Should we consider paranasal and chest computed tomography in severe asthma patients?

BACKGROUND: It is essential to recognize and treat findings that can simulate or worsen symptoms to improve asthma control and thereby to reduce costs. Guidelines highlight a paranasal (PS) and chest computed tomography (CT) scan as a tool for disease evaluation and, although they suggest its indication in patients whom presentation is atypical, there are not well-defined criteria. OBJECTIVES: To describe the most common findings in the PS and chest CT in severe asthma patients and to analyse the characteristics of asthmatics with the finding of nasal polyps or bronchiectasis. METHODS: We retrospectively reviewed the medical records of 161 adults with confirmed severe asthma who had undergone to PS and/or chest CT. Clinical data from their electronic health record and the findings from a PS and/or chest CT within the last five years were collected. RESULTS: In the PS CT, 70.5% of patients presented mucous thickening and 46.7% presented nasal polyps. Both findings were associated with male gender and level of blood eosinophils. In chest CT, 28% of individuals showed atelectasis, 16.5% air trapping, 17.7% affectation of the small airway, 11.6% pulmonary infiltrates and 10.4% emphysema. Bronchiectasis were identified in 60.4% of subjects, who were older and had poorer lung function. CONCLUSION: Paranasal and thoracic computed tomography are important tools in the treatment of severe asthma because they allow us to detect highly prevalent findings in this disease that can lead to poorer control of it.

Sputum periostin in patients with different severe asthma phenotypes.

BACKGROUND: Identifying inflammatory phenotypes is relevant in severe uncontrolled asthma. The aim of this study was to identify the different clinical, inflammatory, functional, and molecular phenotypes in patients with severe asthma and to investigate the potential role of sputum periostin as a biomarker of severe asthma phenotypes. PATIENTS AND METHODS: Sputum induction was performed in 62 patients diagnosed with severe asthma. Skin prick testing, lung function tests, exhaled nitric oxide, hematimetry, and total serum IgE were performed. Periostin was measured in sputum supernatants. RESULTS: Patients with asthma were phenotyped and 80% had late-onset asthma, 50% had fixed airflow obstruction, and 66% showed a Th2-high phenotype. With respect to inflammatory phenotypes, 71% were eosinophilic and 25% mixed granulocytic. Periostin levels were higher in patients with fixed as compared to variable airflow limitation (69.76 vs 43.84 pg/ml, P < 0.05) and in patients with eosinophilic as compared to mixed granulocytic phenotype (61.58 vs 37.31 pg/ml, P < 0.05). There was an inverse correlation between postbronchodilator FEV1 /FVC and periostin levels (-0.276, P < 0.05). CONCLUSION: This study demonstrates the utility of periostin in phenotyping severe asthma. Periostin levels in sputum are associated with persistent airflow limitation in asthma patients with airway eosinophilia despite treatment with high-dose inhaled corticosteroids.

Recent trends in COPD prevalence in Spain: a repeated cross-sectional survey 1997-2007.

We aimed to describe changes in the prevalence of chronic obstructive pulmonary disease (COPD) in Spain by means of a repeated cross-sectional design comparing two population-based studies conducted 10 yrs apart. We compared participants from IBERPOC (Estudio epidemiológico de EPOC en España) (n = 4,030), conducted in 1997, with those of EPI-SCAN (Epidemiologic Study of COPD in Spain) (n = 3,802), conducted in 2007. Poorly reversible airflow obstruction compatible with COPD was defined according to the old European Respiratory Society definitions. COPD prevalence in the population between 40 to 69 yrs of age dropped from 9.1% (95% CI 8.1-10.2%) in 1997 to 4.5% (95% CI 2.4-6.6%), a 50.4% decline. The distribution of COPD prevalence by severity also changed from 38.3% mild, 39.7% moderate and 22.0% severe in 1997, to 85.6% mild, 13.0% moderate and 1.4% severe in 2007, and in the 40-69 yr EPI-SCAN sub-sample to 84.3% mild, 15.0% moderate and 0.7% severe. Overall, underdiagnosis was reduced from 78% to 73% (not a significant difference) and undertreatment from 81% to 54% (p<0.05) within this 10-yr frame. The finding of a substantial reduction in the prevalence of COPD in Spain is unexpected, as were the observed changes in the severity distribution, and highlights the difficulties in comparisons between repeated cross-sectional surveys of spirometry in the population.

