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Severe asthma imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity, co-morbidities, complexity in care pathways and differences between national or regional healthcare systems. Better understanding of the mechanisms has enabled a stratified approach to the management of severe asthma, supporting the use of targeted treatments with biologicals. However, there are still many issues that require further clarification. These include selection of a certain biological (as they all target overlapping disease phenotypes), the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based) and its costeffectiveness. The EAACI Guidelines on the use of biologicals in severe asthma follow the GRADE approach in formulating recommendations for each biological and each outcome. In addition, a management algorithm for the use of biologicals in the clinic is proposed, together with future approaches and research priorities.

AimTo study whether mortality and cardiovascular morbidity differ in non-invasive ventilation (NIV)-treated patients with severe obesity-hypoventilation syndrome (OHS) as compared with CPAP-treated patients with obstructive sleep apnea syndrome (OSAS), and to identify independent predictors of mortality in OHS.Material and methodsTwo retrospective cohorts of OHS and OSAS were matched 1:2 according to sex, age (±10 year) and length of time since initiation of CPAP/NIV therapy (±6 months).ResultsThree hundred and thirty subjects (110 patients with OHS and 220 patients with OSAS) were studied. Mean follow-up time was 7±4 years. The five year mortality rates were 15.5% in OHS cohort and 4.5% in OSAS cohort (p< 0.05). Patients with OHS had a 2-fold increase (OR 2; 95% CI: 1.11–3.60) in the risk of mortality and 1.86 fold (OR 1.86; 95% CI: 1.14–3.04) increased risk of having a cardiovascular event. Diabetes, baseline diurnal SaO2 < 83%, EPAP < 7 cmH2O after titration and adherence to NIV < 4 hours independently predicted mortality in OHS.ConclusionMortality of severe OHS is high and substantially worse than that of OSAS. Severe OHS should be considered a systemic disease that encompasses respiratory, metabolic and cardiovascular components that require a multimodal therapeutic approach.

PurposeGrouping COPD subjects into clinical phenotypes might be useful for the management of the disease, but the clinical implications of such classification are still not totally clear, especially regarding prognosis. The primary objective of this study was to assess whether the mortality rates were different between four predefined clinical phenotypes.Patients and methodsThis is a retrospective, observational study carried out at the COPD clinic of a University Hospital. A total of 891 COPD patients were classified, according to the Spanish COPD guidelines, into the following four phenotypes: asthma–COPD overlap (ACO; 75 subjects), nonexacerbator (NONEX; 531 subjects), exacerbator with chronic bronchitis (EXCB; 194 subjects), and exacerbator with emphysema (EXEMPH; 91 subjects). We compared the mortality outcomes between the phenotypes.ResultsAfter a follow-up of 48.4±25.2 months, there were 194 deaths (21.8%). There were significant differences in all-cause mortality between phenotypes. The ACO phenotype had the best long-term prognosis, whereas EXEMPH had the highest risk of death. NONEX and EXCB mortality figures were in between the other two groups. We also found some differences in the causes of death, and patients with EXEMPH were at a higher risk of dying because of COPD itself. The differences in mortality did not seem related to the classification into phenotypes in itself but to disparities in COPD severity and comorbidity load between groups.ConclusionClassifying COPD patients according to several predefined clinical phenotypes can identify clusters of subjects with different mortality outcomes. Some phenotypes are associated with a specific cause of death. The mechanisms that underlie these differences seem to be related to COPD severity and comorbidities.

Background: Obesity hypoventilation syndrome (OHS) can be treated with noninvasive positive pressure ventilation (NIPPV). Once clinical stability is achieved, continuous positive airway pressure (CPAP) can be recommended in many cases. However, some patients respond only partially to CPAP and NIPPV is a better option for them. Objectives: To assess treatment effectiveness in 2 groups of patients: those who could be switched to CPAP after polysomnographic titration and those who required NIPPV. Methods: A prospective study of 24 OHS patients was conducted, 11 were treated with CPAP and 13 with NIPPV. Morning and evening arterial blood gases were measured. Daytime and overnight oximetric recordings were performed. A post hoc analysis compared both groups. Results: Neither group exhibited deterioration on morning-to-evening blood gases. All patients in the CPAP group presented SaO₂ of less than 90% (CT90%) for <15% of the time on nocturnal and daytime recordings. In the NIPPV group, 8 patients had either daytime or nocturnal CT90% ≧15%. There were no intergroup differences regarding age, body mass index, Epworth scale values or PaO₂/PaCO₂ prior to treatment. FVC in the NIPPV group was lower than in the CPAP group (p = 0.01). Apnea-hypopnea index was higher (56 ± 23 vs. 36 ± 23, p = 0.049) and baseline CT90% was lower (76 ± 19% vs. 92 ± 14%, p = 0.03) in the CPAP group. Conclusions: Two patient subtypes can be identified. Those controlled with CPAP have better spirometry and a significantly higher apnea-hypopnea index. None of these patients showed daytime hypoxemia and all exhibited satisfactory overnight oxygenation. However, 61% of the NIPPV group had suboptimal oximetry results. Nocturnal/diurnal oximetries should be made to assess treatment efficacy in stable OHS patients who fail to achieve good control with CPAP.

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