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Switching inhaler regimens can be driven by poor disease control but also by nonclinical factors, such as cost and environmental impact. The consequences of switching for nonclinical reasons are largely unclear.To systematically review the real-world consequences of switching inhaler regimens for nonclinical reasons in asthma and/or chronic obstructive pulmonary disease patients.Embase, MEDLINE, EBM Reviews, and EconLit were searched to November 21, 2020. Conference searches and reference checking were also performed. Real-world studies of asthma and/or chronic obstructive pulmonary disease patients undergoing a switch in inhaler regimen for any reason apart from clinical need were included. Two reviewers screened and extracted data. Key outcomes included symptom control, exacerbations, and patient-doctor relationships.A total of 8,958 records were screened and 21 studies included. Higher-quality (matched comparative) studies were prioritized. Five matched studies (6 datasets) reported on symptom control: 5 datasets (n = 7,530) with unclear patient consent reported improved disease control following switching, and 1 dataset (n = 1,648) with non-consented patients reported significantly worsened disease control. Three matched studies (5 datasets, n = 10,084) reported on exacerbation rate ratios; results were heterogeneous depending on the definition used. Two studies (n = 137) reported that switching inhaler regimens could have a negative impact on the doctor-patient relationship, especially when the switches were non-consented. Study quality was generally low.Switching inhaler regimens is a complex issue that can have variable clinical consequences and can harm the patient-doctor relationship. Limited high-quality evidence was identified, and study designs were heterogeneous. A robust framework is needed to guide the personalized switching of inhalers.

The Respimat® Soft Mist™ inhaler (SMI) has recently been improved, with a re-usable device replacing the disposable version. Certain countries are currently phasing out the disposable inhaler. This study aimed to assess patient satisfaction with and preference for the re-usable device. This 4–6-week, multicentre, open-label, prospective, real-world, non-interventional study was conducted across six European countries. Patients with chronic obstructive pulmonary disease were enrolled between October and December 2019, in three cohorts: (1) currently using the re-usable Respimat SMI; (2) switched from disposable Respimat SMI at study entry; and (3) naïve to any Respimat SMI. Patients were assessed using the Patient Satisfaction and Preference Questionnaire (PASAPQ) and Ease of Handling Questionnaire. In total, 262 patients were enrolled. At follow-up, the mean PASAPQ score was 83.3/100 overall, with similar results across all three patient cohorts. Most patients were ‘satisfied’ or ‘very satisfied’ with the re-usable device. The overall score for willingness to continue using the device was 87.8/100. In total, 13 adverse events were recorded, none of which was classified as serious. This study provides real-world evidence for practitioners to start patients on Respimat re-usable, irrespective of a patient’s prior experience with this inhaler. Plain language summary: Inhalers are often used to treat patients with chronic obstructive pulmonary disease (COPD). However, there are many available, which can lead to confusion and poor inhaler technique. It is important for a patient to be happy with their inhaler. This study looked at how patients liked the re-usable Respimat® Soft Mist™ inhaler vs. their previous inhaler. It also asked whether they would be willing to continue using the device at the end of the study period.After 4–6 weeks of using the re-usable device, patients reported that they were happy with the inhaler and most would be willing to carry on using it.Overall, these results show that doctors can prescribe Respimat re-usable to patients, even if the patient has not used the inhaler before.

Background Inhaler selection is important when managing respiratory conditions; a patient’s inhalation technique should be appropriate for the selected device, and patients should ideally be able to use a device successfully regardless of disease severity. The NEXThaler is a multidose dry-powder inhaler with a breath-actuated mechanism (BAM) and dose counter that activates only following inhalation, so effectively an ‘inhalation counter’. We assessed inspiratory flow through the NEXThaler in two studies and examined whether inhalation triggered the BAM. Methods The two studies were open-label, single-arm, and single visit. One study recruited patients with asthma aged ≥ 18 years; the other recruited patients with chronic obstructive pulmonary disease (COPD) aged ≥ 40 years. All patients inhaled twice through a placebo NEXThaler. The inspiratory profile through the device was assessed for each inhalation using acoustic monitoring, with flow at and time to BAM firing, peak inspiratory flow (PIF), and total inhalation time assessed. Results A total of 40 patients were enrolled in the asthma study: 20 with controlled asthma and 20 with partly controlled/uncontrolled asthma. All patients were able to trigger the BAM, as evidenced by the inhalation counter activating on closing the device. Mean flow at BAM firing following first inhalation was 35.0 (range 16.3–52.3) L/min; mean PIF was 64.6 (35.0–123.9) L/min. A total of 72 patients were enrolled in the COPD study, with data analysed for 69 (mean forced expiratory volume in 1 s 48.7% predicted [17–92%]). As with the asthma study, all patients, regardless of airflow limitation, were able to trigger the BAM. Mean flow at BAM firing following first inhalation was 41.9 (26.6–57.1) L/min; mean PIF was 68.0 (31.5–125.4) L/min. Device usability was rated highly in both studies, with 5 min sufficient to train the patients, and a click heard shortly after inhalation in all cases (providing feedback on BAM firing). Conclusions Inhalation flows triggering the BAM in the NEXThaler were similar between patients with controlled and partly controlled/uncontrolled asthma, and were similar across COPD airflow limitation. All enrolled patients were able to activate the device.

Additional file 1. Device usability questionnaire and results.

ObjectivesThe large number of available medicines and devices makes it almost impossible to have sufficient knowledge of each individual medicine and device, especially for general practitioners. This may lead to suboptimal treatment, more exacerbations, hospitalisations and higher treatment costs. Reducing the number of medicines and devices, based on rational criteria, allows physicians and pharmacists to build experience with a more limited set of medicines and to standardise the inhalation instructions.MethodsIn this study inhalers are compared by means of the System of Objectified Judgement Analysis (SOJA) method. The following selection criteria were applied: uniformity in device, number of steps per inhalation, risk of errors, hygienic aspects, feedback mechanism, and risk of inhalation with an empty inhaler.ResultsSubstantial differences were seen in the overall scores, with the Ellipta device showing the highest score, followed by Diskus/Accuhaler, Genuair and Nexthaler. Several devices require more or less identical techniques, such Ellipta and Diskus/Accuhaler as well as Genuair and Novolizer. When patients use these devices in combination this increases their uniformity, because additional medicines become available for the devices: starting therapy with Diskus or Novolizer and follow-up with Ellipta or Genuair. The resistance of Respimat and Breezhaler is lower than that of other devices, which makes these devices suitable for patients who cannot generate sufficient inhalation flow.ConclusionsA substantial reduction of inhalers, combined with optimal and standardised instructions, should improve the care of patients with chronic obstructive pulmonary disease.

