Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

What Factors Influence In-Hospital Mortality Following Aseptic Revision Total Hip Arthroplasty? A Single-Center Analysis of 13,203 Patients

BACKGROUND

Revision total hip arthroplasty (rTHA) is associated with an extended surgical period, an increased hospitalization period, expanded blood loss, and high mortality rates. The purpose of the present study was to assess the risk factors that contribute to in-hospital mortality following aseptic rTHA.

METHODS

We performed a retrospective examination of the medical records of all patients who underwent elective rTHA surgery at our tertiary referral arthroplasty center between March 1996 and March 2019. The study involved a group of 13,203 patients, including 70 who expired during hospitalization and 13,133 in the control group. Baseline characteristics, medical history, comorbidities, and surgery-related parameters of the patients were recorded. Logistic regression analyses were performed to examine the association between independent variables and in-hospital mortalities, which were presented as odds ratios (ORs) and confidence intervals (CIs).

RESULTS

Patient factors associated with in-hospital mortality included hepatitis C (OR 75.5, 95% CI 3.5 to 1,625.2), chronic obstructive pulmonary disease (OR 30.7, 95% CI 6.5 to 145.7), rheumatoid arthritis (OR 28.9, 95% CI 3.8 to 218.5), history of myocardial infarction (OR 24.9, 95% CI 4.4 to 140.8), history of cerebrovascular disease (OR 23.1, 95% CI 3.8 to 142), congestive heart failure (OR 18.9, 95% CI 3.8 to 94.2), and diabetes mellitus (OR 10.2, 95% CI 2.4 to 42.6). Surgical factors included the history of multiple prior revisions (OR 1.75, 95% CI 1.1 to 2.7), postoperative blood transfusion (OR 2.8, 95% CI 1.1 to 7.3), and decreased preoperative hemoglobin (OR 2.3, 95% CI 1.7 to 3.1).

CONCLUSIONS

Several patient-related and intraoperative factors significantly increased the risk of in-hospital mortality following aseptic rTHA. Vigilance and close perioperative monitoring are essential for patients undergoing this complex surgery.

LEVEL OF EVIDENCE

III.

A novel application of lemmatize and thematic analysis to understand protective measures perspectives of patients with chronic respiratory disease during the first outbreak of COVID-19 pandemic: a qualitative study

Objective

To describe the perspectives of a group of COPD patients during the first outbreak of the COVID-19 pandemic and narrate the emotions and polarity (acceptance-rejection) regarding living with COPD during the pandemic.

Design/methods

We used a novel application of lemmatization and thematic analysis of participants' narratives. A study was carried out with eight patients with moderate-severe-very severe COPD during the first outbreak of COVID-19 using purposive sampling. In-depth interviews and field notes from the researchers were used to collect data. A statistical content analysis (lemmatization) of the patients' narratives was performed. Additionally, inductive thematic analysis was used to identify emerging themes. This study was conducted following the guidelines of Consolidated Criteria/Standards for Reporting Qualitative Research. The study was conducted in accordance with the principles articulated in the WMA Declaration of Helsinki. Participants provided verbal informed consent prior to their inclusion as previously described.

Results

The average age of our sample was 65 years, and 75% of the patients suffered from moderate COPD, 12.5% from severe COPD, and 12.5% from very severe COPD according to GOLD criteria. The lemmatized and sentiment analysis showed a predominance of positive emotions, and the polarity of the interviews indicated a very slight positive trend towards acceptance of the experience lived during the pandemic. Additionally, three main themes were identified: (1) Confinement and restriction measures, (2) COVID-19 and protective measures, and (3) Clinical care during the first outbreak of the pandemic.

Conclusion

Patients experienced confinement with a feeling of security and protection. They strictly respect social distancing. They used masks, but these caused them to feel short of breath and fatigue, especially FFP2 masks. Half of the patients rejected the possibility of being vaccinated. Finally, they were very satisfied with the clinical care they received in the COPD unit of their hospital. Our results show that COPD patients have not experienced a negative impact of the COVID-19 pandemic.

