Exacerbations of Chronic Obstructive Pulmonary Disease and Quality of Life of Patients

Factors Associated with Non-Adherence to Self-Management Among Patients with Chronic Obstructive Pulmonary Disease: A Survey Using the Delphi Technique and Analytic Hierarchy Process

Background

The relevant factors and patterns of non-adherence to self-management among patients with chronic obstructive pulmonary disease (COPD) need to be elucidated to improve self-management.

Purpose

This study was a survey to prioritize the relevance of factors associated with non-adherence to COPD self-management using the Delphi technique and analytic hierarchy process (AHP).

Patients and Methods

A total of 15 expert panels were established to determine the priority of relevant factors in a three-round Delphi survey and an AHP. To develop the preliminary conceptual framework for non-adherence to COPD self-management, findings from a systematic literature review, a qualitative study using in-depth interviews with COPD patients, and the first round of the Delphi survey were integrated. Based on the preliminary framework, the content validity ratio (CVR) was analyzed to examine the consensus among expert panels in the second and third rounds of the Delphi survey, and the relative weight was determined by pairwise comparisons between alternative factors in the AHP.

Results

In developing the preliminary conceptual framework, 8 factor categories and 53 factors were identified as relevant to non-adherence to COPD self-management. Of the 53 factors, 22 factors with a CVR of 0.49 or higher were identified in the Delphi survey. A total of 14 of the 53 factors were common to both the Delphi survey and AHP with high weights. The most notable factors were prolonged treatment, experience of treatment failure, and unknown effects of medication.

Conclusion

Through consensus decision-making by experts, 14 factors were identified as relevant factors associated with non-adherence to COPD self-management. A hierarchical and systematic framework incorporating factors associated with non-adherence to COPD self-management was developed in this study. Further research is needed to develop intervention strategies based on factors associated with non-adherence to COPD self-management.

Prediction of gold stage in patients hospitalized with COPD exacerbations using blood neutrophils and demographic parameters as risk factors

Background

Patients hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations are unable to complete the pulmonary function test reliably due to their poor health conditions. Creating an easy-to-use instrument to identify the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage will offer valuable information that assists clinicians to choose appropriate clinical care to decrease the mortality in these patients. The objective of this study was to develop a prediction model to identify the GOLD stage in the hospitalized exacerbation of chronic obstructive pulmonary disease (ECOPD) patients.

Methods

This prospective study involved 155 patients hospitalized for ECOPD. All participants completed lung function tests and the collection of blood neutrophils and demographic parameters. Receiver operating characteristic (ROC) curve was plotted based on the data of 155 patients, and was used to analyze the disease severity predictive capability of blood neutrophils and demographic parameters. A support vector regression (SVR) based GOLD stage prediction model was built using the training data set (75%), whose accuracy was then verified by the testing data set (25%).

Results

The percentage of blood neutrophils (denoted as NEU%) combined with the demographic parameters was associated with a higher risk to severe episode of ECOPD. The area under the ROC curve was 0.84. The SVR model managed to predict the GOLD stage with an accuracy of 90.24%. The root-mean-square error (RMSE) of the forced expiratory volume in one second as the percentage of the predicted value (denoted as FEV₁%pred) was 8.84%.

Conclusions

The NEU% and demographic parameters are associated with the pulmonary function of the hospitalized ECOPD patients. The established prediction model could assist clinicians in diagnosing GOLD stage and planning appropriate clinical care.

Nutrition as a modifiable factor in the onset and progression of pulmonary function impairment in COPD: a systematic review

CONTEXT

Chronic obstructive lung disease (COPD) is a progressive lung disease characterized by persistent airflow limitation. An increasing amount of evidence suggests an effect of dietary quality on the risk of COPD in the general population and pulmonary function decline in patients with COPD.

OBJECTIVE

The association of dietary intake and nutrient status with COPD risk and onset, as well as pulmonary function decline (change in forced expiratory volume in 1 second, forced vital capacity, or the ratio of the former to the latter) in patients with COPD was investigated in this systematic review.

DATA SOURCES

The PubMed database was searched by combining terms of pulmonary function or COPD with diet, nutrient status, or nutritional supplementation.

