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Worldwide patterns of bronchodilator responsiveness: results from the Burden of Obstructive Lung Disease study

Rationale

Criteria for a clinically significant bronchodilator response (BDR) are mainly based on studies in patients with obstructive lung diseases. Little is known about the BDR in healthy general populations, and even less about the worldwide patterns.

 Methods

10 360 adults aged 40 years and older from 14 countries in North America, Europe, Africa and Asia participated in the Burden of Obstructive Lung Disease study. Spirometry was used before and after an inhaled bronchodilator to determine the distribution of the BDR in population-based samples of healthy non-smokers and individuals with airflow obstruction.

 Results

In 3922 healthy never smokers, the weighted pooled estimate of the 95th percentiles (95% CI) for bronchodilator response were 284 ml (263 to 305) absolute change in forced expiratory volume in 1 s from baseline (FEV1); 12.0% (11.2% to 12.8%) change relative to initial value (%FEV1i); and 10.0% (9.5% to 10.5%) change relative to predicted value (%FEV1p). The corresponding mean changes in forced vital capacity (FVC) were 322 ml (271 to 373) absolute change from baseline (FVC); 10.5% (8.9% to 12.0%) change relative to initial value (FVCi); and 9.2% (7.9% to 10.5%) change relative to predicted value (FVCp). The proportion who exceeded the above threshold values in the subgroup with spirometrically defined Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2 and higher (FEV1/FVC <0.7 and FEV1% predicted <80%) were 11.1%, 30.8% and 12.9% respectively for the FEV1-based thresholds and 22.6%, 28.6% and 22.1% respectively for the FVC-based thresholds.

 Conclusions

The results provide reference values for bronchodilator responses worldwide that confirm guideline estimates for a clinically significant level of BDR in bronchodilator testing.

The relationship between clinical outcomes and medication adherence in difficult-to-control asthma

Medication non-adherence and the clinical implications in difficult-to-control asthma were audited. Prescription issue data from 115 patients identified sub-optimal adherence (<80%) in 65% of patients on inhaled corticosteroids (ICS) or combined ICS/long-acting β2 agonist (LABA). In those using separate ICS and LABA, adherence to LABA (50%) was significantly better than to ICS (14.3%). Patients with sub-optimal ICS adherence had reduced FEV1 and higher sputum eosinophil counts. Adherence ratio was an independent predictor of previous ventilation for acute severe asthma (p=0.008). The majority of patients with difficult-to-control asthma are non-adherent with their asthma medication. Non-adherence is correlated with poor clinical outcomes.

Physiotherapy interventions in the BTS guidelines on the management of asthma (2011): a need for change?

Updates to the British Thoracic Society (BTS) asthma guidelines have been recently highlighted by Turner and colleagues.1 2 To our concern, the content on physiotherapy interventions has not been revised or updated since the 2006 version.

We reviewed the contents of the new BTS guidelines relevant for physiotherapists. The timescale for literature search indicates that the relevant section was last updated in February 2006, with coverage in Medline extending from 1996 to 2005.

Thus, we searched PubMed for English language papers published between January 2006 and December 2010 and found 32 indexed as randomised controlled trials. In the Cochrane Database of Systematic Reviews we found updates or revisions to all cited documents, with those updated in 2004 and 2005 and not quoted in the guideline.

A corresponding document, not referred to in the BTS guidelines, the joint BTS and the Association of Chartered Physiotherapists in...

Clinical management and outcome of refractory asthma in the UK from the British Thoracic Society Difficult Asthma Registry

Refractory asthma represents a significant unmet clinical need. Data from a national online registry audited clinical outcome in 349 adults with refractory asthma from four UK specialist centres in the British Thoracic Society Difficult Asthma Network. At follow-up, lung function improved, with a reduction in important healthcare outcomes, specifically hospital admission, unscheduled healthcare visits and rescue courses of oral steroids. The most frequent therapeutic intervention was maintenance oral corticosteroids and most steroid sparing agents (apart from omalizumab) demonstrated minimal steroid sparing benefit. A significant unmet clinical need remains in this group, specifically a requirement for therapies which reduce systemic steroid exposure.

[Management pulmonary metastases: when operate?].

Thirty percent of patients suffering from malignant disease will develop pulmonary metastases. Effective chemotherapy is lacking for many of these tumors. Many studies suggest survival benefit in selected patients when pulmonary metastasectomy allows complete resection. Several operative approach may be offered in order to achieve complete resection and maximal lung sparring. Pre-operative workup must assess the control of the primary tumor and the possibility of performing complete resection.

Minimally invasive approaches may offer better quality life and equivalent oncologic outcomes than open approach.

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