Rehabilitation of Patients with Coexisting COPD and Heart Failure

Chronic Obstructive Pulmonary Disease in Heart Failure: Challenges in Diagnosis and Treatment for HFpEF and HFrEF

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF), and it has a significant impact on the prognosis and quality of life of patients. Additionally, COPD is independently associated with lower adherence to first-line HF therapies. In this review, we outline the challenges of identifying and managing HF with preserved (HFpEF) and reduced (HFrEF) ejection fraction with coexisting COPD.

RECENT FINDINGS

Spirometry is necessary for COPD diagnosis and prognosis but is underused in HF. Therefore, misdiagnosis is a concern. Also, disease-modifying drugs for HF and COPD are usually safe but underprescribed when HF and COPD coexist. Patients with HF-COPD are poorly enrolled in clinical trials. Guidelines recommend that HF treatment should be offered regardless of COPD presence, but modern registries show that undertreatment persists. Treatment gaps could be attenuated by ensuring an accurate and earlier COPD diagnosis in patients with HF, clarifying the concerns related to pharmacotherapy safety, and increasing the use of non-pharmacologic treatments. Acknowledging the uncertainties, this review aims to provide key clinical resources to support better physician-patient co-decision-making and improve collaboration between health professionals.

Development and Validation of Prediction Models for Exacerbation, Frequent Exacerbations and Severe Exacerbations of Chronic Obstructive Pulmonary Disease: A Registry Study in North China

In COPD patients, exacerbation has a detrimental influence on the quality of life, disease progression and socioeconomic burden. This study aimed to develop and validate models to predict exacerbation, frequent exacerbations and severe exacerbations in COPD patients. We conducted an observational prospective multicenter study. Clinical data of all outpatients with stable COPD were collected from Beijing Chaoyang Hospital and Beijing Renhe Hospital between January 2018 and December 2019. Patients were followed up for 1 year. The data from Chaoyang Hospital was used for modeling dataset, and that of Renhe Hospital was used for external validation dataset. The final dataset included 456 patients, with 326 patients as the model group and 130 patients as the validation group. Using LABA + ICS, frequent exacerbations in the past year and CAT score were independent risk factors for exacerbation in the next year (OR = 2.307, 2.722 and 1.147), and FVC %pred as a protective factor (OR = 0.975). Combined with chronic heart failure, frequent exacerbations in the past year, blood EOS counts and CAT score were independent risk factors for frequent exacerbations in the next year (OR = 4.818, 2.602, 1.015 and 1.342). Using LABA + ICS, combined with chronic heart failure, frequent exacerbations in the past year and CAT score were independent risk factors for severe exacerbations in the next year (OR = 1.950, 3.135, 2.980 and 1.133). Based on these prognostic models, nomograms were generated. The prediction models were simple and useful tools for predicting the risk of exacerbation, frequent exacerbations and severe exacerbations of COPD patients in North China.

Global research publications on cardiovascular and pulmonary rehabilitation and their alignment with population rehabilitation needs: An ecological study

PURPOSE

Towards informing health research policy and planning, this article evaluates the relationship of the research publications in cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) with the rehabilitation needs arising from cardiovascular diseases (except stroke) and chronic respiratory diseases, over time (1990-2017).

METHODS

Ecological study using a secondary analysis and linear regressions of public domain data to associate two datasets of population-level data: (1) research publications for CR and PR (data from the PubMed database); and (2) global need for CR and PR (data from the Global Burden of Disease study).

RESULTS

The percentage of both CR and PR publications (among total rehabilitation research) significantly decreased from 1990 to 2017 (both: p < 0.01). PR needs and research publications were aligned: around 5% of total rehabilitation needs and rehabilitation research. For CR needs (around 2%, but significantly increasing since 1990), we found a greater portion of CR research publications (6.5% or over). Finally, we found an inverse association among the percentage of CR research publications and CR needs (b = -6.08; r2  = 0.37, p = 0.001).

CONCLUSION

The portion of CR and PR research (among total rehabilitation research) is declining over time. Yearly percentage of CR publications were greater than those of PR but for lower level of rehabilitation need, but the disparate trend was significantly decreasing over time. Population rehabilitation needs and their alignment with research volume must be one factor in the design of population-centred, equitable health research priorities.

