Eosinophil Subtypes in Adults with Asthma and Adults with Chronic Obstructive Pulmonary Disease.

Rationale: There is a differential response to eosinophilic modulation between patients with asthma and those with chronic obstructive pulmonary disease (COPD). There is also evidence of different subtypes of eosinophils in murine models. However, no study has compared eosinophil subtypes in individuals with COPD and in those with asthma. Objectives: Study the differences in eosinophils subtypes based in the surface protein expression in COPD patients and asthmatic patients. Methods: We studied 10 stable subjects in each of four groups: subjects with COPD, subjects with asthma, smokers without COPD, and healthy volunteers. Subjects with COPD and those with asthma were matched by age, sex, and FEV1% predicted. The following variables were determined: anthropometrics, smoking, exacerbation history, medication use, lung function, and comorbidities. Using flow cytometry and confocal microscopy from blood samples, we determined differences in eosinophil surface proteins and classified them as 1) resident eosinophils (Siglec-8+CD62L+IL-3Rlo) or 2) inflammatory eosinophils (iEos; Siglec-8+CD62LloIL-3Rhi). IL-5 receptor was also determined. Findings were validated in 59 patients with COPD and in 17 patients with asthma. Measurements and Main Results: Patients with asthma had a higher proportion of iEos (25 ± 15%) compared with those with COPD (0.5 ± 1%), smokers without COPD (0.14 ± 0.24%), and healthy volunteers (0.67 ± 1.72%). In patients with asthma, the proportion of iEos was independent of total eosinophil number. iEos had more IL-5 receptors than resident eosinophils (777.02 ± 124.55 vs. 598.35 ± 318.69; P < 0.01). In patients with COPD, there was no relation between iEos number and inhaled corticosteroid use, disease severity, or exacerbations rate. The findings in patients with COPD and those with asthma were confirmed in validation cohorts. Conclusions: There are differences in the subtypes of circulating eosinophils between patients with asthma and those with COPD. This could have clinical implications in the interpretation of eosinophil significance and the approach to therapy in these patients.

Somatotypes trajectories during adulthood and their association with COPD phenotypes.

RATIONALE: Chronic obstructive pulmonary disease (COPD) comprises distinct phenotypes, all characterised by airflow limitation. OBJECTIVES: We hypothesised that somatotype changes - as a surrogate of adiposity - from early adulthood follow different trajectories to reach distinct phenotypes. METHODS: Using the validated Stunkard's Pictogram, 356 COPD patients chose the somatotype that best reflects their current body build and those at ages 18, 30, 40 and 50 years. An unbiased group-based trajectory modelling was used to determine somatotype trajectories. We then compared the current COPD-related clinical and phenotypic characteristics of subjects belonging to each trajectory. MEASUREMENTS AND MAIN RESULTS: At 18 years of age, 88% of the participants described having a lean or medium somatotype (estimated body mass index (BMI) between 19 and 23 kg·m-2) while the other 12% a heavier somatotype (estimated BMI between 25 and 27 kg·m-2). From age 18 onwards, five distinct trajectories were observed. Four of them demonstrating a continuous increase in adiposity throughout adulthood with the exception of one, where the initial increase was followed by loss of adiposity after age 40. Patients with this trajectory were primarily females with low BMI and D LCO (diffusing capacity of the lung for carbon monoxide). A persistently lean trajectory was seen in 14% of the cohort. This group had significantly lower forced expiratory volume in 1 s (FEV1), D LCO, more emphysema and a worse BODE (BMI, airflow obstruction, dyspnoea and exercise capacity) score thus resembling the multiple organ loss of tissue (MOLT) phenotype. CONCLUSIONS: COPD patients have distinct somatotype trajectories throughout adulthood. Those with the MOLT phenotype maintain a lean trajectory throughout life. Smoking subjects with this lean phenotype in early adulthood deserve particular attention as they seem to develop more severe COPD.

A Delphi Consensus Document on the Use of Single-Inhaler Fixed-Dose Triple Therapies in COPD Patients.

