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Background There is a lack of tools to quantify the response to monoclonal antibodies (mAbs) holistically in severe uncontrolled asthma patients. Objective To develop a valid score to assist specialists in this clinical context. Methods The score was developed in four subsequent phases: (1) elaboration of the theoretical model of the construct intended to be measured (response to mAbs); (2) definition and selection of items and measurement instruments by Delphi survey; (3) weight assignment of the selected items by multicriteria decision analysis using the Potentially All Pairwise RanKings of All Possible Alternatives methodology using the 1000minds software; and (4) face validity assessment of the obtained score. Results Four core items, with different levels of response for each, were selected: severe exacerbations, oral corticosteroid use, symptoms (evaluated by Asthma Control Test), and bronchial obstruction (assessed by FEV1 percent predicted). Severe exacerbations and oral corticosteroid maintenance dose were weighted most heavily (38% each), followed by symptoms (13%) and FEV1 (11%). Higher scores in the weighted system indicate a better response and the range of responses runs from 0 (worsening) to 100 (best possible response). Face validity was high (intraclass correlation coefficient of 0.86). Conclusions The FEV1, exacerbations, oral corticosteroids, symptoms score allows clinicians to quantify response in severe uncontrolled asthma patients who are being treated with mAbs.

Background: Bronchial hypersecretion is a poorly studied symptom in asthma. The aim of the study was to determine the specific characteristics of asthmatics with bronchial hypersecretion. Methods: A total of 142 asthmatics (21.8% men; mean age 49.8 years) were prospectively followed for one year. Mucus hypersecretion was clinically classified into two severity categories: daily sputum production and frequent expectoration but not every day. Clinical and pulmonary function variables associated with mucus hypersecretion were assessed by multiple logistic regression analysis. Results: Daily cough was recorded in 28.9% of patients and sputum production daily or most of the days in 52.1%. Patients with mucus hypersecretion had more dyspnoea, poorer asthma control and quality of life, had suffered from more exacerbations and showed anosmia associated with chronic rhinosinusitis and nasal polyposis more frequently. Factors associated to mucus hypersecretion were anosmia, one exacerbation or more in the previous year and FEV1/ FVC < 70% (AUC 0.75, 95% CI 0.66-0.85) for the first definition of hypersecretion, and anosmia, poor asthma control and age (AUC 0.75, 95% CI 0.67-0.83) for the second definition. Conclusions: Mucus hypersecretion is frequent in patients with asthma, and is associated with chronic upper airways disease, airway obstruction, poor asthma control and more exacerbations.

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.

BACKGROUND Poor adherence to inhaled medication in asthma patients is of great concern. It is one of the main reasons for inadequate asthma control. OBJECTIVE The goal of the research was to determine if motivational messages using short message service (SMS, or text) improved adherence to inhaled medication in patients with asthma. METHODS A prospective multicenter randomized parallel-group clinical trial was conducted in 10 asthma clinics in Spain. Adherence was assessed with electronic monitors (Smartinhaler, Adherium Ltd) connected to inhalers. Patients in the SMS group received psychologist-developed motivational messages every 3 days for 6 months. RESULTS There were 53 patients in the SMS group and 88 patients in the control group. After 6 months, mean electronic adherence was 70% (SD 17%) in the intervention group and 69% (SD 17%) in the control group (P=.82). Significant differences between the study groups in morning and evening adherence to inhaled therapy, asthma control, exhaled nitric oxide levels, or improvement of lung functions were not observed. CONCLUSIONS Motivational messages were not useful to improve adherence to inhaled asthma medication compared with usual care.

We assessed the effectiveness of an asthma educational programme based on a repeated short intervention (AEP-RSI) to improve asthma control (symptom control and future risk) and quality of life.A total of 230 adults with mild-to-moderate persistent uncontrolled asthma participated in a 1-year cluster randomised controlled multicentre study. The AEP-RSI was given in four face-to-face sessions at 3-month intervals, and included administration of a written personalised action plan and training on inhaler technique. Centres were randomised to the AEP-RSI (intervention) group or usual clinical practice group. Specialised centres using a standard educational programme were the gold standard group.A significant improvement in the Asthma Control Test score was observed in all three groups (psd; 1.20±2.02 and 0.56±1.5 versus 2.04±2.72, respectively) and greater increases in the Mini Asthma Quality of Life Questionnaire scores (0.95±1.04 and 0.89±0.84 versus 0.52±0.97, respectively).The AEP-RSI was effective in improving asthma symptom control, future risk and quality of life.

Obstructive asthma in non-smokers (NSA), obstructive asthma in smokers (SA), COPD and eosinophilic COPD (COPDeo) are different forms of COAD. Objectives: To quantify systemic inflammation markers (IL6, IL8, TNFα), T2-related cytokines (IL5 and IL13) and IL17 among different forms of COAD, their utility in distinguishing between them and their role in predicting a T2-high inflammatory pattern. Methods: Cross-sectional study of adults with a post-bronchodilator FEV1/FVC 3% or blood Eos>300 UI/mcl. Cytokine concentrations were determined in blood (Milliplex, Merck Millipore®). Results: Sixty-five COPDeo, 44 SA, 89 COPD, and 94 NSA were included. Serum levels of IL5 and IL13 were higher in NSA compared to COPD: 2.09 (0.61-3.57) pg/ml vs 1.11 (0.12-2.42) pg/ml; (p=0.03) and 2.98 (0.23-7.63) vs 1.25 (0.23-5.31) pg/ml; (p=0.35) respectively. IL8 was elevated in COPD [9.45 (6.61-13.12) pg/ml], COPDeo [9.68 (6.25-12.98)] and SA [9.54 (6.40-14.20)] compared to asthma [7.03 (4.69-10.44)]. IL17 was not different between groups. The diagnostic capacity of each single cytokine (or cytokine combinations) to predict a particular form of COAD was poor (AUC Conclusions: T2 cytokines values were higher in NSA than in COPD, with intermediate values in COPDeo and SA, whereas IL-8 was elevated in COPD, COPDeo and SA in comparison to asthma. These cytokines (alone or combined) lacked enough capacity to distinguish between COAD categories and to predict T2-high pattern.

