Comorbidities and Systemic Effects of Chronic Obstructive Pulmonary Disease

Inflammation as the nexus: exploring the link between acute myocardial infarction and chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), particularly following acute exacerbations (AE-COPD), significantly heightens the risks and mortality associated with acute myocardial infarction (AMI). The intersection of COPD and AMI is characterised by a considerable overlap in inflammatory mechanisms, which play a crucial role in the development of both conditions. Although extensive research has been conducted on individual inflammatory pathways in AMI and COPD, the understanding of thrombo-inflammatory crosstalk in comorbid settings remains limited. The effectiveness of various inflammatory components in reducing AMI infarct size or slowing COPD progression has shown promise, yet their efficacy in the context of comorbidity with COPD and AMI is not established. This review focuses on the critical importance of both local and systemic inflammation, highlighting it as a key pathophysiological connection between AMI and COPD/AE-COPD.

Tongxinluo enhances the effect of atorvastatin on the treatment of atherosclerosis with chronic obstructive pulmonary disease by maintaining the pulmonary microvascular barrier

Atherosclerosis (AS) is a common comorbidity of chronic obstructive pulmonary disease (COPD), and systemic inflammation is an important mechanism of COPD with AS. Tongxinluo (TXL) improves the function of vascular endothelial cells. We aimed to prove that impairment of pulmonary microvascular barrier function is involved in COPD-mediated aggravation of AS and investigate whether TXL enhances the effect of Ato (atorvastatin) on COPD with AS by protecting pulmonary microvascular endothelial barrier function. In vivo, a COPD with atherosclerotic apolipoprotein E knockout (AS ApoE^-/-) mouse model was established by cigarette smoke combined with a high-fat diet. The animals were administered TXL, Ato, and TXL + Ato once a day for 20 weeks. Lung function, lung microvascular permeability, lung inflammation, systemic inflammation, serum lipid levels, atheromatous plaque formation, and endothelial damage biomarkers were measured. In vitro, human pulmonary microvascular endothelial cells (HPMECs) were pretreated with TXL and incubated with cigarette smoke extract to establish the model. The permeability of the endothelial monolayer, inflammatory cytokines, endothelial damage biomarkers, and tight junction (Tj) proteins were determined. Cigarette smoking significantly exacerbated the high-fat diet-induced pulmonary function decline, pulmonary microvascular endothelial barrier dysfunction, inflammation, and atherosclerotic plaques. These changes were reversed by TXL-Ato; the combination was more effective than Ato alone. Furthermore, TXL protected the HPMEC barrier and inhibited inflammation in HPMECs. COPD aggravates AS, possibly through the destruction of pulmonary microvascular barrier function; thus, lung inflammation triggers systemic inflammation. In treating COPD with AS, TXL enhances the antiatherosclerotic effect of Ato, protecting the pulmonary microvascular barrier.

Anabolic-androgenic steroids for patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

Background

Testosterone deficiency is common in chronic obstructive pulmonary disease (COPD) patients. There has been a growing interest in the potential use of anabolic-androgenic steroids (AASs) in patients with COPD recently. However, whether AASs could improve their clinical outcomes remains unknown.

Methods

In order to explore the efficacy of AASs in patients with COPD, systematic search of MEDLINE, Embase, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials (RCTs) of AASs for COPD published before March 17, 2022 was performed.

Results

Data were extracted from 8 articles involving 520 participants. The median number of participants per study was 39.5 and the mean follow up was 14.2 weeks. As compared to the control group, AASs therapy could significantly improve body weight (weighted mean difference (WMD), 1.38 kg; 95% CI, 0.79 to 1.97 kg), fat-free mass (WMD, 1.56 kg; 95% CI, 0.94 to 2.18 kg) and peak workload (WMD, 6.89W; 95% CI, 3.97 to 9.81W) of COPD patients, but no improvements in spirometry indicators and six-minute walking distances (WMD, 16.88 m; 95%, −3.27 to 37.04 m). Based on the available research data, it is uncertain whether AASs treatment could improve the quality of life of COPD patients.

Conclusions

Limited published evidence indicates that AASs therapy provides clinical benefits in patients with COPD. However, longer and larger studies are needed to better clarify the efficacy of AASs and draw final conclusions.

The Six-Minute Stepper Test Is Valid to Evaluate Functional Capacity in Hospitalized Patients With Exacerbated COPD

Background: The six-minute stepper test (6MST) is a self-paced test considered a valid tool to assess functional capacity in stable COPD patients. However, a high floor effect, where a large proportion of participants reach the minimum score when using the measurement instrument, might compromise the test validity in the hospital setting. Therefore, this study aimed at verifying the concurrent validity of 6MST in hospitalized patients with acute exacerbation of COPD (AECOPD).

Methods: A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD were considered for inclusion. On the first day, when patients reached minimum clinical criteria considered as the use of non-invasive ventilation less than 2 h for 6 h/period, dyspnea at rest less than 7 (very severe) on the modified Borg scale, a respiratory rate less than 25 breaths per minute, oxygen pulse saturation greater than 88% (considering use of supplemental oxygen) and absence of paradoxical breathing pattern, they underwent a lung function evaluation and answered three questionnaires: Chronic Respiratory Questionnaire (CRQ), Modified Medical Research Council Dyspnea Scale (MMRC), and COPD Assessment Test (CAT). Then, on two consecutive days, patients performed 6MST or six-minute walk test (6MWT), in random order. Each test was performed twice, and the best performance was recorded. Also, the patient’s severity was classified according to the BODE index. Inspiratory capacity measurements were performed before and after each test execution.

Results: Sixteen patients (69.4 ± 11.4 years) with a mean FEV₁ of 49.4 ± 9.9% predicted were included (9 females). There was a strong correlation of the performance in 6MST (number of cycles) with 6MWT (distance walked in meters) in absolute values (r = 0.87, p < 0.001) as well as with the percentage of predicted normal 6MWT (r = 0.86, p < 0.001). There was a strong correlation between the performance in 6MST with the dynamic hyperinflation (r = 0.72, p = 0.002) and a moderate correlation between 6MST with the percentage of reduction of inspiratory capacity (r = 0.68, p = 0.004). We also identified that 6MST showed moderate negative correlations with CAT (r = −0.62, p = 0.01) and BODE index (r = −0.59, p = 0.01).

Conclusion: It could be concluded that 6MST is valid for evaluating functional capacity in hospitalized patients with exacerbated COPD.

The alterations of retinal vasculature detected on optical coherence tomography angiography associated with chronic obstructive pulmonary disease

OBJECTIVES

This study aimed to evaluate the retinal vasculature of the macula and optic disc in patients with chronic obstructive pulmonary disease (COPD) by optical coherence tomography angiography (OCTA).

METHODS

The right eyes of 70 COPD patients and 71 healthy individuals were evaluated. These patients had moderate airflow limitation and mean PO2 of 60 mmHg, and their average age was less than 60 years. Superficial and deep capillary plexus vascular densities, foveal avascular zone (FAZ) width, and optic disc parameters were measured with OCTA. In addition, the correlation between the PO2 level in COPD patients and superficial, deep, and peripapillary vascular densities and FAZ was examined in the study.

RESULTS

The COPD group had a significant decrease in the vascular density in the superficial (fovea [p = 0.019]; parafovea [p = 0.013]; and perifovea [p = 0.001]) and deep capillary plexus (fovea [p = 0.028]; parafovea [p = 0.005]; and perifovea [p = 0.002]). Also, the enlargement of the FAZ (p = 0.002) and a decrease in the peripapillary vascular density (p = 0.006) were observed in the COPD group. There was a positive correlation between PO2 level and superficial, deep, and peripapillary vascular densities in COPD patients and a negative correlation with FAZ (r = 0.559-0.900).

CONCLUSION

Hypercapnia, respiratory acidosis, and chronic hypoxia associated with COPD may affect the macula and optic nerve, resulting in a serious decrease in vascular density, and OCTA can be a very important tool in the follow-up and treatment of these patients.

