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

Treatment with systemic corticosteroid versus placebo for exacerbations of COPD: A systematic review and meta-analysis

BACKGROUND

For the treatment of COPD exacerbations, systemic corticosteroids are recommended in addition to short-acting bronchodilators. Although there have been several systemic reviews, many of the included studies were conducted before 2007 and a re-evaluation has not been performed since 2014. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety profile of systemic corticosteroids in patients with COPD during exacerbations.

METHODS

We searched relevant randomized control trials (RCTs) and analyzed the treatment failure, relapse, lung function, improvement in PaO2 and PaCO2, dyspnea, quality of life (QOL), length of stay in hospital and adverse events including hyperglycemia and mortality as the outcomes of interest.

RESULTS

We identified a total of 12 RCTs (N = 1336). Systemic corticosteroids significantly reduced the treatment failure (odds ratios; OR 0.41, 95% confidence intervals; CI 0.25 to 0.67) and hospital length of stay (mean difference; MD -1.57 days, 95% CI -2.36 to -0.78) and improved FEV1 (MD 0.18 L, 95% CI 0.08 to 0.28) and dyspnea (transitional dyspnea index; MD 1.90, 95% CI 0.26 to 3.54) in COPD exacerbations compared to placebo. However, systemic corticosteroids were associated with a significantly higher incidence of adverse events (OR 1.83, 95% CI 1.25 to 2.69) and hyperglycemia (OR 2.94, 95% CI 1.68 to 5.14).

CONCLUSIONS

In patients with moderate and severe COPD and severe obstructive impairment during exacerbations, systemic corticosteroids cause more adverse events, including hyperglycemia, than placebo but significantly reduce the treatment failure and hospital length of stay and improve FEV1 and dyspnea.

Influencing factors of good quality of life among chronic obstructive pulmonary disease patients living in Zhejiang Province, China

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive and debilitating disease that affects quality of life (QOL), especially among patients living in poor environments. This study aimed to determine the influencing factors of good QOL among COPD patients living in Zhejiang, China. A cross-sectional study was conducted to collect data from participants in six tertiary hospitals in Zhejiang Province by a simple random sampling method. A validated questionnaire was used to collect general information, environmental factors, and COPD stage. The standardized St. George's Respiratory Questionnaire (SGRQ) was used to assess QOL. Logistic regression was used to determine influencing factors of good QOL among COPD patients at a significance level of α = 0.05. A total of 420 participants were recruited for analysis. The overall prevalence of patients with good QOL was 25.7%. Six variables were found to be associated with good QOL in the multivariable analysis. Patients who were employed had 2.35 times (95% CI 1.03-5.34) greater odds of having good QOL than those who were unemployed. Those whose family income was higher than 100,000 CNY had 2.49 times (95% CI 1.15-5.39) greater odds of having good QOL than those whose family income was lower than 100,000 CNY. Those who had treatment expenses less than 5,000 CNY had 4.57 (95% CI 1.57-13.30) times greater odds of having good QOL than those who had treatment expenses of 5,000 CNY or higher. Those who had mild or moderate airflow limitation were 5.27 times (95% CI 1.61-17.26) more likely to have good QOL than those who were in a severe or very severe stage of COPD. Those who had a duration of illness less than 60 months had 5.57 times (95% CI 1.40-22.12) greater odds of having good QOL than those who had a duration of illness of 120 months or more. Those who were not hospitalized within the past 3 months had 9.39 times (95% CI 1.62-54.43) greater odds of having good QOL than those who were hospitalized more than twice over the past 3 months. Socioeconomic status, disease stage and accessibility were associated with good QOL among COPD patients in Zhejiang Province, China. Increasing family income and implementing measures to improve the accessibility of medical care, including developing a proper system to decrease the cost of treatment for COPD patients, can improve patients' QOL.

Individualised treatment of COPD exacerbations using biomarkers

This review highlights key aspects of treating chronic obstructive pulmonary disease (COPD) exacerbation, focusing on the optimisation of systemic corticosteroid and antibiotic use through personalised treatment using biomarkers. Eosinophil-guided therapy reduces corticosteroid usage which might reduce side effects, while procalcitonin-guided therapy contributes to reduced antibiotic consumption. These approaches, documented through well-conducted randomized controlled trials, suggest the possibility of enhancing COPD exacerbation management, reducing potential side effects, and addressing concerns related to antibiotic resistance.

Long-term mortality after transcatheter aortic valve implantation for aortic stenosis in immunosuppression-treated patients: a propensity-matched multicentre retrospective registry-based analysis

Introduction

Data regarding patients with a previous medical record of immunosuppression treatment who have undergone transcatheter aortic valve implantation (TAVI) are limited and extremely inconclusive. Available studies are mostly short term observations; thus there is a lack of evidence on efficacy and safety of TAVI in this specific group of patients.

Aim

To compare the in-hospital and long-term outcomes between patients with or without a medical history of immunosuppressive treatment undergoing TAVI for aortic valve stenosis (AS).