DATA EXTRACTION

Original studies and systematic reviews and meta-analyses were included. Articles obtained were independently screened for relevance on the bases of title and abstract by 2 researchers. Eventually, 89 articles were included in the analysis.

RESULTS

The unhealthy Western-style diet is associated with an increased risk of COPD and an accelerated decline of pulmonary function. Intake of fruit, vegetables, dietary fibers, vitamins C and E, polyphenols, and β-carotene were individually associated with lower COPD risk, whereas consumption of processed meat was associated with higher COPD risk. Data on the effect of dietary quality on pulmonary function decline in patients with COPD are limited and inconsistent. Strong evidence for beneficial effects on pulmonary function decline was found only for vitamin D supplementation.

CONCLUSION

Considering the increasing burden of COPD, more attention should be given to dietary quality as a modifiable factor in disease development and progression in patients with COPD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021240183.

Effect of periodontal therapy on COPD outcomes: a systematic review

Background

Latest evidence suggests that periodontitis is prevalent among patients with chronic obstructive pulmonary disease (COPD), while recent studies have also reported a potential benefit of periodontal treatment on several COPD outcomes. This systematic review aims to determine the impact of periodontal treatment on exacerbation rate, lung function and quality of life of COPD patients.

Methods

A systematic search of electronic databases of PubMed, Scopus, Virtual Health Library, ScienceDirect, Wiley Online Library, Web of Science, ProQuest Dissertation and Theses Global and Google Scholar was conducted. Search restricted to studies involving human subjects which were published from January 2000 to March 2020 in English language. Distiller Systematic Review software was used for data management. Risk of bias was assessed using Risk of Bias 2 (RoB2) and Risk of Bias for non-randomized studies of intervention (ROBINS-I) tools. Overall quality of evidence was judged based on Grading of Recommendations Assessment, Development and Evaluation working group methodology.

Results

Out of 1442 articles retrieved, 7 full text articles were included in the review. Limited evidence suggests that periodontal treatment in patients with COPD and periodontitis is associated with reduced exacerbation frequency and a slower lung function decline rate, while its effects on quality of life remain unclear. In addition, periodontal treatment in COPD is associated with lower hospitalization rates and reduced all-cause mortality. Significant methodological differences were noted amongst included studies, while very low-to-moderate overall quality of evidence was demonstrated.

Conclusions

Although it is reasonable to advise COPD patients not to neglect their dental health, further studies are warranted to determine the role of periodontal therapy on COPD clinical outcomes.

Trial Registration: PROSPERO 2020 (CRD42020158481). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020158481

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01429-2.

Reducing and managing chronic obstructive pulmonary disease exacerbations with tiotropium + olodaterol

OBJECTIVE

The aim of this study was to review clinical evidence supporting the use of fixed-dose combination of tiotropium and olodaterol, a long-acting muscarinic antagonist (LAMA) and a long-acting β₂-agonist (LABA), respectively, as the initial and follow-up treatment choice in patients with chronic obstructive pulmonary disease (COPD) as per Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 recommendations-the impact of this treatment strategy on the reduction in the risk of exacerbations-and the importance of early therapeutic interventions.

METHODS

For this narrative review, the available literature was searched to identify studies including patients with COPD receiving tiotropium and olodaterol as either monotherapy or combination therapy and studies including patients with COPD receiving inhaled corticosteroids (ICS) in addition to long-acting bronchodilators. Relevant studies were included in the review.

RESULTS

Patients with COPD are often prescribed ICS therapy, which, when used over a long term, can be associated with local and systemic adverse effects. The GOLD 2020 report recommends dual bronchodilator therapy as both an initial and follow-up treatment option. A LABA + LAMA combination is mechanistically synergistic, and cumulative evidence surrounding the efficacy and safety of fixed-dose combination of tiotropium and olodaterol supports therapeutic advantages over monotherapy in most patients with COPD.

CONCLUSIONS

The early stages of COPD may represent a "window of therapeutic opportunity" during which initiation of tiotropium and olodaterol dual bronchodilator therapy may improve lung function and quality of life and reduce exacerbations in patients with COPD.

