Proportional classifications of COPD phenotypes

The reasons for triple therapy in stable COPD patients in Japanese clinical practice

Background

Triple combination therapy involving long-acting muscarinic antagonists long-acting β₂ agonists, and inhaled corticosteroids has recently become an option for maintenance treatment of COPD. Some add-on clinical trials have reported the benefits of these combinations. However, the process to step up to triple therapy varies for individual cases.

Methods

Keio University and affiliated hospitals conducted an observational COPD cohort study, recruiting patients diagnosed as having COPD by pulmonary physicians and those referred for investigation of possible COPD. Their prescription history and clinical course were retrospectively analyzed based on the physicians’ medical records and patient questionnaires. This study was registered with UMIN (UMIN000003470, April 10, 2010).

Results

A total of 95 of the 445 COPD patients (21%) were treated with inhaled corticosteroids/long-acting β₂ agonists/long-acting muscarinic antagonists as maintenance therapy, including 12 in COPD Grade I, 31 in Grade II, 38 in Grade III, and 14 in Grade IV, based on the Global Initiative for Chronic Obstructive Lung Disease spirometric grading. For more than half of the patients on triple therapy, the treatment had been intensified due to unsatisfactory improvement of symptoms, and 32% were treated with triple therapy due to comorbid asthma. In contrast, there were COPD patients whose therapy was maintained after starting with triple therapy because of their serious conditions or concurrent exacerbation at diagnosis (8%).

Conclusion

Triple therapy was often prescribed in the real-life management of COPD, even in patients whose airflow limitation was not severe. To better control symptoms was the major reason for choosing triple therapy, regardless of the severity of COPD, in Japan.

Derivation and validation of clinical phenotypes for COPD: a systematic review

BACKGROUND

The traditional classification of COPD, which relies solely on spirometry, fails to account for the complexity and heterogeneity of the disease. Phenotyping is a method that attempts to derive a single or combination of disease attributes that are associated with clinically meaningful outcomes. Deriving phenotypes entails the use of cluster analyses, and helps individualize patient management by identifying groups of individuals with similar characteristics. We aimed to systematically review the literature for studies that had derived such phenotypes using unsupervised methods.

METHODS

Two independent reviewers systematically searched multiple databases for studies that performed validated statistical analyses, free of definitive pre-determined hypotheses, to derive phenotypes among patients with COPD. Data were extracted independently.

RESULTS

9156 citations were retrieved, of which, 8 studies were included. The number of subjects ranged from 213 to 1543. Most studies appeared to be biased: patients were more likely males, with severe disease, and recruited in tertiary care settings. Statistical methods used to derive phenotypes varied by study. The number of phenotypes identified ranged from 2 to 5. Two phenotypes, with poor longitudinal health outcomes, were common across multiple studies: young patients with severe respiratory disease, few cardiovascular co-morbidities, poor nutritional status and poor health status, and a phenotype of older patients with moderate respiratory disease, obesity, cardiovascular and metabolic co-morbidities.

CONCLUSIONS

The recognition that two phenotypes of COPD were often reported may have clinical implications for altering the course of the disease. This review also provided important information on limitations of phenotype studies in COPD and the need for improvement in future studies.

Prevalence and global initiative for chronic obstructive lung disease group distribution of chronic obstructive pulmonary disease detected by preoperative pulmonary function test

Background

Despite being a major public health problem, chronic obstructive pulmonary disease (COPD) remains underdiagnosed, and only 2.4% COPD patients are aware of their disease in Korea. The objective of this study was to estimate the prevalence of COPD detected by spirometry performed as a preoperative screening test and to determine the Global Initiative for Chronic Obstructive Lung Disease (GOLD) group distribution and self-awareness of COPD.

Methods

We reviewed the medical records of adults (age, ≥40 years) who had undergone spirometry during preoperative screening between April and August 2013 at a tertiary hospital in Korea. COPD was defined as a postbronchodilator forced expiratory volume in 1 s/forced vital capacity ratio of <0.7. We analyzed self-administered COPD questionnaires for the assessment of the frequency of acute exacerbation over the previous year and dyspnea severity using the modified Medical Research Council dyspnea scale and COPD assessment test.

Results

Among 3029 patients aged >40 years who had undergone spirometry as a preoperative screening test, 474 (15.6%; 404 men; median age, 70 years; range, 44–93 years) were diagnosed with COPD. Only 26 (5.5%) patients reported previous diagnosis of COPD (2.1%), emphysema (0.8%), or chronic bronchitis (2.5%). The GOLD group distribution was as follows: 63.3% in group A, 31.2% in group B, 1.7% in group C, and 3.8% in group D.

Conclusions

The prevalence of COPD diagnosed by preoperative spirometry was 15.6%, and only 5.5% patients were aware of their disease. Approximately one-third of the COPD patients belonged to GOLD groups B, C, and D, which require regular treatment.

Managing comorbidities in COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Age and smoking are common risk factors for COPD and other illnesses, often leading COPD patients to demonstrate multiple coexisting comorbidities. COPD exacerbations and comorbidities contribute to the overall severity in individual patients. Clinical trials investigating the treatment of COPD routinely exclude patients with multiple comorbidities or advanced age. Clinical practice guidelines for a specific disease do not usually address comorbidities in their recommendations. However, the management and the medical intervention in COPD patients with comorbidities need a holistic approach that is not clearly established worldwide. This holistic approach should include the specific burden of each comorbidity in the COPD severity classification scale. Further, the pharmacological and nonpharmacological management should also include optimal interventions and risk factor modifications simultaneously for all diseases. All health care specialists in COPD management need to work together with professionals specialized in the management of the other major chronic diseases in order to provide a multidisciplinary approach to COPD patients with multiple diseases. In this review, we focus on the major comorbidities that affect COPD patients. We present an overview of the problems faced, the reasons and risk factors for the most commonly encountered comorbidities, and the burden on health care costs. We also provide a rationale for approaching the therapeutic options of the COPD patient afflicted by comorbidity.

Association between emphysema-like lung on cardiac computed tomography and mortality in persons without airflow obstruction: a cohort study

BACKGROUND

Low lung function is known to predict mortality in the general population, but the prognostic significance of emphysema on computed tomography (CT) in persons without chronic obstructive pulmonary disease (COPD) is uncertain.

OBJECTIVE

To determine whether greater emphysema-like lung on CT is associated with all-cause mortality among persons in the general population without airflow obstruction or COPD.

DESIGN

Prospective cohort study.

SETTING

Population-based, multiethnic sample from 6 U.S. communities.

PARTICIPANTS

2965 participants aged 45 to 84 years without airflow obstruction on spirometry.

MEASUREMENTS

Emphysema-like lung was defined as the number of lung voxels with attenuation less than -950 Hounsfield units on cardiac CT and was adjusted for the number of total imaged lung voxels.

RESULTS

Among 2965 participants, 50.9% of whom had never smoked, there were 186 deaths over a median of 6.2 years. Greater emphysema-like lung was independently associated with increased mortality (adjusted hazard ratio per one-half interquartile range, 1.14 [95% CI, 1.04 to 1.24]; P=0.004) after adjustment for potential confounders, including cardiovascular risk factors and FEV1. Generalized additive models supported a linear association between emphysema-like lung and mortality without evidence for a threshold. The association was of greatest magnitude among smokers, although multiplicative interaction terms did not support effect modification by smoking status.