Introduction: Despite the evidence provided by clinical trials, there are some uncertainties and controversies regarding the use of triple inhaled therapy. With the aim of evaluating clinical practice in specialized respiratory units, a Delphi consensus document was implemented on the use of single-inhaler fixed-dose triple therapies after 1 year of use in Spain. Methods: A scientific committee of COPD experts defined a thematic index, guided a systematic literature review and helped design the Delphi questionnaire. This was sent to the other 45 COPD experts between April and June 2019. Agreement/disagreement on 58 statements was tested in two rounds using a Likert scale. Replies were classified as a consensus when ≥80% of the panelists agreed; a majority when a degree of agreement of ≥66% was reached; and divergence if agreement was <66%. Results: After two rounds, 44.44% of the statements reached consensus, 14.81% reached majority and 40.74% were divergent. Panelists agreed that escalating from double bronchodilation should be phenotype-based and aim to prevent exacerbations but not for improving symptoms. The addition of an antimuscarinic to inhaled corticosteroids combinations achieves improvement in lung function, symptoms and exacerbation prevention. Main safety concerns included the increased risk of pneumonia as compared to bronchodilator therapies, with similar cardiovascular effects. There was no consensus agreement on patient type response based on blood eosinophil counts or obstruction severity. Conclusion: The low degree of consensus among panelists may reflect the complexity of severe COPD management. The information provided here may be useful to clinicians implementing personalized medicine for COPD patients.

Validación pronóstica según los criterios de la GesEPOC 2017 / Prognostic Validation Using GesEPOC 2017 Severity Criteria

Introducción: La Guía española de la EPOC (GesEPOC) ha sido recientemente modificada. El objetivo de este trabajo es valorar la clasificación y el pronóstico de los enfermos según la nueva clasificación de la gravedad. Métodos: Se siguió a 700 enfermos con EPOC (83,9% varones) durante un periodo medio de 5 años en hospitales españoles y de EE. UU. Se midieron datos antropométricos, función pulmonar, disnea medida con la escala mMRC, así como exacerbaciones y los índices de BODE y Charlson. Se clasificaron según el riesgo proporcionado por GesEPOC y se valoró el pronóstico a 5 años. Resultados: Los pacientes tenían una edad media de 66 ± 9,6 años y un FEV1% de 59,7 ± 20,2. El 40,43% de la muestra se encontraba en bajo riesgo. Los sujetos del grupo de alto riesgo presentaban un índice de BODE significativamente mayor que los de bajo riesgo (2,92 ± 0,66 vs. 0,52 ± 1,91, p < 0,001). El índice de Charlson fue similar entre ambos grupos. La mortalidad a 60 meses en el grupo de alto riesgo fue significativamente mayor que en el de bajo riesgo (31,7% vs. 15.5%, p < 0,001). Tanto la disnea como el FEV1% fueron también predictores independientes de mortalidad (p < 0,001), siendo cada uno de ellos no inferior prediciendo mortalidad que el conjunto de los criterios del grupo de alto riesgo de GesEPOC. Conclusiones: La nueva clasificación de la gravedad de GesEPOC predice la mortalidad de forma adecuada. No obstante, tanto el FEV1% como la disnea tienen la misma potencia para predecir mortalidad

Introduction: The Spanish COPD guidelines (GesEPOC) have been recently modified. The aim of this study is to assess this revision and evaluate the prognosis of patients according to the new classification of severity. Methods: A total of 700 COPD patients (83.9% men) were prospectively followed up for a mean period of 5 years in tertiary hospitals in Spain and the USA. Anthropometric data, lung function tests, dyspnea (according to the mMRC scale), BODE and Charlson index were collected. We calculated mortality at 5 years following the risk criteria proposed by the new GesEPOC. Results: Mean age was 66 ± 9.6 years and mean FEV1% was 59.7 ± 20.2. The proportion of patients in the low-risk group was 40.43%. Patients in the high-risk group had a significantly higher BODE index than those in the low-risk group (2.92 ± 0,66 vs. 0.52 ± 1.91, p < 0.001), while the Charlson index score was similar in both groups. Mortality at 60 months was significantly higher in the high-risk group (31.7% vs. 15.5%, p < 0.001). Dyspnea and FEV1% were also independent predictors of mortality (p < 0.001), and neither was inferior to the risk classification proposed by GesEPOC. Conclusions: The new severity index proposed by GesEPOC accurately predicts 5-year mortality. However, dyspnea and FEV1% have the same strength in predicting mortality

