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The effect of chronic obstructive pulmonary disease (COPD) on patients and their perception of wellbeing goes beyond functional respiratory alterations. Fatigue, mood and sleep alterations constitute a complex of interrelated symptoms affecting perception of health status. Fatigue is a highly important symptom due to its frequency, clinical repercussions and association with other manifestations. Functional alterations during sleep are of various degrees of severity and are most important in sleep apnea-hypopnea syndrome. Mood alterations are important because of their frequency, clinical repercussion and prognostic implications. In the last few years, several measurement instruments have been developed to quantify these manifestations, such as the Living with COPD scale (LCOPD), the COPD and Asthma Fatigue Scale (CAFS) and the COPD and Asthma Sleep Impact Scale (CASIS).The present article reviews the clinical relevance of these manifestations and the measurement instruments available for their evaluation.

The education and training of medical personnel in noninvasive ventilation (NIV) is essential in improving outcomes, reducing failures, and avoiding complications associated with the use of ventilation [1]. Furthermore, adequate training of staff provides a cost reduction in patient care. In this regard, a proper training period should be part of the education of respiratory health care professions who are part of the multidisciplinary respiratory team dealing with the NIV.

The occurrence of a bronchopleural fistula (BPF) continues to represent a challenging management problem, and is associated with high morbidity and mortality. A novel and successful technique that uses submucosal injection of a tissue expander for bronchoscopic occlusion of BPFs has been designed. This method may be used either alone or in combination with bronchoscopic instillation of n-butyl-cyanoacrylate glue. The occlusion technique is described, with a presentation of two patients who were successfully treated with this method. The submucosal injection of a tissue expander is an effective, economical and minimally invasive technique for managing BPFs.

There have been significant advances in the knowledge in the thoracic and extrathoracic aspects of chronic obstructive pulmonary disease (COPD) in the past few years. COPD is associated with numerous comorbidities, the prevalences of which have recently been evaluated. Dyspnea has been shown to be associated with neuropsychiatric disturbances, such as anxiety. Muscular dysfunction has been associated with inflammation and oxidative stress, in which respiratory muscle satellite cells play an important role in repair. Respiratory rehabilitation and physiotherapy must form an important part of individualised patient treatment analogous to the pharmacological treatment. As regards acute exacerbations, infection is the cause of 75% of them, sputum characteristics and the suspicion of Pseudomonad being key factors in the antibiotic treatment. Questions, such as markers which can detect the origin of the infection, prognostic factors, or the role of short stay pneumology units, are of particular importance. The variability in COPD treatments and the lack of suitable international clinical guidelines, continue to be subjects of debate. To the poor use of the treatment schemes in the guidelines, can be added the irregular uses of inhaled medication, the insufficient use of medical advice or the low intervention in cigarette smoking in all age groups.

Patients with chronic respiratory failure due to kyphoscoliosis (CHRF-KS) constitute a specific population with impaired health-related quality of life (HRQL). Thus far, no studies have examined factors related to HRQL. The objective of the present study was to identify clinical, functional and exertion-related factors associated with HRQL.We investigated 27 patients (12 males). Respiratory function tests, dyspnea ratings, peripheral and respiratory muscle function and exercise testing were performed. The Chronic Respiratory Disease Questionnaire (CRDQ) was used to assess HRQL. Bivariate correlations were used to investigate the relationships between CRDQ dimensions and the clinical, functional and exertion-related characteristics of the study participants.The general characteristics of the study sample were as follows: age: 61 (IQR: 12) years, FVC: 32.6% (IQR: 10.2) and pCO2: 48 mmHg (IQR: 8.7). Peripheral muscle strength, dyspnea and exercise capacity were identified as significant factors associated with poorer HRQL. The CRDQ dimensions of fatigue and emotional function showed greater correlations with the patients' general characteristics. Dyspnea CRDQ scores did not correlate with dyspnea in any of the scales used.Of the various factors examined, dyspnea, exercise capacity and peripheral muscle strength have been identified as significant factors associated with HRQL in CHRF-KS patients.