LIMITATIONS

Cardiac CT scans did not include lung apices. The number of deaths was limited among subgroup analyses.

CONCLUSION

Emphysema-like lung on CT was associated with all-cause mortality among persons without airflow obstruction or COPD in a general population sample, particularly among smokers. Recognition of the independent prognostic significance of emphysema on CT among patients without COPD on spirometry is warranted.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Asthma, airflow limitation and mortality risk in the general population

Asthma and chronic obstructive pulmonary disease co-exist in a significant proportion of patients. Whether asthma increases mortality risk among subjects with airflow limitation remains controversial. We used data from 2121 adult participants in the population-based Tucson Epidemiological Study of Airway Obstructive Disease cohort. At enrolment (1972-1973), participants completed questionnaires and lung function tests. Participants were categorised into four groups based on the combination of airflow limitation (AL; forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <70%) and physician-confirmed asthma at baseline. Vital status as of January 2011 was assessed through the National Death Index. Cox proportional hazards models were used to test differences in mortality risk across the four airflow limitation/asthma groups. In multivariate Cox models, the AL+/asthma+ group had a 114% increased mortality risk during follow-up compared with the AL-/asthma- group (adjusted HR 2.14; 95% CI 1.64-2.79). The corresponding hazard ratios were 1.09 (95% CI 0.89-1.34) and 1.34 (95% CI 1.14-1.57) for the AL-/asthma+ and AL+/asthma- groups, respectively. Among subjects with airflow limitation, asthma was associated with increased mortality risk (HR 1.58, 95% CI 1.17-2.12). However, this increased risk was substantially reduced and no longer significant after further adjustment for baseline FEV1 levels. Similar results were obtained when airflow limitation was defined as FEV1/FVC less than the lower limit of normal. In a population-based cohort, subjects with concomitant airflow limitation and asthma had an increased risk of dying, which was mainly related to their baseline lung function deficits.

Chronic obstructive pulmonary disease, hospital visits, and comorbidities: National Survey of Residential Care Facilities, 2010

OBJECTIVE

To characterize the prevalence of chronic obstructive pulmonary disease (COPD) among residential care facility (RCF) residents in the United States, and to compare patterns of hospital visits and comorbidities with residents without COPD.

METHOD

Resident data from the 2010 National Survey of Residential Care Facilities were analyzed. Medical history and information on past-year hospital visits for 8,089 adult residents were obtained from interviews with RCF staff.

RESULTS

COPD prevalence was 12.4%. Compared with residents without COPD, emergency department visits or overnight hospital stays in the previous year were more prevalent (p < .05) among residents with COPD. Less than 3% of residents with COPD had no comorbidities. Arthritis, depression, congestive heart failure (CHF), diabetes, coronary heart disease, and asthma were more common (p < .05) among residents with COPD than those without COPD, but Alzheimer's disease was less common.

DISCUSSION

COPD is associated with more emergency department visits, hospital stays, and comorbidities among RCF residents.

Prevalence of asthma with airflow limitation, COPD, and COPD with variable airflow limitation in older subjects in a general Japanese population: the Hisayama Study

BACKGROUND

Elucidating the prevalence of asthma and chronic obstructive pulmonary disease (COPD) is important for designing a public health strategy. Recent studies have discriminated a phenotype of COPD with variable airflow limitation (COPD-VAL) associated with asthma-COPD overlap syndrome. Its prevalence remains uncertain. The age and occupational distributions in the town of Hisayama and in Japan are nearly identical. Each disease's prevalence was estimated for the town's residents.

METHODS

In 2008, town residents (≥ 40 years) were solicited to participate in a health checkup. Individuals with abnormal spirometry (forced expiratory volume in 1s/forced vital capacity [FEV1/FVC]<70% and/or %FVC<80%) were recommended for further evaluations. Two pulmonologists in a blinded fashion reviewed their medical records, including bronchodilator reversibility. Individuals with airflow limitation were classified as having asthma, COPD, COPD-VAL, or other diseases. The prevalence of each disease was then estimated.

RESULTS

A total of 2100 residents (43.4% of residents in the age group) completed spirometry. In 455 residents with abnormal spirometry, 190 residents had further evaluations, and the medical records of 174 residents were reviewed. The prevalence of asthma with airflow limitation, COPD, and COPD-VAL, were 2.0%, 8.4%, and 0.9%, respectively. The prevalence of COPD and COPD-VAL were higher in men and smokers than in women and never-smokers. The prevalence of COPD, but not COPD-VAL or asthma, increased with age.

CONCLUSION

The prevalence of asthma with airflow limitation, COPD, and COPD-VAL were estimated in a population of residents (≥ 40 years) in Hisayama.

Distinguishing adult-onset asthma from COPD: a review and a new approach

Adult-onset asthma and chronic obstructive pulmonary disease (COPD) are major public health burdens. This review presents a comprehensive synopsis of their epidemiology, pathophysiology, and clinical presentations; describes how they can be distinguished; and considers both established and proposed new approaches to their management. Both adult-onset asthma and COPD are complex diseases arising from gene-environment interactions. Early life exposures such as childhood infections, smoke, obesity, and allergy influence adult-onset asthma. While the established environmental risk factors for COPD are adult tobacco and biomass smoke, there is emerging evidence that some childhood exposures such as maternal smoking and infections may cause COPD. Asthma has been characterized predominantly by Type 2 helper T cell (Th2) cytokine-mediated eosinophilic airway inflammation associated with airway hyperresponsiveness. In established COPD, the inflammatory cell infiltrate in small airways comprises predominantly neutrophils and cytotoxic T cells (CD8 positive lymphocytes). Parenchymal destruction (emphysema) in COPD is associated with loss of lung tissue elasticity, and small airways collapse during exhalation. The precise definition of chronic airflow limitation is affected by age; a fixed cut-off of forced expiratory volume in 1 second/forced vital capacity leads to overdiagnosis of COPD in the elderly. Traditional approaches to distinguishing between asthma and COPD have highlighted age of onset, variability of symptoms, reversibility of airflow limitation, and atopy. Each of these is associated with error due to overlap and convergence of clinical characteristics. The management of chronic stable asthma and COPD is similarly convergent. New approaches to the management of obstructive airway diseases in adults have been proposed based on inflammometry and also multidimensional assessment, which focuses on the four domains of the airways, comorbidity, self-management, and risk factors. Short-acting beta-agonists provide effective symptom relief in airway diseases. Inhalers combining a long-acting beta-agonist and corticosteroid are now widely used for both asthma and COPD. Written action plans are a cornerstone of asthma management although evidence for self-management in COPD is less compelling. The current management of chronic asthma in adults is based on achieving and maintaining control through step-up and step-down approaches, but further trials of back-titration in COPD are required before a similar approach can be endorsed. Long-acting inhaled anticholinergic medications are particularly useful in COPD. Other distinctive features of management include pulmonary rehabilitation, home oxygen, and end of life care.

