Definition, epidemiology and natural history of COPD

Pulmonary function tests and impulse oscillometry in severe chronic obstructive pulmonary disease patients' offspring

Background:

Several studies have showed an increased prevalence of airflow obstruction in first degree relatives of individuals with chronic obstructive pulmonary disease (COPD). Considering no specific research had evaluated airway resistance in offspring of patients with severe COPD, we utilized a spirometry and a impulse oscillometry (IO) to evaluate this population.

Materials and Methods:

In this case control study, from November 2011 to July 2012, we consecutively evaluated 54 offsprings of severe COPD patients (case group) admitted in the pulmonary ward, affiliated to the Isfahan University of Medical Sciences and control group. Pulmonary function tests and the IO were obtained for both groups. Student's t-test was used for inter-group comparisons, and P values below 0.05 were taken as significant.

Results:

Abnormal increased airway resistance was seen in cases in comparison with controls (R5 Hz [46.29%, P = 0.01], R25 Hz [42.59%, P < 0.001]). Also, considering the spirometry, case group had pulmonary function parameters less than control group (forced vital capacity [FVC]; P = 0.02, forced expiratory volume in 1^st s; P < 0.001, forced expiratory flow (FEF) 25-75; P < 0.001, FEF 25-75/FVC; P < 0.001) but they were in normal range.

Conclusion:

This study demonstrated increased airway resistance among the severe COPD offsprings. The IO may be a sensitive tool for detection of high risk subjects in families with COPD.

Does COPD have a clinically relevant impact on hearing loss? A retrospective matched cohort study with selection of patients diagnosed with COPD

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) as a multisystemic disease has a measurable and biologically explainable impact on the auditory function detectable in the laboratory. This study tries to clarify if COPD is also a significant and clinically relevant risk factor for hearing impairment detectable in the general practice setting.

DESIGN

Retrospective matched cohort study with selection of patients diagnosed with COPD.

SETTING

12 general practices in Lower Austria.

PARTICIPANTS

Consecutive patients >35 years with a diagnosis of COPD who consulted 1 of 12 single-handed GPs in 2009 and 2010 were asked to participate. Those who agreed were individually 1:1 matched with controls according to age, sex, hypertension, diabetes, coronary heart disease and chronic heart failure.

MAIN OUTCOME MEASURES

Sensorineural hearing impairment as assessed by pure tone audiometry, answers of three questions concerning a self-perceived hearing problem, application of the whispered voice test and the score of the Hearing Inventory for the Elderly, Screening Version (HHIE-S).

RESULTS

194 patients (97 pairs of 194 cases and controls) with a mean age of 65.5 (SD 10.2) were tested. Univariate conditional logistic regression resulted in significant differences in the mean bone conduction hearing loss and in the total score of HHIE-S, in the multiple conditional regression model, only smoking (p<0.0001) remained significant.

CONCLUSIONS

The results of this study do not support the hypothesis that there is an association between COPD and hearing impairment which, if found, would have allowed better management of patients with COPD.

Soluble extracellular Klotho decreases sensitivity to cigarette smoke induced cell death in human lung epithelial cells

Chronic obstructive pulmonary disease (COPD) is currently the third leading cause of death in the US and is associated with an abnormal inflammatory response to cigarette smoke (CS). Exposure to CS induces oxidative stress and can result in cellular senescence in the lung. Cellular senescence can then lead to decreased proliferation of epithelial cells, the destruction of alveolar structure and pulmonary emphysema. The anti-aging gene, klotho, encodes a membrane bound protein that has been shown to be a key regulator of oxidative stress and cellular senescence. In this study the role of Klotho (KL) with regard to oxidative stress and cellular senescence was investigated in human pulmonary epithelial cells exposed to cigarette smoke. Individual clones that stably overexpress Klotho were generated through retroviral transfection and geneticin selection. Klotho overexpression was confirmed through RT-qPCR, Western blotting and ELISA. Compared to control cells, constitutive Klotho overexpression resulted in decreased sensitivity to cigarette smoke induced cell death in vitro via a reduction of reactive oxygen species and a decrease in the expression of p21. Our results suggest that increasing Klotho level in pulmonary epithelial cells may be a promising strategy to reduce cellular senescence and mitigate the risk for the development of COPD.

Efficacy of psychosocial interventions on psychological and physical health outcomes in chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

Psychosocial intervention has been suggested as a potentially effective supplement to medical treatment in chronic obstructive pulmonary disease (COPD), but no reviews so far have quantified the existing research in terms of both psychological and physical health outcomes. We therefore conducted a systematic review and meta-analysis of controlled trials evaluating the effects of psychosocial interventions on psychological and physical health outcomes in COPD.

METHODS

Two independent raters screened 1,491 references for eligibility. Twenty independent studies investigating a total of 1,361 patients were included, assessed for their methodological quality, and subjected to meta-analytic evaluation.

RESULTS

After adjusting for potential publication bias, a statistically significant overall effect was found for psychological (Hedges' g = 0.38, 95% confidence interval, CI = 0.19-0.58; p < 0.001) outcomes. When analyzing individual intervention types, cognitive behavioral therapy appeared to be effective (g = 0.39, CI = 0.15-0.62; p = 0.001) for improving psychological outcomes. In contrast, for physical outcomes, only mind-body interventions (e.g. mindfulness-based therapy, yoga, and relaxation) revealed a statistically significant effect (g = 0.40; CI = 0.01-0.79; p = 0.042).

CONCLUSIONS

Taken together, the results lend support to psychosocial intervention as a tool in the management of COPD. However, due to indications of possible publication bias towards positive findings, the results should be interpreted with some caution, and more high quality research is needed.

Natural history of COPD: Focusing on change in FEV1

The natural history of chronic obstructive pulmonary disease (COPD) is usually described with a focus on change in forced expiratory volume in 1 s (FEV1 ) over time as this allows for exploration of risk factors for an accelerated decline-and thus of developing COPD. From epidemiological studies we have recognized important risk factors such as smoking, exposure to biomass and occupational exposures, but we have also learnt about features such as chronic bronchitis, airway hyper-responsiveness and asthma that seem to accelerate decline in FEV1 independent of exposures. In addition we are gradually beginning to better link early life events to subsequent risk of disease in adulthood. Although more complicated, our current understanding of COPD has come a long way from being a simple image of smoking leading to poor lungs.

Implementation of a targeted screening program to detect airflow obstruction suggestive of chronic obstructive pulmonary disease within a presurgical screening clinic

BACKGROUND

Targeted spirometry screening for chronic obstructive pulmonary disease (COPD) has been studied in primary care and community settings. Limitations regarding availability and quality of testing remain. A targeted spirometry screening program was implemented within a presurgical screening (PSS) clinic to detect undiagnosed airways disease and identify patients with COPD/asthma in need of treatment optimization.

OBJECTIVE

The present quality assurance study evaluated airflow obstruction detection rates and examined characteristics of patients identified through the targeted screening program.

METHODS

The targeted spirometry screening program was implemented within the PSS clinic of a tertiary care university hospital. Current or ex-smokers with respiratory symptoms and patients with a history of COPD or asthma underwent prebronchodilator spirometry. History of airways disease and smoking status were obtained during the PSS assessment and confirmed through chart reviews.

RESULTS

After exclusions, the study sample included 449 current or ex-smokers. Abnormal spirometry results were found in 184 (41%) patients: 73 (16%) had mild, 93 (21%) had moderate and 18 (4%) had severe or very severe airflow obstruction. One hundred eighteen (26%) new cases of airflow obstruction suggestive of COPD were detected. One-half of these new cases had moderate or severe airflow obstruction. Only 34% of patients with abnormal spirometry results had reported a previous diagnosis of COPD. More than one-half of patients with abnormal spirometry results were current smokers.

CONCLUSIONS

Undiagnosed airflow obstruction was detected in a significant number of smokers and ex-smokers through a targeted screening program within a PSS clinic. These patients can be referred for early intervention and secondary preventive strategies.

Treatment of emphysema using bronchoscopic lung volume reduction coil technology: an update on efficacy and safety

In the last decade several promising bronchoscopic lung volume reduction (BLVR) treatments were developed and investigated. One of these treatments is BLVR treatment with coils. The advantage of this specific treatment is that it works independently of collateral flow, and also shows promise for patients with a more homogeneous emphysema disease distribution. Seven years ago, the very first patients were treated with BLVR coil treatment and currently large randomized, controlled trials are underway. The aim of this article is to review the available literature and provide an update on the current knowledge on the efficacy and safety of BLVR treatment with coils.

