Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)

The optimum timing to wean invasive ventilation for patients with AECOPD or COPD with pulmonary infection

COPD is characterized by a progressive decline in lung function and mental and physical comorbidities. It is a significant burden worldwide due to its growing prevalence, comorbidities, and mortality. Complication by bronchial-pulmonary infection causes 50%-90% of acute exacerbations of COPD (AECOPD), which may lead to the aggregation of COPD symptoms and the development of acute respiratory failure. Non-invasive or invasive ventilation (IV) is usually implemented to treat acute respiratory failure. However, ventilatory support (mainly IV) should be discarded as soon as possible to prevent the onset of time-dependent complications. To withdraw IV, an optimum timing has to be selected based on weaning assessment and spontaneous breathing trial or replacement of IV by non-IV at pulmonary infection control window. The former method is more suitable for patients with AECOPD without significant bronchial-pulmonary infection while the latter method is more suitable for patients with AECOPD with acute significant bronchial-pulmonary infection.

Assessing the use of initial oxygen therapy in chronic obstructive pulmonary disease patients: a retrospective audit of pre-hospital and hospital emergency management

BACKGROUND

Carbon dioxide retention in chronic obstructive pulmonary disease (COPD) exacerbations can be a complication of oxygen therapy. Current recommendations suggest an inspired oxygen level (FiO2 ) < 0.28, aiming for saturation (SpO2 ) of 88-92% until arterial blood gas analysis is available.

AIMS

This study aims to assess the use of O2 therapy and FiO2 in the emergency management of patients with a known diagnosis of COPD.

METHODS

Retrospective audit of 150 COPD patients admitted over 18 months, data being extracted from the hospital records.

RESULTS

Of the records reviewed, 57% were male, mean age 75 years. COPD was recognised in 53%. SpO2 recorded in 124 patients, with SpO2 < 88% seen in 40 patients. Oxygen was administered in 123 patients in ambulances; high flow in 111 patients, and only 12 patients received O2 therapy in line with the recommended FiO2 < 0.28. In the emergency department (ED), 112 patients received O2 supplementation; high flow given in 68 patients. Hypercapnia was seen in 71 patients; FiO2 > 0.28 given in 54 patients in ambulances and in 35 patients in ED. Non-invasive ventilation was required in 53 patients; FiO2 > 0.28 given in 29 patients in the ED. Seven patients were admitted to intensive care unit, and 10 patients died.

CONCLUSION

High-flow oxygen is used for the initial treatment of COPD exacerbations, but only 53% are recognised as having COPD. A FiO2 > 0.28 is often initiated before admission and continued in the ED. A larger study would be required to assess any possible harm of this approach, but education of those involved in the care of COPD patients may reduce the risk of complications of hypercapnia.

Biomarker Development for Chronic Obstructive Pulmonary Disease. From Discovery to Clinical Implementation

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality in the world. Regrettably, there are no biomarkers to objectively diagnose COPD exacerbations, which are the major drivers of hospitalization and deaths from COPD. Moreover, there are no biomarkers to guide therapeutic choices or to risk stratify patients for imminent exacerbations and no objective biomarkers of disease activity or disease progression. Although there has been a tremendous investment in COPD biomarker discovery over the past 2 decades, clinical translation and implementation have not matched these efforts. In this article, we outline the challenges of biomarker development in COPD and provide an overview of a developmental pipeline that may be able to surmount these challenges and bring novel biomarker solutions to accelerate therapeutic discoveries and to improve the care and outcomes of the millions of individuals worldwide with COPD.

Can roflumilast, a phosphodiesterase-4 inhibitor, improve clinical outcomes in patients with moderate-to-severe chronic obstructive pulmonary disease? A meta-analysis

Background

Effects of roflumilast on lung function, symptoms, acute exacerbation and adverse events in patients with chronic obstructive pulmonary disease (COPD) are controversial. We aimed to further clarify the efficacy and safety of roflumilast in treatment of moderate-to-severe COPD.

Methods

From 1946 to November 2015, we searched the Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials, ISI Web of Science and American College of Physician using “roflumilast” and “chronic obstructive pulmonary disease” or “COPD”. Randomized controlled trials that reported forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), transition dyspnea index (TDI), St George’s Respiratory Questionnaire (SGRQ), and incidence of COPD exacerbations and adverse events were eligible. We conducted the heterogeneities test and sensitivity analysis, and random-effects or fixed-effects model was applied to calculate risk ratio (RR) and mean difference (MD) for dichotomous and continuous data respectively. Cochrane systematic review software, Review Manager (RevMan), was used to test the hypothesis by Mann-Whitney U-test.

Results

Thirteen trials with a total of 14,563 patients were pooled in our final studies. Except for SGRQ (I² = 63 %, χ² = 1.71, P = 0.07) and adverse events (I² = 94 %, χ² = 0.03, P < 0.001), we did not find statistical heterogeneity in outcome measures. The pooled MD of pre- and post-bronchodilator FEV₁ was 54.60 (95 % confidence interval (CI) 46.02 ~ 63.18) and 57.86 (95 % CI 49.80 ~ 65.91), and both showed significant improvement in patients with roflumilast (z = 12.47, P <0.001; z = 14.07, P < 0.001), so did in FVC (MD 90.37, 95 % CI 73.95 ~ 106.78, z = 10.79, P < 0.001). Significant alleviation of TDI (MD 0.30, 95 % CI 0.14 ~ 0.46, z = 3.67, P < 0.001) and decrease of acute exacerbation (RR 0.86, 95 % CI 0.81 ~ 0.91, z = 5.54, P < 0.001) were also identified in treatment of roflumilast, but without significant difference in SGRQ (MD −1.30, 95 % CI −3.16 ~ 0.56, z = 1.37, P = 0.17). Moreover, roflumilast significantly increased the incidence of adverse events compared with placebo (RR 1.31, 95 % CI 1.16 ~ 1.47, z = 4.32, P < 0.001).

Conclusions

Roflumilast can be considered as an alternative therapy in selective patients with moderate-to-severe COPD.

Long-term outcome of chronic obstructive pulmonary disease patients with acute respiratory failure following intensive care unit discharge in Turkey

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) remains a globally significant cause of mortality, although COPD mortality varies from country to country, and across different regions within each country. The primary objective of this study was to determine the mortality rates of COPD patients who present with acute respiratory failure (ARF) to a tertiary care referral center in different stages of their follow-up (ICU, in-hospital and after discharge). The secondary objective was to determine factors associated with mortality in this group of patients.

RESULTS

Medical records of consecutive COPD patients over a 10-year period were reviewed.The study included 147 patients. Of these, 72 were treated initially with noninvasive positive pressure ventilation (NIPPV), and 12 of these required intubation after NIPPV failed. Therefore, 86 patients were intubated for invasive mechanical ventilation (IMV), while NIPPV was succesful in 60 patients. Survival time was independently associated with advanced age, high APACHE II score, co-morbidity and the need for IMV. The cumulative mortality was 27% in the medical ICU and 31% in hospital following ICU discharge. The mortality rate at 1, 2 and 5 years was 54%, 66% and 84%, respectively.

CONCLUSION

COPD patients admitted to the ICU for ARF have an approximately 70% chance of leaving hospital alive, but half of these may die in the first 6 months after discharge. The risk factors related to mortality were advanced age, high APACHE II score, co-morbidity and IMV requirement.