Purpose Rates of nonadherence to asthma treatment in Spain are between 24% and 76%, which results in poor disease control and increased health care costs. The main objective of this multidisciplinary consensus was to investigate the opinions of health professionals and patients regarding adherence to inhaled therapy in Spain. The results will help to identify the causes of nonadherence and to establish strategies to detect and correct the problem. Methods This research was conducted by using a modified Delphi method organized into 2 rounds and involving a panel of 64 physicians, 16 nurses, and 10 community pharmacists. In addition, 70 patients with asthma completed a simplified 1-round survey, based on the Delphi questionnaire. The items proposed to reach a consensus included topics such as impact and causes of nonadherence, as well as strategies to improve adherence to treatment. Findings Expert panelists reached a consensus on ~80% of the items proposed. They agreed that the lack of control in asthma has an important economic impact. The causes of nonadherence with more agreement were the patients’ beliefs about treatment and the complexity of the inhalation devices. Panelists agreed that the most important strategies to improve adherence were modification of patients’ beliefs, training of professionals in the management of adherence, and personalization of interventions. Most patients only agreed with items that referred to strategies to improve adherence. Implications Although the problems, impact, causes, and interventions regarding nonadherence to asthma treatment are known, adequate monitoring of adherence to treatment is not performed. A multidisciplinary and personalized approach is necessary to control and improve adherence.

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/FVC0.7) that persists after treatment with bronchodilators and inhaled corticosteroids (even after systemic corticosteroids in selected cases), and an objective current diagnosis of asthma (according to GEMA criteria). In cases in which the diagnosis of asthma cannot be demonstrated, marked positive results on a bronchodilator test (FEV

An algorithm to identify patients with ACO rather than asthma or COPD alone http://ow.ly/Viyy308Ehdk

Resumen Introduccion Las guias clinicas de asma recomiendan la adopcion de conductas de evitacion alergenica. Para poder adoptarlas, los pacientes deben conocer las alergias que tienen. Sin embargo, este grado de conocimiento no ha sido hasta ahora evaluado. Los objetivos principales del estudio fueron determinar, en pacientes con asma alergica: a) el grado de conocimiento de sus propias sensibilizaciones alergicas; b) el porcentaje que conocen todas sus alergias y que, ademas, siguen normas de evitacion alergenica (NEA) frente a todas ellas, y c) el eventual impacto de dicho grado de conocimiento sobre el nivel de control del asma. Pacientes y metodos Estudio descriptivo, prospectivo y multicentrico, con inclusion de 147 pacientes reclutados en 9 consultas externas de neumologia. Tras verificar el diagnostico previo de asma alergica, se cumplimento un cuestionario registrando los niveles de control y gravedad del asma, los resultados de los estudios de alergia previos, y la descripcion y el numero de sensibilizaciones alergicas conocidas por el paciente y de NEA seguidas. Resultados Tan solo 72 (49%) pacientes conocian todas sus sensibilizaciones alergicas y unicamente 48 (33%) seguian, ademas, NEA frente a todos los alergenos a los que eran alergicos. No se demostro que existiera ninguna relacion entre el grado de conocimiento de las propias sensibilizaciones alergicas y el nivel de control del asma (p = 0,544). Conclusiones El conocimiento global acerca de la naturaleza alergica de su enfermedad, entre los pacientes asmaticos visitados en los servicios de neumologia espanoles, es insuficiente. Ademas, un adecuado conocimiento de las propias alergias no parece repercutir, por si solo, en un mejor control del asma. Todo ello parece cuestionar la eficacia de las estrategias educativas actuales en este campo y, en consecuencia, estas deberian revisarse.

Resumen Introduccion Las guias clinicas de asma recomiendan la adopcion de conductas de evitacion alergenica. Para poder adoptarlas, los pacientes deben conocer las alergias que tienen. Sin embargo, este grado de conocimiento no ha sido hasta ahora evaluado. Los objetivos principales del estudio fueron determinar, en pacientes con asma alergica: a) el grado de conocimiento de sus propias sensibilizaciones alergicas; b) el porcentaje que conocen todas sus alergias y que, ademas, siguen normas de evitacion alergenica (NEA) frente a todas ellas, y c) el eventual impacto de dicho grado de conocimiento sobre el nivel de control del asma. Pacientes y metodos Estudio descriptivo, prospectivo y multicentrico, con inclusion de 147 pacientes reclutados en 9 consultas externas de neumologia. Tras verificar el diagnostico previo de asma alergica, se cumplimento un cuestionario registrando los niveles de control y gravedad del asma, los resultados de los estudios de alergia previos, y la descripcion y el numero de sensibilizaciones alergicas conocidas por el paciente y de NEA seguidas. Resultados Tan solo 72 (49%) pacientes conocian todas sus sensibilizaciones alergicas y unicamente 48 (33%) seguian, ademas, NEA frente a todos los alergenos a los que eran alergicos. No se demostro que existiera ninguna relacion entre el grado de conocimiento de las propias sensibilizaciones alergicas y el nivel de control del asma (p = 0,544). Conclusiones El conocimiento global acerca de la naturaleza alergica de su enfermedad, entre los pacientes asmaticos visitados en los servicios de neumologia espanoles, es insuficiente. Ademas, un adecuado conocimiento de las propias alergias no parece repercutir, por si solo, en un mejor control del asma. Todo ello parece cuestionar la eficacia de las estrategias educativas actuales en este campo y, en consecuencia, estas deberian revisarse.

