Gender differences in the management and experience of Chronic Obstructive Pulmonary Disease

Aiming to Improve Equity in Lung Health: Sex and Gender

Sex and gender impact risk factors, presentations of, and response to therapy in lung diseases such as chronic obstructive pulmonary disease, asthma, lung cancer, interstitial lung disease, and obstructive sleep apnea. Many physicians lack training in the impact of sex and gender on lung disease, resulting in diagnostic delays. Scales and indices taught in the health care system are largely validated in male populations, thereby limiting their application to females. For transgender and lesbian, gay, bisexual, transgender, and questioning + patients, high rates of bias in health care may limit patients' willingness to seek health care.

Factors Associated with the Non-Exacerbator Phenotype of Chronic Obstructive Pulmonary Disease

Background

Patients with chronic obstructive pulmonary disease (COPD) and no exacerbations may need less maintenance treatment and follow-up. The aim was to identify factors associated with a non-exacerbator COPD phenotype.

Methods

Cross-sectional analysis of 1354 patients from primary and secondary care, with a doctor's diagnosis of COPD. In 2014, data on demographics, exacerbation frequency and symptoms using COPD Assessment Test (CAT) were collected using questionnaires and on spirometry and comorbid conditions by record review. The non-exacerbator phenotype was defined as having reported no exacerbations the previous six months. Multivariable logistic regression with the non-exacerbator phenotype as dependent variable was performed, including stratification and interaction analyses by sex.

Results

The non-exacerbator phenotype was found in 891 (66%) patients and was independently associated with COPD stage 1 (OR [95% CI] 5.72 [3.30-9.92]), stage 2 (3.42 [2.13-5.51]) and stage 3 (2.38 [1.46-3.88]) compared with stage 4, and with CAT score <10 (3.35 [2.34-4.80]). Chronic bronchitis and underweight were inversely associated with the non-exacerbator phenotype (0.47 [0.28-0.79]) and (0.68 [0.48-0.97]), respectively. The proportion of non-exacerbators was higher among patients with no maintenance treatment or a single bronchodilator. The association of COPD stage 1 compared with stage 4 with the non-exacerbator phenotype was stronger in men (p for interaction 0.048). In women, underweight and obesity were both inversely associated with the non-exacerbator phenotype (p for interaction 0.033 and 0.046 respectively), and in men heart failure was inversely associated with the non-exacerbator phenotype (p for interaction 0.030).

Conclusion

The non-exacerbator phenotype is common, especially in patients with no maintenance treatment or a single bronchodilator, and is characterized by preserved lung function, low symptom burden, and by absence of chronic bronchitis, underweight and obesity and heart failure. We suggest these patients may need less treatment and follow-up, but that management of comorbid conditions is important to avoid exacerbations.

Ever Smoking is Not Associated with Performed Spirometry while Occupational Exposure and Respiratory Symptoms are

Objective

Despite recommendations, assessment using spirometry or peak expiratory flow is insufficient in the clinical evaluation of suspected obstructive pulmonary disease. The aim was to investigate factors associated with performing spirometry or peak flow expiratory flow assessment.

Methods

Randomly selected subjects from the general population aged 50-65 completed a respiratory questionnaire with items about the history of previously performed spirometry or peak expiratory flow. The association between ever having had spirometry or peak expiratory flow performed was analyzed for smoking, age, sex, occupational exposures, dyspnea, wheeze, self-reported physician diagnosed asthma and COPD using multivariable logistic regression models. The results are presented as odds ratios (OR) with 95% confidence intervals (95% CIs).

Results

Of the 1105 participants, 43.4% (n=479) had a history of previously performed spirometry or peak expiratory flow. Occupational exposure (OR 1.72, [95% CI] 1.30-2.27), wheeze (OR 2.29, 1.41-3.70), and dyspnea (OR 1.70, 1.11-2.60) were associated with previously performed spirometry. Compared to men, women had spirometry or peak expiratory flow performed less often (OR 0.67, 0.51-0.86). Neither current smoking (OR 0.83, 0.57-1.20) or former smoking (OR 1.27, 0.96-1.67) were associated with performed spirometry or peak expiratory flow.

Conclusion

We found no relation between smoking status and a history of previously performed spirometry or peak expiratory flow in a population-based sample of middle-aged people. This is surprising regarding the strong guidelines which highlight the importance for spirometry surveillance on current smokers due to their increased risk of lung disease. Male sex, respiratory symptoms and occupational exposures to air pollution were associated with previously performed spirometry or peak expiratory flow. The association with occupational exposure may be an effect of pre-employment screening and workplace surveillance, and the findings indicate that females do not receive the same attention regarding spirometry or peak expiratory flow.

Sex-specific characteristics for the coexistence of asthma and COPD in the Canadian population: a cross-sectional analysis of CLSA data

Objective: The coexistence of asthma and COPD (asthma + COPD) is a condition found among patients who present with clinical features of both asthma and COPD. Epidemiological evidence points to an increasingly disproportionate burden of asthma + COPD and COPD in females. The objective of this cross-sectional study is to identify female and male-specific epidemiological and clinical characteristics associated with asthma + COPD.Methods: Baseline data from the comprehensive cohort of Canadian Longitudinal Study on Aging (CLSA) were used in this cross-sectional study which included 30,097 subjects between the ages of 45- and 85-years Participants were categorized into four mutually exclusive groups: asthma + COPD, COPD-only, asthma-only and neither asthma nor COPD.Results: The prevalence was significantly greater in females than males for asthma + COPD (2.71% vs. 1.41%; p < 0.001), COPD-only (3.22% vs. 2.87%; p < 0.001) and asthma-only (13.31% vs. 10.11%; p < 0.001). The association between smoking and asthma + COPD was modified by age in females. Osteoporosis and underactive thyroid disease were significantly more prevalent in females than in males in asthma + COPD, COPD-only and asthma-only groups. In asthma + COPD group, a greater proportion of respiratory symptoms associated with asthma was observed in females whereas a greater proportion of respiratory symptoms associated with COPD was observed in males. Severity of airway obstruction determined by spirometry measurements was greater in males than females.Conclusions: In the Canadian adult population, several epidemiological and clinical characteristics in asthma + COPD varied between females and males. The findings in this study will help healthcare professional in the recognition and management of coexisting asthma and COPD in females and males.

Gender differences in pulmonary function, physical activity, and quality of life of patients with COPD based on data from the Korea National Health and Nutrition Examination Survey 2015 to 2019 from the Perspective of Pulmonary Rehabilitation

The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide, with the fourth highest mortality rate. This study aims to analyze pulmonary function, physical activity, and quality of life (QoL) between genders from the perspective of pulmonary rehabilitation in Korean patients with COPD. This study investigated raw data from the Korea National Health and Nutrition Examination Survey from 2015 to 2019 and included 151 COPD patients (men: 66.55 ± 10.07 years, women: 65.21 ± 11.73) out of 39,759 participants. Pulmonary function, such as forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), and frequency of physical activities (e.g., physical activity for work and leisure, strengthening exercise, and sitting time a day) and QoL by using EQ-5D-3L, were compared between genders in patients with COPD. Smoking status differed in health-related characteristics between genders (P < .001). In pulmonary function, the FVC (men: 3.48 ± 0.98ℓ, women: 2.53 ± 0.56ℓ, P < .05), FEV1 (men: 2.13 ± 0.93 ℓ, women: 1.88 ± 0.53 ℓ, P < .001), FEV6 (men: 3.16 ± 1.00ℓ, women: 2.46 ± 1.56ℓ, P < .001) and peak expiratory flow (men: 5.61 ± 2.44ℓ/s, women: 4.68 ± 1.53ℓ/s, P < .05) was higher in men, however, predicted FEV1 (men: 66.03% ± 23.13%, women: 79.95% ± 18.45%, P < .05) and predicted FEV1/FVC ratio (men: 59.67% ± 15.02%, women: 74.10% ± 10.49%, P < .001) in women. The frequency of strengthening exercise was higher in men (P < .05). QoL of patients with COPD was not significantly different between genders. To provide correct interventions and pulmonary rehabilitation to patients with COPD, gender differences, including physiological and psychological differences, must be considered.