Risk factors for COPD exacerbations in inhaled medication users: the COPDGene study biannual longitudinal follow-up prospective cohort

Background

Despite inhaled medications that decrease exacerbation risk, some COPD patients experience frequent exacerbations. We determined prospective risk factors for exacerbations among subjects in the COPDGene Study taking inhaled medications.

Methods

2113 COPD subjects were categorized into four medication use patterns: triple therapy with tiotropium (TIO) plus long-acting beta-agonist/inhaled-corticosteroid (ICS ± LABA), tiotropium alone, ICS ± LABA, and short-acting bronchodilators. Self-reported exacerbations were recorded in telephone and web-based longitudinal follow-up surveys. Associations with exacerbations were determined within each medication group using four separate logistic regression models. A head-to-head analysis compared exacerbation risk among subjects using tiotropium vs. ICS ± LABA.

Results

In separate logistic regression models, the presence of gastroesophageal reflux, female gender, and higher scores on the St. George’s Respiratory Questionnaire were significant predictors of exacerbator status within multiple medication groups (reflux: OR 1.62–2.75; female gender: OR 1.53 - OR 1.90; SGRQ: OR 1.02–1.03). Subjects taking either ICS ± LABA or tiotropium had similar baseline characteristics, allowing comparison between these two groups. In the head-to-head comparison, tiotropium users showed a trend towards lower rates of exacerbations (OR = 0.69 [95 % CI 0.45, 1.06], p = 0.09) compared with ICS ± LABA users, especially in subjects without comorbid asthma (OR = 0.56 [95 % CI 0.31, 1.00], p = 0.05).

Conclusions

Each common COPD medication usage group showed unique risk factor patterns associated with increased risk of exacerbations, which may help clinicians identify subjects at risk. Compared to similar subjects using ICS ± LABA, those taking tiotropium showed a trend towards reduced exacerbation risk, especially in subjects without asthma.

Trial registration

ClinicalTrials.gov NCT00608764, first received 1/28/2008.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0191-7) contains supplementary material, which is available to authorized users.

Predicting Healthcare Utilization by Patients Admitted for COPD Exacerbation

BACKGROUND

Healthcare utilization, especially length of hospital stay and ICU admission, for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) determine overall outcomes in terms of morbidity, mortality and cost burden. Predicting prolonged hospital stay (PHS) and prolonged intensive care (PIC) for AECOPD is useful for rational allocation of resources in healthcare centres.

AIM

To characterize the pattern of healthcare utilization by COPD patients hospitalized for acute exacerbation, and to identify clinical and laboratory predictors of 'prolonged hospital stay' (PHS) and 'prolonged intensive care'(PIC).

MATERIALS AND METHODS

This study attempted through retrospective data analysis, to identify risk factors and evolve prediction models for increased healthcare utilization namely PHS and PIC for AECOPD. The data were extracted from 255 eligible admissions for AECOPD by 166 patients from Aug 2012 to July 2013. Logistic regression analysis was used for identifying predictors and models were tested with area under receiver operating characteristic curve.

RESULTS

Independent predictors of prolonged hospital stay (≥ 6 days) were chronic respiratory failure at baseline, low saturation at admission, high HbA1c level and positive isolates in sputum culture. Independent predictors of prolonged intensive care (for ≥ 48 hours) were past history of pulmonary tuberculosis, chronic respiratory failure at baseline, low saturation at admission, high leukocyte count and positive culture isolates in sputum. Prediction models evolved from variables available at admission showed AUC 0.805 (95% CI 0.729 - 0.881) and 0.825 (95% CI 0.75 - 0.90) for PHS and ICU admissions respectively.

CONCLUSION

Our prediction models derived from simple and easily available variables show good discriminative properties in predicting PHS and PIC for AECOPD. When prospectively validated, these models are useful for rational allocation of services especially in resource limited settings.

Measurement of pulmonary artery to aorta ratio in computed tomography is correlated with pulmonary artery pressure in critically ill chronic obstructive pulmonary disease patients

AIM

Chronic obstructive pulmonary disease (COPD) is one of the leading chronic diseases and a common cause of death. Identification of COPD patients at high risk for complications and mortality is of utmost importance. Computed tomography (CT) can be used to measure the ratio of the diameter of the pulmonary artery (PA) to the diameter of the aorta (A), and PA/A ratio was shown to be correlated with PA pressure (PAP). However, the prognostic value of PA size remains unclear in patients with COPD. We hypothesized that PA enlargement, as shown by a PA/A ratio greater than 1, could be associated with a higher risk of mortality in COPD patients admitted to the intensive care unit.

METHODS

Data of patients admitted to a medical intensive care unit of a university hospital were retrospectively reviewed between January 2008 and December 2012. Patients who were identified to have a diagnosis of acute exacerbation of COPD and who had an echocardiogram and CT scan were included. Pulmonary artery to aorta ratio was calculated and patients were grouped as PA/A ≤1 and PA/A >1. Comparisons were made between the groups and between patients who died and survived. Correlation analysis, survival analysis, and logistic regression analysis were done, where appropriate.

RESULTS

One hundred six COPD patients were enrolled. There were 40 (37.4%) patients who had a PA/A >1. Echocardiography measured PAP was higher in the group with PA/A >1 than in those with PA/A ≤1 (62.1 ± 23.2 mm Hg vs 45.3 ± 17.9 mm Hg, P = .002). Mortality rate of patients with PA/A >1 was higher (50%) than of those patients with PA/A ≤1 (36.4%), although the difference did not reach a statistical significance (P = .17). Correlation was found between vmeasured PA diameter and PAP (r = 0.51, P = .001) as well as between the Acute Physiology and Chronic Health Evaluation II values and PAP (r = 0.25, P = .025).

CONCLUSION

The PA/A ratio is an easily measured method that can be performed on thorax CT scans. Although, we failed to demonstrate a statistically significant association between higher PA/A and increased mortality, PA/A can be used as a surrogate marker to predict the pulmonary hypertension.

Carbon dioxide dialysis in a swine model utilizing systemic and regional anticoagulation

Background

Extracorporeal carbon dioxide removal (ECCO₂R) has been gaining interest to potentially facilitate gas transfer and equilibrate mild to moderate hypercapnic acidosis, when standard therapy with non-invasive ventilation is deemed refractory. However, concern regarding the effectiveness of low-flow CO₂ removal remains. Additionally, the prospect to steadily reduce hypercapnia via low-flow ECCO₂R technique is limited, especially with regional anticoagulation which potentially reduces the risk of bleeding. Therefore, an in vivo study was conducted to determine the efficacy of CO₂ removal through a modified renal dialysis unit during the carbon dioxide dialysis study using systemic and regional anticoagulation.

Methods

The acute study was conducted for 14 h in landrace pigs (51 ± 3 kg). CO₂ removal using a diffusion membrane oxygenator substituting the hemoconcentrator was provided for 6 h. Blood and gas (100 % O₂) flows were set at 200 and 5 L/min, respectively. Anticoagulation was achieved by systemic heparinization (n = 7) or regional trisodium citrate 4 % (n = 7).

Results

The CO₂ transfer was highest during the initial hour and ranged from 45 to 35 mL/min, achieving near eucapnic values. Regional and systemic anticoagulation were both effective in decreasing arterial pCO₂ (from 8.9 ± 1.3 kPa to 5.6 ± 0.8 kPa and from 8.6 ± 1.0 kPa to 6.3 ± 0.7 kPa, p < 0.05 for both groups, respectively). Furthermore, pH improved (from 7.32 ± 0.08 to 7.47 ± 0.07 and from 7.37 ± 0.04 to 7.49 ± 0.01, p < 0.05) for both regional and systemic anticoagulation groups, respectively. Upon ceasing CO₂ dialysis, hypercapnia ensued. The liver and kidney function test results were normal, and scanning electron microscopy analysis revealed only some cellular and fibrin adhesion on the oxygenator fibre in the heparin group.

