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Abstract Introduction Bronchial stump aspergillosis is a rare entity characterized by cough and hemoptysis. Case presentation We report the case of a 58-year-old Caucasian woman who developed bronchial stump aspergillosis two years after a left upper lobe resection for lung cancer. Bronchial stump aspergillosis was diagnosed as a result of a focus of increased fluorodeoxyglucose activity in a follow-up positron emission tomography and computed tomography scan. She was treated with oral antifungal therapy and presented with good evolution after three months of treatment. Conclusion Bronchial stump aspergillosis is an unusual complication after pulmonary resection. Clinicians should be aware of it when a local recurrence of cancer around the bronchial stump is suspected based on a positive positron emission tomography and computed tomography finding.

Laura Millares,1,2 Eduard Monso1– 4 1Airway Inflammation Research Group, Parc Taulí Research and Innovation Institute - I3PT – Parc Taulí Foundation, Sabadell, Barcelona, Spain; 2Catalan Institute of Oncology – ICO, Badalona, Barcelona, Spain; 3Biomedical Research Network on Respiratory Diseases (CIBERES), Carlos III Health Institute (ISCIII), Madrid, Spain; 4Autonomous University of Barcelona - UAB, Cerdanyola del Vallès, Barcelona, SpainCorrespondence: Eduard Monso, Institut d’ Investigació i Innovació Parc Taulí - I3PT - Fundació Parc Taulí, Parc Taulí 1, Sabadell, 08208, Spain, Tel +347236673, Fax +347175067, Email emonso@tauli.catAbstract: The aim of interventions over the respiratory microbiome in COPD is to preserve the original microbial flora, focusing in taxa with a demonstrated impact on the prognosis of the disease. Inhaled therapy is the main treatment for COPD, and chronic corticosteroid use is recommended for patients with frequent exacerbations. This therapy, however, increases both the bronchial microbial load and the abundance of potentially pathogenic bacteria in patients with low peripheral eosinophil counts, and to minimize its use in patients without peripheral eosinophilia, when possible, may avoid increases in bacterial loads of microorganisms as Haemophilus influenzae and Streptococcus pneumoniae. In exacerbations antibiotics determine a decrease in the microbial diversity, a change that persists during stability periods in frequent exacerbators. High-diversity bronchial microbiomes are enriched in non-dominant genera and determine low exacerbation frequencies and survival improvement. Limiting the antibiotic use to the treatment of exacerbations which would clearly benefit would favor the diversity of the respiratory microbiome and may have a positive impact on quality of life and survival. Oral antiseptics have shown and effect on the bronchial microbiome that was associated with improvements in quality of life, and the gut microbiome may be also modified through the oral administration of probiotics or prebiotics, that potentially may determine decreases in lung inflammation and bronchial hyperreactivity. High fiber diets also favor the production of anti-inflammatory molecules by the digestive flora, which would reach the respiratory system through the bloodstream. Interventional approaches favoring the preservation of the respiratory microbiome in COPD need first to select accurately the patients who would benefit from long-term inhaled corticosteroids and antibiotic treatments during exacerbations, under the hypothesis that keeping a respiratory microbiome close to the healthy subject would favor the respiratory health. Additionally, high fiber diets may be able to modify the gut microbiome and influence the respiratory system through the gut-lung axis. Therapeutic approaches targeting the microbiome to improve COPD, however, still require clinical validation and the identification of patient subtypes who would benefit the most with their use.Keywords: microbiome, COPD, treatment, inhaled corticosteroids, antibiotics, diet

C Lalmolda,1–3 R Coll-Fernández,4 N Martínez,1 M Baré,5 M Teixidó Colet,5 F Epelde,6 E Monsó1–3 On behalf of the COPD Multidisciplinary Management Group 1Respiratory Diseases Department, Hospital Universitari Parc Tauli, 2Ciber de Enfermedades Respiratorias – Ciberes, 3Universitat Autònoma de Barcelona – UAB, 4Rehabilitation Department, Hospital Universitari Parc Tauli, 5Primary Care Unit Vallés Occidental, Institut Català de la Salut, 6Short Stay Unit, Emergency Service, Hospital Universitari Parc Taulí, Barcelona, Spain Background: Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established. Aims: The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year. Materials and methods: COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care.Results: Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0–1] vs 1 [0–2.5]; P=0.022) and in days of admission (0 [0–7] vs 7 [0–12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (β coefficient -0.785, P=0.014, and R2=0.219).Conclusion: A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention. Keywords: COPD, chronic disease management, CDM, rehabilitation, exacerbation, admission