Differences between COPD and asthma may also differentially affect adherence to inhaled drugs in each disease. We aimed to determine differences in behaviour patterns of adherence and non-adherence to inhaled therapy between patients with COPD and patients with asthma using the Test of Adherence to Inhalers (TAI) questionnaire. A total of 910 patients (55% with asthma, 45% with COPD) participated in a cross-sectional multicentre study. Data recorded included sociodemographics, education level, asthma or COPD history, TAI score, the Asthma Control Test (ACT), the COPD Assessment Test (CAT) and spirometry. Asthma patients were statistically significant less adherents, 140 (28%) vs. 201 (49%), and the pattern of non-adherence was more frequently erratic (66.8% vs. 47.8%) and deliberate (47.2% vs. 34.1%) than COPD patients; however unwitting non-adherence was more frequently observed in COPD group (31.2% vs. 22.8%). Moreover, taking together all sample studied, only being younger than 50 years of age (OR 1.88 [95% CI: 1.26-2.81]) and active working status (OR 1.45 [95% CI: 1.00-2.09]) were risk factors for non-adherence in the multivariate analysis, while having asthma remained in the limits of the significance (OR 1.44 [95% CI: 0.97-2.14]). Even though non-adherence to inhalers is more frequently observed in asthma than in COPD patients and exhibited a different non-adherence patterns, these differences are more likely to be related to sociodemographic characteristics. However, differences in non-adherence patterns should be considered when designing specific education programmes tailored to each disease.

Resumen Introduccion Las mujeres ingresan por exacerbaciones de asma con mayor porcentaje que los varones, sin que se conozcan claramente los motivos. El objetivo del estudio es explorar las posibles causas que expliquen este hecho. Pacientes y metodos Estudio prospectivo multicentrico en pacientes ingresados por asma durante 2 anos en servicios de neumologia. Mediante cuestionario se recogieron: caracteristicas demograficas, variables previas al ingreso y durante el mismo que incluian adherencia, ansiedad-depresion, hiperventilacion, y control del asma. Resultados Se recogieron datos de 183 ingresos: 115 mujeres (62,84%). Las mujeres eran de mayor edad (52,4 ± 18,3/43,4 ± 18,7; p = 0,02); habia mayor porcentaje con prescripcion de corticosteroides inhalados (63,2/47,1%; p = 0,03) y sindrome de hiperventilacion (57,3/35,9%; p = 0,02), y una estancia media mayor (7,3 ± 3,4/5,9 ± 3,6; p = 0,02). El porcentaje de fumadoras era menor (21,2/38,8%; p = 0,01), y el FEV 1 al ingreso era mas bajo (58,2% ± 15,9/67,5% ± 17,4; p = 0,03). En el rango de 40 a 60 anos se demostro una asociacion entre ser mujer y la variable ingresos previos. De forma independiente, tambien se asociaron el sexo y la obesidad, con un OR de 16,1 (IC 95%, 1,6-156,7) y de 4,8 (IC 95%, 1,06-22), respectivamente. Conclusiones El porcentaje de ingresos por asma fue mayor en mujeres. Ser mujer entre 40 y 60 anos se asocia con ingresos previos y constituye un factor de riesgo para ingreso por asma, en el que la hipotesis hormonal durante el climaterio podria explicar parte de los hechos. La poliposis y la obesidad son factores de riesgo, independientemente del sexo.

Introduction The reason why there is a higher hospitalization rate due to asthma exacerbations amongst women is unclear. The objective of this study is to explore the possible causes that may explain this fact. Methods A multi-center, prospective study including asthma patients hospitalized in the pulmonary medicine departments during a 2-year period. By means of a questionnaire, the following data were collected: demographic characteristics and treatment compliance, anxiety-depression, hyperventilation and asthma control, both prior to and during the hospitalization. Results 183 patients were included, 115 (62.84%) of whom were women. The women were older (52.4±18.3/43.4±18.7; P =.02), were more frequently prescribed inhaled corticosteroids (63.2%/47.1%; P =.03) and had a higher rate of hyperventilation syndrome (57.3/35.9; P =.02) and a longer mean hospital stay (7.3±3.4/5.9±3.6; P =.02). The percentage of smokers among the women was lower (21.2%/38.8%; P =.01) and the FEV 1 was lower at admittance (58.2%±15.9%/67.5%±17.4%; P =.03). In the 40–60-year-old age range, an association was demonstrated between being female and the ‘previous hospitalizations’ variable (OR, 16.1; 95% CI, 1.6–156.7); sex and obesity were also independently associated (OR, 4.8; 95% CI, 1.06–22). Conclusions In this cohort, the rate of hospitalization for asthma was higher in women than in men. Being a woman between the ages of 40 and 60 is associated with previous hospitalizations and is a risk factor for asthma-related hospitalization. This situation could partially be explained by the hormonal changes during menopause, where polyposis and obesity are independent risk factors.