Conclusions

CO₂ dialysis utilizing either regional or systemic anticoagulation showed to be safe and effective in steady transfer of CO₂ and consequently optimizing pH.

Physical activity assessed in routine care predicts mortality after a COPD hospitalisation

The independent relationship between physical inactivity and risk of death after an index chronic obstructive pulmonary disease (COPD) hospitalisation is unknown. We conducted a retrospective cohort study in a large integrated healthcare system. Patients were included if they were hospitalised for COPD between January 1, 2011 and December 31, 2011. All-cause mortality in the 12 months after discharge was the primary outcome. Physical activity, expressed as self-reported minutes of moderate to vigorous physical activity (MVPA), was routinely assessed at outpatient visits prior to hospitalisation. 1727 (73%) patients were inactive (0 min of MVPA per week), 412 (17%) were insufficiently active (1-149 min of MVPA per week) and 231 (10%) were active (≥150 min of MVPA per week). Adjusted Cox regression models assessed risk of death across the MVPA categories. Among 2370 patients (55% females and mean age 73±11 years), there were 464 (20%) deaths. Patients who were insufficiently active or active had a 28% (adjusted HR 0.72 (95% CI 0.54-0.97), p=0.03) and 47% (adjusted HR 0.53 (95% CI 0.34-0.84), p<0.01) lower risk of death, respectively, in the 12 months following an index COPD hospitalisation compared to inactive patients. Any level of MVPA is associated with lower risk of all-cause mortality after a COPD hospitalisation. Routine assessment of physical activity in clinical care would identify persons at high risk for dying after COPD hospitalisation.

Care of the Surgical ICU Patient with Chronic Obstructive Pulmonary Disease and Pulmonary Hypertension

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease characterized by airflow limitation that is frequently progressive and associated with respiratory impairment. As the fourth leading cause of death in the United States and Europe, COPD results in a substantial and ever increasing economic and social burden [1]. Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are frequently encountered in the intensive care unit (ICU). Although there is no standardized definition, AECOPD are characterized by a significant change in patient symptoms from baseline accompanied by overall increased airway resistance [2]. These exacerbations carry a significant risk to patients, with 10 % in-hospital mortality and 1-year and 2-year all-cause mortality rates of 43 % and 49 %, respectively, in patients with hypercapnic exacerbations [3]. Other studies note in-hospital mortality rates as high as 30 % with worse outcomes associated with older age, severity of respiratory and non-respiratory organ dysfunction, and hospital length of stay [4]. Given that patients transferred to the ICU with AECOPD are at high risk for complications and adverse outcomes, early diagnosis and management are critical to improve patient outcomes and survival in this population.

Focused Screening Identifies Evoxine as a Small Molecule That Counteracts CO2-Induced Immune Suppression

Patients with severe lung disease may develop hypercapnia, elevation of the levels of CO2 in the lungs and blood, which is associated with increased risk of death, often from infection. To identify compounds that ameliorate the adverse effects of hypercapnia, we performed a focused screen of 8832 compounds using a CO2-responsive luciferase reporter in Drosophila S2* cells. We found that evoxine, a plant alkaloid, counteracts the CO2-induced transcriptional suppression of antimicrobial peptides in S2* cells. Strikingly, evoxine also inhibits hypercapnic suppression of interleukin-6 and the chemokine CCL2 expression in human THP-1 macrophages. Evoxine's effects are selective, since it does not prevent hypercapnic inhibition of phagocytosis by THP-1 cells or CO2-induced activation of AMPK in rat ATII pulmonary epithelial cells. The results suggest that hypercapnia suppresses innate immune gene expression by definable pathways that are evolutionarily conserved and demonstrate for the first time that specific CO2 effects can be targeted pharmacologically.

Multidisciplinary COPD disease management program: impact on clinical outcomes

OBJECTIVES

We hypothesized performance improvement interventions would improve COPD guideline-recommended care and decrease COPD exacerbations in primary care clinic practices.

METHODS

We initiated a performance improvement project in 12 clinics to improve COPD outcomes incorporating physician education, case management, web-based decision support (CareManager(TM)), and performance feedback. We collected baseline and one-year follow up data on 242 patients who had COPD with acute exacerbations. We analyzed data by two methods. First, the 12 clinics were cluster randomized to 4 intervention (117 patients) and 8 control (125 patients) clinics which all had access to CareManager(TM) but only intervention clinic physicians received case management, academic detailing, and decision support assistance. Exacerbation rates and guideline adherence were compared. Second, data from all 12 clinics were pooled in a quasi-experimental design comparing baseline and post-implementation of CareManager(TM) to determine the value of system-wide performance improvement during the study period.

RESULTS

In the randomized analysis, baseline demographics were similar. No differences (p = 0.79) occurred in exacerbation rates between intervention and control clinics although both groups had decreased numbers of exacerbations from baseline to follow up (p < 0.05). The pooled data from all 12 clinics demonstrated a reduction (p < 0.05) in mean exacerbations/patient from 2.3 (CI 2.0-2.6) during baseline to 1.4 (CI 1.1-1.7) at one-year follow up. Emergency department visits and hospitalizations/patient decreased (p = 0.003). Patients naïve at study start to depression screening, pneumococcal vaccination, inhaled control medications or smoking cessation had fewer (p < 0.05) exacerbations after these interventions.

CONCLUSION

We observed no difference in exacerbation rates between clinics receiving case management, academic detailing, and ongoing assistance with decision support and controls. Implementation of a web-based disease management system (CareManager(TM)) along with health system-wide COPD performance improvement efforts was associated with fewer COPD exacerbations and increased adherence to guideline recommendations.

Is hypercapnia associated with poor prognosis in chronic obstructive pulmonary disease? A long-term follow-up cohort study

OBJECTIVES

To assess whether hypercapnia may predict the prognosis in chronic obstructive pulmonary disease (COPD).

DESIGN

Prospective cohort study comparing the survival of patients with COPD and normocapnia to those with chronic hypercapnia.

SETTING

Patients with consecutive COPD were enrolled between 1 May 1993 and 31 October 2006 at two medical centres. Follow-up was censored on 31 October 2011.

PARTICIPANTS

A total of 275 patients with stable COPD and aged 40-85 years were enrolled. Diagnosis of hypercapnia was confirmed by blood gas analysis. Patients with near-terminal illness or comorbidities that affect PaCO2 (obstructive sleep apnoea, obesity-related hypoventilation, or neuromuscular disease) were excluded. The outcome of 98 patients with normocapnia and 177 with chronic hypercapnia was analysed.

OUTCOME MEASURES

Overall survival.

RESULTS

Median survival was longer in patients with normocapnia than in those with hypercapnia (6.5 vs 5.0 years, p=0.016). Multivariate COX regression analysis indicated that age (HR=1.043, 95% CI 1.012 to 1.076), Charlson Index, which is a measure of comorbidity (HR=1.172, 95% CI 1.067 to 1.288), use of medication (HR=0.565, 95% CI 0.379 to 0.842), body mass index (BMI) (HR=0.922, 95% CI 0.883 to 0.963), PaCO2 (HR=1.026, 95% CI 1.011 to 1.042), Cor pulmonale (HR=2.164, 95% CI 1.557 to 3.006), non-invasive positive-pressure ventilation (NPPV) (HR=0.615, 95% CI 0.429 to 0.881) and per cent of forced expiratory volume in 1 s (FEV1%) (HR=0.979, 95% CI 0.967 to 0.991), were independent risk factors for mortality.