Optimal delivery of medication via dry powder inhalers, the most commonly prescribed inhaler type, is dependent on a patient achieving a minimum level of inspiratory flow during inhalation. However, measurement of peak inspiratory flow (PIF) against the simulated resistance of a dry powder inhaler is not frequently performed in clinical practice due to time or equipment limitations. Therefore, defining which patient characteristics are associated with lower PIF is critically important to help clinicians optimize their inhaler choice through a more personalized approach to prescribing. The objective of this scoping review was to systematically evaluate patient and disease characteristics determining PIF in patients with chronic obstructive pulmonary disease (COPD). Medline, Cochrane and Embase databases were systematically searched for relevant studies on PIF in patients with COPD published in English between January 2000 and May 2021. The quality of evidence was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation checklist. Of 3382 citations retrieved, 35 publications were included in the review (nine scored as high quality, 13 as moderate, nine as low, and four as very low). Factors correlating with PIF in >70% of papers included both patient characteristics (lower PIF correlated with increased age, female gender, shorter height, decreased handgrip and inspiratory muscle strength, and certain comorbidities) and disease characteristics (lower PIF correlated with markers of lung hyperinflation, lower peak expiratory flow [PEF] and increased disease severity). Other factors correlating with adequate/optimal or improved PIF included education/counseling and exercise/inspiratory muscle training; impaired physical function and errors in inhalation technique/non-adherence were associated with low/suboptimal PIF. In conclusion, clinicians should measure PIF against the simulated resistance of a particular device wherever possible. However, as this often cannot be done due to lack of resources or time, the patient and disease characteristics that influence PIF, as identified in this review, can help clinicians to choose the most appropriate inhaler type for their patients.

Background Asthma and chronic obstructive pulmonary disease (COPD) are widespread chronic conditions with medication frequently delivered by inhalers. These can be challenging to use correctly, but the scale of misuse and the specific aspects of failure are unclear. Methods We used systematic review methods to search 9 databases in May 2015 to identify and review studies that assessed adults (18 years or older) with asthma or COPD using inhalers of various types including pressurised metered dose inhalers (pMDIs), dry powder inhalers and the Respimat inhaler. Studies must have reported the scale of inhaler misuse, variation by type of inhaler or which steps patients had difficulty completing accurately. Results The types of inhalers, inhaler interventions and definitions of failure and misuse varied widely in the 38 studies identified. It was not possible to draw conclusions on the differential failure rates between different types of inhalers or any patient characteristics. Of the studies reporting failure or misuse rates, the majority ranged between 0 and 20%. Studies were inconsistent regarding the number of inhaler steps collected, reported and labelled as critical. Conclusions There is evidence for all identified inhalers that some people may be using them incorrectly, but it is unclear which inhalers have higher rates of misuse or which steps within the inhaler technique are most difficult for patients. The optimal techniques for using inhalers are not standardised. Researchers undertaking future inhaler studies are respectfully directed to our recommendations for future research.

Objective: Healthcare professionals (HCPs) are required to assess and train patients in the correct use of inhalers but are often unable to demonstrate correct technique themselves. We sought to assess the level of training required for HCPs to master and maintain device mastery when using two different dry powder inhalers (DPIs). Methods: We conducted a randomized, un-blinded, crossover study in undergraduate HCPs who undertook a six-step training procedure (intuitive use, patient information leaflet, instructional video, individual tuition from expert, then two repeats of individual tuition) for the use of Turbuhaler® (an established device) and Spiromax® (a newer device, reportedly easier to use). Device mastery (absence of errors) was evaluated by expert assessors at each training step. Maintenance of mastery was assessed 4 ± 1 week (visit 2) and 8 ± 2 weeks (visit 3) after initial training (visit 1). Results: Of 516 eligible participants, 113 (22%) demonstrated device mastery prior to training on Spiromax® compared with 20 (4%) on Turbuhaler® (p < 0.001). The median number of training steps required to achieve mastery was 2 (interquartile range [IQR] 2–4) for Spiromax® and 3 (IQR 2–4) for Turbuhaler® (p < 0.001). A higher number of participants maintained mastery with Spiromax® compared with Turbuhaler®, at visits 2 and 3 (64% vs 41% and 79% vs 65%, respectively; p < 0.001). Conclusions: There are significant differences in the nature and extent of training required to achieve and maintain mastery for Spiromax® and Turbuhaler® devices. The implications on clinical practice, device education delivery, and patient outcomes require further evaluation.

Item does not contain fulltext To identify patients hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD) who have a poor prognosis and might benefit from proactive palliative care, a set of indicators had been developed from the literature. A patient is considered eligible for proactive palliative care when meeting >/=2 criteria of the proposed set of 11 indicators. In order to develop a doctor-friendly and patient-convenient tool, our primary objective was to examine whether these indicators are documented consistently in the medical records. Besides, percentage of patients with a poor prognosis and prognostic value were explored. We conducted a retrospective medical record review of 33 patients. Five indicators; non-invasive ventilation (NIV), comorbidity, body mass index (BMI), previous admissions for acute exacerbation COPD and age were always documented. Three indicators; hypoxaemia and/or hypercapnia, professional home care and actual forced expiratory volume1% (FEV1%) were documented in more than half of the records, whereas the clinical COPD questionnaire (CCQ), medical research council dyspnoea (MRC dyspnoea) and the surprise question were never registered. Besides, 78.8% of the patients met >/=2 criteria and there was a significant association between meeting >/=2 criteria and mortality within 1 year (one-sided Fisher's exact test, p = 0.04). The set of indicators for proactive palliative care in patients with COPD appeared to be user-friendly and feasible.