Resumen Si bien el asma es una de las enfermedades respiratorias cronicas mas prevalentes, existe la sospecha de que la participacion de los centros de neumologia espanoles en su manejo es potencialmente mejorable. Objetivo Determinar el grado de implicacion de los servicios de neumologia espanoles en la asistencia, docencia e investigacion relacionadas con la enfermedad asmatica y especificamente con la de control dificil. Metodo Se remitio una encuesta formada por 75 items que cumplimentaron los responsables de los centros entrevistados. La encuesta interrogaba sobre la asistencia neumologica general y la del asma en particular, asi como la actividad docente e investigadora en la enfermedad asmatica en los cinco anos previos. Resultados De las 107 encuestas enviadas, 69 (64,5%) centros las retornaron cumplimentadas. De estos, 47 (68,1%) reunieron criterios de actividad asistencial destacada en asma. Sin embargo, solo 29 (42%) disponian de una consulta monografica de asma de control dificil y 37 (53,6%) utilizaban un programa de educacion. En el ambito docente, unicamente 31 (44,9%) proporcionaban formacion especifica sobre asma a sus medicos residentes. Y en el de investigacion, 12 (17,4%) referian tener proyectos subvencionados por SEPAR y 25 (36,2%) habian publicado trabajos en revistas con factor de impacto. Conclusiones Si bien la mayoria de los centros neumologicos entrevistados refieren una notable actividad en la asistencia del asma, su implicacion en el abordaje especializado del asma de control dificil es insuficiente. Asi mismo, su participacion en actividades docentes y de investigacion relacionadas con la enfermedad es desigual y limitada a escasos centros.

Although asthma is one of the most prevalent chronic respiratory diseases, the participation of Spanish pulmonology units in the management of asthma may have room for improvement. Objective To determine the degree of involvement of the Spanish pulmonology services in the patient care, education and research related with asthma disease and especially in difficult-to-control asthma. Methods A survey made up of 75 questions was sent to the heads of several pulmonology departments. The survey asked questions pertaining to respiratory disease care in general, and in asthma in particular, as well as the educational activities and research in asthma during the previous five years. Results Out of the 107 surveys sent, 69 (645%) centers filled them out and returned them. Forty-seven (681%) met the criteria for an important level of health-care activity in asthma. However, only 29 (42%) had a monographic consultation for difficult-to-control asthma and 37 (536%) used an education program. As for postgraduate education, only 31 (449%) provided their resident physicians with specific asthma training. And in the research field, 12 (174%) reported having projects funded by SEPAR and 25 (362%) had published studies in journals with an impact factor. Conclusions Although the majority of the pulmonology centers interviewed report a notable activity in asthma patient care, their involvement in the specialized approach for difficult-to-control asthma is insufficient. Likewise, participation in educational activities and research related with the disease is inconsistent and limited to few centers.

Resumen El interes por la investigacion en asma de los neumologos espanoles va en linea ascendente. En el ultimo ano han aparecido en archivos de bronconeumologia 22 articulos sobre asma, 6 mas que en el ano anterior, y se presentaron 56 comunicaciones al Congreso Nacional de la SEPAR, publicadas en el numero especial de la revista, lo que representa un 60% mas que en el congreso del ano anterior. Se realiza una revision critica de todos estos articulos. Los originales aportan nuevos conocimientos epidemiologicos, clinicos y de investigacion basica. Merece mencion especial la publicacion de 2 guias de practica clinica, la Guia Espanola para el Manejo del Asma 2009 (GEMA) y la Guia ALERTA-2 para el manejo de la exacerbacion asmatica; las 2 suponen no solo una actualizacion de su contenido, sino tambien un cambio en la metodologia en su elaboracion que mejora su calidad cientifica.

The Asthma Control Questionnaire™ (ACQ) was developed to assess asthma control. The objective of this study is to determine the cut-off points that best differentiate between several types of asthma control in three versions of the ACQ used in clinical practice.It appears 607 adult asthmatic patients (61% female) were recruited from 43 outpatient clinics in Spain. Once the patients were stratified by severity of asthma, they were then evaluated in an epidemiological study. To determine the optimum cut-off points, the area under the receiver operating characteristics (ROC) curve, as well as sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively), was calculated for each version of the ACQ (ACQ-FEV₁ (forced expiratory volume in the first second), ACQ-PEF (peak expiratory flow), and ACQ-wLF (without lung function)).The optimal cut-off for ACQ-FEV₁ was 1.14 (the sum of 8 points/7 items), for ACQ-PEF 1.28 (the sum of 9 points/7 items), and for ACQ-wLF 0.83 (the sum of 5 points/6 items), and the percentage of correctly classified patients was 76.5%, 77.3%, and 77.2%, respectively. A comparison of ROCs obtained from the three versions of the ACQ shows that ACQ-wLF had a significantly greater area under the curves (AUC) (p = .004) than ACQ-FEV₁. Patients were considered as having some control if their ACQ-FEV₁ score fell between 1.14 and 1.57, if ACQ-PEF values were between 1.28 and 1.57, or if ACQ-wLF scores ranged between 0.83 and 1.5.Our study, which was carried out in a manner which more closely reflects clinical practice, reveals differences in cut-offs used to define well-controlled asthma among three versions of the ACQ.