It has been suggested that sleep-related breathing disorders (SRBD) involve a continuum that develops over the course of life. If modifiable factors could be identified, the progression of SRBD could perhaps be addressed early in life. Although some studies have looked at the evolution of SRBD in pre-pubertal children, very few studies obtained data in adolescents. Anthropometric, clinical and polygraphic variables were collected during a 4-yr follow-up study among 148 normal adolescents after initial cross-sectional analysis. From a total of 267 adolescents studied at baseline (mean+/-sd age 14.3+/-2.1 yrs), 148 (55.4%) were followed up for 4 yrs. During follow-up, there were no significant changes in snoring and polygraphic parameters. However, a tendency toward weight gain with centrally distributed fat was observed. Habitual snorers had a significantly higher body mass index and more centrally distributed fat than nonsnorers. Males had a higher snoring prevalence and a higher number of respiratory events than females. Snoring at baseline, male sex and poor academic performance were significant predictors of snoring at follow-up. Snoring tends to persist during adolescence and male sex acts as a risk factor. A relationship between snoring and academic performance was observed. These findings may have implications for long-term management of sleep-related breathing disorders.

Summary Background The aim of this multicenter study was to investigate the relationship between single nucleotide polymorphisms (SNPs) of the cyclooxygenase-2 ( COX2 ) gene and susceptibility to sarcoidosis, as well as the relation between these SNPs and the evolution of the disease. Material and methods This multicenter investigation involved seven hospitals in Spain. We used a case–control design followed by a prospective follow-up study. Sarcoid patients were recruited from the participating institutions during outpatient routine visits. Age- and gender-matched control subjects were recruited mainly from among outpatients attending the participating hospitals. Four SNPs in the COX2 gene (COX2.5909 T > G, COX2.8473 T > C, COX2.926 G > C, and COX2.3050 G > C) were genotyped using fluorescent hybridization probes among 131 patients with sarcoidosis (63 males; mean age: 47 ± 15 years) and 157 healthy controls (83 males; mean age: 50 ± 16 years). We employed a binomial multiple logistic regression analysis to test the association between the selected SNPs and disease susceptibility. The clinical, functional and radiological prognosis of the sarcoidosis patients was determined after a mean follow-up of 37.4 ± 30.4 months. Results Carriers of the homozygous CC genotype of the COX2.8473 T > C polymorphism had a higher risk of sarcoidosis compared with TT carriers (OR: 3.08; 95% CI: 1.2–7.7; p = 0.035). 84% of patients achieved improvement or complete remission at follow-up. No association between the investigated SNPs and prognosis was seen. Conclusions Our data suggest that the homozygous CC genotype of the COX2.8473 T > C polymorphism may be associated with sarcoidosis susceptibility. No significant association with prognosis was detected.

To describe the characteristics observed in patients diagnosed of hepatopulmonary syndrome (HPS) waiting for orthotopic liver transplantation and those who underwent liver trasplantation.An observational prospective descriptive study was carried out of patients waiting for liver transplantation in whom data of liver illness and lung function tests were analyzed.107 patients of 53.69 years average age were studied (7.7 standard deviation). 24 of them (22.4%) had criteria of HPS. Ortodeoxia was present in the 34% of cases. The lung function tests were normal. In the comparative study between patients with HPS and no HPS, differences in diffusion were found (7.1 vs. 8.6 mmol/min/kPa; p = 0.04), as well as in the shunt (8% vs. 5.3%; p = 0.05) and the forced expiratory volume in one second (2,390 vs. 2,743 ml; p = 0.03). Seven patients were transplanted with correction of oxygenation and vascular dilatations in all of them.HPS is a frequent illness in patients waiting for orthotopic liver transplantation. The main alteration in the blood oxygenation seems owe to shunt, and the diffusion tests is the analysis that could best differentiate patients with HPS. Orthotopic liver transplantation corrects the syndrome in all cases.

