Prevalence and risk factors for pulmonary embolism in patients with suspected acute exacerbation of COPD: a multi-center study

Pulmonary embolism work-up in chronic obstructive pulmonary disease exacerbations: what is the best strategy for clinicians?

PURPOSE OF REVIEW

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are important events in the natural course of COPD, as they increase morbidity and mortality. Acute pulmonary embolism may mimic the symptoms of COPD exacerbations. However, the exact prevalence of pulmonary embolism in unexplained exacerbations of COPD is unclear based on the current data. This review provides a practical approach to patients with COPD complaining of worsening respiratory symptoms.

RECENT FINDINGS

A randomized clinical trial has shown that a routine pulmonary embolism diagnostic work-up does not improve care of patients with acute exacerbations of COPD. However, review of the recent literature suggests that a nonnegligible proportion of otherwise unexplained exacerbations of COPD may be caused by pulmonary embolism. To date, nevertheless, there are limited studies developing and validating clinical models that might aid in the identification of patients requiring additional tests for the diagnosis of pulmonary embolism.

SUMMARY

Until new evidence becomes available, we believe that a routine diagnostic strategy for pulmonary embolism is not appropriate for patients with acute exacerbations of COPD. Recommendations for routine pulmonary embolism diagnostic work-up necessitate further development of prognostic models and conduct of clinical trials that assess important health outcomes.

Chronic obstructive pulmonary disease exacerbation purulence status and its association with pulmonary embolism: protocol for a systematic review with meta-analysis

INTRODUCTION

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) increases the risk of pulmonary embolism (PE). AECOPD and PE have similar symptoms which results in a high proportion of patients with AECOPD undergoing imaging to rule out PE. Finding predictors and explanatory factors of PE in AECOPD, such as purulence status, could help reduce the need for imaging. This systematic review with meta-analysis aims to evaluate if there is an association between purulence status in AECOPD and PE diagnosis.

METHODS AND ANALYSIS

MEDLINE, EMBASE and CENTRAL will be searched from database inception to April 2024. Randomised trials, cohort studies and cross-sectional studies on the prevalence of PE in patients with AECOPD will be included if the prevalence of PE based on the AECOPD purulence status is available. There will be no restriction on language. The primary outcome will be PE at the initial assessment and secondary outcomes will be all venous thromboembolism (deep venous thrombosis (DVT) and PE) and DVT, respectively, diagnosed at the initial assessment. Relative risks with their 95% CI will be calculated by using a Mantel-Haenszel random-effect model to compare the association between the risk of PE and the AECOPD purulence status (purulent vs non-purulent/unknown). Subgroup analyses will be performed based on the type of study, systematic search of PE versus no systematic search of PE and localisation of PE. Risk of bias will be evaluated by the ROBINS-E tool, publication bias will be evaluated with the funnel plot. The manuscript will be drafted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

ETHICS AND DISSEMINATION

This study does not require ethics approval. This work will be submitted for presentation at an international conference and for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023459429.

Thrombelastography and Conventional Coagulation Markers in Chronic Obstructive Pulmonary Disease: A Prospective Paired-Measurements Study Comparing Exacerbation and Stable Phases

Chronic Obstructive Pulmonary Disease (COPD) exacerbation is known for its substantial impact on morbidity and mortality among affected patients, creating a significant healthcare burden worldwide. Coagulation abnormalities have emerged as potential contributors to exacerbation pathogenesis, raising concerns about increased thrombotic events during exacerbation. The aim of this study was to explore the differences in thrombelastography (TEG) parameters and coagulation markers in COPD patients during admission with exacerbation and at a follow-up after discharge. This was a multi-center cohort study. COPD patients were enrolled within 72 h of hospitalization. The baseline assessments were Kaolin-TEG and blood samples. Statistical analysis involved using descriptive statistics; the main analysis was a paired t-test comparing coagulation parameters between exacerbation and follow-up. One hundred patients participated, 66% of whom were female, with a median age of 78.5 years and comorbidities including atrial fibrillation (18%) and essential arterial hypertension (45%), and sixty-five individuals completed a follow-up after discharge. No significant variations were observed in Kaolin-TEG or conventional coagulation markers between exacerbation and follow-up. The Activated Partial Thromboplastin Clotting Time (APTT) results were near-significant, with p = 0.08. In conclusion, TEG parameters displayed no significant alterations between exacerbation and follow-up.