Poor inhaler technique hampers the efficacy of drug therapy in asthma and chronic obstructive pulmonary disease. Not only does this affect individual patient care, but it also impacts on the wider health care economics associated with these conditions. Treatment guidelines recommend a systematic approach to drug class selection; however, standardization of inhaler selection is currently difficult owing to the complexity of the interaction between the inhaler device and the patient. Specifically, individual patient preference can influence how successful a treatment is overall. This article reviews inhaler devices from the patient perspective, with a particular focus on the dry powder inhaler HandiHaler(®) and Respimat(®) Soft Mist™ Inhaler. It discusses factors that influence device preference and treatment compliance and reviews tools that can aid health care professionals to better match inhaler devices to individual patients' needs.

Introduction: Impaired physical performance (PP) and low habitual physical activity (PA) are common features of people with COPD. Recently, a conceptual framework was published in which PP and PA represent associated but separate domains of physical function in the elderly. The question is whether this framework might be applicable as an aid in the understanding of physical functioning impairment in patients with COPD. Aims: The current study had two aims: 1) to determine the distribution of people with COPD over the PP-PA quadrants; and 2) to explore whether differences exist in clinical characteristics between the PP-PA quadrants. Method: PP was measured with a six-minute walk distance (6MWD) and PA was objectively assessed with an accelerometer. In addition, patient- and health status characteristics were systematically acquired. Patients were mapped using a quadrant based on their PP and PA into mutually exclusive categories: I) Low PP (6MWD Results: A total of 662 COPD were included in this study. Distribution over the quadrants was as follow: I=39%, II=19%, III=16%, IV=26%. Statistically significantly differences were found across the quadrants, among others, for age, FEV1, BMI, exacerbation frequency Conclusion: This study shows that COPD patients could be distributed over the PP-PA quadrant and that significant differences were found in clinical characteristics across these quadrants

Table S1. Training on inhaler technique using a six-step process* during the cross-sectional phase, Supplementary material â study governance, training on inhaler technique using a six-step process during the cross-sectional phase, checklist for inhaler errors, serious adverse events by preferred term. Table S2. Checklist for inhaler errors. Table 3. Serious adverse events by preferred term. (DOCX 20 kb)

Background Incorrect inhaler technique is a common cause of poor asthma control. This two-phase pragmatic study evaluated inhaler technique mastery and maintenance of mastery with DuoResp® (budesonide-formoterol [BF]) Spiromax® compared with Symbicort® (BF) Turbuhaler® in patients with asthma who were receiving inhaled corticosteroids/long-acting β2-agonists. Methods In the initial cross-sectional phase, patients were randomized to a 6-step training protocol with empty Spiromax and Turbuhaler devices. Patients initially demonstrating ≥1 error with their current device, and then achieving mastery with both Spiromax and Turbuhaler (absence of healthcare professional [HCP]-observed errors), were eligible for the longitudinal phase. In the longitudinal phase, patients were randomized to BF Spiromax or BF Turbuhaler. Co-primary endpoints were the proportions of patients achieving device mastery after three training steps and maintaining device mastery (defined as the absence of HCP-observed errors after 12 weeks of use). Secondary endpoints included device preference, handling error frequency, asthma control, and safety. Exploratory endpoints included assessment of device mastery by an independent external expert reviewing video recordings of a subset of patients. Results Four hundred ninety-three patients participated in the cross-sectional phase, and 395 patients in the longitudinal phase. In the cross-sectional phase, more patients achieved device mastery after three training steps with Spiromax (94%) versus Turbuhaler (87%) (odds ratio [OR] 3.77 [95% confidence interval (CI) 2.05–6.95], p

COPD and obesity often coexist and there is a complex interaction between them. Our aim was to evaluate the prevalence of obesity in a secondary care COPD population. Furthermore, the presence of comorbidities in obese (COPD

Contains fulltext : 193643.pdf (Publisher’s version ) (Open Access) We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.

Eleonore H Koolen,1 Philip J van der Wees,2 Gert P Westert,2 Richard Dekhuijzen,1 Yvonne F Heijdra,1 Alex J van ’t Hul1 1Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands; 2Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands Introduction: This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options. Theory and methods: The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems. Results: An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care. Discussion: In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care. Conclusion: Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs. Keywords: COPD, COPD management, integrated care, Chronic Care Model, health status

Introduction: An understanding of the level of activation for self-management, defined as patients’ knowledge, skills and self-efficacy regarding self-management is important. It gives clues how self-management may be improved in the individual patient. In this study, the level of activation for self-management was assessed in patients with asthma or COPD at the time of referral by their General Practitioner to a pulmonologist. Method: Between September 2014-December 2016, the integrated health status was determined in patients with asthma or COPD referred to a pulmonologist using a specifically developed diagnostic pathway. Part of this diagnostic pathway is to examine the level of activation for self-management using the 13-item Patient Activation Measurement (PAM-13). The PAM-13 measures patients’ activation for self-management. Four different levels of activation can be distinguished, from very low (PAM-1) to high (PAM-4). Results: 112 valid PAMs were obtained in patients with asthma and 90 in patients with COPD. The distribution of PAM scores in asthma patients was: 35% of the PAM-1, 21% PAM-2, 38% PAM-3 and 5% PAM-4. In COPD patients the distribution was: 30% PAM-1, 28% PAM-2, 36% PAM-3 and 7% PAM-4. Conclusion: In 56% of the asthma patients and in 58% of the COPD patients there is little or no degree of activation for self-management (PAM-1 and PAM-2) at the time of referral from primary to secondary care.