Evaluation of Nutritional Status in Hospitalized Chronic Obstructive Pulmonary Disease Patients and Can C-reactive Protein-to-Albumin Ratio Be Used in the Nutritional Risk Assessment in These Patients

Background

Malnutrition is common in patients diagnosed with chronic obstructive pulmonary disease (COPD). CRP/albumin ratio (CAR) can be used as a parameter to evaluate the inflammatory process and nutritional status together. The aim of this study was to make a general evaluation of the nutritional status of hospitalized patients with COPD and to investigate whether CAR can predict nutritional status in these patients.

Methods

Patients who were hospitalized with COPD who were consulted to the nutrition department were included in the study. The patients' Nutritional Risk Score-2002 (NRS), demographic data, diagnoses, body mass indexes (BMI), nutritional support applied to the patients were recorded. CRP, Albumin, and CAR values of the patients were determined. Patients recommended nutritional follow-up, total parenteral nutrition (TPN) or enteral nutrition (EN) initiated, and oral nutritional supplement (ONS) support were identified.

Results

A total of 393 patients with COPD were analyzed. 88.55% of the patients were in the NRS ≥ 3 risk group. TPN treatment was started in 10.2% of the patients, EN in 10.9%, ONS in 76.3%, and nutritional follow-up was recommended in 2.5% of the patients. While albumin level was lower in patients with NRS ≥ 3, CRP and CAR were higher in patients with NRS ≥ 3 (p < 0.05). There was a negative correlation between NRS-2002 and albumin (p < 0.001). A positive correlation was observed between NRS-2002 and CRP and CAR (p < 0.001). Age and CAR were found to be effective in predicting those with NRS-2002 ≥ 3. The cut-off value for CAR was accepted as 3.26.

Conclusions

The need for nutritional support is high in patients hospitalized with COPD. It is important to evaluate nutritional support needs in these patients, regardless of NRS-2002 and BMI. In this respect, the clinician's observation and the decision are as valuable as the scoring that determines malnutrition. We think that the cut-off value of 3.26 determined for CAR can be used in the nutritional risk assessment in patients with COPD.

Retinal Vascular Changes in Patients with Chronic Obstructive Pulmonary Disease: An Optical Coherence Tomography Angiography Study

Objectives:

In the current study, we aimed to investigate retinal vascular density and blood flow changes in patients with chronic obstructive pulmonary disease (COPD) using optical coherence tomography angiography (OCTA) (AngioVue Avanti, Optovue).

Methods:

Thirty eyes of 30 patients with COPD and 30 eyes of 30 healthy controls were evaluated with OCTA. Foveal and parafoveal vessel density, inner retinal and choriocapillary flow area, and foveal avascular zone (FAZ) area were measured and compared between the groups.

Results:

No statistically significant differences were observed in the outer retinal flow area and choriocapillary flow area measurements between the groups (p=0.609 and p=0.162, respectively). There was no statistically significant difference in FAZ and FAZ perimeter values between the groups (p=0.725 and p=0.820, respectively). Vascular density measurements in the superficial foveal and parafoveal areas were not statistically significantly different between the groups (p>0.05, for all). Deep parafoveal vascular density values of the COPD group were statistically significantly lower than the control group in all investigated areas except the superior and inferior quadrants.

Conclusion:

The results of our study demonstrated for the first time that vascular density decreased in the parafoveal area due to COPD-related hypoxemia and endothelial dysfunction.

Impact of Exercise Capacity Upon Respiratory Functions, Perception of Dyspnea, and Quality of Life in Patients with Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is associated with a high prevalence of morbidity and mortality worldwide. We investigated the effects of exercise capacity upon respiratory functions, perception of dyspnea, and quality of life (QoL) in patients with COPD.

Methods

A total of 512 COPD patients formed the study cohort. They were divided into four subgroups according to the distance walked in the 6-minute walking test (6MWT). We compared respiratory functions, perception of dyspnea, and QoL between groups.

Results

Patients who walked >350 m had significantly better disease-specific QoL scores (p < 0.001) than those of other groups. A negative correlation was found between the walking distance and anxiety, depression, and dyspnea scores (p < 0.001).

Conclusions

In patients who walked <350 m, the reduced walking distance adversely affected respiratory functions, psychological symptoms, and QoL.

Psychometric Properties of Patient-Reported Outcome Measures Assessing Self-Efficacy in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Systematic Review

This systematic review aimed to synthesize the evidence of the psychometric properties of self-efficacy patient-reported outcome measures (PROMs) in patients with chronic obstructive pulmonary disease (COPD). We conducted a systematic search of MEDLINE and other common databases from inception until September 2020. Studies that reported psychometric properties of self-efficacy outcome measures in COPD patients were included. We used the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 2018 guidelines for data extraction and evidence synthesis. Eighteen studies that assessed nine self-efficacy PROMs were eligible for inclusion. The assessment of structural validity indicated sufficient results rating for the Exercise Self-Regulatory Efficacy Scale and the Self-Care-Self-Efficacy Scale, and insufficient rating for the COPD Self-Efficacy Scale and the Pulmonary Rehabilitation Adaptation Index for Self-Efficacy (PRAISE). Construct validity measures displayed sufficient results rating with correlations ranging from -0.48 to - 0.71 between self-efficacy PROMs and other PROMs such as St. George's Respiratory Questionnaire, Hospital Anxiety and Depression Scale and Chronic Respiratory Questionnaire. Internal consistency measures indicated sufficient rating for all self-efficacy PROMs with a Cronbach's alpha range of 0.71 - 0.98. Responsiveness was assessed for the PRAISE with an overall sufficient rating (effect sizes of 0.21 - 0.37). The evidence regarding the psychometric properties of self-efficacy PROMs in COPD is variable. The PRAISE is responsive to changes in self-efficacy in COPD patients attending a pulmonary rehabilitation program. When using self-efficacy PROMs in clinical practice or research, clinicians and researchers should consider the psychometric properties and choose the appropriate outcome measure based on the purpose.

Frailty in Korean patients with chronic obstructive pulmonary disease, using data from the Korea National Health and Nutrition Examination Survey, 2015 and 2016

AIM

To describe frailty, to identify its determinants, and to examine how it affected functioning in Korean patients with chronic obstructive pulmonary disease (COPD). This analysis was based on datasets from the Korea National Health and Nutrition Examination Survey (KNHANES).

BACKGROUND

Most of what is known about the prevalence and determinants of frailty in patients with COPD has come from countries other than Korea. Examining this issue with a representative sample of COPD patients in Korea will shed light on frailty in this population.

METHODS

This cross-sectional study, a secondary data analysis, used datasets from the KNHANES VI (2015) and VII (2016) to understand frailty in 417 patients with COPD (mean age = 65.36; FEV1%predicted value = 78.91). Demographic and clinical data, symptoms, self-rated health, frailty, and functioning were collected in health interviews and health examinations. Descriptive and inferential statistics were used to analyze the data.

RESULTS

One hundred forty-eight participants (35.5%) were frail, 156 (37.4%) were pre-frail, and 113 (27.1%) exhibited no frailty. Multivariate logistic regression showed that self-rated health, stage of COPD based on the Global Initiative for Chronic Obstructive Lung Disease, pain/discomfort, and arthritis were significant predictors of frailty. Multivariate logistic regression also showed that frail participants were more likely to experience limitations in usual activities, after controlling for other covariates.

CONCLUSION

Health care providers who know the determinants of frailty and its relationship with poor functioning will be better prepared to identify at-risk patients with COPD who might benefit from pulmonary rehabilitation.

