receiver Operating characteristic Curve (AUROC)) and the Net Reclassification Improvement (NRI). KEY RESULTS During the study period, a total of 3239 patients were screened and 934 included. In total, 122 (13.2%) of them had a 30-day unplanned readmission or death. The simplified and the early versions of the HOSPITAL score both showed very good accuracy (Brier score 0.11, 95%CI 0.10-0.13). Their AUROC were 0.66 (95%CI 0.60-0.71), and 0.66 (95%CI 0.61-0.71), respectively, without a statistical difference (p value 0.79). Compared with the model at discharge, the model with lab at admission showed improvement in classification based on the continuous NRI (0.28; 95%CI 0.08 to 0.48; p value 0.004). CONCLUSION The early HOSPITAL score performs, at least similarly, in identifying patients at high risk for 30-day unplanned readmission and allows a readmission risk stratification early during the hospital stay. Therefore, this new version offers a timely preparation of transition care interventions to the patients who may benefit the most

Roflumilast--a phosphodiesterase-4 inhibitor licensed for add-on therapy in severe COPD

Roflumilast is a selective phosphodiesterase 4 inhibitor which has been licensed in the European Union since 2010 and in Switzerland since November 2011 as an add-on treatment for patients with chronic obstructive pulmonary disease (COPD) in GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages 3 and 4 (FEV(1) <50% predicted after bronchodilatation) and frequent exacerbations despite correctly-dosed therapy with a long-acting bronchodilator. Roflumilast is designed to target both the systemic and pulmonary inflammation associated with COPD. In this review roflumilast's chemistry, pharmacodynamics, pharmacokinetics, clinical efficacy, safety and tolerability and the current ongoing clinical trials involving roflumilast are outlined. Information has been sourced from the Swiss and US product information monographs, peer-reviewed published literature (identified from a PubMed MEDLINE search 1966 - March 2012 using the term "roflumilast"), the COPD GOLD international guidelines for the management of COPD (Revised 2011) and an independent analysis of phase 3 clinical trial data by FDA staff physicians. Clinical efficacy in terms of a modest gain in FEV(1)% and a reduction in exacerbation rate has been demonstrated in phase 3 clinical trials and roflumilast has been recently incorporated into international treatment guidelines. However data examining roflumilast as add-on therapy to long-acting bronchodilators and ICS (standard therapy) is currently awaited and phase 4 post-marketing studies are required to determine the incidence and severity of adverse events and the long-term beneficial effects of roflumilast as a maintenance therapy for COPD in every-day clinical practice