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Resumen La nueva edicion de 2021 de la Guia Espanola de la EPOC (GesEPOC 2021) propone, junto al tratamiento farmacologico ajustado por estratificacion de riesgo y fenotipo, el abordaje personalizado de los rasgos tratables, definidos como una caracteristica (clinica, fisiologica o biologica) que se puede identificar mediante pruebas diagnosticas o biomarcadores y que tiene un tratamiento especifico. Existen algunos rasgos tratables que tienen un tratamiento no farmacologico y que no fueron contemplados en detalle en la guia, como puede ser la desnutricion, el sedentarismo, el enfisema o la insuficiencia respiratoria. En este capitulo de GesEPOC 2021 se presenta una actualizacion narrativa con recomendaciones sobre tratamiento dietetico, actividad fisica, rehabilitacion respiratoria, oxigenoterapia, ventilacion no invasiva, reduccion de volumen y trasplante pulmonar. Ademas, se incluye una pregunta PICO con recomendacion sobre el uso de oxigeno suplementario durante el ejercicio en pacientes con EPOC sin hipoxemia grave.

The Spanish COPD Guidelines (GesEPOC) were first published in 2012, and since then have undergone a series of updates incorporating new evidence on the diagnosis and treatment of COPD. GesEPOC was drawn up in partnership with scientific societies involved in the treatment of COPD and the Spanish Patients' Forum. Their recommendations are based on an evaluation of the evidence using GRADE methodology, and a narrative description of the evidence in areas in which GRADE cannot be applied. In this article, we summarize the recommendations on the pharmacological treatment of stable COPD based on 9 PICO questions. COPD treatment is a 4-step process: 1) diagnosis, 2) determination of the risk level, 3) initial and subsequent inhaled therapy, and 4) identification and management of treatable traits. For the selection of inhaled therapy, high-risk patients are divided into 3 phenotypes: non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator. Some treatable traits are general and should be investigated in all patients, such as smoking or inhalation technique, while others affect severe patients in particular, such as chronic hypoxemia and chronic bronchial infection. COPD treatment is based on long-acting bronchodilators with single agents or in combination, depending on the patient's risk level. Eosinophilic exacerbators must receive inhaled corticosteroids, while non-eosinophilic exacerbators require a more detailed evaluation to choose the best therapeutic option. The new GesEPOC also includes recommendations on the withdrawal of inhaled corticosteroids and on indications for alpha-1 antitrypsin treatment. GesEPOC offers a more individualized approach to COPD treatment tailored according to the clinical characteristics of patients and their level of complexity.

The isolation of Pseudomonas aeruginosa (PA) in patients with chronic obstructive pulmonary disease (COPD) is associated with increased mortality. Yet, factors associated with first PA sputum isolation, and PA persistence have not been investigated before. The objective of the present study was to investigate risk factors for new acquisition and persistence of PA infection and their relationship with all-cause mortality in patients with COPD. Post-hoc analysis of prospectively collected cohort of 170 COPD patients (GOLD II-IV) who were free of previous PA isolation and followed up every 3-6 months for 85 [50.25-110.25] months. PA was isolated for the first time in 41 patients (24.1%) after 36 [12-60] months of follow-up. Risk factor for first PA isolation were high cumulative smoking exposure, severe airflow limitation, previous severe exacerbations, high fibrinogen levels and previous isolation of Haemophilus Influenzae. PA was isolated again one or more times during follow-up in 58.5% of these patients. This was significantly associated with the presence of CT bronchiectasis and persistence of severe exacerbations, whereas the use of inhaled antibiotic treatment after the first PA isolation (at the discretion of the attending physician) reduced PA persistence. During follow-up, 79 patients (46.4%) died. A single PA isolation did not increase mortality, but PA persistence did (HR 3.06 [1.8-5.2], p = 0.001). We conclude that PA occurs frequently in clinically stable COPD patients, risk factors for a first PA isolation and PA persistence are different, and the latter (but not the former) is associated with increased all-cause mortality.

Introduction Control status may be a useful tool to assess response to treatment at each clinical visit in COPD. Control status has demonstrated to have long-term predictive value for exacerbations, but there is no information about the short-term predictive value of the lack of control and changes in control status over time. Method Prospective, international, multicenter study aimed at describing the short-term (6 months) prognostic value of control status in patients with COPD. Patients with COPD were classified as controlled/uncontrolled at baseline and at 3,6-month follow-up visits using previously validated criteria of control. Moderate and severe exacerbation rates were compared between controlled and uncontrolled visits and between patients persistently controlled, uncontrolled and those changing control status over follow-up. Results A total of 267 patients were analyzed: 80 (29.8%) were persistently controlled, 43 (16%) persistently uncontrolled and 144 (53.7%) changed control status during follow-up. Persistently controlled patients were more frequently men, with lower (not increased) body mass index and higher FEV1(%). During the 6 months following an uncontrolled patient visit the odds ratio (OR) for presenting a moderate exacerbation was 3.41 (95% confidence interval (CI) 2.47–4.69) and OR = 4.25 (95%CI 2.48–7.27) for hospitalization compared with a controlled patient visit. Conclusions Evaluation of control status at each clinical visit provides relevant prognostic information about the risk of exacerbation in the next 6 months. Lack of control is a warning signal that should prompt investigation and action in order to achieve control status.

Background: Two previous national epidemiological studies, IBERPOC in 1997 and EPISCAN in 2007, determined the COPD burden in Spain. Changes in demographics and exposure to risk factors demand the periodic update of COPD prevalence and its determinants. Methods: EPISCAN II aimed to estimate the prevalence of COPD in the general population aged 40 years or older in all 17 regions of Spain. A random population screening sample, requiring 600 participants per region performed a questionnaire plus post-bronchodilator (post-BD) spirometry. Results: A total of 12,825 subjects were initially contacted, and 9433 (73.6%) agreed to participate, of whom 9092 performed a valid spirometry. Baseline characteristics were: 52.6% women, mean ± SD age 60 ± 11 years, 19.8% current- and 34.2% former-smokers. The prevalence of COPD measured by post-BD fixed ratio FEV1/FVC < 0.7 was 11.8% (95% C.I. 11.2–12.5) with a high variability by region (2.4-fold). Prevalence was 14.6% (95% C.I. 13.5–15.7) in males and 9.4% (95% C.I. 8.6–10.2) in females; according to the lower limit of normal (LLN) was 6.0% (95% C.I. 5.5–6.5) overall, by sex being 7.1% (95% C.I. 6.4–8.0) in males and 4.9% (95% C.I. 4.3–5.6) in females. Underdiagnosis of COPD was 74.7%. Cases with COPD were a mean of seven years older, more frequently male, of lower attained education, and with more smokers than the non-COPD population (p < 0.001). However, the number of cigarettes and pack-years in non-COPD participants was substantial, as it was the reported use of e-cigarettes (7.0% vs. 5.5%) (p = 0.045). There were also significant social and clinical differences including living alone, previous respiratory diagnoses, more comorbidities measured with the Charlson index, greater BODE and COTE scores, cognitive impairment, and depression (all p < 0.001). Conclusions: COPD remains prevalent in Spain and frequently underdiagnosed.