Pharmacological smoking cessation of adults aged 30-50 years with COPD

The prevalence of active smokers has remained relatively stable around 20% for several years in Denmark despite knowledge of the harmful effects. Smoking cessation is the most effective way to limit progression and reduce mortality of chronic obstructive pulmonary disease (COPD). Therefore, smoking cessation is particularly important among adults with COPD. The aim of this study was to determine the extent to which adults 30–50 years of age with COPD redeem pharmacotherapy for smoking cessation, and to identify demographic factors that influence the use of smoking cessation medication. We conducted a national retrospective non-interventional registry study, including all Danish patients with COPD (ICD-10 code J.44: chronic obstructive pulmonary disease) aged 30–50 years in the period 2009–2015. We identified 7734 cases, who were matched with controls (15,307) 1:2 on age, sex, and geography. Smoking status was not registered. We found that 18% of cases (with an estimated smoking prevalence at 33–50%) redeemed pharmacological smoking cessation medication in the study period compared to 3% of the controls (with an estimated smoking prevalence at 23%). The OR for cases collecting pharmacological smoking cessation medication was 5.92 [95% CI 5.24–6.70]. Male sex, being unemployed, and receiving social benefits were factors associated with less probability of redeeming pharmacological smoking cessation medication. Our study indicates that attention is needed on smoking cessation in adults aged 30–50 years with COPD, especially if unemployed or receiving social benefits, as these individuals are less likely to redeem pharmacological smoking cessation medication.

Just breathe: a review of sex and gender in chronic lung disease

Chronic lung diseases are the third leading cause of death worldwide and are increasing in prevalence over time. Although much of our traditional understanding of health and disease is derived from study of the male of the species - be it animal or human - there is increasing evidence that sex and gender contribute to differences in disease risk, prevalence, presentation, severity, treatment approach, response and outcomes. Chronic obstructive pulmonary disease, asthma and bronchiectasis represent the most prevalent and studied chronic lung diseases and have key sex- and gender-based differences which are critical to consider and incorporate into clinical and research approaches. Mechanistic differences present opportunities for therapeutic development whereas behavioural and clinical differences on the part of patients and providers present opportunities for greater education and understanding at multiple levels. In this review, we seek to summarise the sex- and gender-based differences in key chronic lung diseases and outline the clinical and research implications for stakeholders.

A Trend Analysis of Chronic Obstructive Pulmonary Disease Mortality in the United States by Race and Sex

Rationale: Chronic respiratory diseases, among which chronic obstructive pulmonary disease (COPD) remains the largest contributor, are the fourth leading cause of death in the United States. Updated mortality trends provide insight for targeted interventions. Objectives: To provide detailed insights into COPD mortality trends. Methods: This study used death certificate data collected from the U.S. Centers for Disease Control WONDER (Wide-Ranging Online Data for Epidemiology Research) system between 2004 and 2018 among Americans 40 years of age and older. We used Joinpoint regression analysis to capture trends in annual age-adjusted COPD mortality rates and of the number of deaths caused by influenza or pneumococcal disease with COPD. To place mortality trends into perspective, we examined influenza and pneumococcal vaccination rates within the same time frame using population survey data. Results: Overall, mortality from COPD decreased, with an annual percentage change (APC) of -0.6% (95% confidence interval [CI], -0.9% to -0.3%) between 2004, at 72.9 deaths per population of 100,000, and 2018, at 67.4 deaths per population of 100,000. COPD mortality in men exceeded that in women; however, mortality in men continued to decline, with an APC of -1.2% (95% CI, -1.5% to -0.9%), unlike mortality in women, whose death rates were overall unchanged. Further stratifying sex by race, we found that African American women were the only sociodemographic group to have had an increase in COPD mortality, with an APC of 1.3% (95% CI, 0.9% to 1.6%). The number of deaths caused by influenza with COPD had increased over time, with an observed APC of 19.58% (95% CI, 6.9% to 33.8%) between 2004 and 2018. Increased influenza mortality paralleled trends of decreased influenza vaccination rates, wherein between 2011 and 2018, there was an APC of -5.1% (95% CI, -8.2% to -2.0%). This trend was also present for those with COPD; 451.4 per 1,000 respondents in 2011 were vaccinated against influenza compared with 352.1 per 1,000 respondents in 2018, resulting in an APC of -1.8% (95% CI, -3.3% to -0.2%). Pneumococcal vaccination rates between 2011 and 2018 remained unchanged; meanwhile, deaths caused by pneumococcal disease with COPD decreased, with an APC of -10.1% (95% CI, -16.6% to -3.1%). Conclusions: COPD mortality has decreased among Americans overall; however, there remain important sociodemographic groups that have not secured the same deceleration in death rates.

Differences Between Men and Women with Chronic Obstructive Pulmonary Disease

There are many differences between men and women in risk factor vulnerability and impact, symptom development, presentation, clinical manifestations, and outcomes of chronic obstructive pulmonary disease (COPD). These differences have been inadequately explored, which is of particular concern in view of the delay in diagnosis and treatment that occurs for both men and women, and the need to use all therapies in a targeted and tailored way for best clinical gain and least harm. Women are generally underrepresented in randomized trials, as are non-tobacco-related phenotypes of COPD. We must garner the information available to better describe optimal treatment approaches.

National Epidemiological Case-Control Study of Pharmacological Smoking Cessation Treatment in Danish Patients with Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that is mainly caused by smoking, and most patients with COPD are either former or current smokers. The optimal way to slow down disease progression and reduce overall mortality is for patients to stop smoking. Patients with COPD are known to have lower socio-economic status and to be more nicotine-dependent than most other smokers and therefore face difficulties when attempting to quit smoking. Pharmacological smoking cessation treatment is known to be the most effective. However, the extent to which this treatment is actually offered to Danish smokers with COPD is unknown.

Aim

The aim of this study was to investigate if patients with COPD were more likely to redeem a prescription for smoking cessation medication compared with matched controls.

Materials and Methods

The study was designed as a registry-based, non-interventional case-control study. All Danish patients with COPD (ICD-10-code J 44 chronic obstructive pulmonary disease) diagnosed between 2009 and 2015 were included (130,797 cases). Controls (252,216) were matched on age, gender and geography. Primary outcome was the number of redeemed prescriptions for smoking cessation medication.

Results

We found that 12% of patients with COPD redeemed a prescription for smoking cessation medication during the eight-year study period. The odds ratio (OR) for redeeming a prescription on smoking cessation medicine was OR 6.22 for patients with COPD compared with their matched controls. We also found that patients with COPD were more likely to redeem smoking cessation medication if they were younger, female or single.

Conclusion

There is substantial room for improvement with respect to pharmacological smoking cessation treatment in Danish patients with COPD. In-depth knowledge of factors contributing to the patients choice of smoking cessation treatment might allow for more personalized guidance of patients with COPD.

