1
|
Meng W, Zeng H, Zhao Z, Xiong R, Chen Y, Li Z. Nemonoxacin achieved a better symptomatic improvement and a prolonged interval to next exacerbation than moxifloxacin for outpatients with acute exacerbations of chronic obstructive pulmonary disease. Sci Rep 2023; 13:16954. [PMID: 37805617 PMCID: PMC10560244 DOI: 10.1038/s41598-023-44188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/04/2023] [Indexed: 10/09/2023] Open
Abstract
Nemonoxacin is a novel non-fluorinated quinolone with strong antibacterial efficacy, but data of its effect on acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is rare. This study was conducted to compare the efficacy of oral nemonoxacin with moxifloxacin in AECOPD outpatients. In this retrospective observational study, a total of 101 AECOPD outpatients initially treated with nemonoxacin or moxifloxacin from July 2021 to March 2022 were enrolled. We collected COPD assessment test (CAT), Transition Dyspnea Indices (TDI) scores, and exacerbations information during 24 weeks follow-up from the electronic medical records. Kaplan-Meier curve was used to analyze the time to the next moderate/severe exacerbation. Compared to the moxifloxacin group, changes in CAT scores and TDI scores were significantly higher in the nemonoxacin group, and the nemonoxacin group also had a greater probability to reach the minimal clinically important difference of CAT (71.40% vs. 97.80%, p < 0.01) and TDI (40.50% vs. 60.00%, p < 0.05) at week 4. Despite no significant difference in the incidence of exacerbations between two groups, patients treated with nemonoxacin had a significantly prolonged time to next moderate/severe exacerbation than those with moxifloxacin (p < 0.05). Nemonoxacin achieved a better symptomatic improvement and a prolonged interval to next moderate/severe exacerbation for AECOPD outpatients.
Collapse
Affiliation(s)
- Weiwei Meng
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Changsha, Hunan, China
| | - Huihui Zeng
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Changsha, Hunan, China
| | - Zhiqi Zhao
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Changsha, Hunan, China
| | - Ruoyan Xiong
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China
- Diagnosis and Treatment Center of Respiratory Disease, Changsha, Hunan, China
| | - Yan Chen
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
- Research Unit of Respiratory Disease, Central South University, Changsha, Hunan, China.
- Diagnosis and Treatment Center of Respiratory Disease, Changsha, Hunan, China.
| | - Zhuo Li
- Center for Clinical Trails and Research, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
| |
Collapse
|
2
|
Schaeffer MR, Louvaris Z, Rodrigues A, Poddighe D, Gayan-Ramirez G, Gojevic T, Geerts L, Heyndrickx E, Van Hollebeke M, Janssens L, Gosselink R, Testelmans D, Langer D. Effects of inspiratory muscle training on exertional breathlessness in patients with unilateral diaphragm dysfunction: a randomised trial. ERJ Open Res 2023; 9:00300-2023. [PMID: 37868146 PMCID: PMC10588797 DOI: 10.1183/23120541.00300-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/09/2023] [Indexed: 10/24/2023] Open
Abstract
Background Unilateral diaphragm dysfunction (UDD) is an underdiagnosed cause of dyspnoea. Inspiratory muscle training (IMT) is the only conservative treatment for UDD, but the mechanisms of improvement are unknown. We characterised the effects of IMT on dyspnoea, exercise tolerance and respiratory muscle function in people with UDD. Methods 15 people with UDD (73% male, 61±8 years) were randomised to 6 months of IMT (50% maximal inspiratory mouth pressure (PI,max), n=10) or sham training (10% PI,max, n=5) (30 breaths twice per day). UDD was confirmed by phrenic nerve stimulation and persisted throughout the training period. Symptoms were assessed by the transitional dyspnoea index (TDI) and exercise tolerance by constant-load cycle tests performed pre- and post-training. Oesophageal (Pes) and gastric (Pga) pressures were measured with a dual-balloon catheter. Electromyography (EMG) and oxygenation (near-infrared spectroscopy) of respiratory muscles were assessed continuously during exercise. Results The IMT group (from 45±6 to 62±23% PI,max) and sham group (no progression) completed 92 and 86% of prescribed sessions, respectively. PI,max, TDI scores and cycle endurance time improved significantly more after IMT versus sham (mean between-group differences: 28 (95% CI 13-28) cmH2O, 3.0 (95% CI 0.9-5.1) points and 6.0 (95% CI 0.4-11.5) min, respectively). During exercise at iso-time, Pes, Pga and EMG of the scalene muscles were reduced and the oxygen saturation indices of the scalene and abdominal muscles were higher post- versus pre-training only in the IMT group (all p<0.05). Conclusion The effects of IMT on dyspnoea and exercise tolerance in UDD were not mediated by an improvement in isolated diaphragm function, but may reflect improvements in strength, coordination and/or oxygenation of the extra-diaphragmatic respiratory muscles.
Collapse
Affiliation(s)
- Michele R. Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Zafeiris Louvaris
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Antenor Rodrigues
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Ghislaine Gayan-Ramirez
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Tin Gojevic
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Linde Geerts
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Elise Heyndrickx
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Luc Janssens
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Electrical Engineering, Faculty of Engineering Technology, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Dries Testelmans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| |
Collapse
|
3
|
Anzueto A, Barjaktarevic IZ, Siler TM, Rheault T, Bengtsson T, Rickard K, Sciurba F. Ensifentrine, a Novel Phosphodiesterase 3 and 4 Inhibitor for the Treatment of Chronic Obstructive Pulmonary Disease: Randomized, Double-Blind, Placebo-controlled, Multicenter Phase III Trials (the ENHANCE Trials). Am J Respir Crit Care Med 2023; 208:406-416. [PMID: 37364283 PMCID: PMC10449067 DOI: 10.1164/rccm.202306-0944oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 06/28/2023] Open
Abstract
Rationale: Ensifentrine is a novel, selective, dual phosphodiesterase (PDE)3 and PDE4 inhibitor with bronchodilator and antiinflammatory effects. Replicate phase III trials of nebulized ensifentrine were conducted (ENHANCE-1 and ENHANCE-2) to assess these effects in patients with chronic obstructive pulmonary disease (COPD). Objectives: To evaluate the efficacy of ensifentrine compared with placebo for lung function, symptoms, quality of life, and exacerbations in patients with COPD. Methods: These phase III, multicenter, randomized, double-blind, parallel-group, placebo-controlled trials were conducted between September 2020 and December 2022 at 250 research centers and pulmonology practices in 17 countries. Patients aged 40-80 years with moderate to severe symptomatic COPD were enrolled. Measurements and Main Results: Totals of 760 (ENHANCE-1) and 789 (ENHANCE-2) patients were randomized and treated, with 69% and 55% receiving concomitant long-acting muscarinic antagonists or long-acting β2-agonists, respectively. Post-bronchodilator FEV1 percentage predicted values were 52% and 51% of predicted normal. Ensifentrine treatment significantly improved average FEV1 area under the curve at 0-12 hours versus placebo (ENHANCE-1, 87 ml [95% confidence interval, 55, 119]; ENHANCE-2, 94 ml [65, 124]; both P < 0.001). Ensifentrine treatment significantly improved symptoms (Evaluating Respiratory Symptoms) and quality of life (St. George's Respiratory Questionnaire) versus placebo at Week 24 in ENHANCE-1 but not in ENHANCE-2. Ensifentrine treatment reduced the rate of moderate or severe exacerbations versus placebo over 24 weeks (ENHANCE-1, rate ratio, 0.64 [0.40, 1.00]; P = 0.050; ENHANCE-2, rate ratio, 0.57 [0.38, 0.87]; P = 0.009) and increased time to first exacerbation (ENHANCE-1, hazard ratio, 0.62 [0.39, 0.97]; P = 0.038; ENHANCE-2, hazard ratio, 0.58 [0.38, 0.87]; P = 0.009). Adverse event rates were similar to those for placebo. Conclusions: Ensifentrine significantly improved lung function in both trials, with results supporting exacerbation rate and risk reduction in a broad COPD population and in addition to other classes of maintenance therapies. Clinical trial registered with www. CLINICALTRIALS gov and EudraCT (ENHANCE-1, www. CLINICALTRIALS gov identifier NCT04535986, EudraCT identifier 2020-002086-34; ENHANCE-2, www. CLINICALTRIALS gov identifier NCT04542057, EudraCT identifier 2020-002069-32).
Collapse
Affiliation(s)
- Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, Texas
- University of Texas Health, San Antonio, Texas
| | - Igor Z. Barjaktarevic
- Division of Pulmonary and Critical Care, University of California, Los Angeles, Los Angeles, California
| | | | | | | | | | - Frank Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
4
|
Rochester CL, Alison JA, Carlin B, Jenkins AR, Cox NS, Bauldoff G, Bhatt SP, Bourbeau J, Burtin C, Camp PG, Cascino TM, Dorney Koppel GA, Garvey C, Goldstein R, Harris D, Houchen-Wolloff L, Limberg T, Lindenauer PK, Moy ML, Ryerson CJ, Singh SJ, Steiner M, Tappan RS, Yohannes AM, Holland AE. Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2023; 208:e7-e26. [PMID: 37581410 PMCID: PMC10449064 DOI: 10.1164/rccm.202306-1066st] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.
Collapse
|
5
|
Donohue JF, Rheault T, MacDonald-Berko M, Bengtsson T, Rickard K. Ensifentrine as a Novel, Inhaled Treatment for Patients with COPD. Int J Chron Obstruct Pulmon Dis 2023; 18:1611-1622. [PMID: 37533771 PMCID: PMC10392818 DOI: 10.2147/copd.s413436] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
Ensifentrine is a novel, potent, and selective dual inhibitor of phosphodiesterase (PDE)3 and PDE4 designed for delivery by inhalation that combines effects on airway inflammation, bronchodilation and ciliary function in bronchial epithelia. In Phase 2 studies in subjects with COPD, ensifentrine demonstrated clinically meaningful bronchodilation and improvements in symptoms and health-related quality of life when administered alone or in combination with current standard of care therapies. Ensifentrine is currently in late-stage clinical development for the maintenance treatment of patients with COPD. This review summarizes non-clinical data as well as Phase 1 and Phase 2 efficacy and safety results of nebulized ensifentrine relevant to the maintenance treatment of patients with COPD.
Collapse
Affiliation(s)
- James F Donohue
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, School of Medicine, Chapel Hill, NC, USA
| | | | | | | | | |
Collapse
|
6
|
Ammous O, Feki W, Lotfi T, Khamis AM, Gosselink R, Rebai A, Kammoun S. Inspiratory muscle training, with or without concomitant pulmonary rehabilitation, for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2023; 1:CD013778. [PMID: 36606682 PMCID: PMC9817429 DOI: 10.1002/14651858.cd013778.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Inspiratory muscle training (IMT) aims to improve respiratory muscle strength and endurance. Clinical trials used various training protocols, devices and respiratory measurements to check the effectiveness of this intervention. The current guidelines reported a possible advantage of IMT, particularly in people with respiratory muscle weakness. However, it remains unclear to what extent IMT is clinically beneficial, especially when associated with pulmonary rehabilitation (PR). OBJECTIVES: To assess the effect of inspiratory muscle training (IMT) on chronic obstructive pulmonary disease (COPD), as a stand-alone intervention and when combined with pulmonary rehabilitation (PR). SEARCH METHODS We searched the Cochrane Airways trials register, CENTRAL, MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO, Physiotherapy Evidence Database (PEDro) ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 20 October 2021. We also checked reference lists of all primary studies and review articles. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared IMT in combination with PR versus PR alone and IMT versus control/sham. We included different types of IMT irrespective of the mode of delivery. We excluded trials that used resistive devices without controlling the breathing pattern or a training load of less than 30% of maximal inspiratory pressure (PImax), or both. DATA COLLECTION AND ANALYSIS We used standard methods recommended by Cochrane including assessment of risk of bias with RoB 2. Our primary outcomes were dyspnea, functional exercise capacity and health-related quality of life. MAIN RESULTS: We included 55 RCTs in this review. Both IMT and PR protocols varied significantly across the trials, especially in training duration, loads, devices, number/ frequency of sessions and the PR programs. Only eight trials were at low risk of bias. PR+IMT versus PR We included 22 trials (1446 participants) in this comparison. Based on a minimal clinically important difference (MCID) of -1 unit, we did not find an improvement in dyspnea assessed with the Borg scale at submaximal exercise capacity (mean difference (MD) 0.19, 95% confidence interval (CI) -0.42 to 0.79; 2 RCTs, 202 participants; moderate-certainty evidence). We also found no improvement in dyspnea assessed with themodified Medical Research Council dyspnea scale (mMRC) according to an MCID between -0.5 and -1 unit (MD -0.12, 95% CI -0.39 to 0.14; 2 RCTs, 204 participants; very low-certainty evidence). Pooling evidence for the 6-minute walk distance (6MWD) showed an increase of 5.95 meters (95% CI -5.73 to 17.63; 12 RCTs, 1199 participants; very low-certainty evidence) and failed to reach the MCID of 26 meters. In subgroup analysis, we divided the RCTs according to the training duration and mean baseline PImax. The test for subgroup differences was not significant. Trials at low risk of bias (n = 3) demonstrated a larger effect estimate than the overall. The summary effect of the St George's Respiratory Questionnaire (SGRQ) revealed an overall total score below the MCID of 4 units (MD 0.13, 95% CI -0.93 to 1.20; 7 RCTs, 908 participants; low-certainty evidence). The summary effect of COPD Assessment Test (CAT) did not show an improvement in the HRQoL (MD 0.13, 95% CI -0.80 to 1.06; 2 RCTs, 657 participants; very low-certainty evidence), according to an MCID of -1.6 units. Pooling the RCTs that reported PImax showed an increase of 11.46 cmH2O (95% CI 7.42 to 15.50; 17 RCTs, 1329 participants; moderate-certainty evidence) but failed to reach the MCID of 17.2 cmH2O. In subgroup analysis, we did not find a difference between different training durations and between studies judged with and without respiratory muscle weakness. One abstract reported some adverse effects that were considered "minor and self-limited". IMT versus control/sham Thirty-seven RCTs with 1021 participants contributed to our second comparison. There was a trend towards an improvement when Borg was calculated at submaximal exercise capacity (MD -0.94, 95% CI -1.36 to -0.51; 6 RCTs, 144 participants; very low-certainty evidence). Only one trial was at a low risk of bias. Eight studies (nine arms) used the Baseline Dyspnea Index - Transition Dyspnea Index (BDI-TDI). Based on an MCID of +1 unit, they showed an improvement only with the 'total score' of the TDI (MD 2.98, 95% CI 2.07 to 3.89; 8 RCTs, 238 participants; very low-certainty evidence). We did not find a difference between studies classified as with and without respiratory muscle weakness. Only one trial was at low risk of bias. Four studies reported the mMRC, revealing a possible improvement in dyspnea in the IMT group (MD -0.59, 95% CI -0.76 to -0.43; 4 RCTs, 150 participants; low-certainty evidence). Two trials were at low risk of bias. Compared to control/sham, the MD in the 6MWD following IMT was 35.71 (95% CI 25.68 to 45.74; 16 RCTs, 501 participants; moderate-certainty evidence). Two studies were at low risk of bias. In subgroup analysis, we did not find a difference between different training durations and between studies judged with and without respiratory muscle weakness. Six studies reported theSGRQ total score, showing a larger effect in the IMT group (MD -3.85, 95% CI -8.18 to 0.48; 6 RCTs, 182 participants; very low-certainty evidence). The lower limit of the 95% CI exceeded the MCID of -4 units. Only one study was at low risk of bias. There was an improvement in life quality with CAT (MD -2.97, 95% CI -3.85 to -2.10; 2 RCTs, 86 participants; moderate-certainty evidence). One trial was at low risk of bias. Thirty-two RCTs reported PImax, showing an improvement without reaching the MCID (MD 14.57 cmH2O, 95% CI 9.85 to 19.29; 32 RCTs, 916 participants; low-certainty evidence). In subgroup analysis, we did not find a difference between different training durations and between studies judged with and without respiratory muscle weakness. None of the included RCTs reported adverse events. AUTHORS' CONCLUSIONS IMT may not improve dyspnea, functional exercise capacity and life quality when associated with PR. However, IMT is likely to improve these outcomes when provided alone. For both interventions, a larger effect in participants with respiratory muscle weakness and with longer training durations is still to be confirmed.