Cigarette Smoking Is Associated With Lower Quadriceps Cross-sectional Area and Attenuation in Older Adults

INTRODUCTION

In addition to well-established links with cardiovascular and respiratory diseases, cigarette smoking may affect skeletal muscle; however, associations with quadriceps atrophy, density, and function are unknown. This study explored the associations of current and former smoking with quadriceps muscle area and attenuation as well as muscle force (assessed as knee extension peak torque) and rate of torque development-a measure of muscle power in older adults.

METHODS

Data from 4469 older adults, aged 66-95 years at baseline in the Age, Gene/Environment Susceptibility-Reykjavik Study with measurements of thigh computed tomography, isometric knee extension testing, self-reported smoking history, and potential covariates were analyzed.

RESULTS

Sex differences were observed in these data; therefore, our final analyses are stratified by sex. In men, both former smokers and current smokers had lower muscle area (with β= -0.10, 95% confidence interval [CI] = -0.17 to -0.03 and β = -0.19, 95% CI = -0.33 to -0.05, respectively) and lower muscle attenuation (ie, higher fat infiltration, β = -0.08, 95% CI = -0.16 to -0.01 and β = -0.17, 95% CI = -0.34 to -0.01, respectively) when compared with never smokers. Smoking status was not associated with male peak torque or rate of torque development. In women, current smoking was associated with lower muscle attenuation (β = -0.24, 95% CI = -0.34 to -0.13) compared to never smoking. Among female smokers (current and former), muscle attenuation and peak torque were lower with increasing pack-years.

CONCLUSIONS

Results suggest that cigarette smoking is related to multiple muscle properties at older age and that these relationships may be different among men and women.

IMPLICATIONS

This article presents novel data, as it examined for the first time the relationship between smoking and computed tomography-derived quadriceps muscle size (cross-sectional area) and attenuation. This study suggests that current cigarette smoking is related to higher muscle fat infiltration, which may have significant health implications for the older population, because of its known association with poor physical function, falls, and hip fractures.

[3-years outcome of follow-up of patients with chronic obstructive pulmonary disease successfully treated by percutaneous coronary intervention due to acute coronary syndrome]

Aim To evaluate results of three-year follow-up in patients after acute coronary syndrome (ACS) associated with chronic obstructive pulmonary disease (COPD) and to identify predictors for delayed serious cardiovascular adverse (SCVAE) events.Material and methods This prospective cohort study included 119 patients with verified COPD who had ACS after a successful urgent percutaneous coronary intervention and were discharged from the hospital without in-hospital complications. Incidence of and time to SCVAE (cardiovascular death, myocardial infarction, stroke, repeated unscheduled myocardial revascularization) were recorded. SCVAE predictors were identified with the Cox regression by stepwise inclusion of variables into the model.Results SCVAE occurred in 33.6 % of ACS patients with COPD. The high rate of repeated myocardial revascularization mostly contributed to the development of delayed SCVAEs (19.3 % of patients). Independent predictors of SCVAE included the total number of stenoses in major coronary artery branches; ankle-brachial index; glomerular filtration rate calculated with the CKD-EPI equation; frequent COPD exacerbations; functional residual capacity of the lungs; and 6-min walk distance.Conclusion New independent predictors of SCVAE were identified in COPD patients after ACS with percutaneous coronary intervention and stenting, including distance in the 6-min walk test, frequent COPD exacerbations, and functional residual volume of the lungs as an index of pulmonary hyperinflation.

Exercise & Sports Science Australia (ESSA) position statement on exercise and chronic obstructive pulmonary disease

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) results in airflow obstruction and a marked reduction in exercise capacity and health-related quality of life (HRQoL). Affecting over 1 in four Australians aged over 75 years, COPD remains one of the major causes of disability and death in the world. To date there have been over 80 randomised controlled trials examining the role of exercise training in a range of settings for individuals with COPD. This review will synthesise existing literature and provide health practitioners with broad evidence-based guidelines for exercise-training in this growing population.

DESIGN

Position stand.

METHODS

Synthesis of randomised controlled trials of exercise training and of existing guidelines for exercise in COPD. Systematic reviews of alternative modes of exercise training will also be reviewed.

RESULTS

There is convincing evidence that in adults with COPD, exercise-training improves exercise capacity, decreases symptoms such as dyspnoea and fatigue, and improves HRQoL. There is emerging evidence in this population that alternative modes of exercise training such as high intensity interval training (HIIT), aquatic based therapy, tai chi and neuromuscular electrical stimulation improve exercise outcomes when compared to no exercise.

CONCLUSIONS

For individuals with COPD, an exercise program of aerobic and strength exercises delivered over at least an 8-week period, that engages lower and upper body skeletal muscles, will deliver significant health improvements. Programs should be individualised, take into consideration relevant co-morbid conditions and be delivered appropriately qualified health practitioners experienced in clinical exercise prescription.

Low Muscle Mass Is a Predictor of Malnutrition and Prolonged Hospital Stay in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Longitudinal Study

BACKGROUND

Malnutrition in chronic obstructive pulmonary disease (COPD) patients is more prevalent during times of exacerbation. Fat-free mass index (FFMI), calf circumference (CC), and adductor muscle pollicis thickness (AMPT) can be used to identify reduced muscle mass and have been found to be good predictors of clinical outcomes in other conditions, but they have not been investigated in COPD. Therefore, this study evaluated low muscle mass as predictor of malnutrition, prolonged length of stay (LOS), and in-hospital death in COPD patients.

METHODS

This prospective cohort study was carried out in hospitalized patients with COPD exacerbation. Malnutrition diagnosis was performed by Subjective Global Assessment, and muscle mass was assessed by FFMI, calculated using fat-free mass from bioelectrical impedance, CC, and AMPT. Clinical outcomes (LOS and in-hospital death) were collected from records.

RESULTS

One hundred seventy-six patients were included (68.2 ± 10.4 years old, 56.2% women); 74.2% were classified as Global Initiative of Chronic Obstructive Lung Disease 2 or 3 and 58.2% as malnourished. The median LOS was 11 (7-19) days, and the incidence of death was 9.1%. Low FFMI and CC predicted malnutrition (low CC: odds ratio [OR], 4.6; 95% CI, 2.2-9.7 and low FFMI: OR, 8.8; 95% CI, 3.7-20.8) and were associated with prolonged LOS (low CC: OR, 2.3; 95% CI, 1.1-4.6 and low FFMI: OR, 2.5; 95% CI, 1.3-4.8).

CONCLUSION

Simple, inexpensive, and noninvasive parameters of muscle mass-FFMI and CC-are good predictors of malnutrition and prolonged LOS in COPD patients experiencing exacerbation.

Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far.

OBJECTIVES

In people with COPD, which interventions are effective at improving objectively-assessed physical activity?

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies.

SELECTION CRITERIA

We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data.

MAIN RESULTS

We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta2-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training.

AUTHORS' CONCLUSIONS

A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.

Chemerin: A Potential Regulator of Inflammation and Metabolism for Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation

Chronic obstructive pulmonary disease (COPD) features chronic inflammatory reactions of both intra- and extrapulmonary nature. Moreover, COPD is associated with abnormal glucose and lipid metabolism in patients, which influences the prognosis and chronicity of this disease. Abnormal glucose and lipid metabolism are also closely related to inflammation processes. Further insights into the interactions of inflammation and glucose and lipid metabolism might therefore inspire novel therapeutic interventions to promote lung rehabilitation. Chemerin, as a recently discovered adipokine, has been shown to play a role in inflammatory response and glucose and lipid metabolism in many diseases (including COPD). Chemerin recruits inflammatory cells to sites of inflammation during the early stages of COPD, leading to endothelial barrier dysfunction, early vascular remodeling, and angiogenesis. Moreover, it supports the recruitment of antigen-presenting cells that guide immune cells as part of the body's inflammatory responses. Chemerin also regulates metabolism via activation of its cognate receptors. Glucose homeostasis is affected via effects on insulin secretion and sensitivity, and lipid metabolism is changed by increased transformation of preadipocytes to mature adipocytes through chemerin-binding receptors. Controlling chemerin signaling may be a promising approach to improve various aspects of COPD-related dysfunction. Importantly, several studies indicate that chemerin expression in vivo is influenced by exercise. Although available evidence is still limited, therapeutic alterations of chemerin activity may be a promising target of therapeutic approaches aimed at the rehabilitation of COPD patients based on exercises. In conclusion, chemerin plays an essential role in COPD, especially in the inflammatory responses and metabolism, and has a potential to become a target for, and a biomarker of, curative mechanisms underlying exercise-mediated lung rehabilitation.