Distribution of clinical phenotypes in patients with chronic obstructive pulmonary disease caused by biomass and tobacco smoke

INTRODUCTION

Exposure to biomass smoke is a risk factor for chronic obstructive pulmonary disease (COPD). It is unknown whether COPD caused by biomass smoke has different characteristics to COPD caused by tobacco smoke.

OBJECTIVE

To determine clinical differences between these two types of the disease.

METHODS

Retrospective observational study of 499 patients with a diagnosis of COPD due to biomass or tobacco smoke. The clinical variables of both groups were compared.

RESULTS

There were 122 subjects (24.4%) in the biomass smoke group and 377 (75.5%) in the tobacco smoke group. In the tobacco group, the percentage of males was higher (91.2% vs 41.8%, P<.0001) and the age was lower (70.6 vs 76.2 years, P<.0001). Body mass index and FEV1% values were higher in the biomass group (29.4±5.7 vs 28.0±5.1, P=.01, and 55.6±15.6 vs 47.1±17.1, P<.0001, respectively). The mixed COPD-asthma phenotype was more common in the biomass group (21.3% vs 5%, P<.0001), although this difference disappeared when corrected for gender. The emphysema phenotype was more common in the tobacco group (45.9% vs 31.9%, P=.009). The prevalence of the chronic bronchitis and exacerbator phenotypes, the comorbidity burden and the rate of hospital admissions were the same in both groups.

CONCLUSION

Differences were observed between COPD caused by biomass and COPD caused by tobacco smoke, although these may be attributed in part to uneven gender distribution between the groups.

COPD phenotypes in a lung cancer screening population

BACKGROUND AND AIMS

COPD (chronic obstructive pulmonary disease) is a very heterogeneous disease, and phenotypic categorization of a high-risk population has many potential benefits. The present study uses a symptom questionnaire, low-dose computed tomography (LDCT) and pulmonary function tests (PFT) to phenotypically subgroup a high-risk population.

METHODS

Study group consisted of current or former smokers who underwent lung cancer screening with LDCT as a subgroup of Pittsburgh Lung Screening Study. In addition to LDCT, PFT and a symptom query questionnaire were obtained from each patient.

RESULTS

The study group consisted of 3183 subjects (age 50-79) subdivided into eight groups according to presence of symptoms, obstruction on PFT and presence of emphysema on LDCT. A total of 501 (15.7%) subjects were asymptomatic, with no airflow obstruction or evidence of emphysema. There were 866 (27.2%) subjects with both obstruction on PFT and emphysema on LDCT, but only 660 (20.7%) had symptoms. Five hundred thirty (16.6%) of the subjects had no emphysema on LDCT but had obstruction on PFT, although only 370 (11.6%) had symptoms. Four hundred seventy-four (14.9%) of subjects had emphysema on LDCT, but no airflow obstruction, with 312 (9.8%) symptomatic. Finally, 812 (25.5%) of subjects had no evidence of airflow obstruction on PFT or emphysema on LDCT, but had symptoms.

CONCLUSION

Combining LDCT with PFT and a comprehensive questionnaire allows subgroup classification of COPD phenotypes in a high-risk population and may lead to earlier intervention and an improved framework for future studies.

Characteristics and self-rated health of overlap syndrome

Background and objective

Overlap syndrome shares features of both asthma and chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate characteristics of overlap syndrome and their effect on self-rated health (SRH).

Methods

We analyzed data from the Fourth Korea National Health and Nutrition Examination Survey of 2007–2009. Subjects with acceptable spirometry and available wheezing history were included. Subjects were classified into four groups based on forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) results and the presence or absence of self-reported wheezing for the previous 12 months: 1) COPD group, defined as having FEV₁/FVC <0.7 without self-reported wheezing history; 2) asthma group, defined as having self-reported wheezing history without FEV₁/FVC <0.7; 3) overlap syndrome group, having both FEV₁/FVC <0.7 and wheezing history; and 4) non-obstructive disease (NOD) group, having neither FEV₁/FVC <0.7 nor self-reported wheezing. SRH was categorized as better or lower based on responses to a questionnaire.

Results

From a total 9,104 subjects, 700 were assigned to the COPD group, 560 to the asthma group, 210 to the overlap syndrome group, and 7,634 to the NOD group. Compared to the other groups, subjects in the overlap syndrome group were more likely to have low lung function, a high proportion of smokers, low socioeconomic status, short education duration, lower SRH, and past diagnosis of pulmonary tuberculosis or bronchiectasis. Multiple logistic regression analysis revealed that both overlap syndrome and asthma groups were independently associated with lower SRH after adjustment for age, sex, socioeconomic status, education level, smoking status, comorbidities, and lung function. Female, old age, low education level, low economic status, smoker and other comorbidities were also associated with lower SRH.

Conclusion

Overlap syndrome was accompanied by high morbidity and was associated with lower SRH, which needs more appropriate care.

Systemic Inflammation in Older Adults With Asthma-COPD Overlap Syndrome

PURPOSE

The role of systemic inflammation on asthma-COPD overlap syndrome is unknown. This study aimed to examine systemic inflammation in asthma-COPD overlap syndrome, and to identify associations between clinical characteristics and inflammatory mediators in asthma-COPD overlap syndrome.

METHODS

In 108 adults older than 55 years comprising healthy controls (n=29), asthma (n=16), COPD (n=21) and asthma-COPD overlap syndrome (n=42), serum high sensitivity C-reactive protein and Interleukin 6 (IL-6) were assayed. Spirometry, induced sputum, quality of life, comorbidities and medications were assessed, and their associations with asthma-COPD overlap syndrome were analyzed using logistic regression. Associations between systemic inflammatory mediators and clinical characteristics were tested in multivariate linear regression models.

RESULTS

Patients with asthma-COPD overlap syndrome had significantly elevated IL-6 levels compared with healthy controls and asthmatics. Age, comorbidity index and IL-6 level were independently associated with asthma-COPD overlap syndrome. FEV1% predicted was inversely associated with IL-6 level, and cardiovascular disease was associated with an increased IL-6 level. Systemic markers were not associated with airway inflammation.

CONCLUSIONS

Systemic inflammation is commonly present in asthma-COPD overlap syndrome, and asthma-COPD overlap syndrome resembled COPD in terms of systemic inflammation. IL-6 is a pivotal inflammatory mediator that may be involved in airflow obstruction and cardiovascular disease and may be an independent treatment target.

The path to personalised medicine in COPD

Our understanding of chronic obstructive pulmonary disease (COPD) has changed dramatically over the past two decades. We have moved from an airflow limitation-centric view to the realisation that COPD is a complex and heterogeneous disease, which leads inevitably to the need for personalising the assessment and treatment of patients with COPD. This review provides a brief perspective of the extraordinary transition that the COPD field has experienced in the last two decades, and speculates on how it should/can move forward in the near future in order to really achieve the goal of personalising COPD medicine in the clinic.

Increased risk of exacerbation and hospitalization in subjects with an overlap phenotype: COPD-asthma

BACKGROUND

Several COPD phenotypes have been described; the COPD-asthma overlap is one of the most recognized. The aim of this study was to evaluate the prevalence of three subgroups (asthma, COPD, and COPD-asthma overlap) in the Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) study population, to describe their main characteristics, and to determine the association of the COPD-asthma overlap group with exacerbations, hospitalizations, limitations due to physical health, and perception of general health status (GHS).