The Development of One New Normal Phase Liquid Chromatography Method and Thermodynamic Investigation of Olodaterol Hydrochloride Enantiomer

In order to improve and replace the enantiomer method outlined in the olodaterol hydrochloride draft monograph (From the European Pharmacopoeia forum), one new, simple, and fast enantioselective normal phase high-performance liquid chromatography chiral method was developed on polysaccharide-based Chiral MX (2) (4.6 × 250 mm, 5 μm) column. n-Hexane, ethanol, and diethylamine in the ratio of 40:60:0.1 (V/V/V) were selected as mobile phase at a flow rate of 0.8 mL/min, and the detection was performed on a photodiode array detector at 225 nm with 5 μL injection volume. The column temperature was set at 40°C for better peak shape and sensitivity. The analysis time can be shortened to 15 min, whereas the resolution between enantiomer and olodaterol was found to be even more than 10.0, which was far better than that obtained with the reported method in this draft monograph. The developed chiral method was validated in accordance with ICH Q2 (R1), including specificity, LOD&LOQ, precision, linearity, accuracy, and robustness. Thereby, the proposed method was demonstrated to be suitable for the determination of enantiomer in olodaterol hydrochloride bulk drug and drug product. Besides, the thermodynamic parameters were evaluated on the basis of Van't Hoff plots that was used to explain correlative chiral recognition mechanisms with the chiral stationary phase.

LincR-PPP2R5C regulates IL-1β ubiquitination in macrophages and promotes airway inflammation and emphysema in a murine model of COPD

Chronic obstructive pulmonary disease (COPD) is a common disease with high global morbidity and mortality. Macrophages release IL-1β and orchestrate airway inflammation in COPD. Previously, we explored the role of a new lncRNA, LincR-PPP2R5C, in regulating Th2 cells in asthma. Here, we established a murine model of COPD and explored the roles and mechanisms by which LincR-PPP2R5C regulates IL-1β in macrophages. LincR-PPP2R5C was highly expressed in pulmonary macrophages from COPD-like mice. LincR-PPP2R5C deficiency ameliorated emphysema and pulmonary inflammation, as characterized by reduced IL-1β in macrophages. Unexpectedly, in both lung tissues and macrophages, LincR-PPP2R5C deficiency decreased the expression of the IL-1β protein but not the IL-1β mRNA. Furthermore, we found that LincR-PPP2R5C deficiency increased the level of ubiquitinated IL-1β in macrophages, which was mediated by PP2A activity. Targeting PP2A with FTY720 decreased IL-1β and improved COPD. In conclusion, LincR-PPP2R5C regulates IL-1β ubiquitination by affecting PP2A activity in macrophages, contributing to the airway inflammation and emphysema in a murine model of COPD. PP2A and IL-1β ubiquitination in macrophages might be new therapeutic avenues for COPD therapy.

Insufficient Pulmonary Rehabilitation Uptake After Severe Exacerbation of COPD: A Multicentre Study in the South West Region of France

Purpose

Pulmonary rehabilitation (PR) is a type of multidisciplinary care strongly recommended after severe exacerbation of chronic obstructive pulmonary disease (COPD). Recently, a national French study reported a very low rate of PR uptake (8.6%); however, important clinical data were missing. Here, we aimed to identify the main factors associated with insufficient PR uptake after hospitalisation for COPD exacerbation.

Patients and Methods

This multicentre retrospective study included patients hospitalised with COPD exacerbation between 1 January 2017 and 31 December 2018, as identified by both coding and a detailed review of medical records. PR was defined as inpatient care in a specialised centre or unit within 90 days of discharge. Multivariate logistic regression was used to identify associations between PR uptake and patient characteristics, such as comorbidities, non-invasive ventilation (NIV), inhaled treatment, and forced expiratory volume in 1 second (FEV1).

