Enfermedad pulmonar obstructiva crónica. Actualización 2014

La enfermedad pulmonar obstructiva crónica (EPOC) es un problema socio-sanitario de primera magnitud por su elevada prevalencia (10% en nuestro País), incidencia creciente (la Organización Mundial de la Salud estima que será la tercera causa de muerte en el mundo en 2020) y elevados costes socio-económicos asociados. En los últimos años se han producido avances notables en el conocimiento y tratamiento de la enfermedad que es ya considerada una enfermedad “prevenible y tratable”. El texto que sigue resume los principales aspectos diagnósticos y terapéuticos de la EPOC a partir de la última versión (2014) del documento de la estrategia GOLD (Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease), el documento de referencia mundial en este ámbito. Hace énfasis especial en la nueva forma de determinar la gravedad de la enfermedad, basada en una valoración multi-dimensional de la EPOC que tiene en cuenta no sólo la severidad de la limitación al flujo aéreo (como se había hecho tradicionalmente hasta ahora), sino que añade dos dimensiones de gran valor clínico y pronóstico (el nivel de síntomas del paciente y la historia previa de agudizaciones de la enfermedad). Con estas tres dimensiones, los pacientes con EPOC se clasifican actualmente en uno de cuatro posibles grupos (A, B, C o D) y el tratamiento farmacológico recomendado se ajusta a esta clasificación.Chronic obstructive pulmonary disease (COPD) is a major public health problem because of its high prevalence (10% in Spain), raising incidence (the World Health Organization predicts that it will be the third cause of death in the world by the year 2020) and high associated socio-economic cost. Over the last few years, there have been very significant advances in the understanding and treatment of COPD, so it is now considered a “preventable and treatable disease”. The following text summarizes the main diagnostic and therapeutic aspects of this disease according to the last version (2014) of the GOLD (Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease) strategy document, which is the global reference for this disease. In particular, it is of note that the current recommendation for the assessment of COPD is multidimensional. It includes the assessment of the level of current symptoms, as well as the traditional assessment of airflow limitation severity and the previous history of exacerbations that can help in predicting the risk of future events. According to these three dimensions, four different groups of patients can be identified (A, B, C, and D), and specific pharmacological treatment is recommended for each of them.

Implications of chronic obstructive pulmonary disease (COPD) on patients’ health status: A western view

SummaryAimTo assess and compare health status among chronic obstructive pulmonary disease (COPD) patients presenting for treatment in six countries and in two healthcare settings using a generic health status instrument.MethodsA population based cross-sectional survey was conducted among 2703 patients and their physicians (1381 in primary and 1322 in specialty care) in five EU countries and the USA. Information was collected on demographic and clinical characteristics, exacerbations and health status estimated using EQ-5D.ResultsThe mean EQ-5D score for COPD patients was similar between primary and specialty settings in all countries except Italy. Approximately, half of the patients indicated some impairment in health status on mobility, usual activities, pain/discomfort and anxiety/depression domains of EQ-5D. Approximately, 5% of patients in EU countries except UK had health status valued as worse than death based on valuations of the general population. Patients suffering from severe breathlessness, experiencing ⩾3 exacerbations in the previous year, categorised as severe according to GOLD criteria, and experiencing day-time and night-time symptoms had significantly impaired health status.ConclusionCOPD patients classified as moderate/severe in clinical practice have worse health status compared to mild patients. This impairment is similar in primary and specialty setting across western countries

Respiratory symptoms and small airway dysfunction in current and former smokers without spirometric COPD

No abstract available

Interleukin-8 expression in bronchoalveolar lavage cells in the evaluation of alveolitis in idiopathic pulmonary fibrosis

AbstractInterleukin-8 (IL-8) is a neutrophilic chemotactic factor which may have a prominent role in the attraction of neutrophils to the lung in idiopathic pulmonary fibrosis (IPF). The objective of this study was to investigate the usefulness of IL-8 expression in bronchoalveolar lavage (BAL) cells in the evaluation of alveolitis in IPF. We analysed the BAL cell expression of IL-8 by immunocytochemistry in 19 patients with IPF (six smokers, three ex-smokers and ten non-smokers) and in a control group composed of 14 individuals (six smokers, eight non-smokers). In IPF, BAL was performed on both the pulmonary lobe with the most extensive involvement and the one less extensively involved on high-resolution computed tomography (HRCT) scans. The percentages and absolute numbers of BAL IL-8+ macrophages from lobes with the most extensive HRCT scan involvement (36 ± 6% and (6 ± 2 × 104 ml−1) (SE) and from those less extensively involved [26% ± 4% and (6 ± 1) × 104 ml−1] were significantly higher with respect to both those from healthy smokers [17% ± 6% and (7 ± 4) × 104 ml−1] and those from non-smokers [2% ± 1% and (1 ± 0·3) × 104 ml−1] (P=0·005 and P=0·001, respectively), without differences between the two lobes. In contrast, both the proportions and the absolute numbers of BAL neutrophils in IPF were significantly higher in lobes with the most extensively involved HRCT scan in comparison with lobes with the least extensive involvement [13% ± 3%, (3 ± 1) × 104 ml−1 vs. 8% ± 2%, (1 ± 0·3) × 104 ml−1, P=0·05]. Moreover, the numbers of BAL neutrophils, but not those of IL-8+ macrophages, correlated with the extent of total pulmonary HRCT scan abnormalities in the most involved lobe (r=0·64, P=0·04). A correlation between neutrophils and IL-8+ cells was not observed. The results of this study suggest that, in IPF, BAL neutrophilia offers a better description of the disease inflammatory process than the expression of IL-8 in BAL cells