METHODS

The PLATINO study is a multicenter population-based survey carried out in five Latin American cities. Outcomes were self-reported exacerbations (defined by deterioration of breathing symptoms that affected usual daily activities or caused missed work), hospitalizations due to exacerbations, physical health limitations, and patients' perception of their GHS obtained by questionnaire. Subjects were classified in three specific groups: COPD--a postbronchodilator (post-BD) FEV₁/FVC ratio of < 0.70; asthma--presence of wheezing in the last year and a minimum post-BD increase in FEV₁ or FVC of 12% and 200 mL; and overlap COPD-asthma--the combination of the two.

RESULTS

Out of 5,044 subjects, 767 were classified as having COPD (12%), asthma (1.7%), and COPD-asthma overlap (1.8%). Subjects with COPD-asthma overlap had more respiratory symptoms, had worse lung function, used more respiratory medication, had more hospitalization and exacerbations, and had worse GHS. After adjusting for confounders, the COPD-asthma overlap was associated with higher risks for exacerbations (prevalence ratio [PR], 2.11; 95% CI, 1.08-4.12), hospitalizations (PR, 4.11; 95% CI, 1.45-11.67), and worse GHS (PR, 1.47; 95% CI, 1.18-1.85) compared with those with COPD.

CONCLUSIONS

The coexisting COPD-asthma phenotype is possibly associated with increased disease severity.

Managing older patients with coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges

Asthma and chronic obstructive pulmonary disease (COPD) are common obstructive airway diseases, especially among older people. These conditions are associated with a significant and increasing disease burden. The diagnosis and management of asthma and COPD in older populations are complex, and consequently clinicians are faced with many therapeutic and diagnostic challenges. Both aging and obstructive airway diseases are associated with complex co-morbidities and these coexisting illnesses confound management. Moreover, the age-related physiological changes that occur in the lungs may lead to airflow limitation, and this may be difficult to distinguish from an active disease state. In practice, management of asthma and COPD is informed by disease-specific clinical practice guidelines; however, most older people with these conditions are excluded from clinical trials that are designed to inform practice, creating major evidence gaps. Furthermore, seldom do clinical practice guidelines consider the complexities of management in older populations. The problems experienced by older people are complex and multifactorial and our approach to management must reflect these challenges. Opportunities exist to improve the management and outcomes for older people with obstructive airway disease and there is an urgent need for clinical trials to test management approaches in this population; current research must consider the challenges and evidence gaps that exist.

Impaired left ventricular filling in COPD and emphysema: is it the heart or the lungs? The Multi-Ethnic Study of Atherosclerosis COPD Study

BACKGROUND

COPD and heart failure with preserved ejection fraction overlap clinically, and impaired left ventricular (LV) filling is commonly reported in COPD. The mechanism underlying these observations is uncertain, but may include upstream pulmonary dysfunction causing low LV preload or intrinsic LV dysfunction causing high LV preload. The objective of this study is to determine if COPD and emphysema are associated with reduced pulmonary vein dimensions suggestive of low LV preload.

METHODS

The population-based Multi-Ethnic Study of Atherosclerosis (MESA) COPD Study recruited smokers aged 50 to 79 years who were free of clinical cardiovascular disease. COPD was defined by spirometry. Percent emphysema was defined as regions &lt; -910 Hounsfield units on full-lung CT scan. Ostial pulmonary vein cross-sectional area was measured by contrast-enhanced cardiac magnetic resonance and expressed as the sum of all pulmonary vein areas. Linear regression was used to adjust for age, sex, race/ethnicity, body size, and smoking.

RESULTS

Among 165 participants, the mean (± SD) total pulmonary vein area was 558 ± 159 mm2 in patients with COPD and 623 ± 145 mm2 in control subjects. Total pulmonary vein area was smaller in patients with COPD (-57 mm2; 95% CI, -106 to -7 mm2; P = .03) and inversely associated with percent emphysema (P &lt; .001) in fully adjusted models. Significant decrements in total pulmonary vein area were observed among participants with COPD alone, COPD with emphysema on CT scan, and emphysema without spirometrically defined COPD.

CONCLUSIONS

Pulmonary vein dimensions were reduced in COPD and emphysema. These findings support a mechanism of upstream pulmonary causes of underfilling of the LV in COPD and in patients with emphysema on CT scan.

Chronic bronchitis in COPD patients is associated with increased risk of exacerbations: a cross-sectional multicentre study

BACKGROUND AND AIMS

Chronic bronchitis (CB) in chronic obstructive pulmonary disease (COPD) patients is associated with increased mortality, frequent exacerbations and faster disease progression. This study investigates the prevalence of CB in a large population of COPD patients to identify features associated with CB.

METHODS

Cross-sectional multicentre study in patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 2-4 from Belgium and Luxembourg.

RESULTS

The 974 patients included were on average 67.8 ± 9.6 years old; 72% were male, FEV1 was 52.5 ± 15.8% of predicted. The prevalence of CB was 64% (622/974). In patients with CB, the number of pack-years smoked and the prevalence of chronic respiratory failure, cachexia and skeletal muscle wasting were significantly higher, whereas FEV1 and FEV1 /VC were lower. The prevalence of CB increased with GOLD stage and was higher in patients with emphysema and those exposed to occupational risk factors. The CB group had more exacerbations, a higher percentage of patients with frequent exacerbations (37.3% vs. 14.2% of patients; p < 0.0001), increased COPD-related, non-intensive care unit hospitalisations and all-cause hospitalisation rates. In multiple logistic regression analysis, frequent exacerbation was the most important independent variable associated with CB, followed by current smoking, chronic respiratory failure, COPD duration and age.

CONCLUSIONS

CB prevalence in GOLD stage 2-4 COPD patients is high. CB is related to current tobacco smoking, and prevalence increases with COPD severity and duration, emphysema and age. CB could be the hallmark of a subtype of COPD easy to identify in clinical practice, associated with increased disease severity and increased risk of exacerbation.

Early chronic obstructive pulmonary disease: Beyond spirometry

The significant healthcare burden associated with chronic obstructive pulmonary disease (COPD) is driving us to improve our understanding of the natural history of this disease. Historically, the focus has been largely centred on diagnosing and treating individuals with moderate and severe disease. However, it is now recognised that the speed of decline in lung function as measured by forced expiratory volume in 1 s occurs faster in the earlier stages of the disease process. As a result, a clearer understanding of the potential benefits of treatment in early COPD is needed. It is recognised that many patients with COPD remain undiagnosed in the community which has prompted global case-finding initiatives. In this review we discuss the difficulties in diagnosing COPD in its early stages, examine the role of case-finding and look at the evidence for early intervention with therapeutic agents. There is a growing interest in the phenotypic variation amongst patients with COPD and we explore the role of phenotyping in early COPD and its potential benefits in providing a more individualised approach to COPD management. The majority of patients with COPD are known to die from non-respiratory causes such as cardiovascular disease. The mechanistic link is thought to relate to systemic inflammation, causing us to question whether earlier interventions could have a beneficial impact on the burden of co-morbidities for patients with COPD.