Results

Among the 325 patients admitted for severe COPD exacerbation, 92 (28.3%) underwent PR within 90 days of discharge. In univariate analysis, relative to those who underwent PR, patients without PR had significantly more comorbidities, were less often treated with triple bronchodilator therapy or NIV, and had a higher FEV1. In multivariate analysis, variables independently associated with the lack of PR uptake were the presence of comorbidities (adjusted odds ratio (aOR) = 1.28 [1.10-1.53], p = 0.003) and a higher FEV1 (aOR = 1.04 [1.02-1.06], p < 0.001). There was no significant correlation between PR uptake and departmental PR centre capacity (notably, some departments had no PR facilities).

Conclusion

These data highlight the lack of PR in the early stages of COPD. Collaboration among all healthcare providers involved in patient management is crucial for improved PR uptake.

CT Chest Imaging Using Normalized Join-Count: Predicting Emphysema Progression in the CanCOLD Study

Background Pre-existing emphysema is recognized as an indicator of future worsening in patients with chronic obstructive pulmonary disease (COPD) when observed through CT imaging. However, it remains uncertain whether additional factors, such as the spatial compactness of CT emphysema, might also serve as predictors of disease progression. Purpose To evaluate the relationship between the compactness of CT emphysema voxels and emphysema progression. Materials and Methods This secondary analysis uses data from the prospective Canadian Cohort Obstructive Lung Disease (CanCOLD) study, examining CT images obtained in participants with and without COPD at baseline and a 3-year follow-up time point (November 2009 to November 2018). Measurements of forced expiratory volume in first second of expiration (FEV1) and diffusing capacity of lung for carbon monoxide (DLco) were collected. The normalized join-count (NJC) measurement from baseline CT images and lung density (LD) changes were analyzed. Emphysema progression was defined as an annualized LD change of less than half an SD below the mean of the participants without COPD with no smoking history. Multivariable linear and logistic regression models were used to assess the association between baseline CT NJC measurements and the annualized change in LD, FEV1, DLco, and emphysema progression versus nonprogression. Results A total of 524 participants (mean age, 66 years ± 10 [SD]; 293 male) (FEV1 percent predicted, 88% ± 19; FEV1/FVC, 67% ± 9; DLco percent predicted, 105% ± 25) were analyzed, 187 (36%) of whom had COPD. CT NJC was associated with the annualized change in LD (P < .001), FEV1 (P = .02), and DLco (P = .01). Additionally, CT NJC predicted emphysema progression versus nonprogression (odds ratio, 2.24; 95% CI: 1.37, 3.50; P < .001). Conclusion The spatial distribution, or "compactness," of CT emphysema voxels predicted emphysema progression in individuals with and without COPD. ClinicalTrials.gov Identifier: NCT00920348 © RSNA, 2024 Supplemental material is available for this article.

Identifying COPD patients with poor health status and low exercise tolerance through the five-repetition sit-to-stand test and modified Medical Research Council Dyspnea Score

BACKGROUND

The objective of this study was to determine whether the concomitant presence of poor health status (COPD Assessment Test, CAT ≥ 10 points) and low exercise tolerance (6-Minute Walking Test, 6MWT < 350 m) is associated with worse clinical characteristics in patients with COPD. In addition, we aimed to develop a readily applicable diagnostic model to discriminate COPD patients with these conditions.

METHODS

A cross-sectional multicenter study involving 208 stable COPD patients (FEV1/FVC < 0.7, smoking history of at least 10 pack-years, and chronic respiratory symptoms) was carried out. The outcome measures were the 6MWT, CAT score, 5-repetition sit-to-stand test (5STS) and modified Medical Research Council Dyspnea Scale (mMRC). Patients were categorized into three groups: no condition (6MWT ≥ 350 m and CAT < 10 points), one condition (6MWT < 350 m or CAT ≥ 10 points), and both conditions (6MWT < 350 m and CAT ≥ 10 points).

