Time-course of upper respiratory tract viral infection and COPD exacerbation.

Viral respiratory tract infections have been implicated as the predominant risk factor for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We aimed to evaluate, longitudinally, the association between upper respiratory tract infections (URTI) caused by viruses and AECOPD.Detection of 18 viruses was performed in naso- and orοpharyngeal swabs from 450 COPD patients (Global Initiative for Chronic Obstructive Lung Disease stages 2-4) who were followed for a mean of 27 months. Swabs were taken during stable periods (n=1909), at URTI onset (n=391), 10 days after the URTI (n=356) and during an AECOPD (n=177) and tested using a multiplex nucleic acid amplification test.Evidence of at least one respiratory virus was significantly higher at URTI onset (52.7%), 10 days after the URTI (15.2%) and during an AECOPD (38.4%), compared with the stable period (5.3%, p<0.001). During stable visits, rhinovirus accounted for 54.2% of all viral infections, followed by coronavirus (20.5%). None of the viruses were identified in two consecutive stable visits. Patients with a viral infection at URTI onset did not have a higher incidence of exacerbation than patients without viral infection (p=0.993). Τhe incidence of any viral infection during an AECOPD was similar between URTI-related AECOPD and non-URTI-related AECOPD (p=0.359). Only 24% of the patients that had a URTI-related AECOPD had the same virus at URTI onset and during an AECOPD. Detection of parainfluenza 3 at URTI onset was associated with a higher risk of an AECOPD (p=0.003). Rhinovirus and coronavirus were the most frequently detected viruses during AECOPD visits, accounting for 35.7% and 25.9% of all viral infections, respectively.The prevalence of viral infection during the stable period of COPD was low. The risk of exacerbation following the onset of URTI symptoms depends on the particular virus associated with the event and was significant only for parainfluenza 3.

Diagnosis, Prevention and Treatment of Stable COPD and Acute Exacerbations of COPD: The Swiss Recommendations 2018.

The Swiss National Guidelines 2013 for chronic obstructive pulmonary disease have been revised in order to acknowledge recent progress in diagnosis and management of this disease. The resulting new Swiss recommendations are based on best evidence from the literature, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018 report and other published national guidelines. Misdiagnosis of chronic obstructive pulmonary disease is common and means that patients do not always receive optimal treatment. To improve the management of patients with chronic obstructive pulmonary disease in Switzerland, these recommendations encourage a more comprehensive assessment of patients, based on the combined assessment of symptoms, degree of airflow limitation, risk of exacerbation and the presence of comorbidities. Recommendations for evidence-based preventive measures, as well as pharmacological and non-pharmacological strategies for the management of both stable and acute exacerbations of chronic obstructive pulmonary disease are provided in this update.

Intensified Therapy with Inhaled Corticosteroids and Long-Acting ß2-Agonists at the Onset of Upper Respiratory Tract Infection to Prevent Chronic Obstructive Pulmonary Disease Exacerbations. A Multicenter, Randomized, Double-Blind, Placebo-controlled Trial.

RATIONALE: The efficacy of intensified combination therapy with inhaled corticosteroids (ICS) and long-acting ß2-agonists (LABA) at the onset of upper respiratory tract infection (URTI) symptoms in chronic obstructive pulmonary disease (COPD) is unknown. OBJECTIVES: To evaluate whether intensified combination therapy with ICS/LABA, at the onset of URTI symptoms, decreases the incidence of COPD exacerbation occurring within 21 days of the URTI. METHODS: A total of 450 patients with stable, moderate to very severe COPD, were included in this investigator-initiated and -driven, double-blind, randomized, placebo-controlled study. At inclusion, patients were assigned to open-labeled low-maintenance dose ICS/LABA. Each patient was randomized either to intensified-dose ICS/LABA or placebo and instructed to start using this medication only in case of a URTI, at the onset of symptoms, twice daily, for 10 days. MEASUREMENTS AND MAIN RESULTS: The incidence of any exacerbation following a URTI was not significantly decreased in the ICS/LABA group, as compared with placebo (14.6% vs. 16.2%; hazard ratio, 0.77; 95% confidence interval, 0.46-1.33; P = 0.321) but the risk of severe exacerbation was decreased by 72% (hazard ratio, 0.28; 95% confidence interval, 0.11-0.74%; P = 0.010). In the stratified analysis, effect size was modified by disease severity, fractional exhaled nitric oxide, and the body mass index-airflow obstruction-dyspnea, and exercise score. Compared with the stable period, evidence of at least one virus was significantly more common at URTI, 10 days after URTI, and at exacerbation. CONCLUSIONS: Intensified combination therapy with ICS/LABA for 10 days at URTI onset did not decrease the incidence of any COPD exacerbation but prevented severe exacerbation. Patients with more severe disease had a significant risk reduction for any exacerbation. Clinical trial registered with www.isrctn.com (ISRCTN45572998).