CT-diagnosed emphysema and prognosis of chronic airflow obstruction: a retrospective study

OBJECTIVE

CT-diagnosed emphysema is associated with poor prognosis in chronic obstructive pulmonary disease (COPD). Its clinical impacts on prognoses of asthma with chronic airflow obstruction (CAO) are not well known. We sought to compare mortalities and prognostic factors in COPD and asthma with CAO by the presence or absence of CT-diagnosed emphysema.

DESIGN

Retrospective cohort study.

SETTING

Referral centre hospital for respiratory disease.

PARTICIPANTS

1272 patients aged over 40 years with CAO (January 2000 to December 2011). CAO was defined as a forced expiratory volume in 1 s/forced vital capacity <0.7 after bronchodilator use throughout the observation period.

PRIMARY AND SECONDARY OUTCOME MEASUREMENTS

Overall mortality served as the primary endpoint. We compared mortalities and prognostic factors of COPD and asthma subgroups with or without emphysema. Secondary endpoints were the prevalence of COPD and asthma in patients with CAO.

RESULTS

Overall, diagnoses included COPD with emphysema in 517 (40.6%) patients, COPD without emphysema in 104 (8.2%) patients, asthma with emphysema in 178 (13.9%) patients, asthma without emphysema in 169 (13.3%) patients, other respiratory diseases (RD) with emphysema in 128 (10.1%) patients, and other RD without emphysema in 176 (13.8%) patients. Patients with asthma without emphysema had the best prognosis followed by those with asthma with emphysema, COPD without emphysema and COPD with emphysema. Each subgroup had distinct prognostic factors. Presence of emphysema was an independent risk factor for de novo lung cancer among patients with CAO.

CONCLUSIONS

Patients with asthma with CAO have a better prognosis than patients with COPD. The presence of CT-diagnosed emphysema predicts poor prognosis in COPD and asthma with CAO.

Longitudinal changes in clinical outcomes in older patients with asthma, COPD and asthma-COPD overlap syndrome

BACKGROUND

The progression of obstructive airway diseases (OADs) including asthma, chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap syndrome in older adults is not well understood.

OBJECTIVE

To examine the prognosis of OADs and to identify potential determinants for longitudinal changes in clinical outcomes.

METHODS

We consecutively recruited 99 older adults (>55 years) with OADs who underwent a multidimensional assessment at baseline and 4 years which involved spirometry, 6-min walk distance (6MWD), assessments of health status (Saint George's Respiratory Questionnaire, SGRQ), comorbidity, and serum and sputum biomarkers. All-cause mortality and respiratory hospitalisation during the follow-up period were recorded. Clinical outcomes were compared between basal and final visits, and changes in clinical outcomes were compared among asthma, COPD and asthma-COPD overlap groups. Associations between clinical parameters, biomarkers and prognosis were examined.

RESULTS

After a median follow-up of 4.2 years, outcome data were available for 75 (75.8%) patients. There were 16 (16.2%) deaths. The BODE index predicted all-cause mortality in older people with OADs. While spirometry, 6MWD and SGRQ deteriorated significantly over the 4 years, there was significant heterogeneity in the longitudinal changes in these clinical outcomes. Participants with COPD had a significant decline in FEV1 (p = 0.003), SGRQ (p = 0.030) and 6MWD [decline of 75.5 (93.4) m, p = 0.024]. The change in 6MWD was lower in the asthma-COPD overlap group. Airflow reversibility was associated with a reduced decline in 6MWD.

CONCLUSION

COPD patients had a poor prognosis compared with asthma and asthma-COPD overlap patients. The BODE index is a useful prognostic indicator in older adults with OADs. Both airway disease diagnosis and BODE index warrant specific attention in clinical practice.

Insight into older peoples' healthcare experiences with managing COPD, asthma, and asthma-COPD overlap

OBJECTIVE

The aim of this study was to explore older peoples' experiences of asthma or COPD with reference to their journey in the healthcare system.

METHODS

We recruited older patients with a confirmed diagnosis of asthma or COPD and invited them to participate in a qualitative interview. Interviews were conducted with 21 participants. A line-by-line analysis of the interviews was performed and they were coded for common themes.

RESULTS

From the data, six main themes emerged, these were; "limits to being", "being with or without a diagnosis", "not being heard or recognized", "expectation, fears, and hopes", "to medicate or not: the underuse, abuse, and misuse", and "needing to understand more". The findings of these interviews provide an important understanding of the behaviors and healthcare needs of older people with asthma and COPD. Older patients' adherence patterns, desire for person-centeredness, and involvement in shared decisions as well as desire for increased objective assessment are described.

CONCLUSIONS

These findings provide an important understanding of the behaviors and healthcare needs of older people with asthma and COPD, an area that has not been well defined. The knowledge gained about older patients' desire for person--centeredness and involvement in shared decisions, as well as desire for increased objective assessment is essential in improving care.

Older peoples' perception of tests used in the assessment and management of COPD and asthma

OBJECTIVES

Outcome assessment is an important part of the management of airways disease, yet older adults may have difficulty with the burden of testing. This study evaluated the patient perception of tests used for the assessment of airways disease in older people.

DATA SOURCE

Older adults (>55 years) with obstructive airway disease and healthy controls (N = 56) underwent inhaler technique assessment, skin allergy testing, venepuncture, fractional exhaled nitric oxide (FENO) and gas diffusion measurement, exercise testing, sputum induction, and questionnaire assessment. They then completed an assessment burden questionnaire across five domains: difficulty, discomfort, pain, symptoms and test duration.

RESULTS

Test perception was generally favourable. Induced sputum had the greatest test burden perceived as being more difficult (mean 0.83, P = 0.001), associated with more discomfort (mean 1.3, P < 0.001), more painful (0.46, P = 0.019), longer test duration (0.84, P < 0.001) and worsening symptoms (0.55, P = 0.001) than the questionnaires. FENO had a more favourable assessment but was assessed to be difficult to perform. Inhaler technique received the most favourable assessment.

CONCLUSIONS

Older adults hold favourable perceptions to a range of tests that they might encounter in the course of their care for airway disease. The newer tests of sputum induction and FENO have some observed difficulties, in particular sputum induction. The results of this study can inform current practice by including details of the test and its associated adverse effects when conducting the test, as well as providing clear explanations of the utility of tests and how the results might aid in patient care.

Bayesian predictors of very poor health related quality of life and mortality in patients with COPD

Background

Chronic obstructive pulmonary disease (COPD) is associated with increased mortality and poor health-related quality of life (HRQoL) compared with the general population. The objective of this study was to identify clinical characteristics which predict mortality and very poor HRQoL among the COPD population and to develop a Bayesian prediction model.

Methods

The data consisted of 738 patients with COPD who had visited the Pulmonary Clinic of the Helsinki and Turku University Hospitals during 1995–2006. The data set contained 49 potential predictor variables and two outcome variables: survival (dead/alive) and HRQoL measured with a 15D instrument (very poor HRQoL < 0.70 vs. typical HRQoL ≥ 0.70).