A randomized controlled trial evaluating the effectiveness of a web-based, computer-tailored self-management intervention for people with or at risk for COPD

Introduction

COPD is a leading cause of morbidity and mortality. Self-management interventions are considered important in order to limit the progression of the disease. Computer-tailored interventions could be an effective tool to facilitate self-management.

Methods

This randomized controlled trial tested the effectiveness of a web-based, computer-tailored COPD self-management intervention on physical activity and smoking behavior. Participants were recruited from an online panel and through primary care practices. Those at risk for or diagnosed with COPD, between 40 and 70 years of age, proficient in Dutch, with access to the Internet, and with basic computer skills (n=1,325), were randomly assigned to either the intervention group (n=662) or control group (n=663). The intervention group received the web-based self-management application, while the control group received no intervention. Participants were not blinded to group assignment. After 6 months, the effect of the intervention was assessed for the primary outcomes, smoking cessation and physical activity, by self-reported 7-day point prevalence abstinence and the International Physical Activity Questionnaire – Short Form.

Results

Of the 1,325 participants, 1,071 (80.8%) completed the 6-month follow-up questionnaire. No significant treatment effect was found on either outcome. The application however, was used by only 36% of the participants in the experimental group.

Conclusion

A possible explanation for the nonsignificant effect on the primary outcomes, smoking cessation and physical activity, could be the low exposure to the application as engagement with the program has been shown to be crucial for the effectiveness of computer-tailored interventions. (Netherlands Trial Registry number: NTR3421.)

COPD prevalence in a north-eastern Italian general population

BACKGROUND

COPD prevalence estimates vary mostly depending on different study methodologies. We evaluated the prevalence and clinical features of COPD, as defined by GOLD and ERS/ATS recommendations in a representative sample of Northern Italy general population.

METHODS

A randomized cross-sectional study was performed. The study participants completed a questionnaire covering: key indicators for considering a diagnosis of COPD, self-reported physician diagnoses of respiratory disease, pharmacological treatment for respiratory disease, indirect costs, occupational and environmental exposures. They also underwent spirometry and physician assessment.

RESULTS

We evaluated 1236 subjects. Daily respiratory symptoms were experienced by 26.7%. Of this group, only 30.7% had previously performed a spirometry. The overall COPD prevalence was: 11.7% according to GOLD criterion; 9.1% according to LLN criterion; 6.8% according to self-reported physician diagnosis. Of note, 48,8% of subjects with a reported diagnosis of COPD had never undergone a spirometry before the study.

CONCLUSIONS

Our study provides an estimation of COPD prevalence in a representative sample of Northern Italy general population relying on both clinical symptoms and spirometry outcomes, and describes the different prevalence rates depending on the adopted diagnostic criterion. Spirometry underuse may account for under-diagnosis and misdiagnosis of COPD. It may result in a major impact on quality of life as well as in economic burden.

Smokers With Adequate Vitamin C Intake Show a Preferable Pulmonary Function Test

OBJECTIVE

Airflow obstruction often results from the chronic inflammation caused by cigarette smoke. It has been concluded that cigarette smoke-induced oxidative damage is prevented by ascorbic acid on a cellular level. The purpose of the current study was to explore the effect of vitamin C intake on pulmonary function in established smokers (100 or more cigarettes) and never-smokers in a Korean population.

METHODS

The 2974 enrolled men and women over the age of 40 in the Korea National Health and Nutrition Examination Survey IV 2008 were divided into 4 groups based on smoking patterns (never-smoker vs established smoker) and vitamin C intake from dietary assessment (higher vs lower; median value: 77.18 mg/day).

RESULTS

Univariate analysis showed associations between forced expiratory volume in 1 second (FEV1), FEV/forced vital capacity (FVC) and age, gender, body mass index (BMI), pack-years, vitamin C intake, and additional micronutrient intake. On multiple logistic regression analysis, the odds ratios (95% confidence interval) for FEV1 < 80% predicted were 1.000 (never-smokers, higher vitamin C intake), 1.067 (0.823, 1.383; never-smokers, lower vitamin C intake), 1.224 (0.871, 1.721; established smokers, higher vitamin C intake), and 1.479 (1.057, 2.072; established smokers, lower vitamin C intake). The odds ratios for FEV1/FVC < 0.70 were 1.177 (0.821, 1.687; never-smokers, lower vitamin C intake), 1.637 (1.094, 2.445; established smokers, higher vitamin C intake), and 2.093 (1.403, 3.122; established smokers, lower vitamin C intake) after adjusting for confounding factors (p < 0.001).

CONCLUSIONS

Korean smokers with adequate vitamin C intake showed a preferable pulmonary function test.

Characteristics of Chronic Obstructive Pulmonary Disease (COPD) Patients Reporting Alpha-1 Antitrypsin Deficiency in the WebMD Lung Health Check Database

Objectives: This study compared characteristics of chronic obstructive pulmonary disease (COPD) among patients with and without alpha-1 antitrypsin deficiency (A1AD). Methods: Data from WebMD's Lung Disease Health Check was analyzed for participants who self-reported a COPD diagnosis (N=177,865) and whether or not they had an A1AD diagnosis (based on a positive response to the question "Do you have alpha-1 antitrypsin deficiency?"). We used regression modeling to determine the relation between A1AD status and demographic characteristics, symptoms, lung function, quality of life, comorbidities, and smoking habits. Results: Out of 177,865 participants who reported a COPD diagnosis, 1,619 (0.92%) also reported an A1AD diagnosis. When compared to the total COPD population, those with A1AD were less likely to be female (odds ratio [OR]=0.68, 95% confidence interval [CI] 0.61, 0.75) or current smokers (OR 0.72, 95% CI 0.62, 0.83), and more likely to know their lung function value (OR=3.44, 95% CI 3.07, 3.87). With regard to symptoms, those with A1AD were less likely to report wheezing (OR=0.82, 95% CI 0.75, 0.91) and chronic cough (OR=0.81, 95% CI 0.73, 0.89) and more likely to report tightness in the chest (OR= 1.19, 95% CI 1.08, 1.32). Overall, A1AD participants had a lower quality of life with a higher proportion reporting severe impairment in work life (OR=1.55, 95% CI 1.39, 1.7), home life (OR=1.40, 95% CI 1.26, 1.56), and personal relationships (OR=1.48, 95% CI 1.32, 1.65). Conclusions: COPD patients with A1AD report significantly worse quality of life relative to the non-A1AD COPD population.

Characteristics of Chronic Obstructive Pulmonary Disease (COPD) Patients Reporting Alpha-1 Antitrypsin Deficiency in the WebMD Lung Health Check Database

Objectives: This study compared characteristics of chronic obstructive pulmonary disease (COPD) among patients with and without alpha-1 antitrypsin deficiency (A1AD). Methods: Data from WebMD's Lung Disease Health Check was analyzed for participants who self-reported a COPD diagnosis (N=177,865) and whether or not they had an A1AD diagnosis (based on a positive response to the question "Do you have alpha-1 antitrypsin deficiency?"). We used regression modeling to determine the relation between A1AD status and demographic characteristics, symptoms, lung function, quality of life, comorbidities, and smoking habits. Results: Out of 177,865 participants who reported a COPD diagnosis, 1,619 (0.92%) also reported an A1AD diagnosis. When compared to the total COPD population, those with A1AD were less likely to be female (odds ratio [OR]=0.68, 95% confidence interval [CI] 0.61, 0.75) or current smokers (OR 0.72, 95% CI 0.62, 0.83), and more likely to know their lung function value (OR=3.44, 95% CI 3.07, 3.87). With regard to symptoms, those with A1AD were less likely to report wheezing (OR=0.82, 95% CI 0.75, 0.91) and chronic cough (OR=0.81, 95% CI 0.73, 0.89) and more likely to report tightness in the chest (OR= 1.19, 95% CI 1.08, 1.32). Overall, A1AD participants had a lower quality of life with a higher proportion reporting severe impairment in work life (OR=1.55, 95% CI 1.39, 1.7), home life (OR=1.40, 95% CI 1.26, 1.56), and personal relationships (OR=1.48, 95% CI 1.32, 1.65). Conclusions: COPD patients with A1AD report significantly worse quality of life relative to the non-A1AD COPD population.