Resumen A pesar de que es conocido que la presencia cronica de microorganismos en las vias aereas de pacientes con enfermedad pulmonar obstructiva cronica (EPOC) en fase de estabilidad conlleva una evolucion desfavorable, ninguna guia de manejo de la enfermedad establece pautas sobre como diagnosticar y tratar este tipo de casos. Con la intencion de orientar a los profesionales, desde la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) se ha elaborado un documento que pretende aportar respuestas clinicas sobre el manejo de pacientes con EPOC en los que se aislan microorganismos de forma puntual o persistente. Dado que la heterogeneidad de las evidencias cientificas disponibles no permite crear una Guia de Practica Clinica, se ha elaborado un documento basado en la literatura cientifica existente y/o en la propia experiencia clinica que aborda tanto la definicion de las diferentes situaciones clinicas como su diagnostico y manejo. El texto ha sido consensuado entre un amplio numero de neumologos con gran experiencia clinica y cientifica en este ambito. Este documento cuenta con el aval del Comite Cientifico de SEPAR.

Background The concept of clinical control has been proposed as an instrument for evaluating patients with COPD. However, the possible association between clinical control, reduced symptom severity and HRQoL has yet to be confirmed. Methods This multicentre, prospective and observational study was carried out in 15 pulmonology clinics in Spain. The patients were followed up for six months, with a baseline visit (V0), followed by visits at three months (V1) and six months (V2). Clinical control was determined at V1, with the application of both clinical criteria and the COPD assessment test (CAT). All patients reported their symptoms by a validated symptom diary (E-RS) using a portable device, and their HRQoL was assessed using the EQ5D questionnaire. The relationship between clinical control and E-RS and HRQoL during follow-up was assessed with t-test. Results A total of 126 patients were screened. After application of the inclusion/exclusion criteria, 93 were finally included (mean age 66 ± 8 years, 84.9% male), with a mean FEV1 predicted of 49.8% ± 16.5%. Of these patients, 44 (47.3%) achieved clinical control at V1, according to CAT criteria, and 50 (53.8%), according to clinical criteria. The E-RS scores differed between controlled and uncontrolled patients at all time points, both according to CAT (mean differences of -4.6, -5.6 and -6.2 units at V0, V1 and V2, respectively, p

Chronic airflow obstruction affects a wide range of airway diseases, the most frequent of which are asthma, COPD, and bronchiectasis; they are clearly identifiable in their extremes, but quite frequently overlap in some of their pathophysiological and clinical characteristics. This has generated the description of new mixed or overlapping disease phenotypes with no clear biological grounds. In this special article, a group of experts provides their perspective and proposes approaching the treatment of chronic airway disease (CAD) through the identification of a series of therapeutic goals (TG) linked to treatable traits (TT) - understood as clinical, physiological, or biological characteristics that are quantifiable using biomarkers. This therapeutic approach needs validating in a clinical trial with the strategy of identification of TG and treatment according to TT for each patient independently of their prior diagnosis.

Melanie Schroeder,1 Nicole Benjamin,2 Laura Atienza,3 Chandroday Biswas,4 Alan Martin,5 John D Whalen,6 José Luis Izquierdo Alonso,7 Juan Antonio Riesco Miranda,8 Juan José Soler-Cataluña,9 Alicia Huerta,3 Afisi S Ismaila10,11 1Value Evidence and Outcomes, GlaxoSmithKline plc., Brentford, UK; 2Global Health Economics, ICON plc., Boston, MA, USA; 3Market Access, GlaxoSmithKline SA, Madrid, Spain; 4Global Health Economics, ICON plc., Bengaluru, Karnataka, India; 5Value Evidence and Outcomes, GlaxoSmithKline plc., Uxbridge, UK; 6Global Health Economics, ICON plc., Abingdon, UK; 7Pneumology, Hospital Universitario de Guadalajara, Guadalajara, Spain; 8Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, Spain; 9Pneumology Department, Hospital Arnau de Vilanova-Lliria (Valencia), Valencia, Spain; 10Value Evidence and Outcomes, GlaxoSmithKline plc., Collegeville, PA, USA; 11Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, CanadaCorrespondence: Afisi S IsmailaGlaxoSmithKline Plc., 1250 South Collegeville Road, Collegeville, PA 19426-0989, USATel +1 (919) 315 8229Email afisi.s.ismaila@gsk.comPurpose: To evaluate the cost-effectiveness of once-daily fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) vs twice-daily budesonide/formoterol (BUD/FOR) in patients with symptomatic chronic obstructive pulmonary disease (COPD) at risk of exacerbations, from the Spanish National Healthcare System perspective.Patients and Methods: The validated GALAXY-COPD model was used to simulate disease progression and predict healthcare costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) over a 3-year time horizon for a Spanish population. Patient characteristics from published literature were supplemented by data from FULFIL (NCT02345161), which compared FF/UMEC/VI vs BUD/FOR in patients with symptomatic COPD at risk of exacerbations. Treatment effects, extrapolated to 3 years, were based on Week 24 results in the FULFIL intent-to-treat population, including change in forced expiratory volume in 1 second, St. George’s Respiratory Questionnaire score, and exacerbation rates. Treatment, exacerbations, and COPD management costs (2019€) were informed by Spanish public sources and published literature. A 3% discount rate for costs and benefits was applied. One-way sensitivity and scenario analyses, and probabilistic sensitivity analysis (PSA), were performed.Results: FF/UMEC/VI treatment led to fewer moderate and severe exacerbations (2.126 and 0.306, respectively) vs BUD/FOR (2.608 and 0.515, respectively), with a mean incremental cost of € 69 and gain of 0.107 QALYs, which resulted in an ICER of € 642 per QALY gained. In sensitivity analyses, the ICER was most sensitive to treatment effect variations in exacerbations and healthcare resource utilization/event costs. Overall, 95% of 1000 PSA simulations resulted in an ICER less than € 11,000 per QALY gained for FF/UMEC/VI vs BUD/FOR, confirming robustness of the results. The probability of FF/UMEC/VI being cost-effective vs BUD/FOR was 100% at a willingness-to-pay threshold of € 30,000 per QALY gained.Conclusion: At the accepted Spanish ICER threshold of € 30,000, FF/UMEC/VI represents a cost-effective treatment option vs BUD/FOR in patients with symptomatic COPD at risk of exacerbations.Keywords: cost-utility analysis, health-related quality of life, incremental cost-effectiveness ratio, fluticasone furoate, vilanterol, umeclidinium