CONCLUSIONS

Increased age, Charlson Index, chronic hypercapnia and Cor pulmonale, and decreased FEV1%, use of medication, BMI and NPPV, were associated with a poor prognosis in patients with COPD.

Airway IL-1β and Systemic Inflammation as Predictors of Future Exacerbation Risk in Asthma and COPD

BACKGROUND

The innate inflammatory pathways involved in the frequent exacerbator phenotypes of asthma and COPD are not well understood. This study aimed to investigate airway innate immune activation and systemic inflammation as predictors of exacerbations in asthma and COPD.

METHODS

In this prospective cohort study, baseline airway IL-1β, serum C-reactive protein, and IL-6 were assessed in 152 participants with stable asthma (n = 63) or COPD (n = 89) and were related to exacerbations over the following 12 months. Clinical characteristics and inflammatory biomarkers were compared between the frequent (two or more exacerbations in the follow-up) and infrequent exacerbators. The frequent exacerbation phenotype and exacerbation frequency were analyzed with multivariable modeling. The relationships among airway inflammation, systemic inflammation, and future exacerbations were examined using path analysis.

RESULTS

Ninety-four participants experienced a total of 201 exacerbations, and 36.4% had two or more exacerbations. Serum IL-6 and sputum gene expression of IL-1β at baseline were higher in the frequent exacerbators with COPD. Significant pathways initiated by previous exacerbations were identified as occurring through activation of the IL-1β-systemic inflammatory axis leading to future exacerbations in COPD. Systemic inflammation was also associated with increased exacerbation risk in asthma.

CONCLUSIONS

Airway IL-1β and systemic inflammation are associated with frequent exacerbations and may mediate a vicious cycle between previous and future exacerbations in COPD. Treatment strategies aimed at attenuating these inflammatory pathways to reduce COPD exacerbations deserve further investigation.

Respiratory infectious phenotypes in acute exacerbation of COPD: an aid to length of stay and COPD Assessment Test

Purpose

To investigate the respiratory infectious phenotypes and their impact on length of stay (LOS) and the COPD Assessment Test (CAT) Scale in acute exacerbation of COPD (AECOPD).

Patients and methods

We categorized 81 eligible patients into bacterial infection, viral infection, coinfection, and non-infectious groups. The respiratory virus examination was determined by a liquid bead array xTAG Respiratory Virus Panel in pharyngeal swabs, while bacterial infection was studied by conventional sputum culture. LOS and CAT as well as demographic information were recorded.

Results

Viruses were detected in 38 subjects, bacteria in 17, and of these, seven had both. Influenza virus was the most frequently isolated virus, followed by enterovirus/rhinovirus, coronavirus, bocavirus, metapneumovirus, parainfluenza virus types 1, 2, 3, and 4, and respiratory syncytial virus. Bacteriologic analyses of sputum showed that Pseudomonas aeruginosa was the most common bacteria, followed by Acinetobacter baumannii, Klebsiella, Escherichia coli, and Streptococcus pneumoniae. The longest LOS and the highest CAT score were detected in coinfection group. CAT score was positively correlated with LOS.

Conclusion

Respiratory infection is a common causative agent of exacerbations in COPD. Respiratory coinfection is likely to be a determinant of more severe acute exacerbations with longer LOS. CAT score may be a predictor of longer LOS in AECOPD.

Predicting In-Hospital Treatment Failure (≤ 7 days) in Patients with COPD Exacerbation Using Antibiotics and Systemic Steroids

Although pharmacological treatment of COPD exacerbation (COPDE) includes antibiotics and systemic steroids, a proportion of patients show worsening of symptoms during hospitalization that characterize treatment failure. The aim of our study was to determine in-hospital predictors of treatment failure (≤ 7 days). Prospective data on 110 hospitalized COPDE patients, all treated with antibiotics and systemic steroids, were collected; on the seventh day of hospitalization, patients were divided into treatment failure (n = 16) or success (n = 94). Measures of inflammatory serum biomarkers were recorded at admission and at day 3; data on clinical, laboratory, microbiological, and severity, as well data on mortality and readmission, were also recorded. Patients with treatment failure had a worse lung function, with higher serum levels of C-reactive protein (CRP), procalcitonin (PCT), tumour necrosis factor-alpha (TNF-α), interleukin (IL) 8, and IL-10 at admission, and CRP and IL-8 at day 3. Longer length of hospital stay and duration of antibiotic therapy, higher total doses of steroids and prevalence of deaths and readmitted were found in the treatment failure group. In the multivariate analysis, +1 mg/dL of CRP at admission (OR, 1.07; 95% CI, 1.01 to 1.13) and use of penicillins or cephalosporins (OR, 5.63; 95% CI, 1.26 to 25.07) were independent variables increasing risk of treatment failure, whereas cough at admission (OR, 0.20; 95% CI, 0.05 to 0.75) reduces risk of failure. In hospitalized COPDE patients CRP at admission and use of specific class of antibiotics predict in-hospital treatment failure, while presence of cough has a protective role.

Incident opioid drug use among older adults with chronic obstructive pulmonary disease: a population-based cohort study

AIMS

The purpose of the present study was to describe the scope, pattern and patient characteristics associated with incident opioid use among older adults with chronic obstructive pulmonary disease (COPD).

METHODS

This was a retrospective population-based cohort study using Ontario, Canada, healthcare administrative data. Study participants were individuals aged 66 years and older with physician-diagnosed COPD, identified using a validated algorithm, who were not receiving palliative care. We examined the incidence of oral opioid receipt between 1 April 2003 and 31 March 2012, as well as several patterns of incident opioid drug use.

RESULTS

Among 107,109 community-dwelling and 16,207 long-term care resident older adults with COPD, 72,962 (68.1%) and 8811 (54.4%), respectively, received an incident opioid drug during the observation period. Among long-term care residents, multiple opioid dispensings (8.8%), dispensings for >30 days' duration (up to 19.8%), second dispensings (35-43%) and early refills (24.2%) were observed. Incident opioid dispensing was also observed to occur during COPD exacerbations (6.9% among all long-term care residents; 18.1% among long-term care residents with frequent exacerbations). These same patterns of incident opioid use occurred among community-dwelling individuals, but with relatively lower frequencies.

CONCLUSIONS

New opioid use was high among older adults with COPD. Potential safety concerns are raised by the degree and pattern of new opioid use, but further studies are needed to evaluate if adverse events are associated with opioid drug use in this older and respiratory-vulnerable population.

Extracorporeal carbon dioxide removal in patients with chronic obstructive pulmonary disease: a systematic review

INTRODUCTION

Extracorporeal carbon dioxide removal (ECCO2R) has been proposed for hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) exacerbations, to avoid intubation or reduce length of invasive ventilation. Balance of risks, efficacy, and benefits of ECCO2R in patients with COPD is unclear.

METHODS

We systematically searched MEDLINE and EMBASE to identify all publications reporting use of ECCO2R in COPD. We looked at physiological and clinical efficacy. A favorable outcome was defined as prevention of intubation or successful extubation. Major and minor complications were compiled.