EARLY COPD: determinantes de la aparición y progresión de la enfermedad pulmonar obstructiva crónica en adultos jóvenes. Protocolo de un estudio caso-control con seguimiento / Determinants of the Appearance and Progression of Early-Onset Chronic Obstructive Pulmonary Disease in Young Adults. A Case-Control Study with Follow-up

Introducción y objetivos: Los determinantes en fases iniciales de la historia natural de la enfermedad pulmonar obstructiva crónica (EPOC) son poco conocidos. Entenderlos mejor es de capital importancia para poder diseñar intervenciones dirigidas a modificar su pronóstico. Los principales objetivos del estudio son: a) caracterizar a una población de adultos jóvenes con EPOC de forma multidimensional; b) comparar estos pacientes con sujetos fumadores con función pulmonar normal; y c) establecer una cohorte de adultos jóvenes con y sin EPOC, que pueda ser seguida a largo plazo para conocer mejor la historia natural de la enfermedad. Participantes y método: EARLY COPD es un estudio multicéntrico de casos y controles que permitirá 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 atención primaria y 12 hospitales de 8 comunidades autónomas españolas. Los participantes eran fumadores o exfumadores (>10 paquetes año) de entre 35-50 años de edad. Los casos presentaban una espirometría obstructiva con un FEV1/FVC<70% y los controles una espirometría normal con un FEV1/FVC≥70%. Las principales variables de estudio que se han determinado son las siguientes: cuestionarios de salud, síntomas, exacerbaciones y actividad física, pruebas de función respiratoria, análisis biológicos de sangre y esputo y TAC de baja radiación. Para el análisis estadístico de los resultados se describirán las características de los pacientes con EPOC y se compararán con los sujetos del grupo control mediante un modelo de regresión logística

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

Prognostic Validation Using GesEPOC 2017 Severity Criteria. / Validación pronóstica según los criterios de la GesEPOC 2017.

INTRODUCTION: The Spanish COPD guidelines (GesEPOC) have been recently modified. The aim of this study is to assess this revision and evaluate the prognosis of patients according to the new classification of severity. METHODS: A total of 700 COPD patients (83.9% men) were prospectively followed up for a mean period of 5 years in tertiary hospitals in Spain and the USA. Anthropometric data, lung function tests, dyspnea (according to the mMRC scale), BODE and Charlson index were collected. We calculated mortality at 5 years following the risk criteria proposed by the new GesEPOC. RESULTS: Mean age was 66±9.6 years and mean FEV1% was 59.7±20.2. The proportion of patients in the low-risk group was 40.43%. Patients in the high-risk group had a significantly higher BODE index than those in the low-risk group (2.92±0,66 vs. 0.52±1.91, p<0.001), while the Charlson index score was similar in both groups. Mortality at 60 months was significantly higher in the high-risk group (31.7% vs. 15.5%, p<0.001). Dyspnea and FEV1% were also independent predictors of mortality (p<0.001), and neither was inferior to the risk classification proposed by GesEPOC. CONCLUSIONS: The new severity index proposed by GesEPOC accurately predicts 5-year mortality. However, dyspnea and FEV1% have the same strength in predicting mortality.

Determinants of the Appearance and Progression of Early-Onset Chronic Obstructive Pulmonary Disease in Young Adults. A Case-Control Study with Follow-up. / EARLY COPD: determinantes de la aparición y progresión de la enfermedad pulmonar obstructiva crónica en adultos jóvenes. Protocolo de un estudio caso-control con seguimiento.