Introduction There is currently no universally accepted definition of asthma−COPD overlap (ACO). Objective To compare the prevalence of ACO in patients with asthma or COPD, and to assess their clinical characteristics and the capacity of the different definitions to predict the risk of exacerbation. Method Prospective observational study with a 12-month follow-up in an asthma cohort and a COPD cohort. Four diagnostic criteria were compared: A) the Spanish 2012 consensus; B) the 2016 international consensus; C) the 2017 consensus between the Spanish COPD guidelines (GesEPOC) and GEMA asthma guidelines; and D) the single criterion of ≥300 eosinophils/μL, proposed by GOLD 2019. The risk of exacerbations was evaluated in each group. Results A total of 345 patients were included, 233 (67.5%) with COPD and 112 (32.5%) with asthma, aged 63 ± 14 years, 70.4% men. Fifteen (4.3%) patients met the criteria for ACO according to the criteria described under A above; 30 (8.7%) with the criteria of B; 118 (34.2%) with the criteria of C; and 97 (28.1%), with the D criterion. The ACO-COPD subtype were older, had worse lung function, and an increased risk of exacerbation compared with the ACO-asthma group. Of all the definitions evaluated, those which distinguished a higher risk of exacerbations were the GesEPOC-GEMA consensus and the GOLD proposal. Conclusions The prevalence of ACO varies enormously depending on the diagnostic criteria used. The ACO population is heterogeneous, and the ACO-COPD subtype is very different from the ACO-asthma subtype. The definitions that include eosinophilia identify ACO patients with a greater risk of exacerbation.

Rationale: Treatment of chronic obstructive pulmonary disease (COPD) with inhaled corticosteroids (ICS) is controversial, because it can reduce the risk of future exacerbations of the disease at the expense of increasing the risk of pneumonia.Objectives: To assess the relationship between the presence of chronic bronchial infection (CBI), reduced number of circulating eosinophils, ICS treatment, and the risk of pneumonia in patients with COPD.Methods: This was a post hoc long-term observational study of an historical cohort of 201 patients with COPD (Global Initiative for Chronic Obstructive Lung Disease II-IV) who were carefully characterized (including airway microbiology) and followed for a median of 84 months. Results were analyzed by multivariate Cox regression and network analysis.Measurements and Main Results: Mean age was 70.3 years, 90.5% of patients were male, mean FEV1 was 49%, 71.6% of patients were treated with ICS, 57.2% of them had bronchiectasis, and 20.9% had

Background Control has been proposed as a dynamic tool that can capture changes in the clinical status of patients with COPD. Methods This prospective, multicenter, observational study aimed to compare changes in control over a 3-month period with changes in risk level, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, and clinical phenotype (nonexacerbator, asthma-COPD overlap, or exacerbator with emphysema or with chronic bronchitis). Control was defined as the presence of low clinical impact, assessed according to the degree of dyspnea, use of rescue medication, physical activity and sputum color, and clinical stability assessed by clinical changes and exacerbations in the last 3 months. Impact and stability were alternatively assessed with COPD Assessment Test (CAT) scores. Results We included 354 patients, with a mean FEV1 of 49.8% ± 16.9%. At 3 months, the proportion of controlled patients was 50.3% according to clinical evaluation and 47.8% according to CAT score. Eighty-seven patients (29.2%) changed their control status as assessed by clinical variables, and 85 patients (28.5%) changed their status according to CAT score. In contrast, the risk level only changed in 26 patients (8.7%) (P Conclusions In only 3 months, almost one-third of patients experienced changes in their control status. Changes in control status were significantly more frequent than changes in phenotype, risk level, and GOLD stage, and resulted in significant changes in health status.

Resumen Introduccion En la actualidad no disponemos de una definicion de solapamiento asma-EPOC (ACO) universalmente aceptada. Objetivo Comparar la prevalencia del ACO en pacientes con asma o EPOC, valorar sus caracteristicas clinicas y la capacidad predictiva de riesgo de agudizacion de las diferentes definiciones. Metodo Estudio prospectivo observacional con seguimiento de 12 meses sobre una cohorte de asma y otra con EPOC. Se comparan 4 criterios diagnosticos: A) el consenso espanol del 2012; B) el consenso internacional del 2016; C) el consenso entre la guia espanola de la EPOC (GesEPOC) y la del asma (GEMA) del 2017; y D) el criterio unico de ≥ 300 eosinofilos/μl, propuesto por GOLD 2019. En cada grupo se evaluo el riesgo de agudizaciones. Resultados Se incluyeron 345 pacientes, 233 (67,5%) con EPOC y 112 (32,5%) con asma, con una edad de 63 ± 14 anos; el 70,4% eran hombres. Quince (4,3%) pacientes cumplian criterios de ACO con criterios A; 30 (8,7%) con los B; 118 (34,2%) con los C; y 97 (28,1%) con el criterio D. El subtipo ACO-EPOC presento mas edad, peor funcion pulmonar y mayor riesgo de agudizacion que los ACO-asma. De todas las definiciones evaluadas, las que presentaron mayor riesgo de agudizaciones fueron la del consenso GesEPOC-GEMA y la propuesta de GOLD. Conclusiones La prevalencia de ACO varia enormemente en funcion del criterio diagnostico utilizado. La poblacion de ACO es heterogenea, con un subtipo ACO-EPOC muy diferente al ACO-asma. Las definiciones que incluyen la eosinofilia identifican a los ACO de mas riesgo de agudizacion.

Borja G Cosio,1,2 Hanaa Shafiek,1,3 Nuria Toledo-Pons,1,2 Amanda Iglesias,1,2 Margalida Barcelo,1 Cristina Represas-Represas,4 Lorena Comeche,5 Pablo Catalan,6 Alberto Fernandez-Villar,4 Jose Luis Lopez- Campos,7 Jose Echave-Sustaeta,5 Juan Jose Soler-Cataluna8 1Respiratory Medicine, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Spain; 2CIBERES-IDISBa, Palma de Mallorca, Spain; 3Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt; 4Respiratory Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain; 5Respiratory Medicine, Hospital Universitario Quironsalud Madrid, Madrid, Spain; 6Respiratory Medicine, Hospital General de Castellón, Castellón, Spain; 7Respiratory Medicine, Hospital Virgen del Rocio-CIBERES, Sevilla, Spain; 8Respiratory medicine, Hospital Arnau de Vilanova-CIBERES, Valencia, SpainCorrespondence: Borja G CosioHospital Universitario Son Espases, Ctra de Valldemossa 79, Palma de Mallorca, 07010, SpainTel +34 871 20 6714Email borja.cosio@ssib.esPurpose: Exacerbations of COPD (ECOPD) are a frequent cause of hospitalization that seemed to ameliorate during the COVID outbreak. We aimed to evaluate the clinical characteristics of COPD-related hospital admissions and mortality in relation to the presence of COVID-19.Patients and Methods: We conducted a case–control study of patients admitted in four teaching hospitals throughout Spain between March 15 and April 30, 2020. Hospital admissions of respiratory cause with and without PCR-proven SARS-CoV-2 infection in patients with COPD were evaluated. Baseline and episode-related clinical characteristics were analyzed. Logistic regression analysis was performed to evaluate the risk for mortality.Results: During the study period, 2101 patients were admitted for respiratory worsening, 1200 (57.1%) with COVID-19. A total of 228 (10.8%) were admitted due to COPD worsening, of whom 52 (22.8%) tested positive for COVID-19. COPD patients with COVID-19, when compared to those without COVID-19, were more frequently males with better lung function (FEV1 postbronchodilator 71% vs 46% respectively, p< 0.001) and had higher mortality (44.9% vs 13.6% respectively, p< 0.001) despite similar age, comorbidities, total days of hospitalization and admission to intensive care unit. COVID-19 and eosinopenia were the strongest risk factors for mortality in the multivariate analysis in the overall COPD population. Inhaled corticosteroid use was not associated to mortality.Conclusion: Hospitalizations for ECOPD without COVID-19 were more frequent than COPD with COVID-19 during the first outbreak, but the latter were associated with higher mortality and low eosinophil counts that warrant further analysis.Keywords: COPD exacerbation, mortality, inhaled corticosteroids, hospitalization