RESULTS

We identified 3123 citations. Ten studies (87 patients), primarily case series, met inclusion criteria. ECCO2R prevented intubation in 65/70 (93%) patients and assisted in the successful extubation of 9/17 (53%) mechanically ventilated subjects. One case-control study matching to noninvasively ventilated controls reported lower intubation rates and hospital mortality with ECCO2R that trended toward significance. Physiological data comparing pre- to post-ECCO2R changes suggest improvements for pH (0.07-0.15 higher), PaCO2 (25 mmHg lower), and respiratory rate (7 breaths/min lower), but not PaO2/FiO2. Studies reported 11 major (eight bleeds requiring blood transfusion of 2 units, and three line-related complications, including one death related to retroperitoneal bleeding) and 30 minor complications (13 bleeds, five related to anticoagulation, and nine clotting-related device malfunctions resulting in two emergent intubations).

CONCLUSION

The technique is still experimental and no randomized trial is available. Recognizing selection bias associated with case series, there still appears to be potential for benefit of ECCO2R in patients with COPD exacerbations. However, it is associated with frequent and potentially severe complications. Higher-quality studies are required to better elucidate this risk-benefit balance.

Using the Electronic Nose to Identify Airway Infection during COPD Exacerbations

BACKGROUND

The electronic nose (e-nose) detects volatile organic compounds (VOCs) in exhaled air. We hypothesized that the exhaled VOCs print is different in stable vs. exacerbated patients with chronic obstructive pulmonary disease (COPD), particularly if the latter is associated with airway bacterial infection, and that the e-nose can distinguish them.

METHODS

Smell-prints of the bacteria most commonly involved in exacerbations of COPD (ECOPD) were identified in vitro. Subsequently, we tested our hypothesis in 93 patients with ECOPD, 19 of them with pneumonia, 50 with stable COPD and 30 healthy controls in a cross-sectional case-controlled study. Secondly, ECOPD patients were re-studied after 2 months if clinically stable. Exhaled air was collected within a Tedlar bag and processed by a Cynarose 320 e-nose. Breath-prints were analyzed by Linear Discriminant Analysis (LDA) with "One Out" technique and Sensor logic Relations (SLR). Sputum samples were collected for culture.

RESULTS

ECOPD with evidence of infection were significantly distinguishable from non-infected ECOPD (p = 0.018), with better accuracy when ECOPD was associated to pneumonia. The same patients with ECOPD were significantly distinguishable from stable COPD during follow-up (p = 0.018), unless the patient was colonized. Additionally, breath-prints from COPD patients were significantly distinguished from healthy controls. Various bacteria species were identified in culture but the e-nose was unable to identify accurately the bacteria smell-print in infected patients.

CONCLUSION

E-nose can identify ECOPD, especially if associated with airway bacterial infection or pneumonia.

Long-term Exercise After Pulmonary Rehabilitation (LEAP): Design and rationale of a randomized controlled trial of Tai Chi

BACKGROUND

Persons with chronic obstructive pulmonary disease (COPD) have reduced exercise capacity and levels of physical activity. Supervised, facility-based pulmonary rehabilitation programs improve exercise capacity and reduce dyspnea, but novel long-term strategies are needed to maintain the benefits gained. Mind-body modalities such as Tai Chi which combine aerobic activity, coordination of breathing, and cognitive techniques that alleviate the physical inactivity, dyspnea, and anxiety and depression that are the hallmarks of COPD are promising strategies.

METHODS/DESIGN

We have designed a randomized controlled study to examine whether Tai Chi will maintain exercise capacity in persons with COPD who have recently completed a supervised pulmonary rehabilitation program, compared to standard care. The primary outcome is 6-min walk test distance at 6 months. Secondary outcomes include health-related quality of life, dyspnea, mood, occurrence of acute exacerbations, engagement in physical activity, exercise self-efficacy, and exercise adherence. Simultaneously, we are conducting a pilot study of group walking. We will enroll 90 persons who will be randomized to one of three arms in a 2:2:1 ratio: Tai Chi, standard care, or group-based walking.

DISCUSSION

The Long-term Exercise After Pulmonary Rehabilitation (LEAP) study is a novel and clinically relevant trial. We will enroll a well-characterized cohort of persons with COPD and will comprehensively assess physiological and psychosocial outcomes. Results of this study will provide the evidence base for persons with COPD to engage in Tai Chi as a low-cost, long-term modality to sustain physical activity in persons who have completed a standard short-term pulmonary rehabilitation program.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, with the ID number of NCT01998724.

Key stakeholders' perspectives on a Web-based advance care planning tool for advanced lung disease

PURPOSE

There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease.

MATERIALS AND METHODS

We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking.

RESULTS

Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users.

CONCLUSIONS

There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.

Updates in the management of stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory process. It is increasingly recognized as a major public health problem, affecting more than 20 million adults in the US. It is also recognized as a leading cause of hospitalizations and is the fourth leading cause of death in the US. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) operates to promote evidence-based management of COPD, increase awareness and encourage research. In 2011, GOLD published a consensus report detailing evidence-based management strategies for COPD, which were last updated in 2015. In recent years, newer strategies and a growing number of new pharmacologic agents to treat symptoms of COPD have also been introduced and show promise in improving the management of COPD. We aim to provide an evidence-based review of the available and upcoming pharmacologic and non-pharmacologic treatment options for stable COPD, with continued emphasis on evidence-based management.

Palliative care in COPD: an unmet area for quality improvement

COPD is a leading cause of morbidity and mortality worldwide. Patients suffer from refractory breathlessness, unrecognized anxiety and depression, and decreased quality of life. Palliative care improves symptom management, patient reported health-related quality of life, cost savings, and mortality though the majority of patients with COPD die without access to palliative care. There are many barriers to providing palliative care to patients with COPD including the difficulty in prognosticating a patient’s course causing referrals to occur late in a patient’s disease. Additionally, physicians avoid conversations about advance care planning due to unique communication barriers present with patients with COPD. Lastly, many health systems are not set up to provide trained palliative care physicians to patients with chronic disease including COPD. This review analyzes the above challenges, the available data regarding palliative care applied to the COPD population, and proposes an alternative approach to address the unmet needs of patients with COPD with proactive primary palliative care.

Prognostic assessment of mortality and hospitalizations of outpatients with advanced chronic obstructive pulmonary disease. Usefulness of the CODEX index

OBJECTIVES

To validate the CODEX index in outpatients with advanced chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

We studied all patients with COPD treated in a chronic respiratory disease unit. We calculated the BODEX and CODEX indices and their relationship with mortality, hospitalisations or both and performed an analysis by number of events (mortality and/or readmissions), using the Cox proportional hazards analysis.

RESULTS

We included 80 patients (90% men) with a mean age of 73.4 years. The mean follow-up was 656 days, with an interquartile range (25-75%) of 417-642 days. Seventeen patients died (21%) and 57 (71.3%) required hospitalisation for COPD. The CODEX index was significantly related to mortality (P<.008; HR: 1.56; 95% CI: 1.1-2.15), hospitalisations (P<.01; HR: 1.35; 95% CI: 1.13-1.62) and the combined variable (P<.03; HR: 1.27; 95% CI: 1.1-1.5). The BODEX index was not associated with mortality (P=.17) but was associated with hospitalisation (P<.001; HR: 1.4; 95% CI: 1.15-1.73) and the combined variable (P<.03; HR: 1.2; 95% CI: 1.02-1.34). There were 187 events during follow-up. Both the CODEX (P<.001; HR: 1.17; 95% CI: 1.1-1.27) and BODEX (P<.02; HR: 1.12; 95% CI: 1.02-1.23) indices were related to the number of events. However, after adjusting for the interaction between the 2 indices, only the CODEX index maintained statistical significance for the combined variable for patients (P<.03) and in the analysis by number of events (P<.001).

