Rationale: Exacerbations of chronic obstructive pulmonary disease (COPD) greatly contribute to declining health status and the progression of the disease, thereby incurring significant direct and indirect health care costs. The prevention of exacerbations, therefore, is an important treatment goal. Objectives: To assess the impact of combination therapy with salmeterol/fluticasone propionate compared with salmeterol alone on moderate and severe exacerbations in patients with severe COPD and a history of repeated exacerbations. Methods: Randomized, double-blind, parallel-group study. After a 4-wk run-in period, 994 clinically stable patients were randomized to one of two treatment groups: 507 patients received the salmeterol/fluticasone combination 50/500 μg twice daily and 487 received salmeterol 50 μg twice daily for 44 wk. Main Results: The total number of exacerbations was 334 in the combination therapy and 464 in the salmeterol group (p < 0.0001). The annualized rate of moderate and severe exacerbations per patient was 0.92 in the combination therapy and 1.4 in the salmeterol group, corresponding to a 35% decrease. In addition, the mean time to first exacerbation in the combination therapy group was significantly longer compared with that of the salmeterol group (128 vs. 93 d, p < 0.0001). Other endpoints, including health-related quality of life, peak expiratory flow, and use of rescue medication, were significantly improved in the combination therapy group. Both treatments were well tolerated. Conclusions: This study demonstrates that combination therapy with salmeterol/fluticasone compared with salmeterol monotherapy significantly reduces the frequency of moderate/severe exacerbations in patients with severe COPD.

Zusammenfassung: Die vorliegende 2019 S2k-Leitlinie der DGP wurde im Gegensatz zu den S3-Vorgänger-Leitlinien aus dem Jahre 2004 und 2010 für Pneumologen verfasst, für Allgemeinärzte liegt eine Leitlinie der Deutschen Gesellschaft für Allgemeinmedizin aus dem Jahre 2014 vor. Die Leitlinie enthält 48 im Konsensusverfahren abgestimmte Empfehlungen und 16 Statements, die im Hintergrundtext in den folgenden neun Kapiteln erläutert werden: Epidemiologie, Physiologie, Klassifizierung, akuter, subakuter bzw. chronischer Husten, Diagnostik und Therapie; dem chronischen idiopathischen Husten wurde ein Extra-Kapitel gewidmet. Weitere Schwerpunkte der Leitlinie sind die Physiologie des Hustens in Erwartung der Einführung neuer Medikamente sowie ausführliche Abhandlungen des Hustens, der durch Affektionen im Bereich der oberen Atemwege oder durch gastroösophagealen Reflux getriggert wird. Hier sollte die Leitlinie dem Pneumologen die zur Diagnostik und Therapie erforderlichen neuesten Kenntnisse aus den Nachbardisziplinen vermitteln. Die klinischen Kapiteln enthalten auch eine kurze Zusammenfassung, praktische Empfehlungen und jeweils ein eigenes Literaturverzeichnis. Drei neue, vereinfachte Algorithmen für den akuten, subakuten und chronischen Husten runden das Kapitel Diagnostik ab.

Acute respiratory tract infections, i. e. rhinitis, sinusitis, pharyngitis, laryngitis, bronchitis, belong to the most common medical conditions with a high economic burden. Nonetheless, there is little agreement concerning their differential diagnosis. This paper will discuss to what extent different anatomical sites of acute respiratory tract infections can be uniquely identified or whether the overlap and consecutive development in signs and symptoms renders these distinctions meaningless. Acute respiratory tract infections are variable but definition of diagnostic categories based on the anatomical sites of the dominant complaints shows that signs and symptoms both overlap to a great extent and/or emerge successively. Thus, in common cold distinguishing between acute symptom-based diagnoses arising from different anatomical sites of the aerodigestive system remains elusive. Therefore, preferred symptomatic treatments should foster a resolution of all possible symptoms as opposed to an isolated treatment of a single symptom (e. g. mucus hypersecretion) according to the presumed anatomical site (i. e. acute bronchitis). Akute Atemwegsinfektionen wie Rhinitis, Sinusitis, Pharyngitis, Laryngitis und Bronchitis sind weit verbreitet und belasten das Gesundheitswesen mit hohen Kosten. Die Differenzialdiagnose ist dennoch umstritten. Die vorliegende Arbeit diskutiert, in welchem Ausmaß akute Atemwegsinfektionen jeweils anatomisch genau lokalisiert werden können (z. B. Pharyngitis, Rhinitis etc.) oder ob eine solche Unterscheidung angesichts überlappender und ineinander übergehender Symptome ohne Bedeutung ist. Akute Atemwegsinfektionen treten mit örtlich und zeitlich wechselnden Symptomen auf. Die diagnostische Einordnung (z. B. Laryngitis oder Bronchitis) basiert auf einer vermuteten anatomischen Lokalisierung der dominierenden Beschwerden. Es zeigt sich allerdings, dass sich die verschiedenen Symptome stark überlappen bzw. in zeitlicher Abfolge auftreten. Eine symptombasierte diagnostische Unterscheidung bei akuten Atemwegsinfektionen in Abhängigkeit von der jeweiligen anatomischen Lokalisation erscheint somit schwierig. Die symptomatische Behandlung sollte daher auf die Verbesserung aller in Frage kommenden Symptome und nicht auf die Behandlung eines einzelnen Symptoms, wie beispielsweise auf die vermehrte Schleimproduktion bei akuter Bronchitis, gerichtet sein.

Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel’s opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.

Pertussis is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis and commonly characterized by severe, repeated coughing episodes.1,2 It is a worldwide public hea...

DACCORD is an observational, non-interventional study being conducted in German primary and secondary care centres. The study aims to describe the impact of disease (including exacerbations) and treatments over 2 years on 'real-life' patients with chronic obstructive pulmonary disease (COPD). Patients had a clinical and spirometry diagnosis of COPD, were aged ≥40 years and, on recruitment, were initiating or changing COPD maintenance medication. The only exclusion criteria were asthma and randomised clinical trial participation. Exacerbations data were collected every 3 months. COPD medication, COPD Assessment Test (CAT) and forced expiratory volume in 1 s (FEV1) were recorded at baseline and after 1 and 2 years. A total of 6122 patients were recruited, 3137 (51.2%) of whom completed the 2-year visit. The mean age of these patients was 65.6 years, 59% were male, 69% had mild or moderate airflow limitation, and their mean COPD Assessment Test (CAT) total score was 20.3. Overall, there was a trend towards decreasing COPD exacerbation rates over the 2-year follow-up period, with rates of 0.390 during Year 1 and 0.347 during Year 2. Rates were lower in patients with no exacerbation during the 6 months prior to entry (0.263 and 0.251 during Years 1 and 2, respectively), with 51.6% of patients having no exacerbation during the 6 months prior to entry and over the 2-year follow-up. Approximately 50% of the overall population experienced a clinically relevant improvement from baseline in CAT total score at Year 1 and 2. When assessed by treatment class (or classes), persistence to medication was high (77.8% in Year 1 and 71.4% in Year 2). Overall, the 2-year follow-up data from DACCORD suggest that for most patients with COPD exacerbations are a rare event. For the majority of patients, the focus should be on managing symptoms, and the impact that these symptoms have on their daily lives. Even for those patients who do exacerbate, although prevention of exacerbations is an important factor, management of symptoms should be a key consideration. DACCORD also suggests that COPD disease progression is not inevitable - providing patients are receiving pharmacological treatment.