The concept of chronic obstructive pulmonary disease (COPD) control has been proposed to guide treatment decisions in COPD. In this study, we aimed to validate the prospective value of this concept in the SPARK study population. Control was assessed based on COPD stability and impact. Patients with low impact and stability during weeks 1–12 were classified as controlled, and exacerbations were measured during a 52-week follow-up. Of the 2044 patients included a majority were non-controlled (80%), frequently due to high impact. During the follow-up, the rate of moderate/severe exacerbations was significantly lower in controlled patients (rate ratio, 0.56, 95% CI 0.48 to 0.65 p

Resumen Objetivo Describir un acuerdo entre expertos basado en la evidencia y la experiencia sobre los aspectos mas relevantes del paciente exacerbador con EPOC. Metodos Se siguio la metodologia Delphi. Tras revisar la evidencia por un comite cientifico y 60 expertos, se elaboro un cuestionario con 3 apartados: diagnostico del paciente exacerbador; tratamiento, y proceso asistencial. La encuesta fue respondida online en 2 rondas por 60 neumologos. El grado de acuerdo siguio la escala Likert de 1 (total desacuerdo) a 9 (total acuerdo), definiendose acuerdo y desacuerdo como una puntuacion de 7-9 o 1-3, respectivamente, otorgada por mas de dos tercios de los participantes. Resultados Se incluyeron un total de 48 aseveraciones, una anadida en la segunda ronda. Hubo consenso en 37 (78,7%) tras la primera ronda (acuerdo), y en 43 (89,5%) tras la segunda (42 acuerdo y 1 desacuerdo). Las afirmaciones con mayor proporcion de expertos en el rango de acuerdo se refirieron a que, en el paciente exacerbador, la infeccion bronquial cronica favorece el deterioro de la funcion pulmonar (93,1%), a que no se deben retirar los broncodilatadores de larga duracion (93,1%), a la conveniencia de personalizar el tratamiento si se dan nuevas exacerbaciones pese a un tratamiento broncodilatador optimo (96,6%), o al cuidado y manejo de este paciente, que debe ser coordinado entre atencion primaria y neumologia (93,1%) y controlado en programas integrados especificos multicomponente (94,8%). Conclusiones La informacion proporcionada por este consenso puede facilitar el diagnostico y tratamiento del paciente exacerbador con EPOC en nuestro ambito.

We aimed to compare clinical characteristics between Asian and Western chronic obstructive pulmonary disease (COPD) patients. This was a sub-analysis of an international, multicenter, prospective cohort study. Asian patients were enrolled in Singapore and South Korea. Western patients were enrolled in Spain, Poland, Ireland, the United Kingdom, and Malta. A total of 349 patients were analyzed. Among them, 110 (32%) patients were Asian and 239 (68%) Western. Male sex was more predominant in Asian than in Western (95% versus 63%, respectively; P

Introduction and objectives: Determinants of chronic obstructive pulmonary disease (COPD) in the early stages of its natural history are not well known. Improving our knowledge of these factors will help to design interventions that can modify prognosis. Study objectives are: a) to characterize a COPD population of young adults aged 35-50 years from a multidimensional point of view; b) to compare these patients with smokers with normal lung function: and c) to create a cohort of young adults aged 35-50 years (smokers or former smokers), with and without COPD, who will be followed in the future to improve understanding of the natural history of the disease. Participants and method: This is a case-control multicenter study aimed at establishing a well characterized cohort of young adults, smokers or former-smokers, with and without COPD, for subsequent follow-up. A total of 311 participants (101 cases and 210 controls) were selected from approximately 30 primary care settings and 12 hospitals in 8 Spanish regions. Subjects were smokers or former smokers (> 10 pack-years) aged 35-50 years. Diagnosis of COPD was based on a post-bronchodilator result of FEV1/FVC < 70%. The main study variables were: questionnaires on health, symptoms, exacerbations and daily physical activity, lung function tests, blood and sputum samples, and low-dose computed tomography. In the statistical analysis, COPD patient characteristics will be described and compared with control subjects using a logistic regression analysis. (C) 2018 SEPAR. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion y objetivos Los determinantes en fases iniciales de la historia natural de la enfermedad pulmonar obstructiva cronica (EPOC) son poco conocidos. Entenderlos mejor es de capital importancia para poder disenar intervenciones dirigidas a modificar su pronostico. Los principales objetivos del estudio son: a) caracterizar a una poblacion de adultos jovenes con EPOC de forma multidimensional; b) comparar estos pacientes con sujetos fumadores con funcion pulmonar normal; y c) establecer una cohorte de adultos jovenes con y sin EPOC, que pueda ser seguida a largo plazo para conocer mejor la historia natural de la enfermedad. Participantes y metodo EARLY COPD es un estudio multicentrico de casos y controles que permitira establecer una cohorte de sujetos para su seguimiento posterior. Se seleccionaron 311 (101 casos y 210 controles) participantes reclutados en una treintena de centros de atencion primaria y 12 hospitales de 8 comunidades autonomas espanolas. Los participantes eran fumadores o exfumadores (> 10 paquetes ano) de entre 35-50 anos de edad. Los casos presentaban una espirometria obstructiva con un FEV1/FVC