In the first phase of model validation we randomly divided the material into a training set (n = 538), and a test set (n = 200). This procedure was repeated ten times in random fashion to obtain independently created training sets and corresponding test sets. Modeling was performed by using the training set, and each model was tested by using the corresponding test set, repeated in each training set. In the second phase the final model was created by using the total material and eighteen most predictive variables. The performance of six logistic regressions approaches were shown for comparison purposes.

Results

In the final model, the following variables were associated with mortality or very poor HRQoL: age at onset, cerebrovascular disease, diabetes, alcohol abuse, cancer, psychiatric disease, body mass index, Forced Expiratory Volume (FEV₁) % of predicted, atrial fibrillation, and prolonged QT time in ECG. The prediction accuracy of the model was 77%, sensitivity 0.30, specificity 0.95, positive predictive value 0.68, negative predictive value 0.78, and area under the ROC curve 0.69. While the sensitivity of the model reminded limited, good specificity, moderate accuracy, comparable or better performance in classification and better performance in variable selection and data usage in comparison to the logistic regression approaches, and positive and negative predictive values indicate that the model has potential in predicting mortality and very poor HRQoL in COPD patients.

Conclusion

We developed a Bayesian prediction model which is potentially useful in predicting mortality and very poor HRQoL in patients with COPD.

Prevalence and characteristics of three clinical phenotypes of chronic obstructive pulmonary disease (COPD)

AIM

To determine the prevalence and analyze the most relevant clinical characteristics of three clinical phenotypes of COPD: emphysema (type 1), chronic bronchitis (type 2) or COPD-asthma (type 3).

METHOD

Observational, multicenter study performed with 331 COPD patients recruited in pulmonology outpatient services. The stratification in three phenotypes was performed with imaging tests, pulmonary function, and a standardized clinical questionnaire.

RESULTS

The 43.2% presented an emphysematous phenotype, 44.7% were chronic bronchitic and the other 12.1% presented a phenotype showing mixed characteristics with asthma. There were no significant differences in the smoking level, in the gasometric values or time of disease evolution. Type 1 patients showed lower FEV1 values in comparison with types 2 and 3, 46.6% (21.1), 55.2% (21.2) and 54.4% (21.8), respectively (p < 0.05), and greater levels of dyspnea (p < 0.05). No significant differences were observed in the percentage of patients who had at least one exacerbation in the last year (68.8%, 63.9%, 64.9%; p = 0.25), in the number of exacerbations (p = 0.56), in the number of visits to the ER (total and due to COPD), or in the number of hospital admittances. Type 2 patients showed a greater prevalence of cardiovascular comorbidities and of sleep apnea syndrome (4.9%, 23.6% and 12.5%, respectively, p < 0.001).

CONCLUSIONS

In COPD, emphysematous patients present worse pulmonary function and greater dyspnea, although there were no differences in the use of hospital health care resources. The greater comorbidity in Group 2 patients may require specific strategies in this subgroup of patients.

A challenge to the seven widely believed concepts of COPD

This review proposes a critical reassessment (based entirely on published evidence) of the following seven common beliefs about chronic obstructive pulmonary disease (COPD): (1) COPD is one disease. (2) There is a valid definition for COPD. (The current definition includes cases of irreversible asthma and bronchiectasis, and occasionally, other obstructive lung conditions). (3) Irreversible asthma in smokers and COPD cannot be differentiated. (4) A "chronic bronchitis" form of COPD exists and is characterized by blue bloater status and normal carbon monoxide diffusion studies. (5) Phenotyping has no bearing on medication choice in COPD. (6) Computerized scoring of lung attenuation on CT scans can diagnose emphysema. (Emphysema scores overlap in irreversible asthma and COPD); however, qualitative visual changes may be useful for differentiation. (7) A definable entity called the overlap (of COPD and asthma) syndrome exists. Conflict over the above-mentioned points denies patients proper phenotype-guided therapy and encourages a multidrug approach to COPD management. The recently coined term, overlap syndrome, invites a double-barreled therapy aimed at asthma and COPD, despite the absence of any agreement about how to define the syndrome and the lack of any related drug trials (in the area of inhaled corticosteroids). A diagnosis of COPD is associated with high morbidity and escalating costs, suggesting the need for a thorough new examination of the evidence.

Chronic obstructive pulmonary disease: lobe-based visual assessment of volumetric CT by Using standard images--comparison with quantitative CT and pulmonary function test in the COPDGene study

PURPOSE

To provide a new detailed visual assessment scheme of computed tomography (CT) for chronic obstructive pulmonary disease (COPD) by using standard reference images and to compare this visual assessment method with quantitative CT and several physiologic parameters.

MATERIALS AND METHODS

This research was approved by the institutional review board of each institution. CT images of 200 participants in the COPDGene study were evaluated. Four thoracic radiologists performed independent, lobar analysis of volumetric CT images for type (centrilobular, panlobular, and mixed) and extent (on a six-point scale) of emphysema, the presence of bronchiectasis, airway wall thickening, and tracheal abnormalities. Standard images for each finding, generated by two radiologists, were used for reference. The extent of emphysema, airway wall thickening, and luminal area were quantified at the lobar level by using commercial software. Spearman rank test and simple and multiple regression analyses were performed to compare the results of visual assessment with physiologic and quantitative parameters.

RESULTS

The type of emphysema, determined by four readers, showed good agreement (κ = 0.63). The extent of the emphysema in each lobe showed good agreement (mean weighted κ = 0.70) and correlated with findings at quantitative CT (r = 0.75), forced expiratory volume in 1 second (FEV(1)) (r = -0.68), FEV(1)/forced vital capacity (FVC) ratio (r = -0.74) (P < .001). Agreement for airway wall thickening was fair (mean κ = 0.41), and the number of lobes with thickened bronchial walls correlated with FEV(1) (r = -0.60) and FEV(1)/FVC ratio (r = -0.60) (P < .001).

CONCLUSION

Visual assessment of emphysema and airways disease in individuals with COPD can provide reproducible, physiologically substantial information that may complement that provided by quantitative CT assessment.

How far is real life from COPD therapy guidelines? An Italian observational study

BACKGROUND

According to the GOLD international guidelines, the treatment of chronic obstructive pulmonary disease (COPD) should be proportional to the severity of airflow obstruction graded according to FEV(1)% predicted. Regular treatment with long-acting bronchodilators should be prescribed for symptomatic patients with FEV(1) < 80%. Inhaled corticosteroids should be added in patients with FEV(1) < 50% predicted and frequent exacerbations.

AIM

To investigate whether pulmonologists follow the GOLD guidelines when prescribing treatment for COPD.

METHODS

A multicenter, cross-sectional, observational study was carried out in 49 Pulmonary Units evenly distributed throughout the country. For each patient the demographic, clinical data and the current therapies were registered in an electronic database.