Material and methods

We conducted a retrospective registry-based analysis including patients undergoing TAVI for AS at 5 centres between January 2009 and August 2017. The primary endpoint was long-term all-cause mortality. Secondary endpoints comprised major vascular complications, life-threatening or disabling bleeding, stroke and new pacemaker implantation.

Results

Of 1451 consecutive patients who underwent TAVI, two propensity-matched groups including 25 patients with a history of immunosuppression and 75 patients without it were analysed. No differences between groups in all-cause mortality were found in a median follow-up time of 2.7 years following TAVI (p = 0.465; HR = 0.73; 95% CI: 0.30-1.77). The rate of major vascular complications (4.0% vs. 5.3%) was similar in the two groups (p = 1.000). There were no statistically significant differences in the composite endpoint combining life-threatening or disabling bleeding, major vascular complications, stroke and new pacemaker implantation (40.0% vs. 20.0%, p = 0.218).

Conclusions

Patients who had undergone TAVI for AS had similar long-term mortality regardless of whether they had a previous medical record of immunosuppression. Procedural complication rates were comparable between the groups.

Osteosarcopenia in Patients with Chronic Obstructive Pulmonary Diseases: Which Pathophysiologic Implications for Rehabilitation?

Chronic obstructive pulmonary disease (COPD) is a burdensome condition affecting a growing number of people worldwide, frequently related to major comorbidities and functional impairment. In these patients, several factors might have a role in promoting both bone and muscle loss, including systemic inflammation, corticosteroid therapies, sedentary behaviours, deconditioning, malnutrition, smoking habits, and alcohol consumption. On the other hand, bone and muscle tissues share several linkages from functional, embryological, and biochemical points of view. Osteosarcopenia has been recently defined by the coexistence of osteoporosis and sarcopenia, but the precise mechanisms underpinning osteosarcopenia in patients with COPD are still unknown. In this scenario, a deeper understanding of the molecular basis of osteosarcopenia might guide clinicians in a personalized approach integrating skeletal muscle health with the pulmonary rehabilitation framework in COPD. Taken together, our results summarized the currently available evidence about the multilevel interactions between osteosarcopenia and COPD to pave the way for a comprehensive approach targeting the most common risk factors of these pathological conditions. Further studies are needed to clarify the role of modern clinical strategies and telemedicine solutions to optimize healthcare delivery in patients with COPD, including osteopenia, osteoporosis, and sarcopenia screening in these subjects.

A 4-Year Retrospective Claims Analysis of Oral Corticosteroid Use and Health Conditions in Newly Diagnosed Medicare FFS Patients with COPD

Purpose

We analyzed population-level administrative claims data for Medicare fee-for-service (FFS) beneficiaries to provide insights on systemic oral corticosteroid (OCS) use patterns and associated health conditions and acute events among patients newly diagnosed with chronic obstructive pulmonary disease (COPD).

Background

COPD is a progressive inflammatory disease of the lungs, characterized by acute exacerbations that may lead to increased mortality. Short courses of systemic corticosteroids (SCS) are recommended to reduce recovery time from exacerbations, although SCS use has been associated with increased risk of adverse events.

Methods

This study used 2013-2019 Medicare 100% FFS research identifiable files, which contain all Medicare Parts A, B, and D paid claims incurred by 100% of Medicare FFS beneficiaries. Descriptive statistics for patients newly diagnosed with COPD were analyzed, including OCS use, select health conditions and acute events, and COPD exacerbations. Statistical models were used to analyze the relationship between the incidence of select health conditions and events and cumulative OCS dosage.

Results

Of Medicare FFS patients newly diagnosed with COPD, 36% received OCS in the 48 months following diagnosis, and 38% of OCS episodes lasted longer than the recommended 5-7 days. Patients had a variety of health conditions or acute events in the 24-month period prior to new COPD diagnosis, such as hypertension, depression/anxiety, type 2 diabetes, or osteoporosis, that could heighten the risks of OCS use. Patients treated with >1000 mg of prednisolone equivalent OCS in the 48 months following COPD diagnosis had a higher incidence of new conditions or events, including cardiovascular disease, heart failure, hypertension, obesity, dyspepsia, infections, and depression/anxiety, than patients with no OCS use.

Conclusion

These results highlight the potential risks of OCS in COPD treatment, including prolonged use among complex Medicare patients, and reinforce the importance of preventive treatment strategies and therapy optimization early in the disease course.

Nebulized corticosteroids versus systemic corticosteroids for patients with acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis comparing the benefits and harms reported by observational studies and randomized controlled trials

Objective: Systematic comparison of the efficacy and safety of nebulized corticosteroids and systemic corticosteroids for treating acute exacerbation of chronic obstructive pulmonary disease reported by high-quality, real-world observational studies and randomized controlled trials.