A cross-sectional prospective design was used to compare the effectiveness of the shuttle walking test (SWT) and the maximal cycle ergometry test (CET) to assess the functional capacity of patients with chronic hypercapnic respiratory failure due to severe kyphoscoliosis. Twenty-four patients completed both the SWT and CET. Heart rate, blood pressure, leg fatigue, chest pain and dyspnea (Borg's scale) were measured immediately after each test. Correlation coefficients and Bland-Altman analysis were used to compare the two methods. Borg's dyspnea, leg and chest pain after exercise were not significantly different between tests. Only heart rate (SWT 130[20.7] versus CET 116[28.75]; p = 0.048) and diastolic blood pressure (SWT: 85.5[13.75] versus CET 95[17.5]; p = 0.021) were slightly but significantly different between the two protocols. There was a good positive correlation between the distance walked in SWT and maximal oxygen consumption (r = 0.675; p < 0.001). SWT and CET testing elicited similar clinical and hemodynamic responses. SWT is a feasible measure of functional capacity in this patient group.

Objectives: Previous clinical audits for chronic obstructive pulmonary disease (COPD) have provided valuable information on the clinical care delivered to patients admitted to medical wards because of COPD exacerbations. However, clinical audits of COPD in an outpatient setting are scarce and no methodological guidelines are currently available. Based on our previous experience, herein we describe a clinical audit for COPD patients in specialized outpatient clinics with the overall goal of establishing a potential methodological workflow., Methods: A pilot clinical audit of COPD patients referred to respiratory outpatient clinics in the region of Andalusia, Spain (over 8 million inhabitants), was performed. The audit took place between October 2013 and September 2014, and 10 centers (20% of all public hospitals) were invited to participate. Cases with an established diagnosis of COPD based on risk factors, clinical symptoms, and a post-bronchodilator FEV1/FVC ratio of less than 0.70 were deemed eligible. The usefulness of formally scheduled regular follow-up visits was assessed. Two different databases (resources and clinical database) were constructed. Assessments were planned over a year divided by 4 three-month periods, with the goal of determining seasonal-related changes. Exacerbations and survival served as the main endpoints., Conclusions: This paper describes a methodological framework for conducting a clinical audit of COPD patients in an outpatient setting. Results from such audits can guide health information systems development and implementation in real-world settings., This study was financially supported by an unrestricted grant from Laboratorios Menarini, SA (Barcelona, Spain).

Eduardo Márquez-Martín,1 Joan B Soriano,2 Myriam Calle Rubio,3 Jose Luis Lopez-Campos1,4 On behalf of the 3E project 1Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, 2Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Cátedra UAM-Linde, 3Servicio de Neumología, Hospital Universitario Clínico San Carlos, 4Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud CarlosIII, Madrid, Spain Objectives: The aim of this study is to evaluate the ability and practice of spirometry, training of technicians, and spirometry features in primary care centers in Spain, evaluating those located in a rural environment against those in urban areas.Methods: An observational cross-sectional study was conducted in 2012 by a telephone survey in 970 primary health care centers in Spain. The centers were divided into rural or urban depending on the catchment population. The survey contacted technicians in charge of spirometry and consisted of 36 questions related to the test that included the following topics: center resources, training doctors and technicians, using the spirometer, bronchodilator test, and the availability of spirometry and maintenance.Results: Although the sample size was achieved in both settings, rural centers (RCs) gave a lower response rate than urban centers (UCs). The number of centers without spirometry in rural areas doubled those in the urban areas. Most centers had between one and two spirometers. However, the number of spirometry tests per week was significantly lower in RCs than in UCs (4 [4.1%] vs 6.9 [5.7%], P