Exhaled nitric oxide and airway caliber during exercise-induced bronchoconstriction.

Data on the relationship between exercise-induced bronchoconstriction (EIB) and exhaled nitric oxide (NO) in adult patients with asthma are controversial. It is unclear whether endogenous NO may act as either a protective or stimulatory factor in the airway response to exercise or whether changes in exhaled NO simply reflect acute narrowing of the airway. The aim of this study was to assess the changes in the fraction of exhaled nitric oxide (FE(NO)) before and after exercise challenge in patients with asthma and to analyze the relationship between FE(NO) and airway obstruction. Twenty-five non-smoking, steroid-naïve, atopic, adult patients with mild persistent asthma and 12 non-smoking, nonatopic, healthy subjects (control group) performed an exercise challenge on a cycloergometer, with monitored ventilation. FEV1 and FE(NO) were measured at baseline and 1, 5, 10, 15 and 20 minutes after the exercise challenge. Eleven of the asthmatic patients had exercise-induced bronchoconstriction (EIB group) and the remaining 14 did not (non-EIB group). Baseline FE(NO) was higher in the EIB and non-EIB asthmatic groups than in the control group. In the EIB group, FE(NO) was significantly lower 5, 10 and 15 minutes after exercise, and the changes in FE(NO) correlated with variation in FEV1 10 and 15 min after exercise. A significant correlation between baseline FE(NO) and maximal post-exercise decrease in FEV1 was found in asthmatic patients (EIB group). In conclusion, exhaled nitric oxide levels transiently decrease during exercise-induced bronchoconstriction in adult patients with asthma. Baseline FE(NO) might predict the airway obstruction resulting after exercise.

[Comparison of carbon dioxide rebreathing during application of continuous positive airway pressure with 3 types of nasal mask]. / Comparación de la reinhalación de anhídrido carbónico originada por 3 mascarillas nasales durante la aplicación de CPAP.

A comparison is made between the end-tidal fractional concentration of carbon dioxide (FETCO2) obtained during application of varying levels of continuous positive airway pressure (CPAP) with a prototype mask (from Carburos Metálicos) and FETCO2 obtained with 2 commonly used nasal masks (Profile Lite and ComfortClassic from Respironics). The nasal FETCO2 was measured on 3 consecutive days in 11 healthy volunteers, 12 patients with severe obstructive sleep apnea-hypopnea syndrome, and 12 hypercapnic patients. A different mask was randomly assigned on each day and the FETCO2 was measured after 3 minutes of CPAP at 4, 5, 6, 8, 10, 15, and 20 cm H2O. Although in all cases a progressive reduction in FETCO2 was observed with increasing CPAP, the effect was greatest with the prototype mask at all pressures. In the 3 different study groups the pressures obtained with the prototype mask were similar to those generated by the CPAP machine. In conclusion, the lower concentration of nasal CO2 obtained using the prototype mask suggests that it causes less rebreathing.

Comparación de la reinhalación de anhídrido carbónico originada por 3 mascarillas nasales durante la aplicación de CPAP / Comparison of carbon dioxide rebreathing during application of Continuous Positive Airway Pressure with 3 types of nasal mask