Collapse
Affiliation(s)
- Omar Ammous
- Faculty of Medicine, University of Sfax, Sfax, Tunisia
| | - Walid Feki
- Department of Respiratory Medicine, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Tamara Lotfi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Rik Gosselink
- Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Ahmed Rebai
- Centre of Biotechnology of Sfax, University of Sfax, Sfax, Tunisia
| | - Samy Kammoun
- Department of Respiratory Medicine, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| |
Collapse
|
7
|
Kerwin EM, Jones PW, Bjermer LH, Maltais F, Boucot IH, Naya IP, Lipson DA, Compton C, Tombs L, Vogelmeier CF. How can the findings of the EMAX trial on long-acting bronchodilation in chronic obstructive pulmonary disease be applied in the primary care setting? Chron Respir Dis 2023; 20:14799731231202257. [PMID: 37800633 PMCID: PMC10903204 DOI: 10.1177/14799731231202257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 08/21/2023] [Indexed: 10/07/2023] Open
Abstract
This review addresses outstanding questions regarding initial pharmacological management of chronic obstructive pulmonary disease (COPD). Optimizing initial treatment improves clinical outcomes in symptomatic patients, including those with low exacerbation risk. Long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) dual therapy improves lung function versus LAMA or LABA monotherapy, although other treatment benefits have been less consistently observed. The benefits of dual bronchodilation in symptomatic patients with COPD at low exacerbation risk, and its duration of efficacy and cost effectiveness in this population, are not yet fully established. Questions remain on the impact of baseline symptom severity, prior treatment, degree of reversibility to bronchodilators, and smoking status on responses to dual bronchodilator treatment. Using evidence from EMAX (NCT03034915), a 6-month trial comparing the LAMA/LABA combination umeclidinium/vilanterol with umeclidinium and salmeterol monotherapy in symptomatic patients with COPD at low exacerbation risk who were inhaled corticosteroid-naïve, we describe how these findings can be applied in primary care.
Collapse
Affiliation(s)
- Edward M Kerwin
- Clinical Trials Department, Altitude Clinical Consulting and Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | | | - Leif H Bjermer
- Department of Clinical Sciences, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - François Maltais
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | | | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Stockley Park West, Uxbridge, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
| |
Collapse
|
8
|
Han MK, Ye W, Wang D, White E, Arjomandi M, Barjaktarevic IZ, Brown SA, Buhr RG, Comellas AP, Cooper CB, Criner GJ, Dransfield MT, Drescher F, Folz RJ, Hansel NN, Kalhan R, Kaner RJ, Kanner RE, Krishnan JA, Lazarus SC, Maddipati V, Martinez FJ, Mathews A, Meldrum C, McEvoy C, Nyunoya T, Rogers L, Stringer WW, Wendt CH, Wise RA, Wisniewski SR, Sciurba FC, Woodruff PG. Bronchodilators in Tobacco-Exposed Persons with Symptoms and Preserved Lung Function. N Engl J Med 2022; 387:1173-1184. [PMID: 36066078 PMCID: PMC9741866 DOI: 10.1056/nejmoa2204752] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Many persons with a history of smoking tobacco have clinically significant respiratory symptoms despite an absence of airflow obstruction as assessed by spirometry. They are often treated with medications for chronic obstructive pulmonary disease (COPD), but supporting evidence for this treatment is lacking. METHODS We randomly assigned persons who had a tobacco-smoking history of at least 10 pack-years, respiratory symptoms as defined by a COPD Assessment Test score of at least 10 (scores range from 0 to 40, with higher scores indicating worse symptoms), and preserved lung function on spirometry (ratio of forced expiratory volume in 1 second [FEV1] to forced vital capacity [FVC] ≥0.70 and FVC ≥70% of the predicted value after bronchodilator use) to receive either indacaterol (27.5 μg) plus glycopyrrolate (15.6 μg) or placebo twice daily for 12 weeks. The primary outcome was at least a 4-point decrease (i.e., improvement) in the St. George's Respiratory Questionnaire (SGRQ) score (scores range from 0 to 100, with higher scores indicating worse health status) after 12 weeks without treatment failure (defined as an increase in lower respiratory symptoms treated with a long-acting inhaled bronchodilator, glucocorticoid, or antibiotic agent). RESULTS A total of 535 participants underwent randomization. In the modified intention-to-treat population (471 participants), 128 of 227 participants (56.4%) in the treatment group and 144 of 244 (59.0%) in the placebo group had at least a 4-point decrease in the SGRQ score (difference, -2.6 percentage points; 95% confidence interval [CI], -11.6 to 6.3; adjusted odds ratio, 0.91; 95% CI, 0.60 to 1.37; P = 0.65). The mean change in the percent of predicted FEV1 was 2.48 percentage points (95% CI, 1.49 to 3.47) in the treatment group and -0.09 percentage points (95% CI, -1.06 to 0.89) in the placebo group, and the mean change in the inspiratory capacity was 0.12 liters (95% CI, 0.07 to 0.18) in the treatment group and 0.02 liters (95% CI, -0.03 to 0.08) in the placebo group. Four serious adverse events occurred in the treatment group, and 11 occurred in the placebo group; none were deemed potentially related to the treatment or placebo. CONCLUSIONS Inhaled dual bronchodilator therapy did not decrease respiratory symptoms in symptomatic, tobacco-exposed persons with preserved lung function as assessed by spirometry. (Funded by the National Heart, Lung, and Blood Institute and others; RETHINC ClinicalTrials.gov number, NCT02867761.).
Collapse
Affiliation(s)
- MeiLan K Han
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Wen Ye
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Di Wang
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Emily White
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Mehrdad Arjomandi
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Igor Z Barjaktarevic
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Stacey-Ann Brown
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Russell G Buhr
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Alejandro P Comellas
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Christopher B Cooper
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Gerard J Criner
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Mark T Dransfield
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Frank Drescher
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Rodney J Folz
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Nadia N Hansel
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Ravi Kalhan
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Robert J Kaner
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Richard E Kanner
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Jerry A Krishnan
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Stephen C Lazarus
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Veeranna Maddipati
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Fernando J Martinez
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Anne Mathews
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Catherine Meldrum
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Charlene McEvoy
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Toru Nyunoya
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Linda Rogers
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - William W Stringer
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Christine H Wendt
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Robert A Wise
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Stephen R Wisniewski
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Frank C Sciurba
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| | - Prescott G Woodruff
- From the Division of Pulmonary and Critical Care (M.K.H., C. Meldrum) and the School of Public Health (W.Y., D.W., E.W.), University of Michigan, Ann Arbor; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (M.A., S.C.L., P.G.W.) and the Cardiovascular Research Institute (S.C.L., P.G.W.), University of California San Francisco, and the San Francisco Veterans Affairs (VA) Healthcare System (M.A.) - both in San Francisco; the Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA (I.Z.B., R.G.B., C.B.C.), and the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (W.W.S.) - both in Los Angeles; the Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (S.-A.B., N.N.H., R.A.W.); the Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City (A.P.C.); the Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); the Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (M.T.D.); Geisel School of Medicine at Dartmouth and Pulmonary and Critical Care Medicine, VA Medical Center, White River Junction, VT (F.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Houston Methodist Academic Medicine Associates, Houston (R.J.F.); the Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine (R.K.), and the Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago (J.A.K.) - both in Chicago; the Department of Genetic Medicine (R.J.K.) and Joan and Sanford I. Weill Department of Medicine (R.J.K., F.J.M.), Weill Cornell Medicine and New York-Presbyterian Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai (L.R.) - both in New York; the Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City (R.E.K.); East Carolina University, Greenville (V.M.), and Duke University School of Medicine, Durham (A.M.) - both in North Carolina; HealthPartners Institute, Bloomington (C. McEvoy), and Minneapolis VA Healthcare System, Minneapolis (C.H.W.) - both in Minnesota; and the Division of Pulmonary, Allergy, and Critical Care Medicine (T.N., F.C.S.) and Epidemiology Data Center (S.R.W.), University of Pittsburgh, Pittsburgh
| |
Collapse
|
9
|
Siddharthan T, Pollard SL, Quaderi SA, Rykiel NA, Wosu AC, Alupo P, Barber JA, Cárdenas MK, Chandyo RK, Flores-Flores O, Kirenga B, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Das SK, Shrestha L, Soares MO, Checkley W, Hurst JR. Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings. JAMA 2022; 327:151-160. [PMID: 35015039 PMCID: PMC8753498 DOI: 10.1001/jama.2021.23065] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects. OBJECTIVE To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older. EXPOSURES Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF. MAIN OUTCOMES AND MEASURES The primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%. CONCLUSIONS AND RELEVANCE This study demonstrated that screening instruments for COPD were feasible to administer in 3 low- and middle-income settings. Further research is needed to assess instrument performance in other low- and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.
Collapse
Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Now with the National Institutes of Health, Bethesda, Maryland
| | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Nepal
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Biomedical Research Unit, A.BPRISMA, Lima, Peru
- Centro de Investigación del Envejecimiento (CIEN), Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Santa Kumar Das
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Laxman Shrestha
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Marta O. Soares
- Centre for Health Economics, University of York, York, United Kingdom
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
| |
Collapse
|
10
|
Suzuki Y, Sato S, Sato K, Inoue S, Shibata Y. Treatment efficacy of LAMA versus placebo for stable chronic obstructive pulmonary disease: A systematic review and meta-analysis. Respir Investig 2022; 60:108-118. [PMID: 34489206 DOI: 10.1016/j.resinv.2021.08.002] [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: 06/06/2021] [Revised: 07/06/2021] [Accepted: 08/09/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Four long-acting muscarinic antagonists (LAMAs), tiotropium, glycopyrronium, aclidinium, and umeclidinium, are currently available for the treatment of stable chronic obstructive pulmonary disease (COPD). However, no integrated analysis has sought to determine the effectiveness of these LAMAs. Thus, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of LAMA versus placebo in patients with stable COPD. METHODS A literature search of relevant randomized control trials that administered LAMA to stable COPD patients was conducted, and the exacerbations, quality of life (QoL), dyspnea score, lung function, and adverse event of patients were evaluated. RESULTS A total of 33 studies were included in this meta-analysis. LAMA significantly decreased the frequency of exacerbations compared to the placebo (OR 0.75; 95% CI 0.66 to 0.85; P < 0.001). The mean changes in the St George's Respiratory Questionnaire score (mean difference, -3.61; 95% CI, -4.27 to -2.95; P < 0.00001), transitional dyspnea index score (mean difference 1.00; 95% CI 0.83 to 1.17; P < 0.00001), and trough FEV1 (mean difference 0.12; 95% CI 0.11 to 0.13; P < 0.0001) indicated significantly greater improvement in the LAMA group than the placebo group. The number of withdrawals due to adverse events in the LAMA group was significantly fewer than that in the placebo group (OR -0.02; 95% CI -0.03 to -0.01; P = 0.002). CONCLUSION LAMA is superior to placebo due to lower frequency of exacerbations and adverse events, as well as higher trough FEV1, QoL, and dyspnea score for stable COPD.
Collapse
Affiliation(s)
- Yasuhito Suzuki
- Department of Pulmonary Medicine, Fukushima Medical University, Fukushima, Japan.
| | - Suguru Sato
- Department of Pulmonary Medicine, Fukushima Medical University, Fukushima, Japan.
| | - Kento Sato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Yamagata, Japan.
| | - Sumito Inoue
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Yamagata, Japan.
| | - Yoko Shibata
- Department of Pulmonary Medicine, Fukushima Medical University, Fukushima, Japan.
| |
Collapse
|
11
|
Adab P, Jordan RE, Fitzmaurice D, Ayres JG, Cheng KK, Cooper BG, Daley A, Dickens A, Enocson A, Greenfield S, Haroon S, Jolly K, Jowett S, Lambe T, Martin J, Miller MR, Rai K, Riley RD, Sadhra S, Sitch A, Siebert S, Stockley RA, Turner A. Case-finding and improving patient outcomes for chronic obstructive pulmonary disease in primary care: the BLISS research programme including cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Chronic obstructive pulmonary disease is a major contributor to morbidity, mortality and health service costs but is vastly underdiagnosed. Evidence on screening and how best to approach this is not clear. There are also uncertainties around the natural history (prognosis) of chronic obstructive pulmonary disease and how it impacts on work performance.
Objectives
Work package 1: to evaluate alternative methods of screening for undiagnosed chronic obstructive pulmonary disease in primary care, with clinical effectiveness and cost-effectiveness analyses and an economic model of a routine screening programme. Work package 2: to recruit a primary care chronic obstructive pulmonary disease cohort, develop a prognostic model [Birmingham Lung Improvement StudieS (BLISS)] to predict risk of respiratory hospital admissions, validate an existing model to predict mortality risk, address some uncertainties about natural history and explore the potential for a home exercise intervention. Work package 3: to identify which factors are associated with employment, absenteeism, presenteeism (working while unwell) and evaluate the feasibility of offering formal occupational health assessment to improve work performance.
Design
Work package 1: a cluster randomised controlled trial with household-level randomised comparison of two alternative case-finding approaches in the intervention arm. Work package 2: cohort study – focus groups. Work package 3: subcohort – feasibility study.
Setting
Primary care settings in West Midlands, UK.
Participants
Work package 1: 74,818 people who have smoked aged 40–79 years without a previous chronic obstructive pulmonary disease diagnosis from 54 general practices. Work package 2: 741 patients with previously diagnosed chronic obstructive pulmonary disease from 71 practices and participants from the work package 1 randomised controlled trial. Twenty-six patients took part in focus groups. Work package 3: occupational subcohort with 248 patients in paid employment at baseline. Thirty-five patients took part in an occupational health intervention feasibility study.
Interventions
Work package 1: targeted case-finding – symptom screening questionnaire, administered opportunistically or additionally by post, followed by diagnostic post-bronchodilator spirometry. The comparator was routine care. Work package 2: twenty-three candidate variables selected from literature and expert reviews. Work package 3: sociodemographic, clinical and occupational characteristics; occupational health assessment and recommendations.
Main outcome measures
Work package 1: yield (screen-detected chronic obstructive pulmonary disease) and cost-effectiveness of case-finding; effectiveness of screening on respiratory hospitalisation and mortality after approximately 4 years. Work package 2: respiratory hospitalisation within 2 years, and barriers to and facilitators of physical activity. Work package 3: work performance – feasibility and acceptability of the occupational health intervention and study processes.
Results
Work package 1: targeted case-finding resulted in greater yield of previously undiagnosed chronic obstructive pulmonary disease than routine care at 1 year [n = 1278 (4%) vs. n = 337 (1%), respectively; adjusted odds ratio 7.45, 95% confidence interval 4.80 to 11.55], and a model-based estimate of a regular screening programme suggested an incremental cost-effectiveness ratio of £16,596 per additional quality-adjusted life-year gained. However, long-term follow-up of the trial showed that at ≈4 years there was no clear evidence that case-finding, compared with routine practice, was effective in reducing respiratory admissions (adjusted hazard ratio 1.04, 95% confidence interval 0.73 to1.47) or mortality (hazard ratio 1.15, 95% confidence interval 0.82 to 1.61). Work package 2: 2305 patients, comprising 1564 with previously diagnosed chronic obstructive pulmonary disease and 741 work package 1 participants (330 with and 411 without obstruction), were recruited. The BLISS prognostic model among cohort participants with confirmed airflow obstruction (n = 1894) included 6 of 23 candidate variables (i.e. age, Chronic Obstructive Pulmonary Disease Assessment Test score, 12-month respiratory admissions, body mass index, diabetes and forced expiratory volume in 1 second percentage predicted). After internal validation and adjustment (uniform shrinkage factor 0.87, 95% confidence interval 0.72 to 1.02), the model discriminated well in predicting 2-year respiratory hospital admissions (c-statistic 0.75, 95% confidence interval 0.72 to 0.79). In focus groups, physical activity engagement was related to self-efficacy and symptom severity. Work package 3: in the occupational subcohort, increasing dyspnoea and exposure to inhaled irritants were associated with lower work productivity at baseline. Longitudinally, increasing exacerbations and worsening symptoms, but not a decline in airflow obstruction, were associated with absenteeism and presenteeism. The acceptability of the occupational health intervention was low, leading to low uptake and low implementation of recommendations and making a full trial unfeasible.
Limitations
Work package 1: even with the most intensive approach, only 38% of patients responded to the case-finding invitation. Management of case-found patients with chronic obstructive pulmonary disease in primary care was generally poor, limiting interpretation of the long-term effectiveness of case-finding on clinical outcomes. Work package 2: the components of the BLISS model may not always be routinely available and calculation of the score requires a computerised system. Work package 3: relatively few cohort participants were in paid employment at baseline, limiting the interpretation of predictors of lower work productivity.
