The economic burden of COPD

Comparative Efficacy of Budesonide/Formoterol with Budesonide, Formoterol or Placebo for Stable Chronic Obstructive Pulmonary Disease: A Meta-Analysis

BACKGROUND The 2018 Global Initiative for Chronic Obstructive Lung Disease publication suggested that the combination of bronchodilator therapy of inhaled glucocorticoid/long-acting β₂ adrenoceptor agonist is more effective in improving pulmonary function and health status in the treatment of patients with acute exacerbations than the individual components; however, it is not known whether this also the case for stable chronic obstructive pulmonary disease (COPD). The purpose of this meta-analysis was to evaluate the effectiveness of budesonide/formoterol in the maintenance and relief therapy of patients with stable COPD. MATERIAL AND METHODS An electronic search of the literature in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was undertaken to identify published randomized controlled trials (RCTs) of ≥12 weeks duration comparing the budesonide/formoterol, with budesonide, formoterol, or placebo in the treatment of patients with stable COPD. The identified RCTs were reviewed. The mean difference (MD) with corresponding 95% confidence interval (CI) was used to pool the results. RESULTS Seven high quality studies with RCTs met the inclusion criteria for meta-analysis. Compared with budesonide alone, the combination therapy of budesonide/formoterol showed significant improvement in the following spirometric indices: pre-dose forced expiratory volume in 1 second (FEV₁) (SMD: 0.26, 95% CI: 0.18, 0.34; P=0.000). In addition, versus formoterol alone, budesonide/formoterol was associated with a significant increase in pre-dose FEV₁ (SMD: 0.12, 95% CI: 0.07, 0.17; P=0.000). A similar pattern was also evident in the comparison to placebo, where budesonide/formoterol yielded greater increase in pre-dose FEV₁ (SMD: 0.24, 95% CI: 0.18, 0.30; P=0.000). Moreover, compared with other controls, the combination of budesonide-formoterol significantly improved morning peak expiratory flow and evening peak expiratory flow, significantly reduced the total score of St. George's Respiratory Questionnaire. CONCLUSIONS For stable COPD patients, compared with controls (monocomponents or placebo), budesonide/formoterol improved pulmonary function and health status. Future larger long-term RCTs are warranted to assess the beneficial clinical efficacy of budesonide/formoterol in COPD patients.

Predictive factors for exacerbation and re-exacerbation in chronic obstructive pulmonary disease: an extension of the Cox model to analyze data from the Swiss COPD cohort

Background

The Swiss COPD cohort was established in 2006 to collect data in a primary care setting. The objective of this study was to evaluate possible predictive factors for exacerbation and re-exacerbation.

Methods

In order to predict exacerbation until the next visit based on the knowledge of exacerbation since the last visit, a multistate model described by Therneau and Grambsch was performed.

Results

Data of 1,247 patients (60.4% males, 46.6% current smokers) were analyzed, 268 (21.5%) did not fulfill spirometric diagnostic criteria for COPD. Data of 748 patients (63% males, 44.1% current smokers) were available for model analysis. In order to predict exacerbation an extended Cox Model was performed. Mean FEV₁/FVC-ratio was 53.1% (±11.5), with a majority of patients in COPD GOLD classes 2 or 3. Hospitalization for any reason (HR1.7; P = 0.04) and pronounced dyspnea (HR for mMRC grade four 3.0; P < 0.001) at most recent visit as well as prescription of short-acting bronchodilators (HR1.7; P < 0.001), inhaled (HR1.2; P = 0.005) or systemic corticosteroids (HR1.8; P = 0.015) were significantly associated with exacerbation when having had no exacerbation at most recent visit. Higher FEV₁/FVC (HR0.9; P = 0.008) and higher FEV₁ values (HR0.9; P = 0.001) were protective. When already having had an exacerbation at the most recent visit, pronounced dyspnea (HR for mMRC grade 4 1.9; P = 0.026) and cerebrovascular insult (HR2.1; P = 0.003) were significantly associated with re-exacerbation. Physical activity (HR0.6; P = 0.031) and treatment with long-acting anticholinergics (HR0.7; P = 0.044) seemed to play a significant protective role. In a best subset model for exacerbation, higher FEV₁ significantly reduced and occurrence of sputum increased the probability of exacerbation. In the same model for re-exacerbation, coronary heart disease increased and hospitalization at most recent visit seemed to reduce the risk for re-exacerbation.

Conclusion

Our data confirmed well-established risk factors for exacerbations whilst analyzing their predictive association with exacerbation and re-exacerbation. This study confirmed the importance of spirometry in primary care, not only for diagnosis but also as a risk evaluation for possible future exacerbations.

Trial registration

Our study got approval by local ethical committee in 2006 (EK Nr. 170/06) and was registered retrospectively on ClinicalTrials.gov (NCT02065921, 19^th of February 2014).

Cost of Severe Chronic Obstructive Pulmonary Disease Exacerbations in a High Burden Region in North India

Background:

Data on costs of acute exacerbations of COPD (AECOPD) in low-income countries are sparse. We conducted a prospective survey to assess direct and indirect costs of severe AECOPD in a tertiary care setting in a high prevalence area of North India.

Methods:

We conducted face-to-face surveys using a semi-structured questionnaire among a convenience sample of 129 consenting patients admitted with AECOPD. Data were collected on out-of-pocket costs of hospitalization, consultation, medications, diagnostics, transportation, lodging, and missed work days for self and their attendants. Out-of-pocket costs were supplemented with World Health Organization-CHOICE estimates. Missed work-days were valued on per capita national income (Indian Rupees [INR] 68,748, US$1,145.8). Median total cost per exacerbation episode was INR 44,390 (Inter-quartile range [IQR]: INR 33,354–63,642; US$739.8, IQR: 555.9–1060.7). Hospital costs constituted the largest component of the costs (71%) followed by other costs directly borne by the patient himself (29%), medicine costs (14%), transportation charges (2%) and diagnostic tests (3%). Indirect costs to caregivers (median INR 1,544, IQR: INR 0–17,370 INR; US$25.7, IQR: US$0–289.5), calculated as financial loss due to missed work days, accounted for 4% of the total cost. Expenses were covered by family members in all but 11 patients.

Conclusions:

AECOPD in India are associated with substantial costs and strategies to reduce the burden of disease such as smoking cessation, influenza and pneumococcal vaccination, etc should be aggressively pursued.

Physical signs in patients with chronic obstructive pulmonary disease

We reviewed the various physical signs of chronic obstructive pulmonary disease, their pathogenesis, and clinical importance. We searched PubMed, EMBASE, and the CINAHL from inception to March 2018. We used the following search terms: chronic obstructive pulmonary disease, physical examination, purse-lip breathing, breath sound intensity, forced expiratory time, abdominal paradox, Hoover's sign, barrel-shaped chest, accessory muscle use, etc. All types of studies were chosen. Globally, history taking and clinical examination of the patients is on the wane. One reason can be a significant development in the field of medical technology, resulting in overreliance on sophisticated diagnostic machines, investigative procedures, and medical tests as first-line modalities of patient's management. In resource-constrained countries, detailed history taking and physical examination should be emphasized as one of the important modalities in patient's diagnosis and management. Declining bedside skills and clinical aptitude among the physician is indeed a concern nowadays. Physical diagnosis of chronic obstructive pulmonary disease (COPD) is the quickest and reliable modalities that can lead to early diagnosis and management of COPD patients. Bedside elicitation of physical signs should always be the starting point for any diagnosis and therapeutic approach.

Guideline adherence in hospital recruited and population based COPD patients

BACKGROUND

Evidence from several studies show poor guideline adherence to COPD treatment, but no such study has been undertaken in Norway. The objectives of this study, was to estimate and compare the guideline adherence to COPD treatment in general population-based and hospital-recruited COPD patients, and find possible predictors of guideline adherence.

METHODS

From the prospective, observational EconCOPD-study, we analysed guideline adherence for 90 population-based COPD cases compared to 245 hospital-recruited COPD patients. Overall guideline adherence was defined as correct pharmacological treatment, and influenza vaccination the preceding year, and having received smoking cessation advice. Multivariate logistic regression analysis was performed with the dichotomous outcome overall guideline adherence adjusting for relevant variables.

RESULTS

The overall guideline adherence for population-based COPD cases was 6.7%, significantly lower than the 29.8% overall guideline-adherence amongst hospital-recruited COPD patients. Adherence to pharmacological treatment guidelines was 10.0 and 35.5%, for the two recruitment sources, respectively. GOLD-stage 3 to 4 was associated with significantly better guideline adherence compared to GOLD-stage 2 (OR (95% CI) 18.9 (8.37,42.7)). The unadjusted difference between the two recruitment sources was completely explained by degree of airflow obstruction.

CONCLUSION

Overall guideline adherence was very low for both recruitment sources. We call for increased attention from authorities and healthcare personnel to improve the quality of care given to this patient group.

What is the impact of GOLD 2017 recommendations in primary care? - a descriptive study of patient classifications, treatment burden and costs

PURPOSE

The changes in grading of disease severity and treatment recommendations for patients with COPD in the 2017 GOLD strategy may present an opportunity for reducing treatment burden for the patients and costs to the health care system. The aim of this study was to assess the implications of the GOLD 2017 grading system in terms of change in distribution across GOLD groups A-D for existing patients in UK primary care and estimate the potential cost savings of implementing GOLD 2017 treatment recommendations in UK primary care.

PATIENTS AND METHODS

Using electronic health record data from the Clinical Practice Research Datalink (CPRD), patients aged ≥35 years with spirometry-confirmed COPD, receiving care during 2016, were included. The cohort was graded according to the GOLD 2017 groups (A-D), and treatment costs were calculated, according to corresponding recommendations, to observe the difference in actual vs predicted costs.