Item does not contain fulltext OBJECTIVE: Lung cancer patients report among the highest distress rates of all cancer patients. Partners report similar distress rates. The present study examined the effectiveness of additional mindfulness-based stress reduction (care as usual [CAU] + MBSR) versus solely CAU to reduce psychological distress in lung cancer patients and/or their partners. METHODS: We performed a multicentre, parallel-group, randomized controlled trial. Mindfulness-based stress reduction is an 8-week group-based intervention, including mindfulness practice and teachings on stress. Care as usual included anticancer treatment, medical consultations, and supportive care. The primary outcome was psychological distress. Secondary outcomes included quality of life, caregiver burden, relationship satisfaction, mindfulness skills, self-compassion, rumination, and posttraumatic stress symptoms. Outcomes were assessed at baseline, post-intervention, and 3-month follow-up. Linear mixed modeling was conducted on an intention-to-treat sample. Moderation (gender, disease stage, baseline distress, participation with/without partner) and mediation analyses were performed. RESULTS: A total of 31 patients and 21 partners were randomized to CAU + MBSR and 32 patients and 23 partners to CAU. After CAU + MBSR patients reported significantly less psychological distress (p = .008, d = .69) than after CAU. Baseline distress moderated outcome: those with more distress benefitted most from MBSR. Additionally, after CAU + MBSR patients showed more improvements in quality of life, mindfulness skills, self-compassion, and rumination than after CAU. In partners, no differences were found between groups. CONCLUSION: Our findings suggest that psychological distress in lung cancer patients can be effectively treated with MBSR. No effect was found in partners, possibly because they were more focused on patients' well-being rather than their own.

The interactions between obesity and chronic obstructive pulmonary disease (COPD) are being increasingly explored. In part, this is due to the globally increasing prevalence rates of obesity. The prevalence of obesity in COPD patients is variable, and it seems that obesity is more common in COPD patients compared with subjects who do not have COPD. However, further studies are encouraged in this area due to observed inconsistencies in the current data. In this review, we focus on the knowledge of the effects of obesity on dyspnea, pulmonary function, exercise capacity and exacerbation risk. Reduction of dyspnea is one of the main therapy targets in COPD care. There is still no consensus as to whether obesity has a negative or even a positive effect on dyspnea in COPD patients. It is hypothesized that obese COPD patients might benefit from favourable respiratory mechanics (less lung hyperinflation). However, despite less hyperinflation, obesity seems to have a negative influence on exercise capacity measured with weight-bearing tests. This negative influence is not seen with weight-supported exercise such as cycling. With respect to severe exacerbations, obesity seems to be associated with better survival. In summary, it is concluded that due to differences in study methodology and cohort selection, there are still too many knowledge gaps to develop guidelines for clinical practice. Further exploration is needed to get conclusive answers.

ObjectiveTimeliness may influence emotional distress during the diagnostic phase of suspected lung cancer patients. We performed a prospective observational study to compare distress and quality of life (QoL) in two medical centres with a Rapid Outpatient Diagnostic Program (RODP) and two using conventional Stepwise Diagnostic Approach (SDA) on the basis of trained nurse-led care. MethodsOutpatients with radiological suspicion of lung cancer completed the Hospital Anxiety and Depression Scale (HADS), European Organization for Research and Treatment of Cancer 30-item Quality of Life Questionnaire (QLQ-C30) and its 13-item Lung Cancer specific module (QLQ-LC13) upon first visit, 2days later, thereafter weekly for 5weeks and after 3months. ResultsThe 72 SDA patients and 121 RODP patients had a mean pre-diagnostic HADS-total score of 13.5 (SD 7.6); 63.4% had a score 10. Baseline QLQ-C30 global QoL was 61.6 (SD 22.7) exceeding reference values for lung cancer patients. Generalized least square models showed a significant centre by time interaction effect: during the first 6weeks, HADS-total scores decreased in RODP patients (13.8-11.9) but sustained in SDA patients (13.1-13.6), whereas QoL showed no relevant changes. Times to diagnosis and discussion of therapy plan for RODP patients were 7 and 11days shorter, respectively. ConclusionsSuspected lung cancer patients had high baseline distress levels. A decrease over time was found in RODP compared with SDA patients. QoL did not change relevantly. Albeit observational, these data indicate that patients experience less distress in rapid diagnostic programs than in stepwise diagnostic evaluation. Copyright (c) 2014 John Wiley & Sons, Ltd.

Item does not contain fulltext BACKGROUND: Inhaled therapy is the cornerstone of pharmacotherapy in patients with asthma and chronic obstructive pulmonary disease (COPD). Appropriate inhalation device selection is as important as drug choice but device-specific guidance appears to be lacking. METHODS: To quantify the level of inhalation-device recommendations in clinical guidelines, a review was conducted by hand-searching national and international asthma and COPD guidelines (Global Initiative for Asthma [GINA] and Global initiative for chronic Obstructive Lung Disease [GOLD] guidelines) and an international guideline on device selection (the American College of Chest Physicians/American College of Asthma, Allergy, and Immunology [ACCP/ACAAI]). For each guideline, the number of pages, tables/figures and references relating to inhalation devices was identified. RESULTS: GINA and GOLD guidelines contain very little inhalation device-specific guidance beyond recommendations for demonstrating and testing correct inhalation technique

Pressure on healthcare budgets is increasing, while at the same time patent protection for many branded inhaled medications has expired, leading to the development and growing availability of generic inhaled medicines. Generic inhaled drugs are therapeutically equivalent to original branded options but may differ in their formulation and inhalation device. This new situation raises questions about the potential impact of switching from branded to generic drug/inhaler combination products in patients with asthma or COPD, with or without their consent, in countries where this is permitted. Inhalation devices, particularly dry powder inhalers, vary markedly in their design, method of operation and drug delivery to the lungs. Current guidelines stress the importance of training patients how to use their inhalers but offer little or no guidance on how this should be achieved. Non-adherence to therapy and incorrect inhaler usage are recognised as major factors in poorly or uncontrolled asthma and COPD and switching patients to a different inhaler device may exacerbate these problems, particularly in patients who disagree to switch. Where switching is permitted or mandatory, adequate patient instruction and follow-up monitoring should be provided routinely.

Inhalation therapy remains the cornerstone of treatment for bronchial diseases. Despite being pharmacologically efficacious, currently available inhaled drugs can have decreased real-life effectiveness due to a variety of factors, including poor inhalation technique. Each device type has its own specifications regarding the optimal way to use it, in terms of device handling and characteristics of the inhalation manoeuvre. Poor inhalation technique is associated with decreased treatment effectiveness. Choosing the optimal device, together with proper education, improves inhalation technique, adherence and outcomes or effectiveness, but has to be performed regularly and rigorously, including visual checking of the patient’s ability to use the inhaler. Some testing devices are also available, as well as various training materials. All healthcare professionals caring for the patient can be involved provided that they have also been properly trained. To optimise treatment effectiveness, healthcare providers should prescribe inhalation device(s) optimised to the patient, accounting for the specific characteristics of each individual, his/her disease, and involved healthcare professionals.