Health and social impacts of COPD and the problem of under-diagnosis

This article deals with the prevalence and the possible reasons of COPD underestimation in the population and gives suggestions on how to overcome the obstacles and make the correct diagnosis in order to provide the patients with the appropriate therapy. COPD is diagnosed in later or very advanced stages. In Italy the rate of COPD under-diagnosis ranges between 25 and 50% and, as a consequence, the patient does not consult his doctor until the symptoms have worsened, mainly due to exacerbations. A missed diagnosis influences the timing of therapeutic intervention, thus contributing to the evolution into more severe stages of the illness. An incisive intervention to limit under-diagnosis cannot act only in remittance (passive diagnosis), but must be the promoter for a series of preventive actions: primary, secondary and rehabilitative. To reduce under-diagnosis, some actions need to be taken, such as screening programs for smokers subjects, use of questionnaires aimed to qualify and monitor the disease severity, spirometry, early diagnosis. There is a consensus regarding diagnoses based on screening of at-risk subjects and symptoms, rather than screening of the general population. In practice, all individuals over 40 years of age with risk factors should make a spirometry test. Screening actions on a national scale can be the following: compilation of questionnaires in waiting rooms of doctor’s offices or performing simple maneuvers to evaluate the expiratory force at pharmacies. It is now widely recognized that COPD is a complex syndrome with several pulmonary and extrapulmonary components; as a result, the airway obstruction as assessed by FEV₁ by itself does not adequately describe the complexity of the disease and FEV₁ cannot be used alone for the optimal diagnosis, assessment, and management of the disease. The identification and subsequent grouping of key elements of the COPD syndrome into clinically meaningful and useful subgroups (phenotypes) can guide therapy more effectively. In conclusion, we firmly believe that an early and correct diagnosis can influence positively the progress of the disease (lowering the lung function impairment), decrease the risk of exacerbations, relieve symptoms and increase the patients’ quality of life leading also to a decrease in costs associated to the exacerbations and hospitalization of the patient.

An increased ratio of serum miR-21 to miR-181a levels is associated with the early pathogenic process of chronic obstructive pulmonary disease in asymptomatic heavy smokers

Heavy smoking is associated with the development of chronic obstructive pulmonary disease (COPD). However, there is no valuable biomarker for evaluating COPD development in heavy smokers because they are usually asymptomatic. This study is aimed at evaluating whether the levels of serum miRNAs can serve as biomarkers for predicting the occurrence of COPD. A rat model of emphysema was induced by enforced smoking, and the dynamic miRNAs expression profile at different stages of emphysema with varying periods of smoking were analyzed by microarray and quantitative real-time polymerase chain reaction (qRT-PCR). The differentially expressing miRNAs were analyzed using Gene Ontology and the KEGG PATHWAY database. The levels of three serum candidate miRNAs were measured by qRT-PCR in 41 healthy controls (HC), 40 asymptomatic heavy smokers, and 49 COPD patients. Following smoking for varying periods, different severities of lung emphysema were observed in different groups of rats, accompanied by altered levels of some serum miRNAs associated with regulating some pathways. Furthermore, the levels of miR-21 were significantly higher in the COPD patients and asymptomatic heavy smokers than in the HC (P < 0.001), while the levels of miR-181a were significantly lower in the COPD patients and asymptomatic heavy smokers than in the HC (P < 0.001). Accordingly, the levels of serum miR-21 and miR-181a as well as their ratios had a high sensitivity (0.854) and specificity (0.850) for evaluating the development of COPD. Our data suggest that the levels of serum miR-21 and miR-181a may be valuable for evaluating the development of COPD in heavy smokers.

Adherence to the Global Initiative for Chronic Obstructive Lung Disease guidelines for management of COPD: a hospital-base study

BACKGROUND AND AIMS

To determine the level of adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, we compared our inpatient management of exacerbations of chronic obstructive pulmonary disease (COPD) to these guidelines.

METHOD

This cross-sectional descriptive study was conducted from January 2011 to April 2012 in a 360-bed teaching hospital in Shiraz, Iran. We recorded the management data for 96 consecutive patients with COPD exacerbation. SPSS 11.5 software (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses.

RESULTS

The mean (standard deviation) age of our patients was 67.3 (14) years, and more than 75% of them were men. Adherence for starting antibiotics was 84.4%. Most of our patients (82.3%) received oxygen therapy, for a level of adherence to GOLD recommendations of 74%. Nearly 95% received a short-acting bronchodilator, and 12.5% received a long-acting bronchodilator. Adherence to the guidelines was 19.8% for oral and 61.4% for inhaled steroids. Adherence to the guidelines was 49% for starting N-acetylcysteine, 77.1% for antitussives and 13.5% for xanthine derivatives (aminophylline and theophylline). The overall adherence to GOLD guidelines was 67.2% at our hospital.

CONCLUSION

The level of adherence to GOLD guidelines for the management of COPD exacerbation was suboptimal at our teaching hospital. Further improvements in adherence to these guidelines are needed.

Measuring respiratory symptoms of COPD: performance of the EXACT- Respiratory Symptoms Tool (E-RS) in three clinical trials

BACKGROUND

Symptomatic relief is an important treatment goal for patients with COPD. To date, no diary for evaluating respiratory symptoms in clinical trials has been developed and scientifically-validated according to FDA and EMA guidelines. The EXACT - Respiratory Symptoms (E-RS) scale is a patient-reported outcome (PRO) measure designed to address this need. The E-RS utilizes 11 respiratory symptom items from the existing and validated 14-item EXACT, which measures symptoms of exacerbation. The E-RS total score quantifies respiratory symptom severity, and 3 domains assess breathlessness, cough and sputum, and chest symptoms.

METHODS

This study examined the performance of the E-RS in each of 3 controlled trials with common and unique validation variables: one 6-month (N = 235, US) and two 3-month (N = 749; N = 597; international). Subjects completed the E-RS as part of a daily eDiary. Tests of reliability, validity, and responsiveness were conducted in each dataset.

RESULTS

In each study, RS-Total score was internally consistent (Cronbach α) (0.88, 0.92, 0.92) and reproducible (intra-class correlation) in stable patients (2 days apart: 0.91; 7 days apart: 0.71, 0.74). RS-Total scores correlated significantly with the following criterion variables (Spearman's rho; p < 0.01, all comparisons listed here): FEV1% predicted (-0.19, -0.14, -0.15); St. George's Respiratory Questionnaire (SGRQ) (0.65, 0.52, 0.51); Breathlessness, Cough, and Sputum Scale (BCSS) (0.89, 0.89); modified Medical Research Council dyspnoea scale (mMRC) (0.40); rescue medication use (0.43, 0.42); Functional Performance Inventory Short-Form (FPI-SF) (0.43); 6-minute walk distance (6-MWT) (-0.30, -0.14) and incremental shuttle walk (ISWT) (-0.18) tests. Correlations between these variables and RS-Breathlessness, RS-Cough and Sputum, RS-Chest Symptoms scores supported subscale validity. RS-Total, RS-Breathlessness, and RS-Chest Symptoms differentiated mMRC levels of breathlessness severity (p < 0.0001). RS-Total and domain scores differentiated subjects with no rescue medication use and 3 or more puffs (p < 0.0001). Sensitivity to changes in health status (SGRQ), symptoms (BCSS), and exercise capacity (6MWT, ISWT) were also shown and responder definitions using criterion- and distribution-based methods are proposed.

CONCLUSIONS

Results suggest the E-RS is a reliable, valid, and responsive measure of respiratory symptoms of COPD suitable for use in natural history studies and clinical trials.

TRIAL REGISTRATION

MPEX: NCT00739648 ; AZ1: NCT00949975 ; AZ 2: NCT01023516.

