Undernutrition state in patients with chronic obstructive pulmonary disease. A critical appraisal on diagnostics and treatment

Multidimensional individualized nutritional therapy for individuals with severe chronic obstructive pulmonary disease: study protocol for a registry-based randomized controlled trial

BACKGROUND

Individuals with severe chronic obstructive pulmonary disease (COPD) are often at risk of undernutrition with low health-related quality of life (HRQoL). Undernutrition can worsen COPD and other comorbidities, be an independent predictor of morbidity and functional decline resulting in increased healthcare consumption and increased risk of death. Especially exacerbations and acute infections result in unintentional weight loss. The aim is to investigate the effect of an individualized nutritional intervention among individuals with severe COPD.

METHODS

An open-label randomized controlled trial with two parallel groups. Participants are recruited from the pulmonary outpatient clinic at the Department of Pulmonary and Infectious Diseases, Copenhagen University Hospital, North Zealand, Denmark, and randomly allocated to either the intervention (intervention + standard of care) or control group (standard of care). The intervention has a duration of 3 months and combines individual nutritional care with adherence support and practical tools. It contains 4 elements including an individual nutritional plan, regular contacts, adherence support, and weight diary. The primary outcome is a difference in HRQoL (EQ-5D-5L) between the intervention and control group 3 months after baseline. Difference in functional capacity (grip strength, 30-s stand chair test, and physical activity), disease-specific quality of life (COPD Assessment Test), anxiety and depression (Hospital Anxiety and Depression Scale), nutritional parameters (energy and protein intake), anthropometry (weight, body mass index, waist, hip, and upper arm circumference), body composition (total fat-free and fat mass and indices), and prognosis (exacerbations, oxygen therapy, hospital contacts, and mortality) 3 months after baseline will be included as secondary outcomes. Data will be collected through home visits at baseline and 1 and 3 months after baseline.

DISCUSSION

Currently, nutritional care is a neglected area of outpatient care among individuals with severe COPD. If this patient-centered approach can demonstrate a positive impact on HRQoL, mortality, and hospital contacts, it should be recommended as part of end-of-life care for individuals with severe COPD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04873856 . Registered on May 3, 2021.

Uncovering undernutrition in chronic obstructive pulmonary disease: Beyond body mass index

BACKGROUND

Undernutrition, a common but treatable complication of chronic obstructive pulmonary disease (COPD), contributes to poor outcomes but is under-detected. Improved detection could prompt dietary intervention which may improve outcomes. We investigated whether adding a measure of muscle mass (fat-free mass index, FFMI) or a malnutrition screening tool (Mini Nutritional Assessment, MNA®) to the commonly used measure of body mass index (BMI), helps detect undernutrition in COPD.

METHODS

We conducted a retrospective chart review of 86 outpatients with COPD. Demographic and disease severity data were collected, and nutritional status assessed using BMI, FFMI and MNA®.

RESULTS

Patients comprised 55% males with median age 71.5 years, severe COPD (median FEV₁ = 0.74 (30.5% predicted)) and high symptom impact (median COPD Assessment Test (CAT) = 23). Twenty-eight percent of patients had low BMI, 27% had low FFMI, 22% were MNA®-classified malnourished and 43% were MNA®-classified at risk of malnutrition. MNA® correlated moderately with BMI and classified 55% of patients with healthy/high BMI as either malnourished or at risk of malnutrition. FFMI and BMI correlated strongly, and low FFMI was present in 5% of patients with healthy/high BMI. The undernutrition measures also showed weak to moderate correlations with disease severity (spirometry data) and MNA® weakly correlated with symptom impact (CAT).

CONCLUSION

The MNA® identified more undernourished patients than FFMI or BMI. It also correlated with disease severity and broader symptom burden. The MNA® appears to be a simple tool for earlier detection of patients who may benefit from dietary intervention, potentially enhancing their quality of life.

Are Undernutrition and Obesity Associated with Post-Discharge Mortality and Re-Hospitalization after Hospitalization with Community-Acquired Pneumonia?

Undernutrition is associated with increased mortality after hospitalization with community-acquired pneumonia (CAP), whereas obesity is associated with decreased mortality in most studies. We aimed to determine whether undernutrition and obesity are associated with increased risk of re-hospitalization and post-discharge mortality after hospitalization. This study was nested within the Surviving Pneumonia cohort, which is a prospective cohort of adults hospitalized with CAP. Patients were categorized as undernourished, well-nourished, overweight, or obese. Undernutrition was based on diagnostic criteria by the European Society for Clinical Nutrition and Metabolism. Risk of mortality was investigated using multivariate logistic regression and re-hospitalization with competing risk Cox regression where death was the competing event. Compared to well-nourished patients, undernourished patients had a higher risk of 90-day (OR 3.0, 95% CI 1.0; 21.4) mortality, but a similar 30-day and 180-day mortality risk. Obese patients had a similar re-hospitalization and mortality risk as well-nourished patients. In conclusion, among patients with CAP, undernutrition was associated with increased risk of mortality. Undernourished patients are high-risk patients, and our results indicate that in-hospital screening of undernutrition should be implemented to identify patients at mortality risk. Studies are required to investigate whether nutritional therapy after hospitalization with CAP would improve survival.