Assessing the Usefulness of the Prevexair Smartphone Application in the Follow-Up High-Risk Patients with COPD

Introduction

This manuscript analyzes the exacerbations recorded by the Prevexair application through the daily analysis of symptoms in high-risk patients with COPD and explores its usefulness in assessing clinical stability with respect to that reported in visits.

Patients and Methods

This study is a multi-centre cohort of COPD patients with the exacerbator phenotype who were monitored over 6 months. The Prevexair application was installed on the patients' smartphones. Patients used the app to record symptom changes, use of medication and use of healthcare resources. It is not established a recommended action plan when worsening of symptoms. At their clinical visit during the follow-up period, patients were asked about exacerbations suffered during these 6 months of monitoring. The investigators who conducted the visit were blinded about the Prevexair app records.

Results

The patients experienced a total of 185 exacerbations according to daily records in the app whereas only 64 exacerbations were recalled during medical visits. Perception became more accurate for severe exacerbations (kappa 0.6577), although we found no factors that predicted poor recall. The proportion of 72.5% patients were classified as unstable if the exacerbations captured by Prevexair were used to define stability, versus 47.8% if the exacerbations recall in visit was used. Two-thirds of the exacerbations recorded in the Prevexair application were not reported to doctors during their clinical visits. Almost half were treated with oral corticosteroids and/or antibiotics and more than one-quarter of the exacerbations treated did not seek medical attention.

Conclusion

The findings of this cohort study confirm that patients do not always remember the exacerbations suffered during their medical visit. The prevexair application is useful in monitoring COPD patients at high risk, in order to a better assessment of exacerbations of COPD during medical visits. Further research must be carried out to evaluate this strategy in clinical practice.

Gallic acid ameliorates COPD-associated exacerbation in mice

COPD is an inflammatory lung disease, which is often exacerbated with microbial infections resulting in worsening of respiratory symptoms. Gallic acid (GA), a naturally occurring phenolic compound is known to possess anti-oxidant/anti-inflammatory activity. We have recently reported that GA protects against the elastase (ET) induced lung inflammation and emphysema and the present work was designed to investigate the beneficial effects of Gallic acid against ET + Lipopolysachharide (LPS) induced COPD exacerbation like condition in mice model. Our data showed that i.t. administration of LPS at 21 days after ET instillation resulted in significant infiltration of inflammatory cells particularly neutrophils (p < 0.0001) into the lungs along with elevated levels of pro-inflammatory cytokines like TNF-α, IL-1β and IL-6 (p < 0.0001). Interestingly, daily administration of GA (200 mg/Kg b. wt.) starting 7 days before ET instillation, significantly blunted the ET + LPS induced inflammation as indicated by reduced number of inflammatory cells particularly neutrophils (p < 0.0001) in BALF along with suppression of myeloperoxidase activity (p = 0.0009) and production of pro-inflammatory cytokines (p < 0.0001). Further, GA also restored the redox imbalance in the lungs towards normal. Additionally, phosphorylation of p65-NF-κB was found to be reduced (p = 0.015), which was associated with downregulation in the gene expression of IL-1β (p = 0.022) and TNF-α (p = 0.04). Conversely, GA treatment resulted in increased protein levels of Nrf2 (p = 0.021) with concomitant increase in transcription of its downstream target genes HO-1 (p = 0.033) and Prdx-1 (p = 0.006). Overall, our data show that GA effectively modulates COPD exacerbation manifestations in mice potentially by restoring redox imbalance in lungs.

Changes in symptoms and health-related quality of life in patients with exacerbated chronic obstructive pulmonary disease

AIMS

To describe changes in symptoms and identify distinct subgroups of symptoms, to determine whether the sample's characteristics predicted changes in symptoms, and to examine how changes in symptoms predicted changes in health-related quality of life (HRQOL) over 6 months in patients with exacerbated chronic obstructive pulmonary disease (COPD).

BACKGROUND

Different patterns of changes in symptoms and their relationship to changes in HRQOL in patients with exacerbated COPD over long periods of time have been understudied.