Estimated central blood volume in cirrhosis

The estimated central blood volume (i.e., blood volume in the heart cavities, lungs and central arterial tree) was determined by multiplying cardiac output by circulatory mean transit time in 19 patients with cirrhosis and compared with sympathetic nervous activity and circulating level of atrial natriuretic factor. Arterial norepinephrine level, an index of overall sympathetic nervous activity (3.08 nmol/L in patients vs. 1.36 nmol/L in controls; p < 0.01) was negatively correlated (r = -0.54, p < 0.01) with estimated central blood volume (mean = 23 ml/kg in patients vs. 27 ml/kg in controls; p < 0.05). Similarly, renal venous norepinephrine level (an index of renal sympathetic tone; 4.26 nmol/L in patients vs. 1.78 nmol/L in controls; p < 0.01) was inversely correlated with estimated central blood volume (r = -0.53, n = 18, p < 0.02). No significant correlation could be established between arterial atrial natriuretic factor level (8.9 pmol/L in patients vs. 9.6 pmol/L in controls; not significant) and estimated central blood volume. Hemodynamic values were subsequently modified with oral propranolol (80 mg). During -adrenergic blockade, the mean estimated central blood volume was not altered significantly, except in six patients who exhibited decreases in mean arterial blood pressure (85 to 69 mm Hg; n = 6) and decreases in mean estimated central blood volume (23.2 to 20.6 ml/kg; n = 6, p < 0.05). Slight increases were observed in mean right atrial pressure (2.2 to 3.7 mm Hg; n = 14, p < 0.05); this change was positively correlated with the change in estimated central blood volume (r = 0.44, n = 14, p = 0.06). In conclusion, reduced estimated central blood volume probably unloads volume receptors and baroreceptors, thus provoking enhanced overall and renal sympathetic nervous activity and thereby contributing to increased water and salt retention in cirrhosis. During -adrenergic blockade estimated central blood volume changes correlated with alterations in preload and afterload. These findings indicate that central circulatory and arterial underfilling is a key element of the hemodynamic derangement observed in cirrhosis

Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled trial

Background: Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level. Aims: The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients. Methods: From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV1 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient’s empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years. Results: IC enhanced self-management (P=0.02), reduced anxiety–depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years. Conclusion: The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force

Hemodynamic alterations in cirrhosis and portal hypertension

Portal hypertension (PHT) is associated with hemodynamic changes in intrahepatic, systemic, and portosystemic collateral circulation. Increased intrahepatic resistance and hyperdynamic circulatory alterations with expansion of collateral circulation play a central role in the pathogenesis of PHT. PHT is also characterized by changes in vascular structure, termed vascular remodeling, which is an adaptive response of the vessel wall that occurs in response to chronic changes in the environment such as shear stress. Angiogenesis, the formation of new blood vessels, also occurs with PHT related in particular to the expansion of portosystemic collateral circulation. The complementary processes of vasoreactivity, vascular remodeling, and angiogenesis represent important targets for the treatment of portal hypertension. Systemic and splanchnic vasodilatation can induce hyperdynamic circulation which is related with multi-organ failure such as hepatorenal syndrome and cirrhotic cadiomyopathy

Improved care of acute exacerbation of chronic obstructive pulmonary disease in two academic emergency departments

Background: Although several chronic obstructive pulmonary disease (COPD) practice guidelines have been published, there is sparse data on the actual emergency department (ED) management of acute exacerbation of COPD (AECOPD). Aims: Our objectives were to examine concordance of ED care of AECOPD in older patients with guideline recommendations and to evaluate whether concordance has improved over time in two academic EDs. Methods: Data were obtained from two cohort studies on AECOPD performed in two academic EDs during two different time periods, 2000 and 2005–2006. Both studies included ED patients, aged 55 and older, who presented with AECOPD, and cases were confirmed by emergency physicians. Data on ED management and disposition were obtained from chart review for both cohorts. Results: The analysis included 272 patients: 72 in the 2000 database and 200 in the 2005–2006 database. The mean age of the patients was 72 years; 50% were women and 80% white. In 2005–2006, overall concordance with guideline recommendations was high (for chest radiography, pulse oximetry, bronchodilators, all ≥ 90%), except for arterial blood gas testing (7% among the admitted) and discharge medication with systemic corticosteroids (42%). Compared to the 2000 data, the use of systemic corticosteroids in the ED improved from 53 to 77% [absolute improvement: 24%, 95% confidence interval (CI): 11–37%], and the use of antibiotics among the patients with respiratory infection symptoms improved from 56 to 78% (absolute improvement: 22%, 95% CI: 6–38%). Conclusions: Overall concordance with guideline-recommended care for AECOPD was high in two academic EDs, and some emergency treatments have improved over time