Conclusions
This programme has addressed some of the major uncertainties around screening for undiagnosed chronic obstructive pulmonary disease and has resulted in the development of a novel, accurate model for predicting respiratory hospitalisation in people with chronic obstructive pulmonary disease and the inception of a primary care chronic obstructive pulmonary disease cohort for longer-term follow-up. We have also identified factors that may affect work productivity in people with chronic obstructive pulmonary disease as potential targets for future intervention.
Future work
We plan to obtain data for longer-term follow-up of trial participants at 10 years. The BLISS model needs to be externally validated. Our primary care chronic obstructive pulmonary disease cohort is a unique resource for addressing further questions to better understand the prognosis of chronic obstructive pulmonary disease.
Trial registration
Current Controlled Trials ISRCTN14930255.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Peymané Adab
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rachel E Jordan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David Fitzmaurice
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jon G Ayres
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - KK Cheng
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brendan G Cooper
- Lung Function and Sleep, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amanda Daley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew Dickens
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alexandra Enocson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Shamil Haroon
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Martin R Miller
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kiran Rai
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Steve Sadhra
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice Sitch
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Robert A Stockley
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
12
|
Efficacy of umeclidinium/vilanterol according to the degree of reversibility of airflow limitation at screening: a post hoc analysis of the EMAX trial. Respir Res 2021; 22:279. [PMID: 34711232 PMCID: PMC8555352 DOI: 10.1186/s12931-021-01859-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Background In patients with chronic obstructive pulmonary disease (COPD), the relationship between short-term bronchodilator reversibility and longer-term response to bronchodilators is unclear. Here, we investigated whether the efficacy of long-acting bronchodilators is associated with reversibility of airflow limitation in patients with COPD with a low exacerbation risk not receiving inhaled corticosteroids. Methods The double-blind, double-dummy EMAX trial randomised patients to umeclidinium/vilanterol 62.5/25 µg once daily, umeclidinium 62.5 µg once daily, or salmeterol 50 µg twice daily. Bronchodilator reversibility to salbutamol was measured once at screening and defined as an increase in forced expiratory volume in 1 s (FEV1) of ≥ 12% and ≥ 200 mL 10−30 min post salbutamol. Post hoc, fractional polynomial (FP) modelling was conducted using the degree of reversibility (mL) at screening as a continuous variable to investigate its relationship to mean change from baseline in trough FEV1 and self-administered computerised-Transition Dyspnoea Index (SAC-TDI) at Week 24, Evaluating Respiratory Symptoms-COPD (E-RS) at Weeks 21–24, and rescue medication use (puffs/day) over Weeks 1–24. Analyses were conducted across the full range of reversibility (−850–896 mL); however, results are presented for the range −100–400 mL because there were few participants with values outside this range. Results The mean (standard deviation) reversibility was 130 mL (156) and the median was 113 mL; 625/2425 (26%) patients were reversible. There was a trend towards greater improvements in trough FEV1, SAC-TDI, E-RS and rescue medication use with umeclidinium/vilanterol with higher reversibility. Improvements in trough FEV1 and reductions in rescue medication use were greater with umeclidinium/vilanterol compared with either monotherapy across the range of reversibility. Greater improvements in SAC-TDI and E-RS total scores were observed with umeclidinium/vilanterol versus monotherapy in the middle of the reversibility range. Conclusions FP analyses suggest that patients with higher levels of reversibility have greater improvements in lung function and symptoms in response to bronchodilators. Improvements in lung function and rescue medication use were greater with umeclidinium/vilanterol versus monotherapy across the full range of reversibility, suggesting that the dual bronchodilator umeclidinium/vilanterol may be an appropriate treatment for patients with symptomatic COPD, regardless of their level of reversibility. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01859-w.
Collapse
|
13
|
Aronson KI, Suzuki A. Health Related Quality of Life in Interstitial Lung Disease: Can We Use the Same Concepts Around the World? Front Med (Lausanne) 2021; 8:745908. [PMID: 34692737 PMCID: PMC8526733 DOI: 10.3389/fmed.2021.745908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/31/2021] [Indexed: 01/17/2023] Open
Abstract
Health-Related Quality of Life (HRQOL) is increasingly viewed as an important patient-centered outcome by leading health organizations, clinicians, and patients alike. This is especially true in the interstitial lung disease community where patients often struggle with progressive and debilitating disease with few therapeutic options. In order to test the effectiveness of new pharmacologic therapies and non-pharmacologic interventions globally in ILD, this will require expansion of clinical research studies to a multinational level and HRQOL will be an important endpoint to many. In order to successfully expand trials across multiple nations and compare the results of studies between different communities we must recognize that there are differences in the concepts of HRQOL across the world and have strategies to address these differences. In this review, we will describe the different global influences on HRQOL both generally and in the context of ILD, discuss the processes of linguistic translation and cross-cultural adaptation of HRQOL Patient Reported Outcome Measures (PROMs), and highlight the gaps and opportunities for improving HRQOL measurement in ILD across the world.
Collapse
Affiliation(s)
- Kerri I. Aronson
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Atsushi Suzuki
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
14
|
Bjermer LH, Boucot IH, Vogelmeier CF, Maltais F, Jones PW, Tombs L, Compton C, Lipson DA, Kerwin EM. Efficacy and Safety of Umeclidinium/Vilanterol in Current and Former Smokers with COPD: A Prespecified Analysis of The EMAX Trial. Adv Ther 2021; 38:4815-4835. [PMID: 34347255 PMCID: PMC8408076 DOI: 10.1007/s12325-021-01855-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/06/2021] [Indexed: 12/25/2022]
Abstract
Introduction Smoking may reduce the efficacy of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD), but its impact on bronchodilator efficacy is unclear. This analysis of the EMAX trial explored efficacy and safety of dual- versus mono-bronchodilator therapy in current or former smokers with COPD. Methods The 24-week EMAX trial evaluated lung function, symptoms, health status, exacerbations, clinically important deterioration, and safety with umeclidinium/vilanterol, umeclidinium, and salmeterol in symptomatic patients at low exacerbation risk who were not receiving ICS. Current and former smoker subgroups were defined by smoking status at screening. Results The analysis included 1203 (50%) current smokers and 1221 (50%) former smokers. Both subgroups demonstrated greater improvements from baseline in trough FEV1 at week 24 (primary endpoint) with umeclidinium/vilanterol versus umeclidinium (least squares [LS] mean difference, mL [95% CI]; current: 84 [50, 117]; former: 49 [18, 80]) and salmeterol (current: 165 [132, 198]; former: 117 [86, 148]) and larger reductions in rescue medication inhalations/day over 24 weeks versus umeclidinium (LS mean difference [95% CI]; current: − 0.42 [− 0.63, − 0.20]; former: − 0.25 − 0.44, − 0.05]) and salmeterol (current: − 0.28 [− 0.49, − 0.06]; former: − 0.29 [− 0.49, − 0.09]). Umeclidinium/vilanterol increased the odds (odds ratio [95% CI]) of clinically significant improvement at week 24 in Transition Dyspnea Index versus umeclidinium (current: 1.54 [1.16, 2.06]; former: 1.32 [0.99, 1.75]) and salmeterol (current: 1.37 (1.03, 1.82]; former: 1.60 [1.20, 2.13]) and Evaluating Respiratory Symptoms–COPD versus umeclidinium (current: 1.54 [1.13, 2.09]; former: 1.50 [1.11, 2.04]) and salmeterol (current: 1.53 [1.13, 2.08]; former: 1.53 [1.12, 2.08]). All treatments were well tolerated in both subgroups. Conclusions In current and former smokers, umeclidinium/vilanterol provided greater improvements in lung function and symptoms versus umeclidinium and salmeterol, supporting consideration of dual-bronchodilator therapy in symptomatic patients with COPD regardless of their smoking status. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01855-y. Patients with chronic obstructive pulmonary disease (COPD) often require daily medication to control their COPD. Many patients with COPD are smokers, and smoking is one of the most common causes of COPD. This means that it is important to find out whether COPD medications are effective in both smokers and nonsmokers. We analyzed data from a clinical trial (EMAX) that investigated the use of a combination of two bronchodilators, which are inhaled medications that help to open the airways. We compared umeclidinium/vilanterol, a dual-bronchodilator combination, with a single bronchodilator (either umeclidinium or salmeterol) over 6 months. We found that both current and former smokers who were treated with umeclidinium/vilanterol had larger improvements in lung function than those receiving umeclidinium or salmeterol. Current or former smokers who were treated with umeclidinium/vilanterol used their reliever inhaler less than those treated with umeclidinium or salmeterol. Patients treated with umeclidinium/vilanterol were generally less likely to experience disease worsening compared with umeclidinium or salmeterol if they were former smokers, or compared with salmeterol if they were current smokers. Our findings suggest that umeclidinium/vilanterol may be more effective than a single bronchodilator for daily treatment of patients with COPD who are current or former smokers. Physicians should consider prescribing a combination of two bronchodilators to patients who have symptoms, whether or not they currently smoke, as well as encouraging smoking cessation for all patients.
Collapse
|
15
|
Zhang C, Zhang M, Wang Y, Xiong H, Huang Q, Shuai T, Liu J. Efficacy and cardiovascular safety of LAMA in patients with COPD: a systematic review and meta-analysis. J Investig Med 2021; 69:1391-1398. [PMID: 34362778 PMCID: PMC8639957 DOI: 10.1136/jim-2021-001931] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is at present the third leading cause of death in the world. Long-acting muscarinic antagonist (LAMA) is widely used as a bronchodilator in patients with COPD. However, there is controversy concerning their cardiovascular safety. This meta-analysis aims to assess the efficacy and cardiovascular safety of LAMAs versus placebo in patients with COPD. We searched Pub Med, Embase, Cochrane Library, and Web of Science to identify studies that compared LAMA with placebo in patients with COPD. Twenty-one studies involving 24,987 participants were finally included in the analysis. There was no significant difference in the incidence of all adverse events (risk ratio (RR)=1.01, 95% CI 1.00 to 1.02, I2=15.2%) and cardiovascular events (RR=0.98, 95% CI 0.88 to 1.09, I2=4.9%) in patients treated with LAMAs versus placebo. LAMAs significantly improved trough forced expiratory volume in 1 s (weighted mean difference (WMD)=0.12, 95% CI 0.10 to 0.14, I2=86.6%), Transitional Dyspnea Index (WMD=0.75, 95% CI 0.56 to 0.94, I2=0%), and St. George's Respiratory Questionnaire (WMD=‒2.50, 95% CI ‒3.32 to ‒1.69, I2=39.8%). Moreover, LAMAs significantly reduced the incidence of exacerbation in patients with COPD (RR=0.85, 95% CI 0.79 to 0.91, I2=69.9%). LAMAs are safe therapy and play a pivotal role in improving lung function, dyspnea, and health status, and reducing the exacerbation in patients with COPD.
Collapse
Affiliation(s)
- Chuchu Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Meng Zhang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Yalei Wang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Huaiyu Xiong
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Qiangru Huang
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Tiankui Shuai
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China.,The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Liu
- Department of Intensive Care Unit, Lanzhou University First Affiliated Hospital, Lanzhou, Gansu, China
| |
Collapse
|
16
|
Aronson KI, Danoff SK, Russell AM, Ryerson CJ, Suzuki A, Wijsenbeek MS, Bajwah S, Bianchi P, Corte TJ, Lee JS, Lindell KO, Maher TM, Martinez FJ, Meek PM, Raghu G, Rouland G, Rudell R, Safford MM, Sheth JS, Swigris JJ. Patient-centered Outcomes Research in Interstitial Lung Disease: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e3-e23. [PMID: 34283696 PMCID: PMC8650796 DOI: 10.1164/rccm.202105-1193st] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: In the past two decades, many advances have been made to our understanding of interstitial lung disease (ILD) and the way we approach its treatment. Despite this, many questions remain unanswered, particularly those related to how the disease and its therapies impact outcomes that are most important to patients. There is currently a lack of guidance on how to best define and incorporate these patient-centered outcomes in ILD research. Objectives: To summarize the current state of patient-centered outcomes research in ILD, identify gaps in knowledge and research, and highlight opportunities and methods for future patient-centered research agendas in ILD. Methods: An international interdisciplinary group of experts was assembled. The group identified top patient-centered outcomes in ILD, reviewed available literature for each outcome, highlighted important discoveries and knowledge gaps, and formulated research recommendations. Results: The committee identified seven themes around patient-centered outcomes as the focus of the statement. After a review of the literature and expert committee discussion, we developed 28 research recommendations. Conclusions: Patient-centered outcomes are key to ascertaining whether and how ILD and interventions used to treat it affect the way patients feel and function in their daily lives. Ample opportunities exist to conduct additional work dedicated to elevating and incorporating patient-centered outcomes in ILD research.
Collapse
|
17
|
Raphaely RA, Mongiardo MA, Goldstein RL, Robinson SA, Wan ES, Moy ML. Pain in Veterans with COPD: relationship with physical activity and exercise capacity. BMC Pulm Med 2021; 21:238. [PMID: 34266401 PMCID: PMC8280683 DOI: 10.1186/s12890-021-01601-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is a common but underappreciated symptom experienced by people with Chronic Obstructive Pulmonary Disease (COPD). The relationships between pain and physical activity (PA) and exercise capacity are poorly understood. METHODS This retrospective secondary analysis includes three cohorts of Veterans with COPD who participated in longitudinal studies evaluating PA and exercise capacity with objective measures of daily step counts and 6-min walk test (6MWT) distance, respectively. Pain was assessed using the bodily pain domain of the Veterans RAND-36. In two cohorts, participants were randomly assigned to a web-based, pedometer-mediated PA intervention which has previously been demonstrated to improve PA. RESULTS Three-hundred and seventy-three (373) unique study participants were included in this analysis. Eighty-three percent (n = 311) of the population reported at least mild pain and/or at least a little bit of interference due to pain at baseline. Cross-sectionally, greater bodily pain was associated with lower 6MWT distance (β = 0.51; 95% CI 0.20, 0.82; p = 0.0013). Longitudinally, worsening bodily pain was associated with a decline in 6MWT distance (β = 0.30; 95% CI 0.03, 0.58; p = 0.0312). There was no association between baseline bodily pain and baseline daily step counts, baseline bodily pain and change in PA, or change in bodily pain and change in PA. Compared to usual care, our PA intervention improved bodily pain scores (β = 6.17; 95% CI 1.84, 10.45; p = 0.0054). Bodily pain scores did not affect the impact of the intervention on daily step counts. CONCLUSION Pain is highly prevalent and significantly associated with lower exercise capacity among Veterans with COPD. Worsening pain co-occurred with decline in exercise capacity but not PA. Our intervention reduced pain, although pain did not affect the impact of the intervention on PA.
Collapse
Affiliation(s)
- Rebecca A Raphaely
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
- Department of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
- Department of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maria A Mongiardo
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
| | - Rebekah L Goldstein
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
| | - Stephanie A Robinson
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
- VA Bedford Healthcare Systems, Bldg 70, 200 Springs Rd, Bedford, MA, 01732, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Emily S Wan
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA
- Harvard Medical School, Boston, MA, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, 1400 VFW Parkway, Mail Code 111P, Boston, MA, 02132, USA.
- Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
18
|
Benefits of budesonide/glycopyrrolate/formoterol fumarate (BGF) on symptoms and quality of life in patients with COPD in the ETHOS trial. Respir Med 2021; 185:106509. [PMID: 34171789 DOI: 10.1016/j.rmed.2021.106509] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND We report the long-term effects of triple therapy with budesonide/glycopyrrolate/formoterol fumarate (BGF) vs glycopyrrolate/formoterol fumarate (GFF) and budesonide/formoterol fumarate (BFF) on symptoms and health-related quality of life (HRQoL) over 52 weeks in the Phase III ETHOS study of patients with moderate-to-very severe COPD. METHODS ETHOS was a randomized, double-blind, multi-center, parallel-group study in symptomatic patients with COPD who experienced ≥1 moderate/severe exacerbation in the previous year. Patients received twice-daily BGF 320/18/9.6 μg, BGF 160/18/9.6 μg, GFF 18/9.6 μg, or BFF 320/9.6 μg, administered via a single Aerosphere inhaler, for 52 weeks. RESULTS The modified intent-to-treat population included 8509 patients (mean age 64.7 years; 59.7% male; mean COPD Assessment Test score, 19.6). BGF significantly reduced rescue medication use vs GFF and BFF (-0.53 puffs/day [p < 0.0001] and -0.35 puffs/day [p = 0.0002], respectively, with BGF 320 over 52 weeks). BGF 320 also significantly improved St George's Respiratory Questionnaire (SGRQ) total score over 24 and 52 weeks vs dual therapies, resulting in the greatest proportion of SGRQ responders vs dual therapies over 24 weeks (52.5% vs 42.5% [GFF] and 45.2% [BFF]) and 52 weeks (47.0% vs 37.8% [GFF] and 41.0% [BFF]). Similar results were observed with BGF 160. Benefits were also observed vs dual therapies in symptomatic endpoints including Transition Dyspnea Index focal score, EXAcerbations of Chronic pulmonary disease Tool total scores and Evaluating Respiratory Symptoms in COPD total scores over 24 and 52 weeks. CONCLUSIONS BGF triple therapy improved symptoms and HRQoL vs dual therapies over 24 and 52 weeks in patients with moderate-to-very severe COPD.