Optimizing the Diagnostic Algorithm for Pulmonary Embolism in Acute COPD Exacerbation Using Fuzzy Rough Sets and Support Vector Machine

Aiming to optimize the diagnosis of pulmonary embolism (PE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), we conducted a retrospective study enrolling 185 AECOPD patients, of whom 90 were diagnosed with PE based on computed tomography pulmonary angiography (CTPA). Ten characteristic indicators and 27 blood indicators were extracted for each patient. First, we quantified the importance of each indicator for diagnosing PE in AECOPD using fuzzy rough sets (FRS) and selected the more important indicators to construct a support vector machine (SVM) diagnosis model called FRS-SVM. The performance of the proposed diagnosis model on the test sets was compared to that of the logistic regression model. The average accuracy and area under the curve (AUC) of the proposed model for the test sets in 10 independent trials were 94.67% and 0.944, respectively, compared to 80.41% and 0.809 for the logistic regression model. Thus, we validated the higher accuracy and stability of the FRS-SVM for PE diagnosis in patients with AECOPD. This model improved the prediction probability before CTPA and can be used in clinical practice to help doctors make decisions.

Prevalence, Risk Factor and Clinical Characteristics of Venous Thrombus Embolism in Patients with Acute Exacerbation of COPD: A Prospective Multicenter Study

Background and Objective

The prevalence of venous thrombus embolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) is higher than in patients without COPD. Owing to the similarity of clinical symptoms between PE and acute exacerbation COPD (AECOPD), PE is likely to be overlooked or underdiagnosed in patients with AECOPD. The aim of the study was to investigate the prevalence, risk factor, clinical characteristics, and prognostic impact of VTE in patients with AECOPD.

Methods

This multicenter, prospective, cohort study was conducted in 11 research centers of China. Data on the baseline characteristics, VTE-related risk factors, clinical symptoms, laboratory examination results, computed tomography pulmonary angiography (CTPA) and lower limb venous ultrasound of AECOPD patients were collected. Patients were followed up for 1 year.

Results

A total of 1580 AECOPD patients were included in the study. The mean (SD) age was 70.4 (9.9) years and 195 (26%) patients were women. The prevalence of VTE was 24.5% (387/1580) and PE was 16.8% (266/1580). VTE patients were older; had higher BMI; and longer course of COPD than non-VTE patients. The history of VTE, cor pulmonale, less purulent sputum, increased respiratory rate, higher D-dimer, and higher NT-proBNP/BNP were independently associated with VTE in hospitalized patients with AECOPD. The mortality at 1-year was higher in patients with VTE than patients without VTE (12.9% vs 4.5%, p<0.01). There was no significant difference in the prognosis of patients with PE in segmental or subsegmental arteries and in main pulmonary arteries or lobar arteries (P>0.05).

Conclusion

VTE is common in COPD patients and is associated with poor prognosis. Patients with PE at different locations had poorer prognosis than patients without PE. It is necessary to perform active screening strategy for VTE in AECOPD patients with risk factors.

Bilateral Deep Vein Thrombosis and Pulmonary Embolism Due to Right Common Iliac Artery Aneurysm with a Contained Rupture

Venous thromboembolism (comprising deep venous thrombosis and/or pulmonary embolism) is a common disease, often of multifactorial cause. Focal iliac artery aneurysms are relatively rare, and only a few reports exist in the literature describing patients with venous thromboembolism resulting from venous floe disruption due to iliac artery aneurysm. Thus, we report a case of a 65-year-old male presenting with pulmonary embolism and bilateral deep vein thrombosis associated with a contained rupture of the right common iliac artery aneurysm.

Prevalence of Pulmonary Embolism and Deep Venous Thromboembolism in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Background

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) increases the risk of pulmonary embolism (PE) and deep venous thrombosis (DVT). AECOPD combined with PE and DVT poses challenges for treatment and management. This necessitates prevention and management to estimate the overall prevalence of PE and DVT among patients with AECOPD and to identify the risk factors.

Methods

We searched the PubMed, Embase, and Cochrane Library databases from their inception to January 9, 2021 and extracted the data from the included studies. The risk of bias was assessed for each study. We separately calculated the prevalence of PE and DVT in patients with AECOPD. Subgroup analysis and meta-regression analyses were performed to determine the sources of heterogeneity. Furthermore, we assessed the publication bias.