RESULTS

A total of 26 patients (12,5%) presented both conditions. These patients experienced a higher degree of dyspnea (p = 0.001), smoking pack-years (p = 0.011), severe obstruction (p = 0.006), and time on 5STS (p = 0.001). The probability of having both conditions directly increased with the time spent on the 5STS (β=0.188; p = 0.010) and the degree of dyspnea (β=1.920; p < 0.001) (R2=0.413). The scoring system, using the 5STS and dyspnea as surrogate measures, demonstrated adequate calibration between the predicted and observed risk (linear R2=0.852).

CONCLUSIONS

COPD patients with concurrent conditions have worse clinical status. The diagnostic model developed to discriminate these patients shows good internal validation.

Personal exposure to airborne organic pollutants and lung function changes among healthy older adults

Epidemiological evidence on the impact of airborne organic pollutants on lung function among the elderly is limited, and their underlying biological mechanisms remain largely unexplored. Herein, a longitudinal panel study was conducted in Jinan, Shandong Province, China, involving 76 healthy older adults monitored over a span of five months repetitively. We systematically evaluated personal exposure to a diverse range of airborne organic pollutants using a wearable passive sampler and their effects on lung function. Participants' pulmonary function indicators were assessed, complemented by comprehensive multi-omics analyses of blood and urine samples. Leveraging the power of interaction analysis, causal inference test (CIT), and integrative pathway analysis (IPA), we explored intricate relationships between specific organic pollutants, biomolecules, and lung function deterioration, elucidating the biological mechanisms underpinning the adverse impacts of these pollutants. We observed that bis (2-chloro-1-methylethyl) ether (BCIE) was significantly associated with negative changes in the forced vital capacity (FVC), with glycerolipids mitigating this adverse effect. Additionally, 31 canonical pathways [e.g., high mobility group box 1 (HMGB1) signaling, phosphatidylinositol 3-kinase (PI3K)/AKT pathway, epithelial mesenchymal transition, and heme and nicotinamide adenine dinucleotide (NAD) biosynthesis] were identified as potential mechanisms. These findings may hold significant implications for developing effective strategies to prevent and mitigate respiratory health risks arising from exposure to such airborne pollutants. However, due to certain limitations of the study, our results should be interpreted with caution.

Arsenic exposure and pulmonary function decline: Potential mediating role of TRAIL in chronic obstructive pulmonary disease patients

BACKGROUND

Environmental arsenic (As) exposure is strongly related to the progression of chronic obstructive pulmonary disease (COPD). Pulmonary epithelial cells apoptosis is implicated in the pathophysiological mechanisms of COPD. However, the role of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), one biomarker of apoptosis, remains unclear in As-mediated pulmonary function alternations in COPD patients.

METHODS

This study included 239 COPD patients. The serum level of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) was measured by enzyme-linked immunosorbent assay (ELISA). The blood As level was determined through inductively coupled plasma mass spectrometry (ICP-MS).

RESULTS

Blood As levels exhibited a negative and dose-dependent correlation with pulmonary function. Per unit elevation of blood arsenic concentrations was related to reductions of 0.339 L in FEV1, 0.311 L in FVC, 1.171% in FEV1/FVC%, and 7.999% in FEV1% in COPD subjects. Additionally, a positive dose-response correlation of blood As with serum TRAIL was found in COPD subjects. Additionally, the level of serum TRAIL was negatively linked to lung function. Elevated TRAIL significantly mediated As-induced decreases of 11.05%, 13.35%, and 31.78% in FVC, FEV1, and FEV1%, respectively among the COPD patients.

CONCLUSION

Blood As level is positively correlated with pulmonary function decline and serum TRAIL increase in individuals with COPD. Our findings suggest that elevated TRAIL levels may serve as a mediating mechanism through which As contributes to declining lung function in COPD patients.