Originales. Volumen 46, Numero 08, Agosto 2010 Texto completo Anterior | Siguiente Descargar PDF Buscar en medline articulos de: Fernando Caballero Martinez Vicente Plaza Santiago Quirce Gancedo Margarita Fernandez Benitez Fernando Gomez Ruiz Antolin Lopez Vina Jesus Molina Paris Jose Antonio Quintano Jimenez Ramona Soler Vilarrasa Jose Ramon Villa Asensi Santiago Balmes Estrada Buscar: Busqueda avanzada Valoracion externa de las recomendaciones de la GEMA2009 por un panel multiprofesional de expertos en asma Fernando Caballero Martineza; Vicente Plazab; Santiago Quirce Gancedoc; Margarita Fernandez Benitezd; Fernando Gomez Ruize; Antolin Lopez Vinaf; Jesus Molina Parisg; Jose Antonio Quintano Jimenezh; Ramona Soler Vilarrasai; Jose Ramon Villa Asensij; Santiago Balmes Estradab a Unidad de Formacion e Investigacion, Area 6 Servicio Madrileno Salud, Madrid, Espana b Servicio de Neumologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Espana c Servicio de Alergologia, Hospital Universitario La Paz, Madrid, Espana d Servicio de Alergologia infantil, Clinica Universidad de Navarra, Pamplona, Navarra, Espana e Servicio de Medicina de Familia, Centro de Salud de Bargas, Toledo, Espana f Servicio de Neumologia, Hospital Universitario Puerta de Hierro, Madrid, Espana g Servicio de Medicina de Familia, EAP Francia I, Fuenlabrada, Madrid, Espana h Servicio de Medicina de Familia, Centro de Salud Lucena I, Lucena, Cordoba, Espana i Servicio de Otorrinolaringologia, Hospital de Son Dureta, Palma de Mallorca, Espana j Servicio de Neumologia pediatrica, Hospital Infantil del Nino Jesus, Madrid, Espana Arch Bronconeumol. 2010;46:411-9. Objetivos Valorar el grado de acuerdo de un panel de expertos en asma de diferentes especialidades con las recomendaciones que propone la Guia Espanola para el Manejo del Asma (GEMA) 2009. Material y metodos El estudio se efectuo en 4 fases: 1) constitucion del comite cientifico formado por los 9 coordinadores de GEMA2009, para la seleccion de las recomendaciones de la Guia que conforman el cuestionario Delphi del estudio (56 items); 2) seleccion de un panel estatal multicentrico con 74 expertos en asma de todas las especialidades implicadas en la Guia (neumologos, alergologos, medicos de familia, otorrinolaringologos, y especialistas de pediatria); 3) encuesta Delphi en 2 rondas (con valoracion personal de cada item mediante escala Likert de 5 puntos), por correo electronico, con informe a panelistas de resultados intermedios; y 4) analisis y discusion de resultados por el comite cientifico del proyecto. Resultados Se aprecio un consenso de criterio en 49 de las 56 cuestiones analizadas ya en la primera ronda. Tras la interaccion del panel, se lograron consensuar 53 items de la encuesta, en el sentido favorable al acuerdo del panel con las recomendaciones GEMA. En una de las cuestiones no consensuadas, sobre indicacion de inmunoterapia en asma alergica, se aprecio una significativa disparidad de opinion entre especialidades. En otra, sobre las medidas de control ambiental en alergia a acaros, se aprecio una manifiesta oposicion del panel (55%), y en la ultima, sobre la necesidad de cambiar de trabajo en pacientes con sindrome reactivo de disfuncion de la via aerea, se observo una ausencia significativa de criterio establecido en buena parte de los encuestados (40% expresan «ni de acuerdo, ni en desacuerdo»). Conclusiones La valoracion externa por expertos en asma de diferentes especialidades constata un elevado nivel de acuerdo profesional con las recomendaciones formuladas en GEMA2009 (93%). Probablemente el desacuerdo evidenciado en 3 de las recomendaciones reflejan la escasez de evidencias, o su gran variabilidad, para establecer recomendaciones consistentes. Estas cuestiones podrian representar areas susceptibles de un mayor esfuerzo investigador futuro. Palabras clave: Asma. Guia Practica Clinica. Consenso profesional. Delphi. External Assessment of the GEMA2009 Recommendations by a Multidisciplinary Expert Panel on Asthma Objectives To assess the level of agreement on the GEMA 2009 clinical recommendations by a Spanish expert panel on asthma. Materials and methods The study was divided into four stages: 1) establishment of a 9 member scientific committee (GEMA authors) for selection of GEMA recommendations to use in the survey; 2) formation of a panel of 74 professionals with expertise in this field (pulmonologists, allergists, family doctors, ear, nose and throat and paediatric specialists); 3) Delphi survey in two rounds, sent by mail, with intermediate processing of opinions and a report to the panel members; and 4) analysis and discussion of results for the Scientific Committee. Results Seventy four participants completed the two rounds of survey. During the first round, a consensus was reached in 49 out of 56 questions analysed. Following discussion by the panel, the consensus was increased to a total of 53 items in the survey. With respect to the remaining questions, Insufficient consensus was obtained on the rest of the questions, due to differing views between sub-specialists, or lack of criteria by most of the experts. Conclusions The external analysis by asthma experts from different specialities showed a high level of professional agreement with the GEMA 2009 recommendations in Spain (96.5%). The disagreement shown in three recommendations reflect the lack of a high level evidence. These issues represent areas of interest for future research.

A total of 16 articles (Table 1), were published in the Archivos de Bronconeumologia in the past year (December 2008 to November 2009), 9 of which were Originals, which was 17.6% of the originals published in that period. Fortunately, the tendency of a decreasing interest in asthma by pneumologists does not seem to have materialised as was feared a few years ago, on the contrary it seems that research is increasing. All articles that appeared in the journal during the period mentioned are reviewed.