Results

The meta-analysis included 20 studies involving 5,854 people. The overall prevalence of PE and DVT among patients with AECOPD was 11% (95% CI: 0.06–0.17) and 9% (95% CI: 0.06–0.12), respectively. Subgroup analysis demonstrated that the prevalence of PE among patients with AECOPD was 12, 2, 7, and 16% in the European, South-East Asia, Western Pacific, and Eastern Mediterranean regions, respectively, and the DVT was 10, 9, 9, and 4%, respectively. The prevalence of PE among patients with AECOPD aged ≥ 70 and <70 years old was 6 and 15%, respectively, and the DVT was 8 and 9%, respectively. The prevalence of PE among patients with AECOPD diagnosed within 48 h and other times (beyond 48 h or not mentioned) was 16 and 6%, respectively, and DVT was 10 and 7%, respectively.

Conclusion

The pooled prevalence of PE and DVT among patients with AECOPD was insignificantly different between the different age groups and the WHO regions. However, the early diagnosis was associated with a higher prevalence of PE. Clinicians and the public need to further improve the awareness of prevention and management for PE and DVT among patients with AECOPD.

Systematic Review Registration

PROSPERO, identifier CRD42021260827.

The prevalence and clinical features of pulmonary embolism in patients with AE-COPD: A meta-analysis and systematic review

BACKGROUND

The prevalence of pulmonary embolism (PE) in the acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) is highly controversial. We conducted a systematic review and meta-analysis to summarize the epidemiology and characteristics of PE with AE-COPD for current studies.

METHODS

We searched the PubMed, EMBASE, Cochrane Library and Web of Science databases for studies published prior to October 21, 2020. Pooled proportions with 95% confidence intervals (95% CIs) were calculated using a random effects model. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals were used as effect measures for dichotomous and continuous variables, respectively.

RESULTS

A total of 17 studies involving 3170 patients were included. The prevalence of PE and deep vein thrombosis (DVT) in AE-COPD patients was 17.2% (95% CI: 13.4%-21.3%) and 7.1% (95% CI: 3.7%-11.4%%), respectively. Dyspnea (OR = 6.77, 95% CI: 1.97-23.22), pleuritic chest pain (OR = 3.25, 95% CI: 2.06-5.12), lower limb asymmetry or edema (OR = 2.46, 95% CI:1.51-4.00), higher heart rates (MD = 20.51, 95% CI: 4.95-36.08), longer hospital stays (MD = 3.66, 95% CI: 3.01-4.31) were associated with the PE in the AE-COPD patients. Levels of D-dimer (MD = 1.51, 95% CI: 0.80-2.23), WBC counts (MD = 1.42, 95% CI: 0.14-2.70) were significantly higher and levels of PaO2 was lower (MD = -17.20, 95% CI: -33.94- -0.45, P<0.05) in the AE-COPD with PE group. The AE-COPD with PE group had increased risk of fatal outcome than the AE-COPD group (OR = 2.23, 95% CI: 1.43-3.50).

CONCLUSIONS

The prevalence of PE during AE-COPD varies considerably among the studies. AE-COPD patients with PE experienced an increased risk of death, especially among the ICU patients. Understanding the potential risk factors for PE may help clinicians identify AE-COPD patients at increased risk of PE.

PROSPERO REGISTRATION NUMBER

CRD42021226568.

Pulmonary embolism with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease. The incidence of COPD is growing annually in China, and it is a significant and growing public health burden. Multivariate analysis showed that COPD was one of the independent risk factors for the occurrence of pulmonary embolism (PE), and the incidence of PE was significantly higher in COPD patients than in normal subjects. However, PE is often overlooked in patients with acute exacerbation of COPD (AECOPD) because there are many similarities in clinical symptoms between PE and AECOPD, which are difficult to distinguish, resulting in the failure of timely treatment and poor prognosis. Therefore, it is of great significance to understand the clinical manifestations, diagnosis, and treatment of COPD combined with PE for making a more accurate diagnosis, providing timely and effective treatment, and improving the prognosis of such patients.

Hypercoagulable State in COPD-A Comprehensive Literature Review

Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory disease with multisystemic manifestations. Studies either held on stable disease patients or during exacerbations have demonstrated that COPD is strongly related to venous thromboembolism and cardiovascular events. The aim of the present review of the literature was to provide an in-depth overview regarding the alterations of coagulation factors and prothrombotic changes generated in patients with stable COPD and during COPD exacerbations.