Concepción Montón,1,2 Elena Prina,1 Xavier Pomares,1,3 Jose R Cugat,4 Antonio Casabella,5 Joan Carles Oliva,6 Miguel Gallego,1,3 Eduard Monsó1,3 1Department of Respiratory Medicine, Hospital De Sabadell, Institut Universitari Parc Taulí-UAB, Sabadell, Spain; 2Health Services Research on Chronic Diseases Network-REDISSEC, Galdakao, Spain; 3CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain; 4Department of Respiratory Medicine, Fundació Althaia, Manresa, Spain; 5Laboratory of Microbiology-UDIAT, Institut Universitari Parc Taulí-UAB, Sabadell, Spain; 6Epidemiology and Assessment Unit, Fundació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, SpainCorrespondence: Concepción MontónDepartment of Respiratory Medicine, Hospital de Sabadell, Institut Universitari Parc Tauli-UAB, Parc Taulí 1, Sabadell, Barcelona 08208, SpainTel +34 93 7458262Email cmonton@tauli.catIntroduction: Long-term use of nebulized or oral antibiotics is common in the treatment of cystic fibrosis and non-cystic fibrosis bronchiectasis. To date, however, few studies have focused on the use of nebulized antibiotics in COPD patients. The aims of this study are: to establish whether a combination of nebulized colistin plus continuous cyclic azithromycin in severe COPD patients with chronic bronchial infection due to Pseudomonas aeruginosa reduces the frequency of exacerbations, and to assess the effect of this treatment on microbiological sputum isolates.Material and methods: A retrospective cohort was created for the analysis of patients with severe COPD and chronic bronchial infection due to P. aeruginosa treated with nebulized colistin at the Respiratory Day Care Unit between 2005 and 2015. The number and characteristics of COPD exacerbations (ECOPD) before and up to two years after the introduction of nebulized colistin treatment were recorded.Results: We analyzed 32 severe COPD patients who received nebulized colistin for at least three months (median 17 months [IQR 7–24]). All patients but one received combination therapy with continuous cyclic azithromycin (median 24 months [IQR 11–30]). A significant reduction in the number of ECOPD from baseline of 38.3% at two years of follow-up was observed, with a clear decrease in P. aeruginosa ECOPD (from 59.5% to 24.6%) and a P. aeruginosa eradication rate of 28% over the two-year follow-up.Conclusion: In patients with severe COPD and chronic bronchial infection due to P. aeruginosa, combination therapy with nebulized colistin and continuous cyclic azithromycin significantly reduced the number of ECOPD, with a marked decrease in P. aeruginosa sputum isolates.Keywords: COPD, exacerbation, azithromycin, colistin, Pseudomonas aeruginosa

Antoni Sicras Mainar,1 Alicia Huerta,2 Ruth Navarro Artieda,3 Eduard Monsó,4,5 Sarah H Landis,6 Afisi S Ismaila7,8 1Scientific Direction, Health Economics and Outcomes Research (HEOR) Department, Real Life Data, Madrid, Spain; 2Market Access Department, GlaxoSmithKline SA, Madrid, Spain; 3Medical Documentation Department, Hospital Germans Trias I Pujol, Badalona, Spain; 4Pulmonology Service, Hospital Parc Taulí, Barcelona, Spain; 5CIBERES – Ciber De Enfermedades Respiratorias, Madrid, Spain; 6Real World Evidence and Epidemiology Department, GlaxoSmithKline, Uxbridge, UK; 7Value Evidence and Outcomes Department, GlaxoSmithKline, Collegeville, PA, USA; 8Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, CanadaCorrespondence: Alicia HuertaMarket Access Department, GlaxoSmithKline SA, C/Severo Ochoa 2, Madrid 28760, SpainTel +34 91 807 0821Fax +34 9 187 0500Email donha_ali@hotmail.comPurpose: Guidelines recommend the use of triple therapy with an inhaled corticosteroid (ICS), a long-acting β2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA) to reduce the risk of future exacerbations in symptomatic COPD patients with a history of exacerbations. This study aimed to estimate COPD-related healthcare resource use and costs, and subsequent exacerbation rates, for patients initiating multiple-inhaler triple therapy (MITT) early (≤30 days) versus late (31–180 days) following an exacerbation, in a real-world clinical setting.Patients and methods: This was an observational, longitudinal, retrospective study using electronic medical records from the Spanish database of the Red de Investigación en Servicios Sanitarios Foundation. Patients ≥40 years old with a confirmed COPD diagnosis who were newly prescribed MITT up to 180 days after an exacerbation between January 2013 and December 2015 were included. Patients were followed from the date of MITT initiation for up to 12 months to assess COPD-related health care resource use (routine and emergency visits, hospitalizations, pharmacologic treatment), exacerbation rate, and costs (€2017); these endpoints were compared between early versus late groups.Results: The study included 1280 patients who met selection criteria: mean age 73 years, 78% male, and 41% had severe/very severe lung function impairment. The proportion of patients initiating MITT early versus late was 61.6% versus 38.4%, respectively. There were no statistically significant differences in baseline characteristics between groups. During follow-up, health care resource consumption was lower in the early versus late group, especially primary care and ED visits, leading to lower total costs (€1861 versus €1935; P