Experience-oriented tobacco-use prevention lecture using a COPD-simulation mask for junior high school students

We recently developed a mask that simulates the experience of having one of the major diseases caused by tobacco smoking: chronic obstructive pulmonary disease (COPD). Here we examined the effects of a tobacco-use prevention lecture accompanied by a pseudo-COPD experience created with this mask on adolescents' attitude toward smoking. Junior high school students (12-13 years old, n=165) in Japan were the subjects. The students attended a 30-min tobacco-use prevention lecture with slides and movie clips and engaged in a light exercise session wearing the COPD-simulation mask for 15min. Before and after the lecture, the students' attitudes toward smoking were evaluated by the Kano test for social nicotine dependence (KTSND). The total KTSND scores decreased significantly from 9.9±4.4 (mean±SD, n=149) to 7.5±5.3 (n=144). Ninety-eight students wore the COPD mask, and their modified Borg scale scores increased significantly from 0.7±1.0 to 3.2±2.1 after exercise (P<0.0001). To the questionnaire item "Do you think you understand the suffering of individuals with COPD?", 24 and 51 students answered "definitely yes" and "yes", whereas 16, 4 and 1 answered "Cannot say," "no" and "definitely no", respectively. The KTSND scores were significantly smaller in the former affirmative group compared to the latter negative group (P<0.05). Of the 98 students who wore the simulation mask, 83 reported being satisfied with this pseudo-COPD experience. The tobacco-use prevention lecture with the pseudo-COPD experience created by the simulation mask was effective and safe.

Pain in patients with COPD: a systematic review and meta-analysis

OBJECTIVES

To systematically investigate the prevalence of pain, factors related with pain and pain management interventions in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND STUDY ELIGIBILITY CRITERIA

PubMed (MEDLINE), EMBASE, CINAHL and PsychINFO from 1966 to December 2013. Studies were included if they presented clinical data on pain or symptom burden in patients with COPD, or pain as a domain of quality of life (QoL). All types of study designs were included.

RESULTS

Of the 1571 articles that were identified, 39 met the inclusion criteria and were included in this review. Fourteen studies focused on pain and symptom burden (including pain) in patients with COPD and 25 studies focused on QoL using a questionnaire that included a separate pain domain. Reported pain prevalence in high-quality studies ranged from 32 to 60%. Included studies report that pain is more prevalent in patients with COPD compared to participants from the general population. Comorbidity, nutritional status, QoL and several symptoms were related to pain. None of the included studies reported a significant relationship between lung function and pain prevalence or severity. However, studies investigating pain in patients with moderate COPD reported higher pain prevalence compared to studies in patients with severe of very severe COPD.

CONCLUSIONS

Although literature on this topic is limited and shows substantial heterogeneity, pain seems to be a significant problem in patients with COPD and is related to several other symptoms, comorbidity and QoL. Data synthesis suggests that pain is more prevalent in patients with moderate COPD compared to patients with severe or very severe COPD. Further research is needed and should focus on determining a more accurate pain prevalence, investigating the relationship between pain prevalence, disease severity and comorbidity and explore implementation and efficacy of pain management interventions in patients with COPD.

The lung volume reduction coil for the treatment of emphysema: a new therapy in development

Lung volume reduction (LVR) coil treatment is a novel therapy for patients with severe emphysema. In this bilateral bronchoscopic treatment, approximately 10 LVR coils per lobe are delivered under fluoroscopic guidance in two sequential procedures. The LVR coil reduces lung volume by compressing the most destructed areas of the lung parenchyma and restores the lung elastic recoil. Both patients with upper- and lower-lobe predominant emphysema as well as a homogeneous emphysema distribution can be treated. LVR coil treatment results in an improvement of pulmonary function, exercise tolerance and quality of life. The LVR-coil treatment has been evaluated in several European clinical trials since 2008 and received CE mark approval in 2010. Currently, two large multicenter randomized controlled trials are underway in Europe and North America to assess the efficacy and safety of the LVR-coil treatment at 12 months compared with usual care. In this review, we share our experience with the LVR-coil treatment.

Effects of yoga training in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

INTRODUCTION

Currently, several studies have assessed the effect of yoga training on the management of chronic obstructive pulmonary disease (COPD), but these studies involved a wide variation of sample and convey inconclusive results. Hence, the present study was performed a systematic review and meta-analysis to investigate the efficacy of yoga training in COPD patients.

METHODS

PubMed, EMBASE, the Cochrane Library, Google Scholar, and ClinicalTrials.gov databases were searched for relevant studies. The primary outcomes were forced expiratory volume in one second (FEV1), FEV1% predicted (% pred). Secondary outcomes included 6-min walking distance (6 MWD), arterial oxygen tension (PaO2), and arterial carbon dioxide tension (PaCO2). Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated, and heterogeneity was assessed with the I(2) test.

RESULTS

Five randomized controlled trials (RCTs) involving 233 patients fulfilled the inclusion criteria. Yoga training significantly improved FEV1 (WMD: 123.57 mL, 95% CI: 4.12-243, P=0.04), FEV1% pred (WMD: 3.90%, 95% CI: 2.27-5.54, P<0.00001), and 6 MWD (WMD: 38.84 m, 95% CI: 15.52-62.16, P=0.001). However, yoga training had no significant effects on PaO2 (WMD: 1.29 mmHg, 95% CI: -1.21-3.78, P=0.31) and PaCO2 (WMD: -0.76 mmHg, 95% CI: -2.06-0.53, P=0.25).

CONCLUSIONS

The current limited evidence suggested that yoga training has a positive effect on improving lung function and exercise capacity and could be used as an adjunct pulmonary rehabilitation program in COPD patients. However, further studies are needed to substantiate our preliminary findings and to investigate the long-term effects of yoga training.

Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update

Non-invasive mechanical ventilation (NIV) was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation. Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea, the overlap syndrome (COPD and obstructive sleep apnea), neuromuscular disorders, obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure. In this review we discuss the different types of NIV, the specific conditions in which they can be used as well as the indications, recommendations, and evidence supporting the efficacy of NIV.

An estimate of the prevalence of COPD in Africa: a systematic analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is among the leading causes of death globally, accounting for about 3 million deaths worldwide in 2011. We aimed to estimate the prevalence of COPD in Africa in the year 2010 to provide the information that could assist health policy in the region.

METHODS

We conducted a systematic review of Medline, EMBASE and Global Health for studies on COPD published between 1990 and 2012. We included original population based studies providing estimates of the prevalence of COPD. We considered the reported estimates in terms of the mean age of the sample, sex ratio, the year of study and the country of the study as possible covariates. RESULTS from two different types of studies, i.e., based on spirometric and non-spirometric diagnosis of COPD, were further compared. The United Nation Population Division's population figures were used to estimate the number of COPD cases in the year 2010.

RESULTS

Our search returned 243 studies, from which only 13 met our selection criteria and only five were based on spirometry. The difference in the median prevalence of COPD in persons aged 40 years or older based on spirometry data (13.4%; IQR: 9.4%-22.1%) and non-spirometry data (4.0%; IQR: 2.1%-8.9%) was statistically significant (p = 0.001). There was no significant effect of the gender or the year of the study on the reported prevalence of COPD in either set of studies. The prevalence of COPD increased with age in spirometry-based studies (p = 0.017), which is a plausible finding suggesting internal consistency of spirometry-based estimates, while this trend was not observed in studies using other case definitions. When applied to the appropriate age group (40 years or more), which accounted for 196.4 million people in Africa in 2010, the estimated prevalence translates into 26.3 million (18.5-43.4 million) cases of COPD. Comparable figures for the year 2000 based on the same prevalence rates would amount to 20.0 million (14.1-33.1), suggesting an increase of 31.5% over a decade that is attributable to ageing of the African population alone.

CONCLUSION

Our findings suggest that COPD is likely to already represent a very large public health problem in Africa. Moreover, rapidly ageing African population should expect a steady increase in the number of COPD cases in the next decade and beyond. The quantity and quality of available evidence does not match the size of the problem. There is a need for more research on COPD prevalence, but also incidence, mortality and risk factors in Africa. We hope this study will raise awareness of COPD in Africa and encourage further research.

COPD management according to old and new GOLD guidelines: an observational study with Italian general practitioners

BACKGROUND

Guideline recommendations for COPD management are only partially applied within primary care clinical practice.

OBJECTIVE

To compare the COPD management by Italian general practitioners (GPs) according to either the old GOLD (oGOLD) or the new GOLD (nGOLD) guidelines.

