Bronchiectasis in older patients with chronic obstructive pulmonary disease : prevalence, diagnosis and therapeutic management

The prevalence of bronchiectasis in patients with alpha-1 antitrypsin deficiency: initial report of EARCO

BACKGROUND

Although bronchiectasis has been recognised as a feature of some patients with Alpha1-Antitrypsin deficiency the prevalence and characteristics are not widely known. We wished to determine the prevalence of bronchiectasis and patient characteristics. The first cohort of patients recruited to the EARCO (European Alpha1 Research Collaboration) International Registry data base by the end of 2021 was analysed for radiological evidence of both emphysema and bronchiectasis as well as baseline demographic features.

RESULTS

Of the first 505 patients with the PiZZ genotype entered into the data base 418 (82.8%) had a reported CT scan. There were 77 (18.4%) with a normal scan and 38 (9.1%) with bronchiectasis alone. These 2 groups were predominantly female never smokers and had lung function in the normal range. The remaining 303 (72.5%) ZZ patients all had emphysema on the scan and 113 (27%) had additional evidence of bronchiectasis.

CONCLUSIONS

The data indicates the bronchiectasis alone is a feature of 9.1% of patients with the PiZZ genotype of Alpha1-antitrypsin deficiency but although emphysema is the dominant lung pathology bronchiectasis is also present in 27% of emphysema cases and may require a different treatment strategy.

Respiratory manifestations of Marfan syndrome: a narrative review

Objective

The prevalence of Marfan syndrome (MFS) is estimated to be 1 in 10,000 to 15,000 individuals, but the phenotype of MFS may not be apparent and hence its diagnosis may not be considered by clinicians. Furthermore, the effects of MFS on the lungs and breathing are underrecognized despite the high morbidity that can occur. The objective of this Narrative Review is to delineate the molecular consequences of a defective fibrillin-1 protein and the skeletal and lung abnormalities in MFS that may contribute to respiratory compromise. It is important for clinicians to be cognizant of these MFS-associated respiratory conditions, and a contemporaneous review is needed.

Background

MFS is an autosomal dominant, connective tissue disorder caused by mutations in the FIBRILLIN-1 (FBN1) gene, resulting in abnormal elastic fibers as well as increased tissue availability of transforming growth factor-beta (TGFβ), both of which lead to the protean clinical abnormalities. While these clinical characteristics are most often recognized in the cardiovascular, skeletal, and ocular systems, MFS may also cause significant impairment on the lungs and breathing.

Methods

We searched PubMed for the key words of “Marfan syndrome,” “pectus excavatum,” and “scoliosis” with that of “lung disease,” “breathing”, or “respiratory disease.” The bibliographies of identified articles were further searched for relevant articles not previously identified. Each relevant article was reviewed by one or more of the authors and a narrative review was composed.

Conclusions

Though the classic manifestations of MFS are cardiovascular, skeletal, and ocular, FBN1 gene mutation can induce a variety of effects on the respiratory system, inducing substantial morbidity and potentially increased mortality. These respiratory effects may include chest wall and spinal deformities, emphysema, pneumothorax, sleep apnea, and potentially increased incidence of asthma, bronchiectasis, and interstitial lung disease. Further research into approaches to prevent respiratory complications is needed, but improved recognition of the respiratory complications of MFS is necessary before this research is likely to occur.

Relationship between the presence of bronchiectasis and acute exacerbation in Thai COPD patients

Background

The prevalence rate of bronchiectasis in COPD is variable. Coexisting bronchiectasis and COPD may influence COPD severity and exacerbation.

Objective

We investigated whether bronchiectasis is associated with frequent or severe COPD exacerbation. Lower airway bacterial and mycobacterial infections are a possible mechanism for bronchiectasis.

Materials and methods

A cross-sectional study was conducted in 2013–2014. COPD exacerbations and hospitalizations were reviewed. Spirometry and CT were performed. COPD symptoms were assessed by using the COPD assessment test (CAT) and modified Medical Research Council (mMRC) dyspnea scale. Sputum inductions were performed and specimens were sent for microbiology.

