Related Articles

Relationship between the Use of Inhaled Steroids for Chronic Respiratory Diseases and Early Outcomes in Community-Acquired Pneumonia.

PLoS One. 2013;8(9):e73271

Authors: Almirall J, Bolíbar I, Serra-Prat M, Palomera E, Roig J, Hospital I, Carandell E, Agustí M, Ayuso P, Estela A, Torres A, Community-Acquired Pneumonia in Catalan Countries (PACAP)

Abstract
BACKGROUND: The role of inhaled steroids in patients with chronic respiratory diseases is a matter of debate due to the potential effect on the development and prognosis of community-acquired pneumonia (CAP). We assessed whether treatment with inhaled steroids in patients with chronic bronchitis, COPD or asthma and CAP may affect early outcome of the acute pneumonic episode.
METHODS: Over 1-year period, all population-based cases of CAP in patients with chronic bronchitis, COPD or asthma were registered. Use of inhaled steroids were registered and patients were followed up to 30 days after diagnosis to assess severity of CAP and clinical course (hospital admission, ICU admission and mortality).
RESULTS: Of 473 patients who fulfilled the selection criteria, inhaled steroids were regularly used by 109 (23%). In the overall sample, inhaled steroids were associated with a higher risk of hospitalization (OR=1.96, p = 0.002) in the bivariate analysis, but this effect disappeared after adjusting by other severity-related factors (adjusted OR=1.08, p=0.787). This effect on hospitalization also disappeared when considering only patients with asthma (OR=1.38, p=0.542), with COPD alone (OR=4.68, p=0.194), but a protective effect was observed in CB patients (OR=0.15, p=0.027). Inhaled steroids showed no association with ICU admission, days to clinical recovery and mortality in the overall sample and in any disease subgroup.
CONCLUSIONS: Treatment with inhaled steroids is not a prognostic factor in COPD and asthmatic patients with CAP, but could prevent hospitalization for CAP in patients with clinical criteria of chronic bronchitis.

PMID: 24039899 [PubMed - in process]

Related Articles

Video-assisted thoracoscopic lobectomy for non-small cell lung cancer in patients with severe chronic obstructive pulmonary disease.

J Thorac Dis. 2013 Aug;5(Suppl 3):S253-9

Authors: Wang W, Xu Z, Xiong X, Yin W, Xu X, Shao W, Chen H, He J

Abstract
OBJECTIVE: To assess the feasibility, safety and long-term outcomes of video-assisted thoracic surgery (VATS) lobectomy for the treatment of non-small cell lung cancer (NSCLC) in patients with severe chronic obstructive pulmonary disease (COPD).
METHODS: The clinical data of patients with NSCLC and severe COPD (preoperative FEV1% <50%) who underwent VATS lobectomy from January 2000 to January 2011 were retrospectively analyzed to identify their demographic parameters, postoperative complications and outcomes.
RESULTS: The preoperative FEV1/FVC was <70% and FEV1% <50% in all 61 patients in this study, with a mean preoperative FEV1 of 0.99 L (0.54-1.58 L) and mean FEV1% of 38.4% (22-49.82%). All of the 61 patients underwent the VATS lobectomy or sleeve resection plus systemic lymph node dissection. The mean operative time was 218 minutes (120-355 minutes), with a mean intraoperative blood loss of 342 mL (50-1,600 mL). None of the patients converted to thoracotomy. Multivariate statistical analysis revealed that age and TNM staging after tumor resection were independent predictive factors for the 5-year survival in those patients (P=0.014 and 0.013).
CONCLUSIONS: With preoperative imaging studies, pulmonary function assessment and target positioning, VATS lobectomy can be safely and effectively performed for patients with NSCLC and severe COPD to achieve a satisfying long-term survival outcome.

PMID: 24040533 [PubMed]

Characteristics of a COPD population categorised using the GOLD framework by health status and exacerbations.

Respir Med. 2013 Aug 30;

Authors: Jones PW, Nadeau G, Small M, Adamek L

Abstract
GOLD proposed a COPD assessment framework focussed on symptoms measured by the COPD Assessment Test™ (CAT) or the mMRC and on exacerbation risk based on poor lung function (FEV1 <50%) or a history of ≥2 exacerbations in the previous year. This analysis examined the characteristics of COPD patients recruited from routine clinical settings and classified using the GOLD framework. 1041 European COPD patients (38.5% from primary care) from the Adelphi Respiratory Disease Specific Programme with information on CAT, mMRC, spirometry and exacerbation history in the previous year were analysed. Their mean age was 64.9 ± 9.9 years and mean FEV1 was 62.5 ± 17.8% predicted; 80% were in GOLD 2 spirometric grade or milder. CAT and mMRC cut points identified different groups of patients; using CAT, the composition was: Group A 9.3%, Group B 48.5%, Group C 0.7% and Group D 41.5%. 80% were classified as high risk based on exacerbation history and 25% of patients in a low risk category (GOLD A and B) had 1 exacerbation in the previous year. The incidence of diabetes, hypertension and hyperlipidaemia rose with worsening GOLD group (all p < 0.0001); diabetes GOLD A 4%, GOLD B 16%, GOLD D 29%; hypertension GOLD A 38%, GOLD B 55%, GOLD D 65%; hyperlipidaemia GOLD A 13%, GOLD B 30%, GOLD D 37%. In patients seen in routine clinical settings, 25% of GOLD low risk patients had one exacerbation per year and the incidence of cardio-vascular and metabolic diseases increases with worsening GOLD group.