RESEARCH DESIGN AND METHODS

Observational study in different Italian areas. A total of 176 GPs enrolled their patients with a COPD diagnosis. Questionnaires were used to collect data on: COPD symptoms, disease severity, exacerbations, prescribed pharmacological and non-pharmacological treatments. COPD severity was estimated according to oGOLD and nGOLD guidelines.

RESULTS

A total of 526 subjects had complete information to assess COPD severity level according to guidelines (symptoms level, spirometry, history of exacerbations). The investigated subjects were more frequently males (71.2%) with a mean age of 72.5 years, and ex-smokers (44.4%). GPs reported sufficient control of the disease in 47.2% of the subjects with over two exacerbations in the last 12 months. Most patients have moderate COPD (51.5%), according to oGOLD, and belong to D groups (high risk, more symptoms) (45.6%), according to nGOLD. Overall, a low use of post-bronchodilator spirometry (65.1%) and of pulmonary rehabilitation (13.4%) was shown. The results highlighted a low prescriptive appropriateness but with higher value according to nGOLD than oGOLD: 61.4% vs 35.6%.

STUDY LIMITATIONS

Prescription data only provide limited information to judge prescribing quality, thus the results have to be evaluated with caution; moreover, this study was not designed to assess the difference between oGOLD and nGOLD.

CONCLUSIONS

Guideline recommendations are applied only partially within clinical practice. A higher prescriptive appropriateness is shown by GPs using nGOLD classification. This might be due to the fact that nGOLD, with respect to oGOLD, takes into account anamnestic usual features considered by GPs in their clinical practice.

Non-invasive ventilation during exercise training for people with chronic obstructive pulmonary disease

BACKGROUND

Exercise training as a component of pulmonary rehabilitation improves health-related quality of life (HRQL) and exercise capacity in people with chronic obstructive pulmonary disease (COPD). However, some individuals may have difficulty performing exercise at an adequate intensity. Non-invasive ventilation (NIV) during exercise improves exercise capacity and dyspnoea during a single exercise session. Consequently, NIV during exercise training may allow individuals to exercise at a higher intensity, which could lead to greater improvement in exercise capacity, HRQL and physical activity.

OBJECTIVES

To determine whether NIV during exercise training (as part of pulmonary rehabilitation) affects exercise capacity, HRQL and physical activity in people with COPD compared with exercise training alone or exercise training with sham NIV.

SEARCH METHODS

We searched the following databases between January 1987 and November 2013 inclusive: The Cochrane Airways Group specialised register of trials, AMED, CENTRAL, CINAHL, EMBASE, LILACS, MEDLINE, PEDro, PsycINFO and PubMed. 

SELECTION CRITERIA

Randomised controlled trials that compared NIV during exercise training versus exercise training alone or exercise training with sham NIV in people with COPD were considered for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion in the review, extracted data and assessed risk of bias. Primary outcomes were exercise capacity, HRQL and physical activity; secondary outcomes were training intensity, physiological changes related to exercise training, dyspnoea, dropouts, adverse events and cost.

MAIN RESULTS

Six studies involving 126 participants who completed the study protocols were included. Most studies recruited participants with severe to very severe COPD (mean forced expiratory volume in one second (FEV1) ranged from 26% to 48% predicted). There was an increase in percentage change peak and endurance exercise capacity with NIV during training (mean difference in peak exercise capacity 17%, 95% confidence interval (CI) 7% to 27%, 60 participants, low-quality evidence; mean difference in endurance exercise capacity 59%, 95% CI 4% to 114%, 48 participants, low-quality evidence). However, there was no clear evidence of a difference between interventions for all other measures of exercise capacity. The results for HRQL assessed using the St George's Respiratory Questionnaire do not rule out an effect of NIV (total score mean 2.5 points, 95% CI -2.3 to 7.2, 48 participants, moderate-quality evidence). Physical activity was not assessed in any study. There was an increase in training intensity with NIV during training of 13% (95% CI 1% to 27%, 67 participants, moderate-quality evidence), and isoload lactate was lower with NIV (mean difference -0.97 mmol/L, 95% CI -1.58mmol/L to -0.36 mmol/L, 37 participants, moderate-quality evidence). The effect of NIV on dyspnoea or the number of dropouts between interventions was uncertain, although again results were imprecise. No adverse events and no information regarding cost were reported. Only one study blinded participants, whereas three studies used blinded assessors. Adequate allocation concealment was reported in four studies.

AUTHORS' CONCLUSIONS

The small number of included studies with small numbers of participants, as well as the high risk of bias within some of the included studies, limited our ability to draw strong evidence-based conclusions. Although NIV during lower limb exercise training may allow people with COPD to exercise at a higher training intensity and to achieve a greater physiological training effect compared with exercise training alone or exercise training with sham NIV, the effect on exercise capacity is unclear. Some evidence suggests that NIV during exercise training improves the percentage change in peak and endurance exercise capacity; however, these findings are not consistent across other measures of exercise capacity. There is no clear evidence that HRQL is better or worse with NIV during training. It is currently unknown whether the demonstrated benefits of NIV during exercise training are clinically worthwhile or cost-effective.

Measuring respiratory symptoms in clinical trials of COPD: reliability and validity of a daily diary

BACKGROUND

Although respiratory symptoms are characteristic features of COPD, there is no standardised method for quantifying their severity in stable disease.

OBJECTIVE

To evaluate the EXACT-Respiratory Symptom (E-RS) measure, a daily diary comprising 11 of the 14 items in the Exacerbations of Chronic Pulmonary Disease Tool (EXACT).

METHODS

Qualitative: patient focus group and interviews to address content validity. Quantitative: secondary data analyses to test reliability and validity.

RESULTS

Qualitative: n=84; mean (SD) age 65 (10) years, FEV1 1.2(0.4) L; 44% male. Subject descriptions of their respiratory symptoms were consistent with E-RS content and structure. Quantitative: n=188; mean (SD) age 66 (10) years, FEV1 1.2(0.5) L; 50% male. Factor analysis (FA) showed 3 subscales: RS-Breathlessness, RS-Cough & Sputum, and RS-Chest Symptoms; second-order FA supported a general factor and total score. Reliability (total and subscales): 0.88, 0.86, 0.73, 0.81; 2-day test-retest ICC: 0.90, 0.86, 0.87, 0.82, respectively.

VALIDITY

Total scores correlated significantly (p < 0.0001) with SGRQ Total (r=0.75), Symptoms (r=0.66), Activity (r=0.57), Impact (r=0.70) scores; subscale correlations were also significant (r=0.26, p < 0.05 (RS-Chest Symptoms with Activity) to r=0.69, p < 0.0001 (RS-Cough & Sputum with Symptoms). RS-Breathlessness correlated with rescue medication use (r=0.32, p < 0.0001), clinician-reported mMRC (r=0.33, p < 0.0001), and FEV1% predicted (r=-0.17, p < 0.05). E-RS scores differentiated groups based on chronic bronchitis diagnosis (p < 0.01-0.001), smoking status (p < 0.05-0.001), and rescue medication use (p < 0.05-0.0001).

CONCLUSIONS

Results suggest the RS-Total is a reliable and valid instrument for evaluating respiratory symptom severity in stable COPD. Further study of sensitivity to change is warranted.

Examining the relationship between anxiety and depression and exacerbations of COPD which result in hospital admission: a systematic review

Objectives

Exacerbations of chronic obstructive pulmonary disease (COPD) are the third largest cause of emergency hospital admissions in the UK. This systematic literature review explored the relationship between the hospitalization rates and the COPD comorbidities, anxiety, and depression.

Methods

The Centre for Research Dissemination’s framework for systematic reviews was followed using search terms relating to COPD, anxiety, depression, and hospital admission. Papers identified were assessed for relevance and quality, using a suitable Critical Appraisal Skills Programme tool and Mixed Methods Assessment Tool.

Results

Twenty quantitative studies indicated that anxiety and depression led to a statistically significant increase in the likelihood of COPD patients being hospitalized. These comorbidities also led to an increased length of stay and a greater risk of mortality postdischarge. Other significant factors included lower Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise scores, female gender, lower socioeconomic status, poorer patient perceived quality of life, increased severity of lung function, and less improvement in dyspnea from admission to discharge. It was also highlighted that only 27%–33% of those with depression were being treated for it. Four qualitative studies revealed that patients saw anxiety and depression as a major factor that affected their ability to cope with and self-manage their condition.