Resumen Introduccion En 2007 el estudio EPISCAN actualizo los resultados de IBERPOC en 1997. Debido a los cambios demograficos y en la exposicion a factores de riesgo, es importante actualizar los datos de prevalencia y determinantes de la EPOC de forma periodica. El presente articulo resume el protocolo y las herramientas de EPISCAN II. Material y metodos El objetivo principal de EPISCAN II es estimar la prevalencia de la EPOC en la poblacion general residente en Espana de 40 anos o mas en las 17 comunidades autonomas. El tamano muestral requiere 600 participantes (300 hombres y 300 mujeres) por centro, seleccionando a 10.200 participantes en visita corta (cuestionario mas espirometria forzada posbroncodilatador) y de entre ellos a 800 (400 con EPOC y 400 sin EPOC) que tambien realizaran una visita larga (prueba de la marcha, sangre, difusion, pulsioximetria, bioimpedancia y TC de baja radiacion). Resultados El primer participante se recluto el 28 de febrero del 2017. A fecha de 22 de noviembre del 2017, contamos con un total de 3.581 participantes incluidos, de los cuales 422 ya han realizado la visita larga. Se estima que el trabajo de campo terminara alrededor de diciembre de 2018. La nueva informacion de imagen, biomarcadores y nuevas exposiciones, como el cigarrillo electronico o contaminacion ambiental, entre otros, permitiran una nueva cuantificacion del problema de la EPOC. Conclusiones EPISCAN II actualizara la prevalencia y los determinantes de la EPOC en Espana y permitira comparar resultados espirometricos y otros aspectos de la EPOC entre las 17 comunidades autonomas.

Introduction The EPISCAN study, published in 2007, was an update of the results of the 1997 IBERPOC study. Changes in demographics and exposure to risk factors demand the periodic update of prevalence and determining factors in COPD. This article is a summary of the protocol and tools used in EPISCAN II. Materials and methods The primary objective of EPISCAN II is to estimate the prevalence of COPD among the general population aged 40 years or more in the 17 autonomous communities of Spain. The sample size requires 600 participants (300 men and 300 women) per center, selected by screening 10 200 participants in a short visit (questionnaire plus forced post-bronchodilator spirometry). Of these, 800 (400 with COPD and 400 without COPD) will also perform a long visit (including a walking test, blood tests, determination of diffusion, pulse oximetry and bioimpedance, and low radiation CT). Results The first participant was recruited on 28 February 2017. As of 22 November 2017, a total of 3581 participants had been included, of whom 422 had already performed the long visit. It is estimated that the field work will be completed by December 2018. The new imaging data, biomarkers, and information on new exposures, such as electronic cigarettes and environmental pollution, will help us re-quantify the burden of COPD. Conclusions EPISCAN II will provide updated information on prevalence and determinants of COPD in Spain, allowing for the comparison of spirometric results and other factors associated with COPD among the 17 autonomous communities.

Background and objective Cardiovascular (CV) diseases are frequent in patients with chronic obstructive pulmonary disease (COPD). Likewise, chronic bronchial infection (CBI) is also frequent in COPD and it is associated with systemic inflammation, a well-known CV risk factor. The objective of this study was to investigate the relationship between CBI, systemic inflammation and incident CV events. Methods A post hoc analysis of prospectively collected cohort of 201 COPD patients [Global Initiative for Chronic Obstructive Lung Disease (GOLD) II-IV] followed up every 3-6 months for 84 months was conducted. CBI was defined as ≥3 positive pathogenic microorganisms sputum cultures over 1 year, separated by ≥3 months. Systemic inflammation was assessed by circulating levels of C-reactive protein and fibrinogen. Fatal and non-fatal CV events, including coronary and cerebrovascular events as well as arrhythmia episodes, were prospectively recorded. For analysis, they were analysed separately and combined in a composite variable. Results As hypothesized, CBI was associated with persistent systemic inflammation and a significantly higher incidence of CV events (HR: 3.88; 95% CI: 1.83-8.22), mainly of coronary origin independent of age, number and severity of exacerbations, comorbidities, other CV risk factors, lung function, BMI, smoking status and treatments. These associations were particularly significant in patients with CBI by Pseudomonas aeruginosa (PA). Conclusion CBI, particularly by PA, is associated with sustained and enhanced systemic inflammation and a higher incidence of CV events (especially coronary events). The possibility that treating CBI may decrease systemic inflammation and CV events in COPD deserves prospective, interventional studies.

Aims To identify the obstacles hindering the appropriate management of chronic obstructive pulmonary disease (COPD) in Spain based on consensus amongst clinicians and administrators. Methods A two-round modified Delphi questionnaire was sent to clinicians (pulmonologists and GPs) and administrators, all experts in COPD. The scientific committee developed the statements and selected the participating experts. Four areas were explored: diagnosis, training, treatment, and clinical management. Panellists' agreement was assessed using a 9-point Likert scale, with scores of 1 to 3 indicating disagreement and 7 to 9, agreement. Consensus was considered to exist when 70% of the participants agreed or disagreed with the statement. Results Respective response rates for the first and second round were 68% and 91% for clinicians, and 60% and 100% for administrators. The statements attracting the highest degree of consensus were: "Not enough nursing resources (time, staff, duties) are allocated for performing spirometry" (85.3% clinicians; 75% administrators); "Nurses need specific training in COPD" (84.8% clinicians; 100% administrators); "Rehabilitation programs are necessary for treating patients with COPD" (94.1% clinicians; 91.7% administrators); and "Integrated care processes facilitate the deployment of educational programs on COPD" (79.4% clinicians; 83.3% administrators). Conclusions This document can inform the development and implementation of specific initiatives addressing the existing obstacles in COPD management. What's known COPD is a prevalent and underdiagnosed disease that causes substantial morbidity and mortality. The National COPD Strategy established objectives and work programmes to apply in Spain. There are barriers impeding the application of interventions contemplated in the COPD strategy. What's new Different agents involved in COPD management agree that the main challenges to improve COPD management are resource shortages in primary care nursing and lack of training in the use of COPD clinical guidelines. Clinicians and administrators involved in COPD management support the implementation of urgent measures to tackle the underdiagnosis of COPD, especially in primary care, along with the routine inclusion of respiratory rehabilitation programmes for COPD.

The prevalence of chronic obstructive pulmonary disease (COPD) is rising faster in women in some countries. An observational time trends study was performed to assess the evolution of hospital admissions for COPD in men and women in Spain from 1998 to 2018. ICD-9 diagnostic codes (490–492, 496) from the minimum basic data set of hospital discharges were used. Age-standardised admission rates were calculated using the European Standard Population. Joinpoint regression models were fitted to estimate the annual percent change (APC). In 2018, the age-standardised admission rate per 100,000 population/year for COPD was five times higher in men (384.8, 95% CI: 381.7, 387.9) than in women (78.6, 95% CI: 77.4, 79.9). The average annual percent change (AAPC) was negative over the whole study period in men (−1.7%/year, 95% CI: −3.1, −0.2) but positive from 2010 to 2018 (1.1%/year, 95% CI: −0.8, 2.9). In women, the APC was −6.0% (95%CI: −7.1, −4.9) from 1998 to 2010, but the trend reversed direction in the 2010–2018 period (7.8%/year, 95% CI: 5.5, 10.2). Thus, admission rates for COPD decreased from 1998 to 2010 in both men and women but started rising again until 2018, modestly in men and sharply in women.

