Pulmonary function and sputum characteristics predict CT phenotype and severity of COPD.

Eur Respir J. 2012 Dec 20;

Authors: Camiciottoli G, Bigazzi F, Paoletti M, Cestelli L, Lavorini F, Pistolesi M

Abstract
Airway obstruction and parenchymal destruction underlie COPD phenotype and severity. We aimed at predicting by clinical and pulmonary function data the predominant type and the severity of the pathologic changes quantitatively assessed by CT.Airway wall thickness (AWT-Pi10) and percentage of low attenuation area (%LAA-950) were measured in 100 (learning set) of 473 COPD outpatients undergoing clinical and functional evaluation. Original CT measurements were translated by principal components analysis onto a plane with novel coordinates CT1 and CT2 depending, respectively, on the difference (prevalent mechanism of airflow limitation) and on the sum (severity) of AWT-Pi10 and %LAA-950. CT1 and CT2 estimated in the learning set by cross-validated models of clinical and functional variables were used to classify 373 patients in the testing set.A model based on DL,CO %, TLC%, purulent sputum predicted CT1 (r=0.64; p<.01). A model based on FEV1/VC, FRC%, purulent sputum predicted CT2 (r=0.77; p<.01). Classification of patients of the testing set obtained by models-predicted CT1 and CT2 reflected, according to correlations with clinical and functional variables, both COPD phenotype and severity.Multivariate models based on pulmonary function variables and sputum purulence classify patients according to overall severity and predominant phenotype of COPD as assessed quantitatively by CT.

PMID: 23258785 [PubMed - as supplied by publisher]

Physical activity in COPD patients: patterns and bouts.

Eur Respir J. 2012 Dec 20;

Authors: Donaire-Gonzalez D, Gimeno-Santos E, Balcells E, Rodríguez DA, Farrero E, Batlle JD, Benet M, Ferrer A, Barberà JA, Gea J, Rodriguez-Roisin R, Antó JM, Garcia-Aymerich J

Abstract
The present study aims to describe the pattern of physical activity and the frequency, duration and intensity of physical activity bouts in patients with chronic obstructive pulmonary disease (COPD), to assess how these patterns differ according to COPD severity, and to explore whether these patients meet the general guidelines for physical activity for older adults.One hundred seventy-seven patients (94% male, mean(SD) age 71(8) years, and FEV1 52(16)%) wore the SenseWear(®) Pro2 Armband accelerometer for 8 consecutive days. Physical activity bouts were defined as periods of ≥10 min above 1.5 METs and classified according to their median intensity.Patients engaged in activity a median of 86 min·d(-1), and 57% of that time was spent in bouts. Median frequencies of bouts per day were 4 and 3 for all- and moderate-to-vigorous intensities, respectively. With increasing COPD severity, time in physical activity, proportion of time in bouts, and frequency of bouts decreased. Sixty-one percent of patients fulfilled the recommended physical activity guidelines.In conclusion, COPD patients of all spirometric severity stages engage in physical activity bouts of moderate-to-vigorous intensities. Patients with severe and very severe COPD perform their daily activities in fewer and shorter bouts than those in mild and moderate stages.

PMID: 23258786 [PubMed - as supplied by publisher]

Tiotropium improved lung function and delayed exacerbations in poorly controlled asthma.

Ann Intern Med. 2012 Dec 18;157(12):JC6-3

Authors: Greenstone M

Abstract
QUESTION In adults with poorly controlled asthma who are receiving inhaled corticosteroids (ICSs) and long-acting β-agonists (LABAs), does tiotropium improve control? METHODS DESIGN 2 randomized placebo-controlled trials (PrimoTinA-asthma 1 [Trial 1] and PrimoTinA-asthma 2 [Trial 2]). ClinicalTrials.gov NCT00772538 and NCT00776984. ALLOCATION {Concealed}.*† BLINDING Blinded† (patients, clinicians, {data collectors, outcome assessors,}* and sponsor). FOLLOW-UP PERIOD 48 weeks. SETTING Clinical centers in 15 countries. PATIENTS Adults 18 to 75 years of age (Trial 1: n = 459, mean age 53 y, 63% women; Trial 2: n = 453, mean age 53 y, 58% women) who had a ≥ 5 year history of asthma; persistent airflow limitation despite daily ICSs and LABAs; ≥ 1 exacerbation treated with systemic glucocorticoids in the past year; asthma diagnosed at &lt; 40 years of age; score ≥ 1.5 on Asthma Control Questionnaire 7 (ACQ7); and were life-long nonsmokers or had a smoking history of &lt; 10 years with no smoking in the past year. Exclusion criteria included chronic obstructive pulmonary disease (COPD), serious comorbid illness, and current use of anticholinergic bronchodilators. INTERVENTION 2 puffs of 2.5 µg tiotropium (Trial 1: n = 237; Trial 2: n = 219) or placebo (Trial 1: n = 222; Trial 2: n = 234) with a soft-mist inhaler (Respimat) each morning. Patients maintained their pretrial maintenance asthma therapy of ICSs and LABAs. Salbutamol was provided as a rescue medication. OUTCOMES Peak FEV1 response (within 3 h of receipt of maintenance and study drugs) and trough FEV1 at 24 weeks, and time to first severe asthma exacerbation (requiring initiation or at least doubling of systemic glucocorticoids for ≥ 3 d) at 48 weeks. Secondary outcomes included the ACQ7 and Asthma Quality of Life Questionnaire (AQLQ) at 24 weeks, and adverse events. PATIENT FOLLOW-UP 90% (Trial 1) and 89% (Trial 2). MAIN RESULTS The main results are in the Table. Clinically important differences in the ACQ-7 and AQLQ were not achieved. Across both trials, 8% of the tiotropium group and 9% of the placebo group had serious adverse events. CONCLUSION In adults with asthma that was poorly controlled on inhaled corticosteroids and long-acting β-agonists, tiotropium improved lung function and time to first severe exacerbation.Tiotropium vs placebo for poorly controlled asthma‡OutcomesMean difference between tiotropium and placebo in change from baseline (95% CI)Trial 1Trial 2Peak FEV1 at 24 wk (mL)86 (20 to 152)154 (91 to 217)Trough FEV1 at 24 wk (mL)88 (27 to 149)111 (53 to 169)Severe exacerbationsHazard ratio (CI)TiotropiumPlaceboTime to first event (d)2822260.79 (0.62 to 1.00)‡CI defined in Glossary.