Se describe la fracción end-tidal de anhídrido carbónico (FETCO2) originada con una mascarilla prototipo (Carburos Metálicos) durante la aplicación de diferentes niveles de presión positiva continua en la vía aérea (CPAP) y se compara con la desarrollada por 2 mascarillas nasales de uso habitual (Profile Lite y ComfortClassic, Respironics). En 11 voluntarios sanos, 12 pacientes con síndrome de apneas-hipopneas obstructivas durante el sueño de carácter grave y 12 enfermos hipercápnicos, se midió, de forma aleatoria en 3 días sucesivos, la FETCO2 nasal después de 3 min de CPAP a 4, 5, 6, 8, 10, 15 y 20 cmH2O con cada una de las mascarillas. Aunque en todos los casos se logró una reducción progresiva de la FETCO2 al incrementar la presión, ésta fue mayor con la mascarilla prototipo, para cualquier nivel de presión. En los 3 grupos del estudio las presiones alcanzadas en la mascarilla prototipo fueron similares a las generadas por la máquina de CPAP. En conclusión, la menor concentración de anhídrido carbónico nasal durante la aplicación de la mascarilla prototipo induce a pensar que origina una menor reinhalación

A comparison is made between the end-tidal fractional concentration of carbon dioxide (FETCO2) obtained during application of varying levels of continuous positive airway pressure (CPAP) with a prototype mask (from Carburos Metálicos) and FETCO2 obtained with 2 commonly used nasal masks (Profile Lite and ComfortClassic from Respironics). The nasal FETCO2 was measured on 3 consecutive days in 11 healthy volunteers, 12 patients with severe obstructive sleep apnea-hypopnea syndrome, and 12 hypercapnic patients. A different mask was randomly assigned on each day and the FETCO2 was measured after 3 minutes of CPAP at 4, 5, 6, 8, 10, 15, and 20 cm H2O. Although in all cases a progressive reduction in FETCO2 was observed with increasing CPAP, the effect was greatest with the prototype mask at all pressures. In the 3 different study groups the pressures obtained with the prototype mask were similar to those generated by the CPAP machine. In conclusion, the lower concentration of nasal CO2 obtained using the prototype mask suggests that it causes less rebreathing

Cost-effectiveness of formoterol and salbutamol as asthma reliever medication in Sweden and in Spain.

This study aimed to evaluate the cost-effectiveness of formoterol (Oxis) Turbuhaler 4.5 microg and salbutamol 200 microg as reliever medications in Sweden and Spain. The study used data on effectiveness (exacerbations and symptom-free days) and resource utilisation from an open, 6-month, parallel-group, multicentre randomised trial with 18,124 asthma patients in 24 countries. Country-specific unit costs for Sweden and for Spain were used to transform resource utilisation data into costs. Total healthcare costs were not significantly different between formoterol and salbutamol dry powder inhalers in Sweden, whereas in Spain, the healthcare costs were 20% higher for formoterol vs. salbutamol pressurised metered dose inhalers. Total healthcare costs increased with disease severity, defined according to the Global Initiative for Asthma guidelines. Compared with salbutamol, formoterol produced statistically significant improvements in effectiveness, less reliever and maintenance medication usage, reduced healthcare resource utilisation, with no increase or a limited increase in healthcare cost.

Costes de la EPOC en España. Estimación a partir de un estudio epidemiológico poblacional / Costs of chronic obstructive pulmonary disease in Spain. Estimation from a population-based study

OBJETIVO: En los estudios realizados hasta ahora, el coste de la enfermedad pulmonar obstructiva crónica (EPOC) puede estar sobrestimado porque han incluido a pacientes previamente diagnosticados que consultaron por sus síntomas, por lo que la gravedad puede ser superior a la que realmente tendría una población no seleccionada obtenida de la población general. El propósito del presente estudio fue estimar el coste directo de la EPOC basándose en una muestra representativa del conjunto de la población española de entre 40 y 69 años (estudio IBERPOC). MÉTODO: El coste se evaluó retrospectivamente a través de un cuestionario referido al último año en los 363 pacientes con EPOC del estudio IBERPOC. Un neumólogo realizó a todos ellos una espirometría estandarizada en cada una de las 7 áreas geográficas en las que se llevó a cabo el estudio. RESULTADOS: La asistencia hospitalaria fue el coste más elevado (41 por ciento del coste total), seguido del tratamiento farmacológico (37 por ciento). El coste por paciente fue de 98,39 , y por paciente previamente diagnosticado, de 909,5 . El coste de la EPOC grave por persona fue más de tres veces el coste de la EPOC moderada y más de 7 veces el coste de la EPOC leve. El coste anual estimado de la EPOC en España fue de 238,82 millones de euros (información referida a 1997). CONCLUSIÓN: Éste es el primer estudio que estima el coste de la EPOC en una muestra representativa de la población general, que es inferior al calculado por los estudios que han analizado una muestra seleccionada con diagnóstico previo de EPOC. La distribución del gasto no se ajusta a las prácticas asistenciales recomendables, por lo que son necesarias actuaciones que optimicen los recursos empleados en el seguimiento y en el tratamiento de la enfermedad, prestando especial atención a su diagnóstico temprano (AU)