Methods: MEDLINE, EMBASE, and Cochrane Library databases were searched from the database creation date to 1 April 2022. Eligible observational studies and randomized controlled trials with changes in lung function and blood gas analysis results as the primary endpoints of interest, and the numbers of deteriorations and adverse events as the secondary endpoints were sought.

Results: Of the 2,837 identified studies, 22 were eligible and included in our analysis (N = 5,764 patients). Compared with systemic corticosteroids, nebulized corticosteroids resulted in comparable improvements in predicted FEV₁%, FEV₁, PaO₂, PaCO₂, and SaO₂ at the treatment endpoint; however, observational studies reported more significant treatment outcomes with nebulized corticosteroids for FEV₁ [mean difference, 0.26; 95% confidence interval (CI), 0.17–0.35; p < 0.005]. In terms of adverse reactions, the risks of gastrointestinal symptoms were 11% [Log risk ratio (LogRR) = 0.10; 95% confidence interval, 0.05–0.15; p < 0.005] higher for systemic corticosteroids than for nebulized corticosteroids in randomized controlled trials, while the risks of hyperglycemia were 6% (LogRR = 0.06; 95% CI, 0.01–0.11; p = 0.01) and 13% (LogRR = 0.12; 95% CI, 0.09–0.16; p < 0.005) higher in observational studies and randomized controlled trials, respectively.

Conclusion: According to our meta-analysis, either study type supported that nebulized corticosteroids can be used as an alternative to systemic corticosteroids for treating acute exacerbation of the chronic obstructive pulmonary disease. However, more well-designed prospective studies are needed to determine the optimal dose of nebulized corticosteroids and the advantages of sequential therapy.

The efficacy and safety of antibiotics and glucocorticoids in the treatment of elderly patients with chronic obstructive emphysema: systematic review and meta-analysis

Background

To systematically evaluate the efficacy and safety of inhaled corticosteroids (ICS) combined with antibiotics in the treatment of elderly chronic obstructive pulmonary disease (COPD) patients, and to provide some reference for the optimization of clinical treatment regimen for elderly COPD patients.

Methods

Combination of perfect search and keywords from the Chinese and foreign language databases, and the Cochrane Collaboration Center provided Review Manger 5.2 software [Cochrane Information Management System (IMS)] for statistical analysis, and the risk ratio (RR) of dichotic variables was adopted. RR and 95% confidence interval (95% CI) were used as efficacy and side effects analysis statistics in metaanalysis.

Results

After independent screening by two researchers, 18 studies were included into the meta-analysis. After data analysis and statistics, the results of meta-analysis showed that the observation group (glucocorticoid combined with antibiotic treatment) and the control group (glucocorticoid therapy) first second forced expiratory volume (FEV1%) expected value (OR =1.21; 95% CI: 0.11–2.32; P=0.03), and 6-min walking distances (6-MWDs) (OR =12.92; 95% CI: 4.61–21.22; P=0.002), the COPD Assessment Test (CAT) score (OR =3.08; 95% CI: 2.58−3.57; P<0.00001) the improvement was statistically significant; incidence of adverse reactions (OR =1.24; 95% CI: 0.58–2.67; P=0.58), the incidence of acute exacerbation (OR =0.65; 95% CI: 0.39–1.08; P=0.10), FEV1 (OR =0.07; 95% CI: 0.01–0.15; P=0.09). There was no statistical difference.

Discussion

The combination of glucocorticoids and antibiotics in elderly patients with stable COPD can significantly improve their lung function and exercise ability with minimal adverse reactions.

Association Between Dexamethasone Treatment After Hospital Discharge for Patients With COVID-19 Infection and Rates of Hospital Readmission and Mortality

IMPORTANCE

Current guidelines recommend use of dexamethasone, 6 mg/d, up to 10 days or until discharge for patients hospitalized with COVID-19. Whether patients who received less than 10 days of corticosteroids during hospitalization for COVID-19 benefit from continuing treatment at discharge has not been determined.

OBJECTIVE

To assess whether continuing dexamethasone treatment at discharge is associated with reduced all-cause readmissions or mortality postdischarge.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted at 15 medical centers within Kaiser Permanente Southern California. The population included adults who received less than 10 days of dexamethasone, 6 mg/d, until discharge during hospitalization for COVID-19 and were discharged alive between May 1 and September 30, 2020.

EXPOSURES

Continued dexamethasone treatment at discharge.

MAIN OUTCOMES AND MEASURES

All-cause readmissions or mortality within 14 days from discharge.