Item does not contain fulltext BACKGROUND: Using a fixed ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) < 0.70 instead of the lower limit of normal (LLN) to define chronic obstructive pulmonary disease (COPD) may lead to overdiagnosis of COPD in elderly patients with heart failure (HF) and consequently unnecessary treatment with possible adverse health effects. OBJECTIVE: The aim of this study was to determine COPD prevalence in patients with chronic HF according to two definitions of airflow obstruction. METHODS: Spirometry was performed in 187 outpatients with stable chronic HF without pulmonary congestion who had a left ventricular ejection fraction LLN). In contrast to patients with LLN-COPD, potentially misclassified patients did not differ significantly from those without COPD regarding respiratory symptoms and risk factors for COPD. CONCLUSIONS: One fifth, rather than one third, of the patients with chronic HF had concomitant COPD using the LLN instead of the fixed ratio. LLN may identify clinically more important COPD than a fixed ratio of 0.7.

Item does not contain fulltext BACKGROUND: Physical activity and health status deteriorate early in the course of chronic obstructive pulmonary disease (COPD). This can only partially be explained by the degree of airflow limitation. Changes in (resting and dynamic) lung volumes are known to be associated with functional impairments and thus might influence physical activity level. The aim of the present cross-sectional study was to explore the contribution of dynamic hyperinflation during daily life activities (ADL) in the decline in physical activity. METHODS: Airflow limitation and inspiratory capacity at rest to total lung capacity ratio (IC/TLC) as a measure of resting hyperinflation were measured in 59 patients with COPD (GOLD I-IV). Mean daily physical activity was assessed with a tri-axial accelerometer. Measurements of dynamic hyperinflation during ADL (DeltaIC and inspiratory reserve volume at end ADL) were performed at patients' home using a portable breath-by-breath system. RESULTS: Multiple regression analysis showed that resting as well as ADL-induced dynamic hyperinflation independently contributed to decreased daily physical activity, together explaining 45.8% of the variance in physical activity. In contrast to hyperinflation, the severity of airflow limitation (FEV1) appeared to have no unique part in explaining how physically (in-) active patients were. CONCLUSIONS: The presence of resting hyperinflation and occurrence of dynamic hyperinflation during ADL contribute to reduced physical activity levels in patients with COPD, independently of the degree of airflow limitation.

Item does not contain fulltext PURPOSE: The sleep quality, as assessed by polysomnography (PSG), of patients with chronic obstructive pulmonary disease (COPD) can be severely disturbed. The manual analysis of PSGs is time-consuming, and computer systems have been developed to automatically analyze PSGs. Studies on the reliability of automated analyses in healthy subjects show varying results, and the purpose of this study was to assess whether automated analysis of PSG by one certain automatic system in patients with COPD provide accurate outcomes when compared to manual analysis. METHODS: In a retrospective study, the full-night polysomnographic recordings of patients with and without COPD were analyzed automatically by Matrix Sleep Analysis software and manually. The outcomes of manual and automated analyses in both groups were compared using Bland-Altman plots and Students' paired t tests. RESULTS: Fifty PSGs from patients with COPD and 57 PSGs from patients without COPD were included. In both study groups, agreement between manual and automated analysis was poor in nearly all sleep and respiratory parameters, like total sleep time, sleep efficiency, sleep latency, amount of rapid eye movement sleep and other sleep stages, number of arousals, apnea-hypopnea index, and desaturation index. CONCLUSION: Automated analysis of PSGs by the studied automated system in patients with COPD has poor agreement with manual analysis when looking at sleep and respiratory parameters and should, therefore, not replace the manual analysis of PSG recordings in patients with COPD.

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) are held responsible for a decline in health status (HS). This may not apply equally to all exacerbations, because different definitions are required for quite different illnesses. Selection of definitions and the sensitivity of the HS instrument may affect results regarding the impact of exacerbations. Sensitivity of a new HS instrument, which covers different and more aspects, has not yet been tested, with respect to exacerbations. Objectives: Confirmation of the negative HS effect of exacerbations by using a highly differentiated instrument, and to evaluate which aspects of HS are affected most. Methods: One hundred and sixty-eight ambulatory patients with COPD were evaluated prospectively with regard to a wide range of HS aspects, at the beginning and end of a 1-year follow-up. Recording of symptom changes and treatment on monthly diary cards resulted in the identification of event-based exacerbations. HS was assessed via a newly validated instrument integrating both physiological and non-physiological sub-domains. Parametric correlations were calculated between exacerbation frequency and HS scores at the end of the study. Partial corre-lations were then explored using HS scores at baseline to correct for prior HS levels. Results: Correlations between -exacerbation frequency and HS sub-domains were found to be frequent, predominantly in non-physiological sub--domains. After correction for HS scores at baseline, only 2 sub-domains (belonging to the main domain ‘Complaints') remained significantly but weakly correlated. Conclusion: Exacerbation frequency and HS show weak correlations after a year, but most of these disappear after correction for prior HS levels. In such exacerbations, aggravated HS probably takes much longer to manifest itself.

Item does not contain fulltext INTRODUCTION: This prospective study was carried out to investigate if metronome-paced tachypnea (MPT) can serve as an accurate diagnostic tool to identify patients with chronic obstructive pulmonary disease (COPD) who are susceptible to develop dynamic hyperinflation during exercise. Commonly, this is assessed by measuring change in inspiratory capacity (IC) during cardiopulmonary exercise testing (CPET), which, however, is complex and laborious. METHODS: Fifty-three patients with COPD (FEV(1) 58 +/- 22%pred) and 20 age-matched healthy subjects were characterized by lung function testing and performed CPET (reference standard) and MPT. The repeatability coefficient of IC (10.2%) was used as cut-off to classify subjects as hyperinflators during CPET. Subsequently, dynamic hyperinflation was measured after MPT. With receiver operating characteristic analysis, the optimal cut-off for MPT-induced dynamic hyperinflation was determined and sensitivity and specificity of MPT to identify hyperinflators were evaluated. RESULTS: With 10.2% decrease in IC as cut-off for CPET-induced dynamic hyperinflation, the optimal cut-off for MPT was 11.1% decrease in IC. Using these cut-offs, MPT had a sensitivity of 85% and specificity of 85% to identify the subjects who hyperinflated during CPET. CONCLUSIONS: The MPT test shows good overall accuracy to identify subjects who are susceptible to develop dynamic hyperinflation during CPET. Before considering the use of MPT as a screening tool for dynamic hyperinflation in COPD, sensitivity and specificity need further evaluation.