[Costs of chronic obstructive pulmonary disease in Spain. Estimation from a population-based study]. / Costes de la EPOC en España. Estimación a partir de un estudio epidemiológico poblacional.

OBJECTIVE: In the studies carried out to date, the cost of chronic obstructive pulmonary disease (COPD) may have been overestimated due to the inclusion of previously diagnosed patients seeking medical attention for their symptoms. As a result, the severity of the cases included in these studies may have been greater than in an unselected sample of the general population. The aim of the present study was to estimate the direct cost of COPD on the basis of a representative sample of the overall Spanish population between 40 and 69 years of age (from the IBERPOC study). METHOD: The cost was evaluated retrospectively by means of a questionnaire completed by the 363 patients with COPD from the IBERPOC study with questions referring to the previous year. Standardized spirometry was performed on all the patients by a pneumologist in each of the 7 geographical areas in which the study was carried out. RESULTS: Hospitalization accounted for the greatest expenditure (41% of total), followed by drug therapy (37%). The cost was euro;98.39 per patient, and euro;909.50 per previously diagnosed patient. The cost per person of severe COPD was more than 3 times that of moderate COPD and more than 7 times that of mild COPD. The estimated annual cost of COPD in Spain was euro;238.82 million (for 1997). CONCLUSION: The present study, which was the first to estimate the cost of COPD in a representative sample of the general population, found the cost to be lower than in studies analyzing samples of patients with previous diagnoses of COPD. The cost distribution is not in line with recommended health care practices, underlining the need to optimize resources used to monitor and treat the disease, with an emphasis on early diagnosis.

Formoterol as relief medication in asthma: a worldwide safety and effectiveness trial.

The aim of the study was to compare the safety and effectiveness of as-needed formoterol with salbutamol in a large international real-life asthma study. Children and adults (n=18,124) were randomised to 6 months as-needed treatment with open-label formoterol 4.5 microg Turbuhaler or salbutamol 200 microg pressurised metered dose inhaler or equivalent. Primary safety variables were asthma-related and nonasthma-related serious adverse events (SAE)s and adverse events (AE)s resulting in discontinuation (DAE)s. The primary efficacy variable was time to first asthma exacerbation. The incidences of AEs, SAEs and DAEs arising from SAEs were not significantly different between treatments. DAEs for nonserious AEs were higher with formoterol. Asthma-related AEs decreased with formoterol (1,098 (12.3%) versus 1,206 (13.5%)), asthma-related SAEs were similar (108 (1.2%) versus 121 (1.4%)) but more asthma-related DAEs occurred in the formoterol group (89 (1.0%) versus 48 (0.5%)). Time to first exacerbation was prolonged (hazard ratio 0.86) and less as-needed and maintenance medication was used with formoterol. Reductions of exacerbations with as-needed formoterol versus salbutamol increased with increasing age and asthma medication level. This real-life study demonstrates that formoterol as-needed has a similar safety profile to salbutamol, and its use as a reliever therapy is associated with fewer asthma symptoms and exacerbations.

Effect of montelukast added to inhaled budesonide on control of mild to moderate asthma.