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.

Comparison of the 2017 and 2015 Global Initiative for Chronic Obstructive Lung Disease Reports. Impact on Grouping and Outcomes.

RATIONALE: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) document has modified the grading system directing pharmacotherapy, but how this relates to the previous one from 2015 and to comorbidities, hospitalizations, and mortality risk is unknown. OBJECTIVES: The aim of this study was to evaluate the changes in the GOLD groups from 2015 to 2017 and to assess the impact on severity, comorbidities, and mortality within each group. METHODS: We prospectively enrolled and followed, for a mean of 5 years, 819 patients with chronic obstructive pulmonary disease (84% male) in clinics in Spain and the United States. We determined anthropometrics, lung function (FEV1%), dyspnea score (modified Medical Research Council scale), ambulatory and hospital exacerbations, and the body mass index, obstruction, dyspnea, and exercise capacity (BODE) and Charlson indexes. We classified patients by the 2015 and 2017 GOLD ABCD system, and compared the differential realignment of the same patients. We related the effect of the reclassification in BODE and Charlson distribution as well as chronic obstructive pulmonary disease and all-cause mortality between the two classifications. MEASUREMENTS AND MAIN RESULTS: Compared with 2015, the 2017 grading decreased by half the proportion of patients in groups C and D (20.5% vs. 11.2% and 24.6% vs. 12.9%; P < 0.001). The distribution of Charlson also changed, whereas group D was higher than B in 2015, they become similar in the 2017 system. In 2017, the BODE index and risk of death were higher in B and D than in A and C. The mortality risk was better predicted by the 2015 than the 2017 system. CONCLUSIONS: Compared with 2015, the GOLD ABCD 2017 classification significantly shifts patients from grades C and D to categories A and B. The new grading system equalizes the Charlson comorbidity score in all groups and minimizes the differences in BODE between groups B and D, making the risk of death similar between them.

¿Qué hay de nuevo en la GOLD 2017? / What's New in GOLD 2017?

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EPOC: inflamación bronquial y sistémica / COPD: bronchial and systemic inflammation

La enfermedad pulmonar obstructiva crónica (EPOC) se considera una enfermedad inflamatoria de la víaaérea, en la que puede coexistir una inflamación sistémica de bajo grado. La etiología es multifactorial, pero,fundamentalmente, condicionada por una respuesta inflamatoria amplificada y anómala al humo del tabaco.En esta respuesta están involucradas la inmunidad innata y la adquirida. Esta última es de característica linfocitariatipo Th1 (CD8) y su presencia parece asociarse a la progresión a estadios avanzado de la enfermedad.En la actualidad, desconocemos si la inflamación bronquial y sistémica están relacionadas o si actúan comocompartimentos independientes. La mayor parte de los datos que tenemos sobre la EPOC se obtienen de estudiostransversales, por lo que no se puede establecer una relación de causalidad entre los posibles mediadoresinflamatorios y los factores genéticos involucrados en la afectación pulmonar y extrapulmonar de estaenfermedad. Necesitamos nuevos estudios que nos permitan categorizar la respuesta inflamatoria con losdiferentes fenotipos de la EPOC(AU)

Chronic obstructive pulmonary disease (COPD) is considered to be an inflammatory disease of the airways, inwhich there can be low-grade systemic inflammation. The etiology of this disease is multifactorial but ismainly due to an anomalous and amplified inflammatory response to tobacco smoke. This inflammatoryresponse involves innate and acquired immunity. The latter is characterized by a Th1-type (CD8) responseand its presence seems to be associated with progression to advanced stages of the disease. Currently, it isunknown whether bronchial and systemic inflammation are related or whether they act as independentcompartments. Most of the available data on COPD are drawn from cross-sectional studies and consequentlya causal relation between the possible inflammatory mediators and the genetic factors involved in pulmonaryand extrapulmonary involvement in this disease cannot be established. Further studies are required thatwould allow the inflammatory response to be correlated with the distinct COPD phenotypes(AU)

