Saturday, February 18, 2017

LAMA plus LABA versus LABA plus ICS for stable COPD (free full text from The Cochrane Library)


Three classes of inhaler medications are used to manage chronic obstructive pulmonary disease (COPD): long-acting beta-agonists (LABA), long-acting muscarinic antagonists (LAMA), and inhaled corticosteroids (ICS). When two classes of medications are required, LAMA plus LABA (LAMA+LABA) and LABA plus ICS (LABA+ICS) are often selected because these combinations can be administered via a single medication device. The previous Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidance recommended LABA+ICS as the first-line treatment for managing stable COPD in high-risk people of categories C and D. However, the updated GOLD 2017 guidance recommends LAMA+LABA over LABA+ICS.;jsessionid=41D11BDBD96F61F6133E5DDBCDD5A748.f02t02


To compare the benefits and harms of LAMA+LABA versus LABA+ICS for treatment of people with stable COPD.


We performed an electronic search of the Cochrane Airways Group Specialised Register (2 February 2016), (4 June 2016), and the World Health Organization Clinical Trials Search Portal (4 June 2016), followed by a handsearch (5 June 2016). Two review authors screened and scrutinised the selected articles.


We included individual randomised controlled trials, parallel-group trials, and cross-over trials comparing LAMA+LABA and LABA+ICS for stable COPD. The minimum accepted trial duration was one month and trials should have been conducted in an outpatient setting.


Two review authors independently extracted data and evaluated risk of bias. We resolved any discrepancies through discussion. We analysed dichotomous data as odds ratios (OR), and continuous data as mean differences (MD), with 95% confidence interval (CI) using Review Manager 5. Exacerbations were measured by counting the number of people experiencing one or more exacerbation.


We included 11 studies comprising 9839 participants in our quantitative analysis. Most studies included people with moderate to severe COPD, without recent exacerbations. One pharmaceutical sponsored trial that included only people with recent exacerbations was the largest study and accounted for 37% of participants. All but one study were sponsored by pharmaceutical companies, thus we rated them as having a high risk of 'other bias'. The unsponsored study was at high risk of performance and detection bias, and possible selective reporting.Five studies recruited GOLD Category B participants, one study recruited Category D participants, two studies recruited Category A/B participants, and three studies recruited participants regardless of category. Follow-up ranged from 6 to 52 weeks.Compared to the LABA+ICS arm, the results for the pooled primary outcomes for the LAMA+LABA arm were as follows: exacerbations, OR 0.82 (95% CI 0.70 to 0.96, P = 0.01, I2 = 17%, low quality evidence); serious adverse events (SAE), OR 0.91 (95% CI 0.79 to 1.05, P = 0.18, I2 = 0, moderate quality evidence); St. George's Respiratory Questionnaire (SGRQ) total score change from the baseline, MD -1.22 (95% CI -2.52 to 0.07, P = 0.06, I2 = 71%, low quality evidence); and trough forced expiratory volume in one second (FEV1) change from the baseline, MD 0.08 L (95% CI 0.06 to 0.09, P < 0.0001, I2 = 50%, moderate quality evidence). Compared to the LABA+ICS arm, the results for the pooled secondary outcomes for the LAMA+LABA arm were as follows: pneumonia, OR 0.57 (95% CI 0.42 to 0.79, P = 0.0006, I2 = 0%, low quality evidence); all-cause death, OR 1.01 (95% CI 0.61 to 1.67, P = 0.88, I2 = 0%, low quality evidence); and SGRQ total score change from the baseline of 4 points or greater (the minimal clinically important difference for the SGRQ is 4 points), OR 1.25 (95% CI 1.09 to 1.44, P = 0.002, I2 = 0%, moderate quality evidence).


For the treatment of COPD, LAMA+LABA has fewer exacerbations, a larger improvement of FEV1, a lower risk of pneumonia, and more frequent improvement in quality of life as measured by an increase over 4 units or more of the SGRQ. These data were supported by low or moderate quality evidence generated from mainly participants with moderate to severe COPD in heterogeneous trials with an observation period of less than one year. Our findings support the recently updated GOLD guidance.
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Friday, February 10, 2017

New issue of Current Respiratory Medicine Reviews (Volume 12 - Number 4) is online

Dear Friends was published new issue of Current Respiratory Medicine Reviews (Volume 12 - Number 4)!

Table of Contents  (For viewing abstracts please visit this link)
Meet Our Editorial Board Member Pp. 247-247
Peter J. Barnes
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Editorial: Obstructive Sleep Apnea (OSA) in the Elderly: Does OSA Decrease Mortality in These Patients When They Have Pneumonia? Pp. 248-249
Salim Surani, Daryelle S. Varon and Joseph Varon
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Review Article
Recognition of the Deteriorating Patient: The Ongoing Evolution of Early Warning Score Systems and their Impact on Patients with Respiratory Disease Pp. 250-260
Sarah Forster, John Blakey and Dominick Shaw
[Abstract] [Purchase Article]
Review Article
Effectiveness of Long-Term Macrolide Therapy in Cryptogenic Organising Pneumonia Pp. 261-270
Tommaso D'Elia
[Abstract] [Purchase Article]
Review Article
Epidemiology and Pathology of Malignant Mesothelioma Pp. 271-276
Jack A. Kastelik, Mahmoud Loubani, Michael Greenstone, Simon Hart and Anne Campbell
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Review Article
Pulmonary Disease in Beta-Thalassemia Pp. 277-285
Demetrios S. Theodoropoulos and Maria S. Theodoropoulou
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Review Article
Surgical Options for Management of Malignant Pleural Mesothelioma in the Current Era Pp. 286-293
Mahmoud Loubani, Syed S. Qadri, Azar Hussain, Mubarak A. Chaudhry and Jack A. Kastelik
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Review Article
Rheumatoid Nodules and Lung Pp. 294-298
Ciro Manzo
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Research Article
Assessment of Mortality Risk in Elderly Persons with Obstructive Sleep Apnea Diagnosed with Pneumonia Pp. 299-305
Charlisa D. Gibson, Eric Yudelevich, Raymond A. Jean, Pius Ochieng and Raymonde E. Jean
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Wednesday, February 1, 2017