BACKGROUND: Proinflammatory leukotrienes, which are not completely inhibited by inhaled corticosteroids, may contribute to asthmatic problems [corrected]. A 16 week multicentre, randomised, double blind, controlled study was undertaken to study the efficacy of adding oral montelukast, a leukotriene receptor antagonist, to a constant dose of inhaled budesonide. METHODS: A total of 639 patients aged 18-70 years with forced expiratory volume in 1 second (FEV(1)) > or =55% predicted and a minimum predefined level of asthma symptoms during a 2 week placebo run in period were randomised to receive montelukast 10 mg (n=326) or placebo (n=313) once daily for 16 weeks. All patients received a constant dose of budesonide (400-1600 microg/day) by Turbuhaler throughout the study. RESULTS: Mean FEV(1) at baseline was 81% predicted. The median percentage of asthma exacerbation days was 35% lower (3.1% v 4.8%; p=0.03) and the median percentage of asthma free days was 56% higher (66.1% v 42.3%; p=0.001) in the montelukast group than in the placebo group. Patients receiving concomitant treatment with montelukast had significantly (p<0.05) fewer nocturnal awakenings and significantly (p<0.05) greater improvements in beta agonist use and morning peak expiratory flow rate (PEFR). CONCLUSIONS: For patients with mild airway obstruction and persistent asthma symptoms despite budesonide treatment, concomitant treatment with montelukast significantly improves asthma control.

Safety of formoterol by Turbuhaler as reliever medication compared with terbutaline in moderate asthma.

The present study compared the safety of 4.5 microg formoterol with 0.5 mg terbutaline, both by Turbuhaler and used as needed, in addition to regular formoterol in moderate asthma. In this double-blind parallel-group study, 357 patients taking a moderate-to-high dose of inhaled corticosteroids and additional terbutaline (2-5 inhalations x day(-1) during run-in) were randomised to either formoterol or terbutaline as needed in addition to formoterol 9 microg b.i.d. over 12 weeks. Adverse events, serum potassium levels, electrocardiogram, vital signs and lung function were assessed monthly; peak expiratory flow and severe asthma exacerbations were recorded daily. Patients used 2.16 (range 0.0-6.3) formoterol and 2.34 (range 0.1-7.5) terbutaline relief inhalations x day(-1). No clinically significant differences in safety variables were found between treatments. Statistically greater increases in cardiac frequency (2.6 beats x min(-1), p=0.03) were found on terbutaline. There were 44 and 52 severe asthma exacerbations with formoterol and terbutaline, respectively, with no significant difference in time to first exacerbation. There was also no difference between treatments for other efficacy measures (peak expiratory flow, forced expiratory volume in one second and morning/evening symptom scores). Formoterol 4.5 microg as needed was at least as safe, well tolerated and effective as terbutaline 0.5 mg in stable patients (requiring up to 6 relief inhalations x day(-1)) taking formoterol plus inhaled corticosteroids regularly over 12 weeks.

[Respiratory symptoms and diagnosis of COPD in smokers of various types to tobacco. Results from the IBERPOC study]. / Síntomas respiratorios y diagnóstico de EPOC en fumadores de distintas labores de tabaco. Resultados del estudio IBERPOC.