EPOC en la mujer / Chronic obstructive pulmonary disease in women

La prevalencia de la enfermedad pulmonar obstructiva crónica (EPOC) se está incrementando en todo el mundo, fundamentalmente a expensas del aumento en las mujeres. En los países desarrollados, la EPOC en la mujer es consecuencia, principalmente, de la exposición al humo de tabaco, y en los países en vías de desarrollo, a la inhalación de los productos de combustión de la biomasa. El infradiagnóstico de la EPOC es más común en las mujeres, ya que ha sido, clásicamente, asociada al sexo masculino. Además, la enfermedad presenta aspectos diferenciales en las mujeres como son: mayor expresión de los aspectos perceptivos (disnea y calidad de vida relacionada con la salud), elevada prevalencia de desnutrición, alta prevalencia de ansiedad y depresión y un patrón de distribución del enfisema diferente al de los varones. Una mejor caracterización fenotípica de la EPOC en la mujer nos permitirá abordar, de modo apropiado, su impacto en el sistema sanitario y diseñar estrategias terapéuticas más individualizadas(AU)

The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide, mainly due to the increase in women. In developed countries, COPD in women is mainly a result of exposure to tobacco smoke and in developing countries to inhalation of biomass combustion products. Underdiagnosis of COPD is more common in women since this disease has classically been associated with men. Moreover, COPD in women shows certain differential features, such as a greater expression of aspects related to perception (dyspnea and health-related quality of life), a high prevalence of malnutrition, anxiety and depression, and a distinct distribution of emphysema from that in men. Better phenotypical characterization of COPD in women would allow its impact on the health system to be more accurately evaluated and more individualized therapeutic strategies to be designed(AU)

Enfermedad pulmonar obstructiva crónica: ¿qué hay más allá del índice BODE? / COPD: what is there beyond BODE index?

La enfermedad pulmonar obstructiva crónica (EPOC) es una enfermedad multidimensional, con una gran heterogeneidad fenotípica que no puede ser representada adecuadamente sólo con el volumen espiratorio forzado durante el primer segundo (FEV1). La evaluación de los pacientes con EPOC requiere de un análisis de múltiples variables que engloben la afectación respiratoria y extrapulmonar. Estas variables deben ser viables en la práctica clínica, no redundantes en su información e impactar en la evolución de la enfermedad. El índice BODE (FEV1, disnea, índice de masa corporal y prueba de la marcha de 6 min) representa el ejemplo más evidente de este enfoque conceptual y su aceptación en la comunidad científica ha sido creciente en los últimos años. No obstante, otros aspectos de la enfermedad no incluidos en el índice BODE, como la hiperinsuflación pulmonar, las exacerbaciones y las comorbilidades, han demostrado ser relevantes dentro de la EPOC. Además, el desarrollo de las nuevas tecnologías podría permitir la incorporación de las técnicas de imagen y los marcadores biológicos (“biomarcadores”) para una mejor caracterización de la enfermedad y un manejo más específico e individualizado de los pacientes. No obstante, la ubicación de todos estos factores dentro del esquema de evaluación de una enfermedad de elevada prevalencia, como la EPOC, está aún por definir (AU)

Chronic obstructive pulmonary disease (COPD) is a multidimensional disease with wide phenotypic heterogeneity that is not adequately reflected by forced expiratory volume in 1 second (FEV1). Assessment of patients with COPD requires analysis of multiple variables that encompass respiratory and extrapulmonary involvement. These variables should be viable in clinical practice, should not provide duplicate information, and should have an effect on the course of the disease. The BODE index (FEV1, dyspnea, body mass index and the 6-minute walk test) is the most obvious example of this conceptual approach and its acceptance among the scientific community has grown in the last few years. Nevertheless, other aspects of the disease not included in the BODE index, such as pulmonary hyperinsufflation, exacerbations and comorbidities, have been shown to be important in COPD. Moreover, the development of new technologies could allow imaging techniques and biomarkers to be incorporated, which would in turn improve characterization of the disease and allow more specific and individually-tailored patient management. Nevertheless, the role of all these factors in the evaluation of a highly prevalent disease such as COPD remains to be defined (AU)