RESULTS

4094 patients (mean age: 70.9 ± 9.4; males 72.4%, female 27.6%) were enrolled. Disease severity was classified as: mild (745), moderate (1722), severe (923), very severe (704). Irrespective of disease severity, inhaled corticosteroids alone or in combination with long-acting bronchodilators were used in 15.2% and 66.8% of patients, respectively. The appropriateness of the pharmacological treatment of the COPD patients was defined in accordance with the GOLD recommendations. The treatment was appropriate in 37.9% of patients and inappropriate in 62.1%, p < 0.0001. The inappropriateness was due to under-prescription in 7.2% and to over-prescription in 54.9% of patients. The presence and the number of exacerbations represented an important trigger for over-prescription at stages I and II.

CONCLUSIONS

This study shows that there is a poor relationship between the recommendations of the GOLD international guidelines and current clinical practice, and that exacerbations may play a role in over-prescription.

Long-acting β-agonists in asthma management: what is the current status?

Large surveillance studies or phase IV clinical studies of long-acting β-agonists (LABA) compared with placebo in asthma patients using variable (from nil to regular) doses of inhaled corticosteroids (ICS) have raised the issue of mortality risk in patients with asthma taking regular LABA. There have been a number of meta-analyses and systematic reviews that have examined the risk of LABA in asthma patients, and the general conclusion is that LABA added to ICS reduces asthma-related hospitalizations compared with ICS alone and there is no statistical increase in mortality. However, LABA without ICS do increase mortality risk in asthma. All reviews and analyses show a greater number of LABA deaths, but not all are statistically significant. A recent meta-analysis found LABA with concomitant ICS had a higher mortality rate in asthma than ICS alone. The flaw in the study is the higher doses of ICS in the control arms, but the implicit message remains: the essential need for enough ICS to control airway inflammation. We suggest that the pragmatic solution is to have LABA only available in the same device as ICS for asthma treatment. We do not think that a study comparing the safety of LABA plus ICS versus ICS alone in asthma is necessary. If such a study is conducted, the measurement of morbidity from increased doses of ICS is an essential design consideration. Furthermore, the critical focus in asthma management should not be forgotten - education of health professionals and the community of the critical role of ICS, and the need for good communication between health professionals and the asthma patient to facilitate good asthma control. The same arguments apply to the asthma-with-chronic obstructive pulmonary disease overlap syndrome in older patients. There is an urgent need to provide medical practitioners with the capability to diagnose the overlap syndrome.

Clinical phenotypes of COPD: identification, definition and implications for guidelines

The term phenotype in the field of COPD is defined as "a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes". Among all phenotypes described, there are three that are associated with prognosis and especially are associated with a different response to currently available therapies. There phenotypes are: the exacerbator, the overlap COPD-asthma and the emphysema-hyperinflation. The exacerbator is characterised by the presence of, at least, two exacerbations the previous year, and on top of long-acting bronchodilators, may require the use of antiinflammatory drugs. The overlap phenotype presents symptoms of increased variability of airflow and incompletely reversible airflow obstruction. Due to the underlying inflammatory profile, it uses to have a good therapeutic response to inhaled corticosteroids in addition to bronchodilators. Lastly, the emphysema phenotype presents a poor therapeutic response to the existing antiinflammatory drugs and long-acting bronchodilators together with rehabilitation are the treatments of choice. Identifying the peculiarities of the different phenotypes of COPD will allow us to implement a more personalised treatment, in which the characteristics of the patients, together with their severity will be key to choose the best treatment option.

Proteomics in asthma and COPD phenotypes and endotypes for biomarker discovery and improved understanding of disease entities

The application of proteomics to respiratory diseases, such as asthma and COPD, has been limited compared to other fields, like cancer. Both asthma and COPD are recognised to be multi-factorial and complex diseases, both consisting of clusters of multiple disease phenotypes. The complexity of these diseases combined with the inaccessibility and invasiveness of disease relevant samples have provided a hurdle to the progress of respiratory proteomics. Advances in proteomic instrumentation and methodology have led to the possibility to identify proteomes in much smaller quantities of biological material. This review focuses on the efforts in respiratory proteomics in relation to asthma and COPD, and the importance of identifying subgroups of disease entities to establish appropriate biomarkers, and to enhance the understanding of underlying mechanisms in each subgroup. Careful phenotype characterisation of patient subpopulations is required to make improvement in the field of heterogeneous diseases such as asthma and COPD, and the clusters of phenotypes are likely to encompass subgroups of disease with distinct molecular mechanisms; endotypes. The utilisation of modern advanced proteomics in endotypes of asthma and COPD will likely contribute to the increased understanding of disease mechanisms, establishment of biomarkers for these endotypes and improved patient care.

Improvement of Airflow Limitation by Fluticasone Propionate/Salmeterol in Chronic Obstructive Pulmonary Disease: What is the Specific Marker?

Backgrounds: Inhaled corticosteroids (ICS)/inhaled long-acting beta₂-agonists (LABA) combination drugs are widely used for the long-term management of chronic obstructive pulmonary disease (COPD). However, COPD is a heterogeneous condition and treatment with ICS is associated with a higher risk of pneumonia. The identification of a specific marker for predicting the efficacy of ICS/LABA on pulmonary function would be useful in the treatment of COPD. Methods: Fourteen COPD patients receiving tiotropium therapy participated consecutively. The relationship between the baseline exhaled nitric oxide (FE_NO) levels as well as serum markers and changes in pulmonary function by fluticasone propionate (FP)/salmeterol (SAL) were analyzed. Results: FP/SAL therapy significantly improved forced vital capacity, forced expiratory volume in 1 s (FEV₁), and the third phase slope of the single nitrogen washout curve (ΔN₂) as well as the FE_NO level. The baseline FE_NO levels and positive specific IgE (atopy+) were significantly associated with airway obstructive changes assessed by FEV₁ and ΔN₂. A baseline FE_NO level >35 ppb yielded 80.0% sensitivity and 66.7% specificity for identifying the subjects with significant improvement in FEV₁ (greater than 200 mL). An atopy+ yielded 60.0% sensitivity and 88.9% specificity for an improvement in FEV₁. When combined with FE_NO > 35 ppb and atopy+, it showed 40% sensitivity and 100.0% specificity for FEV₁ improvement. Alternatively, COPD subjects with FE_NO ≤ 35 ppb and atopy− did not show significant improvement in FEV₁. Conclusion: Combining FE_NO and specific IgE may be a useful marker for predicting the response to ICS/LABA on airflow limitation in COPD.

A study of the effect of proinflammatory cytokines on the epithelial cells of smokers, with or without COPD

INTRODUCTION

Cigarette smoke is the main cause of inflammation in COPD. The mechanisms that differentiate smokers who develop COPD are diverse. In this study, we analyzed the presence of cytokines in the respiratory secretions of smokers with or without COPD and the secretory properties of the differentiated bronchial epithelium obtained from the individuals themselves after exposure to tobacco smoke.

MATERIAL AND METHODS

Twenty-seven smokers were studied, 12 of whom had COPD that had not been previously treated with steroids. In 11, samples were obtained by means of induced sputum, and the remaining samples were collected from bronchial aspiration after bronchoscopy. Concentrations of IL-8, IL-13 and TNFα in the supernatant were determined. The results obtained were compared between individuals with and without COPD, and we studied their relationship with the severity of COPD as expressed by the degree of obstruction, dyspnea, presence of hypersecretion and intensity of smoking. Bronchial epithelial cell cultures were obtained by air-liquid interface in 4 smokers. The samples were exposed to increasing concentrations of cigarette smoke (5-20%) and the epithelial mRNA expressions of MUC5AC, IL8 and TNFα were determined.