Collapse
|
19
|
Lewthwaite H, Jensen D, Ekström M. How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2021; 16:1581-1598. [PMID: 34113091 PMCID: PMC8184148 DOI: 10.2147/copd.s277523] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/09/2021] [Indexed: 12/17/2022] Open
Abstract
Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg's 0-10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.
Collapse
Affiliation(s)
- Hayley Lewthwaite
- School of Environmental & Life Sciences, College of Engineering, Science and Environment, University of Newcastle, Ourimbah, Australia
- UniSA: Allied Health and Human Performance, Innovation, Implementation and Clinical Translation in Health, University of South Australia, Adelaide, Australia
| | - Dennis Jensen
- Department of Kinesiology and Physical Education, McGill University, Montréal, Québec, Canada
- Research Institute of the McGill University Health Centre, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Research Centre for Physical Activity and Health, Faculty of Education, McGill University, Montréal, Canada
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| |
Collapse
|
20
|
Kalluri M, Luppi F, Vancheri A, Vancheri C, Balestro E, Varone F, Mogulkoc N, Cacopardo G, Bargagli E, Renzoni E, Torrisi S, Calvello M, Libra A, Pavone M, Bonella F, Cottin V, Valenzuela C, Wijsenbeek M, Bendstrup E. Patient-reported outcomes and patient-reported outcome measures in interstitial lung disease: where to go from here? Eur Respir Rev 2021; 30:30/160/210026. [PMID: 34039675 PMCID: PMC9488962 DOI: 10.1183/16000617.0026-2021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/02/2021] [Indexed: 12/03/2022] Open
Abstract
Patient-reported outcome measures (PROMs), tools to assess patient self-report of health status, are now increasingly used in research, care and policymaking. While there are two well-developed disease-specific PROMs for interstitial lung diseases (ILD) and idiopathic pulmonary fibrosis (IPF), many unmet and urgent needs remain. In December 2019, 64 international ILD experts convened in Erice, Italy to deliberate on many topics, including PROMs in ILD. This review summarises the history of PROMs in ILD, shortcomings of the existing tools, challenges of development, validation and implementation of their use in clinical trials, and the discussion held during the meeting. Development of disease-specific PROMs for ILD including IPF with robust methodology and validation in concordance with guidance from regulatory authorities have increased user confidence in PROMs. Minimal clinically important difference for bidirectional changes may need to be developed. Cross-cultural validation and linguistic adaptations are necessary in addition to robust psychometric properties for effective PROM use in multinational clinical trials. PROM burden of use should be reduced through appropriate use of digital technologies and computerised adaptive testing. Active patient engagement in all stages from development, testing, choosing and implementation of PROMs can help improve probability of success and further growth. PROMs are essential tools for research and care in ILD and IPF. They report patient perceptions of the impact of disease and its treatments on whole-person wellbeing and can guide research to make care more patient-centred.https://bit.ly/3s7Y0a8
Collapse
Affiliation(s)
- Meena Kalluri
- Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada .,Shared first and last authorship
| | - Fabrizio Luppi
- Respiratory Diseases Unit, University of Milano-Bicocca. "S. Gerardo" Hospital, Monza, Italy.,Shared first and last authorship
| | - Ada Vancheri
- Regional Referral Center for Rare Lung Diseases, University - Hospital "Policlinico G. Rodolico - San Marco", Catania, Italy
| | - Carlo Vancheri
- Dept of Clinical and Experimental Medicine, Regional Referral Centre for Rare Lung Diseases, University - Hospital "Policlinico G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Elisabetta Balestro
- Dept of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Francesco Varone
- UOC Pneumologia, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Nesrin Mogulkoc
- Dept of Pulmonology, Ege University Hospiral, Bornova, Izmir, Turkey
| | - Giulia Cacopardo
- UOSD UTIR, A.R.N.A.S. Ospedali Civico Di Cristina Benfratelli, Palermo, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Siena University, Siena, Italy
| | - Elizabeth Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, Imperial College, London, UK
| | - Sebastiano Torrisi
- Dept of Clinical and Experimental Medicine, Regional Referral Centre for Rare Lung Diseases, University - Hospital "Policlinico G. Rodolico - San Marco", University of Catania, Catania, Italy
| | | | - Alessandro Libra
- Regional Referral Center for Rare Lung Diseases, University - Hospital "Policlinico G. Rodolico - San Marco", Catania, Italy
| | - Mauro Pavone
- Dept of Clinical and Experimental Medicine, Regional Referral Centre for Rare Lung Diseases, University - Hospital "Policlinico G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Francesco Bonella
- Pneumology Dept, Centre for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Vincent Cottin
- Dept of Respiratory Medicine, National Reference Coordinating Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,University of Lyon, INRAE, IVPC, Lyon, France
| | - Claudia Valenzuela
- Pulmonology Dept, Hospital Universitario de la Princesa, Universidad Autonoma Madrid, Madrid, Spain.,Shared first and last authorship
| | - Marlies Wijsenbeek
- Centre of excellence, Interstitial Lung Diseases and Sarcoidosis, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Shared first and last authorship
| | - Elisabeth Bendstrup
- Dept of Respiratory Diseases and Allergy, Centre for Rare Lung Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Shared first and last authorship
| | | |
Collapse
|
21
|
Todt BC, Szlejf C, Duim E, Linhares AOM, Kogiso D, Varela G, Campos BA, Baghelli Fonseca CM, Polesso LE, Bordon INS, Cabral BT, Amorim VLP, Piza FMT, Degani-Costa LH. Clinical outcomes and quality of life of COVID-19 survivors: A follow-up of 3 months post hospital discharge. Respir Med 2021; 184:106453. [PMID: 34010740 PMCID: PMC8116128 DOI: 10.1016/j.rmed.2021.106453] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Over 66 million people worldwide have been diagnosed with COVID-19. Therefore, understanding their clinical evolution beyond hospital discharge is essential not only from an individual standpoint, but from a populational level. OBJECTIVES Our primary aim was to assess the impact of COVID-19 on health-related quality of life (HRQoL) 3 months after hospital discharge. Additionally, we screened for anxiety and depression and assessed important clinical outcomes. METHODS This was a single-center cohort study performed in Sao Paulo (Brazil), in which participants were contacted by telephone to answer a short survey. EQ-5D-3L was used to assess HRQoL and clinical data from patients' index admission were retrieved from medical records. RESULTS We contacted 251 participants (59.8% males, mean age 53 years old), 69.7% of which had presented with severe COVID-19. At 3 months of follow-up, 6 patients had died, 51 (20.3%) had visited the emergency department again and 17 (6.8%) had been readmitted to hospital. Seventy patients (27.9%) persisted with increased dyspnoea and 81 had a positive screening for anxiety/depression. Similarly, patients reported an overall worsening of EQ-5D-3L single summary index at 3 months compared to before the onset of COVID-19 symptoms (0.8012 (0.7368 - 1.0) vs. 1.0(0.7368 - 1.0), p < 0.001). This affected all 5 domains, but especially pain/discomfort and anxiety/depression. Only female sex and intensive care requirement were independently associated with worsening of HRQoL. CONCLUSION Patients hospitalized for COVID-19 frequently face persistent clinical and mental health problems up to 3 months following hospital discharge, with significant impact on patients' HRQoL.
Collapse
Affiliation(s)
- Beatriz Costa Todt
- Internal Medicine Residency Program, Hospital Israelita Albert Einstein, Brazil
| | - Claudia Szlejf
- Department of Big Data, Hospital Israelita Albert Einstein, Brazil
| | - Etienne Duim
- Department of Diagnostic and Ambulatory Medicine, Hospital Israelita Albert Einstein, Brazil
| | | | | | | | | | | | | | | | | | - Victor L P Amorim
- Hospital Municipal Dr. Moysés Deutsch, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, Internal Medicine Department, Hospital Israelita Albert Einstein, Brazil
| | - Felipe M T Piza
- Hospital Municipal Dr. Moysés Deutsch, Brazil; Intensive Care Unit, Hospital Israelita Albert Einstein, Brazil
| | - Luiza Helena Degani-Costa
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Internal Medicine Department, Hospital Israelita Albert Einstein, Brazil.
| |
Collapse
|
22
|
Obi ON, Judson MA, Birring SS, Maier LA, Wells AU, Lower EE, Baughman RP. Assessment of dyspnea in sarcoidosis using the Baseline Dyspnea Index (BDI) and the Transition Dyspnea Index (TDI). Respir Med 2021; 191:106436. [PMID: 33992496 DOI: 10.1016/j.rmed.2021.106436] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/22/2021] [Accepted: 04/21/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The Borg and Modified Medical Research Council (mMRC) dyspnea scales have been used to evaluate dyspnea in sarcoidosis. The Baseline Dyspnea Index (BDI) and Transitional Dyspnea Index (TDI) are useful for the assessment of dyspnea in COPD. It is not known if the BDI-TDI accurately assesses dyspnea in sarcoidosis patients. METHODS Data was analyzed from the Registry for Advanced Sarcoidosis (ReAS), a multi-national database enrolling patients with advanced sarcoidosis and a comparison group of sarcoidosis patients with non-advanced disease. At baseline, patients completed a BDI questionnaire along with spirometry, 6-min walk distance (6MWD), mMRC, Borg score, fatigue assessment score (FAS) and HRQoL assessments using Kings Sarcoidosis Questionnaire (KSQ) and St Georges Respiratory Questionnaire (SGRQ). At 12-months, patients with advanced disease completed a TDI questionnaire along with the other measures. Correlations between BDI and baseline variables, and between TDI and changes in baseline variables were evaluated. RESULTS There was significant correlation (p < 0.001 for all) between BDI and baseline 6MWD (rho = 0.336), FVC% (rho = 0.387), FEV1% (rho = 0.285), DLCO% (rho = 0.355), mMRC (rho = -0.721), Borg score (rho = -0.389), FAS (rho = -0.669), SGRQ (rho = -0.785), and KSQ (rho = 0.318 to 0.724). At follow-up, TDI correlated with BDI, but not with changes in pulmonary function or other dyspnea measures. CONCLUSION BDI scores correlated with pulmonary function, 6MWD, and other dyspnea measures. TDI scores did not correlate with changes in pulmonary function or other dyspnea measures. BDI may be a useful independent measure of dyspnea in sarcoidosis patients. The role of TDI needs further evaluation in longitudinal studies associated with changes in clinical parameters.
Collapse
Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, 3E-149E Brody Medical Sciences Building, 600 Moye Blvd, Mail Stop 628, Brody School of Medicine, East Carolina University, Greenville, NC, 27834-4354, USA.
| | - Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, New York, 12208, USA
| | | | - Lisa A Maier
- Division of Environmental and Occupational Health Sciences, National Jewish Health, University of Colorado Denver, USA; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, USA; Department of Medicine, School of Medicine, University of Colorado Denver, USA; Department of Environmental/Occupational Health, Colorado School of Public Health, University of Colorado Denver, USA
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, SW3 6NP, UK
| | - Elyse E Lower
- Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | |
Collapse
|
23
|
Vogelmeier CF, Naya IP, Maltais F, Bjermer L, Kerwin EM, Tombs L, Jones PW, Compton C, Lipson DA, Boucot IH. Treatment of COPD with Long-Acting Bronchodilators: Association Between Early and Longer-Term Clinically Important Improvement. Int J Chron Obstruct Pulmon Dis 2021; 16:1215-1226. [PMID: 33976543 PMCID: PMC8106450 DOI: 10.2147/copd.s295835] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/22/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction This post hoc analysis of the “Early MAXimization of bronchodilation for improving COPD stability” (EMAX) trial investigated whether patients achieving early clinically important improvement (CII) sustained longer-term improvements and lower risk of clinically important deterioration (CID). Methods Patients were randomized to umeclidinium/vilanterol, umeclidinium, or salmeterol for 24 weeks. The patient-reported outcomes (PROs) Transition Dyspnea Index (TDI), Evaluating Respiratory Symptoms, St George’s Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT) were assessed. CII, defined as attaining minimum clinically important differences (MCID) in ≥2 PROs, was assessed at Weeks 4, 12 and 24. CID was defined as a deterioration in CAT, SGRQ, TDI by the MCID and/or a moderate/severe exacerbation from Day 30. Results Of 2425 patients, 50%, 53% and 51% achieved a CII at Weeks 4, 12 and 24, respectively. Patients with a CII at Week 4 versus those without had significantly greater odds of achieving a CII at Weeks 12 and 24 (odds ratio: 5.57 [95% CI: 4.66, 6.66]; 4.09 [95% CI: 3.44, 4.86]). The risk of a CID was higher in patients who did not achieve a CII at Week 4 compared with patients who did (hazard ratio [95% CI]: 2.09 [1.86, 2.34]). Patients treated with umeclidinium/vilanterol versus either monotherapy had significantly greater odds of achieving CII at Weeks 4, 12 and 24. Conclusion Achieving a CII at Week 4 was associated with longer-term improvement in PROs and a reduced risk of deterioration. Further research is required to investigate the importance of an early response to treatment on the long-term disease course.
Collapse
Affiliation(s)
- Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Ian P Naya
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK.,RAMAX Ltd, Bramhall, Cheshire, UK
| | - François Maltais
- Centre De Pneumologie, Institut Universitaire De Cardiologie Et De Pneumologie De Québec, Université Laval, Québec, Canada
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Edward M Kerwin
- Altitude Clinical Consulting and Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Brentford, Middlesex, UK
| | - Paul W Jones
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Chris Compton
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - David A Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Isabelle H Boucot
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK.,Medical Emerging Markets, GSK, Brentford, Middlesex, UK
| |
Collapse
|
24
|
Kerwin E, Feldman G, Pearle J, De La Cruz L, Edwards M, Beaudot C, Georges G. Efficacy and Safety of Inhaled Glycopyrronium Bromide in COPD: A Randomized, Parallel Group, Dose-Ranging Study (GLIMMER). COPD 2021; 18:181-190. [PMID: 33709856 DOI: 10.1080/15412555.2021.1894111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This Phase II, randomized, parallel group study was conducted as part of US regulatory requirements to identify the most appropriate dose of the long-acting muscarinic antagonist glycopyrronium bromide (GB) for use in a single-inhaler triple-therapy combination with the inhaled corticosteroid beclomethasone dipropionate plus the long-acting β2-agonist formoterol fumarate. Eligible subjects were adults with COPD and post-bronchodilator forced expiratory volume in 1 s (FEV1) 40-80% predicted. Subjects were randomized to receive inhaled double-blind GB 6.25, 12.5, 25 or 50 µg or placebo, all twice daily (BID), or open-label tiotropium 18 µg once daily for six weeks. The primary objective was to evaluate the efficacy of GB versus placebo in terms of FEV1 area under the curve between 0 and 12 h at Week 6. Of 733 subjects randomized, 682 (93.0%) completed the study. For the primary endpoint, all GB doses were superior to placebo (p < 0.05), with a dose-response up to 25 µg BID, and 25 and 50 µg BID both superior to 6.25 µg BID (p < 0.05). Results for the secondary spirometry endpoints were consistent with the primary endpoint. Overall, the efficacy of GB 25 and 50 µg BID was broadly consistent with that of tiotropium. The incidence of adverse events, both overall and for the most common preferred terms, was low and similar in all treatment groups, including placebo (overall, 22.3-29.3%). Based on the totality of the efficacy and safety data, the optimal GB dose is 25 µg BID.