Trends in Hospital Admissions for Chronic Obstructive Pulmonary Disease in Men and Women in Spain, 1998 to 2018

The prevalence of chronic obstructive pulmonary disease (COPD) is rising faster in women in some countries. An observational time trends study was performed to assess the evolution of hospital admissions for COPD in men and women in Spain from 1998 to 2018. ICD-9 diagnostic codes (490–492, 496) from the minimum basic data set of hospital discharges were used. Age-standardised admission rates were calculated using the European Standard Population. Joinpoint regression models were fitted to estimate the annual percent change (APC). In 2018, the age-standardised admission rate per 100,000 population/year for COPD was five times higher in men (384.8, 95% CI: 381.7, 387.9) than in women (78.6, 95% CI: 77.4, 79.9). The average annual percent change (AAPC) was negative over the whole study period in men (−1.7%/year, 95% CI: −3.1, −0.2) but positive from 2010 to 2018 (1.1%/year, 95% CI: −0.8, 2.9). In women, the APC was −6.0% (95%CI: −7.1, −4.9) from 1998 to 2010, but the trend reversed direction in the 2010–2018 period (7.8%/year, 95% CI: 5.5, 10.2). Thus, admission rates for COPD decreased from 1998 to 2010 in both men and women but started rising again until 2018, modestly in men and sharply in women.

Health care service use and costs for a cohort of high-needs elderly diabetic patients

AIMS

To describe the impact of diabetes comorbidities on the health care services use and costs of a cohort of elderly patients with diabetes and high health care needs (HHCN), based on real-world data.

METHODS

We focused on a cohort of diabetic patients with HHCN belonging to Resource Utilization Bands 4 and 5 according to the Adjusted Clinical Group (ACG) system. Their comorbidities were assessed using the clinical diagnoses that the ACG system assigns to single patients by combining different information flows. Regression models were applied to analyze the associations between comorbidities and health care service use or costs, adjusting for age and sex.

RESULTS

Our analyses showed that all health care service usage measures (e.g. access to emergency care; number of outpatient visits) and the total annual costs and pharmacy costs are associated significantly with comorbidity class. Instead, no differences in hospitalization rates by comorbidity class were revealed.

CONCLUSION

The association between a larger number of comorbidities and higher total health care service usage and costs was seen mainly for primary care services. This underscores the need to strengthen primary care for today's aging and multimorbid population.

Healthcare Service Usage and Costs for Elderly Patients with Obstructive Lung Disease

Background

The worldwide prevalence of obstructive lung disease (OLD) is increasing, especially among people >65 years old, and nearly three in four adults with OLD have two or more comorbid conditions. This study describes the impact of such comorbidities on the healthcare service usage and related costs in a country with universal health coverage, basing on a large cohort of elderly patients with OLD and employing real-world data.

Methods

We carried out a retrospective cohort study on a large population of elderly (age >64 years) patients with OLD served by a Local Health Unit in northern Italy. Their comorbidities were assessed using the clinical diagnoses assigned by the Adjusted Clinical Group (ACG) system to individual patients by combining different information flows. Correlations between number of comorbidities and total annual healthcare service usage and costs were examined with Spearman's test. Regression models were applied to analyze the associations between the above-mentioned variables, adjusting for age and sex.

Results

All types of healthcare service usage (access to emergency care; number of outpatient visits; number of hospital admissions) and pharmacy costs increased significantly with the number of comorbidities. Average total annual costs increased steadily with the number of comorbidities, ranging from € 1158.84 with no comorbidities up to € 9666.60 with 6 comorbidities or more. Poisson regression analyses showed an independent association between the number of comorbidities and the use of every type of healthcare service.

Conclusion

These results based on real-world data provide evidence that the burden of care for OLD patients related to their comorbidities is independent of and in addition to the burden related to OLD alone and is strongly dependent on the number of comorbidities, suggesting a holistic approach to multimorbid patients with OLD is the most sound public health strategy.

No gender-related bias in COPD diagnosis and treatment in Sweden: a randomised, controlled, case-based trial

Introduction

COPD is a major cause of morbidity and mortality. The prevalence, morbidity and mortality of COPD among females have increased. Previous studies indicate a possible gender bias in the diagnosis and management of COPD. The present study aims to determine if there is gender bias in the management of COPD in Sweden.

Methods

This was a double-blind, randomised (1:1), controlled, parallel-group, web-based trial using the hypothetical case scenario of a former smoker (40 pack-years and quit smoking 3 years ago) who was male or female. The participants were blind to the randomisation and the purpose of the trial. The case progressively revealed more information with associated questions on how the physician would manage the patient. Study participants chose from a list of tests and treatments at each step of the case scenario.

Results

In total, 134 physicians were randomised to a male (n=62) or a female (n=72) case. There was no difference in initial diagnosis (61 (98%) male cases and 70 (97%) female cases diagnosed with COPD) and planned diagnostic procedures between the male and female cases. Spirometry was chosen by all the physicians as one of the requested diagnostic tests. The management of the hypothetical COPD case did not differ by sex of the responding physician.

Conclusion

In Sweden, diagnosis and management of a hypothetical patient with COPD did not differ by the gender of the patient or physician.

No gender-related bias in COPD managementhttps://bit.ly/3gTsWoG

Deciphering patterns of respiratory medication use in Ireland to target interventions appropriately: a focus on COPD

BACKGROUND

Ireland has the highest rates of overnight hospitalisations for COPD in the OECD, yet lacks estimates of the prevalence of this disease or its pharmacological management. We aimed to estimate the age and sex-specific prevalence of symptomatic COPD and to identify patterns of respiratory medication use to inform interventions to improve pharmacotherapy in this condition.

METHODS

We used the national pharmacy claims database, with data on a publically insured cohort in 2016. We restricted to those aged ≥ 45 years with full eligibility for that year and examined the age and sex distribution of respiratory medications, and patterns of medication use in those suggestive of COPD.

RESULTS

In this cohort, 23% filled at least one prescription for a respiratory medication; 14% of males and 16% of females received at least one dispensing of an ICS inhaler. The proportion dispensed a long-acting muscarinic receptor antagonist (LAMA) was considerably lower. Of those newly initiated on a LAMA, 24% did not receive another within 60 days of the last covered day. The prevalence of medication use suggestive of COPD was 15% in males and 16% in females.

CONCLUSION

The prevalence of medication use consistent with the management of symptomatic COPD mirrors international prevalence estimates. Several patterns raise concern: high ICS use in older adults, under use of LAMA therapy and poor persistence of those newly initiated. We recommend the development of an intervention to assist in the implementation of new national prescribing guidelines for the management of COPD.

New Mexico Female Miners Have Lower Odds for COPD than Their Male Counterparts

Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity among miners. There is an increasing number of women in the mining industry and the differences in their risk for COPD compared to men miners are not understood. Our objective is to compare the odds for COPD between male and female miners. Using cross-sectional data from the Mining Dust in the United States (MiDUS) Cohort, that included New Mexico miners between 1989 and 2018, we compared the odds for airflow obstruction or chronic bronchitis between women and men. There were 299 women in this diverse cohort of 7,464 miners. Compared to men, female miners reported lower cumulative smoking but higher prevalence of current smoking. Multivariable analysis showed that women miners had significantly lower odds for having airflow obstruction (OR 0.40; 95% CI (0.26, 0.6)) and chronic bronchitis (OR 0.31, 95% CI (0.19, 0.53)) than men. Future studies need to determine whether this sex difference is explained by residual confounders or true biological difference.

Gender differences in COPD management in a Sicilian general practice setting: a cohort study evaluating the impact of educational interventions

Aim

The aim of this study was to measure gender differences among COPD patients' quality of care (QOC) before and after two educational interventions in Southern Italy.