Home-based management on hospital re-admission rates in COPD patients: A systematic review

AIM

To determine the impact of home-based management on hospital re-admission rates in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review methodology was utilized, combining meta-analysis, where appropriate, or a narrative analysis of the data from included studies.

DATA SOURCES

Electronic databases CINAHL, MEDLINE, PubMed, Embase and SAGE journals for primary papers, 2015 to 2021, were searched between December 2020 and March 2021, followed by hand-searching key journals, and reference lists of retrieved papers.

METHODS

The review followed the guidance of PRISMA. Data were extracted using a predesigned data extraction tool. Quality appraisal was undertaken using RevMan 'risk of bias' tool. Meta-analysis was undertaken using RevMan software.

RESULTS

This review integrates evidence from eight studies, five Random Control Trials, two observational studies and one retrospective study. The studies span three continents, Asia, Europe and North America, and include 3604 participants with COPD. Home-based management in patients with COPD resulted in a statistically significant reduction in rates of hospital readmission. For the outcomes, length of stay and mortality, while slightly in favour of home-based management, the results were not statistically significant.

CONCLUSION

Given the burden of COPD on healthcare systems, and crucially on individuals, this review identified a reduction in hospital re-admission rate, a clinically important outcome.

IMPACT

This study focused on the impact on hospital re-admission rates among the COPD patient cohort when home-based management was involved. A statistically significant reduction in rates of re-admission to the hospital was identified. This is positive for the patient, in terms of hospital avoidance, and reduces the burden on hospital systems. Further research is needed to determine the impact on cost-effectiveness and to quantify the most ideal type of care package that would be recommended for home-based management.

Risk of Mortality and Cardiovascular Events in Patients with Chronic Obstructive Pulmonary Disease Treated with Azithromycin, Roxithromycin, Clarithromycin, and Amoxicillin

Background: Prior research has raised concerns regarding the use of macrolides and their association with an increased risk of cardiovascular events. Methods: We conducted a cohort study, where we explored the cardiovascular risks associated with the treatment of COPD patients using macrolide antibiotics-namely azithromycin, clarithromycin, and roxithromycin-with amoxicillin serving as a reference. The study focused on COPD patients in an outpatient setting and included a thorough 3-year follow-up. Patients were categorized into four groups based on their treatment. The primary analysis utilized an adjusted Cox model, supplemented by sensitivity analysis through inverse probability of treatment weighting. Results: No significant differences were found in major adverse cardiovascular events (MACE-stroke, acute myocardial infarction, cardiovascular death) between the macrolide groups, and the amoxicillin/hazard ratios (HR) were azithromycin HR = 1.01, clarithromycin HR = 0.99, and roxithromycin HR = 1.02. Similarly, sensitivity analysis showed no disparities in all-cause mortality and cardiovascular death among the groups. Conclusions: Overall, the study revealed no evidence of increased risk of MACE, all-cause mortality, or cardiovascular death in COPD patients treated with these macrolides compared to amoxicillin over a 3-year period.

Exposure limits for indoor volatile substances concerning the general population: The role of population-based differences in sensory irritation of the eyes and airways for assessment factors