Collapse
Affiliation(s)
- Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Gregory Feldman
- South Carolina Pharmaceutical Research, Spartanburg, SC, USA
| | - James Pearle
- California Research Medical Group, Inc, Fullerton, CA, USA
| | | | | | | | - George Georges
- Global Clinical Development, Chiesi USA, Inc, Cary, NC, USA
| |
Collapse
|
25
|
The Effectiveness of 3 Combined Therapeutic Regimens in Egyptian Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease: A Randomized Double-Blind Prospective Pilot Study. Curr Ther Res Clin Exp 2021; 94:100625. [PMID: 34306265 PMCID: PMC8296082 DOI: 10.1016/j.curtheres.2021.100625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/03/2021] [Indexed: 11/21/2022] Open
Abstract
LABA+ICS, LAMA+ICS and LABA+LAMA improved FEV1 % predicted The three therapeutic combinations showed statistically similar safety profiles and efficacy The results of this pilot study suggest that TNF-α, fibrinogen and IL-6 can be used to monitor disease progression or guide therapeutic decisions.
Background There are differences of opinion about both the most effective combined therapeutic strategy and the clinical benefit of inhaled corticosteroids in nonasthmatic patients with chronic obstructive pulmonary disease. Furthermore, many inflammatory cytokines are reportedly correlated with severity of the disease. Objectives To compare the effectiveness of long acting β-agonist + long-acting muscarinic antagonist (LABA + LAMA) versus LABA + inhaled corticosteroid and LAMA + inhaled corticosteroid in nonasthmatic patients with moderate-to-severe chronic obstructive pulmonary disease. To assess the changes that occurred in plasma concentrations of tumor necrosis factor α, fibrinogen, and interleukin 6, and correlate these with disease activity. Methods In this pilot study, 45 nonasthmatic patients with moderate to severe chronic obstructive pulmonary disease were randomized into 3 groups with 15 patients in each group. Group I (LABA + inhaled corticosteroid) received formoterol/budesonide, group II (LAMA + inhaled corticosteroid) received tiotropium/budesonide and group III (LABA + LAMA) received formoterol/tiotropium for 12 weeks. Patients were assessed initially and then at 4 and 12 weeks by measuring the changes that occurred in forced expiratory volume in 1 second as a percent of predicted and in the modified Medical Research Council dyspnea scale. Plasma concentrations of tumor necrosis factor α, fibrinogen, and interleukin 6 were simultaneously measured. Results The 3 study groups were statistically similar with respect to their demographic data and disease characteristics. All therapeutic options produced an improvement in forced expiratory volume in 1 second as a percent of predicted and in the modified Medical Research Council dyspnea scale as well as a reduction in plasma concentrations of the inflammatory markers. The effects produced by the three therapeutic combinations on forced expiratory volume in 1 second as a percent of predicted, plasma tumor necrosis factor α, interleukin 6, and fibrinogen concentrations were statistically similar after 4 and 12 weeks (4 weeks after treatment: P = 0.358, P = 0.284, P = 0.155, and P = 0.155, respectively, and 12 weeks after treatment: P = 0.710, P = 0.773, P = 0.240, and P = 0.076, respectively). Conclusions In nonasthmatic patients with moderate to severe chronic obstructive pulmonary disease, the 3 therapeutic combinations showed similar effectiveness. The results of this pilot study also suggest that inflammatory markers can be used to track disease activity. Clinicaltrials.gov identifier: NCT04520230. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)
Collapse
|
26
|
Effects of Tiotropium/Olodaterol on Activity-Related Breathlessness, Exercise Endurance and Physical Activity in Patients with COPD: Narrative Review with Meta-/Pooled Analyses. Adv Ther 2021; 38:835-853. [PMID: 33306188 PMCID: PMC7889690 DOI: 10.1007/s12325-020-01557-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/29/2020] [Indexed: 01/17/2023]
Abstract
Abstract One of the most debilitating symptoms of chronic obstructive pulmonary disease (COPD) is breathlessness, which leads to avoidance of physical activities in daily living and hastens clinical deterioration. Treatment of patients with COPD with inhaled long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) combination therapy improves airflow limitation, reduces breathlessness compared with LAMA or LABA monotherapies, and improves health status and quality of life. A large clinical trial programme focusing on the effects of tiotropium/olodaterol combination therapy demonstrated that this LAMA/LABA combination improves lung function and reduces hyperinflation (assessed by serial inspiratory capacity measurements) compared with either tiotropium alone or placebo in patients with COPD. Tiotropium/olodaterol also increases exercise endurance capacity and improves patient perception of the intensity of breathlessness compared with placebo. In this narrative review, we focus on the relationship between improving symptoms during activity, the ability to remain active in daily life and how this may impact quality of life. We consider the benefits of therapy optimisation by means of dual bronchodilation with tiotropium/olodaterol, and present new data from meta-analyses/pooled analyses showing that tiotropium/olodaterol improves inspiratory capacity compared with placebo and tiotropium and improves exercise endurance time compared with placebo after 6 weeks of treatment. We also discuss the importance of taking a holistic approach to improving physical activity, including pulmonary rehabilitation and exercise programmes in parallel with bronchodilator therapy and psychological programmes to support behaviour change. Graphic Abstract ![]()
Collapse
|
27
|
Abstract
Evaluating symptoms is a central part of the chronic obstructive pulmonary disease (COPD) assessment system as suggested by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Considering the pros and cons of all currently available tests, GOLD suggests using primarily the modified Medical Research Council dyspnea scale or the COPD Assessment Test. Based on the test results, patients are categorized as having a low or high level of symptoms. This level then becomes one of the 2 dimensions of the ABCD grading system, which was designed to match the best initial treatment option to the individual patient's needs.
Collapse
|
28
|
Vitacca M, Malovini A, Balbi B, Aliani M, Cirio S, Spanevello A, Fracchia C, Maniscalco M, Corica G, Ambrosino N, Paneroni M. Minimal Clinically Important Difference in Barthel Index Dyspnea in Patients with COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:2591-2599. [PMID: 33116476 PMCID: PMC7585803 DOI: 10.2147/copd.s266243] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022] Open
Abstract
Background The Barthel Index dyspnea (BId) is responsive to physiological changes and pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). However, the minimum clinically important difference (MCID) has not been established yet. Aim To identify the MCID of BId in patients with COPD stratified according to the presence of chronic respiratory failure (CRF) or not. Materials and Methods Using the Medical Research Council (MRC) score as an anchor, receiver operating characteristic curves and quantile regression were retrospectively evaluated before and after pulmonary rehabilitation in 2327 patients with COPD (1151 of them with CRF). Results The median post-rehabilitation changes in BId for all patients were −10 (interquartile range = −17 to −3, p<0.001), correlating significantly with changes in MRC (r = 0.57, 95% CI = 0.53 to 0.59, p<0.001). Comparing different methods of assessment, the MCID ranged from −6.5 to −9 points for patients without and −7.5 to −12 points for patients with CRF. Conclusion The most conservative estimate of the MCID is −9 points in patients with COPD, without and −12 in those with CRF. This estimate may be useful in the clinical interpretation of data, particularly in response to intervention studies.
Collapse
Affiliation(s)
- Michele Vitacca
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Lumezzane, Brescia, Italy
| | - Alberto Malovini
- Istituti Clinici Scientifici Maugeri IRCCS, Laboratory of Informatics and Systems Engineering for Clinical Research of the Institute of Pavia, Pavia, Italy
| | - Bruno Balbi
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Veruno, Novara, Italy
| | - Maria Aliani
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Cassano Delle Murge, Bari, Italy
| | - Serena Cirio
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Pavia, Pavia, Italy
| | - Antonio Spanevello
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Tradate, Varese, Italy.,University of Insubria, MACRO, Varese, Italy
| | - Claudio Fracchia
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Montescano, Pavia, Italy
| | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Telese, Benevento, Italy
| | - Giacomo Corica
- Istituti Clinici Scientifici Maugeri IRCCS, Health Directorate of the Institute of Lumezzane, Brescia, Italy
| | - Nicolino Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Montescano, Pavia, Italy
| | - Mara Paneroni
- Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation Unit of the Institute of Lumezzane, Brescia, Italy
| |
Collapse
|
29
|
Watz H, Rickard K, Rheault T, Bengtsson T, Singh D. Symptom Improvement Following Treatment with the Inhaled Dual Phosphodiesterase 3 and 4 Inhibitor Ensifentrine in Patients with Moderate to Severe COPD - A Detailed Analysis. Int J Chron Obstruct Pulmon Dis 2020; 15:2199-2206. [PMID: 32982212 PMCID: PMC7502392 DOI: 10.2147/copd.s263025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/20/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Ensifentrine is an inhaled first-in-class dual inhibitor of phosphodiesterase (PDE) 3 and 4. In a four-week randomized, double-blind, placebo-controlled, parallel-group study in patients with chronic obstructive pulmonary disease (COPD), nebulized ensifentrine 0.75 to 6mg twice daily significantly improved bronchodilation and symptoms, with all doses being well tolerated. Here, we report data for a number of prespecified exploratory and post hoc endpoints from this study that help to further profile the effect of ensifentrine on symptoms. Methods Eligible patients were males or females aged 40-75 years with COPD, post-bronchodilator forced expiratory volume in 1 second 40-80% predicted. Other than being clinically stable for at least four weeks prior to entry, there were no symptomatic inclusion or exclusion criteria. The outcome measures reported in this manuscript are the Evaluating Respiratory Symptoms [E-RS™:COPD] questionnaire total score and subscales (breathlessness, cough/sputum and chest symptoms) at Weeks 1-4, Transition Dyspnea Index (TDI) focal score at Weeks 2 and 4, and St George's Respiratory Questionnaire - COPD Specific (SGRQ-C) total score and domain data (symptoms, activity and impacts) at Week 4. Results There was a gradual improvement versus placebo with all ensifentrine doses for all three E-RS™:COPD subscales from Week 1 to Week 4, with the greatest ensifentrine effect on the breathlessness subscale, and all four doses superior to placebo from Week 2 onwards (p<0.05). For TDI focal score, all ensifentrine doses were superior to placebo at Weeks 2 and 4 (p<0.05). In the individual SGRQ-C domains at Week 4, ensifentrine had the greatest effect on the symptoms domain, with ensifentrine 6mg superior to placebo (p<0.05). Conclusion In these analyses, ensifentrine demonstrated a notable early and meaningful effect on dyspnea, with this effect observed across two different assessment tools.
Collapse
Affiliation(s)
- Henrik Watz
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Grosshansdorf, Germany
| | | | | | | | - Dave Singh
- Medicines Evaluation Unit, University of Manchester & Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
30
|
Beaulieu J, Jensen D, O'Donnell DE, Brouillard C, Tracey L, Vincent S, Nadreau É, Bernard E, Bernard S, Maltais F. Relieving exertional dyspnea during the 3-min constant speed shuttle test in patients with COPD with indacaterol/glycopyrronium versus tiotropium: the RED trial. Ther Adv Respir Dis 2020; 14:1753466620939507. [PMID: 32663102 PMCID: PMC7361488 DOI: 10.1177/1753466620939507] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Exertional dyspnea is a cardinal feature of chronic obstructive pulmonary disease (COPD) and a major cause of activity limitation. Although dual bronchodilation is more effective than bronchodilator monotherapy at improving resting pulmonary function, it is unclear to which extent this translates into superior relief of exertional dyspnea. Methods: We conducted a randomized controlled, double-blind, cross-over trial comparing indacaterol 110 µg/glycopyrronium 50 µg once daily (OD) with tiotropium 50 µg OD in patients with moderate to severe COPD and resting hyperinflation (functional residual capacity >120% of predicted value). The primary outcome was Borg dyspnea score at the end of a 3-min constant speed shuttle test after 3 weeks of treatment. Secondary outcomes included changes in Borg dyspnea score after the first dose of study medication, expiratory flows and lung volumes. Statistical analysis was conducted using a cross-over analysis of variance model with repeated measurements. Results: A total of 50 patients with COPD and a mean forced expiratory volume in 1 s of 54 ± 11% (mean ± SEM) predicted participated in the cross-over phase of the trial. Compared with baseline, there was a decrease in dyspnea after the first dose of medication with indacaterol/glycopyrronium [mean −1.00, 95% confidence interval (CI) −1.49 to −0.52] but not with tiotropium alone (mean −0.36, 95% CI −0.81 to 0.08). The reduction in dyspnea after the first dose was statistically significant between the two treatments (mean difference of −0.64, 95% CI −1.11 to −0.17). Despite indacaterol/glycopyrronium providing further bronchodilation and lung deflation throughout the trial, the reduction in dyspnea was not sustained at 3 weeks of treatment (mean between-treatment difference at 3 weeks of 0.09, 95% CI −0.44 to 0.61). Conclusion: In comparison with bronchodilator monotherapy, indacaterol/glycopyrronium provided greater immediate exertional dyspnea relief, although this difference was not sustained after 3 weeks of therapy despite evidence of further bronchodilation and lung deflation. The reviews of this paper are available via the supplemental material section.
Collapse
Affiliation(s)
- Jessie Beaulieu
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec; Université Laval, Québec, QC, Canada
| | - Dennis Jensen
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, QC, Canada
| | - Denis E O'Donnell
- Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Cynthia Brouillard
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec; Université Laval, Québec, QC, Canada
| | - Lauren Tracey
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, QC, Canada
| | - Sandra Vincent
- Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Éric Nadreau
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec; Université Laval, Québec, QC, Canada
| | - Emmanuelle Bernard
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec; Université Laval, Québec, QC, Canada
| | - Sarah Bernard
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec; Université Laval, Québec, QC, Canada
| | - François Maltais
- Centre de pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec, 2725 chemin Ste-Foy, QC G1V 4G5, Canada
| |
Collapse
|
31
|
Higashimoto Y, Ando M, Sano A, Saeki S, Nishikawa Y, Fukuda K, Tohda Y. Effect of pulmonary rehabilitation programs including lower limb endurance training on dyspnea in stable COPD: A systematic review and meta-analysis. Respir Investig 2020; 58:355-366. [PMID: 32660900 DOI: 10.1016/j.resinv.2020.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/27/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022]
Abstract
Pulmonary rehabilitation (PR) is recommended as an effective treatment for patients with chronic obstructive pulmonary disease (COPD). Previous meta-analyses showed that PR improves exercise capacity and health-related quality of life (HRQOL). However, they did not evaluate the effect of PR on the sensation of dyspnea. We searched six databases in May 2019 for randomized controlled trials (RCTs) that examined PR, including supervised lower limb endurance training as a minimal essential component that was continued for 4-12 weeks, in patients with stable COPD, with changes from baseline dyspnea as a primary outcome. Secondary outcomes were changes in exercise capacity, HRQOL, activity of daily life (ADL), physical activity (PA), and adverse events. We calculated the pooled weighted mean difference (MD) using a random effects model. We identified 42 studies with 2150 participants. Compared with the control, PR improved dyspnea, as shown using the British Medical Research Council (MRC) questionnaire (MD, -0.64; 95% CI, -0.99 to -0.30; p = 0.0003), transitional dyspnea index (MD, 1.95; 95% CI, 1.09 to 2.81; p = 0.0001), modified Borg score during exercise (MD, -0.62; 95% CI, -1.10 to -0.14; p = 0.01), and Chronic Respiratory Questionnaire (CRQ) dyspnea score (MD, 0.91; 95% CI, 0.39 to 1.44; p = 0.0007). PR significantly increased exercise capacity measured by the 6 min walking distance time, peak workload, and peak VO2. It improved HRQOL measured by the St. George's Respiratory Questionnaire and CRQ, but not on PA or ADL. These results indicated that PR programs including lower limb endurance training improve dyspnea, HRQOL, and exercise capacity in patients with stable COPD.