Frailty and rehabilitation outcome in older patients with cardiorespiratory disease: preliminary multidimensional data

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are two clinical conditions often associated with cognitive dysfunctions, psychological distress, poor quality of life (QoL), and functional worsening. In addition, since patients suffering from these conditions are often older adults, frailty syndrome represents a further and important issue to be investigated. The present preliminary study aimed to perform a multidimensional assessment of CHF and/or COPD older patients (age ≥65) undergoing cardiac or pulmonary rehabilitation. The characteristics of the included patients (30 CHF and 30 COPD) resulted almost similar, except for the COPD patients' longer duration of illness and better performances in Addenbrooke's cognitive examination III subtests and short physical performance battery (SPPB). No significant differences were found in the frailty evaluation, but a consistent number of patients resulted to be frail (CHF=36.7% vs COPD=26.6%). After the rehabilitation program, a significant improvement was found in the whole sample concerning the executive functions (14.34±2.49 vs 15.62±2.22, p=0.001), quality of life (58.77±18.87 vs 65.82±18.45, p=0.003), depressive and anxious symptoms (6.27±4.21 vs 3.77±3.39, p=0.001 and 5.17±3.40 vs 3.38±3.21, p=0.001), frailty status [4.00 (3.00,5.00) vs 3.00 (3.00,5.00) p=0.035] and functional exercise abilities [SPPB, 7.40±3.10 vs 9.51±3.67, p=0.0002; timed up and go test, 14.62±4.90 vs 11.97±4.51, p<0.0001; 6-minute walking test, 353.85±127.62 vs 392.59±123.14, p=0.0002]. Preliminary results showed a substantial homogeneity of CHF and COPD older patients' cognitive, psychosocial, frailty, and functional characteristics. Nevertheless, the specific rehabilitation intervention appears promising in both clinical populations. This trial has been registered with the ClinicalTrials.gov, NCT05230927 registration number (clinicaltrials.gov/ct2/show/NCT05230927).

Correlation between the Treg/Thl7 Index and the Efficacy of PD-1 Monoclonal Antibody in Patients with Advanced Non-Small-Cell Lung Cancer Complicated with Chronic Obstructive Pulmonary Disease

Objective

It was to explore the correlation between regulatory T cells (Treg)/T helper cell 17 (Thl7) and the efficacy of receiving a programmed death protein-1 (PD-1) monoclonal antibody (mAb) in patients with advanced non-small-cell lung cancer (NSCLC) complicated with chronic obstructive pulmonary disease (COPD).

Methods

The research subjects were 82 patients who were clinically evaluated and treated in the Respiratory Department of Suqian Hospital connected with Xuzhou Medical University from January to December 2021. All of the patients were given PD-1 immunotherapy, and 50 healthy people were chosen as the control group. Classification was carried out according to tumor type and tumor stage. The levels of Th17 and Treg/Th17 in the peripheral blood of patients with different tumor-node-metastasis (TNM) stages and different types were compared, and the immune function, lung function (forced expiratory volume in one second/forced vital capacity (FEV1%/FVC), FEV1%, and FVC), and changes in inflammatory factors were compared before and after treatment. The levels of interleukin (IL)-17, IL-6, tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β were compared between the two groups. The correlation between Th17 cells and Treg cells in the peripheral blood of patients with NSCLC complicated with COPD was analyzed.

Results

After treatment, the levels of IL-17, IL-6, TNF-α, and TGF-β in patients with NSCLC combined with COPD were notably superior to those in the control group (P < 0.05). The immune function and lung function of the patients were improved after treatment. There were 43 cases of squamous cell carcinoma, 30 cases of adenocarcinoma, and 9 cases of large cell carcinoma. The proportion of Th17 cells to CD4+ T cells in the blood of the three types of patients and the proportion of CD4⁺CD25^HiCD127^Lo regulatory T cells to CD4+ lymphocyte cells in Treg cells showed no considerable difference among the different case types (P > 0.05). No considerable difference was indicated in Treg/Th17 in peripheral blood between stage IIIB and stage IV lung cancer patients (P > 0.05). A positive linear correlation was revealed between Th17 cells and Treg cells in the peripheral blood of patients with NSCLC combined with COPD, R = 0.26, P = 0.039.

Conclusion

Treg and Th17 cells were shown to be much higher in lung cancer patients with COPD, which could lead to immunosuppression and tumor growth. PD-1 therapy for NSCLC has demonstrated efficacy and can improve patients' immunological state while being extremely safe.