Introduction: Two RCTs suggest that vitamin D supplementation lowers exacerbation frequency in vitamin D deficient COPD patients (Lehouck, A. et al. Ann Intern Med 2012; 156:105-14/Martineau, A.R. et al. Lancet Respir Med 2015; 3:e24-5). However, information regarding the effect of vitamin D on the rate of mature elastin degradation is lacking. We hypothesized that vitamin D supplementation in vitamin D deficient (serum 25-[OH]D Methods: pDES was measured by LC-MS/MS in 142 COPD patients from the Leuven vitamin D intervention trial (100,000 IU vitamin D supplementation or placebo every 4 weeks for 1 year). Results: At baseline, no significant correlation was found between 25-[OH]D and pDES levels. No significant interaction between 25-[OH]D change and pDES change was found in the placebo arm. In the vitamin D supplementation arm, a significant negative association was found between pDES change and baseline 25-[OH]D levels (r=-0.44;p

The aim of this study was to develop and explore the diagnostic accuracy of a decision tree derived from a large real-life primary care population. Data from 9297 primary care patients (45% male, mean age 53±17 years) with suspicion of an obstructive pulmonary disease was derived from an asthma/chronic obstructive pulmonary disease (COPD) service where patients were assessed using spirometry, the Asthma Control Questionnaire, the Clinical COPD Questionnaire, history data and medication use. All patients were diagnosed through the Internet by a pulmonologist. The Chi-squared Automatic Interaction Detection method was used to build the decision tree. The tree was externally validated in another real-life primary care population (n=3215). Our tree correctly diagnosed 79% of the asthma patients, 85% of the COPD patients and 32% of the asthma–COPD overlap syndrome (ACOS) patients. External validation showed a comparable pattern (correct: asthma 78%, COPD 83%, ACOS 24%). Our decision tree is considered to be promising because it was based on real-life primary care patients with a specialist's diagnosis. In most patients the diagnosis could be correctly predicted. Predicting ACOS, however, remained a challenge. The total decision tree can be implemented in computer-assisted diagnostic systems for individual patients. A simplified version of this tree can be used in daily clinical practice as a desk tool., A real-life diagnostic decision tree that can be implemented in digital decision-making programmes http://ow.ly/VnHut

Item does not contain fulltext BACKGROUND AND AIMS: Little information is available on real-life occurrence of oral thrush in COPD patients treated with ICS. We investigated oral thrush incidence in COPD patients prescribed FDC ICS/LABA therapies and assessed whether it is modulated by the ICS type, dose, and delivery device. METHODS: We conducted a historical, observational, matched cohort study (one baseline year before and one outcome year after initiation of therapy) using data from the UK Optimum Patient Care Research Database. We assessed oral thrush incidence in patients initiating long-acting bronchodilators or FDC ICS/LABA therapy. We then compared different combination therapies (budesonide/formoterol fumarate dihydrate [BUD/FOR] and fluticasone propionate/salmeterol xinafoate [FP/SAL]) and devices (DPI and pMDI). RESULTS: Patients prescribed FDC ICS/LABA had significantly greater odds of experiencing oral thrush than those prescribed long-acting bronchodilators alone (adjusted OR 2.18 [95% CI 1.84-2.59]). Significantly fewer patients prescribed BUD/FOR DPI developed oral thrush compared with FP/SAL DPI (OR 0.77 [0.63-0.94]) when allowing for differences in prescribed doses between the drugs. A significantly smaller proportion of patients developed oral thrush in the FP/SAL pMDI arm than in the FP/SAL DPI arm (OR 0.67 [0.55-0.82]). Additionally, in the FP/SAL cohort (both DPI and pMDI), increased risk of oral thrush was significantly associated with high ICS daily dose (OR 1.97 [1.22-3.17] vs low daily dose). CONCLUSIONS: ICS use increases oral thrush incidence in COPD and this effect is dose-dependent for FP/SAL therapies. Of the therapies assessed, FP/SAL pMDI and BUD/FOR DPI may be more protective against oral thrush.

Item does not contain fulltext Chronic obstructive pulmonary disease (COPD) is one of the leading causes of disability and death worldwide. Although COPD is considered to be a preventable and treatable disease, there are concerns that COPD remains substantially underdiagnosed and undertreated. Even in mild disease, patients suffer from significant impairments in health status, which places a considerable burden on patients as well as society. Symptomatic patients are likely to progress to more advanced disease. To avoid breathlessness, they adapt and gradually reduce their activities, which, inevitably, leads to further deconditioning. As a consequence, a progressive deterioration in physical activity with increasing severity of COPD can be observed. Because physical activity is closely related to exacerbation rate, hospitalization, and mortality in patients with COPD, it is important to recognize the role of pharmaceutical interventions in enabling patients to stay physically active. Bronch(iol)odilation not only has important direct effects (symptom relief), but also exerts indirect effects on exercise capacity, exacerbation rate, health status, and mortality. In patients with COPD, the latter effects may be even more important than the direct effects. In this review the current view on causes and consequences of activity limitation in COPD is summarized. From this perspective, the rationale behind bronch(iol)odilator therapy as the cornerstone of treatment for patients with COPD will be discussed. 01 juni 2012