OBJECTIVE Home mechanical ventilation is used with patients with severe, chronic respiratory failure, a condition that has a serious impact on quality of life. The aim of this study was to produce a translation and cultural adaptation of the Severe Respiratory Insufficiency. Questionnaire for the Spanish population, the first health-related quality of life questionnaire specifically designed for patients receiving home mechanical ventilation. METHODS Four bilingual German-Spanish translators were used to translate and back-translate the questionnaire. Meetings were held with the translators following each step of the translation process to produce a single version that could be used in the next step. At the end of the process, the questionnaire was piloted to assess its comprehensibility. A scoring system using a scale of 1 (lowest) to 10 (highest) was used to rate both translation difficulty and the naturalness of the language produced. The equivalence of the original and translated items was also evaluated. RESULTS Three Spanish versions of the questionnaire were produced. Task difficulty was rated as quite low: the mean (SD) ratings were 1.4 (0.6) for translation and 2.2 (1.1) for back translation. The naturalness of the translated items was rated as very high, with scores improving with the successive versions (version 1, 8.4; version 2, 8.7; version 3, 9.1; P< .001). Thirty of the questionnaire items (61.2%) were judged to be fully equivalent, 13 (26.5%) to be similar, and 6 (12.2%) to be non-equivalent. The meaning conveyed by 5 of the items was changed or clarified during piloting. CONCLUSIONS The translation of the questionnaire using the translation-back-translation procedure has produced a version that is both comparable to the original and accessible to the Spanish population. Its validity is currently being tested in a multicenter study.

Objective To validate the Spanish Severe Respiratory Insufficiency (SRI) questionnaire, the first health-related quality-of-life questionnaire specific for patients receiving home mechanical ventilation (HMV). Study Design and Setting This multicenter prospective study enrolled 115 patients (53 males, age 62 ± 13 years) receiving HMV, recruited from five hospitals. Patients were scheduled for two visits during which sociodemographic and clinical data were recorded, and both the Spanish SRI and the SF-36 questionnaires were administered. Viability was assessed by recording timing and the response rate in the questionnaire. Reliability was assessed using intraclass correlation coefficient (ICC) and Cronbach alpha coefficient. Validity was studied by factor analysis, by a correlation test between the SRI and SF-36 questionnaires, and by establishing several simple, plausible, ad hoc hypotheses. Results The SRI was administered in 10 ± 5 minutes with ≥96% responses for most items. Cronbach alpha coefficient was >0.7 for all scales except social relationships. ICCs were above 0.8 for all scales. Criterion validity obtained high correlations with SF-36, especially in psychosocial well-being and physical functioning scales. Factor analysis explained 60% of the variability. All ad hoc hypotheses were fulfilled. Conclusion The Spanish version of the SRI questionnaire has good psychometric properties, similar to those of the original questionnaire.

Background Continuous positive airway pressure (CPAP) is the main treatment for obstructive sleep apnea–hypopnea syndrome (OSAHS). Polysomnography (PSG) is the gold standard for CPAP titration. However, alternative methods have been sought to titrate CPAP at less expense in terms of time and resources. The aim of this study was to analyze CPAP success in controlling OSAHS symptoms and adverse effects by two titration methods. Methods This was a retrospective, observational cohort study in which 200 CPAP-naive patients who had been referred to our sleep laboratory and diagnosed with OSAHS were evaluated on two consecutive visits. During the first visit, an initial CPAP pressure was established either by split-night PSG or by using a mathematical formula. On the second visit, 1 month later, symptom persistence and adverse effects of CPAP treatment were assessed. Results Patients included were 157 males (78.5%) and 43 females (21.5%) aged 56 ± 10 years. 87 patients (43.5%) were titrated by PSG and 113 (56.5%) using the formula. At the second visit, symptoms had improved significantly for both groups with no significant differences in the presence of adverse effects. The initial pressure had to be readjusted in five patients. Conclusions This study suggests that formula titration can control symptoms as effectively as split-night titration. A prompt evaluation of the patient is advisable in order to ensure compliance with treatment and to correct possible adverse effects.