An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.

Association of bone mineral density with lung function in a Chinese general population: the Xinxiang rural cohort study

Background

Bone mineral density (BMD) has been positively associated with lung function in patients diagnosed with respiratory diseases such as chronic obstructive pulmonary disease (COPD) and cystic fibrosis. However, the relationship between BMD and lung function is inconsistent in the general population.

Methods

To investigate the association between BMD and lung function in a Chinese general population, a total of 1024 adults aged 40–70 years old from Qiliying (an industrial polluted exposure area) and Langgongmiao (the reference area with non-industrial pollution) were recruited and underwent BMD and spirometry tests.

Results

Both BMD and lung function levels were lower in the exposed area compared to the reference area. In addition, BMD and lung function levels were also lower in females compared to males. Both Spearman and partial correlation analyses showed that BMD was positively correlated with FVC and FEV₁. After adjusting linear regression analyses for potential confounding factors, every 0.1 g/cm² drop in BMD was associated with 53.0 mL decrease in FVC and 33.5 mL decrease in FEV₁.

Conclusions

A reduction of BMD is associated with lower lung function in a general population from China.

A Low Lean-to-Fat Ratio Reduces the Risk of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Patients with a Normal or Low Body Mass Index

Background

Increased risk of acute exacerbation of chronic obstructive pulmonary disease (COPD) has been reported in patients who are overweight and obese. However, the effects of body fat in patients with normal or low body mass index (BMI) and COPD remain unknown. This study aimed to examine the association between acute exacerbations of COPD and the lean-to-fat (LTF) ratio in patients with a normal or low BMI.

Material/Methods

Patients with COPD (n=68) underwent assessment of body composition, in whom 43 cases had a normal BMI (18.5 to 25 kg/m²) and 14 cases were underweight (<18.5 kg/m²). Patients with COPD were treated according to current clinical guidelines and underwent regular follow-up for one year. Acute exacerbations of COPD were recorded.

Results

BMI, the fat-free mass index (FFMI), skeletal muscle mass index (SMMI), and LTF ratio had no significant effect of the risk of acute exacerbations of COPD in the whole study cohort, but a low LTF ratio was significantly associated with reduced risk of acute exacerbations of COPD in the subgroup with a BMI<25 kg/m² (OR=4.528; P<0.05). The Fat Mass Index (FMI) had a protective effect in the whole cohort (OR=0.292; P=0.024) and in the subgroup with BMI <25 kg/m² (OR=0.253, P=0.049). The cumulative incidence of acute exacerbations of COPD was significantly increased in the patients with a high LTF ratio in the whole cohort (P=0.047) and in the subgroup with BMI <25 kg/m² (P=0.014).

Conclusions

In patients with BMI <25 kg/m², the LTF ratio was positively correlated with the risk of occurrence of acute exacerbations of COPD.

Determinants of frailty in primary care patients with COPD: the Greek UNLOCK study

Background

Frailty is a state of increased vulnerability that has a significant risk of unfavorable outcomes such as increased dependency and/or death, but little is known about frailty in people with chronic obstructive pulmonary disease (COPD).

Method

We aimed to determine the prevalence of frailty in COPD patients and to identify the associated risk factors. Two hundred fifty-seven COPD patients enrolled from primary care in Greece between 2015 and 2016. Physicians used structured interviews to collect cross-sectional data including demographics, medical history, symptoms and COPD Assessment Tool (CAT) or modified Medical Research Council Dyspnea scale (mMRC) score. Patients were classified into severity groups according to GOLD 2017 guidelines. Participants completed the The Frail Non-Disabled (FiND) questionnaire, exploring the frailty and disability domains. In the present analyses, frail patients with and without mobility disability were pooled and were compared to non-frail patients. Factors associated with frailty were analyzed using univariate and multivariate logistic regression.

Results

Mean (SD) age was 65 (12.3) with 79% males. The majority of patients suffered with frailty (82%) of which 76.8% had mobility disability. 84.2% were married/with partner and 55.4% retired. 55.6% were current smokers. Uncontrolled disease (≥10 CAT score) was reported in 91.1% and 37.2% of patients had ≥2 exacerbations in the past year. Dyspnea (38%) and cough (53.4%) were the main symptoms. Main comorbidities were hypertension (72.9%), hyperlipidaemia (24.6%) and diabetes (11%).

Risk of frailty was significantly increased with age (OR; 95%CI: 1.05; 1.02–1.08), hypertension (2.25; 1.14–4.45), uncontrolled disease (≥10 CAT score 4.65; 1.86–11.63, ≥2 mMRC score 5.75 (2.79–11.85) or ≥ 2 exacerbations 1.73; 1.07–2.78), smoking cessation (ex compared to current smokers: 2.37; 1.10–5.28) and GOLD status (B&D compared to A&C groups: CAT-based 4.65; 1.86–11.63; mMRC-based: 5.75; 2.79–11.85). In multivariate regression smoking cessation and GOLD status remained significant. Gender, body mass index, occupational or marital status, symptoms and other comorbidities were not significant.

Conclusions

Frailty with mobility disability is common in COPD patients and severity of disease increases the risk. It is possible that frail patients are more likely to quit smoking perhaps because of their disability and uncontolled disease. Routine assessment of frailty in addition to COPD control may allow early interventions for preventing or delaying progression of frailty and improvement in COPD disease.

Comparison of Diaphragmatic Stretch Technique and Manual Diaphragm Release Technique on Diaphragmatic Excursion in Chronic Obstructive Pulmonary Disease: A Randomized Crossover Trial

Background

Chronic Obstructive Pulmonary Disease (COPD) impairs the function of the diaphragm by placing it at a mechanical disadvantage, shortening its operating length and changing the mechanical linkage between its various parts. This makes the diaphragm's contraction less effective in raising and expanding the lower rib cage, thereby increasing the work of breathing and reducing the functional capacity.

Aim of the Study

To compare the effects of diaphragmatic stretch and manual diaphragm release technique on diaphragmatic excursion in patients with COPD.

Materials and Methods

This randomised crossover trial included 20 clinically stable patients with mild and moderate COPD classified according to the GOLD criteria. The patients were allocated to group A or group B by block randomization done by primary investigator. The information about the technique was concealed in a sealed opaque envelope and revealed to the patients only after allocation of groups. After taking the demographic data and baseline values of the outcome measures (diaphragm mobility by ultrasonography performed by an experienced radiologist and chest expansion by inch tape performed by the therapist), group A subjects underwent the diaphragmatic stretch technique and the group B subjects underwent the manual diaphragm release technique. Both the interventions were performed in 2 sets of 10 deep breaths with 1-minute interval between the sets. The two outcome variables were recorded immediately after the intervention. A wash-out period of 3 hours was maintained to neutralize the effect of given intervention. Later the patients of group A and group B were crossed over to the other group.

Results

In the diaphragmatic stretch technique, there was a statistically significant improvement in the diaphragmatic excursion before and after the treatment. On the right side, p=0.00 and p=0.003 in the midclavicular line and midaxillary line. On the left side, p=0.004 and p=0.312 in the midclavicular and midaxillary line. In manual diaphragm release technique, there was a statistically significant improvement before and after the treatment. On the right side, p=0.000 and p=0.000 in the midclavicular line and midaxillary line. On the left side, p=0.002 and p=0.000 in the midclavicular line and midaxillary line. There was no statistically significant difference in diaphragmatic excursion in the comparison of the postintervention values of both techniques.