RESULTS

A total of 1164 patients with a median age of 55 (IQR, 44-66) years were identified. Most patients were of Hispanic ethnicity (822 [70.6%]) and male (674 [57.9%]) and required oxygen support during hospitalization (1048 [90.0%]). Of the 1164 patients, 692 (59.5%) continued dexamethasone, 6 mg/d, at discharge. A balanced cohort was created using propensity score and inverse probability of treatment weighting. The adjusted odds ratio (OR) for readmissions or mortality within 14 days was 0.87 (95% CI, 0.58-1.30) for patients who continued dexamethasone therapy at discharge compared with those who did not. Similar results were produced by a sensitivity analysis that restricted the treatment group to those who received exactly 10 days of dexamethasone (OR, 0.89; 95% CI, 0.55-1.43) and by subgroup analyses stratified by the duration of dexamethasone treatment as an inpatient (1-3 days: OR, 0.71; 95% CI, 0.43-1.16; 4-9 days: OR, 1.01; 95% CI, 0.48-2.12), oxygen requirement at discharge (room air: OR, 0.91; 95% CI, 0.53-1.59; supplemental oxygen use: OR, 0.76; 95% CI, 0.42-1.37), and disease duration at discharge (≤10 days: OR, 0.81; 95% CI, 0.49-1.33; >10 days: OR, 0.94; 95% CI, 0.48-1.86).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with COVID-19, continuing treatment with dexamethasone, 6 mg/d, at discharge was not associated with a reduction in 14-day all-cause readmission or mortality. This finding suggests that dexamethasone should not be routinely prescribed beyond discharge for individuals with COVID-19.

Risk factors and prediction score model for unplanned readmission among neonates with NRDS under one year of age: A retrospective cohort study

OBJECTIVE

This study aimed to analyze the risk factors and establish a prediction score model for unplanned readmission among neonates with neonatal respiratory distress syndrome (NRDS) for respiratory problems under one year of age.

METHODS

This retrospective cohort study enrolled 230 neonates with NRDS who were admitted between January 2020 and December 2020. The infants were classified into two subgroups based on whether they were readmitted for respiratory problems under one year of age: readmit group and non-readmit group. Readmission risk factors for NRDS were analyzed by logistic regression and a prediction score model was generated.

RESULTS

Among the 230 enrolled infants, 51 (22%) were readmitted, and 179 (78%) were not readmitted. In univariate analysis, compared with non-readmit group infants, readmit group infants had a significantly younger birth gestational age (31.9 ± 2.3 vs. 32.8 ± 2.5 weeks, p = 0.012), lower birth weight (1,713.7 ± 501.3 g vs. 1,946.8 ± 634.4 g, p = 0.007), older age at discharge (41.7 vs. 31.7 days, p = 0.012), higher proportion of necrotizing enterocolitis (NEC) (31% vs. 16%, p = 0.016), higher rate of blood transfusion (39% vs. 25%, p = 0.049), higher rate of postnatal dexamethasone (DEX) administration (28% vs. 9.5%, p = 0.001), and higher rate of home oxygen therapy (HOT) (57% vs. 34%, p = 0.003). Moreover, readmit group infants had significantly longer antibiotic days usage (12.0 vs. 10.0 days, p = 0.026) and a longer duration of hospital stay (41.0 vs. 31.0 days, p = 0.012) than non-readmit group infants. The multivariate logistic regression analysis showed that taking readmission as a target variable, postnatal DEX administration (OR: 2.689, 95% CI: 1.168-6.189, p = 0.020), HOT (OR: 2.071, 95% CI: 1.060-4.046, p = 0.033), and NEC (OR: 2.088, 95% CI: 0.995-4.380, p = 0.051) could be regarded as risk factors for readmission. A scoring model predicting readmission was administered with a positive predictive value of 0.651 (95% CI: 0.557-0.745, p = 0.002), with a sensitivity of 0.412 and a specificity of 0.888 at a cut-off of 3.5 points, which were evaluated on the receiver operating characteristic curve.

CONCLUSIONS

Postnatal DEX administration, HOT, and NEC were risk factors for readmission of NRDS. NRDS infants with a predictive score of 3.5 points or more were at high risk for unplanned readmission.

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.

Airline transportation and arrival time of international disease spread: A case study of Covid-19

In this era of globalization, airline transportation has greatly increased international trade and travel within the World Airport Network (WAN). Unfortunately, this convenience has expanded the scope of infectious disease spread from a local to a worldwide occurrence. Thus, scholars have proposed several methods to measure the distances between airports and define the relationship between the distances and arrival times of infectious diseases in various countries. However, such studies suffer from the following limitations. (1) Only traditional statistical methods or graphical representations were utilized to show that the effective distance performed better than the geographical distance technique. Researchers seldom use the survival model to quantify the actual differences among arrival times via various distance methods. (2) Although scholars have found that most diseases tend to spread via the random walk rather than the shortest path method, this hypothesis may no longer be true because the network has been severally altered due to recent COVID-related travel reductions. Therefore, we used 2017 IATA (International Air Transport Association) to establish an airline network via various chosen path strategies (random walk and shortest path). Then, we employed these two networks to quantify each model's predictive performance in order to estimate the importation probability function of COVID-19 into various countries. The effective distance model was found to more accurately predict arrival dates of COVID-19 than the geographical distance model. However, if pre-Covid airline data is included, the path of disease spread might not follow the random walk theory due to recent flight suspensions and travel restrictions during the epidemic. Lastly, when testing effective distance, the inverse distance survival model and the Cox model yielded very similar importation risk estimates. The results can help authorities design more effective international epidemic prevention and control strategies.

CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care

Background

Chronic obstructive pulmonary disease (COPD) are managed predominantly in primary care. However, key opportunities to optimize treatment are often not realized due to unrecognized disease and delayed implementation of appropriate interventions for both diagnosed and undiagnosed individuals. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) is the first-of-its-kind, collaborative, interventional COPD registry. It comprises an integrated quality improvement program focusing on patients (diagnosed and undiagnosed) at a modifiable and higher risk of COPD exacerbations. The first step in CONQUEST was the development of quality standards (QS). The QS will be imbedded in routine primary and secondary care, and are designed to drive patient-centered, targeted, risk-based assessment and management optimization. Our aim is to provide an overview of the CONQUEST QS, including how they were developed, as well as the rationale for, and evidence to support, their inclusion in healthcare systems.

Methods

The QS were developed (between November 2019 and December 2020) by the CONQUEST Global Steering Committee, including 11 internationally recognized experts with a specialty and research focus in COPD. The process included an extensive literature review, generation of QS draft wording, three iterative rounds of review, and consensus.

Results

Four QS were developed: 1) identification of COPD target population, 2) assessment of disease and quantification of future risk, 3) non-pharmacological and pharmacological intervention, and 4) appropriate follow-up. Each QS is followed by a rationale statement and a summary of current guidelines and research evidence relating to the standard and its components.

Conclusion

The CONQUEST QS represent an important step in our aim to improve care for patients with COPD in primary and secondary care. They will help to transform the patient journey, by encouraging early intervention to identify, assess, optimally manage and followup COPD patients with modifiable high risk of future exacerbations.

Validation of COPDPredict™: Unique Combination of Remote Monitoring and Exacerbation Prediction to Support Preventative Management of COPD Exacerbations

Background

COPDPredict™ is a novel digital application dedicated to providing early warning of imminent COPD (chronic obstructive pulmonary disease) exacerbations for prompt intervention. Exacerbation prediction algorithms are based on a decision tree model constructed from percentage thresholds for disease state changes in patient-reported wellbeing, forced expiratory volume in one second (FEV₁) and C-reactive protein (CRP) levels. Our study determined the validity of COPDPredict™ to identify exacerbations and provide timely notifications to patients and clinicians compared to clinician-defined episodes.

Methods

In a 6-month prospective observational study, 90 patients with COPD and frequent exacerbations registered wellbeing self-assessments daily using COPDPredict™ App and measured FEV₁ using connected spirometers. CRP was measured using finger-prick testing.

Results

Wellbeing self-assessment submissions showed 98% compliance. Ten patients did not experience exacerbations and treatment was unchanged. A total of 112 clinician-defined exacerbations were identified in the remaining 80 patients: 52 experienced 1 exacerbation; 28 had 2.2±0.4 episodes. Sixty-two patients self-managed using prescribed rescue medication. In 14 patients, exacerbations were more severe but responded to timely escalated treatment at home. Four patients attended the emergency room; with 2 hospitalised for <72 hours. Compared to the 6 months pre-COPDPredict™, hospitalisations were reduced by 98% (90 vs 2, p<0.001). COPDPredict™ identified COPD-related exacerbations at 7, 3 days (median, IQR) prior to clinician-defined episodes, sending appropriate alerts to patients and clinicians. Cross-tabulation demonstrated sensitivity of 97.9% (95% CI 95.7-99.2), specificity of 84.0% (95% CI 82.6-85.3), positive and negative predictive value of 38.4% (95% CI 36.4-40.4) and 99.8% (95% CI 99.5-99.9), respectively.

Conclusion

High sensitivity indicates that if there is an exacerbation, COPDPredict™ informs patients and clinicians accurately. The high negative predictive value implies that when an exacerbation is not indicated by COPDPredict™, risk of an exacerbation is low. Thus, COPDPredict™ provides safe, personalised, preventative care for patients with COPD.

Effect of different corticosteroid regimes for hospitalised patients with exacerbated COPD: pooled analysis of individual participant data from the REDUCE and CORTICO-COP trials

Background

Systemic corticosteroid administration for severe acute exacerbations of COPD (AECOPD) reduces the duration of hospital stays. Corticosteroid-sparing regimens have showed non-inferiority to higher accumulated dose regimens regarding re-exacerbation risk in patients with AECOPD. However, it remains unclear whether 14-day or 2–5-day regimens would result in shorter admission durations and changes in mortality risk. We explored this by analysing the number of days alive and out of hospital based on two randomised controlled trials with different corticosteroid regimens.

Methods

We pooled individual patient data from the two available multicentre randomised trials on corticosteroid-sparing regimens for AECOPD: the REDUCE (n = 314) and CORTICO-COP (n = 318) trials. In the 14-day regimen group, patients were older, fewer patients received pre-treatment with antibiotics and more patients received pre-treatment with systemic corticosteroids. Patients randomly allocated to the 14-day and 2–5-day regimens were compared, with adjustment for baseline differences.