Collapse
Affiliation(s)
- Yuji Higashimoto
- Department of Rehabilitation Medicine, Kindai University, Faculty of Medicine, Osaka, Japan.
| | - Morihide Ando
- Department of Pulmonary Medicine, Ogaki Municipal Hospital, Gifu, Japan
| | - Akiko Sano
- Department of Respiratory Medicine and Allergology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Sho Saeki
- Department of Respiratory Medicine and Allergology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Yusaku Nishikawa
- Department of Respiratory Medicine and Allergology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Kanji Fukuda
- Department of Rehabilitation Medicine, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Yuji Tohda
- Department of Respiratory Medicine and Allergology, Kindai University, Faculty of Medicine, Osaka, Japan
| |
Collapse
|
32
|
Dransfield MT, Garner JL, Bhatt SP, Slebos DJ, Klooster K, Sciurba FC, Shah PL, Marchetti NT, Sue RD, Wright S, Rivas-Perez H, Wiese TA, Wahidi MM, Goulart de Oliveira H, Armstrong B, Radhakrishnan S, Shargill NS. Effect of Zephyr Endobronchial Valves on Dyspnea, Activity Levels, and Quality of Life at One Year. Results from a Randomized Clinical Trial. Ann Am Thorac Soc 2020; 17:829-838. [PMID: 32223724 PMCID: PMC7328183 DOI: 10.1513/annalsats.201909-666oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 03/30/2020] [Indexed: 12/15/2022] Open
Abstract
Rationale: Bronchoscopic lung volume reduction with Zephyr Valves improves lung function, exercise tolerance, and quality of life of patients with hyperinflated emphysema and little to no collateral ventilation.Objectives:Post hoc analysis of patient-reported outcomes (PROs), including multidimensional measures of dyspnea, activity, and quality of life, in the LIBERATE (Lung Function Improvement after Bronchoscopic Lung Volume Reduction with Pulmonx Endobronchial Valves used in Treatment of Emphysema) study are reported.Methods: A total of 190 patients with severe heterogeneous emphysema and little to no collateral ventilation in the target lobe were randomized 2:1 to the Zephyr Valve or standard of care. Changes in PROs at 12 months in the two groups were compared: dyspnea with the Transitional Dyspnea Index (TDI), focal score; the Chronic Obstructive Pulmonary Disease Assessment Test (CAT; breathlessness on hill/stairs); Borg; the EXAcerbations of Chronic pulmonary disease Tool-PRO, dyspnea domain; activity with the TDI, magnitude of task/effort/functional impairment, CAT (limited activities), and the St. George's Respiratory Questionnaire (SGRQ), activity domain; and psychosocial status with the SGRQ, impacts domain, and CAT (confidence and energy).Results: At 12 months, patients using the Zephyr Valve achieved statistically significant and clinically meaningful improvements in the SGRQ; CAT; and the TDI, focal score, compared with standard of care. Improvements in the SGRQ were driven by the impacts and activity domains (P < 0.05 and P < 0.001, respectively). Reduction in CAT was through improvements in breathlessness (P < 0.05), energy level (P < 0.05), activities (P < 0.001), and increased confidence when leaving home (P < 0.05). The TDI measures of effort, task, and functional impairment were uniformly improved (P < 0.001). The EXAcerbations of Chronic Pulmonary Disease Tool (EXACT)-PRO, dyspnea domain, was significantly improved in the Zephyr Valve group. Improvements correlated with changes in residual volume and residual volume/TLC ratio.Conclusions: Patients with severe hyperinflated emphysema achieving lung volume reductions with Zephyr Valves experience improvements in multidimensional scores for breathlessness, activity, and psychosocial parameters out to at least 12 months.Clinical trial registered with www.clinicaltrials.gov (NCT01796392).
Collapse
Affiliation(s)
- Mark T. Dransfield
- Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Justin L. Garner
- Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Surya P. Bhatt
- Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frank C. Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pallav L. Shah
- Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Nathaniel T. Marchetti
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Richard D. Sue
- St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Shawn Wright
- St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Hiram Rivas-Perez
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | | | - Momen M. Wahidi
- Duke University Medical Center, Duke University, Durham, North Carolina
| | | | | | | | | | - for the LIBERATE Study Group
- Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
- Royal Brompton Hospital and Imperial College, London, United Kingdom
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
- St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
- Department of Medicine, University of Louisville, Louisville, Kentucky
- Norton Healthcare, Louisville, Kentucky
- Duke University Medical Center, Duke University, Durham, North Carolina
- Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- QST Consultations Ltd., Allendale, Michigan; and
- Pulmonx Corporation, Redwood City, California
| |
Collapse
|
33
|
Donohue JF, Kerwin E, Barnes CN, Moran EJ, Haumann B, Crater GD. Efficacy of revefenacin, a long-acting muscarinic antagonist for nebulized therapy, in patients with markers of more severe COPD: a post hoc subgroup analysis. BMC Pulm Med 2020; 20:134. [PMID: 32393215 PMCID: PMC7216337 DOI: 10.1186/s12890-020-1156-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/20/2020] [Indexed: 12/24/2022] Open
Abstract
Background Revefenacin, a once-daily, long-acting muscarinic antagonist delivered via standard jet nebulizer, increased trough forced expiratory volume in 1 s (FEV1) in patients with moderate to very severe chronic obstructive pulmonary disease (COPD) in prior phase 3 trials. We evaluated the efficacy of revefenacin in patients with markers of more severe COPD. Methods A post hoc subgroup analysis of two replicate, randomized, phase 3 trials was conducted over 12 weeks. Endpoints included least squares change from baseline in trough FEV1, St. George’s Respiratory Questionnaire (SGRQ) responders, and transition dyspnea index (TDI) responders at Day 85. This analysis included patient subgroups at high risk for COPD exacerbations and compared patients who received revefenacin 175 μg and placebo: severe and very severe airflow limitation (percent predicted FEV1 30%–< 50% and < 30%), 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD) D, reversibility (≥ 12% and ≥ 200 mL increase in FEV1) to short-acting bronchodilators, concurrent use of long-acting β agonists and/or inhaled corticosteroids, older age (> 65 and > 75 years), and comorbidity risk factors. Results Revefenacin demonstrated significant improvements in FEV1 versus placebo at Day 85 among the intention-to-treat (ITT) population and all subgroups. Additionally, there was a greater number of SGRQ and TDI responders in the ITT population and the majority of subgroups analyzed among patients who received revefenacin versus placebo. For the SGRQ responders, the odds of response (odds ratio > 2.0) were significantly greater in the revefenacin arm versus the placebo arm among the severe airflow obstruction, very severe airflow obstruction and 2011 GOLD D subgroups. For the TDI responders, the odds of response (odds ratio > 2.0) were significantly greater among the severe airflow obstruction subgroup and patients aged > 75 years. Conclusions Revefenacin showed significantly greater improvements in FEV1 versus placebo in the ITT population and all subgroups. Furthermore, there were a greater number of SGRQ and TDI responders in the ITT population, and in the majority of patient subgroups among patients who received revefenacin versus placebo. Based on the data presented, revefenacin could be a therapeutic option among patients with markers of more severe COPD. Trial registration Clinical trials registered with www.clinicaltrials.gov (Studies 0126 [NCT02459080; prospectively registered 22 May 2015] and 0127 [NCT02512510; prospectively registered 28 July 2015]).
Collapse
Affiliation(s)
- James F Donohue
- Pulmonary Medicine, UNC School of Medicine, 321 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Edward Kerwin
- Clinical Research Institute of Southern Oregon, LLC, 3860 Crater Lake Ave, Medford, OR, 97504, USA
| | - Chris N Barnes
- Theravance Biopharma US, Inc., 901 Gateway Blvd, South San Francisco, CA, 94080, USA
| | - Edmund J Moran
- Theravance Biopharma US, Inc., 901 Gateway Blvd, South San Francisco, CA, 94080, USA
| | - Brett Haumann
- Theravance Biopharma US, Inc., 901 Gateway Blvd, South San Francisco, CA, 94080, USA
| | - Glenn D Crater
- Theravance Biopharma US, Inc., 901 Gateway Blvd, South San Francisco, CA, 94080, USA.
| |
Collapse
|
34
|
Wang C, Yang T, Kang J, Chen R, Zhao L, He H, Assam PN, Su R, Bourne E, Ballal S, DeAngelis K, Dorinsky P. Efficacy and Safety of Budesonide/Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler in Chinese Patients with COPD: A Subgroup Analysis of KRONOS. Adv Ther 2020; 37:1591-1607. [PMID: 32152869 PMCID: PMC7140742 DOI: 10.1007/s12325-020-01266-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION This pre-specified subgroup analysis evaluated the efficacy and safety of budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler (BGF MDI) triple therapy versus corresponding dual therapies in the China subgroup of the phase III, double-blind KRONOS study in patients with moderate to very severe chronic obstructive pulmonary disease (COPD). METHODS Patients were randomized 2:2:1:1 to BGF MDI 320/18/9.6 μg, glycopyrrolate/formoterol fumarate (GFF) MDI 18/9.6 μg, budesonide/formoterol fumarate (BFF) MDI 320/9.6 μg, or budesonide/formoterol fumarate dry powder inhaler (BUD/FORM DPI) 400/12 μg twice daily for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) over weeks 12-24. Secondary endpoints included symptoms, health-related quality of life, and safety. Rate of moderate/severe COPD exacerbations was an additional efficacy endpoint. RESULTS In the China subgroup (n = 432; 22.7% of the KRONOS population), BGF MDI demonstrated nominally significant improvements in the primary endpoint versus BFF MDI (least squares mean (LSM) difference 68 mL; P = 0.0035) and BUD/FORM DPI (LSM difference 78 mL; P = 0.0010) but not GFF MDI (LSM difference - 4 mL; P = 0.8316). BGF MDI demonstrated at least numerical improvements versus comparators in secondary lung function and symptom endpoints. BGF MDI reduced the rate of moderate/severe COPD exacerbations versus GFF MDI (rate ratio 0.41; P = 0.0030), with numerical benefits versus BFF MDI and BUD/FORM DPI. All treatments were well tolerated. CONCLUSIONS Results demonstrated that BGF MDI showed benefits on lung function (vs inhaled corticosteroid/long-acting β2-agonist), as well as symptoms and exacerbations relative to dual therapies. Findings support BGF MDI use in Chinese patients with moderate to very severe COPD. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02497001.
Collapse
Affiliation(s)
- Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, No. 2, East Yinghua Street, Chaoyang District, Beijing, 100029, China.
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.
- National Clinical Research Center for Respiratory Diseases, Beijing, China.
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Respiratory Medicine, Capital Medical University, Beijing, China.
| | - Ting Yang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, No. 2, East Yinghua Street, Chaoyang District, Beijing, 100029, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Department of Respiratory Medicine, Capital Medical University, Beijing, China
| | - Jian Kang
- The First Hospital of China Medical University, Shenyang, China
| | - Rongchang Chen
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Zhao
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Huijie He
- The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, Inner Mongolia, China
| | | | - Rong Su
- AstraZeneca, Shanghai, China
| | | | | | | | | |
Collapse
|
35
|
Chen R, Zhong N, Wang HY, Zhao L, Mei X, Qin Z, Huang J, Assam PN, Maes A, Siddiqui S, Martin UJ, Reisner C. Efficacy And Safety Of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler (GFF MDI) Formulated Using Co-Suspension Delivery Technology In Chinese Patients With COPD. Int J Chron Obstruct Pulmon Dis 2020; 15:43-56. [PMID: 32021143 PMCID: PMC6956867 DOI: 10.2147/copd.s223638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/30/2019] [Indexed: 12/03/2022] Open
Abstract
Background Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI) is a long-acting muscarinic antagonist/long-acting β2-agonist fixed-dose combination therapy delivered by MDI, formulated using innovative co-suspension delivery technology. The PINNACLE-4 study evaluated the efficacy and safety of GFF MDI in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD) from Asia, Europe, and the USA. This article presents the results from the China subpopulation of PINNACLE-4. Methods In this randomized, double-blind, placebo-controlled, parallel-group Phase III study (NCT02343458), patients received GFF MDI 18/9.6 µg, glycopyrrolate (GP) MDI 18 µg, formoterol fumarate (FF) MDI 9.6 µg, or placebo MDI (all twice daily) for 24 weeks. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 second at Week 24. Secondary lung function endpoints and patient-reported outcome measures were also assessed. Safety was monitored throughout the study. Results Overall, 466 patients from China were included in the intent-to-treat population (mean age 63.6 years, 95.7% male). Treatment with GFF MDI improved the primary endpoint compared to GP MDI, FF MDI, and placebo MDI (least squares mean differences: 98, 104, and 173 mL, respectively; all P≤0.0001). GFF MDI also improved daily total symptom scores and time to first clinically important deterioration versus monocomponents and placebo MDI, and Transition Dyspnea Index focal score versus placebo MDI. Rates of treatment-emergent adverse events were similar across the active treatment groups and slightly higher in the placebo MDI group. Conclusion GFF MDI improved lung function and daily symptoms versus monocomponents and placebo MDI and improved dyspnea versus placebo MDI. All treatments were well tolerated with no unexpected safety findings. Efficacy and safety results were generally consistent with the global PINNACLE-4 population, supporting the use of GFF MDI in patients with COPD from China.
Collapse
Affiliation(s)
- Rongchang Chen
- Shenzhen Institute of Respiratory Diseases, Shenzhen People's Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Nanshan Zhong
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Diseases, National Clinical Research Centre for Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Hao-Yan Wang
- Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Li Zhao
- Sheng Jing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Xiaodong Mei
- Anhui Provincial Hospital, Hefei, Anhui, People's Republic of China
| | - Zhiqiang Qin
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Juan Huang
- Formerly of AstraZeneca, Shanghai, People's Republic of China
| | | | | | | | | | | |
Collapse
|
36
|
Skolnik NS, Nguyen TS, Shrestha A, Ray R, Corbridge TC, Brunton SA. Current evidence for COPD management with dual long-acting muscarinic antagonist/long-acting β 2-agonist bronchodilators. Postgrad Med 2020; 132:198-205. [PMID: 31900019 DOI: 10.1080/00325481.2019.1702834] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Long-acting inhaled bronchodilator medications are recommended as initial maintenance therapy for many patients with COPD. These medications include long-acting muscarinic antagonists (LAMA) and long-acting β2-agonists (LABA). Combinations of long-acting bronchodilator agents (LAMA/LABA) and inhaled corticosteroids combined with LABA (ICS/LABA) are also used as initial or follow-up therapy in patients with more severe symptoms or at risk of COPD exacerbations. This review summarizes the position of LAMA/LABA combinations in treatment recommendations, and the evidence supporting their placement relative to LAMA monotherapy and ICS/LABA combination therapy, as well as differences within the LAMA/LABA class. Most studies show that LAMA/LABA treatment leads to greater improvements in lung function and symptoms than LAMA monotherapy or ICS/LABA treatment. There are fewer studies comparing the impact of different medication classes on patients' risk of exacerbations; however, the available evidence suggests that LAMA/LABA treatment and LAMA monotherapy lead to a similar reduction in exacerbation risk, while the effect of LAMA/LABA compared with ICS/LABA remains unclear. The incidence of adverse events is similar with LAMA/LABA and LAMA alone. There is a lower risk of pneumonia with LAMA/LABA compared with ICS/LABA. This evidence supports the use of LAMA/LABA combinations as an initial maintenance therapy option for symptomatic patients with low exacerbation risk and severe breathlessness or patients with severe symptoms who are at risk of exacerbations, and as follow-up treatment in patients with uncontrolled symptoms or exacerbations on bronchodilator monotherapy.
Collapse
Affiliation(s)
- Neil S Skolnik
- Family/Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Jenkintown, PA, USA
| | - Trang Susan Nguyen
- Roseman University of Health Sciences, College of Pharmacy, Henderson, NV, USA
| | - Aarisha Shrestha
- Family/Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Jenkintown, PA, USA
| | - Riju Ray
- US Medical Affairs, GSK, Research Triangle Park, NC, USA
| | | | | |
Collapse
|
37
|
Vogelmeier CF, Kerwin EM, Bjermer LH, Tombs L, Jones PW, Boucot IH, Naya IP, Lipson DA, Compton C, Barnes N, Maltais F. Impact of baseline COPD symptom severity on the benefit from dual versus mono-bronchodilators: an analysis of the EMAX randomised controlled trial. Ther Adv Respir Dis 2020; 14:1753466620968500. [PMID: 33167780 PMCID: PMC7659027 DOI: 10.1177/1753466620968500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/25/2020] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Symptom relief is a key treatment goal in patients with chronic obstructive pulmonary disease (COPD). However, there are limited data available on the response to bronchodilator therapy in patients at low risk of exacerbations with different levels of symptom severity. This study compared treatment responses in patients with a range of symptom severities as indicated by baseline COPD assessment test (CAT) scores. METHODS The 24-week EMAX trial evaluated the benefits of umeclidinium/vilanterol versus umeclidinium or salmeterol in symptomatic patients at low exacerbation risk who were not receiving inhaled corticosteroids. This analysis assessed lung function, symptoms, health status, and short-term deterioration outcomes in subgroups defined by a baseline CAT score [<20 (post hoc) and ⩾20 (pre-specified)]. Outcomes were also assessed using post hoc fractional polynomial modelling with continuous transformations of baseline CAT score covariates. RESULTS Of the intent-to-treat population (n = 2425), 56% and 44% had baseline CAT scores of <20 and ⩾20, respectively. Umeclidinium/vilanterol demonstrated favourable improvements compared with umeclidinium and salmeterol for the majority of outcomes irrespective of the baseline CAT score, with the greatest improvements generally observed in patients with CAT scores <20. Fractional polynomial analyses revealed consistent improvements in lung function, symptoms and reduction in rescue medication use with umeclidinium/vilanterol versus umeclidinium and salmeterol across a range of CAT scores, with the largest benefits seen in patients with CAT scores of approximately 10-21. CONCLUSIONS Patients with symptomatic COPD benefit similarly from dual bronchodilator treatment with umeclidinium/vilanterol. Fractional polynomial analyses demonstrated the greatest treatment differences favouring dual therapy in patients with a CAT score <20, although benefits were seen up to scores of 30. This suggests that dual bronchodilation may be considered as initial therapy for patients across a broad range of symptom severities, not only those with severe symptoms (CAT ⩾20).Trial registration: NCT03034915, 2016-002513-22 (EudraCT number).The reviews of this paper are available via the supplemental material section.