RESULTS

When applying GOLD 2013 criteria, less than half of the cohort (46%) was assigned to GOLD A or B, as compared to 86% when applying the GOLD 2017 grading. The actual mean annual maintenance treatment cost was £542 per patient vs a predicted £389 for treatment according to the 2017 GOLD strategy.

CONCLUSION

There is a potential to make significant cost savings by implementing the grading and treatment recommendations from the 2017 GOLD strategy.

Prolonged stay predictors in patients admitted with chronic obstructive pulmonary disease acute exacerbation

Objectives:

The study aimed to identify the factors related to prolonged stay in those patients admitted with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) to our hospital.

Methods:

We conducted a retrospective study by reviewing the medical records of all patients admitted with AECOPD to the University Hospital Complex of Santiago de Compostela in 2007 and 2008. To identify variables independently associated with length of stay, we conducted a logistic regression including those variables which proved to be significant in the univariate analysis.

Results:

Six hundred and sixty-one patients were assessed; 76.6% were male and the mean age was 74.5 years (standard deviation [SD]: 11.48). The mean stay was 11.9 days (SD: 8) and 24% of all patients required prolonged stay. Factors associated with prolonged mean stay in multivariate analysis were admission to the Intensive Care Unit (odds ratio [OR], 14.7), hospitalization by internal medicine (OR, 2.1), and use of noninvasive mechanical ventilation (OR, 1.75).

Conclusions:

Prolonged stay in AECOPD is primarily related to the unit patients are admitted to, and to the need for more intensive care.

Refractive surgery: the most cost-saving technique in refractive errors correction

AIM

To compare the lifetime and annual economic burden of spectacles, contact lenses, and refractive surgery in correction of refractive errors.

METHODS

This is a cross-sectional study with convenience sampling which 120 patients were interviewed in a tertiary referral hospital in the Iranian health care system. The bottom-up based cost of illness approach was estimated using a face-to-face interview to assess the direct and indirect cost of different refractive errors correction of any correction technologies.

RESULTS

Correction with spectacle imposes a total direct cost of US dollar (US$) 342.5 (±8.41) per year and US$9373.5 (±230.1) per lifetime to each patient. These figures for the contact lenses were obtained US$198.3 (±0.12) and US$5203.1 (±256.3) and for refractive surgery were obtained US$19.1 (±1.2) and US$568.1 (±64.6), respectively. Overall, based on age-adjusted prevalence rates, astigmatism had the highest share of refractive errors economic burden with a lifetime direct cost of slightly less than US$5.49 billion, while hyperopia and myopia imposed less than US$5.24 and 4.2 billion on patients, respectively. The annually imposed cost on each individual Iranian patient with refractive errors is US$308.5.

CONCLUSION

Based on 18mo post refractive surgery course observation, which is generalized to whole life, refractive surgery significantly imposed much less cost compared with spectacles and contact lenses. Refractive errors among Iranians result in considerable economic burden. Using the refractive surgery instead of other two correction methods has the ability to reduce this economic loss in the future.

Variations in practice patterns and resource utilization in patients treated for chronic obstructive pulmonary disease

RATIONALE, AIMS, AND OBJECTIVES

Several studies have looked at patient-related variables influencing hospital length of stay (LOS) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, there has been increasing recognition that physician-related factors also play a significant role. This study aims to evaluate differences in practice patterns between teaching and nonteaching services and their effect on LOS in a large community hospital.

METHODS

A retrospective study of 354 patients admitted to Florida Hospital, Orlando, with AECOPD between January 2009 and December 2011. Patients who presented with acute respiratory failure requiring mechanical ventilation were excluded. Practice patterns of interest were use of oral versus intravenous systemic steroids, use of oral versus intravenous antibiotics, and utilization of consultations.

RESULTS

Length of stay was significantly lower in the teaching compared with the nonteaching group (2.80 vs. 5.04 days, P < .001). There was significantly greater use of oral steroids (85% vs. 8.9%, P < .001), greater use of oral antibiotics (72% vs. 33%, P < .001), and lower utilization of consults (0.3 vs. 1.4 consults per patient, P < .001) in the teaching compared with the nonteaching group. The teaching service was independently associated with decreased LOS in a multivariable regression model. However, after adjustment for the difference in practice patterns between the 2 groups, the teaching service was no longer associated with decreased LOS. Of the practice patterns, only utilization of consults was independently associated with increased LOS.

CONCLUSIONS

The teaching service had decreased LOS compared with the nonteaching service in patients hospitalized for AECOPD. The observed difference was completely explained by differences in practice patterns between the 2 groups. The study identifies an opportunity for more efficient and cost-effective care of AECOPD patients through streamlining of consultations, use of oral steroids in lieu of IV steroids, and antibiotic stewardship.

Continuous remote monitoring of COPD patients-justification and explanation of the requirements and a survey of the available technologies

Remote patient monitoring should reduce mortality rates, improve care, and reduce costs. We present an overview of the available technologies for the remote monitoring of chronic obstructive pulmonary disease (COPD) patients, together with the most important medical information regarding COPD in a language that is adapted for engineers. Our aim is to bridge the gap between the technical and medical worlds and to facilitate and motivate future research in the field. We also present a justification, motivation, and explanation of how to monitor the most important parameters for COPD patients, together with pointers for the challenges that remain. Additionally, we propose and justify the importance of electrocardiograms (ECGs) and the arterial carbon dioxide partial pressure (PaCO2) as two crucial physiological parameters that have not been used so far to any great extent in the monitoring of COPD patients. We cover four possibilities for the remote monitoring of COPD patients: continuous monitoring during normal daily activities for the prediction and early detection of exacerbations and life-threatening events, monitoring during the home treatment of mild exacerbations, monitoring oxygen therapy applications, and monitoring exercise. We also present and discuss the current approaches to decision support at remote locations and list the normal and pathological values/ranges for all the relevant physiological parameters. The paper concludes with our insights into the future developments and remaining challenges for improvements to continuous remote monitoring systems. Graphical abstract ᅟ.

Secondhand Smoke Induces Inflammation and Impairs Immunity to Respiratory Infections

Despite advocacy to reduce smoking-related diseases, >1 billion people worldwide continue to smoke. Smoking is immunosuppressive and an important etiological factor in the development of several human disorders including respiratory diseases like chronic obstructive pulmonary disease. However, there is a critical gap in the knowledge of the role of secondhand smoke (SHS) in inflammation and immunity. We therefore studied the influence of SHS on pulmonary inflammation and immune responses to respiratory infection by nontypeable Haemophilus influenzae (NTHI) recurrently found in chronic obstructive pulmonary disease patients. Chronic SHS-exposed mice were chronically infected with NTHI and pulmonary inflammation was evaluated by histology. Immune cell numbers and cytokines were measured by flow cytometry and ELISA, respectively. Chronic SHS exposure impaired NTHI P6 Ag-specific B and T cell responses following chronic NTHI infection as measured by ELISPOT assays, reduced the production of Abs in serum and bronchoalveolar lavage, and enhanced albumin leak into the bronchoalveolar lavage as determined by ELISA. Histopathological examination of lungs revealed lymphocytic accumulation surrounding airways and bronchovasculature following chronic SHS exposure and chronic infection. Chronic SHS exposure enhanced the levels of inflammatory cytokines IL-17A, IL-6, IL-1β, and TNF-α in the lungs, and impaired the generation of adaptive immunity following either chronic infection or P6 vaccination. Chronic SHS exposure diminished bacterial clearance from the lungs after acute NTHI challenge, whereas P6 vaccination improved clearance equivalent to the level seen in air-exposed, non-vaccinated mice. Our study provides unequivocal evidence that SHS exposure has long-term detrimental effects on the pulmonary inflammatory microenvironment and immunity to infection and vaccination.

Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Current guidelines recommend that patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) should be treated with systemic corticosteroid for seven to 14 days. Intermittent systemic corticosteroid use is cumulatively associated with adverse effects such as osteoporosis, hyperglycaemia and muscle weakness. Shorter treatment could reduce adverse effects.

OBJECTIVES

To compare the efficacy of short-duration (seven or fewer days) and conventional longer-duration (longer than seven days) systemic corticosteroid treatment of adults with acute exacerbations of COPD.

SEARCH METHODS

Searches were carried out using the Cochrane Airways Group Specialised Register of Trials, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials) and ongoing trials registers up to March 2017.

SELECTION CRITERIA

Randomised controlled trials comparing different durations of systemic corticosteroid defined as short (i.e. seven or fewer days) or longer (i.e. longer than seven days). Other interventions-bronchodilators and antibiotics-were standardised. Studies with participants requiring assisted ventilation were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

Eight studies with 582 participants met the inclusion criteria, of which five studies conducted in hospitals with 519 participants (range 28 to 296) contributed to the meta-analysis. Mean ages of study participants were 65 to 73 years, the proportion of male participants varied (58% to 84%) and COPD was classified as severe or very severe. Corticosteroid treatment was given at equivalent daily doses for three to seven days for short-duration treatment and for 10 to 15 days for longer-duration treatment. Five studies administered oral prednisolone (30 mg in four, tapered in one), and two studies provided intravenous corticosteroid treatment. Studies contributing to the meta-analysis were at low risk of selection, performance, detection and attrition bias. In four studies we did not find a difference in risk of treatment failure between short-duration and longer-duration systemic corticosteroid treatment (n = 457; odds ratio (OR) 0.72, 95% confidence interval (CI) 0.36 to 1.46)), which was equivalent to 22 fewer per 1000 for short-duration treatment (95% CI 51 fewer to 34 more). No difference in risk of relapse (a new event) was observed between short-duration and longer-duration systemic corticosteroid treatment (n = 457; OR 1.04, 95% CI 0.70 to 1.56), which was equivalent to nine fewer per 1000 for short-duration treatment (95% CI 68 fewer to 100 more). Time to the next COPD exacerbation did not differ in one large study that was powered to detect non-inferiority and compared five days versus 14 days of systemic corticosteroid treatment (n = 311; hazard ratio 0.95, 95% CI 0.66 to 1.37). In five studies no difference in the likelihood of an adverse event was found between short-duration and longer-duration systemic corticosteroid treatment (n = 503; OR 0.89, 95% CI 0.46 to 1.69, or nine fewer per 1000 (95% CI 44 fewer to 51 more)). Length of hospital stay (n = 421; mean difference (MD) -0.61 days, 95% CI -1.51 to 0.28) and lung function at the end of treatment (n = 185; MD FEV1 -0.04 L; 95% CI -0.19 to 0.10) did not differ between short-duration and longer-duration treatment.