Conclusion

The diaphragmatic stretch technique and manual diaphragm release technique can be safely recommended for patients with clinically stable COPD to improve diaphragmatic excursion.

Analysis of the Relationship Between Hemorheologic Parameters, Aluminum, Manganese, and Selenium in Smokers

Smoking is a significant risk factor in fatal pathologies including cardio-cerebrovascular and respiratory diseases. Aluminum (Al) is a toxic element without known biological function, but with recognized toxic effects. Manganese (Mn) and selenium (Se) are essential trace elements involved in cellular antioxidant defense mechanisms. Al, Mn, and Se carry out their metabolic activities via blood flow and tissue oxygenation. The structure and number of red blood cells (RBC) play important role in tissue oxygenation throughout blood flow. Increased hematocrit (Hct) as a result of probable hypoxia induces disturbed blood flow, RBC aggregation (RBC Agg), RBC deformability index (Tk), and oxygen delivery index (ODI). Therefore, we aimed to investigate the effects of altered Al, Mn, and Se levels on number, structure, and function of RBCs (Hct, blood and plasma viscosity (BV and PV, respectively), RBC Agg, Tk, ODI) in smokers without diagnosis of chronic obstructive pulmonary disease (COPD) in a study group (n = 128) categorized as ex-smokers (ES), smokers (S), and healthy controls (HC). Elements were analyzed in serum using ICP-OES. BV and PV were measured via Brookfield and Harkness viscometers at 37 °C, respectively. Smokers had statistically higher serum Al and Mn levels, BV, RBC, Hgb, Hct, PV, fibrinogen, RBC Agg, Tk₄₅, and pulmonary blood flow rate, but lower serum Se levels and ODI₄₅ values versus HC. In conclusion, increased Al, Mn, and hemorheological parameters and decreased Se and ODI₄₅ might result from inflammatory response in defense mechanism in smokers without diagnosis of COPD. Our results point out that serum Al, Mn, and Se with hemorheological parameters may be beneficial markers of tissue oxygenation and defense mechanism before the clinic onset of COPD in smokers.

Physiological predictors Of peak inspiRatory flow using Observed lung function resultS (POROS): evaluation at discharge among patients hospitalized for a COPD exacerbation

Background

Peak inspiratory flow (PIF) as generated through the resistance of a dry powder inhaler (DPI) device is a critical patient-dependent maneuver impacting the success of DPI medication delivery. Despite its importance, it is not routinely measured in clinical practice. Little is currently known about the relationship, if any, between PIF through DPI devices, routine spirometry and disease outcomes.

Aim

The aim of this study was to identify potential predictors of PIF for different DPIs from spirometric parameters and patient characteristics and explore the association between PIF and follow-up events.

Patients and methods

A retrospective observational study at discharge among patients hospitalized for a COPD exacerbation at Attikon hospital, Athens, Greece. Spirometry was performed using an Easy on-PC™ spirometer. PIF was measured through four DPI resistances using the In-Check™ DIAL. Regression analyses were used to investigate the association between PIF through resistances and spirometric parameters obtained at discharge, comorbidities and demographic parameters.

Results

Forty-seven COPD patients (mean [±SD], age 71 [±9] years, 72% males, 51% current smokers) were included in this study. Overall, 85% and 15% were classified as GOLD (2017) groups D and C, respectively. Most prevalent comorbidities were hypertension (70%) and cardiovascular disease (53%). In the final regression model, higher PIF was significantly associated with the following: higher FEV₁ and % predicted peak expiratory flow (PEF) for Turbohaler^® (R-squared value 0.374); higher FEV₁ and diagnosis of gastroesophageal reflux disease (GERD) for Aerolizer^® (R-squared value 0.209) and higher FEV₁, younger age and diagnosis of ischemic heart disease (IHD) for Diskus^® (R-squared value 0.350). However, R-squared values for all three devices were weak (<0.4).

Conclusion

The study did not provide evidence to support the use of surrogate measurements for PIF through device resistance, which could assist in determining the appropriateness of inhaler device type. Although PIF measurement is feasible in patients at discharge and could be a valuable addition to the standard of care in COPD management, it needs to be measured directly.

RETRACTED: Protective effect of exogenous hydrogen sulfide on pulmonary artery endothelial cells by suppressing endoplasmic reticulum stress in a rat model of chronic obstructive pulmonary disease

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief. An Expression of Concern for this article was previously published while an investigation was conducted (see related editorial: https://doi.org/10.1016/j.biopha.2022.113812). This retraction notice supersedes the Expression of Concern published earlier. Concern was raised about the reliability of the Western blot data in Figure 4A, which appear to represent a distinct phenotype as found in many other publications, as detailed here: https://pubpeer.com/publications/029A84E50BD071A2088140723E3CF0; and here: https://docs.google.com/spreadsheets/d/1r0MyIYpagBc58BRF9c3luWNlCX8VUvUuPyYYXzxWvgY/edit#gid=262337249. Independent analysis confirmed the presence of suspected image duplications between the Western blots in Figure 4A and those contained in Yan et al (2017). The journal requested the corresponding author comment on these concerns and provide the associated raw data. The authors did not respond to this request and therefore the Editor-in-Chief decided to retract the article.

Validation of a bioelectrical impedance analysis system for body composition assessment in patients with COPD

OBJECTIVE

To investigate the validity of an eight-contact electrode bioelectrical impedance analysis (BIA) system within a household scale for assessing whole body composition in COPD patients.

METHODS

Seventeen patients with COPD (mean age = 67 ± 8 years; mean FEV1 = 38.6 ± 16.1% of predicted; and mean body mass index = 24.7 ± 5.4 kg/m2) underwent dual-energy X-ray absorptiometry (DEXA) and an eight-contact electrode BIA system for body composition assessment.

RESULTS

There was a strong inter-method correlation for fat mass (r = 0.95), fat-free mass (r = 0.93), and lean mass (r = 0.93), but the correlation was moderate for bone mineral content (r = 0.73; p < 0.01 for all). In the agreement analysis, the values between DEXA and the BIA system differed by only 0.15 kg (-6.39 to 6.70 kg), 0.26 kg (-5.96 to 6.49 kg), -0.13 kg (-0.76 to 0.50 kg), and -0.55 kg (-6.71 to 5.61 kg) for fat-free mass, lean mass, bone mineral content, and fat mass, respectively.

CONCLUSIONS

The eight-contact electrode BIA system showed to be a valid tool in the assessment of whole body composition in our sample of patients with COPD.

Is decreased lung function associated with chronic kidney disease? A retrospective cohort study in Korea

OBJECTIVE

There is some evidence that lung function and chronic kidney disease (CKD) may be related. We evaluated the impact of lung function on the development of CKD in a large-scale longitudinal study.

METHOD

Retrospective longitudinal analyses were conducted among subjects who participated in comprehensive health check-ups at least four times during 7 years (between 2006 and 2012). We investigated the development of CKD during the follow-up period according to lung function status.

RESULTS

Ten thousand one hundred and twenty-eight individuals (mean age =51.2 years) without CKD at baseline were enrolled. During the mean follow-up of 5 years (58.5±14.4 months), 167 of the 10 128 subjects (1.6%) developed CKD. Multivariable Cox proportional hazards analyses adjusting for age, sex, body mass index, systolic blood pressure, fasting glucose, estimated glomerular filtration rate, uric acid, triglycerides, serum albumin, and the presence of diabetes and hypertension revealed that a decrease of 10% in the forced expiratory volume in 1s (FEV₁)/forced vital capacity (FVC) ratio was associated with a 35% increase in the development of CKD during the follow-up. The incidence of CKD was higher in those with an FEV₁/FVC ratio <0.8 compared with those with FEV₁/FVC ratio ≥0.8 (HR=1.454; 95% CI 1.042 to 2.028, p=0.028).