Implications

Findings from the systematic review have highlighted a need for better recognition and treatment of anxiety and depression amongst individuals with COPD. Ongoing research will develop and test strategies for promoting better management and self-management as a means of reducing hospital admissions.

Validity of a questionnaire-based diagnosis of chronic obstructive pulmonary disease in a general population-based study

Background

The diagnosis of chronic obstructive pulmonary disease (COPD) is based on airflow obstruction. In epidemiological studies, spirometric data have often been lacking and researchers have had to rely almost solely on questionnaire answers. The aim of this study is to assess the diagnostic accuracy of questionnaire answers to detect COPD.

Methods

A sample of the Swedish general population without physician-diagnosed asthma was randomly selected and interviewed using a respiratory questionnaire. All eligible subjects aged 25–75 years (n = 3892) performed spirometry for detection of airflow obstruction using Global Initiative for Chronic Obstructive Lung Disease (GOLD) or American Thoracic Society (ATS)/European Respiratory Society (ERS) criteria. Sensitivity, specificity, positive likelihood ratio (LR+), positive predictive values (PPVs), and negative predictive values (NPVs) were calculated to define diagnostic accuracy of questionnaire answers.

Results

The sensitivity of the question “Have you been diagnosed by a physician as having COPD or emphysema?” in detecting airflow obstruction was 5.7% using GOLD, and 9.8% using ATS/ERS, criteria; specificity was 99.7% for GOLD and 99.5% for ATS/ERS. Sensitivity, specificity, and PPV were higher for the question compared to self-reported symptoms of chronic bronchitis in identifying subjects with airflow obstruction.

Conclusions

The high specificity and good PPV suggest that the question “Have you been diagnosed by a physician as having COPD or emphysema?” is more likely to identify those who do not have airflow obstruction, whereas the low sensitivity of this question could underestimate the real burden of COPD in the general population.

The impact of virtual admission on self-efficacy in patients with chronic obstructive pulmonary disease - a randomised clinical trial

AIMS AND OBJECTIVES

To investigate how virtual admission during acute exacerbation influences self-efficacy in patients with chronic obstructive pulmonary disease, compared with conventional hospital admission.

BACKGROUND

Telemedicine solutions have been highlighted as a possible way to increase self-efficacy in patients with chronic diseases, such as chronic obstructive pulmonary disease. However, little is known about how telemedicine-based virtual admission as a replacement of hospital admission during acute exacerbation affects chronic obstructive pulmonary disease patients' self-efficacy.

DESIGN

This study was a nonblinded, randomised clinical multicentre trial. The study was a substudy to The Virtual Hospital, investigating the feasibility and safety of telemedicine-based treatment at home for patients with acute exacerbation of chronic obstructive pulmonary disease.

METHODS

Participants were consecutively randomised to virtual admission or conventional hospital admission. Data from 50 patients were analysed. Self-efficacy was assessed at baseline, three days after discharge, and also six weeks and three months after discharge, using the Danish version of 'The chronic obstructive pulmonary disease self-efficacy scale'.

RESULTS

Intergroup comparison showed no significant differences between the two groups at baseline, three days after discharge, six weeks after discharge or three months after discharge. Furthermore, intragroup comparison did not reveal significant differences in the chronic obstructive pulmonary disease self-efficacy scale mean sum score within the two groups.

CONCLUSIONS

The results of the study suggest that there is no difference between self-efficacy in chronic obstructive pulmonary disease patients undergoing virtual admission, compared with conventional hospital admission. However, the anticipated sample size could not be reached, which prompts caution regarding interpretation of the findings.

RELEVANCE TO CLINICAL PRACTICE

This study provides new insight into how virtual admission affects chronic obstructive pulmonary disease patients' self-efficacy. Clinicians should consider the timing, duration and the content in the design of telemedical interventions directed at improving chronic obstructive pulmonary disease patients' self-efficacy, as telemedicine solutions alone may not be sufficient to enhance self-efficacy.

A comparison of muscle strength and endurance, exercise capacity, fatigue perception and quality of life in patients with chronic obstructive pulmonary disease and healthy subjects: a cross-sectional study

Background

Chronic obstructive pulmonary disease (COPD) has significant systemic effects that substantially impact quality of life and survival. The purpose of this study was to assess and compare peripheral muscle strength and endurance, exercise capacity, fatigue perception and quality of life between patients with COPD and healthy subjects.

Methods

Twenty COPD patients (mean FEV₁ 49.3 ± 19.2%) and 20 healthy subjects were included in the study. Pulmonary function testing and six-minute walk test (6MWT) were performed. Peripheral muscle strength was measured with a hand-held dynamometer, peripheral muscle endurance was evaluated with sit-ups, squats and modified push-ups tests. Fatigue perception was assessed using the Fatigue Impact Scale (FIS) and Fatigue Severity Scale (FSS). General quality of life was determined with the Nottingham Health Profile (NHP), and cough-specific quality of life was evaluated with the Leicester Cough Questionnaire (LCQ).

Results

Pulmonary functions, strength of shoulder abductor and flexor muscles, numbers of sit-ups and squats, 6MWT distance and 6MWT% were significantly lower in COPD patients than in healthy subjects (p < 0.05). FIS psychosocial sub-dimension and total scores, NHP scores for all sub-dimensions except pain sub-dimension of the COPD group were significantly higher than those of healthy subjects (p < 0.05). The LCQ physical, psychological and social sub-dimensions and total scores were significantly lower in COPD patients than in healthy subjects (p < 0.05).

Conclusions

Pulmonary functions, peripheral muscle strength and endurance, exercise capacity and quality of life were adversely affected in patients with COPD. There are greater effect of fatigue on psychosocial functioning and general daily life activities and effect of cough on the quality of life in patients with COPD. This study supports the idea that COPD patients must be evaluated in a comprehensive manner for planning pulmonary rehabilitation programs.

A decision support system to determine optimal ventilator settings

BACKGROUND

Choosing the correct ventilator settings for the treatment of patients with respiratory tract disease is quite an important issue. Since the task of specifying the parameters of ventilation equipment is entirely carried out by a physician, physician's knowledge and experience in the selection of these settings has a direct effect on the accuracy of his/her decisions. Nowadays, decision support systems have been used for these kinds of operations to eliminate errors. Our goal is to minimize errors in ventilation therapy and prevent deaths caused by incorrect configuration of ventilation devices. The proposed system is designed to assist less experienced physicians working in the facilities without having lung mechanics like cottage hospitals.

METHODS

This article describes a decision support system proposing the ventilator settings required to be applied in the treatment according to the patients' physiological information. The proposed model has been designed to minimize the possibility of making a mistake and to encourage more efficient use of time in support of the decision making process while the physicians make critical decisions about the patient. Artificial Neural Network (ANN) is implemented in order to calculate frequency, tidal volume, FiO2 outputs, and this classification model has been used for estimation of pressure support / volume support outputs. For the obtainment of the highest performance in both models, different configurations have been tried. Various tests have been realized for training methods, and a number of hidden layers mostly affect factors regarding the performance of ANNs.

RESULTS

The physiological information of 158 respiratory patients over the age of 60 and were treated in three different hospitals between the years 2010 and 2012 has been used in the training and testing of the system. The diagnosed disease, core body temperature, pulse, arterial systolic pressure, diastolic blood pressure, PEEP, PSO2, pH, pCO2, bicarbonate data as well as the frequency, tidal volume, FiO2, and pressure support / volume support values suitable for use in the ventilator device have been recommended to the physicians with an accuracy of 98,44%. Performed experiments show that sequential order weight/bias training was found to be the most ideal ANN learning algorithm for regression model and Bayesian regulation backpropagation was found to be the most ideal ANN learning algorithm for classification models.

CONCLUSIONS

This article aims at making independent of the choice of parameters from physicians in the ventilator treatment of respiratory tract patients with proposed decision support system. The rate of accuracy in prediction of systems increases with the use of data of more patients in training. Therefore, non-physician operators can use systems in determination of ventilator settings in case of emergencies.