AUTHORS' CONCLUSIONS

Information from a new large study has increased our confidence that five days of oral corticosteroids is likely to be sufficient for treatment of adults with acute exacerbations of COPD, and this review suggests that the likelihood is low that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes than are seen with longer (10 to 14 days) courses. We graded most available evidence as moderate in quality because of imprecision; further research may have an important impact on our confidence in the estimates of effect or may change the estimates. The studies in this review did not include people with mild or moderate COPD; further studies comparing short-duration systemic corticosteroid versus conventional longer-duration systemic corticosteroid for treatment of adults with acute exacerbations of COPD are required.

Comparative analysis of the psychometric parameters of two quality-of-life questionnaires, the SGRQ and CAT, in the assessment of patients with COPD exacerbations during hospitalization: A multicenter study

The aim of this study was to assess health-related quality of life (HRQL) in patients with chronic obstructive pulmonary disease (COPD) and to discuss the different tools available for its assessment. The most widely used assessments are the St. George respiratory questionnaire (SGRQ) and the COPD assessment test (CAT) questionnaire. Both have a different difficulty in exam completion, calculation, and scoring. No studies exist that analyze the validity and internal consistency of using both questionnaires on patients admitted to the hospital for a COPD exacerbation. A multicenter, cross-sectional analytic observational study of patients admitted to the hospital due to a COPD exacerbation (CIE 491.2). During their hospital stay, they were administered the SGRQ and the CAT questionnaire within the framework of a therapeutic education program (APRENDEPOC). Descriptive and comparative analysis, correlations between the scales (Pearson’s correlation index), consistency and reliability calculations (Cronbach’s α), and a forward stepwise multiple linear regression were performed, with significant correlations in both questionnaires considered p < 0.01 with the total scores. A statistical significance of p < 0.05 was assumed. Altogether, 231 patients were admitted for a COPD exacerbation (n = 77) at Hospital Clínic of Barcelona (HCB) and (n = 154) at Hospital Universitario General of Castellón (HUGC). The sample profile was not homogeneous between both centers, with significant differences in HRQL between hospitals. Correlation were noted between both scales (p < 0.01), along with high levels of internal consistency and reliability (CAT 0.836 vs. SGRQ 0.827). The HRQL is related to dyspnea, wheezing, daytime drowsiness, and edema, as well as to the need to sleep in a sitting position, anxiety, depression, and dependence on others in the execution of daily activities. Our regression analysis showed that the SGRQ questionnaire could predict more changes in HRQL with a higher number of variables.

Effect of Upright and Slouched Sitting Postures on the Respiratory Muscle Strength in Healthy Young Males

Objective

The present study compared the effects of upright and slouched sitting postures on the respiratory muscle strength in healthy young males.

Methods

A total of 35 adult male subjects aged 18–35 years participated in this study. Respiratory muscle strength was determined by measurement of sniff nasal inspiratory pressure (SNIP) using a MicroRPM device in the upright and slouched sitting positions. The subjects were asked to perform the pulmonary function test including peak expiratory flow (PEF), forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), and FEV₁/FVC ratio at baseline. Body composition was also determined.

Results

There was a significant difference of SNIP score between upright sitting and slouched sitting positions (p = 0.04). The mean difference of SNIP score between upright sitting and slouched sitting positions was 8.7 cmH₂O. Significant correlations were found between SNIP in upright sitting and FEV₁% predicted values [R = .651], SNIP in slouched sitting and FEV₁% predicted values [R = .579], and SNIP in upright sitting and SNIP in slouched sitting positions [R = .926] (p < 0.05 for all). There were no significant correlations between SNIP scores, demographic variables, and other baseline clinical data (p > 0.05).

Conclusions

The slouched sitting position had a lower SNIP score compared to upright sitting position suggesting a reduced diaphragm tension and movement as a result of altered body posture.

COMET: a multicomponent home-based disease-management programme versus routine care in severe COPD

The COPD Patient Management European Trial (COMET) investigated the efficacy and safety of a home-based COPD disease management intervention for severe COPD patients.

The study was an international open-design clinical trial in COPD patients (forced expiratory volume in 1 s <50% of predicted value) randomised 1:1 to the disease management intervention or to the usual management practices at the study centre. The disease management intervention included a self-management programme, home telemonitoring, care coordination and medical management. The primary end-point was the number of unplanned all-cause hospitalisation days in the intention-to-treat (ITT) population. Secondary end-points included acute care hospitalisation days, BODE (body mass index, airflow obstruction, dyspnoea and exercise) index and exacerbations. Safety end-points included adverse events and deaths.

For the 157 (disease management) and 162 (usual management) patients eligible for ITT analyses, all-cause hospitalisation days per year (mean±sd) were 17.4±35.4 and 22.6±41.8, respectively (mean difference −5.3, 95% CI −13.7 to −3.1; p=0.16). The disease management group had fewer per-protocol acute care hospitalisation days per year (p=0.047), a lower BODE index (p=0.01) and a lower mortality rate (1.9% versus 14.2%; p<0.001), with no difference in exacerbation frequency. Patient profiles and hospitalisation practices varied substantially across countries.

The COMET disease management intervention did not significantly reduce unplanned all-cause hospitalisation days, but reduced acute care hospitalisation days and mortality in severe COPD patients.

Comparison of COPD Assessment Test and Clinical COPD Questionnaire to predict the risk of exacerbation

Background and objective

Guidelines recommend the use of simple but comprehensive tools such as COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ) to assess health status in COPD patients. We aimed to compare the ability of CAT and CCQ to predict exacerbation in COPD patients.

Methods

We organized a multicenter prospective cohort study that included COPD patients. The relationships between CAT, CCQ, and other clinical measurements were analyzed by correlation analysis, and the impact of CAT and CCQ scores on exacerbation was analyzed by logistic regression analyses and receiver operating characteristic curve.

Results

Among 121 COPD patients, CAT and CCQ score correlated with other symptom measures, lung function and exercise capacity as well. Compared with patients who did not experience exacerbation, those who experienced exacerbation (n=45; 38.2%) exhibited more severe airflow limitation, were more likely to have a history of exacerbation in the year prior to enrollment, and demonstrated higher CAT scores. CCQ scores were not significantly associated with exacerbations. A CAT score of ≥15 was an independent risk factor for exacerbation (adjusted odds ratio [aOR], 2.40; 95% CI, 1.03–6.50; P=0.04). Furthermore, CAT scores of ≥15 demonstrated an increased predictive ability for exacerbation compared with currently accepted guidelines for the use of CAT (≥10) and CCQ (≥1) in the assessment of COPD patients (area under the curve for CAT ≥15, CAT ≥10, and CCQ ≥1 was 0.61±0.04, 0.53±0.03, and 0.50±0.03, respectively; P=0.03).

Conclusion

A CAT score of ≥15 indicates increased risk of exacerbation in COPD patients, whereas there is no evidence for increased risk based on CCQ score.

Metabolomics in COPD Acute Respiratory Failure Requiring Noninvasive Positive Pressure Ventilation

We aimed to investigate whether metabolomic analysis can discriminate acute respiratory failure due to COPD exacerbation from respiratory failure due to heart failure and pneumonia. Since COPD exacerbation is often overdiagnosed, we focused on those COPD exacerbations that were severe enough to require noninvasive mechanical ventilation. We enrolled stable COPD subjects and patients with acute respiratory failure requiring noninvasive mechanical ventilation due to COPD, heart failure, and pneumonia. We excluded subjects with history of both COPD and heart failure and patients with obstructive sleep apnea and obstructive lung disease other than COPD. We performed metabolomics analysis using NMR. We constructed partial least squares discriminant analysis (PLS-DA) models to distinguish metabolic profiles. Serum (p=0.001, R² = 0.397, Q² = 0.058) and urine metabolic profiles (p < 0.001, R² = 0.419, Q² = 0.142) were significantly different between the four diagnosis groups by PLS-DA. After excluding stable COPD patients, the metabolomes of the various respiratory failure groups did not cluster separately in serum (p=0.2, R² = 0.631, Q² = 0.246) or urine (p=0.065, R² = 0.602, Q² = −0.134). However, several metabolites in the serum were reduced in patients with COPD exacerbation and pneumonia. We did not find a metabolic profile unique to COPD exacerbation, but we were able to clearly and reliably distinguish stable COPD patients from patients with respiratory failure in both serum and urine.

Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: Comparison with GOLD 2011

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project has been working to improve awareness, prevention and management of this disease. The aim of this study is to evaluate how COPD patients are reclassified by the 2017 GOLD system (versus GOLD 2011), to calculate the level of agreement between these two classifications in allocation to categories and to compare the performance of each classification to predict future exacerbations. Two-hundred COPD patients (>40 years, post bronchodilator forced expiratory volume in one second/forced vital capacity<0.7) followed in pulmonology consultation were recruited into this prospective multicentric study. Approximately half of the patients classified as GOLD D [2011] changed to GOLD B [2017]. The extent of agreement between GOLD 2011 and GOLD 2017 was moderate (Cohen's Kappa = 0.511; p < 0.001) and the ability to predict exacerbations was similar (69.7% and 67.6%, respectively). GOLD B [2017] exacerbated 17% more than GOLD B [2011] and had a lower percent predicted post bronchodilator forced expiratory volume in one second (FEV1). GOLD B [2017] turned to be the predominant category, more heterogeneous and with a higher risk of exacerbation versus GOLD B [2011]. Physicians should be cautious in assessing the GOLD B [2017] patients. The assessment of patients should always be personalized. More studies are needed to evaluate the impact of the 2017 reclassification in predicting outcomes such as future exacerbations and mortality.