A structural equation model-based study on the status and influencing factors of acute exacerbation readmission of elderly patients with chronic obstructive pulmonary disease within 30 days

Objective

To investigate the circumstances that lead to acute exacerbation readmission of elderly patients with chronic obstructive pulmonary disease (COPD) within 30 days and to explore the influencing factors of readmission using a structural equation model to provide evidence for medical staff so that effective intervention measures can be taken.

Methods

The convenience sampling method was used to select 1120 elderly patients with COPD from the respiratory departments of thirteen general hospitals in the Ningxia region, China, from April 2019 to August 2020, who then completed a survey questionnaire. The survey questionnaire contained a general data questionnaire and the modified Medical Research Council, activities of daily living, geriatric depression scale and COPD assessment test scales.

Results

The readmission rate of patients with COPD presenting with acute exacerbation within 30 days was determined to be 21.52%. Therefore, the modified model measures data accurately. The results showed that seasonal factors, family rehabilitation, age factors and overall health status were direct factors in the acute exacerbation readmission of patients with COPD within 30 days of hospital discharge. Smoking is not only a direct factor for acute exacerbation readmission within 30 days but also an indirect factor through disease status; disease status and chronic disease are not only direct factors for acute exacerbation readmission within 30 days but also indirect factors through the patient’s overall health status.

Conclusions

The rate of patients with COPD presenting with acute exacerbation within 30 days is high; while taking measures to prevent readmission based on influencing factors that directly impact admission rates, attention should also be paid to the interaction between these factors.

Prediction of 30-day risk of acute exacerbation of readmission in elderly patients with COPD based on support vector machine model

Background

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is an important event in the process of disease management. Early identification of high-risk groups for readmission and appropriate measures can avoid readmission in some groups, but there is still a lack of specific prediction tools. The predictive performance of the model built by support vector machine (SVM) has been gradually recognized by the medical field. This study intends to predict the risk of acute exacerbation of readmission in elderly COPD patients within 30 days by SVM, in order to provide scientific basis for screening and prevention of high-risk patients with readmission.

Methods

A total of 1058 elderly COPD patients from the respiratory department of 13 general hospitals in Ningxia region of China from April 2019 to August 2020 were selected as the study subjects by convenience sampling method, and were followed up to 30 days after discharge. Discuss the influencing factors of patient readmission, and built four kernel function models of Linear-SVM, Polynomial-SVM, Sigmoid-SVM and RBF-SVM based on the influencing factors. According to the ratio of training set and test set 7:3, they are divided into training set samples and test set samples, Analyze and Compare the prediction efficiency of the four kernel functions by the precision, recall, accuracy, F1 index and area under the ROC curve (AUC).

Results

Education level, smoking status, coronary heart disease, hospitalization times of acute exacerbation of COPD in the past 1 year, whether long-term home oxygen therapy, whether regular medication, nutritional status and seasonal factors were the influencing factors for readmission. The training set shows that Linear-SVM, Polynomial-SVM, Sigmoid-SVM and RBF-SVM precision respectively were 69.89, 78.07, 79.37 and 84.21; Recall respectively were 50.78, 69.53, 78.74 and 88.19; Accuracy respectively were 83.92, 88.69, 90.81 and 93.82; F1 index respectively were 0.59, 0.74, 0.79 and 0.86; AUC were 0.722, 0.819, 0.866 and 0.918. Test set precision respectively were86.36, 87.50, 80.77 and 88.24; Recall respectively were51.35, 75.68, 56.76 and 81.08; Accuracy respectively were 85.11, 90.78, 85.11 and 92.20; F1 index respectively were 0.64, 0.81, 0.67 and 0.85; AUC respectively were 0.742, 0.858, 0.759 and 0.885.

Conclusions

This study found the factors that may affect readmission, and the SVM model constructed based on the above factors achieved a certain predictive effect on the risk of readmission, which has certain reference value.

Detection of nutritional risk and hospital stay in the hospitalized elderly adult

Introduction

Background and aims: a high nutritional risk can independently be associated with a longer hospital stay in elderly patients. This study aims to establish the prevalence of the risk of malnutrition and its associated factors in a high-complexity level hospital in Bogotá, Colombia, during 2018. Methods: a cross-sectional study. The prevalence of the risk of malnutrition was measured using a malnutrition-screening tool (MST), and the association with hospital stage, age, and patient diagnoses was assessed. Results: a total of 7,192 patients comprised the cohort. Age range was 61 to 108 years, with an average of 77.1 ± 9.2 years, and subjects were mostly female (55.5 %). We identified as main conditions urinary tract infections (8.4 %), congestive heart failure (5.4 %), and chronic obstructive pulmonary disease with an acute exacerbation (4.6 %). The prevalence of the risk of malnutrition was 41.4 %, significantly associated with longer hospital stays (p < 0.001), older age (p < 0.001), and a diagnosis of delirium (OR = 5.98, 95 % CI: 2.78 to 12.86), diarrhea and gastroenteritis (OR = 5.01, 95 % CI: 2.44 to 10.32), gastrointestinal hemorrhage (OR = 4.44, 95 % CI: 2.38 to 8.28), specified pneumonia (OR = 4.43, 95% CI: 2.11 to 9.30), and high blood pressure (3.94, 95 % CI: 2.07 to 7.50). Other diagnoses included abdominal pain (other) (OR = 3.80, 95 % CI: 1.81 to 7.99), urinary tract infections (OR = 3.64, 95 % CI: 2.07 to 6.24), acute bronchitis (OR = 3.22, 95 % CI: 1.56 to 6.65), and bacterial pneumonia (OR = 3.02, 95 % CI: 1.65 to 5.55). Conclusion: the prevalence of the risk of malnutrition in our institution is approximately one in two patients, with a significant association to increased hospital stay ≥ 8 days, patient age ≥ 80 years, and mainly diagnoses of delirium, diarrhea, and gastroenteritis of suspected infectious etiology.