Prognostic Role of Chronic Obstructive Pulmonary Disease and Asthma Physiology Score for in-Hospital and 1-year Mortality in Patients with Acute Exacerbations of COPD

Background and Objectives: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) often lead to high mortality. Chronic obstructive pulmonary disease and asthma physiology score (CAPS) is a simple clinical severity score. The aim of this study was to explore whether CAPS could be an effective predictor for in-hospital and 1-year mortality in AECOPD patients. Methods. We used CAPS to grade all patients and record their clinical characteristics. The receiver operator characteristic (ROC) curve was used to determine the cut-off of CAPS that discriminated survivors and non-survivors. Univariate and multivariate logistic regression analyses and Cox regression analyses were used to identify the risk factors for in-hospital and 1-year mortality, respectively. Results. 240 patients were enrolled in our study; 18 patients died during hospitalization and 29 patients died during the 1-year follow-up. Compared with in-hospital survivors, those who died were older (80.83 ± 6.06 vs. 76.94 ± 8.30 years old, P = 0.019) and had a higher percentage of congestive heart failure (61.1% vs. 14.4%, P < 0.001), higher CAPS levels (31.11 ± 10.05 vs. 16.49 ± 7.11 points, P < 0.001), and a lower BMI (19.48 ± 3.26 vs. 21.50 ± 3.86, P = 0.032). The area under the ROC curve of CAPS for in-hospital death was 0.91 (95% CI: 0.85–0.96) with a sensitivity of 0.889 and a specificity of 0.802 for a cut-off point of 21 points. CAPS ≥21 points was an independent risk factor for in-hospital mortality after adjustment for relative risk (RR) (RR = 13.28, 95% CI: 1.97–89.53, P = 0.008). Univariate Cox regression analysis showed that a CAPS ≥21 points (HR = 4.07, 95% CI: 1.97–8.44) was a risk factor for 1-year mortality. However, multivariate Cox regression analysis showed that CAPS (HR = 2.24, 95% CI: 0.90–5.53) was not associated with 1-year mortality. Conclusion: A CAPS ≥21 points was a strong and independent risk factor for in-hospital mortality in AECOPD patients and CAPS had no impact on the 1-year mortality in patients with acute exacerbations of COPD after discharge.

Reliability and Validity of the Japanese Version of the Barthel Index Dyspnea Among Patients with Respiratory Diseases

Purpose

Japan has only a few respiratory disease-specific activity of daily living scales that are accepted outside of Japan, and they are not widely used. The Barthel Index dyspnea (BI-d), an improved version of the Barthel Index (BI), may be popular in Japan. The purpose of this study was to develop the Japanese version of BI-d (J-BI-d) and investigate its reliability and validity.

Patients and Methods

The J-BI-d was developed using the basic guidelines for scale translation. The study included patients with chronic respiratory disease, receiving outpatient care at two centers between January 2019 and February 2020. Scores on the J-BI-d, modified Medical Research Council scale (mMRC scale), BI, respiratory function tests, and 6-minute walk distance (6MWD) test were measured. To verify the test–retest reliability, the J-BI-d was re-administered, and the intraclass correlation coefficient (ICC) was obtained. Internal consistency was verified by Cronbach’s alpha reliability coefficient, and criterion-related validity was verified through a correlation analysis of the J-BI-d with mMRC scale and 6MWD test. Divergent validity was verified through correlation analysis between the J-BI-d and BI.

Results

Data for 57 participants (mean age 74.4 ± 8.3 years) were analyzed, and reliability testing was performed with 42 of them. The mean time to retest was 8.1 ± 3.0 days, and the ICC (2, 1) was 0.76 (95% CI: 0.62–0.85), indicating high reliability. Cronbach’s alpha reliability coefficient was 0.81, indicating high internal consistency. Correlation coefficients of the J-BI-d with 6MWD test (r = −0.46, p < 0.01) and mMRC scale (ρ = 0.76, p < 0.01) indicated high criterion-related validity. The J-BI-d and BI had a weak negative correlation (r = −0.29, p < 0.05), indicating high divergent validity.

Conclusion

The results of this study demonstrate high reliability and appropriate validity of the J-BI-d in patients with chronic respiratory disease.