Impaired calcium signaling in muscle fibers from intercostal and foot skeletal muscle in a cigarette smoke-induced mouse model of COPD

INTRODUCTION

Respiratory and locomotor skeletal muscle dysfunction are common findings in chronic obstructive pulmonary disease (COPD); however, the mechanisms that cause muscle impairment in COPD are unclear. Because Ca2+ signaling in excitation-contraction (E-C) coupling is important for muscle activity, we hypothesized that Ca2+ dysregulation could contribute to muscle dysfunction in COPD.

METHODS

Intercostal and flexor digitorum brevis muscles from control and cigarette smoke-exposed mice were investigated. We used single cell Ca2+ imaging and Western blot assays to assess Ca2+ signals and E-C coupling proteins.

RESULTS

We found impaired Ca2+ signals in muscle fibers from both muscle types, without significant changes in releasable Ca2+ or in the expression levels of E-C coupling proteins.

CONCLUSIONS

Ca2+ dysregulation may contribute or accompany respiratory and locomotor muscle dysfunction in COPD. These findings are of significance to the understanding of the pathophysiological course of COPD in respiratory and locomotor muscles. Muscle Nerve 56: 282-291, 2017.

Reduced Frizzled Receptor 4 Expression Prevents WNT/β-Catenin-driven Alveolar Lung Repair in Chronic Obstructive Pulmonary Disease

RATIONALE

Chronic obstructive pulmonary disease (COPD), in particular emphysema, is characterized by loss of parenchymal alveolar tissue and impaired tissue repair. Wingless and INT-1 (WNT)/β-catenin signaling is reduced in COPD; however, the mechanisms thereof, specifically the role of the frizzled (FZD) family of WNT receptors, remain unexplored.

OBJECTIVES

To identify and functionally characterize specific FZD receptors that control downstream WNT signaling in impaired lung repair in COPD.

METHODS

FZD expression was analyzed in lung homogenates and alveolar epithelial type II (ATII) cells of never-smokers, smokers, patients with COPD, and two experimental COPD models by quantitative reverse transcriptase-polymerase chain reaction, immunoblotting, and immunofluorescence. The functional effects of cigarette smoke on FZD4, WNT/β-catenin signaling, and elastogenic components were investigated in primary ATII cells in vitro and in three-dimensional lung tissue cultures ex vivo. Gain- and loss-of-function approaches were applied to determine the effects of FZD4 signaling on alveolar epithelial cell wound healing and repair, as well as on expression of elastogenic components.

MEASUREMENTS AND MAIN RESULTS

FZD4 expression was reduced in human and experimental COPD lung tissues as well as in primary human ATII cells from patients with COPD. Cigarette smoke exposure down-regulated FZD4 expression in vitro and in vivo, along with reduced WNT/β-catenin activity. Inhibition of FZD4 decreased WNT/β-catenin-driven epithelial cell proliferation and wound closure, and it interfered with ATII-to-ATI cell transdifferentiation and organoid formation, which were augmented by FZD4 overexpression. Moreover, FZD4 restoration by overexpression or pharmacological induction led to induction of WNT/β-catenin signaling and expression of elastogenic components in three-dimensional lung tissue cultures ex vivo.

CONCLUSIONS

Reduced FZD4 expression in COPD contributes to impaired alveolar repair capacity.

Undiagnosed Chronic Obstructive Pulmonary Disease Contributes to the Burden of Health Care Use. Data from the CanCOLD Study

RATIONALE

Chronic obstructive pulmonary disease (COPD) remains undiagnosed in many individuals with persistent airflow limitation. These individuals may be susceptible to exacerbation-like respiratory events that consume health care resources.

OBJECTIVES

To compare exacerbation-like respiratory events, event prevalence, and differences in the odds of using medication and/or health services between subjects with diagnosed and undiagnosed COPD.

METHODS

Subjects sampled from the general population participating in the CanCOLD (Canadian Cohort Obstructive Lung Disease) study, with at least 12 months of exacerbation-event follow-up who were classified as having physician-diagnosed or undiagnosed COPD were assessed. Exacerbation-like respiratory events were captured using a questionnaire administered every 3 months.

MEASUREMENTS AND MAIN RESULTS

A total of 355 subjects were undiagnosed and 150 were diagnosed with COPD. Undiagnosed subjects were less symptomatic and functionally impaired, had been prescribed fewer respiratory medications, and had better health status. The incidence of reported exacerbation-like events was higher in diagnosed subjects and increased in both groups with the severity of airflow obstruction. Although subjects with diagnosed COPD were more often prescribed medication for exacerbation events, health service use for exacerbation events was similar in both groups.

CONCLUSIONS

Most subjects with COPD in Canada remain undiagnosed. These subjects are less symptomatic and impaired, which may partly explain lack of diagnosis. Although patients with undiagnosed COPD experience fewer exacerbations than those with diagnosed COPD, they use a similar amount of health services for exacerbation events; thus, the overall health system burden of exacerbations in those with undiagnosed COPD is considerable.

Health resource utilization for inpatients with COPD treated with nebulized arformoterol or nebulized formoterol

OBJECTIVE

Arformoterol is the (R,R)-enantiomer of formoterol. Preclinical studies suggest that it is a stronger bronchodilator than the racemic (R,R/S,S)-formoterol; however, its potential clinical advantages have not been demonstrated. This study compared the length of stay (LOS), 30-day readmission rates, and doses of rescue medication administered in hospitalized patients with COPD who were treated with nebulized arformoterol or nebulized formoterol.

METHODS

This retrospective analysis utilized data from Premier, Inc. (Charlotte, NC, USA), the largest nationwide hospital-based administrative database. COPD patients ≥40 years of age were included if they were hospitalized between January 2011 and July 2014, had no asthma diagnoses, and were treated with nebulized arformoterol or nebulized formoterol. LOS was measured from the day the patients initiated the study medication (index day). Rescue medications were defined as short-acting bronchodilators used from the index day onward. Multivariate statistical models included a random effect for hospital and controlled for patient demographics, hospital characteristics, admission characteristics, prior hospitalizations, comorbidities, pre-index service use, and pre-index medication use.

RESULTS

A total of 7,876 patients received arformoterol, and 3,612 patients received nebulized formoterol. There was no significant difference in 30-day all-cause (arformoterol =11.9%, formoterol =12.1%, odds ratio [OR] =0.981, P=0.82) or COPD-related hospital readmission rates (arformoterol =8.0%, formoterol =8.0%, OR =1.002, P=0.98) after adjusting for covariates. The adjusted mean LOS was significantly shorter for arformoterol-treated vs formoterol-treated patients (4.6 vs 4.9 days, P=0.039), and arformoterol-treated patients used significantly fewer doses of rescue medications vs formoterol-treated patients (5.9 vs 6.6 doses, P=0.006).

CONCLUSION

During inpatient stays, treating with arformoterol instead of nebulized formoterol may lead to shorter LOS and lower rescue medication use.

Comparison of hospital outcomes and resource use in acute COPD exacerbation patients managed by teaching versus nonteaching services in a community hospital

RATIONALE, AIMS, AND OBJECTIVES

The impact of teaching versus nonteaching services on outcomes and resource use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is unknown. The aim of the study is to evaluate the impact of an internal medicine teaching service compared to a nonteaching service on outcomes and resource use in patients admitted with AECOPD in a community teaching hospital.

METHODS

A retrospective cohort study of patients admitted for a primary diagnosis of chronic obstructive pulmonary disease exacerbation to Florida Hospital Orlando, a large community teaching hospital, between January 1, 2011, and December 31, 2014. Data were extracted from Premier administrative database. Risk adjusted length of stay (LOS), cost of hospitalization, 30-day readmissions, and mortality rate were measured. Risk adjustment for outcomes was based on Premier CareScience methodology.

RESULTS

A total of 1419 patients were included, 306 in the teaching group and 1113 in the nonteaching group. Risk adjusted cost and LOS were significantly lower in the teaching group compared to the nonteaching group (observed/expected cost 0.66 vs 1.06, P < .001) and (observed/expected LOS 0.93 vs 1.69, P < .001), respectively. No significant difference was found between the 2 groups in risk adjusted mortality and readmissions (P = .48 and .89, respectively). Use of consults was significantly lower in the teaching groups with 73% vs 31% of the patient in the teaching group had no consults compared to the nonteaching group (P < .001). The teaching service was significantly associated with decreased use of consults after adjustment for other variables (odds ratio, 0.17, 95% CI, 0.15-0.23, P < .001).

CONCLUSION

The teaching service had more favorable outcomes compared to nonteaching services in patients hospitalized for AECOPD. The physician practice model has a major impact on the cost, LOS, and use of consults in patients with AECOPD.

Socioeconomic impact of asthma, chronic obstructive pulmonary disease and asthma-COPD overlap syndrome

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is defined as having both features of asthma and COPD, which are airway hyper-responsiveness and incompletely reversible airway obstruction. However, socioeconomic impact of ACOS have not been well appreciated.

METHODS

Adults with available wheezing history and acceptable spirometry were selected from the fourth Korean National Health and Nutrition Examination Survey (KNHANES IV) in 2007-2009. Their data were merged with the Korean National Health Insurance claim data. 'Asthma group' was defined as having self-reported wheezing history and FEV₁/FVC ≥0.7, 'COPD group' was defined as having FEV₁/FVC <0.7 and no wheezing, 'ACOS group' was defined as having both wheezing and FEV₁/FVC <0.7, and 'no airway disease (NAD) group' was defined as having no wheezing and FEV₁/FVC ≥0.7.