Collapse
Affiliation(s)
- Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-Universität Marburg, Germany
- Member of the German Centre for Lung Research (DZL), Baldingerstraße, Marburg 35043, Germany
| | - Edward M. Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Leif H. Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Lee Tombs
- Precise Approach Ltd, Contingent Worker on Assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | | | | | - Ian P. Naya
- GSK, Brentford, Middlesex, UK
- RAMAX Ltd., Bramhall, Cheshire, UK
| | - David A. Lipson
- Respiratory Clinical Sciences, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - François Maltais
- Centre de Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| |
Collapse
|
38
|
Singh D, D’Urzo AD, Donohue JF, Kerwin EM, Molins E, Chuecos F, Ribera A, Jarreta D. An Evaluation Of Single And Dual Long-Acting Bronchodilator Therapy As Effective Interventions In Maintenance Therapy-Naïve Patients With COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:2835-2848. [PMID: 31827323 PMCID: PMC6902852 DOI: 10.2147/copd.s217710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022] Open
Abstract
Background Ideally, treatment recommendations for maintenance therapy-naïve patients with COPD should be based on studies conducted specifically in this population. We have reviewed evidence from previous studies of pharmacological treatments in maintenance therapy-naïve patients with COPD and performed a new post-hoc analysis of dual bronchodilator treatment in this population, aiming to assess the effectiveness of these interventions. Materials and methods A literature review identified clinical trials that included analyses of patients with COPD who were maintenance therapy-naïve with long-acting β2-agonists (LABA) or long-acting muscarinic antagonists (LAMA). Additionally, a post-hoc subgroup analysis was conducted for maintenance therapy-naïve patients with COPD in two large phase III, randomized, double-blind, 24-week trials investigating the efficacy of aclidinium bromide/formoterol fumarate (AB/FF) fixed-dose combination versus monotherapy or placebo (ACLIFORM [NCT01462942] and AUGMENT [NCT01437397]). Results Treatment-naïve patients with COPD often represent a population of patients at the earliest stage at which most patients seek treatment. Of nine relevant studies identified, all reported positive findings for efficacy of LABA, LAMA, or LABA/LAMA treatment in maintenance therapy-naïve populations. Improvements were observed in lung function, symptoms, and health status versus monotherapy or placebo. Post-hoc analysis of ACLIFORM and AUGMENT demonstrated that AB/FF was effective in improving lung function in patients who had received no prior maintenance therapy. AB/FF showed improvements in 1 hr post-dose FEV1, trough FEV1, and patient-reported outcomes versus placebo and monotherapies. Combined with reviews of previous studies in maintenance therapy-naïve patients, these findings suggest that earlier intervention with a dual bronchodilator maintenance therapy, such as AB/FF, may provide significantly greater benefits than LAMA or LABA mono-bronchodilator therapy as a first maintenance treatment for COPD. Conclusion These data show that therapeutic intervention is effective in treatment-naïve patients. Intervention with dual bronchodilator therapy as a first maintenance treatment for COPD may provide greater benefits than LAMA or LABA monotherapy.
Collapse
Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Anthony D D’Urzo
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina Pulmonary Critical Medicine, Chapel Hill, NC, USA
| | | | - Eduard Molins
- BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| | | | - Anna Ribera
- BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| | - Diana Jarreta
- BioPharmaceuticals R&D, AstraZeneca, Barcelona, Spain
| |
Collapse
|
39
|
Maltais F, Bjermer L, Kerwin EM, Jones PW, Watkins ML, Tombs L, Naya IP, Boucot IH, Lipson DA, Compton C, Vahdati-Bolouri M, Vogelmeier CF. Efficacy of umeclidinium/vilanterol versus umeclidinium and salmeterol monotherapies in symptomatic patients with COPD not receiving inhaled corticosteroids: the EMAX randomised trial. Respir Res 2019; 20:238. [PMID: 31666084 PMCID: PMC6821007 DOI: 10.1186/s12931-019-1193-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/20/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Prospective evidence is lacking regarding incremental benefits of long-acting dual- versus mono-bronchodilation in improving symptoms and preventing short-term disease worsening/treatment failure in low exacerbation risk patients with chronic obstructive pulmonary disease (COPD) not receiving inhaled corticosteroids. METHODS The 24-week, double-blind, double-dummy, parallel-group Early MAXimisation of bronchodilation for improving COPD stability (EMAX) trial randomised patients at low exacerbation risk not receiving inhaled corticosteroids, to umeclidinium/vilanterol 62.5/25 μg once-daily, umeclidinium 62.5 μg once-daily or salmeterol 50 μg twice-daily. The primary endpoint was trough forced expiratory volume in 1 s (FEV1) at Week 24. The study was also powered for the secondary endpoint of Transition Dyspnoea Index at Week 24. Other efficacy assessments included spirometry, symptoms, heath status and short-term disease worsening measured by the composite endpoint of clinically important deterioration using three definitions. RESULTS Change from baseline in trough FEV1 at Week 24 was 66 mL (95% confidence interval [CI]: 43, 89) and 141 mL (95% CI: 118, 164) greater with umeclidinium/vilanterol versus umeclidinium and salmeterol, respectively (both p < 0.001). Umeclidinium/vilanterol demonstrated consistent improvements in Transition Dyspnoea Index versus both monotherapies at Week 24 (vs umeclidinium: 0.37 [95% CI: 0.06, 0.68], p = 0.018; vs salmeterol: 0.45 [95% CI: 0.15, 0.76], p = 0.004) and all other symptom measures at all time points. Regardless of the clinically important deterioration definition considered, umeclidinium/vilanterol significantly reduced the risk of a first clinically important deterioration compared with umeclidinium (by 16-25% [p < 0.01]) and salmeterol (by 26-41% [p < 0.001]). Safety profiles were similar between treatments. CONCLUSIONS Umeclidinium/vilanterol consistently provides early and sustained improvements in lung function and symptoms and reduces the risk of deterioration/treatment failure versus umeclidinium or salmeterol in symptomatic patients with low exacerbation risk not receiving inhaled corticosteroids. These findings suggest a potential for early use of dual bronchodilators to help optimise therapy in this patient group.
Collapse
Affiliation(s)
- François Maltais
- Centre de Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Canada.
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, OR, USA
| | - Paul W Jones
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Michael L Watkins
- Respiratory Research and Development, GSK, Research Triangle Park, NC, USA
| | - Lee Tombs
- Precise Approach Ltd, contingent worker on assignment at GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Ian P Naya
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | | | - David A Lipson
- Respiratory Research and Development, GSK, Collegeville, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Compton
- Global Specialty & Primary Care, GSK, Brentford, Middlesex, UK
| | - Mitra Vahdati-Bolouri
- Respiratory Discovery Medicine, Respiratory Research and Development, GSK, Stevenage, Hertfordshire, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Germany, Member of the German Center for Lung Research (DZL), Marburg, Germany
| |
Collapse
|
40
|
Mahler DA, Kerwin E, Murray L, Dembek C. The Impact of Twice-Daily Indacaterol/Glycopyrrolate on the Components of Health-Related Quality of Life and Dyspnea in Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6. [PMID: 31539467 DOI: 10.15326/jcopdf.6.4.2019.0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Chronic cough, dyspnea, and excessive sputum production, the characteristic symptoms of chronic obstructive pulmonary disease (COPD), can negatively affect patients' health-related quality of life (HRQoL). The fixed-dose combination of a long-acting beta2-adrenergic agonist and a long-acting muscarinic antagonist (LABA/LAMA) have been shown to improve HRQoL and COPD symptoms as measured by the St George's Respiratory Questionnaire (SGRQ) and the Transition Dyspnea Index (TDI) total scores. However, the impact of a LABA/LAMA on the individual components of HRQoL and dyspnea with daily activities is unknown. Methods Secondary analysis of pooled data from 2 replicate, phase 3, 12-week, randomized, placebo, and active-controlled trials of twice-daily indacaterol/glycopyrrolate (IND/GLY) were analyzed. Change from baseline in HRQoL and dyspnea was measured by SGRQ and TDI, respectively. Total and component scores were evaluated using linear mixed models. Logistic regression was used to analyze the proportion of patients achieving minimum clinically important difference. Study outcomes were further explored in patient subgroups. Results A total of 2038 patients from FLIGHT1/FLIGHT2 studies were evaluated. IND/GLY significantly improved SGRQ component scores (symptoms [-7.3], activity [-3.6], and impacts [-5.0]); all P < 0.001 compared with placebo. IND/GLY also significantly improved symptoms scores compared with IND and GLY (-3.5 and -3.7, respectively; both P < 0.001). Patients treated with IND/GLY also had significant improvements in TDI component scores compared with placebo: functional impairment (0.48), magnitude of task (0.61), and magnitude of effort (0.54); all P < 0.001. All component scores were significantly higher for IND/GLY compared with IND and GLY (P ≤ 0.002 for all). Conclusions Twice-daily IND/GLY significantly improved total scores as well as components of HRQoL and dyspnea in patients with COPD. These data demonstrate multiple clinical benefits of LABA/LAMA maintenance therapy in the COPD population. ClinicalTrials.gov: NCT01727141 and NCT01712516.
Collapse
Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Edward Kerwin
- Clinical Research Institute of Southern Oregon, Medford, Oregon
| | | | - Carole Dembek
- Sunovion Pharmaceuticals Inc., Marlborough, Massachusetts
| |
Collapse
|
41
|
Chéhère B, Grosbois JM, Chenivesse C, Wallaert B, Bougault V. Exploiting local facilities for post-pulmonary rehabilitation maintenance programs in fibrotic idiopathic interstitial pneumonia patients: A pilot study. Respir Med Res 2019; 76:45-47. [PMID: 31527017 DOI: 10.1016/j.resmer.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/17/2019] [Accepted: 07/21/2019] [Indexed: 10/26/2022]
Affiliation(s)
- B Chéhère
- University of Lille, EA 7369, URePSSS, Multidisciplinary Research Unit in Sport Health Society, 59000 Lille, France; Univ Brest, ORPHY, 29200 Brest, France.
| | - J-M Grosbois
- FormAction Santé, 59840 Pérenchies, France; Department of Respiratory Medicine, Centre Hospitalier Germon et Gauthier, 62408 Béthune, France.
| | - C Chenivesse
- CHU Lille, Department of Immuno-Allergology and Respiratory Diseases, Competence Centre for Rare Pulmonary Diseases, University of Lille, 59000 Lille, France.
| | - B Wallaert
- Department of Respiratory Medicine, Centre Hospitalier Germon et Gauthier, 62408 Béthune, France; CHU Lille, Department of Immuno-Allergology and Respiratory Diseases, Competence Centre for Rare Pulmonary Diseases, University of Lille, 59000 Lille, France.
| | - V Bougault
- University of Lille, EA 7369, URePSSS, Multidisciplinary Research Unit in Sport Health Society, 59000 Lille, France; LAMHESS, Université Côte d'Azur, 06100 Nice, France.
| |
Collapse
|
42
|
Maltais F, Ferguson GT, Feldman GJ, Deslee G, Bourdin A, Fjällbrant H, Siwek-Posłuszna A, Jenkins MA, Martin UJ. A Randomized, Double-Blind, Double-Dummy Study of Glycopyrrolate/Formoterol Fumarate Metered Dose Inhaler Relative to Umeclidinium/Vilanterol Dry Powder Inhaler in COPD. Adv Ther 2019; 36:2434-2449. [PMID: 31267366 DOI: 10.1007/s12325-019-01015-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI), formulated using co-suspension delivery technology, is the only approved fixed-dose combination long-acting muscarinic antagonist/long-acting β2-agonist (LAMA/LABA) delivered via MDI. Direct comparisons of GFF MDI versus other LAMA/LABAs have not previously been performed. We assessed the efficacy and safety of GFF MDI relative to umeclidinium/vilanterol dry powder inhaler (UV DPI) in patients with moderate-to-very severe chronic obstructive pulmonary disease (COPD). METHODS In this phase IIIb randomized, double-blind, double-dummy, multicenter, 24-week study, patients received GFF MDI 18/9.6 μg (equivalent to glycopyrronium/formoterol fumarate dihydrate 14.4/10 μg; two inhalations per dose, twice-daily; n = 559) or UV DPI 62.5/25 μg (one inhalation, once-daily; n = 560). Primary endpoints were change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) and peak change from baseline in FEV1 within 2 h post-dose, both over 24 weeks. Additional lung function, symptom and safety endpoints were also assessed. RESULTS For the primary endpoints, GFF MDI was non-inferior to UV DPI (using a margin of - 50 mL) for peak FEV1 (least squares mean [LSM] difference - 3.4 mL, 97.5% confidence interval [CI] - 32.8, 25.9) but not for trough FEV1 (LSM difference - 87.2 mL; - 117.0, - 57.4). GFF MDI was nominally superior to UV DPI for onset of action (p < 0.0001) and was nominally non-inferior to UV DPI for all symptom endpoints (Transition Dyspnea Index focal score, Early Morning/Night-Time Symptoms COPD instrument scores, and COPD Assessment Test score). Exacerbation and safety findings were similar between groups. CONCLUSIONS Over 24 weeks of treatment, GFF MDI was non-inferior to UV DPI for peak FEV1, but not for morning pre-dose trough FEV1. GFF MDI had a faster onset of action versus UV DPI. There were no clinically meaningful differences between treatments in symptom endpoints. Both treatments were well tolerated with similar safety profiles. TRIAL REGISTRATION NCT03162055 (Clinicaltrials.gov) FUNDING: AstraZeneca.
Collapse
|
43
|
Effect of smoking status on lung function, patient-reported outcomes, and safety among patients with COPD treated with indacaterol/glycopyrrolate: Pooled analysis of the FLIGHT1 and FLIGHT2 studies. Respir Med 2019; 155:113-120. [PMID: 31344660 DOI: 10.1016/j.rmed.2019.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Smoking continues to be a major risk factor for COPD and may impact the efficacy of COPD treatments, with guidelines supporting the crucial importance for current smokers of smoking cessation. A post-hoc analysis of the FLIGHT1 and FLIGHT2 studies assessed the impact of smoking status on the efficacy and safety of indacaterol/glycopyrrolate (IND/GLY) 27.5/15.6 μg twice daily versus its monocomponents or placebo in patients with COPD. METHODS This post-hoc analysis of pooled data from the replicate, 12-week, placebo-controlled FLIGHT1 and FLIGHT2 studies compared the efficacy and safety of IND/GLY with that of IND, GLY, and placebo in patients with moderate-to-severe COPD. Baseline data from 2038 patients were pooled and grouped by smoking status (52% were current smokers and 48% were ex-smokers). The effects of treatment on lung function, patient-reported outcomes (PROs), and safety were evaluated by baseline smoking status. RESULTS Treatment with IND/GLY resulted in significant improvements in lung function measurements compared with placebo, irrespective of smoking status. Improvements in St George's Respiratory Questionnaire and transition dyspnea index were significantly greater than placebo in both current and ex-smokers, whereas changes in COPD assessment test were significant only among current smokers. Improvements in lung function and PROs were greater with IND/GLY compared with its monocomponents in current and ex-smokers. The incidences of AEs and SAEs were similar between current and ex-smokers. CONCLUSIONS IND/GLY demonstrated significant improvements in lung function and PROs, independent of baseline smoking status. The safety profile of IND/GLY did not differ between current and ex-smokers.