Background The diagnostic yield of bronchoscopy in patients with endoscopically nonvisible (peripheral) tumors varies from 40% to 56%. Increasingly, molecular markers in bronchial washings are being investigated to improve the diagnostic yield. The aim of this study was to analyze the diagnostic value of the Ras association domain family 1A gene (RASSF1A) methylation analysis in washings in nondiagnostic bronchoscopy in the analysis of patients with suspected lung cancer who had peripheral tumors. Furthermore, the additional diagnostic value of Kirsten rat sarcoma 2 viral oncogene homolog ( KRAS ) mutations with RASSF1 methylation was analyzed. Methods From a prospectively collected series, 129 patients with lung cancer and 28 control subjects were analyzed retrospectively regarding the methylation status of the promoter region of the RASSF1A gene by quantitative methylation-specific polymerase chain reaction and KRAS point mutations by using the sensitive Point-EXACCT method. Results A total of 40% of the lung cancer patients had peripheral tumors, and 17 patients had a nondiagnostic bronchoscopy. In these patients, RASSF1A methylation was detected in the washings of four patients (24%), and KRAS mutations were detected in the washings of two patients (12%). In total, 29% of the false-negative or doubtful cytology results were accompanied by RASSF1A methylation or KRAS mutation results that were highly suggestive of malignancy. The proportion of RASSF1A methylation was significantly higher in central and larger tumors. No relevant RASSF1A methylation was detected in control samples. Conclusions Our data suggest that the molecular analysis of two biomarkers in nondiagnostic bronchial washings may better guide diagnostic procedures in patients with suspected lung cancer.

Background Mechanical ventilation induces diaphragm muscle atrophy, which plays a key role in difficult weaning from mechanical ventilation. The signaling pathways involved in ventilator-induced diaphragm atrophy are poorly understood. The current study investigated the role of Toll-like receptor 4 signaling in the development of ventilator-induced diaphragm atrophy. Methods Unventilated animals were selected for control: wild-type (n = 6) and Toll-like receptor 4 deficient mice (n = 6). Mechanical ventilation (8 h): wild-type (n = 8) and Toll-like receptor 4 deficient (n = 7) mice.Myosin heavy chain content, proinflammatory cytokines, proteolytic activity of the ubiquitin-proteasome pathway, caspase-3 activity, and autophagy were measured in the diaphragm. Results Mechanical ventilation reduced myosin content by approximately 50% in diaphragms of wild-type mice (P less than 0.05). In contrast, ventilation of Toll-like receptor 4 deficient mice did not significantly affect diaphragm myosin content. Likewise, mechanical ventilation significantly increased interleukin-6 and keratinocyte-derived chemokine in the diaphragm of wild-type mice, but not in ventilated Toll-like receptor 4 deficient mice. Mechanical ventilation increased diaphragmatic muscle atrophy factor box transcription in both wild-type and Toll-like receptor 4 deficient mice. Other components of the ubiquitin-proteasome pathway and caspase-3 activity were not affected by ventilation of either wild-type mice or Toll-like receptor 4 deficient mice. Mechanical ventilation induced autophagy in diaphragms of ventilated wild-type mice, but not Toll-like receptor 4 deficient mice. Conclusion Toll-like receptor 4 signaling plays an important role in the development of ventilator-induced diaphragm atrophy, most likely through increased expression of cytokines and activation of lysosomal autophagy.

‘Mycobacterium sherrisii’ is an undescribed species that appears to be emerging, in particular, among HIV-positive patients originating from Africa. To describe ‘M. sherrisii’, to ensure that the species name is validly published and to define its phylogenetic position, we collected 11 of these strains reported in five previous studies, and subjected them to biochemical identification, cell-wall mycolic acid analysis and sequencing of multiple housekeeping genes. The bacteria formed smooth and generally non-chromogenic colonies after 2–3 weeks of subculture at 24–37 °C; photochromogenic and scotochromogenic pigmentation were exhibited by three and two strains, respectively. The strains were positive for the heat-stable catalase test, but negative in tests for hydrolysis of Tween 80, nitrate reduction, β-glucosidase and 3-day arylsulfatase. Mycolic acid patterns, obtained by HPLC, resembled a trimodal profile similar to those of type strains of Mycobacterium simiae, Mycobacterium lentiflavum, Mycobacterium triplex and Mycobacterium genavense. The 16S rRNA gene sequences of the 11 strains differed by 4 bp (99.7 % similarity) from that of the type strain of the closest related species, M. simiae ATCC 25275T. Levels of internal transcribed spacer (ITS) and partial hsp65 and rpoB gene sequence similarity between the two taxa were 95.8 % (271/283 bp), 97.5 % (391/401 bp) and 95.2 % (700/735 bp), respectively. On the basis of these results, we propose the formal recognition of Mycobacterium sherrisii sp. nov. The type strain is 4773T ( = ATCC BAA-832T = DSM 45441T).

Objective: To perform a systematic review of articles published in the last 25 years on prevalence and course of distress and quality of life surrounding the diagnostic process of suspected cancer, and the influence of rapid diagnostic programs. Methods: Twenty-three articles were identified via Pubmed, PsycINFO, and reference lists of articles. Except for three randomized clinical trials and one case control study all studies were uncontrolled cohort studies. Results: Most studies involved patients with suspected breast cancer and therefore had a sex selection bias. Four studies on the effect of rapid outpatient diagnostic programs were found. Studies showed very high prevalence of anxiety, decreasing in case of a benign diagnosis but increasing or sustaining in patients waiting for results or after cancer diagnosis though not significantly more in rapid programs. Quality of life was low and showed varying patterns. Conclusions: Distress in the diagnostic phase of cancer is a major problem and the rapid decrease of anxiety in patients eventually not diagnosed with cancer suggests a benefit of rapid diagnostic programs. The available evidence however is limited and shows some inconsistencies. Studies differ in subjects, objective and are limited by quality and quantity. Conflicting results prohibit a conclusion on patients ultimately diagnosed with cancer. Copyright © 2011 John Wiley & Sons, Ltd.