PMID: 24041746 [PubMed - as supplied by publisher]

Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease.

Cochrane Database Syst Rev. 2013 Sep 16;9:CD009552

Authors: Cheyne L, Irvin-Sellers MJ, White J

Abstract
BACKGROUND: Tiotropium and ipratropium bromide are both recognised treatments in the management of people with stable chronic obstructive pulmonary disease (COPD). There are new studies which have compared tiotropium with ipratropium bromide, making an update necessary.
OBJECTIVES: To compare the relative effects of tiotropium to ipratropium bromide on markers of quality of life, exacerbations, symptoms, lung function and serious adverse events in patients with COPD using available randomised controlled trial (RCT) data.
SEARCH METHODS: We identified RCTs from the Cochrane Airways Group Specialised Register of trials (CAGR) and ClinicalTrials.gov up to November 2012.
SELECTION CRITERIA: We included parallel group RCTs of 12 weeks duration or longer comparing treatment with tiotropium with ipratropium bromide for patients with stable COPD.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and then extracted data on study quality and outcome results. We contacted trial sponsors for additional information. We analysed the data using Cochrane Review Manager (RevMan 5.2).
MAIN RESULTS: This review included two studies of good methodological quality that enrolled 1073 participants with COPD. The studies used a similar design and inclusion criteria and were of at least 12 weeks duration; the participants had a mean forced expiratory volume in one second (FEV1) of 40% predicted value at baseline. One study used tiotropium via the HandiHaler (18 µg) for 12 months and the other via the Respimat device (5 µg and 10 µg) for 12 weeks. In general, the treatment groups were well matched at baseline but not all outcomes were reported for both studies. Overall the risk of bias across the included RCTs was low.For primary outcomes this review found that at the three months trough (the lowest level measured before treatment) FEV1 significantly increased with tiotropium compared to ipratropium bromide (mean difference (MD) 109 mL; 95% confidence interval (CI) 81 to 137, moderate quality evidence, I(2) = 62%). There were fewer people experiencing one or more non-fatal serious adverse events on tiotropium compared to ipratropium (odds ratio (OR) 0.5; 95% CI 0.34 to 0.73, high quality evidence). This represents an absolute reduction in risk from 176 to 97 per 1000 people over three to 12 months. Concerning disease specific adverse events, the tiotropium group were also less likely to experience a COPD-related serious adverse event when compared to ipratropium bromide (OR 0.59; 95% CI 0.41 to 0.85, moderate quality evidence).For secondary outcomes, both studies reported fewer hospital admissions in the tiotropium group (OR 0.34; 95% CI 0.15 to 0.70, moderate quality evidence); as well as fewer patients experiencing one or more exacerbations leading to hospitalisation in the people on tiotropium in both studies (OR 0.56; 95% CI 0.31 to 0.99, moderate quality evidence). There was no significant difference in mortality between the treatments (OR 1.39; 95% CI 0.44 to 4.39, moderate quality evidence). One study measured quality of life using the St George's Respiratory Questionnaire (SGRQ); the mean SGRQ score at 52 weeks was lower in the tiotropium group than the ipratropium group (lower on the scale is favourable) (MD -3.30; 95% CI -5.63 to -0.97, moderate quality evidence). There were fewer participants suffering one of more exacerbations in the tiotropium arm (OR 0.71; 95% CI 0.52 to 0.95, high quality evidence) and there was also a reported difference in the mean number of exacerbations per person per year which reached statistical significance (MD -0.23; 95% CI -0.39 to -0.07, P = 0.006, moderate quality evidence). From the 1073 participants there were significantly fewer withdrawals from the tiotropium group (OR 0.58; 95% CI 0.41 to 0.83, high quality evidence).
AUTHORS' CONCLUSIONS: This review shows that tiotropium treatment, when compared with ipratropium bromide, was associated with improved lung function, fewer hospital admissions (including those for exacerbations of COPD), fewer exacerbations of COPD and improved quality of life. There were both fewer serious adverse events and disease specific events in the tiotropium group, but no significant difference in deaths with ipratropium bromide when compared to tiotropium. Thus, tiotropium appears to be a reasonable choice (instead of ipratropium bromide) for patients with stable COPD, as proposed in guidelines. We would advise some caution with tiotropium via the Respimat inhaler and suggest waiting for further information from an ongoing head-to-head trial comparing mortality in relation to tiotropium delivery devices and doses.

PMID: 24043433 [PubMed - as supplied by publisher]