Collapse
|
44
|
Tsujimura Y, Hiramatsu T, Kojima E, Tabira K. Effect of pulmonary rehabilitation with assistive use of short-acting β2 agonist in COPD patients using long-acting bronchodilators. Physiother Theory Pract 2019; 37:719-728. [PMID: 31294667 DOI: 10.1080/09593985.2019.1641866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Assistive use of short-acting β2 agonists (SABAs) reportedly improves exercise tolerance, activities of daily living, and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD). However, the effect of SABA on physical activity (PA) is unclear.Objective: This study aimed to determine whether assistive use of SABA increases PA and whether additional pulmonary rehabilitation (PR) can aid further improvement.Methods: Twelve outpatients with COPD and dyspnea during daily activities despite regular use of long-acting bronchodilators were enrolled. This study comprised a 2-week pre-intervention investigation, a 12-week investigation of SABA effects, and an 8-week investigation of the additional effects of PR. Assistive use of SABA was allowed up to 4 times per day after the pre-intervention period. PA was measured for 14 consecutive days using an accelerometer sensor. Dyspnea, exercise tolerance, and HRQOL were evaluated at entry, at 4 and 12 weeks after initiating SABA use, and after completing PR.Results: Assistive use of SABA improved breathlessness during daily activities and increased PA (p < .001). PA and HRQOL were also improved following PR (p < .001 and p = .013, respectively).Conclusions: Combined therapy of SABA and PR can increase PA and HRQOL in COPD patients.
Collapse
Affiliation(s)
- Yasuhiko Tsujimura
- Hiramatsu Clinic of Internal and Respiratory Medicine, Komaki, Japan.,Division of Health Science, Graduate School of Health Science, Kio University, Nara, Japan
| | - Tetsuo Hiramatsu
- Hiramatsu Clinic of Internal and Respiratory Medicine, Komaki, Japan
| | - Eiji Kojima
- Department of Respiratory Medicine, Komaki City Hospital, Komaki, Japan
| | - Kazuyuki Tabira
- Division of Health Science, Graduate School of Health Science, Kio University, Nara, Japan
| |
Collapse
|
45
|
Tashkin DP, Goodin T, Bowling A, Price B, Ozol-Godfrey A, Sharma S, Sanjar S. Effect of smoking status on lung function, patient-reported outcomes, and safety among COPD patients treated with glycopyrrolate inhalation powder: pooled analysis of GEM1 and GEM2 studies. Respir Res 2019; 20:135. [PMID: 31266489 PMCID: PMC6604131 DOI: 10.1186/s12931-019-1112-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/25/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Smoking is a major risk factor for COPD and may impact the efficacy of COPD treatments; however, a large proportion of COPD patients continue to smoke following diagnosis. METHODS This post-hoc analysis of pooled data from the replicate 12-week, placebo-controlled GEM1 and GEM2 studies assessed the impact of smoking status on the efficacy and safety of glycopyrrolate 15.6 μg twice daily vs placebo in patients with moderate-to-severe COPD. Data from 867 patients enrolled in GEM1 and GEM2 were pooled for analysis and grouped by smoking status (57% current smokers, 43% ex-smokers). Forced expiratory volume in 1 s (FEV1) area under the curve from 0 to 12 h, trough FEV1, forced vital capacity, St George's Respiratory Questionnaire (SGRQ) total score, COPD assessment test (CAT) score, transition dyspnea index (TDI) focal score, daily symptom scores, and rescue medication use were assessed in current smokers and ex-smokers. Incidences of adverse events (AEs) and serious AEs (SAEs) were also assessed. RESULTS Treatment with glycopyrrolate resulted in significant improvements in all lung function measures, independent of smoking status. In both current and ex-smokers, changes from baseline in trough FEV1 were less marked in patients taking inhaled corticosteroids (ICS) than those not receiving ICS. Changes from baseline in SGRQ total score and rescue medication use were significantly greater with glycopyrrolate compared with placebo, regardless of smoking status. Changes in the CAT score, TDI focal score, and daily symptom scores significantly improved versus placebo, but only in current smokers. Improvements in patient-reported outcomes (PROs) with glycopyrrolate relative to placebo were numerically greater in current smokers than ex-smokers. The incidences of AEs and SAEs were similar regardless of smoking status. CONCLUSIONS In this post-hoc analysis of GEM1 and GEM2, glycopyrrolate use led to significant improvements in lung function, independent of baseline smoking status; improvements were less marked among patients receiving background ICS, regardless of baseline smoking status. Improvements in PROs were greater with glycopyrrolate than placebo, and the magnitude of changes was numerically greater among current smokers. The safety profile of glycopyrrolate was comparable between current smokers and ex-smokers.
Collapse
Affiliation(s)
- Donald P Tashkin
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | | | | | - Barry Price
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | | | | | | |
Collapse
|
46
|
Ohar JA, Sharma S, Goodin T, Bowling A, Price B, Ozol-Godfrey A, Sanjar S. Efficacy of Indacaterol/Glycopyrrolate in Patients with COPD by Airway Reversibility at Baseline: A Pooled Analysis of the FLIGHT1 and FLIGHT2 12-Week Studies. COPD 2019; 16:133-139. [PMID: 31242792 DOI: 10.1080/15412555.2019.1612341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Bronchodilator reversibility occurs in patients with COPD. Pooled analysis of two 12-week, placebo-controlled randomised studies (FLIGHT1 [NCT01727141]; FLIGHT2 [NCT01712516]) assessed the effect of bronchodilator reversibility on lung function, patient-reported outcomes, and safety in 2,043 patients with moderate-to-severe COPD treated with indacaterol/glycopyrrolate (IND/GLY) 27.5/15.6 µg twice daily. Reversibility was defined as post-bronchodilator increase in forced expiratory volume in one second (FEV1) of ≥12% and ≥0.200 L. Overall, mean reversibility (mean post-bronchodilator FEV1 increase) was 22.8%, and 54.5% of patients met reversibility criteria. IND/GLY resulted in significant (p < 0.05) placebo-adjusted improvements from baseline at Week 12 in reversible and non-reversible patients in FEV1 area under the curve from 0 to 12 hours (0.308 L and 0.170 L, respectively), trough FEV1 (0.260 L and 0.174 L), St. George's Respiratory Questionnaire total score (-6.3 and -3.5), COPD Assessment Test total score (-2.3 and -1.2), daily rescue medication use (-1.52 and -0.79), and daily total symptom score (-0.86 and -0.63); Transition Dyspnoea Index focal score also showed improvements (1.93 and 1.29) at Week 12, irrespective of reversibility status. Improvements in lung function and rescue medication use were significantly (p < 0.05) greater in IND/GLY patients in the reversible subgroup compared with the non-reversible subgroup. The safety profile was similar across treatment groups and reversibility subgroups. Overall, treatment with IND/GLY led to significant improvements in lung function and PROs in patients with moderate-to-severe COPD, regardless of reversibility status, with greater improvements in the reversible subgroup. Safety profile was not affected by reversibility status.
Collapse
Affiliation(s)
- Jill A Ohar
- a Wake Forest University , Winston-Salem , NC , USA
| | - Sanjay Sharma
- b Sunovion Pharmaceuticals Inc. , Marlborough , MA , USA
| | - Thomas Goodin
- b Sunovion Pharmaceuticals Inc. , Marlborough , MA , USA
| | - Alyssa Bowling
- b Sunovion Pharmaceuticals Inc. , Marlborough , MA , USA
| | - Barry Price
- b Sunovion Pharmaceuticals Inc. , Marlborough , MA , USA
| | | | - Shahin Sanjar
- b Sunovion Pharmaceuticals Inc. , Marlborough , MA , USA
| |
Collapse
|
47
|
Ohar JA, Bowling A, Goodin T, Price B, Ozol-Godfrey A, Sharma S, Sanjar S. Efficacy and safety of glycopyrrolate in patients with COPD by reversibility: pooled analysis of GEM1 and GEM2 12-week studies. Int J Chron Obstruct Pulmon Dis 2019; 14:461-470. [PMID: 30863047 PMCID: PMC6388797 DOI: 10.2147/copd.s194102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Bronchodilator reversibility has been reported in patients with COPD, although correlations between reversibility and treatment response are unclear. The effect of reversibility on lung function, health status, and dyspnea was assessed in patients with moderate-to-severe COPD receiving glycopyrrolate (GLY) 15.6 µg twice daily vs placebo in the Glycopyrrolate Effect on syMptoms and lung function 1 and 2 (GEM1 and GEM2) replicate, 12-week, placebo-controlled studies. Patients and methods Reversibility was defined as a post-bronchodilator increase of ≥12% and ≥0.200 L in FEV1. FEV1 area under the curve from 0 to 12 hours (AUC0-12 h), trough FEV1, St George's Respiratory Questionnaire (SGRQ) total score, COPD Assessment Test (CAT™) score, Transition Dyspnea Index (TDI) focal score, daily symptom scores, and rescue medication use were assessed by reversibility status. Incidences of adverse events and serious adverse events were also assessed. Results Data from 846 patients enrolled in GEM1 and GEM2 with known reversibility status were pooled for post hoc analysis. GLY significantly improved FEV1 AUC0-12 h, trough FEV1, SGRQ and CAT total scores, and rescue medication use compared with placebo in reversible and nonreversible patients. Significant improvements in TDI focal score and daily symptom scores with GLY over placebo were observed only among reversible patients. Improvements in FEV1 AUC0-12 h (0.165 vs 0.078 L; P<0.001) and trough FEV1 (0.173 vs 0.070 L; P<0.001) were clinically relevant (based on minimal clinically important differences) and significantly greater in reversible compared with nonreversible patients receiving GLY. The safety profile of GLY was not affected by reversibility status. Conclusion In this post hoc analysis, GLY was associated with significant improvements in lung function and patient-reported outcomes compared with placebo, mostly independent of reversibility status. In patients receiving GLY, improvements in lung function were greater in reversible compared with nonreversible patients. Reversibility status did not meaningfully impact the safety profile of GLY.
Collapse
Affiliation(s)
- Jill A Ohar
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA,
| | | | | | - Barry Price
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA
| | | | | | | |
Collapse
|
48
|
Singh D, Fabbri LM, Vezzoli S, Petruzzelli S, Papi A. Extrafine triple therapy delays COPD clinically important deterioration vs ICS/LABA, LAMA, or LABA/LAMA. Int J Chron Obstruct Pulmon Dis 2019; 14:531-546. [PMID: 30880943 PMCID: PMC6400232 DOI: 10.2147/copd.s196383] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Current pharmacological therapies for COPD improve quality of life and symptoms and reduce exacerbations. Given the progressive nature of COPD, it is arguably more important to understand whether the available therapies are able to delay clinical deterioration; the concept of “clinically important deterioration” (CID) has therefore been developed. We evaluated the efficacy of the single-inhaler triple combination beclometasone dipropionate, formoterol fumarate, and glycopyrronium (BDP/FF/G), using data from three large 1-year studies. Methods The studies compared BDP/FF/G to BDP/FF (TRILOGY), tiotropium (TRINITY), and indacaterol/glycopyrronium (IND/GLY; TRIBUTE). All studies recruited patients with symptomatic COPD, FEV1 <50%, and an exacerbation history. We measured the time to first CID and to sustained CID, an endpoint combining FEV1, St George’s Respiratory Questionnaire (SGRQ), moderate-to-severe exacerbations, and death. The time to first CID was based on the first occurrence of any of the following: a decrease of ≥100 mL from baseline in FEV1, an increase of ≥4 units from baseline in SGRQ total score, the occurrence of a moderate/severe COPD exacerbation, or death. The time to sustained CID was defined as: a CID in FEV1 and/or SGRQ total score maintained at all subsequent visits, an exacerbation, or death. Results Extrafine BDP/FF/G significantly extended the time to first CID vs BDP/FF (HR 0.61, P<0.001), tiotropium (0.72, P<0.001), and IND/GLY (0.82, P<0.001), and significantly extended the time to sustained CID vs BDP/FF (HR 0.64, P<0.001) and tiotropium (0.80, P<0.001), with a numerical extension vs IND/GLY. Conclusion In patients with symptomatic COPD, FEV1 <50%, and an exacerbation history, extrafine BDP/FF/G delayed disease deterioration compared with BDP/FF, tiotropium, and IND/GLY. Trial registration The studies are registered in ClinicalTrials.gov: TRILOGY, NCT01917331; TRINITY, NCT01911364; TRIBUTE, NCT02579850.
Collapse
Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK,
| | - Leonardo M Fabbri
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Stefano Vezzoli
- Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | | | - Alberto Papi
- Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| |
Collapse
|
49
|
Kostikas K, Greulich T, Mackay AJ, Lossi NS, Aalamian-Mattheis M, Nunez X, Pagano VA, Patalano F, Clemens A, Vogelmeier CF. Treatment response in COPD: does FEV 1 say it all? A post hoc analysis of the CRYSTAL study. ERJ Open Res 2019; 5:00243-2018. [PMID: 30815470 PMCID: PMC6387992 DOI: 10.1183/23120541.00243-2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 01/19/2023] Open
Abstract
The association between clinically relevant changes in patient-reported outcomes (PROs) and forced expiratory volume in 1 s (FEV1) in patients with chronic obstructive pulmonary disease (COPD) has rarely been investigated. Using CRYSTAL, a 12-week open-label study in symptomatic, nonfrequently exacerbating patients with moderate COPD, we assessed at baseline the correlations between several PROs (Baseline Dyspnoea Index, modified Medical Research Council dyspnoea scale, COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ)), and between FEV1 and PROs. Associations between clinically relevant responses in FEV1, CAT, CCQ and Transition Dyspnoea Index (TDI) at week 12 were also assessed. Using data from 4324 patients, a strong correlation was observed between CAT and CCQ (rs=0.793) at baseline, with moderate or weak correlations between other PROs, and no correlation between FEV1 and any PRO. At week 12, 2774 (64.2%) patients were responders regarding TDI, CAT or CCQ, with 583 (13.5%) responding using all three measures. In comparison, 3235 (74.8%) were responders regarding FEV1, TDI, CAT or CCQ, with 307 (7.1%) responding concerning all four parameters. Increases in lung function were accompanied by clinically relevant improvements of PROs in a minority of patients. Our results also suggest that PROs are not interchangeable. Thus, the observed treatment success in a clinical trial may depend on the selected parameters.
Collapse
Affiliation(s)
| | - Timm Greulich
- Dept of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Alexander J. Mackay
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | | | | | | | - Andreas Clemens
- Novartis Pharma AG, Basel, Switzerland
- Dept of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- These two authors contributed equally to this work
| | - Claus F. Vogelmeier
- Dept of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Giessen, Germany
- These two authors contributed equally to this work
| |
Collapse
|
50
|
Derom E, Brusselle GG, Joos GF. The once-daily fixed-dose combination of olodaterol and tiotropium in the management of COPD: current evidence and future prospects. Ther Adv Respir Dis 2019; 13:1753466619843426. [PMID: 31002020 PMCID: PMC6475840 DOI: 10.1177/1753466619843426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/18/2019] [Indexed: 11/17/2022] Open
Abstract
Long-acting bronchodilators are the cornerstone of pharmacologic treatment of chronic obstructive pulmonary disease (COPD). Spiolto® or Stiolto® is a fixed-dose combination (FDC) containing two long-acting bronchodilators, the long-acting muscarinic receptor antagonist tiotropium (TIO) and the long-acting β2-adrenoceptor agonist olodaterol (OLO), formulated in the Respimat® Soft Mist™ inhaler. A total of 13 large, multicentre studies of up to 52 weeks' duration have documented its efficacy in more than 15,000 patients with COPD. TIO/OLO 5/5 µg FDC significantly increases pulmonary function compared with placebo and its respective constituent mono-components TIO 5 µg and OLO 5 µg. TIO/OLO 5/5 µg also results in statistically and clinically significant improvements in patient-reported outcomes, such as dyspnoea, use of rescue medication, and health status. Addition of OLO 5 µg to TIO 5 µg reduces the rate of moderate-to-severe exacerbations by approximately 10%. Compared with placebo and TIO 5 µg, TIO/OLO 5/5 µg significantly improves exercise capacity (e.g. endurance time) and physical activity, the latter increase being reached by a unique combination behavioural modification intervention, dual bronchodilatation and exercise training. Overall, the likelihood for patients to experience a clinically significant benefit is higher with TIO/OLO 5/5 µg than with its constituent mono-components, which usually yield smaller improvements which do not always reach statistical significance, compared with baseline or placebo. This supports the early introduction of TIO/OLO 5/5 µg in the management of patients with symptomatic COPD.
Collapse
Affiliation(s)
- Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ingang 12, Route 1404, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | - Guy G. Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Guy F. Joos
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|