RESULTS

Among a total of 11,656 subjects, ACOS comprise 2.2%; COPD, 8.4%; asthma, 5.8% and NAD, 83.6%. Total length of healthcare utilization and medical costs of ACOS group was the top among four groups (P<0.001), though inpatient medical cost was the highest in COPD group (P=0.025). Multiple linear regression analyses showed that ACOS group (β=12.63, P<0.001) and asthma group (β=6.14, P<0.001) were significantly associated with longer duration of healthcare utilization and ACOS group (β=350,475.88, P=0.008) and asthma group (β=386,876.81, P<0.001) were associated with higher medical costs.

CONCLUSIONS

This study demonstrated that ACOS independently influences healthcare utilization after adjusting several factors. In order to utilize limited medical resources efficiently, it may be necessary to find and manage ACOS patients.

Relationship of Steroid Dosing and Duration of Mechanical Ventilation in Adult Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

The optimal steroid dose for patients who require mechanical ventilation (MV) for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is unknown.

OBJECTIVE

The primary objective of the study is to describe the relationship between steroid doses prescribed and duration of MV.

METHODS

This was a retrospective study of patients admitted between October 2013 and September 2014 who were prescribed steroids and received MV for ≥48 hours for AECOPD.

RESULTS

Fifty-four patients were included in the study. Median maintenance daily dose of 300 mg/d (IQR: 150-300) prednisone equivalent was prescribed upon initiation of MV. The maintenance daily dose prescribed upon initiation of MV was visually plotted and was categorized into 2 groups: high dose (≥300 mg; n = 28) and low dose (<300 mg; n = 26). There was no relationship observed between the maintenance dose prescribed and duration of MV ( P = .44) or intensive care unit (ICU) length of stay (LOS; P = .63). Seventeen (31.5%) patients developed an infection during their hospital stay. These patients received a higher cumulative dose of steroids compared to those without an infection ( P = .035).

CONCLUSION

No relationship was observed between maintenance steroid dose prescribed and the duration of MV or ICU LOS. Evaluation of a safe and effective dose and duration of steroids in this population is warranted.

COPD and stroke: are systemic inflammation and oxidative stress the missing links?

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation and loss of lung function, and is currently the third largest cause of death in the world. It is now well established that cardiovascular-related comorbidities such as stroke contribute to morbidity and mortality in COPD. The mechanisms linking COPD and stroke remain to be fully defined but are likely to be interconnected. The association between COPD and stroke may be largely dependent on shared risk factors such as aging and smoking, or the association of COPD with traditional stroke risk factors. In addition, we propose that COPD-related systemic inflammation and oxidative stress may play important roles by promoting cerebral vascular dysfunction and platelet hyperactivity. In this review, we briefly discuss the pathogenesis of COPD, acute exacerbations of COPD (AECOPD) and cardiovascular comorbidities associated with COPD, in particular stroke. We also highlight and discuss the potential mechanisms underpinning the link between COPD and stroke, with a particular focus on the roles of systemic inflammation and oxidative stress.

Australian and New Zealand Pulmonary Rehabilitation Guidelines

BACKGROUND AND OBJECTIVE

The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence-based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts.

METHODS

The Guideline methodology adhered to the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. Nine key questions were constructed in accordance with the PICO (Population, Intervention, Comparator, Outcome) format and reviewed by a COPD consumer group for appropriateness. Systematic reviews were undertaken for each question and recommendations made with the strength of each recommendation based on the GRADE (Gradings of Recommendations, Assessment, Development and Evaluation) criteria. The Guidelines were externally reviewed by a panel of experts.

RESULTS

The Guideline panel recommended that patients with mild-to-severe COPD should undergo PR to improve quality of life and exercise capacity and to reduce hospital admissions; that PR could be offered in hospital gyms, community centres or at home and could be provided irrespective of the availability of a structured education programme; that PR should be offered to patients with bronchiectasis, interstitial lung disease and pulmonary hypertension, with the latter in specialized centres. The Guideline panel was unable to make recommendations relating to PR programme length beyond 8 weeks, the optimal model for maintenance after PR, or the use of supplemental oxygen during exercise training. The strength of each recommendation and the quality of the evidence are presented in the summary.

CONCLUSION

The Australian and New Zealand Pulmonary Rehabilitation Guidelines present an evaluation of the evidence for nine PICO questions, with recommendations to provide guidance for clinicians and policymakers.

Tuberculosis associated chronic obstructive pulmonary disease

OBJECTIVES

Reviewed the epidemiology, clinical characteristics, mechanisms, and treatment of tuberculosis associated chronic obstructive pulmonary disease.

DATA SOURCE

We searched PubMed, EMBASE, and the CINAHL from inception to June 2016. We used the following search terms: Tuberculosis, COPD, Tuberculosis associated COPD, and so forth. All types of study were chosen.

RESULTS AND CONCLUSION

Chronic obstructive pulmonary disease (COPD) and tuberculosis are significant public health problems, particularly in developing countries. Although, smoking is the conventional risk factor for COPD, nonsmoking related risk factors such as biomass fuel exposure, childhood lower-respiratory tract infections, chronic asthma, outdoor air pollution, and prior history of pulmonary tuberculosis have become important risk factors of COPD, particularly in developing countries. Past history of tuberculosis as a risk factor of chronic airflow obstruction has been reported in several studies. It may develop during the course of tuberculosis or after completion of tuberculosis treatment. Developing countries with large burden of tuberculosis can contribute significantly to the burden of chronic airflow obstruction. Prompt diagnosis and treatment of tuberculosis should be emphasized to lessen the future burden of chronic airflow obstruction.

Impact of a COPD comprehensive case management program on hospital length of stay and readmission rates

Background

COPD accounts for the highest rate of hospital admissions among major chronic diseases. COPD hospitalizations are associated with impaired quality of life, high health care utilization, and poor prognosis and result in an economic and a social burden that is both substantial and increasing.

Aim

The aim of this study is to determine the efficacy of a comprehensive case management program (CCMP) in reducing length of stay (LOS) and risk of hospital admissions and readmissions in patients with COPD.

Materials and methodology

We retrospectively compared outcomes across five large hospitals in Vancouver, BC, Canada, following the implementation of a systems approach to the management of COPD patients who were identified in the hospital and followed up in the community for 90 days. We compared numbers, rates, and intervals of readmission and LOS during 2 years of active program delivery compared to 1 year prior to program implementation.

Results

A total of 1,564 patients with a clinical diagnosis of COPD were identified from 2,719 hospital admissions during the 3 years of study. The disease management program reduced COPD-related hospitalizations by 30% and hospitalizations for all causes by 13.6%. Similarly, the rate of readmission for all causes showed a significant decline, with hazard ratios (HRs) of 0.55 (year 1) and 0.51 (year 2) of intervention (P<0.001). In addition, patients’ mean LOS (days) for COPD-related admissions declined significantly from 10.8 to 6.8 (P<0.05).

Conclusion

A comprehensive disease management program for COPD patients, including education, case management, and follow-up, was associated with significant reduction in hospital admissions and LOS.

Airflow limitation severity and post-operative pulmonary complications following extra-pulmonary surgery in COPD patients

BACKGROUND AND OBJECTIVE

The association between airflow limitation severity and post-operative pulmonary complications (PPCs) among COPD patients undergoing extra-pulmonary surgery is unknown. We evaluated the association between forced expiratory volume in 1 s (FEV₁ ) and PPC in COPD patients undergoing extra-pulmonary surgery.

METHODS

Using prospective cohort of PPC evaluation for extra-pulmonary surgery, we identified 694 COPD patients who conducted PPC evaluation before extra-pulmonary surgery between March 2014 and January 2015 at a tertiary hospital, Seoul, Korea.

RESULTS

The overall incidence of PPC was 24.4%. The incidence of PPC in quintiles 1-5 of FEV₁ (% predicted) was 31.4, 25.8, 23.7, 21.6 and 19.7%, respectively (P for trend: 0.019). In fully adjusted multivariable models, the relative risks (RRs, 95% CI) for PPC comparing participants in quintiles 1-4 of FEV₁ (% predicted) with those in quintile 5 were 1.69 (1.03-2.79), 1.41 (0.83-2.37), 1.26 (0.75-2.11) and 1.30 (0.76-2.22), respectively (P for trend: 0.046). The association of severe airflow limitation with respiratory failure and post-operative exacerbations was stronger in participants who did not use bronchodilators compared with those who did.

CONCLUSION

We found a progressive and significant relationship between severity of airflow limitation and the incidence of PPC in COPD patients undergoing extra-pulmonary surgery. Furthermore, perioperative bronchodilator use was associated with a reduced risk of respiratory failure and post-operative exacerbations in patients with severe airflow limitation.

Effectiveness of diagnostic screening tests in mass screening for COPD using a cooperative regional system in a region with heavy air pollution: a cross-sectional study

OBJECTIVES

This study aimed to evaluate the effectiveness of a cooperative healthcare model for early detection and diagnosis of chronic obstructive pulmonary disease (COPD).

METHODS

This was a cross-sectional observational study. We performed diagnosis of COPD at 4 public health centres in Ōmuta, Japan from March 2015 to March 2016, by adding screening for COPD at the time of routine medical evaluations. All patients aged over 40 years were eligible to participate. Among 397 eligible patients, 293 agreed to participate in the study.

RESULTS

The estimated prevalence of COPD in Ōmuta was 10% among patients aged over 40 years and was 17% among smokers. Among those who were screened, over half of them had questionnaire scores over the cut-off of 17 points and decreased FEV1/FVC%, indicating COPD (p>0.05). 30 patients with suspected COPD were referred for further investigation at a local central hospital, but only 6 underwent further medical examinations.