METHODS

In this longitudinal study, participants with COPD (N = 42) had been admitted to a medical ward or had visited a pulmonary medicine clinic for treatment of exacerbation. Descriptive and inferential statistics were used to analyze data from questionnaires that assessed symptoms and HRQOL at baseline, daily symptoms over 6 months, and HRQOL at 6 months after exacerbation.

RESULTS

Not all participants experienced improved symptoms over time. Two sets of subgroups (improving &worsening; constantly better &constantly worse) emerged, based on 6-month changes in symptoms. Sample characteristics of the improving and worsening subgroups were similar, whereas usual dyspnea and HRQOL were significantly different in the constantly better and constantly worse subgroups. Little change in HRQOL was found in the total sample, but HRQOL deteriorated in the worsening subgroup, although deterioration was not meaningful. Changes in symptoms significantly predicted changes in HRQOL over 6 months.

CONCLUSION

Assessing patients' symptoms after exacerbations of COPD may enable health care providers to identify those at risk of future exacerbations and poorer HRQOL.0.

Baseline health status and setting impacted minimal clinically important differences in COPD: an exploratory study

OBJECTIVES

Minimal clinically important differences (MCIDs) are used as fixed numbers in the interpretation of clinical trials. Little is known about its dynamics. This study aims to explore the impact of baseline score, study setting, and patient characteristics on health status MCIDs in chronic obstructive pulmonary disease (COPD).

STUDY DESIGN AND SETTING

Baseline and follow-up data on the COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and St. George's Respiratory Questionnaire (SGRQ) were retrospectively analyzed from pulmonary rehabilitation (PR) and routine clinical practice (RCP). Anchor- and distribution-based MCID estimates were calculated and tested between settings, gender, age, Global initiative for Obstructive Lung Disease (GOLD) classification, comorbidities, and baseline health status.

RESULTS

In total, 658 patients were included with 2,299 change score measurements. MCID estimates for improvement and deterioration ranged for all subgroups 0.50-6.30 (CAT), 0.10-0.84 (CCQ), and 0.33-12.86 (SGRQ). Larger MCID estimates for improvement and smaller ones for deterioration were noted in patients with worse baseline health status, females, elderly, GOLD I/II patients, and patients with less comorbidities. Estimates from PR were larger.

CONCLUSION

Baseline health status and setting affected MCID estimates of COPD health status questionnaires. Patterns were observed for gender, age, spirometry classification, and comorbidity levels. These outcomes would advocate the need for tailored MCIDs.

Follow-up interviews from The Salford Lung Study (COPD) and analyses per treatment and exacerbations

The Salford Lung Study in chronic obstructive pulmonary disease (SLS COPD) was a 12-month, Phase III, open-label, randomised study comparing the effectiveness and safety of initiating once-daily fluticasone furoate 100 µg/vilanterol 25 µg (FF/VI) with continuing usual care (UC). Follow-up interviews were conducted among a subset of 400 patients who completed SLS COPD to further understand patients’ experiences with treatment outcomes and the impact of COPD, and potential risk factors associated with higher rates of exacerbations during SLS COPD. Another objective was to explore how such patient-centred outcomes differed by randomised treatment. Patients’ perceived control over COPD and effects on quality of life (QoL) were similar between treatment groups at the time of the follow-up interview, but more patients in the FF/VI group compared with UC reported perceived improvements in COPD control and QoL during the study. Of patients who experienced ≥2 exacerbations during SLS COPD, a greater percentage were women, were unemployed or homemakers, or were on long-term sick leave. Having ≥2 exacerbations also appeared to be associated with smoking, seeing a hospital specialist, a feeling of having no/little control over COPD, perceived worsening of feelings of control and reduced overall QoL since the start of the study, being aware of impending exacerbation occurrence and a more severe last exacerbation. Initiation of FF/VI was associated with a greater perceived improvement in patients’ control of their COPD and QoL throughout SLS COPD than continuation of UC. Suggestions that smoking status and feelings of control are potentially related to exacerbation require further investigation.