Results

The number of days alive and out of hospital within 14 days from recruitment was higher for the 2–5 day regimen group (mean 8.4 days; 95% confidence interval [CI] 8.0–8.8) than the 14-day regimen patient group (4.2 days; 95% CI3.4–4.9; p < 0.001). The 14-day AECOPD group had longer hospital stays (mean difference, 5.4 days [standard error ± 0.6]; p < 0.0001) and decreased likelihood of discharge within 30 days (hazard ratio [HR] 0.5; 95% CI 0.4–0.6; p < 0.0001). Comparing the 14-day regimen and the 2–5 day regimen group showed no differences in the composite endpoint ‘death or ICU admission’ (odds ratio [OR] 1.4; 95% CI 0.8–2.3; p = 0.15), new or aggravated hypertension (OR 1.5; 95% CI 0.9–2.7; p = 0.15), or mortality risk (HR 0.8; 95% CI 0.4–1.5; p = 0.45) during the 6-month follow-up period.

Conclusion

14-day corticosteroid regimens were associated with longer hospital stays and fewer days alive and out of hospital within 14 days, with no apparent 6-month benefit regarding death or admission to ICU in COPD patients. Our results favour 2–5 day regimens for treating COPD exacerbations. However, prospective studies are needed to validate these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01745-5.

The Potential for Phospholipids in the Treatment of Airway Inflammation: An Unexplored Solution

Asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) are major inflammatory respiratory diseases. Current mainstay therapy for asthma, and chronic obstructive pulmonary disease are corticosteroids, which have well-established side effect profiles. Phospholipids (PLs) are ubiquitous, diverse compounds with varying functions such as their structural role incell membrane, energy storage, and cell signaling.Recent advances in understanding PLs role as inflammatory mediators in the body as well as their widespread long-standing use as carrier molecules in drug delivery demonstrate the potential application of phospholipids in modulating inflammatory conditions. This review briefly explains the main mechanisms of inflammation in chronic respiratory diseases, currentanti-inflammatory treatments and areas of unmet need. The structural features, roles of endogenous and exogenous phospholipids, including their use as pharmaceutical excipients are reviewed. Current research on the immunomodulatory properties of PLs and their potentialapplication in inflammatory diseasesis the major section of this review. Considering the roles of PLs as inflammatory mediators and their safety profile established in pharmaceutical formulations, these small molecules demonstrate great potential as candidates in respiratory inflammation. Future studies need to focus on the immunomodulatory properties and the underlying mechanisms of phospholipids in respiratory inflammatory diseases.

Efficacy and Safety of Different Doses of Systemic Corticosteroids in COPD Exacerbation

BACKGROUND

Although systemic corticosteroids (SCS) have long been used to treat patients with COPD exacerbation, the recommended dose remains controversial. We aimed to perform a meta-analysis and an indirect treatment comparison to investigate the efficacy and safety of different doses of SCS in subjects with COPD exacerbation.

METHODS

Studies were identified by searching different databases for randomized controlled trials that investigated the efficacy and safety of SCS with placebo in subjects with exacerbation of COPD. The different doses of SCS were assigned to low-dose (ie, initial dose ≤ 40 mg prednisone equivalent/d [PE/d]), medium-dose (initial dose = 40-100 mg PE/d, and high-dose (initial dose > 100 mg PE/d) groups. The indirect treatment comparison was performed between low-, medium-, and high-dose SCS groups.

RESULTS

Twelve trials with 1,375 participates were included. Compared to placebo, the risk of treatment failure was lower in the low-dose SCS groups (risk ratio 0.61 [95% CI 0.43-0.88], P = .007) and high-dose SCS groups (risk ratio 0.64 [95% CI 0.48-0.85], P = .002); the FEV₁ was significantly improved in low-dose (mean difference 0.09 [95% CI 0.06-0.12], P < .001), medium-dose (mean difference 0.23 [95% CI 0.02-0.44], P = .036), and high-dose SCS groups (mean difference 0.09, [95% CI 0.03-0.15], P < .001, respectively). Regarding safety, the incidence of hyperglycemia was higher in high-dose SCS groups versus placebo (risk ratio 2.52 [95% CI 1.13-5.62], P = .02). The indirect comparison between low-, medium-, and high-dose SCS found that the risk of treatment failure and changes in FEV₁ were similar between these doses of SCS.

CONCLUSIONS

This meta-analysis indicates that low-dose SCS (initial dose ≤ 40 mg PE/d) was sufficient and safer for treating subjects with COPD exacerbation, and it was noninferior to higher doses of SCS (initial dose > 40 mg PE/d) in improving FEV₁ and reducing the risk of treatment failure. However, our findings need to be verified in head-to-head randomized controlled trials.