Integrating a tailored e-health self-management application for chronic obstructive pulmonary disease patients into primary care: a pilot study

Background

Changes in reimbursement have been compelling for Dutch primary care practices to apply a disease management approach for patients with chronic obstructive pulmonary disease (COPD). This approach includes individual patient consultations with a practice nurse, who coaches patients in COPD management. The aim of this study was to gauge the feasibility of adding a web-based patient self-management support application, by assessing patients’ self-management, patients’ health status, the impact on the organization of care, and the level of application use and appreciation.

Methods

The study employed a mixed methods design. Six practice nurses recruited COPD patients during a consultation. The e-Health application included a questionnaire that captured information on demographics, self-management related behaviors (smoking cessation, physical activity and medication adherence) and their determinants, and nurse recommendations. The application provided tailored feedback messages to patients and provided the nurse with reports. Data were collected through questionnaires and medical record abstractions at baseline and one year later. Semi-structured interviews with patients and nurses were conducted. Descriptive statistics were calculated for quantitative data and content analysis was used to analyze the qualitative data.

Results

Eleven patients, recruited by three nurses, used the application 1 to 7 times (median 4). Most patients thought that the application supported self-management, but their interest diminished after multiple uses. Impact on patients’ health could not be determined due to the small sample size. Nurses reported benefits for the organization of care and made suggestions to optimize the use of the reports.

Conclusion

Results suggest that it is possible to integrate a web-based COPD self-management application into the current primary care disease management process. The pilot study also revealed opportunities to improve the application and reports, in order to increase technology use and appreciation.

Tregs and HLA-DR expression in sputum cells of COPD patients treated with tiotropium and formoterol

Immune cells expressing the activation markers HLA-DR and regulatory T cells (Tregs) may be involved in the regulation of chronic inflammation in chronic obstructive pulmonary disease (COPD). In this study we analyzed native and activated cell profiles in sputum of 22 stable COPD patients receiving formoterol (F) or formoterol + tiotropium (F + T) for 3 months. Cells were isolated from induced sputum and were examined on Coulter flow cytometer using fluorescent antibodies specific for CD3, CD4, CD8, CD14, CD19, CD25, CD127, and HLA-DR antigens. Cell profiles and cell activation were assessed by analysis of HLA-DR, CD25, and CD127 co-expression in double-stained samples. Tregs were defined as CD4⁺CD25(high) CD127(low) cells. We found that the combined therapy significantly decreased the CD8⁺ cell number (p < 0.01). At baseline, HLA-DR was expressed in about 10 % of sputum T or B cells and a higher expression was found on monocytes. The HLA-DR expression on lymphocytes, but not monocytes, was significantly lower (p < 0.01) in patients treated with F + T. Fractions of activated [CD4⁺ CD25⁺] cells were also significantly lower in the combined therapy group, except for the subpopulation of CD4⁺CD25(high) CD127(low) cells which was not altered. We conclude that tiotropium in add-on therapy to formoterol affects Treg cell profiles and decreases HLA-DR expression in airway lymphocytes.

Learning Bayesian networks for clinical time series analysis

INTRODUCTION

Autonomous chronic disease management requires models that are able to interpret time series data from patients. However, construction of such models by means of machine learning requires the availability of costly health-care data, often resulting in small samples. We analysed data from chronic obstructive pulmonary disease (COPD) patients with the goal of constructing a model to predict the occurrence of exacerbation events, i.e., episodes of decreased pulmonary health status.

METHODS

Data from 10 COPD patients, gathered with our home monitoring system, were used for temporal Bayesian network learning, combined with bootstrapping methods for data analysis of small data samples. For comparison a temporal variant of augmented naive Bayes models and a temporal nodes Bayesian network (TNBN) were constructed. The performances of the methods were first tested with synthetic data. Subsequently, different COPD models were compared to each other using an external validation data set.

RESULTS

The model learning methods are capable of finding good predictive models for our COPD data. Model averaging over models based on bootstrap replications is able to find a good balance between true and false positive rates on predicting COPD exacerbation events. Temporal naive Bayes offers an alternative that trades some performance for a reduction in computation time and easier interpretation.

Tele-monitoring reduces exacerbation of COPD in the context of climate change--a randomized controlled trial

BACKGROUND

A home based tele-monitoring system was developed to assess the effects of heat stress (days > 25°C) on clinical and functional status in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Sixty-two COPD patients (GOLD II-IV) were randomized into a tele-monitoring Group (TG, N = 32) or Control Group (CG, N = 30). Tele-monitoring included 1) daily clinical status (COPD Assessment Test-CAT), 2) daily lung function and 3) weekly 6-minute walk test (6MWT). Duration of monitoring lasted a total of nine months (9 M).

RESULTS

From June 1st-August 31st 2012, 32 days with heat stress (29.0 ± 2.5°C) were recorded and matched with 32 thermal comfort days (21.0 ± 2.9°C). During heat stress, the TG showed a significant reduction in lung function and exercise capacity (FEV1% predicted: 51.1 ± 7.2 vs. 57.7 ± 5.0%; P <0.001 and 6MWT performance: 452 ± 85 vs. 600 ± 76 steps; P <0.001) and increase in CAT scores (19.2 ± 7.9 vs. 16.2 ± 7.2; P <0.001).Over summer, significantly fewer TG patients suffered exacerbation of COPD compared to CG patients (3 vs. 14; P = 0.006). Over entire 9 M follow-up, the TG group had fewer exacerbations compared to CG (7 vs. 22; P = 0.012), shorter cumulative hospital stay (34 vs. 97 days) and 43% fewer specialist consultations (24. vs. 42; P = 0.04).

CONCLUSION

Heat stress affects clinical and functional status in COPD. Tele-monitoring reduces exacerbation frequency and health care utilization during heat stress and other periods of the year.

TRIAL REGISTRATION DRKS-ID

DRK00000705.

Diagnosis of chronic obstructive pulmonary disease earlier than current Global Initiative for Obstructive Lung Disease guidelines using a feasible spirometry parameter (maximal-mid expiratory flow/forced vital capacity)

Some patients suffer from clinical symptoms of chronic obstructive pulmonary disease (COPD) but their pulmonary function tests are in the normal range (at risk group). The objective of this study was to discover a practical test to distinguish these patients from non-COPD subjects. A total of 77 subjects including 40 COPD patients, 37 subjects at risk for developing COPD, and 32 control subjects were entered in this study. The accuracy of maximal-mid expiratory flow (MMEF)/forced vital capacity (FVC) for the diagnosis of COPD in at risk patients and its capability to differentiate from early COPD and normal patients were evaluated. Body plethysmography was used for measurement of lung volume as the Global Initiative for Obstructive Lung Disease standard. MMEF/FVC in the at risk group of COPD (0.73 ± 0.19) was significantly lower than the normal control group (0.9 ± 0.24, respectively), and also, it was significantly higher than the COPD group (0.31 ± 0.17). There was significant correlation between the MMEF/FVC and amount of smoking measured by pack year ( r2 = 0.112, p = 0.005) and stages of COPD (Spearman’s ρ = 0.82, p = 0.0001). Early stage COPD (smoker subjects without spirometry derangement) can be diagnosed by MMEF/FVC. Using this tool we may be able to detect this highly preventable disease at an earlier stage.

Hospitalizations for chronic obstructive pulmonary disease exacerbations and their impact on disease and subsequent morbidity and mortality

In chronic obstructive pulmonary disease (COPD), progressive airflow limitation is a risk factor for development of disease exacerbations, which, when severe, may require hospitalization. In the discussed study, a large cohort of patients hospitalized for their first COPD exacerbation were analyzed in terms of subsequent hospitalizations and mortality risk. COPD hospitalizations were found to be a risk factor for subsequent COPD-related hospitalizations, to increase their incidence and to increase the disease-related mortality risk. Male gender was also identified as a risk factor for a higher COPD-related morbidity and mortality. Hospitalizations for COPD exacerbation should be considered as additional criterion for disease severity in tailoring the disease management.

Increased risk and related factors of depression among patients with COPD: a population-based cohort study

Background

Depression is a common and mostly undertreated problem in patients with chronic diseases. However, population-based studies on the association between chronic obstructive pulmonary disease (COPD) and subsequent depression are limited in Asian populations. This study evaluated the incidence and risk factors of depression for patients with COPD in Taiwan.