CONCLUSIONS

The combination of a COPD questionnaire and medical examination is effective as a COPD screening tool. Future research should investigate behavioural interventions for smoking cessation that can be offered in a cooperative model, as well as for improving participation in COPD screening and for encouraging early presentation for treatment in those suspected of having COPD.

Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Guidelines have provided positive recommendations for pulmonary rehabilitation after exacerbations of chronic obstructive pulmonary disease (COPD), but recent studies indicate that postexacerbation rehabilitation may not always be effective in patients with unstable COPD.

OBJECTIVES

To assess effects of pulmonary rehabilitation after COPD exacerbations on hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life (HRQL) and exercise capacity).

SEARCH METHODS

We identified studies through searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PEDro (Physiotherapy Evidence Database) and the Cochrane Airways Review Group Register of Trials. Searches were current as of 20 October 2015, and handsearches were run up to 5 April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing pulmonary rehabilitation of any duration after exacerbation of COPD versus conventional care. Pulmonary rehabilitation programmes had to include at least physical exercise (endurance or strength exercise, or both). We did not apply a criterion for the minimum number of exercise sessions a rehabilitation programme had to offer to be included in the review. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS

We expected substantial heterogeneity across trials in terms of how extensive rehabilitation programmes were (i.e. in terms of number of completed exercise sessions; type, intensity and supervision of exercise training; and patient education), duration of follow-up (< 3 months vs ≥ 3 months) and risk of bias (generation of random sequence, concealment of random allocation and blinding); therefore, we performed subgroup analyses that were defined before we carried them out. We used standard methods expected by Cochrane in preparing this update, and we used GRADE for assessing the quality of evidence.

MAIN RESULTS

For this update, we added 11 studies and included a total of 20 studies (1477 participants). Rehabilitation programmes showed great diversity in terms of exercise training (number of completed exercise sessions; type, intensity and supervision), patient education (from none to extensive self-management programmes) and how they were organised (within one setting, e.g. pulmonary rehabilitation, to across several settings, e.g. hospital, outpatient centre and home). In eight studies, participants completed extensive pulmonary rehabilitation, and in 12 studies, participants completed pulmonary rehabilitation ranging from not extensive to moderately extensive.Eight studies involving 810 participants contributed data on hospital readmissions. Moderate-quality evidence indicates that pulmonary rehabilitation reduced hospital readmissions (pooled odds ratio (OR) 0.44, 95% confidence interval (CI) 0.21 to 0.91), but results were heterogenous (I² = 77%). Extensiveness of rehabilitation programmes and risk of bias may offer an explanation for the heterogeneity, but subgroup analyses were not statistically significant (P values for subgroup effects were between 0.07 and 0.11). Six studies including 670 participants contributed data on mortality. The quality of evidence was low, and the meta-analysis did not show a statistically significant effect of rehabilitation on mortality (pooled OR 0.68, 95% CI 0.28 to 1.67). Again, results were heterogenous (I² = 59%). Subgroup analyses showed statistically significant differences in subgroup effects between trials with more and less extensive rehabilitation programmes and between trials at low and high risk for bias, indicating possible explanations for the heterogeneity. Hospital readmissions and mortality studies newly included in this update showed, on average, significantly smaller effects of rehabilitation than were seen in earlier studies.High-quality evidence suggests that pulmonary rehabilitation after an exacerbation improves health-related quality of life. The eight studies that used St George's Respiratory Questionnaire (SGRQ) reported a statistically significant effect on SGRQ total score, which was above the minimal important difference (MID) of four points (mean difference (MD) -7.80, 95% CI -12.12 to -3.47; I² = 64%). Investigators also noted statistically significant and important effects (greater than MID) for the impact and activities domains of the SGRQ. Effects were not statistically significant for the SGRQ symptoms domain. Again, all of these analyses showed heterogeneity, but most studies showed positive effects of pulmonary rehabilitation, some studies showed large effects and others smaller but statistically significant effects. Trials at high risk of bias because of lack of concealment of random allocation showed statistically significantly larger effects on the SGRQ than trials at low risk of bias. High-quality evidence shows that six-minute walk distance (6MWD) improved, on average, by 62 meters (95% CI 38 to 86; I² = 87%). Heterogeneity was driven particularly by differences between studies showing very large effects and studies showing smaller but statistically significant effects. For both health-related quality of life and exercise capacity, studies newly included in this update showed, on average, smaller effects of rehabilitation than were seen in earlier studies, but the overall results of this review have not changed to an important extent compared with results reported in the earlier version of this review.Five studies involving 278 participants explicitly recorded adverse events, four studies reported no adverse events during rehabilitation programmes and one study reported one serious event.

AUTHORS' CONCLUSIONS

Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.

Differences in systemic adaptive immunity contribute to the 'frequent exacerbator' COPD phenotype

BACKGROUND

Some COPD patients are more susceptible to exacerbations than others. Mechanisms underlying these differences in susceptibility are not well understood. We hypothesized that altered cell mediated immune responses may underlie a propensity to suffer from frequent exacerbations in COPD.

METHODS

Peripheral blood mononuclear cells (PBMCs) were obtained from 24 stable COPD patients, eight frequent exacerbators (≥3 diary-card exacerbations/year) and 16 infrequent exacerbators (< 3 diary-card exacerbations/year). Detailed multi-parameter flow cytometry was used to study differences in innate and adaptive systemic immune function between frequent and infrequently exacerbating COPD patients.

RESULTS

The 24 COPD patients had a mean (SD) age of 76.3 (9.4) years and FEV₁ 1.43 (0.60)L, 53.3 (18.3)% predicted. PBMCs of frequent exacerbators (FE) contained lower frequencies of CD4+ T central memory cells (CD4+ Tcm) compared to infrequent exacerbators (IE) (FE = 18.7 %; IE = 23.9 %; p = 0.035). This observation was also apparent in absolute numbers of CD4+ Tcm cells (FE = 0.17 × 10^6/mL; IE = 0.25 × 10^6/mL; p = 0.035). PBMCs of FE contained a lower frequency of CD8+ T effector memory cells expressing HLA-DR (Human Leukocyte Antigen - D Related) compared to IE COPD patients (FE = 22.7 %; IE = 31.5 %; p = 0.007).

CONCLUSION

Differences in the adaptive systemic immune system might associate with exacerbation susceptibility in the 'frequent exacerbator' COPD phenotype. These differences include fewer CD4+ T central memory cells and CD8+ T effector memory cells.

TRIAL REGISTRATION

Not applicable.

Correlates of disease-specific knowledge in Chinese patients with COPD

Background

This study aimed to determine the associations of various sociodemographic factors with the level of disease-specific knowledge among Hong Kong Chinese patients with COPD.

Methods

A cross-sectional survey of 100 Chinese adults with COPD recruited from outpatient clinics was conducted from September 2009 to September 2010. Data on the knowledge specific to COPD and patients’ sociodemographics were collected from face-to-face interviews. Primary outcome of disease-specific knowledge was measured using 65-item Bristol COPD Knowledge Questionnaire (BCKQ), summing up the 65 items as the BCKQ overall score. Associations of sociodemographic factors with the BCKQ overall score were evaluated using the linear regression model.

Results

The mean BCKQ overall score of our patients was 41.01 (SD: 10.64). The knowledge in topics of “Smoking” and “Phlegm” achieved the first (3.97, SD: 0.82) and second (3.91, SD: 1.17) highest mean scores, respectively, while the topic of “Oral steroids” returned the lowest mean score of 1.89 (SD: 1.64). The BCKQ overall score progressively declined (P<0.001) with increase in education level, with the highest BCKQ overall score of 46.71 at no formal education among all subgroups. Compared to nondrinkers, current drinkers were associated with lower total BCKQ score.

Conclusion

We found that among COPD patients in outpatient clinics, impairments in the level of COPD knowledge were evident in patients who were current drinkers or had higher level of education.

Independent effect of prior exacerbation frequency and disease severity on the risk of future exacerbations of COPD: a retrospective cohort study

Few studies have researched the independent effect of COPD severity on the risk of future exacerbations adjusted by previous exacerbation frequency. We aimed to analyse the independent effect of COPD severity on the risk of exacerbations in the following year, and whether this effect was stronger or not than the effect of a previous history of exacerbations. We conducted a retrospective population-based cohort study including 900 patients with confirmed COPD. Exacerbation frequency was observed for the previous year and for the following year. Patients were defined as ‘Frequent Exacerbator’ (FE) phenotype if they suffered ⩾2 exacerbations in a year, and were categorised according to the severity of COPD (GOLD Grades 1–4). Odds ratios (ORs) were estimated by logistic regression adjusting for age, gender, smoking status, severity of COPD and being FE in the previous year. The main predictor of being FE among all grades of COPD severity was a history of frequent exacerbations in the previous year: adjusted OR 4.97; 95% confidence interval (CI) (3.54–6.97). COPD severity was associated with a higher risk of being FE: Crude OR GOLD Grade 4 3.86; 95% CI (1.50–9.93). However, this association diminished after adjusting for being FE in the previous year: adjusted OR 2.08; 95% CI (0.75–5.82). Our results support that a history of frequent exacerbations in the previous year is the most important independent predictor of exacerbations in the following year, also among the most severe COPD patients. Severity of COPD would be associated with a higher risk of exacerbations, but this effect would be partly determined by the exacerbations suffered in the previous year.

Incidence of utilization- and symptom-defined COPD exacerbations in hospital- and population-recruited patients

Objectives

The objectives of this study were to estimate the impact of recruitment source and outcome definition on the incidence of acute exacerbations of COPD (AECOPD) and explore possible predictors of AECOPD.