Procalcitonin could safely halve antibiotic administration in COPD exacerbations (Free full text from European Respiratory Review 2017)

Our latest meta-analysis is now available online!!
Current evidence suggests that serum procalcitonin could safely halve antibiotic administration in COPD exacerbations!
Challenges in the differentiation of the aetiology of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have led to significant overuse of antibiotics. Serum procalcitonin, released in response to bacterial infections, but not viral infections, could possibly identify AECOPD requiring antibiotics. In this meta-analysis we assessed the clinical effectiveness of procalcitonin-based protocols to initiate or discontinue antibiotics in patients presenting with AECOPD.
Based on a prospectively registered protocol, we reviewed the literature and selected randomised or quasi-randomised trials comparing procalcitonin-based protocols to initiate or discontinue antibiotics versus standard care in AECOPD. We followed Cochrane and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidance to assess risk of bias, quality of evidence and to perform meta-analyses.
We included eight trials evaluating 1062 patients with AECOPD. Procalcitonin-based protocols decreased antibiotic prescription (relative risk (RR) 0.56, 95% CI 0.43–0.73) and total antibiotic exposure (mean difference (MD) −3.83, 95% CI (−4.32–−3.35)), without affecting clinical outcomes such as rate of treatment failure (RR 0.81, 0.62–1.06), length of hospitalisation (MD −0.76, −1.95–0.43), exacerbation recurrence rate (RR 0.96, 0.69–1.35) or mortality (RR 0.99, 0.58–1.69). However, the quality of the available evidence is low to moderate, because of methodological limitations and small overall study population.
Procalcitonin-based protocols appear to be clinically effective; however, confirmatory trials with rigorous methodology are required.
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Sunday, January 29, 2017

Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report published in Blue Journal

This Executive Summary of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document.
The most significant changes include: 
i) the assessment of COPD has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; 
ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; 
iii) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; 
iv) nonpharmacologic therapies are comprehensively presented and; 
v) the importance of comorbid conditions in managing COPD is reviewed. 
Link to full text:

Wednesday, January 25, 2017

Pneumonology Quiz – Case 4 (free article from Archives of Hellenic Medicine)

Dear friends read new Pneumology Quiz from Archives of Hellenic Medicine!
A 34-year-old female patient presented to the emergency department with 6 hours’ history of sudden onset of breathlessness associated with severe pleuritic chest pain, minimal hemoptysis and pyrexia. She denied any other symptoms. She
had only returned from a business meeting in South Africa a week ago and she was quite concerned of the possibility of having contracted a tropical infection, although she had followed vaccination and hygiene advice given by an infectious disease specialist before her departure, four weeks ago. Her past medical history included two episodes of miscarriage. On examination, she was tachycardic (95 bpm) with normal blood pressure (140/75 mmHg), tachypneic (22 bpm) with normal oxygen saturation (95% on room air) and pyrexial (37.4 oC). A detailed clinical examination did not yield positive clinical findings. Full blood count, urea and electrolytes, as well as c-reactive protein (CRP) were all within normal range. Chest X-ray was insignificant.
Full free text:

Previous cases:

Pneumonology Quiz - Case 1

Pneumonology Quiz - Case 2

Pneumonology Quiz – Case 3

Friday, January 20, 2017

Introducing COPD Research and Practice

Dear friends we are happy to present you new Respiratory Journal: COPD Research and Practice!
COPD Research and Practice publishes basic and clinical research and cutting edge reviews related to chronic obstructive pulmonary disease (COPD). The journal aims to facilitate discussion and dissemination of knowledge to help translate new ideas from bench to bedside by encouraging international and interdisciplinary collaboration.
Editorial from Editor in Chief Professor Mario Cazzola from the University of Rome Tor Vergata, Rome, Italy:
COPD is now the fourth leading cause of death globally, and the World Health Organization (WHO) has predicted that it will become the third most common cause of death in the world by 2030 [1]. In developed countries, current information estimates a prevalence of 8 % to 10 % among adults 40 years of age and older, whereas in developing countries, prevalence varies significantly among countries and is difficult to quote [2].
It is estimated that more than 210 million people have the disease worldwide [3]. Concerning a large number of subjects, COPD generates important health and social costs. However, although COPD is one of the most common chronic diseases and has a high health and social impact, it is still poorly recognized among the general public and also clinicians. Consequently, there is a major and urgent need to better understand this complex disease.
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Saturday, January 14, 2017

2017 Lung Cancer Guidelines: The Eighth Edition Lung Cancer Stage Classification

Stage classification provides a nomenclature about the anatomic extent of a cancer; a consistent language provides the ability to communicate about a specific patient and about cohorts of patients in clinical studies. This paper summarizes the eighth edition of lung cancer stage classification, which is the worldwide standard as of January 1, 2017.

This revision is based on a large global database, a sophisticated analysis, extensive internal validation as well as multiple assessments confirming generalizability.

Practicing clinicians must be familiar with the stage classification system when managing contemporary patients with lung cancer.