CONCLUSIONS

Limited airflow as measured by the FEV₁/FVC ratio was associated with an increased risk of CKD.

Cigarette Smoke Increases Endothelial CXCL16-Leukocyte CXCR6 Adhesion In Vitro and In Vivo. Potential Consequences in Chronic Obstructive Pulmonary Disease

Cardiovascular disease (CVD) is a major comorbidity in chronic obstructive pulmonary disease (COPD). Although the mechanism of its development remains largely unknown, it appears to be associated with cigarette consumption and reduced lung function. Therefore, the aim of this study was to investigate the potential link between water-soluble cigarette smoke extract (CSE)-induced endothelial dysfunction and the function of CXCL16/CXCR6 axis on the initial attachment of leukocytes, in addition to its possible impact on COPD-associated systemic inflammation. To do this, we employed several experimental approaches, including RNA silencing and flow cytometry analysis, the dynamic flow chamber technique, and intravital microscopy in the cremasteric arterioles of animals exposed to cigarette smoke (CS). CSE-induced arterial CXCL16 expression, leading to increased platelet–leukocyte and mononuclear cell adhesiveness. CSE-induced CXCL16 expression was dependent on Nox5 expression and subsequent RhoA/p38 MAPK/NF-κB activation. Flow cytometry analysis revealed that COPD patients (n = 35) presented greater numbers of activated circulating platelets (PAC-1⁺ and P-selectin⁺) expressing CXCL16 and CXCR6 as compared with age-matched controls (n = 17), with a higher number of CXCR6⁺-platelets in the smoking COPD group than in ex-smokers. This correlated with enhanced circulating CXCR6⁺-platelet–leukocyte aggregates in COPD patients. The increase in circulating numbers of CXCR6-expressing platelets and mononuclear cells resulted in enhanced platelet–leukocyte and leukocyte adhesiveness to CSE-stimulated arterial endothelium, which was greater than that found in age-matched controls and was partly dependent on endothelial CXCL16 upregulation. Furthermore, CS exposure provoked CXCL16-dependent leukocyte–arteriolar adhesion in cremasteric arterioles, which was significantly reduced in animals with a nonfunctional CXCR6 receptor. In conclusion, we provide the first evidence that increased numbers of CXCR6-expressing circulating platelets and mononuclear leukocytes from patients with COPD might be a marker of systemic inflammation with potential consequences in CVD development. Accordingly, CXCL16/CXCR6 axis blockade might constitute a new therapeutic approach for decreasing the risk of CVD in COPD patients.

Relationship between PPARα mRNA expression and mitochondrial respiratory function and ultrastructure of the skeletal muscle of patients with COPD

Peripheral muscle dysfunction is an important complication in patients with chronic obstructive pulmonary disease (COPD). The objective of this study was to explore the relationship between the levels of peroxisome proliferator-activated receptor α (PPARα) mRNA expression and the respiratory function and ultrastructure of mitochondria in the vastus lateralis of patients with COPD. Vastus lateralis biopsies were performed on 14 patients with COPD and 6 control subjects with normal lung function. PPARα mRNA levels in the muscle tissue were detected by real-time PCR. A Clark oxygen electrode was used to assess mitochondrial respiratory function. Mitochondrial number, fractional area in skeletal muscle cross-sections, and Z-line width were observed via transmission electron microscopy. The PPARα mRNA expression was significantly lower in COPD patients with low body mass index (BMIL) than in both COPD patients with normal body mass index (BMIN) and controls. Mitochondrial respiratory function (assessed by respiratory control ratio) was impaired in COPD patients, particularly in BMIL. Compared with that in the control group, mitochondrial number and fractional area were lower in the BMIL group, but were maintained in the BMIN group. Further, the Z-line became narrow in the BMIL group. PPARα mRNA expression was positively related to mitochondrial respiratory function and volume density. In COPD patients with BMIN, mitochondria volume density was maintained, while respiratory function decreased, whereas both volume density and respiratory function decreased in COPD patients with BMIL. PPARα mRNA expression levels are associated with decreased mitochondrial respiratory function and volume density, which may contribute to muscle dysfunction in COPD patients.

Effect of pre existing respiratory conditions on survival of lung cancer patients: A nationwide population-based cohort study

BACKGROUND

Common diseases with potential to increase the risk of death from lung cancer have so far not been studied in large populations.

METHODS

We did a population-based retrospective cohort study using nationwide health insurance claims data from 2005 to 2012 in Korea including 205 403 lung cancer patients. Multivariate-adjusted hazard ratios (aHRs) of lung cancer mortality by presence, time intervals with lung cancer diagnosis and combinations of pre-existing chronic obstructive pulmonary disease (COPD), pneumonia, asthma and tuberculosis were calculated using the Cox-proportional hazards model.

RESULTS

The total number of person-years of follow-up was 397 780 and 60.2% of patients died (mean survival 23.2 months after lung cancer diagnosis). Lung cancer patients with previous respiratory disease had increased aHR for mortality (COPD, hazard ratio [HR] = 1.32, CI 1.29-1.35; pneumonia, HR = 1.14, CI 1.08-1.19; and asthma, HR = 1.11, CI 1.06-1.16). Risks were positively associated with longer duration of pre-existing disease diagnosis; cases with >5 years since diagnosis compared to <2 years: COPD, HR = 2.91, CI 2.82-3.00; pneumonia, HR = 1.67, CI 1.51-1.85; asthma, HR = 1.56, CI 1.45-1.68; and tuberculosis, HR = 2.03, CI 1.90-2.17. Furthermore, elevated HRs of death were found among patients with multiple pre-existing co-morbidities.

CONCLUSION

Hazards of death from lung cancer are significantly increased in cases with pre-existing lung disease, and worse with longer durations, and with multiple combinations before cancer diagnosis. Patients and physicians should be aware of these meaningful risk/prognostic factors for lung cancer when identifying high-risk patient groups.

Prevalence of osteoporosis and osteopenia in stable patients of chronic obstructive pulmonary disease in Sub-Himalayan region of Himachal Pradesh, India

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a lifestyle-related chronic inflammatory pulmonary disease and a major cause of morbidity and mortality globally. Osteoporosis and osteopenia are common observations in COPD and degree of the loss of bone mineral density (BMD) has been found to be proportionate to the severity of the disease.

OBJECTIVES

Our objective was to study the prevalence of osteoporosis and osteopenia in stable COPD patients in Indian Sub-Himalayan population.

MATERIALS AND METHODS

This study was performed on 84 patients of COPD attending as outpatient in the Pulmonary Medicine Department after application of inclusion and exclusion criteria. A control group of 60 healthy controls was selected for comparison with COPD group. Spirometry was done on patients to stage the severity of COPD according to global initiative for chronic obstructive lung disease criteria. Dual-energy X-ray absorptiometry scan of the lumbar spine was done using bone densitometer to determine the severity of reduced BMD. The patients were categorized according to the World Health Organization criterion for definition of reduced BMD.

RESULTS

In the present study, a total of 45.2% patients had osteoporosis, 41.6% patients had osteopenia while the rest 13% patients had normal bone density in the COPD group. The prevalence of low bone density was about 4 times higher in COPD group as compared to control group. There were 15.48 times higher chances of low BMD in COPD patients as compared to healthy controls.

CONCLUSIONS

Reduced BMD is a common comorbid entity in COPD patients which leads to increase in bone fragility and susceptibility to fracture. It is recommended that all the patients with COPD should be screened for osteoporosis to initiate the treatment for the disorder before they develop fractures.

Symptom variability and control in COPD: Advantages of dual bronchodilation therapy

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disorder characterized by usually progressive development of airflow obstruction that is not fully reversible. While most patients will experience symptoms throughout the day or in the morning upon awakening, many patients do not experience their symptoms as constant but report variability in symptoms during the course of the day or over time. Symptom variability adversely affects patients' health status and increases the risk of COPD exacerbations.