CONCLUSIONS

Both the CODEX and BODEX indices are useful for predicting hospitalisations, although the prognostic ability of the CODEX index is greater than that of the BODEX index, both for mortality and hospitalisations.

Comparison of clinical characteristics and outcomes between aspiration pneumonia and community-acquired pneumonia in patients with chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) patients often have dysphagia through age and several co-morbidities, leading to aspiration pneumonia (AsP). COPD patients also have increased risk of developing community-acquired pneumonia (CAP). Using a national inpatient database in Japan, we aimed to compare clinical characteristics and outcomes between AsP and CAP in COPD patients and to verify the factors that affect in-hospital morality.

Methods

We retrospectively collected data on COPD patients (age ≥40 years) who were admitted for AsP or CAP in 1,165 hospitals across Japan between July 2010 and May 2013. We performed multivariable logistic regression analyses to examine the association of various factors with all-cause in-hospital mortality for AsP and CAP.

Results

Of 87,330 eligible patients, AsP patients were more likely to be older, male and have poorer general condition and more severe pneumonia than those with CAP. In-hospital mortality in the AsP group was 22.7 % and 12.2 % in the CAP group. After adjustment for patient background, AsP patients had significantly higher mortality than CAP patients (adjusted odds ratio, 1.19; 95 % confidence interval, 1.08–1.32). Subgroup analyses showed higher mortality to be associated with male gender, underweight, dyspnea, physical disability, pneumonia severity, and several co-morbidities. Further, older age and worse level of consciousness were associated with higher mortality in the CAP group, whereas those were not associated in the AsP group.

Conclusions

Clinical characteristics differed significantly between AsP and CAP in COPD patients. AsP patients had significantly higher mortality than those with CAP.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0064-5) contains supplementary material, which is available to authorized users.

Severe hypoalbuminemia is a strong independent risk factor for acute respiratory failure in COPD: a nationwide cohort study

Background

Acute respiratory failure (ARF) is a life-threatening event, which is frequently associated with the severe exacerbations of chronic obstructive pulmonary disease (COPD). Hypoalbuminemia is associated with increased mortality in patients with COPD. However, to date, little is known regarding whether or not hypoalbuminemia is a risk factor for developing ARF in COPD.

Methods

We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. A total of 42,732 newly diagnosed COPD patients (age ≥40 years) from 1997 to 2011 were enrolled. Among them, 1,861 (4.36%) patients who had received albumin supplementation were defined as hypoalbuminemia, and 40,871 (95.6%) patients who had not received albumin supplementation were defined as no hypoalbuminemia.

Results

Of 42,732 newly diagnosed COPD patients, 5,248 patients (12.3%) developed ARF during the 6 years follow-up period. Patients with hypoalbuminemia were older, predominantly male, had more comorbidities, and required more steroid treatment and blood transfusions than patients without hypoalbuminemia. In a multivariable Cox regression analysis model, being elderly was the strongest independent risk factor for ARF (adjusted hazard ratio [HR]: 4.63, P<0.001), followed by hypoalbuminemia (adjusted HR: 2.87, P<0.001). However, as the annual average dose of albumin supplementation was higher than 13.8 g per year, the risk for ARF was the highest (adjusted HR: 11.13, 95% CI: 10.35–11.98, P<0.001).

Conclusion

Hypoalbuminemia is a strong risk factor for ARF in patients with COPD. Therefore, further prospective studies are required to verify whether or not albumin supplementation or nutritional support may help to reduce the risk of ARF in patients with COPD.

Applying a low-flow CO2 removal device in severe acute hypercapnic respiratory failure

A novel and portable extracorporeal CO2-removal device was evaluated to provide additional gas transfer, auxiliary to standard therapy in severe acute hypercapnic respiratory failure. A dual-lumen catheter was inserted percutaneously in five subjects (mean age 55 ± 0.4 years) and, subsequently, connected to the CO2-removal device. The median duration on support was 45 hours (interquartile range 26-156), with a blood flow rate of approximately 500 mL/min. The mean PaCO2 decreased from 95.8 ± 21.9 mmHg to 63.9 ± 19.6 mmHg with the pH improving from 7.11 ± 0.1 to 7.26 ± 0.1 in the initial 4 hours of support. Three subjects were directly weaned from the CO2-removal device and mechanical ventilation, one subject was converted to ECMO and one subject died following withdrawal of support. No systemic bleeding or device complications were observed. Low-flow CO2 removal adjuvant to standard therapy was effective in steadily removing CO2, limiting the progression of acidosis in subjects with severe acute hypercapnic respiratory failure.

Exacerbation and functional capacity of patients with COPD undergoing an exercise training program: longitudinal study

Objective To analyze if there is influence of body weight, body mass index (BMI), body composition, dyspnoea, grip strength and tolerance to exertion in the occurrence of exacerbation during a 12-month follow up of patients with COPD who underwent a physical training program. Material and methods Sixty three patients were distributed in two groups, (Exacerbation Group — EG, n = 29; Non-Exacerbated Group — NEG, n = 34). The Mann Whitney test was used for the comparison between groups, the Friedman test (posthoc Dunn) to compare the assessments and the logistic regression analysis, with a significance level of p < 0.05. Results There is a significant difference between the groups in age and walked distance (WD) in the sixminute walk test (6MWT). The WD was reduced in 6th, 9th and 12th month revaluation compared to baseline and 3 months for the EG. Logistic regression analysis showed a significant interaction between the lean body mass and the WD, BMI with the lean body mass and the BMI with the WD, this and the isolated dyspnoea, and lean body mass with body weight. Conclusion Involving several variables along the follow up of patients with COPD in physical therapy programs is important, since it may prevent or reduce the chance of the occurrence of exacerbations. In addition, older patients with less tolerance to physical activity had a higher number of episodes of exacerbation, even when participating in a physiotherapy program associated to exercise training.

Viral Etiology of Chronic Obstructive Pulmonary Disease Exacerbations during the A/H1N1pdm09 Pandemic and Postpandemic Period

Viral infections are one of the main causes of acute exacerbations of chronic obstructive pulmonary disease (AE-COPD). Emergence of A/H1N1pdm influenza virus in the 2009 pandemic changed the viral etiology of exacerbations that were reported before the pandemic. The aim of this study was to describe the etiology of respiratory viruses in 195 Spanish patients affected by AE-COPD from the pandemic until the 2011-12 influenza epidemic. During the study period (2009–2012), respiratory viruses were identified in 48.7% of samples, and the proportion of viral detections in AE-COPD was higher in patients aged 30–64 years than ≥65 years. Influenza A viruses were the pathogens most often detected during the pandemic and the following two influenza epidemics in contradistinction to human rhino/enteroviruses that were the main viruses causing AE-COPD before the pandemic. The probability of influenza virus detection was 2.78-fold higher in patients who are 30–64 years old than those ≥65. Most respiratory samples were obtained during the pandemic, but the influenza detection rate was higher during the 2011-12 epidemic. There is a need for more accurate AE-COPD diagnosis, emphasizing the role of respiratory viruses. Furthermore, diagnosis requires increased attention to patient age and the characteristics of each influenza epidemic.

Comparative study on health care utilization and hospital outcomes of severe acute exacerbation of chronic obstructive pulmonary disease managed by pulmonologists vs internists

Background

Care for many chronic health conditions is delivered by both specialists and generalists. Differences in patients’ quality of care and management between generalists and specialists have been well documented for asthma, whereas a few studies for COPD reported no differences.