Results

We recruited 72 patients. Global Initiative for Chronic Obstructive Lung Disease (GOLD) A, B, C, and D, were noted in 20%, 27.1%, 14.3%, and 38.6% of the patients, respectively. Frequent exacerbations (≥2) and/or ≥1 hospitalization in the previous year were observed in 40.3% of patients. Median mMRC of COPD with frequent and non-frequent exacerbations was 1.0 (range 1–2) and 2.0 (range 1–3), (p=0.002), respectively. Median CAT of COPD with frequent and non-frequent exacerbations was 20.5 (3–37) and 11.0 (2–32), (p=0.004), respectively. CT-detected bronchiectasis was observed in 47.2% of patients. Median mMRC of COPD with and without bronchiectasis was 1.0 (0–4) and 1.0 (0–4) (p=0.22), respectively. Median CAT of COPD with and without bronchiectasis was 16.2 (95% CI: 12.9–19.6) and 13.0 (3–37), (p=0.49), respectively. The lower post-bronchodilator forced expiratory volume in 1 second (FEV₁) of COPD with frequent exacerbations than those without was noted (p=0.007). The post-bronchodilator forced expiratory volume at 1 second percent in patients with and without bronchiectasis was not different (p=0.91). After adjusting for gender, severity of airflow obstruction, severity of COPD symptoms, the odds ratio for bronchiectasis with frequent and/or severe exacerbation was 4.99 (95% CI: 1.31–18.94), (p=0.018). Neither bacterial nor mycobacterial airway infection was associated with bronchiectasis or frequent exacerbation.

Conclusions

Bronchiectasis is common in Thai COPD. It was associated with frequent exacerbation or hospitalization. Mycobacterial tuberculosis in COPD patients with bronchiectasis was uncommon.

An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

[Inhaled colistin in elderly patients with non-cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa bronchial infection]

BACKGROUND

Bronchiectasis is a frequent cause of admission for elderly patients and chronic respiratory diseases. Although some guidelines recommend long-term treatment with inhaled antibiotics in non-cystic fibrosis bronchiectasis with chronic Pseudomonas aeruginosa (P. aeruginosa) infection, there is limited evidence supporting these prolonged antibiotic treatments in this population. The aim of this study was to assess the effectiveness of inhaled colistin in elderly patients with bronchiectasis and chronic bronchial P. aeruginosa infection in reducing hospital readmissions.

MATERIAL AND METHODS

A prospective, controlled and open label study was conducted on patients with bronchiectasis diagnosed by computed tomography and persistence of P. aeruginosa in sputum after appropriate antimicrobial therapy. All patients received education, and physiotherapy training. The intervention group also received nebulized colistin 1 million IU twice a day for one year. Data were collected on the demographics, clinical and functional characteristics, admissions in previous year, and sputum microbiology. Patients were followed up every two months for one year, with readmissions, microbiological results, functional tests, and deaths being evaluated.

RESULTS

The study included 39 patients, of whom 20 received nebulized colistin and 19 conventional therapy. There were no differences between the two groups in baseline clinical and functional characteristics or previous hospital stay. The mean age was 77.7+/-5, Charlson index 2.85, and FEV1% 41.3+/-15. Five patients (25%) stopped the nebulized treatment because of adverse effects. P. aeruginosa was eradicated in 45% of the colistin treated patients, and in only one of the control group (statistically significant), but at the end of the study year, there were no differences in the number of hospital admissions (control group 1.6+/-1.7 and 2.7+/-3 colistin group), or days of stay (19+/-31 and 23+/-20). There were no differences in lung function or clinical symptoms between the two groups No significant changes were observed in P. aeruginosa A antibiotic sensitivity or in sputum flora.

CONCLUSIONS

More patients in the treatment group achieved Pseudomonas eradication, but benefits in clinical symptoms, lung function or use of healthcare resources in our elderly patients, could not be demonstrated. Adverse effects were common. Further studies are needed in order to identify factors associated with response, or subgroups of patients with bronchiectasis and chronic infection with P. aeruginosa, who benefit from (expensive) long term treatments with inhaled antibiotics.