METHODS

We examined data from the literature on symptom variability and control in patients with COPD, with focus on the use of inhaled bronchodilator therapy with long-acting muscarinic antagonist agents (LAMA) plus long-acting β₂-agonists (LABA); in particular twice-daily fixed-dose combination LAMA/LABA therapy with aclidinium/formoterol.

RESULTS

Correct diagnosis and assessment of COPD requires comprehensive clinical and functional evaluation and consideration of individual needs to support the clinical decisions necessary for effective long-term management. Combining bronchodilators from different and complementary pharmacological classes with distinct mechanisms of action can increase the magnitude of bronchodilation as opposed to increasing the dose of a single bronchodilator.

CONCLUSIONS

The use of inhaled bronchodilator therapy with LAMA/LABA fixed-dose combinations in patients with stable COPD is supported by current evidence. This treatment approach provides robust effects on lung function and symptom control and may improve patients' adherence to treatment. Administration of the long-acting bronchodilators aclidinium and formoterol as twice daily fixed-dose aclidinium/formoterol 400/12 μg has the potential to control symptoms throughout the 24 h in patients with stable moderate-to-severe COPD.

Symptom profiles and inflammatory markers in moderate to severe COPD

BACKGROUND

Physical and psychological symptoms are the hallmark of patients' subjective perception of their illness. The purpose of this analysis was to determine if patients with COPD have distinctive symptom profiles and to examine the association of symptom profiles with systemic biomarkers of inflammation.

METHODS

We conducted latent class analyses of three physical (dyspnea, fatigue, and pain) and two psychological symptoms (depression and anxiety) in 302 patients with moderate to severe COPD using baseline data from a longitudinal observational study of depression in COPD. Systemic inflammatory markers included IL1, IL8, IL10, IL12, IL13, INF, GM-CSF, TNF-α (levels >75^thcentile was considered high); and CRP (levels >3 mg/L was considered high). Multinominal logistic regression models were used to examine the association between symptom classes and inflammation while adjusting for key socio-demographic and disease characteristics.

RESULTS

We found that a 4-class model best fit the data: 1) low physical and psychological symptoms (26%, Low-Phys/Low-Psych), 2) low physical but moderate psychological symptoms (18%, Low-Phys/Mod Psych), 3) high physical but moderate psychological symptoms (25%, High-Phys/Mod Psych), and 4) high physical and psychological symptoms (30%, High-Phys/High Psych). Unadjusted analyses showed associations between symptom class with high levels of IL7, IL-8 (p ≤ .10) and CRP (p < .01). In the adjusted model, those with a high CRP level were less likely to be in the High-Phys/Mod-Psych class compared to the Low-Phys/Low-Psych (OR: 0.41, 95%CI 0.19, 0.90) and Low-Phys/Mod-Psych classes (OR: 0.35, 95%CI 0.16, 0.78); elevated CRP was associated with in increased odds of being in the High-Phys/High-Psych compared to the High-Phys/Mod-Psych class (OR: 2.22, 95%CI 1.08, 4.58). Younger age, having at least a college education, oxygen use and depression history were more prominent predictors of membership in the higher symptom classes.

CONCLUSIONS

Patients with COPD can be classified into four distinct symptom classes based on five commonly co-occurring physical and psychological symptoms. Systemic biomarkers of inflammation were not associated with symptom class. Additional work to test the reliability of these symptom classes, their biological drivers and their validity for prognostication and tailoring therapy in larger and more diverse samples is needed.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01074515 .

Nutritional status and its relationship with different dimensions of functional status in patients with chronic obstructive pulmonary disease

ABSTRACT Objective: To investigate whether there is a relationship between nutritional status and limitations in activities of daily living in patients with chronic obstructive pulmonary disease. Methods: A cross sectional study was conducted from July to December 2011 in Santa Catarina. Seventeen chronic obstructive pulmonary disease patients [age (years) = 67±8; forced expiratory volume in one second (% of the predicted value) = 38.6±16.1; body mass index (kg/m2) = 24.7±5.4] underwent the assessments: pulmonary function (spirometry); functional status (London Chest Activity of Daily Living scale, physical activities in daily life, and Glittre ADL-Test; nutritional status (anthropometry and dual-energy X-Ray absorptiometry). Results: The total score of the London Chest Activity of Daily Living scale correlated with fat-free mass (r=-0.50; p=0.04) and lean mass (r=-0.50; p=0.04). The lying time in physical activities in daily life correlated with bone mineral content (r=-0.50; p=0.04). Nutricional status was not correlated with time spent on Glittre ADL-test. Conclusion: Variables that reflect muscle mass depletion are related to variables of self-reported limitation in activities of daily living. Bone mineral content is correlated with time patients spend lying, reflecting the impact of inactive postures on the nutritional status of these patients.

Multiple Circulating Cytokines Are Coelevated in Chronic Obstructive Pulmonary Disease

Inflammatory biomarkers, including cytokines, are associated with COPD, but the association of particular circulating cytokines with systemic pathology remains equivocal. To investigate this, we developed a protein microarray system to detect multiple cytokines in small volumes of serum. Fourteen cytokines were measured in serum from never-smokers, ex-smokers, current smokers, and COPD patients (GOLD stages 1–3). Certain individual circulating cytokines (particularly TNFα and IL-1β) were significantly elevated in concentration in the serum of particular COPD patients (and some current/ex-smokers without COPD) and may serve as markers of particularly significant systemic inflammation. However, numerous circulating cytokines were raised such that their combined, but not individual, elevation was significantly associated with severity of disease, and these may be further indicators of, and contributors to, the systemic inflammatory manifestations of COPD. The coelevation of numerous circulating cytokines in COPD is consistent with the insidious development, chronic nature, and systemic comorbidities of the disease.

New aspect for systemic effects of COPD: eye findings

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) has multisystemic implications and comorbidities. Hypoxia and systemic inflammation are thought to involve oculary structures. In this study, our aim is to evaluate retinal nerve fiber and choroidal thickness and retinal vessel diameter using the spectral-domain optical coherence tomography (SD-OCT) in COPD subjects.

METHODS

Forty-three subjects diagnosed with COPD according to the Global Initiative for Chronic Obstructive Lung Disease criteria at the Pulmonology Department of Pamukkale University were enrolled in the study. All subjects underwent respiratory function testing and a carbon monoxide diffusion test. To determine hypoxic state, arterial blood gas analysis was performed. The control group consisted of 31 subjects with comparable age and gender distribution. All participants underwent a standard ophthalmic examination including visual acuity assessment, biomicroscopy, air-puff tonometry, indirect retinoscopy, and SD-OCT measurements.

RESULTS

The mean subfoveal choroidal thickness (SFCT), foveal thickness, and retinal arteriolar caliber were found to be similar in both groups, while the mean retinal venular caliber value was markedly higher in the COPD group. The mean peripapillary retinal nerve fiber layer (RNFL) thickness was 100.2±11.8 µm in the COPD group and 105.6 ± 8.1 µm in the control group (P = .03). The inferior quadrant RNFL was significantly thinner in the COPD group.

CONCLUSIONS

The results of this study showed increasing diameter of the retinal veins, thinning of the RNFL, and SFCT may be associated to chronic inflammation and hypoxia in subjects with COPD. Future guidelines may include ocular findings to the present systemic manifestations of COPD.

Risk of bipolar disorder in patients with COPD: a population-based cohort study

BAKCGROUND

Few studies have investigated the relationship between chronic obstructive pulmonary disease (COPD) and bipolar outcomes in the world. We sought to investigate the association between COPD and risk of bipolar disorder in a large national sample.