PMID: 23247952 [PubMed - in process]

Review: In asthma controlled with ICSs plus LABAs, stopping LABAs increases asthma impairment.

Ann Intern Med. 2012 Dec 18;157(12):JC6-4

Authors: Singh J

Abstract
QUESTION In patients with asthma controlled with inhaled corticosteroids (ICSs) plus a long-acting β2-agonist (LABA), what are the effects of discontinuing LABAs? REVIEW SCOPE Included studies compared LABA discontinuation and unchanged ICS dose with continued use and unchanged dose of both LABAs and ICSs in patients ≥ 4 years of age who had asthma and were receiving combined LABA (salmeterol or formoterol fumarate dihydrate) and ICS therapy twice daily for ≥ 3 months, and had well-controlled asthma for ≥ 3 months before LABA discontinuation. Outcomes included emergency department visit or unscheduled consultation for asthma, use of systemic corticosteroids, withdrawal from treatment due to lack of efficacy or loss of asthma control, serious adverse events, quality of life (Asthma Quality of Life Questionnaire), asthma control (Asthma Control Questionnaire), symptom-free days, rescue bronchodilator use, death, and hospitalization. REVIEW METHODS MEDLINE, EMBASE/Excerpta Medica, Cochrane Library, ClinicalTrials.gov, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database (all to Aug 2010); manufacturer trials registries; reviews; and reference lists were searched for randomized controlled trials (RCTs). Manufacturers of salmeterol and formoterol were contacted. 5 RCTs (n = 1352, mean age 38 to 47 y, 49% to 65% women) met selection criteria. All studies included older adolescents (≥ 15 y) or adults, and ICSs and LABAs were delivered in a single inhaler. All studies had low risk for bias based on randomization, allocation concealment, blinding, and intention-to-treat analysis. Risk for bias was high for loss to follow-up (12% to 38% discontinued treatment and were excluded from some analyses). All studies were funded by study drug manufacturers. MAIN RESULTS The main results are in the Table. No deaths or hospitalizations occurred in either group. CONCLUSION In patients with asthma controlled with inhaled corticosteroids plus a long-acting β2-agonist (LABA), discontinuation of LABAs worsens asthma control and quality of life.LABA discontinuation (D/C) vs continuation (C) in patients with asthma controlled with combined ICS and LABA therapy*OutcomesNumber of trials (n)Weighted event ratesAt 12 to 16 wkLABA-D/CLABA-CRRI (95% CI)NNH (CI)Emergency or unscheduled visits†3 (949)2.4%1.0%124% (-21 to 535)NSUse of systemic corticosteroids4 (1257)3.2%1.9%68% (-16 to 238)NSLoss of control‡4 (1257)14%4.2%227% (116 to 396)11 (6 to 21)RRR (CI)NNT (CI)Serious adverse events5 (1342)1.1%1.3%21% (-109 to 71)NSMean difference (CI)§AQLQ||2 (359)0.32 lower (0.14 to 0.51)ACQ¶3 (645)0.24 higher (0.13 to 0.35)Symptom-free days4 (1230)9.2% fewer (1.6 to 17)Rescue bronchodilator use4 (1226)0.71 puffs/d more (0.29 to 1.14)*ACQ = Asthma Control Questionnaire; AQLQ = Asthma Quality of Life Questionnaire; ICS = inhaled corticosteroid; LABA = long-acting β2-agonist; NS = not significant; other abbreviations defined in Glossary. Weighted event rates, RRI, RRR, NNH, NNT, and CI calculated from control event rates and risk ratios in article using a random-effects model.†Emergency department visit or unscheduled consultation for asthma.‡Withdrawal from treatment due to lack of efficacy or loss of asthma control.§Differences in scores favor LABA continuation group.||Score range 1 to 7, higher scores = better quality of life.¶Score range 0 to 6, lower scores = better asthma control.

PMID: 23247953 [PubMed - in process]