Assessment factors (AFs) are essential in the derivation of occupational exposure limits (OELs) and indoor air quality guidelines. The factors shall accommodate differences in sensitivity between subgroups, i.e., workers, healthy and sick people, and occupational exposure versus life-long exposure for the general population. Derivation of AFs itself is based on empirical knowledge from human and animal exposure studies with immanent uncertainty in the empirical evidence due to knowledge gaps and experimental reliability. Sensory irritation in the eyes and airways constitute about 30-40% of OELs and is an abundant symptom in non-industrial buildings characterizing the indoor air quality and general health. Intraspecies differences between subgroups of the general population should be quantified for the proposal of more 'empirical' based AFs. In this review, we focus on sensitivity differences in sensory irritation about gender, age, health status, and vulnerability in people, based solely on human exposure studies. Females are more sensitive to sensory irritation than males for few volatile substances. Older people appear less sensitive than younger ones. However, impaired defense mechanisms may increase vulnerability in the long term. Empirical evidence of sensory irritation in children is rare and limited to children down to the age of six years. Studies of the nervous system in children compared to adults suggest a higher sensitivity in children; however, some defense mechanisms are more efficient in children than in adults. Usually, exposure studies are performed with healthy subjects. Exposure studies with sick people are not representative due to the deselection of subjects with moderate or severe eye or airway diseases, which likely underestimates the sensitivity of the group of people with diseases. Psychological characterization like personality factors shows that concentrations of volatile substances far below their sensory irritation thresholds may influence the sensitivity, in part biased by odor perception. Thus, the protection of people with extreme personality traits is not feasible by an AF and other mitigation strategies are required. The available empirical evidence comprising age, lifestyle, and health supports an AF of not greater than up to 2 for sensory irritation. Further, general AFs are discouraged for derivation, rather substance-specific derivation of AFs is recommended based on the risk assessment of empirical data, deposition in the airways depending on the substance's water solubility and compensating for knowledge and experimental gaps. Modeling of sensory irritation would be a better 'empirical' starting point for derivation of AFs for children, older, and sick people, as human exposure studies are not possible (due to ethical reasons) or not generalizable (due to self-selection). Dedicated AFs may be derived for environments where dry air, high room temperature, and visually demanding tasks aggravate the eyes or airways than for places in which the workload is balanced, while indoor playgrounds might need other AFs due to physical workload and affected groups of the general population.

Associations between different body mass index and lung function impairment in Chinese people aged over 40 years: a multicenter cross-sectional study

OBJECTIVE

The aim of this study was to explore the associations between different body mass index (BMI) levels and different lung function impairment (LFI) in Chinese people aged over 40 years.

METHODS

We used a multi-stage stratified cluster random sampling method to investigate 3000 residents aged over 40 years from 5 areas in Hubei province of China in 2019-20. The data on questionnaire, physical measurements, and spirometry of the participants were collected. The associations of different BMI levels with different LFI were analyzed using multivariate logistic regressions after complex weighting. The spirometry data were analyzed using one-factor analysis of variance (ANOVA), and post-hoc was performed using the least significance difference (LSD)-t test.

RESULTS

A total of 2860 subjects were included. The prevalence (95%CI) of obstructive lung disease (OLD), restrictive lung disease (RLD), mixed lung disease (MLD), chronic obstructive pulmonary disease (COPD), COPD mild, and COPD moderate/severe/very severe were 24.1% (95% CI: 22.2-26.2), 11.6% (95% CI: 10.3-12.9), 4.0% (95% CI: 3.3-4.8), 12.6% (95% CI: 11.0-14.1), 7.2% (95% CI: 6.0-8.4), and 5.3% (95% CI: 4.3-6.4) respectively. After multivariate adjustment, the risk of OLD, COPD, and COPD mild decreased with the increment of BMI levels (both P for trend < 0.05). When compared to the normal weight group, the overweight group and obese group were at lower risk of experiencing OLD than normal group, the ORs were 0.77 (95% CI: 0.59-0.99) and 0.59 (95% CI: 0.40-0.86) respectively. The obese group was at lower risk for people with COPD mild (OR: 0.42, 95%CI: 0.21-0.85). Participants in underweight group were more likely to experience COPD and COPD moderate/severe/very severe, the ORs were 2.82 (95% CI: 1.07-7.39) and 3.89 (95% CI: 1.28-11.87) respectively.

CONCLUSION

Higher BMI levels were associated with an decreased risk of OLD and COPD. Obesity had a protective effect on lung function in OLD patients and COPD patients. However, there was no significant difference in RLD and MLD prevalence between different BMI groups.