Background: Clinical control in chronic obstructive pulmonary disease (COPD) has not been completely characterized. A proposal of clinical control criteria (CCC) has been recently defined and validated as a tool for determining control, but there is scarce information on patients with severe COPD. Objective: To evaluate clinical control in severe COPD using the CCC. Patients and Methods: The study design was observational, multicenter, cross-sectional study involving 4801 patients with severe COPD in Spain. Clinical control was defined according to clinical impact (dyspnea grade, use of rescue treatment in last week, sputum color, and daily physical activity) and stability (exacerbations in last 3 months and patient's perception about health status). Clinical control of COPD was alternatively evaluated with the COPD assessment test (CAT) and the presence of exacerbations in the last 3 months. Results: According to CCC, 61.0% of patients had low clinical impact, and 41.4% showed clinical stability. Overall, 29.9% of patients had both low clinical impact and stability (controlled), whereas 70.1% showed high clinical impact and/or no clinical stability (non-controlled). COPD control was also assessed by using only the definition of CAT, The study described within the paper was sponsored by Chiesi Espana SAU.

[Background]: Bronchiectasis (BE) impact the clinical course and prognosis of patients with chronic obstructive pulmonary disease (COPD). Yet, the temporal evolution of BE in these patients is unknown. This study seeks to assess the temporal evolution of BE in persons with COPD., [Methods]: 201 moderate-to-severe patients were recruited between 2004 and 2007 and followed up at least every 6 monts (median of 102 months). To investigate the temporal evolution of BE, in 2015 a second high-resolution computed tomography scan (HRCT) was obtained in survivors and compared with the one obtained at recruitment., [Results]: 99 (49.3%) died during follow-up. The second HRCT could be obtained in 77 patients and showed that (1) in 27.3% of patients BE never developed, in 36.4% they remained stable, in 16.9% they increased in size and/or extension, and in 19.5% new BE emerged; and that (2) the presence of chronic purulent sputum (hazard ratio [HR], 2.8 [95% confidence interval {CI}, 1.3–5.8]), number of hospitalizations due to exacerbatons (HR, 1.2 [95% CI, 1.1–1.5]), and number of pathogenic microorganism (PPM) isolations (HR, 1.1 [95% CI, 1.02–1.3]) were independent risk factors for the progression or development of BE., [Conclusions]: The presence of chronic purulent sputum production, number of PPMs isolated in sputum, and number of hospitalizations due to exacerbations of COPD are independent risk factors of BE progression in patients with COPD.

Background: Studies of patients with cancer affected by coronavirus disease 2019 (COVID-19) are needed to assess the impact of the disease in this sensitive population, and the influence of different cancer treatments on the COVID-19 infection and seroconversion. Material and Methods: We performed a retrospective analysis of all patients hospitalized with RT-PCR positive for COVID-19 in our region to assess the prevalence of cancer patients and describe their characteristics and evolution (Cohort 1). Concurrently, a transversal study was carried out in patients on active systemic cancer treatment for symptomatology and seroprevalence (IgG/IgM by ELISA-method) against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Cohort 2). Results: A total of 215 patients (Cohort 1) were admitted to hospital with a confirmed COVID-19 infection between February 28 and April 30, 2020, and 17 died (7.9%). A medical record of cancer was noted in 43 cases (20%), 6 of them required Intensive care unit ICU attention (14%), and 7 died (16%). There were thirty-six patients (83%) who tested IgG/IgM positive for SARS-CoV-2. Patients on immunosuppressive therapies presented a lower ratio of seroconversion (40% vs. 8%, p = 0.02). In Cohort 2, 166 patients were included in a symptoms-survey and tested for SARS-CoV-2. Any type of potential COVID-19-related symptom was referred up to 67.4% of patients (85.9% vs. 48.2% vs. 73.9%, for patients on chemotherapy, immunotherapy and targeted therapies respectively, p &lt, 0.05). The seroprevalence ratio was 1.8% for the whole cohort with no significant differences by patient or treatment characteristics. Conclusion: Patients with cancer present higher risks for hospital needs for COVID-19 infection. The lack of SARS-CoV-2 seroconversion may be a concern for patients on immunosuppressive therapies. Patients receiving systematic therapies relayed a high rate of potentially COVID-19-related symptoms, particularly those receiving chemotherapy. However, the seroconversion rate remains low and in the range of general population.

In 2019, The Global Initiative for Chronic Obstructive Lung Disease (GOLD) modified the grading system for patients with COPD, creating 16 subgroups (1A–4D). As part of the COPD Cohorts Collaborative International Assessment (3CIA) initiative, we aim to compare the mortality prediction of the 2015 and 2019 COPD GOLD staging systems. We studied 17 139 COPD patients from the 3CIA study, selecting those with complete data. Patients were classified by the 2015 and 2019 GOLD ABCD systems, and we compared the predictive ability for 5-year mortality of both classifications. In total, 17 139 patients with COPD were enrolled in 22 cohorts from 11 countries between 2003 and 2017; 8823 of them had complete data and were analysed. Mean±sd age was 63.9±9.8 years and 62.9% were male. GOLD 2019 classified the patients in milder degrees of COPD. For both classifications, group D had higher mortality. 5-year mortality did not differ between groups B and C in GOLD 2015; in GOLD 2019, mortality was greater for group B than C. Patients classified as group A and B had better sensitivity and positive predictive value with the GOLD 2019 classification than GOLD 2015. GOLD 2015 had better sensitivity for group C and D than GOLD 2019. The area under the curve values for 5-year mortality were only 0.67 (95% CI 0.66–0.68) for GOLD 2015 and 0.65 (95% CI 0.63–0.66) for GOLD 2019. The new GOLD 2019 classification does not predict mortality better than the previous GOLD 2015 system., GOLD 2019 staging system created 16 subgroups. GOLD 2015 and GOLD 2019 are not strong predictors of mortality, and do not have sufficient discriminatory power to be used as a tool for risk classification of mortality in patients with COPD. https://bit.ly/3idBuaN

The phenotypic characteristics of chronic obstructive pulmonary disease (COPD) in individuals younger than 50 years of age (early COPD) are not well defined. This prospective, multi-centre, case-control study sought to describe these characteristics and compare them with those of smokers (>= 10 pack-years) of similar age with normal spirometry (controls). We studied 92 cases (post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC), In part, by CIBERES, SEPAR, FIS (CP16/00039, PI17/00369, PI18/01008) and an unrestricted grant from Boehringer-Ingelheim. Funding information for this article has been deposited with the Crossref Funder Registry.

