Identifying patients at risk of late recovery (≥ 8 days) from acute exacerbation of chronic bronchitis and COPD

Terms and Definitions Used to Describe Recurrence, Treatment Failure and Recovery of Acute Exacerbations of COPD: A Systematic Review of Observational Studies

Introduction

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are important clinical events, with many patients experiencing multiple AECOPDs annually. The terms used in the literature to define recurring AECOPD events are inconsistent and may impact the ability to describe the true burden of these events. We undertook a systematic review to identify and summarize terms and definitions used in observational studies to describe AECOPD-related events occurring after an initial AECOPD (hereafter “subsequent AECOPD”).

Methods

PubMed was searched (2000–2019) for observational studies on subsequent AECOPD events using broad search strings for “COPD”, “exacerbation”, and “subsequent exacerbation events”. Only English-language studies were included. Small studies (n<50) and studies focusing on hospital re-admission only were excluded. Extracted data were analyzed descriptively to generate a narrative summary, using a thematic approach to group studies utilizing similar terms for subsequent AECOPD.

Results

Forty-seven studies were included. No single, distinct terms or definitions were used to define and identify multiple occurrences of AECOPDs, though most (46) studies used one or more of four clustered terms and definitions: reapse (n = 13), recurrence/re-exacerbation (n = 11), treatment failure (n = 12) and non-recovery/time to recovery (n = 16). Heterogeneity was observed within and between the four clusters with respect to study setting, starting point for observing subsequent AECOPDs, time frame to identify a subsequent AECOPD (except for studies using “time to recovery”), and basis for identifying a subsequent exacerbation.

Conclusion

Our review demonstrates that subsequent AECOPDs (including events such as relapse, recurrence/re-exacerbation, treatment failure, non-recovery/time to recovery) are ill-defined in the observational study literature, emphasizing the need to reach consensus on precise and objective definitions (for example, when one AECOPD ends and another begins). Use of standardized terminology and definitions may aid comparability between, and synthesis of, studies, thus improving the understanding of the natural history and burden of exacerbations in COPD patients.

Prulifloxacin Effectiveness in Moderate-to-Severe Acute Exacerbations of Chronic Bronchitis: Α Noninterventional, Multicentre, Prospective Study in Real-Life Clinical Practice-The "AIOLOS" Study

Real-world evidence regarding the effectiveness of prulifloxacin in the treatment of acute exacerbations of chronic bronchitis (AECB) is limited. Therefore, this study aimed to assess the rates and time to symptom improvement and resolution in patients with moderate-to-severe AECB who were given prulifloxacin in the routine care in Greece. This observational, prospective study, conducted in 15 hospital-based clinics across Greece, enrolled outpatients >40 years old, with moderate-to-severe AECB, for whom the physician had decided to initiate treatment with prulifloxacin. Data were collected at prulifloxacin onset (baseline), 7-10 days after baseline, and at least 28 days after therapy completion. Between 23 November 2015 and 27 January 2018, 305 patients (males: 76.4%; mean (standard deviation) (SD) age: 69.7 (9.8) years; Anthonisen type I/II: 94.8%; chronic bronchitis duration >10 years: 24.9%) were consecutively enrolled. At baseline, >80% had increased sputum volume, cough, dyspnoea, and sputum purulence. Prulifloxacin improved symptoms in 99.7% of the patients after a mean (SD) of 5.47 (3.57) days, while symptoms fully recovered after a mean (SD) of 10.22 (5.00) days in 95.4%. The rate of adverse events related to prulifloxacin was 1.3% (serious: 0.7%). In the routine care in Greece, prulifloxacin was highly effective in moderate-to-severe AECB, while displaying a predictable safety profile.

Chronic bronchitis is associated with severe exacerbation and prolonged recovery period in Chinese patients with COPD: a multicenter cross-sectional study

BACKGROUND

Chronic bronchitis (CB) is closely associated with the frequency and severity of chronic obstructive pulmonary disease (COPD) exacerbation. However, little is known about the impact of CB on COPD exacerbations, severe and non-severe, and on recovery from an exacerbation.

METHODS

We conducted a nation-wide multicenter cross-sectional survey in China between September 2007 and December 2008. Eleven hospitals participated in this study. Patients' demographic information, presence of CB, overall numbers of COPD exacerbation and severe exacerbation leading to emergency visit, hospitalization and intensive care unit (ICU) stay in the past year, recovery period following the last exacerbation, and well- or poor-recovery were recorded.