A pesar de la naturaleza diversa de las enfermedades respira-torias cronicas, su expresion clinica resulta bastante limitada ensintomas, por lo que su manifestacion puede ser solapada. Por estemotivo, el diagnostico diferencial de la patologia pulmonar cro-nica precisa de estudios complementarios que ayuden al clinico adiferenciar unas enfermedades de otras. Entre estos estudios com-plementarios, la radiologia de torax, como estudio anatomico, ylas pruebas de funcion respiratoria, como valoracion funcional, tie-nen una especial relevancia. De estas ultimas, la espirometria haadquirido un papel principal como primera evaluacion funcionalen pacientes con enfermedades respiratorias, ya que, a pesar de susimplicidad, aporta una informacion muy completa sobre la fisio-logia pulmonar. Sin embargo, a pesar de que la espirometria es unatecnica diagnosticasencilla,noinvasiva,fiableysegura,numerosostrabajos muestran la existencia de problemas de infrautilizacion

This study aims to describe the distribution of interstitial lung diseases (ILD) in the South of Spain. Methods: A prospective multicentre population-based registry was established in nine provinces in the south of Spain with a population of 6,848,243 during a 3-year period (1998–2000). The number of participant physicians was 36 among 29 public hospitals. The number of diagnoses recorded was 66, divided in eight categories and coded according to ICD-9. A consensus document was elaborated for the classification of diseases and their diagnostic criteria. The number of cases declared was analysed each 3 months and communicated to each one of the participants. Results: There were 744 cases of them registered with an annual incidence of 3.62 cases/100,000. 40.1% of diagnoses were biopsy confirmed. Men had a slightly higher incidence (4.18 cases/100,000/year) than women (3.07 cases/100,000/year). The most frequent diseases found were: idiopathic interstitial pneumonias (38.58%), ILD associated to systemic diseases (20.97%), and Sarcoidosis (11.69%). According to province distribution, most of the cases were grouped in an area between the provinces of Seville and Cordoba, which comprised more than 50% of cases. Conclusions: The study of the incidence of ILD depicts an intermediate situation from previous studies on the incidence and distribution of this group of diseases.

The purpose of this study was: 1) To determine the effect of non invasive ventilation (NIV) in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure, and 2) To find out whether there are differences in the results according to the site where ventilation in applied.Meta-analysis of randomized controlled trials (RCTs) published included studies in MEDLINE, EMBASE, Cochrane Controled Trials Register and Teseo. Study selection included RCTs in COPD patients with acute respiratory failure with PaCO245 mmHg or pH7.35, with underwent NIV versus standard therapy. Mortality, rate of tracheal intubation and length of stay were analized. Individual studies were rated as to their validity and quality by two investigators using the Jadad score. A different meta-analysis was made for intensive-care unit (ICU) RCTs and wards RCTs.Five ICU RCTs and four ward RCTs were included. There was a reduction in hospital mortality (ICU, OR = 0.35; 95% confidence interval [CI], 0.15 to 0.83; n = 166; p = 0.02; ward, OR = 0.39; 95% CI, 0.20 to 0.76; n = 296; p = 0.005) and in the need for intubation (ICU, OR = 0.18; 95% CI, 0.10 to 0.35; n= 219; p0,00001; ward, OR = 0.43; IC 95%, 0.24-0.78; n = 270; p = 0.006). Length of stay was lower in the NIV group upon ICU trials (WMD, 3.7 days; 95% CI, 5.46 to 1.93 days). Only one ward RCT showed significant differences in the length of stay. Published data did not allow a meta-analysis for length of stay.NIV decreases mortality and the need for intubation in COPD patients with acute respiratory failure both in ICU and ward. In ICU non-invasive ventilation decreases the length of stay too.