Fundamento y objetivo El objetivo de este estudio es evaluar las propiedades de medicion de la version espanola del Cuestionario de Control del Asma (ACQ, en sus siglas en ingles) cuando se sustituye la pregunta sobre el volumen espiratorio maximo en el primer segundo (VEMS) en el cuestionario original (ACQ-VEMS) por el flujo espiratorio maximo (ACQ-FEM) y cuando se elimina la pregunta de funcion respiratoria (ACQ-sFR). Material y metodo En este estudio participo un total de 607 pacientes. Realizaron 3 visitas: basal, a las 2 y a las 6 semanas. Se evaluaron la validez, la fiabilidad y la sensibilidad al cambio de ambas versiones del ACQ. Resultados Las puntuaciones del ACQ-FEM y ACQ-sFR presentaron, respectivamente, una correlacion de 0,38 y 0,39 con el numero de exacerbaciones. Una mejoria en los sintomas y un mejor control del asma percibido por el medico y el paciente se relacionaron de forma significativa con mejores puntuaciones en ambos cuestionarios (p Conclusiones La sustitucion del VEMS por el FEM, o su eliminacion, no altera las propiedades de medicion del ACQ. Se recomienda la utilizacion de las versiones simplificadas solo en el contexto de la investigacion y no combinar en un mismo analisis las puntuaciones obtenidas con versiones diferentes del cuestionario.

Objetivo Se sospecha que el seguimiento de las recomendaciones terapeuticas del asma entre los profesionales sanitarios es bajo. El presente estudio se ha realizado con el objeto de determinar la opinion, el conocimiento y cumplimiento de las recomendaciones de la Guia Espanola para el Manejo del Asma (GEMA) entre los profesionales sanitarios espanoles. Material y metodos Se elaboro un cuestionario de 15 preguntas de respuesta multiple que recogian la opinion y conocimiento general sobre las guias de asma, el grado de seguimiento de estas y, especificamente, de las recomendaciones diagnosticas y terapeuticas de la GEMA. El cuestionario se cumplimento de forma voluntaria, individual y anonima. Resultados Rellenaron el cuestionario 1.066 profesionales: 241 (22,6%) neumologos y 244 (22,9%) profesionales de enfermeria de la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR); 221 (20,7%) pediatras-neumologos de la Sociedad Espanola de Neumologia Pediatrica (SENP); 220 (20,6%) medicos de atencion primaria de la Sociedad Espanola de Medicina de Familia y Comunitaria (semFYC); 181 (17%) medicos de atencion primaria de la Sociedad Espanola de Medicina Rural y Generalista (SEMERGEN), y 38 (3,6%) de otras sociedades. De ellos, 805 (76%) opinaron que las guias para el manejo del asma eran utiles o muy utiles y 771 (72%) conocian la GEMA, pero 388 (36%) reconocian que seguian poco o nunca sus recomendaciones. Entre los medicos participantes, 243 (30,3%) fueron clasificados como malos cumplidores de la GEMA. El analisis multivariante revelo que los profesionales provenientes de las areas centro y sur espanolas, los de atencion primaria, los poco convencidos de la utilidad de las guias o los que no las conocen, y los que no empleaban la espirometria se asociaron con un menor cumplimiento de la guia. Conclusiones Si bien la mayoria de los profesionales sanitarios espanoles encuestados conoce y estima positiva la GEMA, el grado de cumplimiento de esta es bajo. Los futuros programas docentes encaminados a difundir las guias de asma deberian considerar el perfil del medico no cumplidor de la GEMA e incorporar estrategias educativas dirigidas especificamente a dichos profesionales.

Objective Health care professionals' adherence to asthma guidelines is believed to be low. The aim of the present study was to determine the knowledge, attitudes, and adherence of Spanish health care professionals with respect to the Spanish Guidelines for Asthma Management (GEMA). Material and methods A multiple choice test with 15 questions was constructed. Items assessed knowledge of and opinions and adherence to asthma guidelines in general and the GEMA in particular. Test completion was voluntary, individual, and anonymous. Results A total of 1066 physicians and nurses took the test. The sample consisted of 241 (22.6%) respiratory medicine specialists and 244 (22.9%) nurses from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), 221 (20.7%) pediatric pulmonologists from the Spanish Society of Pediatric Pulmonology (SENP), 220 (20.6%) general practitioners from the Spanish Society of Family and Community Medicine (semFYC), 181 (17%) general practitioners from the Spanish Society of Rural and General Medicine (SEMERGEN), and 38 (3.6%) others. Asthma guidelines were considered useful or very useful by 805 (76%), and 771 (72%) stated they were familiar with the GEMA. However, 388 (36%) admitted that they followed guidelines seldom or never. The level of adherence to the GEMA was poor for 243 (30.3%) respondents. The multivariate analysis revealed that low adherence was associated with the following characteristics: coming from the geographic center or south of Spain; being a primary care physician, unfamiliar with guidelines, or unconvinced of their utility; and not being a user of spirometry. Conclusions Even though the majority of Spanish health care professionals surveyed seem to know of the GEMA, their adherence to those guidelines is very low. Educational programs that seek to improve knowledge of asthma guidelines should consider the profile of professionals with low adherence to the GEMA so as to include educational strategies that target them specifically.