The Salford Lung Study was a 12-month trial during which patients were either given the drug fluticasone furoate/vilanterol (FF/VI) in addition to existing treatment or continued their usual medication. Henrik Svedsater at GlaxoSmithKline plc. UK and co-workers conducted follow-up interviews with 400 study participants to examine patient perceptions of trial outcomes, COPD management and disease treatments. Throughout the drug trial, patients given FF/VI were convinced that their control of COPD and quality of life improved. During the follow-up interviews both groups had similar perceptions of these two elements, but perceived improvement in COPD control was generally greater with FF/VI. Many participants felt that suffering multiple exacerbations was linked primarily to smoking and perceived worsening of control; this warrants further investigation.

The feasibility of early pulmonary rehabilitation and activity after COPD exacerbations: external pilot randomised controlled trial, qualitative case study and exploratory economic evaluation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) affects > 3 million people in the UK. Acute exacerbations of COPD (AECOPD) are the second most common reason for emergency hospital admission in the UK. Pulmonary rehabilitation is usual care for stable COPD but there is little evidence for early pulmonary rehabilitation (EPR) following AECOPD, either in hospital or immediately post discharge.

OBJECTIVE

To assess the feasibility of recruiting patients, collecting data and delivering EPR to patients with AECOPD to evaluate EPR compared with usual care.

DESIGN

Parallel-group, pilot 2 × 2 factorial randomised trial with nested qualitative research and an economic analysis.

SETTING

Two acute hospital NHS trusts. Recruitment was carried out from September 2015 to April 2016 and follow-up was completed in July 2016.

PARTICIPANTS

Eligible patients were those aged ≥ 35 years who were admitted with AECOPD, who were non-acidotic and who maintained their blood oxygen saturation level (SpO₂) within a prescribed range. Exclusions included the presence of comorbidities that affected the ability to undertake the interventions.

INTERVENTIONS

(1) Hospital EPR: muscle training delivered at the patient's hospital bed using a cycle ergometer and (2) home EPR: a pulmonary rehabilitation programme delivered in the patient's home. Both interventions were delivered by trained physiotherapists. Participants were allocated on a 1 : 1 : 1 : 1 ratio to (1) hospital EPR (n = 14), (2) home EPR (n = 15), (3) hospital EPR and home EPR (n = 14) and (4) control (n = 15). Outcome assessors were blind to treatment allocation; it was not possible to blind patients.

MAIN OUTCOME MEASURES

Feasibility of recruiting 76 participants in 7 months at two centres; intervention delivery; views on intervention/research acceptability; clinical outcomes including the 6-minute walk distance (6WMD); and costs. Semistructured interviews with participants (n = 27) and research health professionals (n = 11), optimisation assessments and an economic analysis were also undertaken.

RESULTS

Over 7 months 449 patients were screened, of whom most were not eligible for the trial or felt too ill/declined entry. In total, 58 participants (76%) of the target 76 participants were recruited to the trial. The primary clinical outcome (6MWD) was difficult to collect (hospital EPR, n = 5; home EPR, n = 6; hospital EPR and home EPR, n = 5; control, n = 5). Hospital EPR was difficult to deliver over 5 days because of patient discharge/staff availability, with 34.1% of the scheduled sessions delivered compared with 78.3% of the home EPR sessions. Serious adverse events were experienced by 26 participants (45%), none of which was related to the interventions. Interviewed participants generally found both interventions to be acceptable. Home EPR had a higher rate of acceptability, mainly because patients felt too unwell when in hospital to undergo hospital EPR. Physiotherapists generally found the interventions to be acceptable and valued them but found delivery difficult because of staffing issues. The health economic analysis results suggest that there would be value in conducting a larger trial to assess the cost-effectiveness of the hospital EPR and hospital EPR plus home EPR trial arms and collect more information to inform the hospital cost and quality-adjusted life-year parameters, which were shown to be key drivers of the model.

CONCLUSIONS

A full-scale randomised controlled trial using this protocol would not be feasible. Recruitment and delivery of the hospital EPR intervention was difficult. The data obtained can be used to design a full-scale trial of home EPR. Because of the small sample and large confidence intervals, this study should not be used to inform clinical practice.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18634494.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 11. See the NIHR Journals Library website for further project information.