Methods

In this prospective cohort study, COPD patients were identified from primary care electronic medical records (EMRs). Twelve process indicators concerning diagnosis, preventative measures and therapeutic processes were developed as a measure of QOC. Educational interventions consisted of clinical seminars and audits on COPD QOC at baseline, and at 12 and 24 months. QOC indicators were stratified by gender: odds ratios (ORs) (males as reference group) of having a good QOC indicator were calculated at baseline, 12 and 24 months, with 95% confidence intervals (CIs) using hierarchical generalised linear models.

Results

Of 46 326 people registered in the EMRs, 1463 COPD patients (3.1%) were identified, of which 37% were women. QOC indicators reflecting best practice 24 months after the educational programme were generally not different to baseline, often favouring men. On the other hand, the composite global QOC indicator suggested that while a good overall QOC at baseline was significantly higher in men than women (OR: 0.74; 95% CI: 0.57–0.96), it became nonsignificant at 24 months (OR: 0.96; 95% CI: 0.72–1.29).

Conclusions

Specific QOC indicators among COPD patients often favoured men. However, several gender disparities seen at baseline disappeared at 24 months, suggesting that even general educational interventions which do not target gender can improve the gender disparity in QOC.

This observational study shows that quality of care (QOC) is better among male COPD patients in primary care. Planned educational interventions over 24 months abolished gender difference in global QOC, although not in all QOC items.https://bit.ly/3cfwPST

Sex differences between women and men with COPD: A new analysis of the 3CIA study

BACKGROUND

There is partial evidence that COPD is expressed differently in women than in men, namely on symptoms, pulmonary function, exacerbations, comorbidities or prognosis. There is a need to improve the characterization of COPD in females.

METHODS

We obtained and pooled data of 17 139 patients from 22 COPD cohorts and analysed the clinical differences by sex, establishing the relationship between these characteristics in women and the prognosis and severity of the disease. Comparisons were established with standard statistics and survival analysis, including crude and multivariate Cox-regression analysis.

RESULTS

Overall, 5355 (31.2%) women were compared with men with COPD. Women were younger, had lower pack-years, greater FEV₁%, lower BMI and a greater number of exacerbations (all p < 0.05). On symptoms, women reported more dyspnea, equal cough but less expectoration (p < 0.001). There were no differences in the BODE index score in women (2.4) versus men (2.4) (p = 0.5), but the distribution of all BODE components was highly variable by sex within different thresholds of BODE. On prognosis, 5-year survival was higher in COPD females (86.9%) than in males (76.3%), p < 0.001, in all patients and within each of the specific comorbidities that we assessed. The crude and adjusted RR and 95% C.I. for death in males was 1.82 (1.69-1.96) and 1.73 (1.50-2.00), respectively.

CONCLUSIONS

COPD in women has some characteristic traits expressed differently than compared to men, mainly with more dyspnea and COPD exacerbations and less phlegm, among others, although long-term survival appears better in female COPD patients.

Utilization and determinants of use of non-pharmacological interventions in COPD: Results of the COSYCONET cohort

BACKGROUND

Guidelines for chronic obstructive pulmonary disease (COPD) recommend supplementing pharmacotherapy with non-pharmacological interventions. Little is known about the use of such interventions by patients. We analyzed the utilization of a number of non-pharmacological interventions and identified potential determinants of use.

METHODS

Based on self-reports, use of interventions (smoking cessation, influenza vaccination, physiotherapy, sports program, patient education, pulmonary rehabilitation) and recommendation to use were assessed in 1410 patients with COPD. The utilization was analyzed according to sex and severity of disease. Potential determinants of utilization included demographic variables and disease characteristics and were analyzed using logistic regression models.

RESULTS

Influenza vaccination in the previous autumn/winter was reported by 73% of patients. About 19% were currently participating in a reimbursed sports program, 10% received physiotherapy, 38% were ever enrolled in an educational program, and 34% had ever participated in an outpatient or inpatient pulmonary rehabilitation program. Out of 553 current or former smokers, 24% had participated in a smoking cessation program. While reports of having received a recommendation to use mainly did not differ according to sex, women showed significantly (p < 0.05) higher utilization rates than men for all interventions except influenza vaccination. Smoking was a predictor for not having received a recommendation for utilization and also significantly associated with a reduced odds of utilization. We found a correlation between recommendation to use and utilization.

CONCLUSIONS

Utilization of non-pharmacological interventions was lower in men and smokers. A recommendation or offer to use by the physician could help to increase uptake.

Sex Differences in Veterans Admitted to the Hospital for Chronic Obstructive Pulmonary Disease Exacerbation

Rationale: As chronic obstructive pulmonary disease (COPD) prevalence in women has outpaced that in men, COPD-related hospitalization and mortality are now higher in women. Presentation, evaluation, and treatment of COPD differ between women and men. Despite higher smoking rates in Veterans, little work has characterized differences in Veterans with COPD by sex. Objectives: To determine risk factors for 30-day readmission among Veterans hospitalized for COPD exacerbations and how they differed by sex. Methods: We performed a retrospective observational analysis of Veterans receiving primary care in Veterans Health Affairs facilities. We included Veterans Administration-based hospitalizations for Veterans with a COPD exacerbation (identified by International Classification of Disease, Ninth Revision codes) who survived to discharge between fiscal years 2012 and 2015. Primary outcome was 30-day readmission. Predictors ascertained before hospitalization included smoking status (current, former, never), pulmonary function testing, pulmonary medication prescriptions, and medical and psychiatric comorbidities (identified by International Classification of Disease, ninth revision codes). We created combined and sex-stratified multivariate logistic regression models to identify associations with 30-day readmission. Results: Our sample included 48,888 Veterans (4% women). Compared with men, women Veterans were younger, more likely to be nonwhite, and differed in smoking status. Women were more likely to have asthma, drug use, and several psychiatric comorbidities. Before hospitalization, women were less likely to have pulmonary function testing (76% vs. 78%; P = 0.01) or be treated with antimuscarinic (43% vs. 48%) or combined long-acting bronchodilator/inhaled corticosteroid (61% vs. 64%) inhalers. Women were more likely to receive nicotine-replacement therapy (all P < 0.01). Women had shorter length of stay (median days, 2 vs. 3; P = 0.04) and lower 30-day readmission rate (20% vs. 22%; P = 0.01). In adjusted models including both sexes, age, antimuscarinic use, comorbidities, and diagnosis of drug or alcohol use were associated with readmission; there was no association with sex and readmission risk. In models stratified by sex, associations were similar between women and men. Conclusions: This study suggests differences between women and men hospitalized for COPD regarding presentation, evaluation, and management. Readmission is strongly influenced by comorbidities, suggesting individualized and comprehensive case management may reduce readmission risk for women and men with COPD.

Effect of Gender on Lung Function and Patient-Reported Outcomes in Patients with COPD Receiving Nebulized Glycopyrrolate

Purpose

The clinical manifestation of COPD can differ by gender, with women experiencing worse lung function and health-related quality of life than men. Additionally, women tend to report more symptoms given the same disease severity. Accordingly, the impact of gender on efficacy and safety in patients with moderate-to-very-severe COPD was examined following 12 weeks of nebulized glycopyrrolate (GLY) 25 µg twice daily (BID) or placebo.