Objective

The objective of this study is to compare consistency with Global initiative for chronic Obstructive Lung Disease guidelines, as well as rate, health care utilization, and hospital outcomes of severe acute exacerbation (AE) of COPD patients managed by pulmonologists and internists.

Materials and methods

This is a 12-month prospective, comparative observational study among 208 COPD patients who were regularly managed by pulmonologists (Group A) and internists (Group B). Clinical data, health care utilization, and hospital outcomes of the two groups were statistically compared.

Results

Out of 208 enrolled patients, 137 (Group A) and 71 (Group B) were managed by pulmonologists and internists, respectively. Pharmacological treatment corresponding to disease severity stages between the two groups was not statistically different. Group A received care consistent with guidelines in terms of annual influenza vaccination (31.4% vs 9.9%, P<0.001) and pulmonary rehabilitation (24.1% vs 0%, P<0.001) greater than Group B. Group A had reduced rates (12.4% vs 23.9%, P=0.033) and numbers of severe AE (0.20±0.63 person-years vs 0.41±0.80 person-years, P=0.029). Among patients with severe AE requiring mechanical ventilation, Group A had reduced mechanical ventilator duration (1.5 [1–7] days vs 5 [3–29] days, P=0.005), hospital length of stay (3.5 [1–20] days vs 16 [6–29] days, P=0.012), and total hospital cost ($863 [247–2,496] vs $2,095 [763–6,792], P=0.049) as compared with Group B.

Conclusion

This study demonstrated that pulmonologists followed national COPD guidelines more closely than internists. The rates and frequencies of severe AE were significantly lower in patients managed by pulmonologists, and length of hospital stay and cost were significantly lower among the patients with severe AE who required mechanical ventilation.

Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline

BACKGROUND

COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations.

METHODS

In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion.

RESULTS

The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD.

CONCLUSIONS

This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.

Impact of acetazolamide use in severe exacerbation of chronic obstructive pulmonary disease requiring invasive mechanical ventilation

PURPOSE

To analyse the impact of acetazolamide (ACET) use in severe acute decompensation of chronic obstructive pulmonary disease requiring mechanical ventilation and intensive care unit (ICU) admission.

PATIENTS AND METHODS

Retrospective pair-wise, case-control study with 1:1 matching. Patients were defined as cases when they had received acetazolamide (500 mg per day) and as controls when they did not received it. Patients were matched according to age, severity on admission (pH, PaO2/FiO2 ratio) and SAPSII score. Our primary endpoint was the effect of ACET (500 mg per day) on the duration of mechanical ventilation. Our secondary endpoints were the effect of ACET on arterial blood gas parameters, ICU length of stay (LOS) and ICU mortality.

RESULTS

Seventy-two patients were included and equally distributed between the two studied groups. There were 66 males (92%). The mean age (± SD) was 69.7 ± 7.4 years ranging from 53 to 81 years. There were no differences between baseline characteristics of the two groups. Concomitant drugs used were also not significantly different between two groups. Mean duration of mechanical ventilation was not significantly different between ACET(+) and ACET(-) patients (10.6±7.8 days and 9.6±7.6 days, respectively; P = 0.61). Cases had a significantly decreased serum bicarbonate, arterial blood pH, and PaCO2 levels. We did not found any significant difference between the two studied groups in terms of ICU LOS. ICU mortality was also comparable between ACET(+) and ACET(-) groups (38% and 52%, respectively; P = 0.23).

CONCLUSION

Although our study some limitations, it suggests that the use of insufficient acetazolamide dosage (500 mg/d) ACET (500 mg per day) has no significant effect on the duration of mechanical ventilation in critically ill COPD patients requiring invasive mechanical ventilation. Our results should be confirmed or infirmed by further studies.

Gastro-oesophageal reflux disease increases the risk of intensive care unit admittance and mechanical ventilation use among patients with chronic obstructive pulmonary disease: a nationwide population-based cohort study

Introduction

Gastro-oesophageal reflux disease (GORD) is common among chronic obstructive pulmonary disease (COPD) patients and may have a deleterious effect on COPD prognosis. However, few studies have investigated whether GORD increases the risk of severe outcomes such as intensive care unit (ICU) admittance or mechanical ventilator use among COPD patients.

Methods

Propensity score matching by age, sex, comorbidities and COPD severity was used to match the 1,210 COPD patients with GORD sourced in this study to 2,420 COPD patients without GORD. The Kaplan-Meier method was used to explore the incidence of ICU admittance and machine ventilation with the log rank test being used to test for differences. Cox regression analysis was used to explore the risk of ICU admittance and mechanical ventilation use for patients with and without GORD.

Results

During the 12-month follow-up, GORD patients and non-GORD patients had 5.22 and 3.01 ICU admittances per 1000 person-months, and 4.34 and 2.41 mechanical ventilation uses per 1000 person-month, respectively. The log rank test revealed a difference in the incidence of ICU admittance and machine ventilation between the two cohorts. GORD was found to be an independent predicator of ICU admittance (adjusted hazard ratio (HR_adj) 1.75, 95% confidence interval (CI) 1.28-2.38) and mechanical ventilation (HR_adj 1.92, 95% CI 1.35-2.72).

Conclusion

This is the first investigation to detect a significantly higher incidence rate and independently increased risk of admission to an ICU and mechanical ventilation use among COPD patients who subsequently developed GORD during the first year following their GORD diagnosis than COPD patients who did not develop GORD.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0849-1) contains supplementary material, which is available to authorized users.

Newly diagnosed gastroesophageal reflux disease increased the risk of acute exacerbation of chronic obstructive pulmonary disease during the first year following diagnosis--a nationwide population-based cohort study

BACKGROUND

While prior studies have demonstrated that chronic obstructive pulmonary disease (COPD) is associated with gastroesophageal reflux disease (GERD), and that GERD is associated with acute exacerbations of COPD (AECOPD), no study to date has been able to establish temporality in this relationship. The purpose of this cohort study was to explore the impact of a new diagnosis of GERD on the risk of subsequent AECOPD.

METHODS

We used a retrospective population-based cohort design to analyse the data of 1976 COPD subjects with GERD as an exposure cohort and 3936 COPD subjects without GERD as a comparison group. We individually tracked each subject in this study for 12 months and identified those subjects who experienced an episode of AECOPD. Hazard ratios (HR) were calculated using Cox proportional hazards regression analysis.

RESULTS

The incidence of AECOPD was 4.08 and 2.79 per 100 person-year in individuals with and without GERD, respectively (p = 0.012). Following adjustment for sex, age, ischaemic heart disease, heart failure, atrial fibrillation, hypertension, osteoporosis, anxiety, diabetes mellitus, angina, stroke, anaemia, dementia, occupational category, monthly insurance premium, number of OPD visits and COPD severity. The stepwise Cox regression analysis revealed that GERD was independently associated with an increased risk of AECOPD (HR = 1.48, 95% CI = 1.10-1.99).

CONCLUSION

This study demonstrated that GERD is an independent risk factor for AECOPD. Caution should be exercised when assessing GERD symptoms in patients with COPD.