BACKGROUND: The aim of this study was to investigate the sociodemographic characteristics, smoking habits, the prevalence of respiratory symptoms and chronic obstructive pulmonary disease (COPD) in four groups of smokers: of cigarettes (SCt), of cigars (SCigar), of both (SB), of cigars currently but of cigarettes in the past (SCigarExCt) and of cigarettes currently but of cigars in the past (SCtExCigar). METHOD: A multicenter epidemiological study enrolling 4,035 subjects aged between 40 and 69 years. One thousand nine hundred sixty-three were non-smokers and 1,146 were current smokers. Among the smokers, 869 were SCt, 37 were SCigar, 97 were SB, 86 were SCigarExCt and 57 were SCtExCigar. We analyzed sociodemographic characteristics, smoking and the prevalence of respiratory symptoms and COPD. RESULTS: Cigar smokers were usually men, of lower socioeconomic status (p < 0.001) and older than cigarette smokers (p < 0.001), but CO concentrations in expired air were lower in the SCigar group than in the SCt group (5 ppm vs 15.7; p < 0.001). Informants who believed their smoking was not detrimental to their health or to that of second-hand smokers made up 86.5% of the SCigar group and 79.1% of the SCigarExCt group. COPD was diagnosed in 13.2% of the SCt group, in 24.7% of the SB group, and in 12.8% of the SCigarExCt group, in comparison with 4% of the non-smokers (p < 0.001 for all comparisons). CONCLUSIONS: SCigar are mainly older men with lower educational levels. Their concentrations of CO in expired air are low and they have little awareness of the health risks posed by their habit. SCigar who were once smokers of cigarettes have a higher prevalence of respiratory symptoms and COPD than non-smokers and the same prevalence of COPD as SCt.

Síntomas respiratorios y diagnóstico de EPOC en fumadores de distintas labores de tabaco. Resultados del estudio IBERPOC / Respiratory symptoms and diagnosis of COPD in smokers of various types to tobacco. Results from the IBERPOC study

FUNDAMENTO: El objetivo de este estudio fue investigar las características sociodemográficas y de tabaquismo, así como la presencia de síntomas respiratorios y enfermedad pulmonar obstructiva crónica (EPOC) en cuatro grupos de fumadores: de cigarrillos (FC), de cigarros (FP), de cigarrillos y cigarros (FCP), de cigarros que fueron fumadores de cigarrillos (FPEC) y de cigarrillos que fueron fumadores de cigarros (FCEP).MÉTODO: Estudio epidemiológico multicéntrico que incluyó a 4.035 individuos entre 40 y 69 años; 1.963 no fumadores, y 1.146 fumadores activos. Entre estos últimos, 869 eran FC, 37 FP, 97 FCP, 86 FPEC y 57 FCEP. Se analizaron sus características sociodemográficas y de tabaquismo, así como los síntomas respiratorios y la presencia de EPOC.RESULTADOS: Los FP fueron con mayor frecuencia varones, de clases sociales más deprimidas (p < 0,001) y de mayor edad que los FC (p < 0,001), pero sus concentraciones de CO en aire espirado fueron inferiores a las de los FC (5 ppm frente a 15,7; p < 0,001). El 86,5 per cent de los FP y el 79,1 per cent de los FPEC pensaban que consumir este tipo de tabaco no era perjudicial para su salud ni para la de los fumadores pasivos. La EPOC se diagnosticó en el 13,2 per cent de los FC, en el 24,7 per cent de los FCP y en el 12,8 per cent de los FPEC, frente al 4 per cent de los no fumadores (p < 0,001 en todas las comparaciones).CONCLUSIONES: Los FP son mayoritariamente varones de más edad que los FC y pertenecen a estratos educacionales deprimidos. Tienen concentraciones bajas de CO en su aire espirado y escaso conocimiento de los riesgos que este hábito supone para su salud. Los FPEC tienen más alta incidencia de síntomas respiratorios y de EPOC que los no fumadores e idéntica incidencia de EPOC que los FC (AU)

Inspiratory neural drive response to hypoxia adequately estimates peripheral chemosensitivity in OSAHS patients.