EPOC y malnutrición / COPD disease and malnutrition

La pérdida de peso y la desnutrición relacionadas, fundamentalmente, con la pérdida de la masa magrapueden aparecer en estadios avanzados de la enfermedad pulmonar obstructiva crónica (EPOC) y constituyenun exponente claro de su heterogeneidad fenotípica. Su presencia está asociada a un peor pronóstico,independientemente del volumen espiratorio forzado durante el primer segundo. Los umbrales de riesgomás aceptados son 21 para el índice de masa corporal (IMC), y para el IM libre de grasa (IMLG) 17 y 14 paravarones y mujeres, respectivamente. La coexistencia de ambos defi ne la situación de mayor gravedad nutricional(caquexia). No obstante, una disminución del IMLG es un factor de riesgo independiente, aunqueno superior a un BMI bajo. Por ello, aunque la obtención del IMLG por impedancia bioeléctrica es fi able yrelativamente fácil de obtener, nosotros recomendamos la realización de esta prueba sólo en los casos deEPOC con peso bajo (IMC < 21), junto con una evaluación nutricional más específi ca.En la actualidad, carecemos de estudios longitudinales que nos aporten datos sobre el comportamiento delIMC dentro de la evolución natural de la enfermedad. Además, no hay evidencias científi cas sólidas que nosconfi rmen cuáles son los principales mecanismos de la desnutrición en la EPOC. Esto explica la difi cultad delmanejo terapéutico de estos pacientes, el cual no ha mostrado avances en las últimas décadas. No obstante,con la evidencia actual, en los pacientes con caquexia, parece razonable iniciar un tratamiento nutricionalindividualizado en combinación con programas de rehabilitación pulmonar (ejercicio). Son necesarios nuevosestudios que permitan avanzar en el conocimiento de la fi siopatología, y sobre el papel que pueden desempeñarotras opciones terapéuticas (hormonas, antiinfl amatorios) en la desnutrición de los pacientes con EPOC(AU)

Weight loss and malnutrition related mainly to lean mass loss can develop in advanced stages of chronicobstructive pulmonary disease (COPD) and are a clear indication of phenotypic heterogeneity. The presenceof weight loss and malnutrition is associated with a worse prognosis, independently of forced expiratoryvolume in 1 second (FEV1).The most widely accepted thresholds for risk are 21 for the body mass index (BMI) and 17 and 14 for menand women, respectively, for the fat-free mass index (FFMI). The coexistence of both defi nes a situation ofgreater nutritional risk (cachexia). Nevertheless, a reduction in FFMI is an independent risk factor, althoughnot superior to a low BMI. Therefore, although obtaining FFMI by bioelectric impedanciometry is reliableand relatively easy, we recommend the use of this procedure only in patients with COPD and low weight(BMI < 21), together with more specifi c nutritional evaluation.Currently, longitudinal studies providing data on the behavior of BMI within the natural course of thedisease are lacking. Moreover, there is no solid scientifi c evidence that confi rms the main mechanisms ofmalnutrition in COPD. This lack of evidence explains the diffi culty of the therapeutic management of thesepatients, which has not advanced in the last few decades. Nevertheless, current evidence suggests thatinitiating individually-tailored nutritional treatment combined with pulmonary rehabilitation programs(exercise) is reasonable in patients with cachexia. Further studies are required to provide greater insightinto the physiopathology and the role of other therapeutic options (hormones, antiinfl ammatory drugs) inmalnutrition in patients with COPD(AU)

[COPD disease and malnutrition]. / EPOC y malnutrición.