Chronic obstructive pulmonary disease (COPD) is a complex heterogeneous disease, in which several factors combine to give the final clinical expression. Both early and more recent studies have shown that forced expiratory volume in one second (FEV1), despite being an extremely important parameter to predict the progression of the disease, is a poor surrogate marker for symptoms perception. Accordingly, patient-reported outcomes (PROs) have gained popularity as a measure of the impact of treatment from the patients' perspective, since they represent the individuals' perception of their health status, beyond any physiological limitations. Several such PROs, therefore, are currently included in multidimensional COPD evaluation. This multidimensional approach helps identify different patient types and individualize, up to a certain point, pharmacological treatment. In this multidimensional approach it is important to highlight the importance of long-acting bronchodilators in COPD treatment strategies. Long-acting bronchodilators are cost-effective and have been shown to achieve the greatest functional and clinical improvements in COPD. As a result, long-acting bronchodilators are now the main pharmacological treatment for COPD at all stages of the disease. Until recently, tiotropium was the leading bronchodilator for the treatment of COPD. The clinical development of this medication, unprecedented in inhaled therapy, involved tens of thousands of patients and yielded consistent outcomes in terms of lung function, symptoms, quality of life, exacerbations, and prognosis. However, new long-acting bronchodilators have recently been developed or are currently under development. In this review, we evaluate the effects of aclidinium bromide, a novel long-acting bronchodilator, on PROs in COPD. Aclidinium is a novel long-acting muscarinic antagonist with a good safety profile for the treatment of COPD, and has proven efficacy in both objective functional measurements and PROs. Comparison studies with tiotropium have shown it to have similar lung function improvement and a similar impact on PROs, including quality of life or symptom perception.

Background Clinical audits have emerged as a potential tool to summarize the clinical performance of healthcare over a specified period of time. However, the effectiveness of audit and feedback has shown inconsistent results and the impact of audit and feedback on clinical performance has not been evaluated for COPD exacerbations. In the present study, we analyzed the results of two consecutive nationwide clinical audits performed in Spain to evaluate both the in-hospital clinical care provided and the feedback strategy. Methods The present study is an analysis of two clinical audits performed in Spain that evaluated the clinical care provided to COPD patients who were admitted to the hospital for a COPD exacerbation. The first audit was performed from November–December 2008. The feedback strategy consisted of personalized reports for each participant center, the presentation and discussion of the results at regional, national and international meetings and the creation of health-care quality standards for COPD. The second audit was part of a European study during January and February 2011. The impact of the feedback strategy was evaluated in term of clinical care provided and in-hospital survival. Results A total of 94 centers participated in the two audits, recruiting 8,143 admissions (audit 1∶3,493 and audit 2∶4,650). The initially provided clinical care was reasonably acceptable even though there was considerable variability. Several diagnostic and therapeutic procedures improved in the second audit. Although the differences were significant, the degree of improvement was small to moderate. We found no impact on in-hospital mortality. Conclusions The present study describes COPD hospital care in Spanish hospitals and evaluates the impact of peer-benchmarked, individually written and group-oral feedback strategy on the clinical outcomes for treating COPD exacerbations. It describes small to moderate improvements in the clinical care provided to COPD patients with no impact on in-hospital mortality.

Rationale: Little is known about the longitudinal changes associated with using the 2013 update of the multidimensional GOLD strategy for chronic obstructive pulmonary disease (COPD). Objective: To determine the COPD patient distribution of the new GOLD proposal and evaluate how this classification changes over one year compared with the previous GOLD staging based on spirometry only. Methods: We analyzed data from the CHAIN study, a multicenter observational Spanish cohort of COPD patients who are monitored annually. Categories were defined according to the proposed GOLD: FEV1%, mMRC dyspnea, COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and exacerbations-hospitalizations. One-year follow-up information was available for all variables except CCQ data. Results: At baseline, 828 stable COPD patients were evaluated. On the basis of mMRC dyspnea versus CAT, the patients were distributed as follows: 38.2% vs. 27.2% in group A, 17.6% vs. 28.3% in group B, 15.8% vs. 12.9% in group C, and 28.4% vs. 31.6% in group D. Information was available for 526 patients at one year: 64.2% of patients remained in the same group but groups C and D show different degrees of variability. The annual progression by group was mainly associated with one-year changes in CAT scores (RR, 1.138; 95% CI: 1.074-1.206) and BODE index values (RR, 2.012; 95% CI: 1.487-2.722). Conclusions: In the new GOLD grading classification, the type of tool used to determine the level of symptoms can substantially alter the group assignment. A change in category after one year was associated with longitudinal changes in the CAT and BODE index., AstraZeneca.