Treatment of COPD Exacerbation in Switzerland: Results and Recommendations of the European COPD Audit.

BACKGROUND: The European COPD Audit initiated by the European Respiratory Society (ERS) evaluated the management of hospital admissions due to exacerbation of chronic obstructive pulmonary disease (COPD) in several European countries. Data on the treatment of severe acute exacerbations of COPD (AECOPDs) in Switzerland are scarce. OBJECTIVES: In light of the GOLD 2010 guidelines, this work aims to examine the quality of care for AECOPD and to provide specific recommendations for the management of severe AECOPD in Switzerland. METHODS: A total of 295 patients requiring hospital admission to 19 Swiss hospitals due to exacerbation of COPD during a predefined 60 days in 2011 were included in the study. We compared the Swiss data to the official GOLD 2010 recommendations and to the results of the other European countries. RESULTS: Approximately 43% of the Swiss patients with severe AECOPD were current smokers at hospital admission, compared to 33% of the patients in other European countries (p < 0.001). In Switzerland and in Europe, spirometry data were not available for most patients at hospital admission (65 and 60%, respectively; p = 0.08). In comparison to other European countries, antibiotics were prescribed 14% less often in Switzerland (p < 0.001). Only 79% of the patients in the Swiss cohort received treatment with a short-acting bronchodilator at admission. CONCLUSIONS: Considering the overall high standard of health care in Switzerland, in light of the GOLD 2010 guidelines we are able to make 7 recommendations to improve and standardize the management of severe AECOPD for patients treated in Switzerland.

Long-term follow-up and survival after Ultraflex stent insertion in the management of complex malignant airway stenoses.

BACKGROUND: Despite being commercially available for a few years now, the literature regarding the outcome of Ultraflex stent insertion in complex malignant airway stenoses is sparse. OBJECTIVES: To assess long-term complications and survival in patients with complex malignant airway stenoses treated with insertion of nitinol stents. METHODS: 60 consecutive patients with Ultraflex stent insertion for malignant airway stenoses were included. Follow-up was obtained in all patients. RESULTS: 62 Ultraflex stents (covered = 51, uncovered = 11) were implanted in 60 patients. Diagnoses were bronchial carcinoma (n = 50), esophageal carcinoma (n = 3) and metastases (n = 7). Stents were inserted in the trachea (n = 5), main bronchi/intermediate bronchus (n = 22), from main bronchi/intermediate bronchus to lobar bronchi (n = 28) or in the lobar bronchi themselves (n = 7). Successful reopening of the stenoses and relief were achieved in all patients. There was no procedure-related mortality. Complications included mucous plugging in 8%, stenosing granulation tissue in 5%, tumor ingrowth in 5% and stent migration in 5% of patients. Using Kaplan-Meier estimates, the overall mean survival was 160 days (standard error: 30). Median survival was 91 days. The overall 3- and 6-month survival were 52 and 20%, respectively. Death (n = 59, 98%) was attributed mainly to disease progression with cachexia and metastases, pneumonia (n = 5, 10%), and hemoptysis (n = 1, 2%). CONCLUSION: Ultraflex stents have a low complication rate and can be effectively used in complex malignant airway stenoses with marked asymmetry or irregularity, angulation or changing diameters.

Design and validation of an interpretative strategy for cardiopulmonary exercise tests.

BACKGROUND AND OBJECTIVE: Cardiopulmonary exercise testing (CPET) is a common investigation for the evaluation of exertional dyspnoea. At present, there is no consensus on the best interpretative strategy and none of the available algorithms have been validated. The aim of this study was to develop and validate a standardized strategy for the interpretation of CPET. METHODS: This study analysed 199 CPETs from patients with exertional dyspnoea. Using a set of 100 CPETs a standardized interpretation using a four-step approach was developed that scored: examination quality, performance, exercise limitation and cofactors. A second set of 99 CPETs was interpreted by two experts in the field, initially independently and then in a consensus conference. The standardized interpretation was compared with each expert, the expert's consensus and the original clinical reports. RESULTS: Matching between the standardized interpretation strategy and the expert consensus was 82%, 82% with one expert and 86% with a second expert and 64% with the original clinical reports. From one to four exercise-relevant cofactors were found in 77% of the patients. CONCLUSION: The standardized interpretation showed a precision comparable to the opinion of a single expert and significantly improved the consistency in CPET reports in a pulmonary centre with different physicians and varying degrees of expertise.