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Tailoring of corticosteroids in COPD management.

This literature review updates the reader on the new studies regarding steroid therapy over the last year in stable COPD and in exacerbations.

In stable COPD, we critique the 2011 update and 2013 revision of the GOLD guidelines, discuss why combining inhaled corticosteroids (ICS) with long-acting beta-agonists (LABA) (ICS/LABA) is preferable over LABA alone and review the literature for intraclass differences, finding that the evidence does not clearly support superiority of any particular ICS/LABA. We also address other comparisons against ICS/LABA, including triple therapy.

We briefly review which type of inhaler should be chosen. For exacerbations, we report the REDUCE trial findings favouring a 5-day course of systemic steroids, and other...

The exposome: a new paradigm to study the impact of environment on health

Environmental factors, here taken to include pollutants, lifestyle factors and behaviours, can play an important role in serious, chronic pathologies with large societal and economic costs, including respiratory disease. However, measurement of the environmental component in epidemiological studies has traditionally relied on much more uncertain and incomplete assessments than measurement of the genome. The ‘exposome’ has therefore been proposed as a new paradigm to encompass the totality of human environmental (meaning all non-genetic) exposures from conception onwards, complementing the genome. Evidently, there are large challenges in developing the exposome concept into a workable approach for epidemiological research. These include: (1) the accurate and reliable measurement...

Cardiorespiratory responses to 6-minute walk test in interstitial lung disease: not always a submaximal test

This study aimed to compare cardiorespiratory responses to 6MWT and cardiopulmonary exercise test (CPET) in people with ILD. Methods: 47 participants with ILD (27 idiopathic pulmonary fibrosis (IPF), mean age 71 (SD 12) years, diffusing capacity for carbon monoxide (TLCO) 49(15) %predicted) undertook CPET and 6MWT on the same day in random order. Oxygen uptake (VO2), ventilation (VE) and carbon dioxide production (VCO2) were assessed during each test using a portable metabolic cart. Results: The VO2peak during the 6MWT was lower than during CPET (1.17(0.27) vs 1.30(0.37) L.min-1, p=0.001), representing an average of 94% (range 62-135%) of CPET VO2peak. Achieving a higher percentage of CPET VO2peak on 6MWT was associated with lower TLCO %predicted (r=-0.43, p=0.003) and more desaturation du...

The association between childhood asthma and adult chronic obstructive pulmonary disease

There is epidemiological evidence to suggest that events in childhood influence lung growth and constitute a significant risk for adult COPD. The aim of the study is to evaluate for an association between childhood asthma and adult COPD.

Methods : This longitudinal, prospective study of 6–7-year-old children with asthma has been regularly reviewed every 7 years to the current analysis at 50 years of age. Participants completed respiratory questionnaires and lung function spirometry with postbronchodilator response. At the age of 50, subjects were classified to the following subgroups: non-asthmatics, asthma remission, current asthma and COPD which was defined by FEV1 to FVC ratio postbronchodilator of less than 0.7.

Results : Of the remaining survivors, 346 participated in the current study (participation rate of 76%) of whom 197 completed both questionnaire and lung function testing. As compared with children without symptoms of wheeze to the age of 7, (non-asthmatics) children with severe asthma had an adjusted 32 times higher risk for developing COPD (95% CI 3.4 to 269). In this cohort, 43% of the COPD group had never smoked. There was no evidence of a difference in the rate of decline in FEV1 (mL/year, 95th CI) between the COPD group (17, 10 to 23) and the other groups: non-asthmatics (16, 12 to 21), asthma remission (20, 16 to 24) and current asthma (19, 13 to 25).

Conclusions : Children with severe asthma are at increased risk of developing COPD.

The Clinical COPD Questionnaire: response to pulmonary rehabilitation and minimal clinically important difference

The Clinical COPD Questionnaire (CCQ) is a simple 10-item, health-related quality of life questionnaire (HRQoL) with good psychometric properties. However, little data exists regarding the responsiveness of the CCQ to pulmonary rehabilitation (PR) or the minimal clinically important difference (MCID). The study aims were to assess the responsiveness of the CCQ to PR, to compare the responsiveness of the CCQ to other HRQoL questionnaires and to provide estimates for the MCID.

Methods The CCQ, St George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ) and COPD Assessment Test (CAT) were measured in 261 patients with COPD before and after outpatient PR. Pre to post PR changes and Cohen's effect size were calculated. Changes in CCQ were compared with changes in other HRQoL questionnaires. Using an anchor-based approach and receiver operating characteristic (ROC) curves, the CCQ change cutoffs that identified patients achieving the known MCID for other health status questionnaires with PR were identified.

Results The CCQ, SGRQ, CRQ and CAT all significantly improved with PR with an effect size of −0.39, −0.33, 0.62 and −0.25, respectively. CCQ change correlated significantly with change in SGRQ, CRQ and CAT (r=0.48, −0.56, 0.54, respectively; all p<0.001). ROC curves consistently identified a CCQ change cutoff of −0.4 as the best discriminating value to identify the MCID for the SGRQ, CRQ and CAT (area under curve: 0.71, 0.75 and 0.77, respectively; all p<0.001).

Conclusions The CCQ is responsive to PR with an estimated clinically important improvement of −0.4 points. The CCQ is a practical alternative to more time-consuming measures of HRQoL.

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