An index of the fractal characteristic of an airway tree is associated with airflow limitations and future body mass index reduction in COPD patients

Disorders of the fractality of an airway tree and a vessel tree have been studied in pulmonary diseases. Here we successfully applied Mishima's D to the bronchial minimal inner cross-sectional area (iCSA) measured in multidetector computed tomography (MDCT) images of chronic obstructive pulmonary disease (COPD) and non-COPD smokers (n = 162), by defining D in the following formula: logN(≥X) = -D × logX + c, where X is a certain iCSA value, N(≥X) is the number of airway branches having iCSA greater than or equal to X, and c is a constant. Mathematically, this D of iCSA was associated with the expected reduction ratio of iCSA at bifurcations, which can be estimated by 2^-1/D. This D of iCSA also correlated weakly with the box-counting fractal dimension and Weibel's reduction ratio over airway generations, which indicated that the airway tree was not a perfect fractal object and that the branch bifurcation was asymmetric. The D of iCSA showed positive correlations with lung function measurements of airflow limitation in study participants. In addition, D of iCSA representing the periphery showed an association with future body mass index reduction, most likely as an indicator of energy efficacy for breathing as predicted by Hess-Murray's law. D of iCSA may be helpful to understanding the pathogenesis of obstructive lung diseases.NEW & NOTEWORTHY An airway tree is a fractal object. We showed that the distribution of minimal inner cross-sectional area (iCSA) of airway branches can be expressed by a fractal index, D, of minimal iCSA. This D was correlated with airflow limitation and future body mass index reduction in chronic obstructive pulmonary disease patients, as predicted by Hess-Murray's law.

Screening for comorbidities in COPD

Due to growing recognition of comorbidities, COPD is no longer considered a disease affecting only the respiratory system. Its management now entails the early diagnosis and treatment of comorbidities. However, although many studies have examined the impact of comorbidities on the evolution of COPD and patients' quality of life, very few have explored the means to systematically identify and manage them. The aims of this article are to summarise the state of current knowledge about comorbidities associated with COPD and to propose a possible screening protocol in the outpatient setting, emphasising the areas needing further research.

[Undernutrition of the elderly]

Malnutrition remains a particularly important issue in elderly. Physiological ageing induces many changes but ageing cannot entirely explain a Protein-Energy Malnutrition (PEM). Nutritionnal screening is indicated once a year in community medicine or in the first 48hours in case of an acute disease or of hospitalization. The Mini Nutritional Assessment is recommended for screening and for the diagnostic of malnutrition. Possible aetiologies are large and must be investigated in order to be careful not to dismiss curable disease and to be able to take corrective actions. PEM is associated to functional decline, length of stay in hospital and to morbi-mortality. Recommendations for dietary intakes in healthy old subjects are about 30 kcal/kg/day and 1 g/kg/day of protein and are strongly enhanced in case of acute or chronic diseases. The nutritional strategy depends on spontaneous food intake, medical situation, patient profile and opinion. Appropriate nutritional care could reduce morbidity-mortality and prevent functional decline in various disease contexts.

Can muscle protein metabolism be specifically targeted by nutritional support and exercise training in chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) associates with several extra-pulmonary effects. Muscle dysfunction and wasting is one of the most prominent extra-pulmonary effects and contributes to exercise limitation and health related quality of life (HRQoL), morbidity as well as mortality. The loss of muscle mass is characterised by an impaired balance between protein synthesis (anabolism) and protein breakdown (catabolism) which relates to nutritional disturbances, muscle disuse and the presence of a systemic inflammation, among other factors. Current approaches to reverse skeletal muscle dysfunction and wasting attain only modest improvements. The development of new therapeutic strategies aiming at improving skeletal muscle dysfunction and wasting are needed. This requires a better understanding of the underlying molecular pathways responsible for these abnormalities. In this review we update recent research on protein metabolism, nutritional depletion as well as physical (in)activity in relation to muscle wasting and dysfunction in patients with COPD. We also discuss the role of nutritional supplementation and exercise training as strategies to re-establish the disrupted balance of protein metabolism in the muscle of patients with COPD. Future areas of research and clinical practice directions are also addressed.