The aim of the present study was to examine the relationships between the responses to progressive isocapnic hypoxia and hypoxic withdrawal test in patients with obstructive sleep apnoea-hypopnoea syndrome (OSAHS) and to analyse the determinants of carotid body sensitivity in OSAHS. Nineteen consecutive OSAHS patients and 13 healthy subjects were selected. Ventilatory (delta V'I/Sa,O2/BSA) and inspiratory neural drive (delta P0.1/Sa,O2) responses to progressive isocapnic hypoxia were determined. Peripheral chemosensitivity was evaluated by the hypoxic withdrawal test, which measures the decrease in ventilation caused by two breaths of 100% oxygen (%delta V'I). Withdrawal response and ventilatory and inspiratory neural drive responses to hypoxia were lower in OSAHS patients than in control subjects. In patients with OSAHS, %delta V'I correlated significantly with delta V'I/Sa,O2/BSA and with delta P0.1/Sa,O2. On stepwise multiple linear regression analysis, a strong correlation between %delta V'I and delta P0.1/Sa,O2 was found. Moreover, %delta V'I, delta V'I/Sa,O2/BSA and delta P0.1/Sa,O2 were significantly correlated with minimum arterial oxygen saturation and with arousal index. Obstructive sleep apnoea-hypopnoea syndrome patients have a strong relationship between peripheral chemosensitivity and respiratory response to hypoxia, suggesting that hypoxic stimulation of central chemoreceptors is minimally relevant in obstructive sleep apnoea-hypopnoea syndrome. Moreover, sensitivity of the carotid body in patients with obstructive sleep apnoea-hypopnoea syndrome is related to sleep disruption and to nocturnal hypoxia.

Interpretation of quality of life scores from the St George's Respiratory Questionnaire.

The aim of the study was to obtain the general population norms for the St. George's Respiratory Questionnaire (SGRQ), a specific questionnaire for respiratory diseases. The IBERPOC project was a cross-sectional study of representative samples of the general population aged between 40-69 yrs. The study sample was composed of 862 individuals. All participants considered as "probable cases" of chronic obstructive pulmonary disease (COPD) (n=460) were eligible to complete the SGRQ and among the rest of the nonprobable COPD participants (n=3,571), 10 individuals from each defined age and sex group were eligible (n=402). Weights were applied to restore general population representativity of the sample. Mean forced expiratory volume in one second (FEV1) predicted was 89.4% (SD=16.5%; range: 16-131%). Chronbach's alpha coefficients were >0.7 in the symptoms, activity and impact scales, and >0.9 in the overall scale. Symptom scale score was significantly higher among males (11.6 versus 7.8; p<0.01) and activity scale score was significantly higher among females (12.2 versus 14.6; p=0.04). In a multiple linear regression model, respiratory diseases (asthma and COPD) and FEV1 % over pred showed the strongest association with the SGRQ total score. Smoking, sex, age and education were independently associated with the total SGRQ score. These results indicate that individuals from the general population presented some of the problems that are important when measuring health-related quality of life in respiratory patients, and provide St George's Respiratory Questionnaire norms, a useful method for interpreting the St George's Respiratory Questionnaire score in a given patient or study samples.

Reduction of lung distensibility in acromegaly after suppression of growth hormone hypersecretion.

Whether the growth of the lungs in acromegaly is due to alveolar hypertrophy or alveolar hyperplasia is a subject of debate. To discriminate these hypotheses, we compared pulmonary distensibility and diffusing capacity among 11 patients with active acromegaly and 11 matched control subjects, evaluating the response of pulmonary distensibility and diffusing capacity to suppression of growth hormone (GH) hypersecretion. We performed lineal and exponential analyses of quasistatic pressure-volume curves. Patients with active acromegaly had a greater TLC, lung compliance, and shape constant, K, than did normal subjects. We found no significant differences between the study groups in carbon monoxide diffusing capacity or diffusing capacity per unit of alveolar volume. After treatment, patients with inactive acromegaly showed a reduced TLC (6.95 +/- 1.40 [mean +/- SD] L versus 6.35 +/- 1.23 L), reduced lung compliance (3.61 +/- 0.90 L/kPa versus 2.36 +/- 0.79 L/ kPa), reduced K coefficient (2.62 +/- 0.65 kPa(-)(1) versus 1.35 +/- 0.40 kPa(-)(1)), and increased maximal recoil pressure (1.74 +/- 0.38 kPa versus 2.28 +/- 0.25 kPa). We conclude that the increased lung distensibility with normal diffusion capacity demonstrated in patients with active acromegaly, which was partly reversible after suppression of GH hypersecretion, suggests that lung growth in acromegaly may result from an increase in alveolar size.