Eduardo Márquez-Martín1, Pilar Cejudo Ramos1, José Luis López-Campos1, María del Pilar Serrano Gotarredona2, Silvia Navarro Herrero2, Rodrigo Tallón Aguilar1, Emilia Barrot Cortes1, Francisco Ortega Ruiz11Medical-Surgical Unit of Respiratory Diseases, University Hospital Virgen del Rocío, Seville, Spain; 2Radiodiagnostic Unit, University Hospital Virgen del Rocío, Seville, SpainBackground: More accurate phenotyping of COPD is of great interest since it may have prognostic and therapeutic consequences. We attempted to explore the possible relationship between the extent of emphysema, as assessed by high-resolution computed tomography (HRCT), and COPD severity. We also included some study variables involving exercise tolerance evaluation and peripheral muscle strength (PMS) measurement.Methods: Sixty-four patients with COPD (mean age 64 ± 7 years) were enrolled in a prospective observational cross-sectional study. All patients underwent clinical and functional evaluations: assessment of dyspnea, body mass index (BMI), health status assessment, spirometry testing, and arterial blood gas analysis. The extent of emphysema was graded using HRCT. Functional capacity was evaluated by a cardiopulmonary maximal exercise testing (CPET), the shuttle walking test, and by estimation of PMS.Results: Half of the study patients had an emphysematous phenotype. There was a significant correlation between the score derived from analysis of HRCT images and BMI and respiratory functional parameters, as well as VO2 max (maximal oxygen uptake) and chest pull 1RM (1 rep max). Compared with subjects with a nonemphysematous phenotype, those with an emphysematous phenotype showed a lower BMI, a reduced PMS, and displayed a lower power at CPET. Significant differences in lung function tests were found for diffusing capacity and hyperinflation. No significant differences in quality of life were observed between the two study groups.Conclusions: Compared with subjects with a nonemphysematous phenotype, subjects with an emphysematous phenotype has a different profile in terms of BMI, lung function, PMS, and exercise capacity.Keywords: chronic obstructive pulmonary disease, exercise tolerance, emphysema, phenotypes, lung function

José Luis Lopez-Campos, Pilar Cejudo, Eduardo Marquez, Francisco Ortega, Esther Quintana, Carmen Carmona, Emilia BarrotUnidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospitales Universitarios Virgen del Rocío, Seville, SpainAim: It has been recently shown that the original BODE index has a high degree of correlation with two modified BODE indexes using maximal oxygen uptake expressed either as mL/min/kg (mBODE) or as the percentage predicted (mBODE%). In this study we investigated the agreement between the two modified BODE indexes (mBODE and mBODE%) in patients with stable chronic obstructive pulmonary disease (COPD).Methods: A total of 169 patients with stable COPD were enrolled in this cross-sectional study. Differences between the two mBODE indexes were assessed using kappa coefficients and Bland-Altman plots. One out of every three patients underwent the six-minute walking test to investigate the agreement with the original BODE index.Results: Correlations between the two mBODE indexes with each other (r = 0.96, P < 0.001) and with the original BODE index (mBODE r = 0.88, P < 0.001; mBODE% r = 0.93, P < 0.001) were excellent. However, the two mBODE indexes were significantly different from each other (mBODE 5.27 ± 2.3 versus mBODE% 4.31 ± 2.5; P < 0.001). The kappa coefficients were significantly lower (entire study group k = 0.5, P < 0.001) for every GOLD stage. The mean difference between the two mBODE indexes was 0.8 ± 0.6 units. Differences with the original BODE were higher for the mBODE (1.8 ± 0.9) than for the mBODE% (0.6 ± 0.8).Conclusions: The new mBODE indexes are highly correlated but significantly different from each other. The differences between the novel indexes deserve further scrutiny.Keywords: BODE index, chronic obstructive pulmonary disease, exercise testing, multidimensional evaluation, oxygen uptake

A 33-year-old man with rheumatic heart disease presented with acute chest pain and diaphoresis. Five years earlier, he had undergone replacement of the mitral and aortic valves. EKG showed ST elevation in left-sided leads V8 and V9.