Contains fulltext : 98259.pdf (Publisher’s version ) (Closed access) Diaphragm muscle weakness in patients with chronic obstructive pulmonary disease (COPD) is associated with increased morbidity and mortality. Recent studies indicate that increased contractile protein degradation by the proteasome contributes to diaphragm weakness in patients with COPD. The aim of the present study was to investigate the effect of proteasome inhibition on diaphragm function and contractile protein concentration in an animal model for COPD. Elastase-induced emphysema in hamsters was used as an animal model for COPD; normal hamsters served as controls. Animals were either treated with the proteasome inhibitor Bortezomib (iv) or its vehicle saline. Nine months after induction of emphysema, specific force-generating capacity of diaphragm bundles was measured. Proteolytic activity of the proteasome was assayed spectrofluorometrically. Protein concentrations of proteasome, myosin, and actin were measured by means of Western blotting. Proteasome activity and concentration were significantly higher in the diaphragm of emphysematous hamsters than in normal hamsters. Bortezomib treatment reduced proteasome activity in the diaphragm of emphysematous and normal hamsters. Specific force-generating capacity and myosin concentration of the diaphragm were reduced by ~25% in emphysematous hamsters compared with normal hamsters. Bortezomib treatment of emphysematous hamsters significantly increased diaphragm-specific force-generating capacity and completely restored myosin concentration. Actin concentration was not affected by emphysema, nor by bortezomib treatment. We conclude that treatment with a proteasome inhibitor improves contractile function of the diaphragm in emphysematous hamsters through restoration of myosin concentration. These findings implicate that the proteasome is a potential target of pharmacological intervention on diaphragm weakness in COPD. 01 juli 2011

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are both common diseases with major impact and seem to coexist more frequently than expected from their separate population prevalences. However, estimates of combined prevalence must be interpreted carefully because of imperfections and difficulties in assessment of both diseases. This review aims to highlight HF prevalence in patients with COPD and vice versa, with a critical analysis of studies performed. First, definition, diagnosis, and prevalence of COPD and of HF will be discussed. Subsequently, an overview of important studies concerning combined prevalence with their limitations will be presented. Finally, pathogenic mechanisms and diagnostic considerations in clinical practice will be discussed.

Background One of the contributors to exercise limitation in COPD is dynamic hyperinflation. Although dynamic hyperinflation appears to occur during several exercise protocols in COPD and seems to increase with increasing disease severity, it is unknown whether dynamic hyperinflation occurs at different severity stages according to the Global initiative for chronic Obstructive Lung Disease (GOLD) in daily life. The present study, therefore, aimed to compare dynamic hyperinflation between COPD GOLD stages II-IV during daily activities. Methods Thirty-two clinically stable patients with COPD GOLD II (n = 10), III (n = 12), and IV (n = 10) participated in this study. Respiratory physiology during a daily activity was measured at patients' homes with Oxycon Mobile. Inspiratory capacity maneuvers were performed at rest, at 2-min intervals during the activity, and at the end of the activity. Change in inspiratory capacity is commonly used to reflect change in end-expiratory lung volume (ΔEELV) and, therefore, dynamic hyperinflation. The combination of static and dynamic hyperinflation was reflected by inspiratory reserve volume (IRV) during the activity. Results Overall, increase in EELV occurred in GOLD II-IV without significant difference between the groups. There was a tendency for a smaller ΔEELV in GOLD IV. ΔEELV was inversely related to static hyperinflation. IRV during the daily activity was related to the level of airflow obstruction. Conclusions Dynamic hyperinflation occurs independent of GOLD stage during real-life daily activities. The combination of static and dynamic hyperinflation, however, increases with increasing airflow obstruction.

Contains fulltext : 80686.pdf (Publisher’s version ) (Closed access) We recently demonstrated aberrant staining of fibrillin-1 in lung tissue specimens with emphysematous lesions. In this study, we have extended this observation by an elaborate analysis of the elastic fibre. Using domain-specific antibodies to fibrillin-1, and to other elastin fibre-associated molecules, lung tissue derived from patients without obvious clinical emphysema, but harbouring various degrees of microscopical emphysematous lesions, was analysed. In addition, the fibrillin-regulated growth factor TGF-beta was studied. Electron microscopy and biochemical analysis of desmosine (a marker for elastin) were also performed. Results were compared with lung tissue derived from patients with clinical emphysema. Domain-specific antibodies recognizing the C-terminal, N-terminal, and middle part of fibrillin-1 showed aberrant staining patterns associated with increasing degrees of microscopical emphysema. Staining for elastin, emilin-1, and fibulin-2 was, however, not aberrant. TGF-beta staining was markedly increased. On the electron microscopic, but not light microscopical, level, initial elastic fibre degradation was noticed in specimens with microscopical emphysema. Lung specimens from patients with clinical emphysema also displayed fragmented fibrillin-1 staining and, in addition, displayed extensive degradation of the elastic fibre. The results suggest that fibrillin-1 anomalies and TGF-beta overexpression are associated with initial events occurring during the emphysematous process. Based on these and other data, a mechanism for emphysematogenesis is proposed.

Aerosol inhalation is considered the optimal route for administering the majority of drugs for the treatment of obstructive airways diseases. A number of Pressurised Metered-Dose and Dry Powder Inhalers are available for this purpose. However, inhalation of therapeutic aerosols is not without difficulty; it requires precise instructions on the inhalation manoeuvre, which is different from spontaneous normal breathing. Also, the characteristics of the inhaler device have to be suitable for the user. Available data indicate a frequent lack of knowledge demonstrated by health professionals and patients on the inhalation manoeuvre and handling of inhalers, resulting in a reduction of therapeutic benefit. This paper reviews the literature concerning the fundamental aspects of inhaler devices, inhalation manoeuvre and device selection, in an attempt to increase the knowledge of, and to optimise the clinical use of, therapeutic inhalers.

Contains fulltext : 79827.pdf (Publisher’s version ) (Open Access) A non-chromogenic, slowly growing Mycobacterium strain was isolated from a maxillary sinus lavage from a symptomatic patient in Riyadh, Saudi Arabia. It was initially identified as a member of the Mycobacterium tuberculosis complex by a commercial line-probe assay. Its 16S rRNA, hsp65 and rpoB gene and 16S-23S internal transcribed spacer sequences were unique; phylogenetic analysis based on the 16S rRNA gene sequence groups this organism close to Mycobacterium szulgai and Mycobacterium malmoense. Its unique biochemical properties and mycolic acid profile support separate species status. We propose the name Mycobacterium riyadhense sp. nov. to accommodate this strain. The type strain is NLA000201958(T) (=CIP 109808(T) =DSM 45176(T)).