Patients and Methods

GLY and placebo pooled data from the replicate 12-week GOLDEN 3 and 4 studies (n=861) were grouped by gender. Endpoints reported were change from baseline in trough forced expiratory volume in 1 second (FEV1), St George's Respiratory Questionnaire (SGRQ) and EXAcerbations of COPD Tool-Respiratory Symptoms (EXACT-RS) total scores. Safety was evaluated by reviewing the incidence of adverse events (AEs) and serious AEs.

Results

Men (placebo: 54.7%; GLY: 56.1%) were generally older with a greater proportion of high cardiovascular risk and use of background long-acting β2-agonists or inhaled corticosteroids. GLY treatment resulted in significant, clinically important improvements in trough FEV1, regardless of gender. Patients treated with GLY reported significant improvements in SGRQ total score, irrespective of gender; however, the improvement was numerically higher in women. Although EXACT-RS improved in both genders, only women experienced a significant improvement. Overall, GLY was well tolerated with a numerically lower incidence of AEs in men than women.

Conclusion

Treatment with nebulized GLY resulted in lung function, SGRQ total score, and EXACT-RS total score improvements regardless of gender. However, only EXACT-RS showed significantly greater improvements in women compared with men. Treatment with GLY was generally well tolerated across genders. These data support the efficacy and safety of GLY 25 µg BID in patients with moderate-to-very-severe COPD, independent of gender. Gender similarities in airflow improvement and differences in symptom-reporting augment the evidence supporting the consideration of individualized treatment plans for COPD patients.

Rhythmic auditory stimulation increases 6-Minute walk distance in individuals with COPD: A repeated measures study

OBJECTIVE

To evaluate if there is an increase in 6-minute walk distance in individuals with chronic obstructive pulmonary disease (COPD) while walking to rhythmically enhanced music.

BACKGROUND

Individuals with COPD are less active. Walking with rhythmically enhanced music may help Participant's walk farther while simultaneously distracting from symptoms of dyspnea.

METHODS

Twenty-five men (age = 70.7 ± 4.5 yr), with moderate-to-severe COPD (FEV1 = 47.4 ± 9.7% predicted) completed three, 6 min walk tests (6MWT) in random order. Walks were completed with music, with music that was rhythmically enhanced, or without music. Walking distance and perceived dyspnea were measured.

RESULTS

Participant's walked 12 m, 95% CI [20.5-, 2.6], p = 0.015 further during the 6MWT when listening to rhythmically enhanced music when compared to no music. Onset of dyspnea was not different between the three walking conditions.

CONCLUSIONS

Rhythmically-enhanced music may be a useful tool to increase walking distance in Participant's with COPD.

Clinical Characteristics of Chronic Obstructive Pulmonary Disease in Female Patients: Findings from a KOCOSS Cohort

PURPOSE

The prevalence of chronic obstructive pulmonary disease (COPD) in females has increased, changing the concept of COPD as a disease mostly limited to males. In this study, the clinical characteristics of COPD in females were investigated.

PATIENTS AND METHODS

The study was based on a multicenter cohort of COPD patients recruited from 54 medical centers in South Korea. Sex-based differences in general characteristics, exposure risk factors, depression scores, results of pulmonary function tests, COPD exacerbation, symptom scores, and radiologic findings were evaluated. Sex-related differences in the annual FEV₁ change over 5 years were analyzed in a linear mixed model.

RESULTS

Of the 2515 patients enrolled in this study, 8.1% were female. Female patients who had a higher BMI and a lower level of education were less likely to be smokers, were more exposed to passive smoking/biomass, and were more depressed compared to males. The rates of bronchiectasis, previous childhood respiratory infection, and asthma were higher in females. Female patients also had more symptoms and a poorer exercise capacity than males, but no significant differences were observed in terms of exacerbations. Radiologic findings revealed that male patients had worse emphysema, and female patients had worse bronchiectasis, as determined based on chest X-ray and computed tomography findings. On pulmonary function tests, female patients had less obstruction and less annual FEV₁ loss over 5 years.

CONCLUSION

This study revealed differences in the clinical parameters between male and female patients with COPD, including general characteristics, disease characteristics, and clinical outcomes.

Differences in COPD Exacerbation Risk Between Women and Men: Analysis From the UK Clinical Practice Research Datalink Data

BACKGROUND

Historically, COPD has been considered to affect mostly older men with a history of smoking; however, in recent times, its prevalence and mortality rates have steadily increased among women.

OBJECTIVES

The goal of this study was to systematically assess differences in COPD expression between women and men in UK primary care clinics who were newly diagnosed with COPD.

METHODS

This retrospective cohort study compared women and men with an incident diagnosis of COPD by using electronic medical records data from the Clinical Practice Research Datalink and linked Hospital Episode Statistics data. The overall study period was between January 1, 2006, and February 28, 2016; patients with an incident diagnosis of COPD between January 1, 2010, and February 28, 2015, were analyzed.

RESULTS

A cohort of 22,429 patients were identified as incident patients and included in the study; 48% of patients with COPD were women. The risk of first moderate or severe exacerbation was 17% greater in women than in men (hazard ratio, 1.17; 95% CI, 1.12-1.23), with a median time to first exacerbation of 504 days for women and 637 days for men. These differences were more prominent in the younger age group (≥ 40 years to < 65 years), as well as in Global Initiative for Chronic Obstructive Lung Disease 2016 groups B, C, and D and in individuals with moderate to severe airflow obstruction. The annual rate of moderate or severe exacerbations was higher in women compared with men in the first, second, and third year of follow-up.

CONCLUSIONS

These results highlight the unmet need for appropriate identification and management of women with COPD in clinical practice.

Dynamic changes in lung responses after single and repeated exposures to cigarette smoke in mice

Cigarette smoke is well recognized to cause injury to the airways and the alveolar walls over time. This injury usually requires many years of exposure, suggesting that the lungs may rapidly develop responses that initially protect it from this repetitive injury. Our studies tested the hypotheses that smoke induces an inflammatory response and changes in mRNA profiles that are dependent on sex and the health status of the lung, and that the response of the lungs to smoke differs after 1 day compared to 5 days of exposure. Male and female wildtype (WT) and Scnn1b-transgenic (βENaC) mice, which have chronic bronchitis and emphysematous changes due to dehydrated mucus, were exposed to cigarette smoke or sham air conditions for 1 or 5 days. The inflammatory response and gene expression profiles were analyzed in lung tissue. Overall, the inflammatory response to cigarette smoke was mild, and changes in mediators were more numerous after 1 than 5 days. βENaC mice had more airspace leukocytes than WT mice, and smoke exposure resulted in additional significant alterations. Many genes and gene sets responded similarly at 1 and 5 days: genes involved in oxidative stress responses were upregulated while immune response genes were downregulated. However, certain genes and biological processes were regulated differently after 1 compared to 5 days. Extracellular matrix biology genes and gene sets were upregulated after 1 day but downregulated by 5 days of smoke compared to sham exposure. There was no difference in the transcriptional response to smoke between WT and βENaC mice or between male and female mice at either 1 or 5 days. Taken together, these studies suggest that the lungs rapidly alter gene expression after only one exposure to cigarette smoke, with few additional changes after four additional days of repeated exposure. These changes may contribute to preventing lung damage.

Women and COPD: do we need more evidence?