RESULTS

A total of 1,101 patients with COPD were enrolled and 890 (80.8%) had CB. Patients with CB reported more history of frequent exacerbations (≥2/patient/year) (59.6% vs. 50.7%, P=0.019) and severe exacerbation (% emergency visit ≥1: 28.0% vs. 16.6%, P=0.001; % hospitalization ≥1: 51.2% vs. 28.0%, P<0.001; %ICU stay ≥1: 6.5% vs. 1.9%, P=0.009). Recovery period following the last exacerbation was longer in patients with CB (19.0±16.2 vs. 15.2±14.7 days, P=0.003) and more patients with CB reported poor recovery (85.8% vs. 78.4%, P=0.003). Multivariate analyses showed that CB was independently associated with severe exacerbation requiring emergency visit (adjusted OR, 1.512, P=0.048) and hospitalization (adjusted OR, 2.031, P<0.001) and prolonged recovery period (adjusted regression coefficient 2.861, P=0.030).

CONCLUSIONS

CB is associated with frequent exacerbations of COPD in Chinese population, especially severe exacerbations requiring emergency visit and hospitalization admission. Additionally, CB significantly prolongs recovery period following COPD exacerbation.

Prognostic factors for clinical failure of exacerbations in elderly outpatients with moderate-to-severe COPD

Background

Acute exacerbations represent a significant burden for patients with moderate-to-severe chronic obstructive pulmonary disease. Each exacerbation episode is frequently associated with a lengthy recovery and impaired quality of life. Prognostic factors for outpatients that may predict poor outcome after treatment with antibiotics recommended in the guidelines, are not fully understood. We aimed to identify pretherapy factors predictive of clinical failure in elderly (≥60 years old) outpatients with acute Anthonisen type 1 exacerbations.

Trial registration

NCT00656747.

Methods

Based on the moxifloxacin in AECOPDs (acute exacerbations of chronic obstructive pulmonary disease) trial (MAESTRAL) database, this study evaluated pretherapy demographic, clinical, sputum bacteriological factors using multivariate logistic regression analysis, with internal validation by bootstrap replicates, to investigate their possible association with clinical failure at end of therapy (EOT) and 8 weeks posttherapy.

Results

The analyses found that the independent factors predicting clinical failure at EOT were more frequent exacerbations, increased respiratory rate and lower body temperature at exacerbation, treatment with long-acting anticholinergic drugs, and in vitro bacterial resistance to study drug. The independent factors predicting poor outcome at 8 weeks posttherapy included wheezing at preexacerbation, mild or moderate (vs extreme) sleep disturbances, lower body temperature at exacerbation, forced expiratory volume in 1 second <30%, lower body mass index, concomitant systemic corticosteroids for the current exacerbation, maintenance long-acting β₂-agonist and long-acting anticholinergic treatments, and positive sputum culture at EOT.

Conclusion

Several bacteriological, historical, treatment-related factors were identified as predictors of early (EOT) and later (8 weeks posttherapy) clinical failure in this older outpatient population with moderate-to-severe chronic obstructive pulmonary disease. These patients should be closely monitored and sputum cultures considered before and after treatment.

Predictors of exacerbations in chronic obstructive pulmonary disease--results from the Bergen COPD cohort study

Background

COPD exacerbations accelerate disease progression.

Aims

To examine if COPD characteristics and systemic inflammatory markers predict the risk for acute COPD exacerbation (AECOPD) frequency and duration.

Methods

403 COPD patients, GOLD stage II-IV, aged 44–76 years were included in the Bergen COPD Cohort Study in 2006/07, and followed for 3 years. Examined baseline predictors were sex, age, body composition, smoking, AECOPD the last year, GOLD stage, Charlson comorbidity score (CCS), hypoxemia (PaO2<8 kPa), cough, use of inhaled steroids, and the inflammatory markers leucocytes, C-reactive protein (CRP), neutrophil gelatinase associated lipocalin (NGAL), soluble tumor necrosis factor receptor 1 (sTNF-R1), and osteoprotegrin (OPG). Negative binomial models with random effects were fitted to estimate the annual incidence rate ratios (IRR). For analysis of AECOPD duration, a generalized estimation equation logistic regression model was fitted, also adjusting for season, time since inclusion and AECOPD severity.

