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Papi A, Forini G, Maniscalco M, Bargagli E, Crimi C, Santus P, Molino A, Bandiera V, Baraldi F, D'Anna SE, Carone M, Marvisi M, Pelaia C, Scioscia G, Patella V, Aliani M, Fabbri LM. Long-term inhaled corticosteroid treatment in patients with chronic obstructive pulmonary disease, cardiovascular disease, and a recent hospitalised exacerbation: The ICSLIFE pragmatic, randomised controlled study. Eur J Intern Med 2024:S0953-6205(24)00283-8. [PMID: 38981765 DOI: 10.1016/j.ejim.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) frequently have cardiovascular comorbidities, increasing the risk of hospitalised COPD exacerbations (H-ECOPDs) or death. This pragmatic study examined the effects of adding an inhaled corticosteroid (ICS) to long-acting bronchodilator(s) (LABDs) in patients with COPD and cardiac comorbidities who had a recent H-ECOPD. METHODS Patients >60 years of age with COPD and ≥1 cardiac comorbidity, within 6 months after discharge following an H-ECOPD, were randomised to receive LABD(s) with or without ICS, and were followed for 1 year. The primary outcome was the time to first rehospitalisation and/or all-cause death. RESULTS The planned number of patients was not recruited (803/1032), limiting the strength of the conclusions. In the intention-to-treat population, 89/403 patients (22.1 %) were rehospitalised or died in the LABD group (probability 0.257 [95 % confidence interval 0.206, 0.318]), vs 85/400 (21.3 %) in the LABD+ICS group (0.249 [0.198, 0.310]), with no difference between groups in time-to-event (hazard ratio 1.116 [0.827, 1.504]; p = 0.473). All-cause and cardiovascular mortality were lower in patients receiving LABD(s)+ICS, with relative reductions of 19.7 % and 27.4 %, respectively (9.8 % vs 12.2 % and 4.5 % vs 6.2 %), although the groups were not formally statistically compared for these endpoints. Fewer patients had adverse events in the LABD+ICS group (43.0 % vs 50.4 %; p = 0.013), with 4.9 % vs 5.4 % reporting pneumonia adverse events. CONCLUSIONS Results suggest addition of ICS to LABDs did not reduce the time-to-combined rehospitalisation/death, although it decreased all-cause and cardiovascular mortality. ICS use was not associated with an increased risk of adverse events, particularly pneumonia.
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Respiratory Unit, CardioRespiratory Department, University Hospital Ferrara, Ferrara, Italy.
| | - Giacomo Forini
- Respiratory Unit, CardioRespiratory Department, University Hospital Ferrara, Ferrara, Italy
| | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese, Terme Institute, Telese, Italy; Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Elena Bargagli
- Department of Medical Sciences, Surgery and Neurosciences, Siena University, Siena, Italy
| | - Claudia Crimi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Respiratory Medicine Unit, Policlinico "G. Rodolico-San Marco" University Hospital, Catania, Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy; Division of Respiratory Diseases, Ospedale Luigi Sacco-University Hospital, Milan, Italy
| | - Antonio Molino
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | | | - Federico Baraldi
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Respiratory Unit, CardioRespiratory Department, University Hospital Ferrara, Ferrara, Italy
| | - Silvestro Ennio D'Anna
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese, Terme Institute, Telese, Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri, IRCCS, Pulmonology and Respiratory Rehabilitation Unit of Bari Institute, Bari, Italy
| | - Maurizio Marvisi
- Department of Internal Medicine, Istituto Figlie di S. Camillo, Cremona, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Giulia Scioscia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Vincenzo Patella
- Department of Internal Medicine ASL Salerno, "Santa Maria della Speranza" Hospital, Salerno, Italy; Postgraduate Program in Allergy and Clinical Immunology, University of Naples "Federico II", Naples, Italy
| | - Maria Aliani
- Istituti Clinici Scientifici Maugeri, IRCCS, Pulmonology and Respiratory Rehabilitation Unit of Bari Institute, Bari, Italy
| | - Leonardo M Fabbri
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Caprino R, Sartori G, Sartori F, Fantin A, Crisafulli E. Factors associated with risk of death in hospitalized patients for exacerbation of chronic obstructive pulmonary disease: an updated scoping review. Expert Rev Respir Med 2024; 18:435-445. [PMID: 38943613 DOI: 10.1080/17476348.2024.2375426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/28/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION The Exacerbation of Chronic Obstructive Pulmonary Disease (ECOPD), especially if leading to hospitalization, increases the risk of death. Our scoping review aims to identify updated mortality risk factors for both short- and long-term periods. AREAS COVERED A comprehensive search, covering the period from January 2013 to February 2024, was performed to identify eligible studies that consider factors associated with death in hospitalized ECOPD. We considered short-term mortality, up to one year (including in-hospital mortality, IHM) and long-term mortality over one year, without time limits. We excluded studies concerning the intensive care area. EXPERT OPINION We considered 38 studies, 32 and 8 reporting data about short- and long-term mortality, respectively. Two studies consider both periods. Several factors, some already known, others newly identified, have been evaluated and discussed. Some of these were related to the characteristics and severity of COPD (age, body mass index, lung impairment), and some considered the response to ECOPD. In this last context, we focused on the increasing role of biomarkers in predicting the mortality of patients, particularly IHM. Our factors associated with a worse prognosis may be helpful in clinical practice to identify patients at risk and, subsequently, determine a personalized approach.