Serum metalloproteinase-9 is related to COPD severity and symptoms - cross-sectional data from a population based cohort-study

BACKGROUND

Chronic obstructive pulmonary disease, COPD, is an increasing cause of morbidity and mortality worldwide, and an imbalance between proteases and antiproteases has been implicated to play a role in COPD pathogenesis. Matrix metalloproteinases (MMP) are important proteases that along with their inhibitors, tissue inhibitors of metalloproteinases (TIMP), affect homeostasis of elastin and collagen, of importance for the structural integrity of human airways. Small observational studies indicate that these biomarkers are involved in the pathogenesis of COPD. The aim of this study was to investigate serum levels of MMP-9 and TIMP-1 in a large Swedish population-based cohort, and their association with disease severity and important clinical symptoms of COPD such as productive cough.

METHODS

Spirometry was performed and peripheral blood samples were collected in a populations-based cohort (median age 67 years) comprising subjects with COPD (n = 594) and without COPD (n = 948), in total 1542 individuals. Serum MMP-9 and TIMP-1 concentrations were measured with enzyme linked immunosorbant assay (ELISA) and related to lung function data and symptoms.

RESULTS

Median serum MMP-9 values were significantly higher in COPD compared with non-COPD 535 vs. 505 ng/ml (P = 0.017), without any significant differences in serum TIMP-1-levels or MMP-9/TIMP-1-ratio. In univariate analysis, productive cough and decreasing FEV1% predicted correlated significantly with increased MMP-9 among subjects with COPD (P = 0.004 and P = 0.001 respectively), and FEV1% predicted remained significantly associated to MMP-9 in a multivariate model adjusting for age, sex, pack years and productive cough (P = 0.033).

CONCLUSION

Productive cough and decreasing FEV1 were each associated with MMP-9 in COPD, and decreasing FEV1 remained significantly associated with MMP-9 also after adjustment for common confounders in this population-based COPD cohort. The increased serum MMP-9 concentrations in COPD indicate an enhanced proteolytic activity that is related to disease severity, and further longitudinal studies are important for the understanding of MMP-9 in relation to the disease process and the pathogenesis of different COPD phenotypes.

Chronic obstructive pulmonary disease exacerbation: A single-center perspective on hospital readmissions

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third most common cause in the United States of hospital readmission within 30 days of discharge. Readmissions, which are attributed to poor quality of care, are costly. We examined the factors associated with 30-day readmission in patients hospitalized with acute exacerbation of COPD. Our hypothesis was that early readmissions among patients with COPD are related to patient factors rather than system or provider factors.

METHODS

We performed a retrospective chart review of all patients discharged from our facility from June 2010 to May 2011 with a primary discharge diagnosis of COPD. Detailed patient characteristics were obtained from the electronic medical record. Patients were followed for 30 days post-discharge date. We examined the differences in baseline characteristics of patients readmitted within 30 days and those not readmitted.

RESULTS

A total of 160 patients were admitted for 192 hospitalizations during the study period; 31 patients (19.4%) were readmitted within 30 days. Patients who were readmitted did not differ from those who were not readmitted of the following factors: baseline medication use, length of stay, and outpatient follow-up postdischarge. Readmitted patients were more likely to be black, to have coronary artery disease, to have a history of alcohol abuse, and to be on supplemental oxygen. Multivariate analysis showed a 2.17 odds of 30-day readmission (95% CI, 1.16-4.09) in patients with alcohol abuse, and 2.52 (95% CI, 1.18-5.38) in those on supplemental oxygen.

CONCLUSION

In our study population, 19.4% of acute exacerbation COPD patients were readmitted within 30 days. Patient factors (such as alcohol abuse and advanced disease) were associated with 30-day readmission.

Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease

RATIONALE

Efforts to reduce 30-day readmission have mostly concentrated on addressing deficiencies in care transitions and outpatient management after discharge. There is growing evidence to suggest that physical inactivity is associated with increased hospitalizations.

OBJECTIVES

We examined whether or not a potentially modifiable factor such as regular physical activity at baseline was associated with lower risk of 30-day readmission in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Patients from a large integrated health system were included in this retrospective cohort study if they were hospitalized for COPD (following the Centers for Medicare and Medicaid Services and National Quality Forum proposed criteria) and discharged between January 1, 2011 and December 31, 2012, aged 40 years or older, on a bronchodilator or steroid inhaler, alive at discharge, and continuously enrolled in the health plan 12 months before the index admission and at least 30 days post discharge. Our main outcome was 30-day all-cause readmission. Regular physical activity was routinely assessed at the time of all outpatient visits and expressed as the total minutes of moderate or vigorous physical activity (MVPA) per week.

MEASUREMENTS AND MAIN RESULTS

The sample included a total of 4,596 patients (5,862 index admissions) with a mean age of 72.3 ± 11 years. The 30-day readmission rate was 18%, with 59% of readmissions occurring in the first 15 days. Multivariate adjusted analyses showed that patients reporting any level of MPVA had a significantly lower risk of 30-day readmission compared with inactive patients (1-149 min/wk of MVPA: relative risk, 0.67; 95% confidence interval, 0.55-0.81; ≥150 min/wk of MVPA: relative risk, 0.66; 95% confidence interval, 0.51-0.87). Other significant independent predictors of increased readmission included anemia, prior hospitalizations, longer lengths of stay, more comorbidities, receipt of a new oxygen prescription at discharge, use of the emergency department or observational stay before the readmission (all, P < 0.05), and being unpartnered (P = 0.08).

CONCLUSIONS

Our findings further support the importance of physical activity in the management of COPD across the care continuum. Although it is possible that lower physical activity is a reflection of worse disease, promoting and supporting physical activity is a promising strategy to reduce the risk of readmission.

Detection of acute deterioration in health status visit among COPD patients by monitoring COPD assessment test score

Background

The Chronic Obstructive Pulmonary Disease Assessment Test (CAT) could play a role in detecting acute deterioration in health status during monitoring visits in routine clinical practice.

Objective

To evaluate the discriminative property of a change in CAT score from a stable baseline visit for detecting acute deterioration in health status visits of chronic obstructive pulmonary disease (COPD) patients.

Methods

The CAT questionnaire was administered to stable COPD patients routinely attending the chest clinic of Chiang Mai University Hospital who were monitored using the CAT score every 1–3 months for 15 months. Acute deterioration in health status was defined as worsening or exacerbation. CAT scores at baseline, and subsequent visits with acute deterioration in health status were analyzed using the t-test. The receiver operating characteristic curve was performed to evaluate the discriminative property of change in CAT score for detecting acute deterioration during a health status visit.

Results

A total of 354 follow-up visits were made by 140 patients, aged 71.1±8.4 years, with a forced expiratory volume in 1 second of 47.49%±18.2% predicted, who were monitored for 15 months. The mean CAT score change between stable baseline visits, by patients’ and physicians’ global assessments, were 0.05 (95% confidence interval [CI], −0.37–0.46) and 0.18 (95% CI, −0.23–0.60), respectively. At worsening visits, as assessed by patients, there was significant increase in CAT score (6.07; 95% CI, 4.95–7.19). There were also significant increases in CAT scores at visits with mild and moderate exacerbation (5.51 [95% CI, 4.39–6.63] and 8.84 [95% CI, 6.29–11.39], respectively), as assessed by physicians. The area under the receiver operating characteristic curve of CAT score change for the detection of acute deterioration in health status was 0.89 (95% CI, 0.84–0.94), and the optimum cut-off point score was at 4, with a sensitivity, specificity, and accuracy of 76.8%, 83.6%, and 82.4%, respectively.

Conclusions

Change in CAT score during monitoring visits is useful for detecting acute deterioration in health status, and a change of 4 units could make a moderate prediction of acute deterioration in health status.