Efficacy and safety of Xuebijing injection and its influence on immunomodulation in acute exacerbations of chronic obstructive pulmonary disease: study protocol for a randomized controlled trial

Background

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the leading cause of mortality in chronic obstructive pulmonary disease (COPD). Traditional Chinese medicine (TCM) has been widely used in Asia as an adjunct treatment for AECOPD to improve the patients’ symptoms. Xuebijing (XBJ) injection is one of the major herbal medicines used in TCM. Previous small-sample clinical trials have proven its efficacy and safety in the treatment of AECOPD; however, the current data on XBJ as an adjunct therapy are insufficient. The present study will be a multi-center randomized clinical trial (RCT) to evaluate the efficacy and safety of XBJ injection in AECOPD and explore its influence on the immune function based on the altered levels of T cells.

Methods

This study will be a prospective, randomized, placebo-controlled, blinded, multi-center trial. A total of 300 eligible patients will be randomly assigned to the treatment or placebo control group in a 1:1 ratio using a central randomization system. The treatment group will receive routine medication plus XBJ injection, and the control group will receive routine medication plus 0.9% NaCl injection. The patients will receive the corresponding treatment for 5 days starting within 24 h of enrollment. The primary outcome, the of rate endotracheal intubation, will be evaluated on day 28 after treatment. The secondary outcomes will include changes in immune and inflammatory indicators, respiratory support, mortality rate after 28 days, blood gas analysis, improvement in Acute physiology and chronic health evaluation (APACHE) II scores and clinical symptoms, and the length and cost of intensive care unit stay and hospitalization. The safety of the interventions will be assessed throughout the trial.

Discussion

This is the first and largest randomized, controlled, blinded trial that evaluates the efficacy of XBJ injection as adjuvant therapy for AECOPD. The results of this trial will provide valuable clinical evidence for recommendations on the management of the disease and identify the underlying mechanisms.

Trial registration

ClinicalTrials.gov, NCT02937974. Registered on 13 October 2016. Chinese clinical trial registry, ChiCTR-IPR-17011667. Registered on 15 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3204-z) contains supplementary material, which is available to authorized users.

Relative impact of COPD and comorbidities on generic health-related quality of life: a pooled analysis of the COSYCONET patient cohort and control subjects from the KORA and SHIP studies

Background

Health-related quality of life (HRQL) is an important patient-reported outcome measure used to describe the burden of chronic obstructive pulmonary disease (COPD) which is often accompanied by comorbid conditions.

Methods

Data from 2275 participants in the COPD cohort COSYCONET and from 4505 lung-healthy control subjects from the population-based KORA and SHIP studies were pooled. Main outcomes were the five dimensions of the generic EQ-5D-3 L questionnaire and two EQ-5D index scores using a tariff based on valuations from the general population and an experience-based tariff.

The association of COPD in GOLD grades 1–4 and of several comorbid conditions with the EQ-5D index scores was quantified by multiple linear regression models while adjusting for age, sex, education, body mass index (BMI), and smoking status.

Results

For all dimensions of the EQ-5D, the proportion of participants reporting problems was higher in the COPD group than in control subjects. COPD was associated with significant reductions in the EQ-5D index scores (-0.05 points for COPD grades 1/2, -0.09 for COPD grade 3, -0.18 for COPD grade 4 according to the preference-based utility tariff, all p < 0.0001). Adjusted mean index scores were 0.89 in control subjects and 0.85, 0.84, 0.81, and 0.72 in COPD grades 1-4 according to the preference-based utility tariff and 0.76, 0.71, 0.68, 0.64, and 0.58 for control subjects and COPD grades 1-4 for the experience-based tariff respectively. Comorbidities had additive negative effects on the index scores; the effect sizes for comorbidities were comparable to or smaller than the effects of COPD grade 3. No statistically significant interactions between COPD and comorbidities were observed. Score differences between COPD patients and control subjects were most pronounced in younger age groups.

Conclusions

Compared with control subjects, the considerable reduction of HRQL in patients with COPD was mainly due to respiratory limitations, but observed comorbidities added linearly to this effect. Younger COPD patients showed a greater loss of HRQL and may therefore be in specific need of comprehensive disease management.

Trial registration

NCT01245933