Venous Thromboembolic Disease in Chronic Inflammatory Lung Diseases: Knowns and Unknowns

Persistent inflammation within the respiratory tract underlies the pathogenesis of numerous chronic pulmonary diseases. There is evidence supporting that chronic lung diseases are associated with a higher risk of venous thromboembolism (VTE). However, the relationship between lung diseases and/or lung function with VTE is unclear. Understanding the role of chronic lung inflammation as a predisposing factor for VTE may help determine the optimal management and aid in the development of future preventative strategies. We aimed to provide an overview of the relationship between the most common chronic inflammatory lung diseases and VTE. Asthma, chronic obstructive pulmonary disease, interstitial lung diseases, or tuberculosis increase the VTE risk, especially pulmonary embolism (PE), compared to the general population. However, high suspicion is needed to diagnose a thrombotic event early as the clinical presentation inevitably overlaps with respiratory disorders. PE risk increases with disease severity and exacerbations. Hence, hospitalized patients should be considered for thromboprophylaxis administration. Conversely, all VTE patients should be asked for lung comorbidities before determining anticoagulant therapy duration, as those patients are at increased risk of recurrent PE episodes rather than DVT. Further research is needed to understand the underlying pathophysiology of in-situ thrombosis in those patients.

Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact

In chronic obstructive pulmonary disease (COPD), exacerbations (ECOPD), characterized by an acute deterioration in respiratory symptoms, are fundamental events impacting negatively upon disease progression, comorbidities, wellbeing and mortality. ECOPD also represent the largest component of the socioeconomic burden of COPD. ECOPDs are currently defined as acute worsening of respiratory symptoms that require additional therapy. Definitions that require worsening of dyspnoea and sputum volume/purulence assume that acute infections, especially respiratory viral infections, and/or exposure to pollutants are the main cause of ECOPD. But other factors may contribute to ECOPD, such as the exacerbation of other respiratory diseases and non-respiratory diseases (e.g., heart failure, thromboembolism). The complexity of worsening dyspnoea has suggested a need to improve the definition of ECOPD using objective measurements such as blood counts and C-reactive protein to improve accuracy of diagnosis and a personalized approach to management. There are three time points when we can intervene to improve outcomes: acutely, to attenuate the length and severity of an established exacerbation; in the aftermath, to prevent early recurrence and readmission, which are common, and in the long-term, establishing preventative measures that reduce the risk of future events. Acute management includes interventions such as corticosteroids or antibiotics and measures to support the respiratory system, including non-invasive ventilation (NIV). Current therapies are broad and better understanding of clinical phenotypes and biomarkers may help to establish a more tailored approach, for example in relation to antibiotic prescription. Other unmet needs include effective treatment for viruses, which commonly cause exacerbations. Preventing early recurrence and readmission to hospital is important and the benefits of interventions such as antibiotics or anti-inflammatories in this period are not established. Domiciliary NIV in those patients who are persistently hypercapnic following discharge and pulmonary rehabilitation can have a positive impact. For long-term prevention, inhaled therapy is key. Dual bronchodilators reduce exacerbation frequency but in patients with continuing exacerbations, triple therapy should be considered, especially if blood eosinophils are elevated. Other options include phosphodiesterase inhibitors and macrolide antibiotics. ECOPD are a key component of the assessment of COPD severity and future outcomes (quality of life, hospitalisations, health care resource utilization, mortality) and are a central component in pharmacological management decisions. Targeted therapies directed towards specific pathways of inflammation are being explored in exacerbation prevention, and this is a promising avenue for future research.

The effect of COPD on the incidence and mortality of hospitalized patients with pulmonary embolism: A nationwide population-based study (2016-2018)

BACKGROUND

To examine the incidence, clinical characteristics, and in-hospital outcomes of pulmonary embolism (PE) among hospitalized patients with or without chronic obstructive pulmonary disease (COPD) in Spain, and to identify predictors of in-hospital-mortality (IHM) after PE among patients with and without COPD.

METHODS

We included all patients aged ≥ 40 years who were hospitalised for PE between 2016 and 2018. Data were collected from the Spanish National Hospital Discharge Database.

RESULTS

We identified 47,190 hospitalizations for PE during the study period, 7.49% with COPD. Adjusted incidence of PE was higher in COPD patients than in those without COPD (IRR 1.16; 95%CI 1.13-1.19). Crude IHM was significantly higher in PE hospitalized patients with COPD than in those without COPD (9.86% vs 3.59%; p<0.001). Predictor factors of IHM in COPD patients with PE included older age, higher Charlson comorbidity index, atrial fibrillation, massive PE and dependence on oxygen prior to hospital admission. However, obesity was associated with lower IHM. For PE hospitalized patients, suffering COPD increased the probability of dying in the hospital (adjusted OR 2.84; 95%CI 2.27-3.55).

CONCLUSIONS

Our results revealed that incidence of PE was higher in COPD patients than in those without COPD. Furthermore, COPD was a risk factor for IHM after PE.