Results

After multivariate adjustment, significant predictors of AECOPD were: female sex [IRR 1.45 (1.14–1.84)], age per 10 year increase [1.23 (1.03–1.47)], >1 AECOPD last year before baseline [1.65 (1.24–2.21)], GOLD III [1.36 (1.07–1.74)], GOLD IV [2.90 (1.98–4.25)], chronic cough [1.64 (1.30–2.06)] and use of inhaled steroids [1.57 (1.21–2.05)]. For AECOPD duration more than three weeks, significant predictors after adjustment were: hypoxemia [0.60 (0.39–0.92)], years since inclusion [1.19 (1.03–1.37)], AECOPD severity; moderate [OR 1.58 (1.14–2.18)] and severe [2.34 (1.58–3.49)], season; winter [1.51 (1.08–2.12)], spring [1.45 (1.02–2.05)] and sTNF-R1 per SD increase [1.16 (1.00–1.35)].

Conclusion

Several COPD characteristics were independent predictors of both AECOPD frequency and duration.

Prediction of acute respiratory disease in current and former smokers with and without COPD

BACKGROUND

The risk factors for acute episodes of respiratory disease in current and former smokers who do not have COPD are unknown.

METHODS

Eight thousand two hundred forty-six non-Hispanic white and black current and former smokers in the Genetic Epidemiology of COPD (COPDGene) cohort had longitudinal follow-up (LFU) every 6 months to determine acute respiratory episodes requiring antibiotics or systemic corticosteroids, an ED visit, or hospitalization. Negative binomial regression was used to determine the factors associated with acute respiratory episodes. A Cox proportional hazards model was used to determine adjusted hazard ratios (HRs) for time to first episode and an acute episode of respiratory disease risk score.

RESULTS

At enrollment, 4,442 subjects did not have COPD, 658 had mild COPD, and 3,146 had moderate or worse COPD. Nine thousand three hundred three acute episodes of respiratory disease and 2,707 hospitalizations were reported in LFU (3,044 acute episodes of respiratory disease and 827 hospitalizations in those without COPD). Major predictors included acute episodes of respiratory disease in year prior to enrollment (HR, 1.20; 95% CI, 1.15-1.24 per exacerbation), airflow obstruction (HR, 0.94; 95% CI, 0.91-0.96 per 10% change in % predicted FEV1), and poor health-related quality of life (HR, 1.07; 95% CI, 1.06-1.08 for each 4-unit increase in St. George's Respiratory Questionnaire score). Risks were similar for those with and without COPD.

CONCLUSIONS

Although acute episode of respiratory disease rates are higher in subjects with COPD, risk factors are similar, and at a population level, there are more episodes in smokers without COPD.

Clinical outcomes and cost analysis of exacerbations in chronic obstructive pulmonary disease

BACKGROUND

Exacerbations are a major cause of disability, hospital admissions, and increased healthcare costs in patients with chronic obstructive pulmonary disease (COPD). This study investigated the clinical outcomes of outpatients with moderate to severe exacerbated COPD and their related costs.

METHODS

An observational study on the outcomes of ambulatory exacerbations of COPD was conducted. The course of the exacerbation was evaluated at a follow-up visit at 4 weeks. A cost analysis that encompassed the use of healthcare resources for treatment of the exacerbation was performed.

RESULTS

A total of 260 patients were included, with a mean age of 68.3 years and a mean FEV1 (% predicted) of 58.9 %. Twenty-two percent of patients had significant cardiovascular comorbidity. The most frequently prescribed antibiotics were moxifloxacin in 137 cases and amoxicillin-clavulanate in 50 cases. The rate of failure at 4 weeks was 12.5 %, with no differences between the two most prescribed antibiotics; however, patients treated with moxifloxacin had symptoms for 1.9 fewer days (P = 0.01). The mean cost of the exacerbation was <euro>344.96 (95 % CI: <euro>48.55-<euro>641.78), with 9.6 % of the costs for drugs and 72.9 % for hospital care of patients for whom treatment had failed.

CONCLUSIONS

Antibiotic treatment of our population was in compliance with local guidelines. The rate of failure observed in our study was lower than that reported in previous studies; however, the small percentage of patients that required hospital attention generated almost two-thirds of the total costs of the exacerbations.