According to the different sociodemographic characteristics of asthma and COPD patients, the adherence to inhaled drugs could also be different. However, there are no studies prospectively evaluating the inhaler adherence in large samples of asthma and COPD patients in the same trial. Objective: To determine the differences between asthma and COPD patients in adherence and non-adherence patterns to inhaled therapy with the Test of the Adherence to Inhalers (TAI). Methods: A total of 910 (500 [55%] asthma and 410 [45%] COPD) patients were included in a cross-sectional observational multicenter study. Participants completed questions about sociodemographics, cultural level, asthma or COPD history, TAI, Morisky-Green test, Asthma Control Test (ACT), COPD Assessment Test (CAT) and recorded spirometry. Results: Patients of the asthma group were significantly women and younger, had higher educational level, active working status, less smokers and more frequently controlled disease with a better pulmonary function than patients of the COPD group. However, they were less adherents (in 10-items TAI), 140 (28%) front 201 (49%), respectively, and they were more frequently erratic (46.4 vs 34.9%) and deliberated (66.8 vs 47.1%) non-adherents, but unwitting non-adherence pattern was more frequent in COPD group (31.2 vs 22.8%). Conclusions: Even though asthma patients have a more favourable sociodemographic and clinical characteristics, they are more non-adherents than COPD patients and exhibit a different pattern of non-adherence type. These points should be considered in the specific educational programs of each disease.

Objetivo Estudios recientes muestran un descenso de la mortalidad y del numero de los ingresos hospitalarios por asma grave en los ultimos anos en diferentes lugares del mundo. Se desconoce la situacion en nuestro pais. El objetivo del presente estudio ha sido determinar la frecuencia anual de las crisis de asma de riesgo vital muy grave en los ultimos anos en diversos centros hospitalarios espanoles. Pacientes y metodos Se revisaron retrospectivamente los registros hospitalarios de los pacientes que precisaron intubacion orotraqueal y ventilacion mecanica por una crisis de asma en 6 hospitales pertenecientes a 5 comunidades autonomas. El estudio recogio el numero anual de casos observado durante el periodo comprendido entre 1997 y 2004. Resultados De los 130 pacientes incluidos, 81 (62%) eran mujeres y 61 (47%) tenian entre 51 y 75 anos de edad. En los 2 ultimos bienios (2001-2002 y 2003-2004) el numero de pacientes recogidos (32 y 18, respectivamente) fue significativamente inferior al observado en los 2 primeros (1997- 1998 y 1999-2000, con 40 cada bienio; p = 0,019). Se constato una incidencia significativamente mayor de casos (n = 81; 62%) durante las estaciones de otono e invierno (p = 0,018). Fallecieron 17 pacientes (13%) y 8 (6%) presentaron secuelas graves. Conclusiones Si bien 6 centros hospitalarios no son lo bastante representativos de la totalidad de los centros espanoles, los resultados del presente estudio podrian orientar hacia un muy probable descenso en nuestro pais de los casos de asma de riesgo vital en los ultimos anos.

Existe un pequeno porcentaje de pacientes con asma en los que no se consigue el control de la enfermedad a pesar de una pauta terapeutica que incluya esteroides inhalados a dosis altas junto a β2-agonistas de accion prolongada. Aunque cuantitativamente son pocos, cualitativamente son muy importantes, ya que son los que tienen mayor morbilidad y los que suponen mas gastos sanitarios por el asma. Este grupo de pacientes puede englobarse dentro del termino “asma de control dificil” y deben separarse de otros tipos de asma mal controlada en las que la causa de la falta de control puede ser evitable, como que el diagnostico sea erroneo, exista alguna comorbilidad, esten presentes factores agravantes, o el paciente no cumpla el tratamiento. Ante un paciente con tratamiento aparentemente adecuado y con su asma mal controlada, antes de prescribir mas farmacos es crucial identificar y tratar todas las condiciones que puedan estar causando el mal control siguiendo un protocolo sistematico y riguroso.

The purpose of the ASES study is to determine the clinical characteristics of Spanish asthmatic patients seen in primary care (PC) and in pneumology (P) departments, comparing the availability of diagnostic methods, morbidity, the type of treatment and follow-up between the two health care settings. ASES is a multicenter, descriptive, cross-sectional study. The physicians were selected by random sampling. The data were collected by the participating physicians using three questionnaires. Data were collected on 2349 asthmatic patients (1298 from hospitals and 1051 from PC). Smokers predominated in the PC setting ( P =0.000). The spirometry was performed at least once a year in 87.2% of the patients seen in P and 39.8% in PC ( P =0.000). Morbidity was high in both groups (P and PC), more than two nighttime awakenings per month (25.5% versus 29%) and emergency visits in previous year (26% versus 21%). A high percent of asthmatic patients was using both inhaled corticoids and long-acting β 2 -agonists (49.5% versus 32%). The 30% of PC patients could not be classified into any step of the treatment. In Spain, the morbidity of disease is high, despite the large use of drugs. Objective monitoring tests have very limited use in PC.

Interest in asthma research among Spanish pneumologists is increasing. In the last year, 22 articles on asthma have been published in Archivos de Bronconeumología, six more than in the previous year. Furthermore, 56 communications were presented at the National Congress of the Spanish Society of Pneumology and Thoracic Surgery and were published in a supplement of the journal, representing 60% more than in the previous year's congress. A critical review of all these articles is provided. The original articles contribute further knowledge on epidemiological and clinical aspects of the disease and basic research. A notable contribution is the publication of two clinical practice guidelines, the Spanish Guideline for the Management of Asthma 2009 and the ALERTA-2 Guideline for the Management of Asthma Exacerbations. These two guidelines represent not only an update but also a change in the methodology used in their drafting, thus improving their scientific quality.