ResumenEl reconocimiento de la heterogeneidad clínica de la EPOC sugiere un abordaje terapéutico específico dirigido por los llamados fenotipos clínicos de la enfermedad. La Guía Española de la EPOC (GesEPOC) es una iniciativa de la SEPAR que, conjuntamente con las sociedades científicas implicadas en la atención a pacientes con EPOC y el Foro Español de Pacientes, ha elaborado una nueva guía de práctica clínica. En el presente artículo se describe la clasificación de gravedad y el tratamiento farmacológico de la EPOC estable. La GesEPOC identifica 4 fenotipos clínicos con tratamiento diferencial: no agudizador, mixto EPOC-asma, agudizador con enfisema y agudizador con bronquitis crónica. La base del tratamiento farmacológico de la EPOC es la broncodilatación, a la que se añaden diversos fármacos según el fenotipo clínico y la gravedad. La gravedad se establecerá por las escalas multidimensionales BODE/BODEx. Una aproximación a la gravedad también se puede conseguir a partir de la obstrucción del flujo aéreo, la disnea, el nivel de actividad física y la historia de agudizaciones. La GesEPOC supone una nueva aproximación al tratamiento de la EPOC más individualizada según las características clínicas de los pacientes.AbstractRecognizing the clinical heterogeneity of COPD suggests a specific therapeutic approach directed by the so-called clinical phenotypes of the disease. The Spanish COPD Guidelines (GesEPOC) is an initiative of SEPAR, which, together with the scientific societies involved in COPD patient care, and the Spanish Patient Forum, has developed these new clinical practice guidelines. This present article describes the severity classification and the pharmacological treatment of stable COPD. GesEPOC identifies four clinical phenotypes with differential treatment: non-exacerbator, mixed COPD-asthma, exacerbator with emphysema and exacerbator with chronic bronchitis. Pharmacological treatment of COPD is based on bronchodilation in addition to other drugs depending on the clinical phenotype and severity. Severity is established by the BODE/BODEx multidimensional scales. Severity can also be approximated by assessing airflow obstruction, dyspnea, level of physical activity and history of exacerbations. GesEPOC is a new, more individualized approach to COPD treatment according to the clinical characteristics of the patients.

Backgrounds: AUDIPOC is a nationwide clinical audit that describes the characteristics, interventions and outcomes of patients admitted to Spanish hospitals because of an exacerbation of chronic obstructive pulmonary disease (ECOPD), assessing the compliance of these parameters with current international guidelines. The present study describes hospital resources, hospital factors related to case recruitment variability, patients' characteristics, and adherence to guidelines. Methodology/Principal Findings: An organisational database was completed by all participant hospitals recording resources and organisation. Over an 8-week period 11,564 consecutive ECOPD admissions to 129 Spanish hospitals covering 70% of the Spanish population were prospectively identified. At hospital discharge, 5,178 patients (45% of eligible) were finally included, and thus constituted the audited population. Audited patients were reassessed 90 days after admission for survival and readmission rates. A wide variability was observed in relation to most variables, hospital adherence to guidelines, and readmissions and death. Median inpatient mortality was 5% (across-hospital range 0-35%). Among discharged patients, 37% required readmission (0-62%) and 6.5% died (0-35%). The overall mortality rate was 11.6% (0-50%). Hospital size and complexity and aspects related to hospital COPD awareness were significantly associated with case recruitment. Clinical management most often complied with diagnosis and treatment recommendations but rarely (, This work was supported by Fondo de Investigacion Sanitaria (FIS), Instituto de Salud Carlos III, Ministerio de Ciencia e Innovacion (PI 08/90129, PI 90486, PI08/90578, PI 07/90503, PI 08/90251, PI 07/90516, PI 08/90529, PI 07/90309, PI 08/90457, PI 08/90129, PI 07/90721, PI 08/90550, PI08/90447, PI07/90403, PI 08/90486), Spanish Respiratory Society (SEPAR) and CIBER de Enfermedades Respiratorias (CIBERES). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.