Weight loss and malnutrition related mainly to lean mass loss can develop in advanced stages of chronic obstructive pulmonary disease (COPD) and are a clear indication of phenotypic heterogeneity. The presence of weight loss and malnutrition is associated with a worse prognosis, independently of forced expiratory volume in 1 second (FEV(1)). The most widely accepted thresholds for risk are 21 for the body mass index (BMI) and 17 and 14 for men and women, respectively, for the fat-free mass index (FFMI). The coexistence of both defines a situation of greater nutritional risk (cachexia). Nevertheless, a reduction in FFMI is an independent risk factor, although not superior to a low BMI. Therefore, although obtaining FFMI by bioelectric impedanciometry is reliable and relatively easy, we recommend the use of this procedure only in patients with COPD and low weight (BMI < 21), together with more specific nutritional evaluation. Currently, longitudinal studies providing data on the behavior of BMI within the natural course of the disease are lacking. Moreover, there is no solid scientific evidence that confirms the main mechanisms of malnutrition in COPD. This lack of evidence explains the difficulty of the therapeutic management of these patients, which has not advanced in the last few decades. Nevertheless, current evidence suggests that initiating individually-tailored nutritional treatment combined with pulmonary rehabilitation programs (exercise) is reasonable in patients with cachexia. Further studies are required to provide greater insight into the physiopathology and the role of other therapeutic options (hormones, antiinflammatory drugs) in malnutrition in patients with COPD.

[COPD: what is there beyond BODE index?]. / Enfermedad pulmonar obstructiva crónica: ¿qué hay más allá del índice BODE?

Chronic obstructive pulmonary disease (COPD) is a multidimensional disease with wide phenotypic heterogeneity that is not adequately reflected by forced expiratory volume in 1 second (FEV(1)). Assessment of patients with COPD requires analysis of multiple variables that encompass respiratory and extrapulmonary involvement. These variables should be viable in clinical practice, should not provide duplicate information, and should have an effect on the course of the disease. The BODE index (FEV(1), dyspnea, body mass index and the 6-minute walk test) is the most obvious example of this conceptual approach and its acceptance among the scientific community has grown in the last few years. Nevertheless, other aspects of the disease not included in the BODE index, such as pulmonary hyperinsufflation, exacerbations and comorbidities, have been shown to be important in COPD. Moreover, the development of new technologies could allow imaging techniques and biomarkers to be incorporated, which would in turn improve characterization of the disease and allow more specific and individually-tailored patient management. Nevertheless, the role of all these factors in the evaluation of a highly prevalent disease such as COPD remains to be defined.

Aspectos sistémicos y factores pronósticos / No disponible

La enfermedad pulmonar obstructiva crónica (EPOC) ha sufrido importantes cambios conceptuales en los últimos años. A esto ha contribuido su reconocimiento como enfermedad inflamatoria, multicompartimental dentro del territorio pulmonar y con clara extensión fuera de éste. Además, se ha observado que esta afectación presenta una gran heterogeneidad (diversidad fenotípica) e impacta de forma relevante en la evolución natural de la enfermedad, sobre todo en formas avanzadas. La importancia de la afectación sistémica incrementa con gran rapidez, incorporando aspectos que antes considerábamos dentro de la comorbilidad que acompañaba a la enfermedad. Múltiples citocinas y mediadores inflamatorios han sido implicados en las vías de unión entre el pulmón y la afectación extrapulmonar, pero permanecen en el campo de la investigación y la especulación. Posiblemente, estas interacciones sean multifactoriales, complejas y condicionadas genéticamente. Esta afectación, más allá de la propia obstrucción de la vía aérea, se ha basado en evidencias científicas sólidas y, a su vez, ha generado nuevos estudios que han demostrado que otros factores afectan a la supervivencia de los pacientes con EPOC, independientemente de la afección pulmonar expresada a través del volumen espiratorio máximo en el primer segundo (FEV1) y la presión arterial de oxígeno (PaO2.). En los próximos años, estos parámetros deberán ser incluidos, de forma racional y adecuada, en las guías y consensos para su implementación en la práctica clínica habitual (AU)

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¿Debemos tener en cuenta la capacidad inspiratoria? / Should we be paying attention to inspiratory capacity?

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