A total of 16 articles (Table 1), were published in the Archivos de Bronconeumología in the past year (December 2008 to November 2009), 9 of which were Originals, which was 17.6% of the originals published in that period. Fortunately, the tendency of a decreasing interest in asthma by pneumologists does not seem to have materialised as was feared a few years ago, on the contrary it seems that research is increasing. All articles that appeared in the journal during the period mentioned are reviewed.

Objectives To assess the level of agreement on the GEMA 2009 clinical recommendations by a Spanish expert panel on asthma. Materials and methods The study was divided into four stages: 1) establishment of a 9 member scientific committee (GEMA authors) for selection of GEMA recommendations to use in the survey; 2) formation of a panel of 74 professionals with expertise in this field (pulmonologists, allergists, family doctors, ear, nose and throat and paediatric specialists); 3) Delphi survey in two rounds, sent by mail, with intermediate processing of opinions and a report to the panel members; and 4) analysis and discussion of results for the Scientific Committee. Results Seventy four participants completed the two rounds of survey. During the first round, a consensus was reached in 49 out of 56 questions analysed. Following discussion by the panel, the consensus was increased to a total of 53 items in the survey. With respect to the remaining questions, Insufficient consensus was obtained on the rest of the questions, due to differing views between sub-specialists, or lack of criteria by most of the experts. Conclusions The external analysis by asthma experts from different specialities showed a high level of professional agreement with the GEMA 2009 recommendations in Spain (96.5 %). The disagreement shown in three recommendations reflect the lack of a high level evidence. These issues represent areas of interest for future research.

The aim of this study was to assess the measurement properties of the Spanish version of Asthma Control Questionnaire (ACQ) when FEV1 item in the original version (ACQ-FEV1) is substituted by peak expiratory flow rate (ACQ-PEF) and when the lung function item is omitted (ACQ-wLF).and 607 patients were enrolled in this study. Three study visits were carried out: at baseline, 2, and 6 weeks later. Validity, reliability and sensitivity to change of both ACQ versions were calculated.ACQ-PEF and ACQ-wLF had a correlation coefficient of 0.38 and 0.39 with no exacerbations. Both symptoms improvement and a better perception of asthma control, both by physicians and patients, were significantly related ro better scores in both versions (P0.01). Cronbach a of ACQ-PEF and ACQ-wLF were 0.83 and 0.87, respectively. Intraclass correlation coefficients of both ACQ-PEF and ACQ-wLF were 0.9 and 0.87. Mean scores of all ACQ versions (ACQ-FEV1, ACQ-PEF and ACQ-wLF) were 1.31 (1), 1.34 (1) and 1.14 (1.1), respectively, being all differences statistically significant Por = 0.003).Replacement of FEV1 by PEF, or its elimination, does not alter the measurement properties of the ACQ questionnaire. Use of ACQ simplified versions is recommended only for investigational purposes, without combining in the same analysis scores obtained with different versions of the questionnaire.

Background Menstruation has been suggested as a possible trigger of near-fatal asthma (NFA), but the evidence supporting this association remains weak. Objective We sought to assess the role of menstruation as a contributing factor in the development of NFA episodes in women of reproductive age. Methods Forty-four female patients of reproductive age with near-fatal attacks were enrolled in a multicenter study. Data on patient and clinical characteristics were collected. We also performed spirometric and allergy studies when the patients were in stable condition. Results Significantly more NFA episodes were observed on the first day of menstruation (11 [25%] patients) than on the remaining days (33 [75%] patients, P = .022), and patients who presented for care on the first day of menstruation used more inhaled salbutamol as rescue medication (9 [9.5] vs 1.8 [3.7] μg/d during the 7 days before the asthma exacerbation, P = .003). Conclusion Menstruation might act as a contributing factor in the development of NFA episodes in patients with unstable asthma. Specific recommendations should be included in educational programs, and the self-management plans of asthmatic women of reproductive age should include the systematic recording of their asthma symptoms and pulmonary function in the perimenstrual phase.

INTRODUCTION: Asthma is a disease that can easily be controlled but it presents a high morbidity rate due to poor patient care. AIMS AND OBJECTIVES: To find out about the quality of the care given to asthmatic patients in Spain, both in primary care and Pneumology Services, assessing how asthma and general morbidity are diagnosed and treated. SUBJECTS AND METHODS: Data were collected from 2346 asthmatic patients, chosen at random, seen in primary care and Pneumology Departments. The data were collected in two different periods: winter- spring and summer-autumn. There was a questionnaire for each center to record the techniques and the prevalence data; there was another questionnaire to record each patient's treatment and the morbidity data. RESULTS: The spirometry was performed at least once a year in 87.2% of the patients seen in primary care and 39.8% in Pneumology Services. Morbidity was high in both groups with more than two night time awakenings per month (25% in Pneumology versus 29% in Primary Care) and visits to the emergency services in the previous year (26% vs 21%). A high percentage of asthmatic patients were using both inhaled corticoids and long-acting b2- agonists (49.5% vs 32%). Thirty percent of the primary care patients could not be classified into any of the recommended treatments in international guidelines. CONCLUSIONS: In Spain, the asthma morbidity is high, despite the large use of drugs. Objective monitoring tests of lung function have been limited in primary care and there is room for improvement in the treatment provided. Conflict of interest and funding ASTRAZENECA Farmaceutica Spain, S.A. financed the logistic aspects of the study.