Personalising exacerbation prediction strategies in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity worldwide. One of the most important features of this disease is exacerbations where a patient’s respiratory symptoms episodically worsen. Exacerbations accounted for over 140000 hospital admissions in 2012 in the United Kingdom with considerably more exacerbations being treated in primary care. Despite significant research in this area in recent years, treatment of acute exacerbations in the community remains limited to oral glucocorticoids, antibiotics and bronchodilators. One of the issues with unpicking the complexity of exacerbations is trying to find out the exact underlying cause and mechanism that leads to symptoms and lung destruction. Currently symptoms are initially guided by symptoms alone though multiple causes of exacerbations have common presentations. This includes viral and bacterial infections and episodes relating to environmental triggers such as pollen and pollution. There is also evidence that cardiovascular factors can contribute to symptoms of breathlessness that can mimic COPD exacerbations. In this editorial we discuss recent advances in the use of precision medicine to more accurately treat exacerbations of COPD. This includes identification of phenotypes that could help rationalise treatment and more importantly identify novel drug targets. We also consider the future role of precision medicine in preventing exacerbations and identifying COPD patients that are at increased risk of developing them.

Do Benefits Outweigh Risks for Corticosteroid Therapy in Acute Exacerbation of Chronic Obstructive Pulmonary Disease in People with Diabetes Mellitus?

Chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) are chronic health conditions with significant impacts on quality and extent of life. People with COPD and DM appear to have worse outcomes in each of the comorbid conditions. Treatment with corticosteroids in acute exacerbation of COPD (AECOPD) has been shown to reduce treatment failure and exacerbation relapse, and to shorten length of hospital stay, but not to affect the inexorable gradual worsening of lung function. Treatment with corticosteroids can lead to a wide spectrum of side effects and complications, including worsening hyperglycemia and deterioration of diabetes control in those with pre-existing DM. The relationship between COPD and DM is rather complex and accumulating evidence indicates a distinct phenotype of the comorbid state. Several randomized controlled trials on corticosteroid treatment in AECOPD excluded people with DM or did not report on outcomes in this subgroup. As such, the perceived benefits of corticosteroids in AECOPD in people with DM have not been validated. In people with COPD and DM, the detrimental side effects of corticosteroids are guaranteed, while the benefits are not confirmed and only presumed based on extrapolation from the general COPD population. Therefore, the potential for harm when prescribing corticosteroids for AECOPD in people with DM cannot be excluded.

Associations among chronic obstructive pulmonary disease with asthma, pneumonia, and corticosteroid use in the general population

Purpose

To evaluate the association among chronic obstructive pulmonary disease (COPD) with asthma, steroid use, and pneumonia in the general population.

Methods

Using Taiwan’s National Health Insurance Research Database to identify patients with incident pneumonia, we established a COPD with asthma cohort of 12,538 patients and a COPD cohort of 25,069 patients. In both cohorts, the risk of incident pneumonia was assessed using multivariable Cox proportional hazards models.

Results

The adjusted hazard ratio (aHR) with 95% confidence interval (CI) for incident pneumonia was 2.38 (2.14, 2.66) in the COPD with asthma cohort, regardless of age, sex, comorbidities, and drug use. COPD cohort without inhaled corticosteroids (ICSs) use served as a reference. The aHR (95% CI) for COPD cohort with ICSs use was 1.34 (0.98, 1.83); that for COPD with asthma cohort without ICSs use was 2.46 (2.20, 2.76); and that for COPD with asthma cohort with ICSs use was 2.32 (1.99, 2.72). COPD cohort without oral steroids (OSs) use served as a reference; the aHR (95% CI) for COPD with asthma cohort without OSs use and with OSs use was 3.25 (2.72, 3.89) and 2.38 (2.07, 2.74), respectively.

Conclusions

The COPD with asthma cohort had a higher risk of incident pneumonia, regardless of age, sex, comorbidities, and ICSs or OSs use. COPD cohort with ICSs use did not have a notable risk of incident pneumonia. The COPD with asthma cohort had a higher risk of incident pneumonia, even without ICSs/OSs use.

Risk factors for early readmission after acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND AND AIMS

Patients discharged after treatment for acute exacerbation of chronic obstructive pulmonary disease (COPD) are at high risk for readmission. We aimed to identify the prevalence and risk factors for readmission.

METHODS

We included 16,105 patients who had claimed their medical expenses from 1 May 2014 to 1 May 2016 after discharge from any medical facility in Korea, following treatment for acute exacerbation of COPD. We analysed the potential risk factors for readmission within 30 days of discharge.

RESULTS

Readmission rate was 26.4% (3989 patients among 15,101 patients) and over 50% of readmissions occurred within 10 days of discharge. Approximately 57% of readmissions occurred due to respiratory causes. Major causes of readmission were COPD (27%), pneumonia (14.2%), and lung cancer (7.1%), in that order. Patients who were readmitted were male, had more comorbidities and were less frequently admitted to tertiary hospitals than those who were not readmitted. Risk factors for readmission within 30 days of discharge were male sex, medical aid coverage, longer hospital stay, longer duration of systemic steroid use during hospital stay, high comorbid condition index, and discharge to skilled nursing facility.