Patients and methods

During a 1-year follow-up, we performed a baseline visit and four telephone interviews of 81 COPD patients and 132 controls recruited from a population-based survey and 205 hospital-recruited COPD patients. Both a definition based on health care utilization and a symptom-based definition of AECOPD were applied. For multivariate analyses, we chose a negative binomial regression model.

Results

COPD patients from the population- and hospital-based samples experienced on average 0.4 utilization-defined and 2.9 symptom-defined versus 1.0 and 5.9 annual exacerbations, respectively. The incidence rate ratios for utilization-defined AECOPD were 2.45 (95% CI 1.22–4.95), 3.43 (95% CI 1.59–7.38), and 5.67 (95% CI 2.58–12.48) with Global Initiative on Obstructive Lung Disease spirometric stages II, III, and IV, respectively. The corresponding incidence rate ratios for the symptom-based definition were 3.08 (95% CI 1.96–4.84), 3.45 (95% CI 1.92–6.18), and 4.00 (95% CI 2.09–7.66). Maintenance therapy (regular long-acting muscarinic antagonists, long-acting beta-2 agonists, inhaled corticosteroids, or theophylline) also increased the risk of AECOPD with both exacerbation definitions (incidence rate ratios 1.65 and 1.73, respectively). The risk of AECOPD was 59%–78% higher in the hospital sample than in the population sample.

Conclusion

If externally valid conclusions are to be made regarding incidence and predictors of AECOPD, studies should be based on general population samples or adjustments should be made on account of a likely higher incidence in other samples. Likewise, the effect of different AECOPD definitions should be taken into consideration.

Long-term integrated telerehabilitation of COPD Patients: a multicentre randomised controlled trial (iTrain)

BACKGROUND

Pulmonary rehabilitation (PR) is an effective intervention for the management of people with chronic obstructive pulmonary disease (COPD). However, available resources are often limited, and many patients bear with poor availability of programmes. Sustaining PR benefits and regular exercise over the long term is difficult without any exercise maintenance strategy. In contrast to traditional centre-based PR programmes, telerehabilitation may promote more effective integration of exercise routines into daily life over the longer term and broaden its applicability and availability. A few studies showed promising results for telerehabilitation, but mostly with short-term interventions. The aim of this study is to compare long-term telerehabilitation with unsupervised exercise training at home and with standard care.

METHODS/DESIGN

An international multicentre randomised controlled trial conducted across sites in three countries will recruit 120 patients with COPD. Participants will be randomly assigned to telerehabilitation, treadmill and control, and followed up for 2 years. The telerehabilitation intervention consists of individualised exercise training at home on a treadmill, telemonitoring by a physiotherapist via videoconferencing using a tablet computer, and self-management via a customised website. Patients in the treadmill arm are provided with a treadmill only to perform unsupervised exercise training at home. Patients in the control arm are offered standard care. The primary outcome is the combined number of hospitalisations and emergency department presentations. Secondary outcomes include changes in health status, quality of life, anxiety and depression, self-efficacy, subjective impression of change, physical performance, level of physical activity, and personal experiences in telerehabilitation.

DISCUSSION

This trial will provide evidence on whether long-term telerehabilitation represents a cost-effective strategy for the follow-up of patients with COPD. The delivery of telerehabilitation services will also broaden the availability of PR and maintenance strategies, especially to those living in remote areas and with no access to centre-based exercise programmes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02258646 .

Reliability and Validity of the Brief Fatigue Inventory and Dyspnea Inventory in People With Chronic Obstructive Pulmonary Disease

CONTEXT

Dyspnea, fatigue, and pain are common in individuals with chronic obstructive pulmonary disease (COPD). However, questionnaires with a similar format are not available to assess their relative severity and interference.

OBJECTIVES

To determine the reliability and validity of the Brief Fatigue Inventory (BFI) and Dyspnea Inventory (DI) in COPD patients who attend pulmonary rehabilitation programs.

METHODS

Participants were recruited from four pulmonary rehabilitation programs to complete a survey package containing: the Chronic Respiratory Questionnaire (CRQ), BFI, and DI; and one week later, to complete the BFI and DI. Retrospective data of the CRQ, BFI, and DI were retrieved from one of the programs.

RESULTS

For the prospective component, there was an 85% response rate (n = 91) for the first package and 83.5% response rate (n = 76) for the second package. Retrospectively, CRQ, BFI, and DI data were retrieved from 48 charts. The BFI and DI demonstrated excellent internal consistency (Cronbach alpha = 0.96 both), and high test-retest reliability (intraclass correlation3,1 = 0.86 and 0.91, respectively). By comparison to the fatigue and dyspnea domains of the CRQ, the BFI showed high concurrent validity (ρ = -0.83), whereas the DI showed moderate (ρ = -0.57) to high (ρ = -0.78) concurrent validity. Factor analysis provided evidence that the items in the BFI and DI measured the intended constructs.

CONCLUSION

The BFI and DI are valid and reliable measures to evaluate fatigue and dyspnea in COPD patients and could be used concurrently with the Brief Pain Inventory to inform the relative severity and interference of these common symptoms in COPD.

Modeling the effectiveness of nebulized terbutaline for decompensated chronic obstructive pulmonary disease patients in the emergency department

Short-acting β2-agonists (SABA) are widely used in the emergency department (ED) to treat patients with decompensated chronic obstructive pulmonary disease (COPD). We sought to model the effectiveness of nebulized SABA (terbutaline) on clinically relevant parameters associated with a reduction in work of breathing or respiratory muscle fatigue in decompensated COPD patients admitted to the ED.Forty consecutive decompensated COPD patients (having received at least one dose of nebulized terbutaline during their stay in the ED) were included in an observational cohort study. The terbutaline dose received at time t was expressed as cumulative dose and as a rate (mg/day). The associations between the terbutaline dose and time-dependent outcome parameters (respiratory rate, heart rate, arterial blood gases, and, as a marker of terbutaline's systemic effect, serum potassium) were analyzed using a nonlinear, mixed-effects model. The effect of various covariates influencing terbutaline's effectiveness (baseline characteristics and concomitant treatments) was assessed on the model.Among the investigated patients, a total of 377 time-dependent observations were available for analysis. Neither the cumulative dose nor the dose rate at time t significantly influenced the arterial blood gas parameters or heart rate. The cumulative dose of terbutaline was associated with a lower serum potassium level (P < 0.001) and, less significantly, a lower respiratory frequency (P = 0.036). In a tertile analysis, the need for post-ED hospitalization was not associated with the cumulative dose or dose rate of terbutaline.Overall, the results of our modeling study strongly suggest that terbutaline dose did not influence time-dependent outcomes other than serum potassium, and thus call into question the systematic administration of inhaled SABA to patients admitted to the ED for decompensated COPD.

Economic and operational burden associated with malnutrition in chronic obstructive pulmonary disease

BACKGROUND

Malnutrition is common in patients with chronic obstructive pulmonary disease (COPD). This study aimed to explore its association with all-cause mortality, emergency hospitalisation and subsequently healthcare costs.

METHODS

A prospective cohort observational pilot study was carried out in outpatients with COPD that attended routine respiratory clinics at a large tertiary Australian hospital during 2011. Electronic hospital records and hospital coding was used to determine nutritional status and whether a patient was coded as nourished or malnourished and information on healthcare use and 1-year mortality was recorded.

RESULTS

Eight hundred and thirty four patients with COPD attended clinics during 2011, of those 286 went on to be hospitalised during the 12 month follow-up period. Malnourished patients had a significantly higher 1-year mortality (27.7% vs. 12.1%; p = 0.001) and were hospitalised more frequently (1.11 SD 1.24 vs. 1.51 SD 1.43; p = 0.051). Only malnutrition (OR 0.36 95% CI 0.14-0.91; p = 0.032) and emergency hospitalisation rate (OR 1.58 95% CI 1.2-2.1; p = 0.001) were independently associated with 1-year mortality. Length of hospital stay was almost twice the duration in those coded for malnutrition (11.57 SD 10.93 days vs. 6.67 SD 10.2 days; p = 0.003) and at almost double the cost (AUD $23,652 SD $26,472 vs. $12,362 SD $21,865; p = 0.002) than those who were well-nourished.

CONCLUSION

Malnutrition is an independent predictor of 1-year mortality and healthcare use in patients with COPD. Malnourished patients with COPD present both an economic and operational burden.

Long-term exercise maintenance in COPD via telerehabilitation: a two-year pilot study

Introduction Pulmonary rehabilitation (PR) is an integral part of the management of chronic obstructive pulmonary disease (COPD). However, many patients do not access or complete PR, and long-term exercise maintenance has been difficult to achieve after PR. This study aimed to investigate feasibility, long-term exercise maintenance, clinical effects, quality of life and use of hospital resources of a telerehabilitation intervention. Methods Ten patients with COPD were offered a two-year follow-up via telerehabilitation after attending PR. The intervention consisted of home exercise, telemonitoring and self-management via a webpage combined with weekly videoconferencing sessions. Equipment included a treadmill, a pulse oximeter and a tablet. Data collected at baseline, one year and two years were six-minute walking distance (6MWD), COPD assessment test (CAT), EuroQol 5 dimensions (EQ-5D), hospitalisations and outpatient visits. Results No dropout occurred. Physical performance, lung capacity, health status and quality of life were all maintained at two years. At one year, 6MWD improved by a mean of 40 metres from baseline, CAT decreased by four points and EQ visual analogue scale (EQ VAS) improved by 15.6 points. Discussion Long-term exercise maintenance in COPD via telerehabilitation is feasible. Results are encouraging and suggest that telerehabilitation can prevent deterioration and improve physical performance, health status and quality of life.

Predictors of Hospitalized Exacerbations and Mortality in Chronic Obstructive Pulmonary Disease

BACKGROUND AND AIM

Exacerbations of chronic obstructive pulmonary disease (COPD) carry significant consequences for patients and are responsible for considerable health-care costs-particularly if hospitalization is required. Despite the importance of hospitalized exacerbations, relatively little is known about their determinants. This study aimed to analyze predictors of hospitalized exacerbations and mortality in COPD patients.