The increasingly female face of chronic obstructive pulmonary disease (COPD) prevalence among women has equalled that of men since 2008, due in part to increased tobacco use among women worldwide and exposure to biomass fuels. This finding is supported by a number of characteristics. There is evidence of susceptibility to smoking and other airborne contaminants, along with epidemiological and phenotypic manifestations. COPD has thus become the leading cause of death in women in the USA. The clinical presentation is characterised by increasingly pronounced dyspnoea with a marked tendency towards anxiety and depression, undernutrition, nonsmall cell lung cancer (especially adenocarcinoma) and osteoporosis. Quality of life is also more significantly impacted. The theories advanced to explain these differences involve the role played by oestrogens, impaired gas exchange in the lungs and smoking habits. While these differences require appropriate therapeutic responses (smoking cessation, pulmonary rehabilitation, long-term oxygen therapy), barriers to the treatment of women with COPD include greater under-diagnosis than in men, fewer spirometry tests and medical consultations. Faced with this serious public health problem, we need to update and adapt our knowledge to the epidemiological changes.

The face of COPD is increasingly female. We need more evidence and a change in how the disease is managed. http://ow.ly/zueL30mWqlS

[Delayed diagnosis is associated with greater disease severity of chronic obstructive pulmonary disease]

OBJECTIVE

To investigate the association of the time of initial diagnosis with the severity of chronic obstructive pulmonary disease (COPD).

METHODS

A total of 803 patients who were diagnosed to have COPD for the first time in our hospital between May 2015 to February 2018 were enrolled in this study.The diagnoses of COPD and asthma COPD overlap (ACO) were made according GOLD guidelines and european consensus definition.Lung function of the patients was graded according to the GOLD guidelines.

RESULTS

The patients with COPD had a mean age of 61.8±9.9 years,including 726 male and 77 female patients.The course of the patients (defined as the time from symptom onset to the establishment of a diagnosis) was 3(0.5,8) years.Among these patients,85.2% had a moderate disease severity (FEV1%&lt;80%),and 48.3% had severe or very severe conditions (FEV1%&lt;50%);47.0% of them were positive for bronchial dilation test.In the overall patients,295(36.7%) were also diagnosed to have ACO,and the mean disease course of ACO[3(1,9) years]was similar to that of COPD[3(0.5,8) years](P&gt;0.05).A significant correlation was found between the disease course and the lung function of the patients.Multiple linear regression analysis showed that an older age and a longer disease course were associated with poorer lung functions and a greater disease severity.

CONCLUSIONS

The delay of the initial diagnosis is significantly related to the severity of COPD.

Treatment response to indacaterol/glycopyrronium versus salmeterol/fluticasone in exacerbating COPD patients by gender: a post-hoc analysis in the FLAME study

Background

The burden of chronic obstructive lung disease (COPD) is increasing in women, with recent evidence suggesting gender differences in disease characteristics and potentially in treatment outcomes.

Methods

FLAME was a 52-week randomized controlled trial in patients with severe-to-very-severe COPD and a history of exacerbations. In this post-hoc analysis, gender-based baseline differences and treatment outcomes between indacaterol/glycopyrronium 110/50 μg once daily (IND/GLY) and salmeterol/fluticasone 50/500 twice daily (SFC) were assessed in terms of rate of exacerbations, time-to-first exacerbation, lung function, health status, and rescue medication use.

Results

This post-hoc analysis included 2557 men and 805 women. Baseline characteristics differed between genders, with women being younger, having better lung function and more often experiencing ≥2 exacerbations in the previous year. Compared with SFC, IND/GLY treatment was associated with reductions in the annualized rates of moderate/severe exacerbations (rate ratio [95% CI]: 0.81 [0.73–0.91], 0.89 [0.74–1.07] in men and women, respectively). Similarly, time-to-first moderate/severe exacerbation was also delayed (hazard ratio [95% CI]: 0.79 [0.70–0.89] and 0.76 [0.63–0.91] in men and women, respectively). Results were similar for all (mild/moderate/severe) exacerbations. Improvements in lung function, health status and rescue medication use with IND/GLY vs SFC were comparable between men and women. The smaller sample size for women may account for some observed discrepancies in treatment responses.

Conclusions

Although there were gender differences in baseline characteristics, IND/GLY demonstrated similar trends for exacerbation prevention and lung function improvement in men and women with moderate-to-very-severe COPD and a history of exacerbations compared with SFC. Small differences in the effects seen between genders may be attributed to the different sizes of the two groups and need to be further evaluated in randomized trials that are appropriately powered for gender analysis.

Trial registration

Post hoc analysis of the FLAME study. ClinicalTrials.gov number: NCT01782326. Registered 1 February 2013.

Gender difference on the knowledge, attitude, and practice of COPD diagnosis and treatment: a national, multicenter, cross-sectional survey in China

PURPOSE

To investigate the gender difference in knowledge, attitude, and practice of COPD diagnosis and treatment in China.

PATIENTS AND METHODS

A nationwide, multicenter, cross-sectional questionnaire study was carried out to investigate patients' understanding and experience of COPD between September 2007 and December 2008.

RESULTS

Two thousand and seventy-two patients were recruited from eleven centers. The final effective questionnaires were those of 1,698 cases, of which 32% were female. Women were younger, had higher body mass index, were more never smokers, and had lesser pack-years (all P<0.01). More women had under elementary education level and monthly income <1,000 RMB (about 160 USD) (all P<0.01). Women had higher ratio of FEV1/FVC (54.1±10.9 vs 50.2±11.5), FEV1% (50.0±19.1 vs 45.4±29.0), and lower short form-36 mental component summary (57.5±26.8 vs 61.3±25.0) (all P<0.01). Fewer women reported severe exacerbation (defined as an acute worsening of respiratory symptoms that results in patient's hospitalization) in the previous year (44.5% vs 51.6%, P<0.05). More women reported that they never heard of COPD before (67.0% vs 59.0%, P<0.01). Less women reported that physician had to tell them they had emphysema (50.5% vs 60.4%) or COPD (31.9% vs 37.9%). Less women had pulmonary function test (PFT) done before (65.2% vs 70.4%, P<0.05). More women reported that they would not repeat PFT annually (91.7% vs 87.6%, P<0.05) and did not know the PFT results (78.6% vs 73.1%, P<0.05). More women reported not having had pulmonary rehabilitation before (87.8% vs 83.6%, P<0.05). Fewer women reported knowing that COPD should be given combined therapy (38.3% vs 44.5%) and long-term treatment (46.1% vs 51.9%) (all P<0.05).

CONCLUSION

Male and female patients had different experiences on COPD diagnosis and treatment. Physicians should pay more attention to patients' education on COPD, especially of women.

Wellbeing and chronic lung disease incidence: The Survey of Health, Ageing and Retirement in Europe

BACKGROUND

Previous studies indicate that psychosocial factors can impact COPD prevalence. However, research into this association has predominantly focused on negative factors such as depression. The aim of this study was to examine whether high subjective wellbeing is associated with a lower risk of developing COPD.

METHODS

The sample consisted of 12,246 participants aged ≥50 years from the Survey of Health, Ageing and Retirement in Europe. We used Cox proportional hazards regression to examine the relationship between wellbeing (measured using the CASP-12) and incidence of COPD over a follow-up period of 9 years.

RESULTS

There was a significant association between wellbeing and COPD risk. In age-adjusted analyses, a standard deviation increase in CASP-12 score was associated with a reduced risk of COPD; hazard ratios (95% confidence intervals) for men and women were 0.67 (0.60-0.75) and 0.80 (0.73-0.87) respectively. After additional adjustment for demographic and health behaviour variables, this association remained significant for men but not for women: the fully-adjusted hazard ratios were 0.80 (0.70-0.91) and 0.91 (0.82-1.03) respectively.

CONCLUSIONS

Greater wellbeing is associated with a reduced risk of COPD, particularly in men. Future research is needed to establish whether gender reliably moderates this association.