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Affiliation(s)
- Rosaria Caprino
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Filippo Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
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Crisafulli E, Sartori G, Huerta A, Gabarrús A, Fantin A, Soler N, Torres A. Association Between Rome Classification Among Hospitalized Patients With COPD Exacerbations and Short-Term and Intermediate-Term Outcomes. Chest 2023; 164:1422-1433. [PMID: 37516272 DOI: 10.1016/j.chest.2023.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Recently, the Rome proposal updated the definition of exacerbation of COPD (ECOPD). However, such severity grade has not yet demonstrated intermediate-term clinical relevance. RESEARCH QUESTION What is the association between the Rome severity classification and short-term and intermediate-term clinical outcomes? STUDY DESIGN AND METHODS We retrospectively grouped hospitalized patients with ECOPD according to the Rome severity classification (ie, mild, moderate, severe). Baseline, clinical, microbiologic, gas analysis, and laboratory variables were collected. In addition, data about the length of hospital stay and mortality (in-hospital and a follow-up time line from 6 months until 3 years) were assessed. RESULTS Of the 347 hospitalized patients, 39% were categorized as mild, 31% were categorized as moderate, and 30% were categorized as severe. Overall, patients with severe ECOPD had an extended length of hospital stay. Although in-hospital mortality was similar among groups, patients with severe ECOPD presented a worse prognosis in all follow-up time points. The Kaplan-Meier curves show the role of the severe classification in the cumulative survival at 1 and 3 years (Gehan-Breslow-Wilcoxon test, P = .032 and P = .004, respectively). The multivariable Cox regression analysis showed a higher risk of death at 1 year when patients presented a severe (hazard ratio, 1.99; 95% CI, 1.49-2.65) or moderate grade (hazard ratio, 1.47; 95% CI, 1.10-1.97) compared with a mild grade. Older patients (aged ≥ 80 years), patients requiring long-term oxygen therapy, or patients reporting previous ECOPD episodes had a higher mortality risk. A BMI between 25 and 29 kg/m2 was associated with a lower risk. INTERPRETATION The Rome classification makes it possible to discriminate patients with a worse prognosis (severe or moderate) until a 3-year follow-up.
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Affiliation(s)
- Ernesto Crisafulli
- Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Arturo Huerta
- Pulmonary and Critical Care Division, Clinica Sagrada Familia, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Albert Gabarrús
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona - Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Néstor Soler
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona - Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona - Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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Crisafulli E, Manco A, Ferrer M, Huerta A, Micheletto C, Girelli D, Clini E, Torres A. Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease. Semin Respir Crit Care Med 2020; 41:817-829. [PMID: 32726837 DOI: 10.1055/s-0040-1702196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) often suffer acute exacerbations (AECOPD) and community-acquired pneumonia (CAP), named nonpneumonic and pneumonic exacerbations of COPD, respectively. Abnormal host defense mechanisms may play a role in the specificity of the systemic inflammatory response. Given the association of this aspect to some biomarkers at admission (e.g., C-reactive protein), it can be used to help to discriminate AECOPD and CAP, especially in cases with doubtful infiltrates and advanced lung impairment. Fever, sputum purulence, chills, and pleuritic pain are typical clinical features of CAP in a patient with COPD, whereas isolated dyspnea at admission has been reported to predict AECOPD. Although CAP may have a worse outcome in terms of mortality (in hospital and short term), length of hospitalization, and early readmission rates, this has only been confirmed in a few prospective studies. There is a lack of methodologically sound research confirming the impact of severe AECOPD and COPD + CAP. Here, we review studies reporting head-to-head comparisons between AECOPD and CAP + COPD in hospitalized patients. We focus on the epidemiology, risk factors, systemic inflammatory response, clinical and microbiological characteristics, outcomes, and treatment approaches. Finally, we briefly discuss some proposals on how we should orient research in the future.
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Affiliation(s)
- Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.,Department of Medicine, Section of Internal Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Alessandra Manco
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Miquel Ferrer
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES (CB06/06/0028), University of Barcelona, Barcelona, Spain
| | - Arturo Huerta
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES (CB06/06/0028), University of Barcelona, Barcelona, Spain
| | - Claudio Micheletto
- Department of Cardiovascular and Thoracic, Pneumology Unit, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Enrico Clini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia and University Hospital of Modena Policlinico, Modena, Italy
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERES (CB06/06/0028), University of Barcelona, Barcelona, Spain
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Crisafulli E, Manco A, Torres A. How may we improve clinical outcomes for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease? A narrative review about possible therapeutic and preventive strategies. Expert Rev Respir Med 2020; 14:493-500. [PMID: 32077337 DOI: 10.1080/17476348.2020.1732823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: In a subset of chronic obstructive pulmonary disease (COPD)patients the course of the disease is complicated by a severe acute exacerbations (AECOPD) that may require hospitalization, at which time negative outcomes may occur up to 30 days after discharge. Several predictors of negative outcomes have been documented.Areas covered: We considered five negative outcomes related to patients hospitalized with AECOPD: treatment failure, noninvasive mechanical ventilation (NIMV) failure, prolonged length of hospital stay (LHS), short-term mortality (≤ 90 days from admission and including the in-hospital mortality), and early readmission (≤30 days from discharge). Possible therapeutic and preventive strategies to improve these outcomes are outlined and discussed.Expert opinion: Several strategies have been proposed to improve outcomes. Among these, steroid or antibiotic use may reduce the risks of treatment failure or of prolonged hospital stay. We note that operator-related factors may influence the outcome of NIMV. However, little has been documented about the short-term mortality or early readmission rates. In general, few interventions consistently improve negative outcomes and prognosis of AECOPD.
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Affiliation(s)
- Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit and Section of Internal Medicine, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Alessandra Manco
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antoni Torres
- Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona - Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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