Smoking characteristics: differences in attitudes and dependence between healthy smokers and smokers with COPD.

OBJECTIVE: To ascertain the differences in smoking characteristics between a group of smokers with COPD and another group of healthy smokers, both of which were identified in a population-based epidemiologic study. DESIGN AND PARTICIPANTS: This is an epidemiologic, multicenter, population-based study conducted in seven areas of SPAIN: A total of 4,035 individuals, men and women aged 40 to 69 years, who were selected randomly from a target population of 236,412 subjects, participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed followed by a bronchodilator test when bronchial obstruction was present. The Fagerström questionnaire was used for study of the degree of physical nicotine dependence, and the Prochazka model was followed for analysis of the smoking cessation phase. RESULTS: Of 1,023 active smokers, 153 (15%) met the criteria for COPD. Smokers with COPD were more frequently men (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.21 to 3.95), were > or = 46 years of age (OR, 1.97; 95% CI, 1.18 to 3.31), had a lower educational level (OR, 1.96; 95% CI, 1.23 to 3.14), and had smoked > 30 pack-years (OR, 3.70; 95% CI, 2.42 to 5.65). Smokers with COPD showed a higher dependence on nicotine than healthy smokers (mean [+/- SD] Fagerström test score, 4.77 +/- 2.45 vs 3.15 +/- 2.38, respectively; p < 0.001) and higher concentrations of CO in exhaled air (mean concentration, 19.7 +/- 16.3 vs 15.4 +/- 12.1 ppm, respectively; p < 0.0001). Thirty-four percent of smokers with COPD and 38.5% of smokers without COPD had never tried to stop smoking. CONCLUSIONS: Smokers with COPD have higher tobacco consumption, higher dependence on nicotine, and higher concentrations of CO in exhaled air, suggesting a different pattern of cigarette smoking. Cases of COPD among smokers predominate in men and in individuals with lower educational levels. A significant proportion of smokers have never tried to stop smoking; thus, advice on cessation should be reinforced in both groups of smokers.

Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study.

OBJECTIVES: To ascertain the prevalence, diagnostic level, and treatment of COPD in Spain through a multicenter study comprising seven different geographic areas. DESIGN AND PARTICIPANTS: This is an epidemiologic, multicenter, population-based study conducted in seven areas of Spain. A total of 4,035 men and women (age range, 40 to 69 years) who were randomly selected from a target population of 236,412 subjects participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed, followed by a bronchodilator test when bronchial obstruction was present. RESULTS: The prevalence of COPD was 9.1% (95% confidence interval [CI], 8.1 to 10.2%), 15% in smokers (95% CI, 12.8 to 17.1%), 12.8% in ex-smokers (95% CI, 10.7 to 14.8%), and 4.1% in nonsmokers (95% CI, 3.3 to 5.1%). The prevalence in men was 14.3% (95% CI, 12.8 to 15. 9%) and 3.9% in women (95% CI, 3.1 to 4.8%). Marked differences were observed between sexes in smoking; the percentage of nonsmokers was 23% in men and 76.3% in women (p<0.0001). The prevalence of COPD varied among the areas, ranging from 4.9% (95% CI, 3.2 to 7.0%) in the area of the lowest prevalence to 18% (95% CI, 14.8 to 21.2%) in the area of the highest. There was no previous diagnosis of COPD in 78.2% of cases (284 of 363). Only 49.3% of patients with severe COPD, 11.8% of patients with moderate COPD, and 10% of patients with mild COPD were receiving some kind of treatment for COPD. Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas, were of male gender, were > 60 years old, had higher educational levels, had > 15 pack-year smoking history, or had symptoms of chronic bronchitis. CONCLUSIONS: COPD is a very frequent disease in Spain, and presents significant geographic variations and a very low level of previous diagnosis and treatment, even in the most advanced cases.