Methods

Using the claims data from the National Health Insurance of Taiwan, we identified 38,010 COPD patients newly diagnosed in 2000–2004 and 38,010 subjects without COPD frequency, matched by sex, age and index date. The incidence rate and hazard ratio for depression were estimated by the end of 2008.

Results

The incidence rate of depression was 1.88 folds higher in the COPD cohort than in the non-COPD cohort (12.2 versus 6.47 per 1,000 person-years, p < 0.0001). The depression risk was the greatest within the first year following COPD diagnosis and tended to decline with follow-up time. Among COPD patients, multivariate analysis showed that younger women and low-income patients were at higher risk of depression. Hospitalization and comorbidities such as hypertension, arthritis, cancer, and heart disease were also significant predictors for depression risk.

Conclusion

This population-based cohort study demonstrated a strong relationship between COPD and subsequent depression. These findings could assist healthcare providers to pinpoint individuals with a higher predisposition to having depression, which could then facilitate the provision of culturally appropriate rehabilitation within the first year after the diagnosis of COPD.

Silica dust, radon and death from non-malignant respiratory diseases in German uranium miners

OBJECTIVE

To quantify the relationship between death from non-malignant respiratory diseases (NMRD) and exposure to silica dust or radon in a cohort of 58,690 former German uranium miners.

METHODS

In the follow-up period from 1946 to 2008, a total of 2336 underlying deaths from NMRDs occurred, including 715 deaths from chronic obstructive pulmonary diseases (COPD) and 975 deaths from silicosis or other pneumoconiosis. Exposure to respirable crystalline silica and radon was individually assessed by means of a comprehensive job-exposure matrix. Risk analyses were based on a linear Poisson regression model with the baseline stratified by age, calendar year and duration of employment.

RESULTS

There was no increase in risk of death from COPDs or any other NMRDs in relation to cumulative exposure to silica (mean=5.9, max=56 mg/m(3)-years), except in the group of deaths from silicosis or other pneumoconiosis. Here, a strong non-linear increase in risk was observed. Cumulative radon exposure (mean=280; max=3224 Working Level Months) was not related to death from COPDs or any other NMRDs.

CONCLUSIONS

The present findings do not indicate a relationship between mortality from COPD with silica dust or radon. However, validity of cause of death and lack of control for smoking remain potential sources of bias.

Clinical validation of the CHRONIOUS wearable system in patients with chronic disease

The CHRONIOUS system defines a powerful and easy to use framework which has been designed to provide services to clinicians and their patients suffering from chronic diseases. The system is composed of a wearable shirt that integrate several body sensors, a portable smart device and a central sub-system that is responsible for the long term storage of the collected patient's data. A multi-parametric expert system is developed for the analysis of the collected data using intelligent algorithms and complex techniques. Apart for the vital signals, dietary habits, drug intake, activity data, environmental and biochemical parameters are recorded. The CHRONIOUS platform is validated through clinical trials in several medical centers and patient's home environments recruiting patients suffering from Chronic Obstructive pulmonary disease (COPD) and Chronic Kidney Disease (CKD) diseases. The clinical trials contribute in improving the system's accuracy, while Pulmonologists and Nephrologists experts utilized the CHRONIOUS platform to evaluate its efficiency and performance. The results of the utilization of the system were very encouraging. The CHRONIOUS system has been proven to be a well-validated real-time patient monitoring and supervision platform, providing a useful tool for the clinician and the patient that would contribute to the more effective management of chronic diseases.

Combined effect of smoking and occupational exposure to dusts, gases or fumes on the incidence of COPD

To assess risk factors related to the development of chronic obstructive pulmonary disease (COPD) including smoking and occupational exposure (OE) to dusts, gases or fumes, we performed a longitudinal 11-year follow-up postal survey. The original study population was a random population sample of 8000 inhabitants of Helsinki aged 20 to 69 years in 1996. Participants of the first postal questionnaire were invited to this follow-up survey in 2007 with 4302 (78%) answers obtained. Cumulative incidence of COPD in 11 years was 3.43% corresponding to an incidence rate of 3.17/1000/year after exclusion of those with self-reported physician-diagnosed COPD and ever COPD in 1996. Smoking and age, but not gender, were associated with incident COPD. Reported family history of COPD increased the cumulative incidence to 8.55% vs 3.04% among those without a family history (p < 0.001). In multivariate analysis, significant independent risk factors for incident COPD were: current smoking in 1996 (OR 4.40 [95% CI 2.89-6.71]), age over 50 (OR 3.42 [95% CI 2.22-5.26]), family history of COPD (OR 2.08 [1.27-3.43]), ever asthma (OR 2.28 [1.35-3.86]), and self-reported OE (OR 2.14 [1.50-3.05]). Occupational exposure to dusts, gases or fumes, assessed both based on self-reported exposure and a job exposure matrix using reported professions, was an independent risk factor for incident COPD. Smoking and OE together yielded an additive effect on incidence of COPD.

Vasodilatory effect of the stable vasoactive intestinal peptide analog RO 25-1553 in murine and rat lungs

Rationale

Stable analogs of vasoactive intestinal peptide (VIP) have been proposed as novel line of therapy in chronic obstructive pulmonary disease (COPD) based on their bronchodilatory and anti-inflammatory effects. We speculated that VIP analogs may provide additional benefits in that they exert vasodilatory properties in the lung, and tested this hypothesis in both ex vivo and in vivo models.

Methods

In isolated perfused mouse lungs and in an in vivo rat model, pulmonary blood vessels were preconstricted by hypoxia and hemodynamic changes in response to systemic (ex vivo) or inhaled (in vivo) administration of the cyclic VIP analog RO 25-1553 were determined.

Results

In mouse lungs, RO 25-1553 reduced intrinsic vascular resistance at normoxia, and attenuated the increase in pulmonary artery pressure in response to acute hypoxia. Consistently, inhalation of RO 25-1553 (1 mg·mL⁻¹ for 3 min) caused an extensive and sustained (> 60 min) inhibition of the pulmonary arterial pressure increase in response to hypoxia in vivo that was comparable to the effects of inhaled sildenafil. This effect was not attributable to systemic cardiovascular effects of RO 25-1553, but to a lung specific reduction in pulmonary vascular resistance, while cardiac output and systemic arterial hemodynamics remained unaffected. No adverse effects of RO 25-1553 inhalation on pulmonary gas exchange, ventilation-perfusion matching, or lung fluid content were detected.

Conclusion

Our findings demonstrate that inhaled delivery of the stable VIP analog RO 25-1553 induces a potent and sustained vasodilatory effect in the pulmonary circulation with no detectable adverse effects. Therapeutic inhalation of RO 25-1553 may provide vascular benefits in addition to its reported anti-inflammatory and bronchodilatory effects in COPD, yet caution is warranted given the overall poor results of vasodilator therapies for pulmonary hypertension secondary to COPD in a series of recent clinical trials.

Role of once-daily glycopyrronium bromide (NVA237) in the management of COPD

Progressive airflow limitation is a hallmark feature of chronic obstructive pulmonary disease (COPD) that ultimately leads to breathlessness, impaired quality of life, and reduced exercise capacity. Pharmacotherapy is used in patients with COPD to prevent and control symptoms, reduce both the frequency and severity of exacerbations, improve health status, and increase exercise tolerance. These strategies are intended to address management issues which promote both current disease control and a reduction in the risk of disease deterioration in the future. At the present time, long-acting β2-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are available for maintenance therapy in patients with persistent symptoms. Tiotropium was the first LAMA to be approved for management of COPD, and many studies have described its beneficial effects on multiple clinically relevant outcomes. Glycopyrronium bromide (NVA237), a new LAMA, has been developed and received regulatory approval for management of COPD in a number of countries around the world. Results from pivotal Phase III trials suggest that NVA237 is safe and well tolerated in patients with moderate to severe COPD, and provides rapid and sustained improvements in lung function. Further, these changes are associated with statistically and clinically meaningful improvements in dyspnea, health-related quality of life, and exercise tolerance. Treatment with NVA237 also results in a significant reduction in risk of exacerbations and the need for rescue medication, and has been comparable with tiotropium with respect to safety and efficacy outcomes. Finally, emerging data indicate that NVA237 is efficacious both as monotherapy and in combination with indacaterol.