Evaluation of Dyspnea in the Elderly

Dyspnea is due to an imbalance between the demand to breathe and the ability to breathe. The prevalence is ∼30% for those 65 years or older with walking on a level surface or up an incline. Dyspnea is a strong predictor of mortality in elderly individuals. Anemia, cardiovascular disease, deconditioning, psychological disorders, and respiratory diseases are common causes of dyspnea. Initial treatments to relieve breathing discomfort should be directed toward improving the pathophysiology of the underlying disease. Simple and inexpensive strategies to relieve dyspnea are available. This article provides an update on the evaluation of chronic dyspnea in elderly individuals.

Experimental dyspnea as a stressor: differential cardiovegetative responses to inspiratory threshold loading in healthy men and women

Dyspnea is associated with an emotional reaction that involves limbic activation. The inspiratory threshold load (ITL) is known to elicit a dyspneic response in healthy subjects. Laboratory-induced stress conditions have been shown to elicit sex-related differences in cardiovascular responses. The aim of this study was to evaluate how healthy men ( n = 8) and women ( n = 9) react and adapt to 5-min periods of ITL at three levels (low, medium, and high) in terms of heart rate (HR), temporal (RMSSD) and spectral (LF, HF, LF/HF ratio) HRV indexes, and rating of breathing discomfort. HR increased with low, medium, and high ITL in men, whereas it increased only with high ITL in women. LF/HF ratio increased at low ITL in both men and women. Modifications appear to depend essentially on increased LF in men and on reduced HF in women. In addition, HRV modifications differ between men and women, following the order of presentation of ITLs. Our results show a continuous and sustained stress in men (increased HR, LF, and LF/HF ratio across ITL presentation) and a stress adaptation in women. Subjective responses of breathing discomfort were not correlated with sympatho-vagal balance modifications for a subgroup of subjects ( n = 10). Breathing against the ITL induced autonomic modifications that are different between men and women, i.e., driven by sympathetic mediated responses in men, whereas women showed a greater parasympathetic modulation of cardiovascular activity. These results highlight the role of the mechanical inspiratory load in the heart rate variability seen in chronic obstructive pulmonary disease.

NEW & NOTEWORTHY Breathing against the ITL induced autonomic modifications driven by sympathetic mediated responses in men, whereas women showed a greater parasympathetic modulation of cardiovascular activity, even for low load. A stress circuit could be at the origin of autonomic modifications induced by ITL. Our results would underline the role of the mechanic inspiratory load in the abnormalities in heart rate variability seen in COPD patients.

Degree of dyspnoea at admission and discharge in patients with heart failure and respiratory diseases

Background

Dyspnoea is a disabling symptom in patients admitted with heart failure (HF) and respiratory diseases (RD). The main aim of this study is to evaluate its intensity at admission and discharge and the relation with quality of life. We also describe its management, intensity, and evolution in HF and RD.

Methods

In this descriptive, cross-sectional study, we included prospectively all patients admitted with decompensated HF and chronic obstructive pulmonary disease (COPD)/pulmonary fibrosis during 4 months. Surveys quantifying dyspnoea (Numerical Rating Scale 1-10) and quality of life (EuroQoL 5d) were administered at discharge.

Results

A total of 258 patients were included: 190 (73.6%) with HF and 68 (26.4%) with RD (62 COPD and 6 pulmonary fibrosis). Mean age was 74.0±1.2 years, and 157 (60.6%) were men. Dyspnoea before admission was 7.5±0.1. Patients with RD showed greater dyspnoea than those with HF both before admission (8.1±0.2 vs. 7.3±0.2, p=0.01) and at discharge (3.2±0.3 vs. 2.0±0.2, p=0.0001). They also presented a higher rate of severe dyspnoea (≥5) at discharge (23 [34.3%] vs. 36 [19.1%], p=0.02). Opioids were used in 41 (15.9%), mean dose 8.7±0.8 mg Morphine Equivalent Daily Dose. HF patients had worse EuroQoL 5d scores than those with RD, due to mobility problems (118 [62.1%] vs. 28 [41.8%], p=0.004), and lower punctuation in Visual Analogue Scale (57.9±1.6 vs. 65.6±1.0, p=0.006).

Conclusions

About a quarter of patients admitted with HF or RD persist with severe dyspnoea at discharge. Opioids are probably underused. HF patients have less dyspnoea than patients with RD but present worse quality of life.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-017-0208-x) contains supplementary material, which is available to authorized users.

Women's Health and Lung Development and Disease

Although the lung is not traditionally thought of as an organ affected by sex-based differences, emerging literature elucidates major differences between men and women in the development, physiology, and predilection to and outcomes in lung diseases. These differences are driven by both differences in sex hormones and differences in environmental exposures. However, in many cases the underlying etiology of these sex- and gender-based differences is unknown. This article outlines the state-of-the-art knowledge on the etiology of sex differences in lung disease, including differences in lung development and physiology, and reviews therapy recommendations that are sex based.

Asthma-chronic obstructive pulmonary disease overlap syndrome - Literature review and contributions towards a Portuguese consensus

INTRODUCTION

Phenotypic overlap between the two main chronic airway pulmonary diseases, asthma and chronic obstructive pulmonary disease (COPD), has been the subject of debate for decades, and recently the nomenclature of asthma-COPD overlap syndrome (ACOS) was adopted for this condition. The definition of this entity in the literature is, however, very heterogeneous, it is therefore important to define how it applies to Portugal.

METHODS

A literature review of ACOS was made in a first phase resulting in the drawing up of a document that was later submitted for discussion among a panel of chronic lung diseases experts, resulting in reflexions about diagnosis, treatment and clinical guidance for ACOS patients.

RESULTS

There was a consensus among the experts that the diagnosis of ACOS should be considered in the concomitant presence of: clinical manifestations characteristic of both asthma and COPD, persistent airway obstruction (post-bronchodilator FEV₁/FVC<0.7), positive response to bronchodilator test (increase in FEV₁ of ≥200mL and ≥12% from baseline) and current or past history of smoking or biomass exposure. In reaching diagnosis, the presence of peripheral eosinophilia (>300eosinophils/μL or >5% of leukocytes) and previous history of atopy should also be considered. The recommended first line pharmacological treatment in these patients is the ICS/LABA association; if symptomatic control is not achieved or in case of clinical severity, triple therapy with ICS/LABA/LAMA may be used. An effective control of the exposure to risk factors, vaccination, respiratory rehabilitation and treatment of comorbidities is also important.

CONCLUSIONS

The creation of initial guidelines on ACOS, which can be applied in the Portuguese context, has an important role in the generation of a broad nationwide consensus. This will give, in the near future, a far better clinical, functional and epidemiological characterization of ACOS patients, with the ultimate goal of achieving better therapeutic guidance.

Management of COPD, equal treatment across age, gender, and social situation? A register study

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease where treatment decisions should be based on disease severity and also should be equally distributed across age, gender, and social situation. The aim of this study was to determine to what extent patients with COPD are offered evidence-based interventions and how the interventions are distributed across demographic and clinical factors in the sample. Baseline registrations of demographic, disease-related, and management-related variables of 7,810 patients in the Swedish National Airway Register are presented. One-third of the patients were current smokers. Patient-reported dyspnea and health-related quality of life were more deteriorated in elderly patients and patients living alone. Only 34% of currently smoking patients participated in the smoking cessation programs, and 22% of all patients were enrolled in any patient education program, with women taking part in them more than men. Less than 20% of the patients had any contact with physiotherapists or dieticians, with women having more contact than men. Men had more comorbidities than women, except for depression and osteoporosis. Women were more often given pharmacological treatments. With increasing severity of dyspnea, participation in patient education programs was more common. Dietician contact was more common in those with lower body mass index and more severe COPD stage. Both dietician contact and physiotherapist contact increased with deteriorated health-related quality of life, dyspnea, and increased exacerbation frequency. The present study showed that COPD management is mostly equally distributed across demographic characteristics. Only a minority of the patients in the present study had interdisciplinary team contacts. Thus, this data shows that the practical implementation of structured guidelines for treatment of COPD varies, to some extent, with regard to age and gender. Also, disease characteristics influence guideline implementation for each individual patient. Quality registers have the strength to follow-up on compliance with guidelines and show whether an intervention needs to be adapted prior to implementation in health care practice.