RESULTS

COPD patients had significantly higher values of IL-8 than healthy smokers (41 [22] vs. 21 [12] pM). The values of IL-8 correlated significantly with the severity of the obstruction (r=0.6; p<0.05), dyspnea (r=0.45; p<0.05) and the presence of hypersecretion. There was no relationship between cytokines and the intensity or duration of the tobacco habit. Cigarette smoke produced a dose-dependent increase in the expression of RNAm for Muc5AC, IL8 and TNFα.

CONCLUSIONS

There are differences in cytokine production (fundamentally IL8) between smokers and smokers with COPD which could be explained by the direct action of cigarette smoke on epithelial cells.

Expiratory flows and airway inflammation in elderly asthmatic patients

Asthma in the elderly is often underrecognized and suboptimally treated, resulting in an increased morbidity and mortality. The characteristics of asthma-related bronchitis and its optimal treatment remain to be determined in this population. We aimed to compare lung function and airway inflammation in elderly and younger asthmatic subjects. Data from two induced sputum databases were analyzed in three groups of asthmatic subjects (18-30 y, n = 136; 31-59 y, n = 385; 60-72 y, n = 172) and one group of healthy elderly subjects (60-89 y, n = 16). Expiratory flows and induced sputum cell counts were analyzed. Airway obstruction was more marked in elderly asthmatics compared with healthy elderly or younger asthmatic subjects (p < 0.01). An increase in sputum neutrophils and a decrease in macrophages and lymphocytes were observed in elderly asthmatics (p < 0.0001). Neutrophil percentages significantly increased with asthma severity in the young and the middle-aged groups, while they remained similar in elderly asthmatics regardless of asthma severity (p < 0.05). Neutrophil percentages weakly correlated with the dose of ICS in all asthmatics (r = 0.17, p < 0.0001). Age and dose of ICS were independent predictors of neutrophil percentage in asthmatic subjects in a regression model (R(2) = 0.12). Asthma in the elderly is associated with a more marked airway obstruction and sputum neutrophilia. Both age and the dose of corticosteroids need to be considered in the interpretation of the clinical relevance of sputum neutrophil count.

The multiple dimensions of airways disease: targeting treatment to clinical phenotypes

PURPOSE OF REVIEW

The recognition that asthma and chronic obstructive pulmonary disease (COPD) are not single diseases, but syndromes made up of multiple separate disorders that overlap, has led to attempts to develop a new taxonomy for the disorders of airflow obstruction. A better understanding of the distinct disorders of airways disease has the potential to inform on underlying mechanisms, risk factors, natural history, monitoring and treatment.

RECENT FINDINGS

Recent attempts to describe the different phenotypes have largely been based on cluster analysis. Preliminary evidence suggests that there may be five distinct phenotypes of airways disease. To date, however, no simple allocation criteria have been validated that enable clinicians to allocate individual patients to specific phenotypic groups. The concept of differential treatment responses in different phenotypes of airways disease has been established with the demonstration that eosinophilic asthma preferentially responds to inhaled corticosteroid therapy or monoclonal antibody against interleukin-5, and severe refractory noneosinophilic asthma to macrolide antibiotics.

SUMMARY

The priority is to further define the distinct phenotypes that make up the syndromes of asthma and COPD. This knowledge could lead to treatments specifically targeted for defined phenotypic groups, rather than for asthma and COPD in general, which represents the current management approach.

Overlap syndrome of asthma and COPD predicts low quality of life

BACKGROUND

In clinical practice, patients whose airway disease shares features of both asthma and chronic obstructive pulmonary disease (COPD) remain poorly recognized.

MATERIAL AND METHODS

The study population consisted of 1546 patients with a diagnosis of asthma or COPD or both. Based on patient-reported outcomes and retrospective medical record data, the study population was divided into three groups: ( 1 ) asthma only, ( 2 ) COPD only, and ( 3 ) both asthma and COPD (overlap syndrome group). We evaluated patient characteristics associated with health-related quality of life (HRQoL).

RESULTS

In many respects, the overlap group fell between the asthma and COPD groups. In the overlap group, however, HRQoL was the poorest of all. In the logistic regression model, with the asthma group as the reference, both the overlap and the COPD group showed higher risk for low HRQoL [odd ratio (OR): 1.9; 95% confidence interval (CI): 1.2-3.2; and OR: 1.8, 95% CI: 1.0-3.2; respectively]. In addition, female gender, obesity, duration of disease, disability pension, and coexisting cardiovascular disease were associated with low HRQoL across the study population.

CONCLUSIONS

Patients with overlapping asthma and COPD differed from those patients with asthma or COPD only. Overlap syndrome was associated with low HRQoL.

Addressing the complexity of chronic obstructive pulmonary disease: from phenotypes and biomarkers to scale-free networks, systems biology, and P4 medicine

Chronic obstructive pulmonary disease (COPD) is a complex disease at the clinical, cellular, and molecular levels. However, its diagnosis, assessment, and therapeutic management are based almost exclusively on the severity of airflow limitation. A better understanding of the multiple dimensions of COPD and its relationship to other diseases is very relevant and of high current interest. Recent theoretical (scale-free networks), technological (high-throughput technology, biocomputing), and analytical improvements (systems biology) provide tools capable of addressing the complexity of COPD. The information obtained from the integrated use of those techniques will be eventually incorporated into routine clinical practice. This review summarizes our current knowledge in this area and offers an insight into the elements needed to progress toward an integrated, multilevel view of COPD based on the novel scientific strategy of systems biology and its potential clinical derivative, P4 medicine (Personalized, Predictive, Preventive, and Participatory).

Overlap Between Asthma and COPD: Where the Two Diseases Converge

Asthma and chronic obstructive pulmonary disease (COPD) are traditionally recognized as distinct diseases, with some clearly separate characteristic. Asthma originates in childhood, is associated with allergies and eosinophils, and is best treated by targeting inflammation, whereas COPD occurs in adults who smoke, involves neutrophils, and is best treated with bronchodilators and the removal of risk factors. However, the distinction between the two is not always clear. Patients with severe asthma may present with fixed airway obstruction, and patients with COPD may have hyperresponsiveness and eosinophilia. Recognizing and understanding these overlapping features may offer new insight into the mechanisms and treatment of chronic airway inflammatory diseases.

Asthma in older adults

Asthma in older people is common and is characterised by underdiagnosis and undertreatment. Ageing is associated with unique issues that modify expression, recognition, and treatment of the disease. In particular, asthma and chronic obstructive pulmonary disease (COPD) both overlap and converge in older people. This concurrence, together with absence of precise diagnostic methods, makes diagnosis complex. A multidimensional assessment that addresses airway problems, comorbidities, risk factors, and management skills will draw attention to key needs for intervention. Increased attention to the complications of asthma and obstructive airway disease in older people is needed, specifically to develop effective systems of care, appropriate clinical practice guidelines, and a research agenda that delivers improved health outcomes.