Introduction: The IMPACT study (NTC02164513) showed the clinical benefit of single-inhaler triple therapy (fluticasone furoate [FF]/umeclidinium [UMEC]/vilanterol [VI]) vs dual therapy with FF/VI and UMEC/VI in symptomatic COPD patients at risk of exacerbations. This was also demonstrated in subgroups with either ≥2 moderate or ≥1 severe exacerbation in the prior year (SG1), or Objective: Assess the cost-effectiveness of FF/UMEC/VI vs FF/VI and UMEC/VI by exacerbation history from a Spanish national healthcare system perspective. Methods: A published model of linked risk equations to predict disease progression, costs, and health outcomes was populated with baseline characteristics and treatment efficacy for SG1 and SG2 from the IMPACT study. Direct costs (€2019) and utilities were based on Spanish public sources and literature. A 3% discount rate for costs and treatment effects was used. Outputs included costs, quality-adjusted life years (QALYs) and incremental cost effectiveness ratios (ICER) over 3 years. Results: In SG1, patients receiving FF/UMEC/VI were predicted to gain 0.059 QALYs with an incremental cost of €414 vs FF/VI (ICER=€7,017/QALY) and 0.059 QALYs gain with cost savings of €675 vs UMEC/VI (ICER=Dominant). In SG2, FF/UMEC/VI had a 0.059 QALY gain an incremental cost of €308 vs FF/VI (ICER=€5,259/QALY) and 0.032 QALYs and €252 vs UMEC/VI (ICER=€7,817/QALY). Conclusions: FF/UMEC/VI is a cost-effective treatment option vs. dual therapies for symptomatic COPD at risk of exacerbations in Spain, irrespective of exacerbation history. Funding: GSK HO-17-17596

In 2019, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) proposed a clinical grading system for patients with chronic obstructive pulmonary disease (COPD) with 4 categories (A-D) based on symptoms and exacerbation history.As part of the COPD Cohorts Collaborative International Assessment (3CIA) initiative, we aim to compare mortality prediction of 2015 and 2019 COPD GOLD staging systems.We studied 17 139 COPD patients from the 3CIA study, selecting those with complete data. Patients were classified by the 2015 and 2019 GOLD ABCD systems and we compared the predictive ability for 5-year mortality of both classifications.17 139 patients with COPD were enrolled in 22 cohorts of 11 countries; 8823 of them had complete data and were analyzed. Mean age was 63.9 years(SD 9.8); 5 552(62.9%) were male and mean FEV1 was 54.8%(SD 22.3). Compared with 2015, the GOLD 2019 classified the patients in milder degrees of COPD:groups C and D decreased from 13.6% to 5.8% and 40% to 17.8% respectively (p

COPD is often not diagnosed, or is diagnosed too late. It is time for a change that anticipates both diagnosis and treatment.https://bit.ly/2BrDSv1

Background and objective The concept of clinical control in COPD has been developed to help in treatment decisions, but it requires validation in prospective studies. Methods This international, multicentre, prospective study aimed to validate the concept of control in COPD. Patients with COPD were classified as controlled/uncontrolled by clinical criteria or CAT scores at baseline and followed up for 18 months. The main outcome was the difference in rate of a composite endpoint of moderate and severe exacerbations or death over the 18-month follow-up period. Results A total of 307 patients were analysed (mean age = 68.6 years and mean FEV1% = 52.5%). Up to 65% and 37.9% of patients were classified as controlled by clinical criteria or CAT, respectively. Controlled patients had significantly less exacerbations during follow-up (by clinical criteria: 1.1 vs 2.6,P< 0.001; by CAT: 1.1 vs 1.9,P= 0.014). Time to first exacerbation was significantly prolonged for patients controlled by clinical criteria only (median: 93 days, IQR: 63; 242 vs 274 days, IQR: 221; 497 days;P< 0.001). Control status by clinical criteria was a better predictor of exacerbations compared to CAT criteria (AUC: 0.67 vs 0.57). Conclusion Control status, defined by easy-to-obtain clinical criteria, is predictive of future exacerbation risk and time to the next exacerbation. The concept of control can be used in clinical practice at each clinical visit as a complement to the current recommendations of initial treatment proposed by guidelines.

Background: There is partial evidence that COPD is expressed differently in women than in men, namely on symptoms, pulmonary function, exacerbations, comorbidities or prognosis. There is a need to improve the characterization of COPD in females. Methods: We obtained and pooled data of 17 139 patients from 22 COPD cohorts and analysed the clinical differences by sex, establishing the relationship between these characteristics in women and the prognosis and severity of the disease. Comparisons were established with standard statistics and survival analysis, including crude and multivariate Cox-regression analysis. Results: Overall, 5355 (31.2%) women were compared with men with COPD. Women were younger, had lower pack-years, greater FEV1%, lower BMI and a greater number of exacerbations (all p < 0.05). On symptoms, women reported more dyspnea, equal cough but less expectoration (p < 0.001). There were no differences in the BODE index score in women (2.4) versus men (2.4) (p = 0.5), but the distribution of all BODE components was highly variable by sex within different thresholds of BODE. On prognosis, 5-year survival was higher in COPD females (86.9%) than in males (76.3%), p < 0.001, in all patients and within each of the specific comorbidities that we assessed. The crude and adjusted RR and 95% C.I. for death in males was 1.82 (1.69–1.96) and 1.73 (1.50–2.00), respectively. Conclusions: COPD in women has some characteristic traits expressed differently than compared to men, mainly with more dyspnea and COPD exacerbations and less phlegm, among others, although long-term survival appears better in female COPD patients.

Resumen Introduccion Aunque la actividad fisica (AF) es una dimension clinica relevante en la EPOC, no existen instrumentos utiles en la practica clinica habitual. Objetivo Crear un nuevo cuestionario especifico, sencillo y de facil aplicacion que detecte el deficit de AF. Metodo Se creo un panel multidisciplinar de expertos en EPOC y se reviso el estado de la cuestion sobre AF, sus determinantes y metodos de medida. Se consensuo la metodologia de seleccion de dimensiones e items especificos por rondas, definiendo las dimensiones e items sobre los que formar la version preliminar. La estructura del cuestionario fue definida de acuerdo con su aplicabilidad en la practica clinica. Los acuerdos se alcanzaron por consenso de los miembros. Resultados Se revisaron un total de 148 items, de los que solo fueron seleccionados directamente 3. Se definio que el cuestionario debia evaluar la intensidad (baja, moderada o intensa), cantidad y frecuencia de AF, asi como la inactividad o sedentarismo. Tambien ofrece informacion sobre el perfil del paciente con baja actividad e incluye una medida de impacto, definido como la percepcion del paciente respecto a sus expectativas de actividad, lo que abarca su experiencia personal, caracteristicas de su entorno y personalidad. El cuestionario queda dividido en 2 bloques: una herramienta destinada a cuantificar la AF y una parte informativa, solo para los pacientes con baja AF, destinada a definir su perfil e impacto. Conclusion El SAQ-COPD es un cuestionario especifico, breve y sencillo, para evaluar la AF en pacientes con EPOC, que se ha definido para que sea aplicable en la practica clinica.