CONCLUSION

Readmission occurred in approximately one-quarter of patients, and was associated with patient-related and clinical factors. Using these results, we can identify high-risk patients for readmission and precautions are needed to be taken before deciding on a discharge plan. Further research is needed to develop accurate tools for predicting the risk of readmission before discharge, and development and evaluation of an effective care programme for COPD patients are necessary.The reviews of this paper are available via the supplemental material section.

Phase II Study of Single/Repeated Doses of Acumapimod (BCT197) to Treat Acute Exacerbations of COPD

Mitogen-activated protein kinase p38 is a key regulator in the inflammation pathway and is activated in the lungs of chronic obstructive pulmonary disease (COPD) patients. Acumapimod is a potent, selective, oral, p38 inhibitor under investigation for treatment of acute exacerbations of COPD (AECOPD). In this Phase II, double-blind, randomized, placebo-controlled dose-exploration study of acumapimod in patients with moderate or severe AECOPD (NCT01332097), patients presenting with AECOPD were randomized to receive single-dose acumapimod (20 mg or 75 mg) on Day 1, repeated single-dose acumapimod (20 mg or 75 mg) on Days 1 and 6, oral prednisone 40 mg (10 days), or placebo. Primary outcome: improvement in forced expiratory volume in 1 s (FEV₁) versus placebo at Day 5 (single doses) and Day 10 (repeated doses). N = 183 patients were randomized; 169 (92%) patients completed the study. Although the primary endpoint (FEV₁ at Day 10) was not met (p = 0.082), there was a significant improvement in FEV₁ with acumapimod repeat-dose 75 mg versus placebo at Day 8 (p = 0.022) which, though not a prespecified endpoint, was part of an overall trend. Differences at lower doses did not achieve significance. Mean change in FEV₁ AUC from baseline to Day 14 in the 75 mg repeat-dose group was significantly higher versus placebo (p = 0.02), prednisone (p = 0.01), and 20 mg single-dose groups (p = 0.015) (post-hoc analysis). EXACT-PRO showed numerical differences versus placebo that did not reach significance. Acumapimod was well tolerated. In conclusion, repeated single-dose acumapimod showed a clinically relevant improvement in FEV₁ over placebo at Day 8, along with consistent numerical differences in EXACT-PRO. These data can be used to determine dose regimens for a proof-of-clinical-concept trial.

Update on management of stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major chronic debilitating condition with significant impact on quality of life, symptoms, comorbidity, health care utilization and longevity. The main pathophysiological hallmark of COPD is expiratory flow limitation which impairs the ability of respiratory system to adequately and properly ventilate. To be able to prognosticate and manage patients with COPD, various societies have developed classifications of disease severity. Current classification schemes combine three elements that include lung function, patient reported symptoms (shortness of breath) and frequency of exacerbations. Global Initiative for Obstructive Lung Disease (GOLD), an international guideline for diagnosis and management of COPD, started using this approach since the 2011 revision. Management according to this scheme has been developed and is in use. Comprehensive COPD management is multifaceted. It includes pharmacologic management, patient education, smoking cessation, influenza and pneumococcal vaccinations, depression and anxiety management, pulmonary rehabilitation, and if indicated, home oxygen therapy. The following chapter will review management recommendations currently in use for stable COPD. We intend to make the chapter to the point and practical and avoid an exhaustive review of the literature.

Dex-CSDH randomised, placebo-controlled trial of dexamethasone for chronic subdural haematoma: report of the internal pilot phase

The Dex-CSDH trial is a randomised, double-blind, placebo-controlled trial of dexamethasone for patients with a symptomatic chronic subdural haematoma. The trial commenced with an internal pilot, whose primary objective was to assess the feasibility of multi-centre recruitment. Primary outcome data collection and safety were also assessed, whilst maintaining blinding. We aimed to recruit 100 patients from United Kingdom Neurosurgical Units within 12 months. Trial participants were randomised to a 2-week course of dexamethasone or placebo in addition to receiving standard care (which could include surgery). The primary outcome measure of the trial is the modified Rankin Scale at 6 months. This pilot recruited ahead of target; 100 patients were recruited within nine months of commencement. 47% of screened patients consented to recruitment. The primary outcome measure was collected in 98% of patients. No safety concerns were raised by the independent data monitoring and ethics committee and only five patients were withdrawn from drug treatment. Pilot trial data can inform on the design and resource provision for substantive trials. This internal pilot was successful in determining recruitment feasibility. Excellent follow-up rates were achieved and exploratory outcome measures were added to increase the scientific value of the trial.

Management of severe acute exacerbations of COPD: an updated narrative review

Background

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.

Main body

In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.

Conclusion

Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.