METHODS

This was a retrospective population-based cohort study. We selected 900 patients with confirmed COPD aged ≥35 years by simple random sampling among all COPD patients in Cantabria (northern Spain) on December 31, 2011. We defined moderate exacerbations as events that led a care provider to prescribe antibiotics or corticosteroids and severe exacerbations as exacerbations requiring hospital admission. We observed exacerbation frequency over the previous year (2011) and following year (2012). We categorized patients according to COPD severity based on forced expiratory volume in 1 second (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grades 1-4). We estimated the odds ratios (ORs) by logistic regression, adjusting for age, sex, smoking status, COPD severity, and frequent exacerbator phenotype the previous year.

RESULTS

Of the patients, 16.4% had ≥1 severe exacerbations, varying from 9.3% in mild GOLD grade 1 to 44% in very severe COPD patients. A history of at least two prior severe exacerbations was positively associated with new severe exacerbations (adjusted OR, 6.73; 95% confidence interval [CI], 3.53-12.83) and mortality (adjusted OR, 7.63; 95%CI, 3.41-17.05). Older age and several comorbidities, such as heart failure and diabetes, were similarly associated.

CONCLUSIONS

Hospitalized exacerbations occurred with all grades of airflow limitation. A history of severe exacerbations was associated with new hospitalized exacerbations and mortality.

Azithromycin induces anti-viral effects in cultured bronchial epithelial cells from COPD patients

Rhinovirus infection is a major cause of chronic obstructive pulmonary disease (COPD) exacerbations and may contribute to the development into severe stages of COPD. The macrolide antibiotic azithromycin may exert anti-viral actions and has been reported to reduce exacerbations in COPD. However, little is known about its anti-viral actions on bronchial epithelial cells at clinically relevant concentrations. Primary bronchial epithelial cells from COPD donors and healthy individuals were treated continuously with azithromycin starting 24 h before infection with rhinovirus RV16. Expression of interferons, RIG-I like helicases, pro-inflammatory cytokines and viral load were analysed. Azithromycin transiently increased expression of IFNβ and IFNλ1 and RIG-I like helicases in un-infected COPD cells. Further, azithromycin augmented RV16-induced expression of interferons and RIG-I like helicases in COPD cells but not in healthy epithelial cells. Azithromycin also decreased viral load. However, it only modestly altered RV16-induced pro-inflammatory cytokine expression. Adding budesonide did not reduce interferon-inducing effects of azithromycin. Possibly by inducing expression of RIG-I like helicases, azithromycin increased rhinovirus-induced expression of interferons in COPD but not in healthy bronchial epithelium. These effects would reduce bronchial viral load, supporting azithromycin’s emerging role in prevention of exacerbations of COPD.

Factors associated with exacerbation in mild- to-moderate COPD patients

INTRODUCTION

COPD exacerbation negatively impacts the patient's quality of life and lung function, increases mortality, and increases socioeconomic costs. In a real-world setting, the majority of patients with COPD have mild-to-moderate airflow limitation. Therefore, it is important to evaluate COPD exacerbation in patients with mild-to-moderate airflow limitation, although most studies have focused on the patients with moderate or severe COPD. The objective of this study was to evaluate factors associated with COPD exacerbation in patients with mild-to-moderate airflow limitation.

METHODS

Patients registered in the Korean COPD Subtype Study cohort were recruited from 37 tertiary referral hospitals in Korea. We obtained their clinical data including demographic characteristics, past medical history, and comorbidities from medical records. Patients were required to visit the hospital to document their COPD status using self-administered questionnaires every 6 months.

RESULTS

A total of 570 patients with mild-to-moderate airflow limitation were enrolled. During the first year of follow-up, 30.5% patients experienced acute exacerbation, with exacerbations being more common in patients with poor lung function. Assessed factors associated with COPD exacerbation included COPD assessment test scores, modified Medical Research Council dyspnea assessment test scores, St George's Respiratory Questionnaire for COPD scores, a previous history of exacerbation, and histories of pneumonia and allergic rhinitis. Logistic regression tests revealed St George's Respiratory Questionnaire for COPD scores (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.04; P=0.034), a previous history of exacerbation (OR, 3.12; 95% CI, 1.35-7.23; P=0.008), and a history of pneumonia (OR, 1.85; 95% CI, 1.06-3.25; P=0.032) as risk factors for COPD exacerbation.

CONCLUSION

Our results suggest that COPD exacerbation in patients with mild-to-moderate airflow limitation is associated with the patient's quality of life, previous history of exacerbation, and history of pneumonia.

Heart failure and levels of other comorbidities in patients with chronic obstructive pulmonary disease in a Swedish population: a register-based study

Background

Despite the fact that heart failure and chronic obstructive pulmonary disease (COPD) often exist together and have serious clinical and economic implications, they have mostly been studied separately. Our aim was to study prevalence of coexisting heart failure and COPD in a Swedish population. A further goal was to describe levels of other comorbidity and investigate where the patients received care: primary, secondary care or both.

Methods

We conducted a register-based, cross-sectional study. The population included all people older than 19 years, living in Östergötland County in Sweden. The data were obtained from the Care Data Warehouse register from the year 2006. The diagnosis-based Adjusted Clinical Groups Case-Mix System 7.1 was used to describe the comorbidity level.

Results

The prevalence of the diagnosis of heart failure in patients with COPD was 18.8 % while it was 1.6 % in patients without COPD. Age standardized prevalence was 9.9 and 1.5 %, respectively. Standardized relative risk for the diagnosis of heart failure in patients with COPD was 6.6. The levels of other comorbidity were significantly higher in patients with coexisting heart failure and COPD compared to patients with either heart failure or COPD alone. Primary care was the only care provider for 36.2 % of patients with the diagnosis of heart failure and 20.7 % of patients with coexisting diagnoses of heart failure and COPD. Primary care participated furthermore in shared care of 21.5 % of patients with the diagnosis of heart failure and 21.7 % of patients with coexisting diagnoses of heart failure and COPD. The share of care between primary and secondary care varied depending on levels of comorbidity both in patients with coexisting heart failure and COPD and patients with heart failure alone.

Conclusion

Patients with coexisting diagnoses of heart failure and COPD are common in the Swedish population. Patients with coexisting heart failure and COPD have higher levels of other comorbidity than patients with heart failure or COPD alone. Primary care in Sweden participates to a great extent in care of patients with diagnoses of heart failure alone and coexisting heart failure and COPD.

Characteristics of COPD Patients Using United States Emergency Care or Hospitalization

Rationale: Several chronic obstructive pulmonary disease (COPD) studies have evaluated risk factors for emergency department (ED) visits or hospitalizations, and found insufficient data available about social and demographic factors that drive these behaviors. This U.S. study was designed to describe the characteristics of COPD patients with ED visits or a hospitalization and to investigate how often common COPD comorbidities are present in these individuals. Methods: Data for 7180 COPD patients regarding demographic factors, comorbidities, smoking status, and ED visits or hospitalization was obtained from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. Logistic regression analysis was used to adjust demographic factors and smoking status to model the correlation between patients with ED visits or hospitalizations and morbidities generating odds ratios (OR) and confidence intervals (CI). Results: Among diagnosed COPD patients in the BRFSS, 16.5% had ED visits or hospitalization in the previous year. These individuals were younger, had a lower socio-economic status (lower education, lower income, and more often unemployed) and 23.4% of the individuals could not visit a doctor because of the financial difficulties compared to 16.7% who had no visit (p<0.0001 for all comparisons). The prevalence of comorbidities was higher in those with ED visits or hospitalization compared to those without. Conclusion: In a population representative of COPD patients, lower socio-economic status and higher comorbidities are associated with ED visits or hospitalization. Studies are needed to further elucidate the complex relationship between COPD, comorbidities, and ED visits or hospitalization.

Dysregulation of Antiviral Function of CD8(+) T Cells in the Chronic Obstructive Pulmonary Disease Lung. Role of the PD-1-PD-L1 Axis

RATIONALE

Patients with chronic obstructive pulmonary disease (COPD) are susceptible to respiratory viral infections that cause exacerbations. The mechanisms underlying this susceptibility are not understood. Effectors of the adaptive immune response-CD8(+) T cells that clear viral infections-are present in increased numbers in the lungs of patients with COPD, but they fail to protect against infection and may contribute to the immunopathology of the disease.

OBJECTIVES

CD8(+) function and signaling through the programmed cell death protein (PD)-1 exhaustion pathway were investigated as a potential key mechanism of viral exacerbation of the COPD lung.

METHODS

Tissue from control subjects and patients with COPD undergoing lung resection was infected with live influenza virus ex vivo. Viral infection and expression of lung cell markers were analyzed using flow cytometry.

MEASUREMENTS AND MAIN RESULTS

The proportion of lung CD8(+) T cells expressing PD-1 was greater in COPD (mean, 16.2%) than in controls (4.4%, P = 0.029). Only epithelial cells and macrophages were infected with influenza, and there was no difference in the proportion of infected cells between controls and COPD. Infection up-regulated T-cell PD-1 expression in control and COPD samples. Concurrently, influenza significantly up-regulated the marker of cytotoxic degranulation (CD107a) on CD8(+) T cells (P = 0.03) from control subjects but not on those from patients with COPD. Virus-induced expression of the ligand PD-L1 was decreased on COPD macrophages (P = 0.04) with a corresponding increase in IFN-γ release from infected COPD explants compared with controls (P = 0.04).

CONCLUSIONS

This study has established a signal of cytotoxic immune dysfunction and aberrant immune regulation in the COPD lung that may explain both the susceptibility to viral infection and the excessive inflammation associated with exacerbations.