Assessing the effect of culturally specific audiovisual educational interventions on attaining self-management skills for chronic obstructive pulmonary disease in Mandarin- and Cantonese-speaking patients: a randomized controlled trial

BACKGROUND

Patient education is a key component in the management of chronic obstructive pulmonary disease (COPD). Delivering effective education to ethnic groups with COPD is a challenge. The objective of this study was to develop and assess the effectiveness of culturally and linguistically specific audiovisual educational materials in supporting self-management practices in Mandarin- and Cantonese-speaking patients.

METHODS

Educational materials were developed using participatory approach (patients involved in the development and pilot test of educational materials), followed by a randomized controlled trial that assigned 91 patients to three intervention groups with audiovisual educational interventions and one control group (pamphlet). The patients were recruited from outpatient clinics. The primary outcomes were improved inhaler technique and perceived self-efficacy to manage COPD. The secondary outcome was improved patient understanding of pulmonary rehabilitation procedures.

RESULTS

Subjects in all three intervention groups, compared with control subjects, demonstrated postintervention improvements in inhaler technique (P<0.001), preparedness to manage a COPD exacerbation (P<0.01), ability to achieve goals in managing COPD (P<0.01), and understanding pulmonary rehabilitation procedures (P<0.05).

CONCLUSION

Culturally appropriate educational interventions designed specifically to meet the needs of Mandarin and Cantonese COPD patients are associated with significantly better understanding of self-management practices. Self-management education led to improved proper use of medications, ability to manage COPD exacerbations, and ability to achieve goals in managing COPD.

CLINICAL IMPLICATION

A relatively simple culturally appropriate disease management education intervention improved inhaler techniques and self-management practices. Further research is needed to assess the effectiveness of self-management education on behavioral change and patient empowerment strategies.

What is asthma-COPD overlap syndrome? Towards a consensus definition from a round table discussion

Patients with asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) have been largely excluded from pivotal therapeutic trials and, as a result, its treatment remains poorly defined and lacking firm evidence. To date, there is no universally accepted definition of ACOS, which has made it difficult to understand its epidemiology or pathophysiology. Despite many uncertainties, there is emerging agreement that some of the key features of ACOS include persistent airflow limitation in symptomatic individuals 40 years of age and older, a well-documented history of asthma in childhood or early adulthood and a significant exposure history to cigarette or biomass smoke. In this perspective, we propose a case definition of ACOS that incorporates these key features in a parsimonious algorithm that may enable clinicians to better diagnose patients with ACOS and most importantly enable researchers to design therapeutic and clinical studies to elucidate its epidemiology and pathophysiology and to ascertain its optimal management strategies.

Gender inequalities in COPD decision-making in primary care

BACKGROUND

COPD is a frequent severe illness that increasingly affects females. Gender inequalities have been reported in COPD care.

OBJECTIVE

To analyze decision-making in primary care for men and women with identical COPD as a function of the gender of the family physician (FP).

METHODS

Cross-sectional, multicenter study in 457 Andalusian FPs, using a self-administered vignette-based questionnaire on COPD featuring a male or female patient, with four variables on clinical reasoning: "tobacco as most important risk factor (RF)", "ordering of spirometry", "COPD as most likely diagnosis", and "referral". Multilevel logistic regression analysis.

RESULTS

Response rate was 67.4% (308/457). In analysis of the four FP gender-patient gender dyads, tobacco was more frequently considered as priority RF for the man than for the woman in the vignette by female (95.6%vs.67.1%) and male (79.8%vs.62.5%) FPs. COPD was more frequently the most likely diagnosis for the man versus woman by female (84.4%vs.49.9%) and male (78.5%vs.57.8%) FPs. Male FPs more frequently ordered spirometry for the man versus woman (68.1%vs.46.8%). There were no differences in referral between male and female patients. Male FPs were more likely than female FPs to consider tobacco as priority RF for the man (p = 002). Female FPs were more likely than male FPs to refer the man (22.5%vs.8%).

CONCLUSIONS

There may be gender inequalities in primary care for COPD in our setting. Diagnostic and therapeutic efforts appear lower in female patients. Male and female FPs only differed in care of the male patient, indicating FP gender-patient gender interaction.

Effects on pulmonary rehabilitation in patients with COPD or ILD: A retrospective analysis of clinical and functional predictors with particular emphasis on gender

BACKGROUND

The response of patients in a pulmonary rehabilitation (PR) is essentially good. However, not all patients benefit from PR to the same extent. In this analysis we wanted to identify the impact of gender and other factors on PR outcomes in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD).

METHODS

Patients suffering from COPD (n = 1492) or ILD (n = 599), treated during an inpatient PR between 1997 and 2015, were analysed according to the effects of PR on exercise capacity and quality of life with regard to the impact of gender or other predictors by univariate and multivariate analyzes.

RESULTS

In the group of COPD patients, 30% did not achieve the expected physical performance during the 6-min walk test (28% of female and 32% of male patients). However, the non-responders initially have had a higher 6-min walking distance (6-MWD) (p < 0.001) and both male and female showed a significant lower BODE index (p = 0.025) in the multivariate analysis. In the ILD-group, 37% females and 43% males were classified as non-responders with regard to the 6-MWD. Also in this group, the non-responders initially have had a higher 6-MWD (p < 0.001). All other variables (age, BMI, lung function, blood gases, C-reactive Protein, Haemoglobin or rehabilitation duration) had no influence on the outcome.

CONCLUSION

Our study supports the positive effects of PR in COPD and ILD patients. In both groups, patients with the biggest limitations benefit most from PR. However, relevant gender differences or other predictors could not be found.

The asthma-COPD overlap syndrome: how is it defined and what are its clinical implications?

It is increasingly recognized that both asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases with a large inter-individual variability with respect to their clinical expression, disease progression, and responsiveness to the available treatments. The introduction of asthma–COPD overlap syndrome (ACOS) may lead to a better clinical characterization and improved treatment of patients with obstructive airways disease. However, it is still in its early phase and several improvements will have to be made. First, a clear definition of ACOS and preferably also its sub-phenotypes, eg, asthma–ACOS and COPD–ACOS, is urgently needed. That would also allow researchers to design clinical studies in well-defined patients. The latter is important since the interpretation of clinical studies performed so far is hampered by the use of many different definitions of ACOS. Second, future studies are needed to investigate the role of state-of-the-art techniques such as computed tomography, genetics, and genomics in the phenotyping of patients with obstructive airways disease, ie, asthma, COPD, and ACOS. Third, longitudinal studies are now needed to better define the clinical implications of ACOS with respect to the long-term outcome and treatment of ACOS and its sub-phenotypes compared to only asthma or COPD.

Commentary on gender differences in prevalence, treatment, and quality of life of patients with chronic rhinosinusitis

Objective:

To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS).

Methods:

Review of the literature and expert opinion.

Results:

From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men.

Conclusions:

Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.