Introduction Physical activity (PA) is a significant clinical dimension in COPD, but no useful tools are available to determine this variable in routine clinical practice. Objective To create a simple, easy-to-use, specific questionnaire to detect PA deficits. Method A multidisciplinary panel of COPD experts was formed to review PA, its determinants, and measuring methods. The methodology for selecting specific dimensions and items was agreed in rounds, and the aspects to be included in the preliminary version were determined. The questionnaire structure was defined according to applicability of these aspects in clinical practice. Agreements were reached by consensus of the members. Results A total of 148 items were reviewed, of which only 3 were directly selected. It was decided that the questionnaire should evaluate the intensity (low, moderate, or intense), amount, and frequency of PA, and inactivity or sedentary lifestyles. It also gathers information on the profile of inactive patients, and includes a measure of impact, defined as the patient's perception of their expectations regarding activity, their personal experience, characteristics of their environment, and their personality. The questionnaire is divided into 2 blocks, one aimed at quantifying PA, and the other at collecting data for defining the profile and impact in patients with low PA only. Conclusion The SAQ-COPD is a simple, short, specific questionnaire, designed to evaluate PA in COPD patients in clinical practice.

Resumen Introduccion EPOCONSUL es la primera auditoria nacional que analiza la atencion sanitaria de la EPOC en consultas de neumologia en Espana. El objetivo principal fue determinar, en un analisis retrospectivo, la distribucion de los niveles de riesgo de la EPOC segun GesEPOC 2017 y evaluar las actuaciones clinicas segun las nuevas recomendaciones. Material y metodos Es una auditoria clinica de diseno trasversal, con reclutamiento de casos consecutivos de EPOC durante un ano. Se evaluo el nivel de riesgo y el fenotipo clinico segun GesEPOC 2017 y su relacion con las intervenciones clinicas realizadas. Resultados El nivel de alto riesgo fue mas frecuente (79,8 versus 20,2%; p Conclusiones La mayoria de los pacientes atendidos en las consultas de neumologia fueron de alto riesgo y con fenotipo clinico no agudizador. La practica clinica realizada fue diferente segun el nivel de riesgo y mayoritariamente acorde con las recomendaciones de GesEPOC, aunque con importantes areas de mejora.

The study aimed to assess the preferences of expert physicians about the requirements for inhalation devices for patients with chronic obstructive pulmonary disease (COPD) and to identify the most relevant advantages and disadvantages to their prescription. In a two-round Delphi survey, 96 Spanish COPD-expert pulmonologists completed an internet-based questionnaire to evaluate the degree of importance of the characteristics of the inhaler devices in their choice for COPD. The requirements needed for use in COPD were that the device permits a high pulmonary deposit of the drug, allowed its dispensation at low inspiratory flows, did not require hand-mouth coordination, generated an exact and reproducible dose, its operation was easy to teach, provided the perception of a correct inhalation, had an intuitive use mechanism and security mechanisms to prevent overdosing and generates a reduced oropharyngeal deposit (very good consensus). Modulite®, Respimat® and NEXThaler® were associated with high pulmonary deposit, and Respimat® showed correct dispensation at low inspiratory flows. All dry-powder inhaler devices were associated with the advantage of not requiring coordination, and Respimat® was the only device considered as difficult to teach by more than 50% of the experts. Breezhaler® and Genuair® were positively associated with patients' awareness of correct inhalation, whereas Spiromax® stood out for its intuitive use mechanism. In conclusion, our study contributes to defining the inhaler device properties required for their use in patients with COPD, and to identify the devices that, in the opinion of experts, best meet each requirement.

The concept of Chronic Obstructive Pulmonary Disease (COPD) control has been developed to inform therapeutic decision-making. We explored the validity of a definition of COPD control in a representative population of patients with COPD in the United Kingdom. Electronic medical records and linked COPD questionnaire data from the Optimum Patient Care Research Database were used to characterize control status. Patients were aged ≥40 years, with spirometry-confirmed COPD, current or ex-smokers, and continuous records throughout the study period. Control was evaluated based on COPD stability and patients' (i) clinical features or (ii) COPD Assessment Test (CAT) score over a three-month baseline period and linked to time to first exacerbation. Of 2788 eligible patients, 2511 (90%) had mild/moderate COPD and 277 (10%) had severe/very severe COPD based on Body Mass Index, Obstruction, Dyspnoea, Exacerbations (BODEx) cut-off of 4. Within the mild/moderate cohort, 4.5% of patients were controlled at baseline according to clinical features and 21.5% according to CAT threshold of 10. Within the severe/very severe cohort, no patients were controlled at baseline according to the proposed clinical features and 8.3% were controlled according to CAT threshold of 20. Compared with uncontrolled patients, time to first exacerbation was longer for controlled patients with mild/moderate COPD but not for those with severe/very severe COPD. Lowering the BODEx threshold for severity classification to 2 increased the number of patients achieving control. CAT scores were not good predictors of the risk of future exacerbation. With the proposed definition, very few patients were defined as controlled.

Following a proposal by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), sponsor of the Spanish COPD Guidelines (GesEPOC) and the Spanish Guidelines on the Management of Asthma (GEMA), authors of both papers have unified the criteria for the diagnosis of asthma-COPD overlap syndrome (ACOS). This consensus defines ACOS as the presence in a given patient of three elements: significant smoking exposure, chronic airflow limitation and asthma. Diagnosis is confirmed when a patient (35years of age or older), smoker or ex-smoker of more than 10 pack-years, presents airflow limitation (post-bronchodilator FEV1/FVC

Resumen A instancias de la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR), promotora de la Guia espanola de la EPOC (GesEPOC) y de la Guia Espanola para el Manejo del Asma (GEMA), autores de ambas guias han unificado criterios diagnosticos del solapamiento asma y EPOC (Asthma-COPD Overlap [ACO]). Este consenso define al ACO como la coexistencia en un mismo paciente de tres elementos: tabaquismo, limitacion cronica al flujo aereo y asma. La confirmacion diagnostica se establece cuando un paciente (≥ 35 anos) fumador o exfumador (≥ 10 paquetes-ano) presenta obstruccion o limitacion cronica al flujo aereo (FEV1/FVC post-broncodilatador Se solicito la opinion (mediante encuesta Delphi modificada) a otros 33 expertos que no habian participado en la elaboracion del consenso. Un 80% de estos lo valoro positivamente, incluso superior a otras propuestas recientes. El consenso GesEPOC-GEMA sobre ACO proporciona una vision unitaria del problema, con una propuesta conceptual sencilla y un algoritmo diagnostico pragmatico, aplicable en cualquier nivel sanitario de nuestro ambito.