METHODS

The insured aged 15 years or more with a new primary diagnosis of COPD (ICD-9: 491, 492, 494 and 496) between 2000 and 2007 were identified from Taiwan's National Health Insurance Research Database. We included individuals with an inpatient diagnosis of COPD and/or at least 1 year of two diagnoses of COPD in outpatient services. These 35,558 cases were compared to 35,558 sex-, age-, residence- and insurance premium-matched controls. We followed both groups until the end of 2008 for incidence of bipolar disorder, defined as ICD-9 codes 296.0-296.16, 296.4-296.81 and 296.89. Competing risk-adjusted Cox regression analyses were applied with adjusting for sex, age, residence, insurance premium, prednisone use, Charlson comorbidity index, diabetes, hypertension, hyperlipidemia, cardiovascular diseases, hospital admission days, outpatients' visits and mortality.

RESULTS

Of the total 71,116 subjects, 202 were newly diagnosed with bipolar disorder during the study period. The mean follow-up time was 6.0 (SD=2.2) years. COPD, younger age, lower economic status, lower dose of prednisone use, higher hospital admission days and higher outpatient visits were independent predictors of bipolar disorder.

CONCLUSIONS

COPD was associated with increased risk of bipolar disorder independent of a number of potential confounding factors in this study.

Chronic obstructive pulmonary disease is not a risk factor for polyneuropathy: A prospective controlled study

Polyneuropathy has been observed in patients with chronic obstructive pulmonary disease (COPD). If polyneuropathy occurs as a complication or extrapulmonary manifestation of COPD, one would expect an increased prevalence among patients with a cryptogenic axonal polyneuropathy. This case-control study aimed to investigate the association between COPD and polyneuropathy. We prospectively included 345 patients with cryptogenic axonal polyneuropathy and 465 controls. A standardized questionnaire assessed the presence of COPD and we verified this diagnosis by contacting the family physician. The severity of COPD was based on the Global Initiative for Chronic Obstructive Lung Disease classification. The prevalence of COPD did not differ between patients with polyneuropathy and controls (15/345 vs. 12/465 respectively; odds ratio (OR) 1.7; 95% confidence interval (CI) [0.8-3.7]). Adjusting for age, gender and possible confounders did not affect these results (adjusted OR 1.7, 95% CI 0.7-4.1). The severity of COPD was similar between patients with polyneuropathy and controls. This study does not support the hypothesis that COPD is a risk factor for polyneuropathy.

The Use of Spinal Manipulative Therapy in the Management of Chronic Obstructive Pulmonary Disease: A Systematic Review

OBJECTIVES

To evaluate the methodologic quality of the evidence for the use of spinal manipulative therapy (SMT) with and without other therapies in the management of chronic obstructive pulmonary disease (COPD).

DESIGN

A systematic review of the literature.

PARTICIPANTS

Any participant of a primary research study that investigated the effect of SMT on COPD. Only studies with participants older than age 18 years with an existing diagnosis of COPD were included.

INTERVENTIONS

Interventions included any form of high-velocity, low-amplitude spinal manipulation with or without other forms of manual therapy, exercise, and/or pharmacologic intervention.

OUTCOME MEASURES

Six-minute walking test, forced expiratory volume in 1 second, forced vital capacity, residual volume, total lung capacity, Chronic Respiratory Questionnaire, St George's Respiratory Questionnaire, and the Hospital Anxiety and Depression Scale.

RESULTS

Six articles met all of the inclusion criteria and were included in the review: three randomized controlled trials (RCTs), one pre-post observational study, one case series, and one single case study. Sample sizes varied from 1 to 33 participants ranging in age from 55 to 85 years. Risk of bias was low for the three RCTs and high for the other studies. All three RCTs used SMT in conjunction with exercise from a pulmonary rehabilitation program. Five of the six studies reported improvements in lung function and exercise performance following SMT intervention.

CONCLUSIONS

This review provides a methodologic evaluation of the evidence for using SMT with and without other therapies in the management of COPD. While the quality of the evidence provided by three RCTs was high, they were all conducted on small sample sizes. These results highlight the need for further research into the use of SMT in conjunction with exercise on people with COPD.

Usefulness of ceruloplasmin testing as a screening methodology for geriatric patients with osteoporosis

[Purpose] To evaluate serum ceruloplasmin levels in geriatric patients with osteoporosis. [Subjects and Methods] Seventy geriatric patients over 65 years of age were recruited. Patients were divided into two groups: group 1 ('OP', n=35) consisted of patients with osteoporosis, and group 2 (n=35) consisted of patients without osteoporosis. Dual-energy X-ray absorptiometry scanning was used in the measurement of bone mineral density in all cases. Inflammatory parameters, including C-reactive protein, sedimentation rate, and serum ceruloplasmin levels were analyzed in blood samples. [Results] No statistical differences in inflammatory parameters were observed between the two groups, however, serum ceruloplasmin levels were significantly higher in group 1 than in group 2. In Pearson analysis, serum ceruloplasmin levels were not found to be correlated with any biochemical parameters. Receiver operator characteristic curve analysis revealed that serum ceruloplasmin levels were predictive of osteoporosis with 85.7% sensitivity and 85.7% specificity over the level of 830.15. [Conclusion] Our study demonstrated that measurement of serum ceruloplasmin levels may have potential as a screening methodology for geriatric patients with osteoporosis.

Heart Failure Impairs Muscle Blood Flow and Endurance Exercise Tolerance in COPD

Heart failure, a prevalent and disabling co-morbidity of COPD, may impair cardiac output and muscle blood flow thereby contributing to exercise intolerance. To investigate the role of impaired central and peripheral hemodynamics in limiting exercise tolerance in COPD-heart failure overlap, cycle ergometer exercise tests at 20% and 80% peak work rate were performed by overlap (FEV1 = 56.9 ± 15.9% predicted, ejection fraction = 32.5 ± 6.9%; N = 16), FEV1-matched COPD (N = 16), ejection fraction-matched heart failure patients (N = 15) and controls (N = 12). Differences (Δ) in cardiac output (impedance cardiography) and vastus lateralis blood flow (indocyanine green) and deoxygenation (near-infrared spectroscopy) between work rates were expressed relative to concurrent changes in muscle metabolic demands (ΔO2 uptake). Overlap patients had approximately 30% lower endurance exercise tolerance than COPD and heart failure (p < 0.05). ΔBlood flow was closely proportional to Δcardiac output in all groups (r = 0.89-0.98; p < 0.01). Overlap showed the largest impairments in Δcardiac output/ΔO2 uptake and Δblood flow/ΔO2 uptake (p < 0.05). Systemic arterial oxygenation, however, was preserved in overlap compared to COPD. Blunted limb perfusion was related to greater muscle deoxygenation and lactate concentration in overlap (r = 0.78 and r = 0.73, respectively; p < 0.05). ΔBlood flow/ΔO2 uptake was related to time to exercise intolerance only in overlap and heart failure (p < 0.01). In conclusion, COPD and heart failure add to decrease exercising cardiac output and skeletal muscle perfusion to a greater extent than that expected by heart failure alone. Treatment strategies that increase muscle O2 delivery and/or decrease O2 demand may be particularly helpful to improve exercise tolerance in COPD patients presenting heart failure as co-morbidity.

Delay in diagnosis of chronic obstructive pulmonary disease: reasons and solutions

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is a crippling disease with a high worldwide prevalence. It is the fifth-leading cause of death worldwide and estimated to become the third-leading cause of death by 2030. This review highlights recent studies that discuss reasons for and possible solutions to the delay in diagnosis of COPD.

RECENT FINDINGS

Delay in COPD diagnosis is multifactorial and can be grouped into healthcare provider-related factors, patient-related factors, and heterogeneity in the disease itself. The current literature strongly supports the lack of awareness and knowledge about COPD among healthcare providers as an important factor in misdiagnosis and/or delays in diagnosis. Ironically, COPD is both underdiagnosed and overdiagnosed.

SUMMARY

Achieving the goal of early diagnosis in COPD needs a major overhaul and culture change in primary care settings. Respiratory symptoms in a smoker 40 years or above should trigger automatic health alert and spirometry indications. Awareness of tobacco-related injury is the first building block in prevention and cure.