Chitosan-Based Nanocarriers for Pulmonary and Intranasal Drug Delivery Systems: A Comprehensive Overview of their Applications

The optimization of respiratory health is important, and one avenue for achieving this is through the application of both Pulmonary Drug Delivery System (PDDS) and Intranasal Delivery (IND). PDDS offers immediate delivery of medication to the respiratory system, providing advantages, such as sustained regional drug concentration, tunable drug release, extended duration of action, and enhanced patient compliance. IND, renowned for its non-invasive nature and swift onset of action, presents a promising path for advancement. Modern PDDS and IND utilize various polymers, among which chitosan (CS) stands out. CS is a biocompatible and biodegradable polysaccharide with unique physicochemical properties, making it well-suited for medical and pharmaceutical applications. The multiple positively charged amino groups present in CS facilitate its interaction with negatively charged mucous membranes, allowing CS to adsorb easily onto the mucosal surface. In addition, CS-based nanocarriers have been an important topic of research. Polymeric Nanoparticles (NPs), liposomes, dendrimers, microspheres, nanoemulsions, Solid Lipid Nanoparticles (SLNs), carbon nanotubes, and modified effective targeting systems compete as important ways of increasing pulmonary drug delivery with chitosan. This review covers the latest findings on CS-based nanocarriers and their applications.

Cough Assessment and Management in Pulmonary Rehabilitation- A Canadian Survey

Pulmonary rehabilitation is a cornerstone intervention for controlling respiratory symptoms in people with chronic respiratory diseases. Chronic cough affects up to 90% of people with chronic respiratory diseases, however, it is currently unknown whether chronic cough is assessed and/or managed in pulmonary rehabilitation. This study aimed to determine if and how chronic cough is assessed and managed in pulmonary rehabilitation. This was a cross-sectional study. Pulmonary rehabilitation programs in Canada were identified via online websites. A representative from each program was invited to complete an online survey including the following topics: program demographics, assessment and management practices, and barriers and facilitators. Of 133 programs contacted, 31 returned a completed survey (23% response rate). Approximately half (52%) of respondents reported enrolling patients with chronic cough. Of those, 45% reported assessing and 62% reported intervening in chronic cough. Inadequate knowledge of assessment and management techniques was commonly identified to be a barrier and increased education was suggested as a possible facilitator. Based on pulmonary rehabilitation programs that responded to our survey, chronic cough is a prevalent symptom; however, it is scarcely assessed and managed. A need for structured education and the use of standardised strategies were reported as facilitators to the assessment and management of chronic cough in pulmonary rehabilitation.

Enabling chronic obstructive pulmonary disease diagnosis through chest X-rays: A multi-site and multi-modality study

PURPOSE

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic illnesses in the world. Unfortunately, COPD is often difficult to diagnose early when interventions can alter the disease course, and it is underdiagnosed or only diagnosed too late for effective treatment. Currently, spirometry is the gold standard for diagnosing COPD but it can be challenging to obtain, especially in resource-poor countries. Chest X-rays (CXRs), however, are readily available and may have the potential as a screening tool to identify patients with COPD who should undergo further testing or intervention. In this study, we used three CXR datasets alongside their respective electronic health records (EHR) to develop and externally validate our models.

METHOD

To leverage the performance of convolutional neural network models, we proposed two fusion schemes: (1) model-level fusion, using Bootstrap aggregating to aggregate predictions from two models, (2) data-level fusion, using CXR image data from different institutions or multi-modal data, CXR image data, and EHR data for model training. Fairness analysis was then performed to evaluate the models across different demographic groups.

RESULTS

Our results demonstrate that DL models can detect COPD using CXRs with an area under the curve of over 0.75, which could facilitate patient screening for COPD, especially in low-resource regions where CXRs are more accessible than spirometry.

CONCLUSIONS

By using a ubiquitous test, future research could build on this work to detect COPD in patients early who would not otherwise have been diagnosed or treated, altering the course of this highly morbid disease.

Systemic antibiotics cause deterioration of emphysema associated with exaggerated inflammation and autophagy

The interaction between the microbial environment and the host is important for immune homeostasis. Recent research suggests that microbiota dysbiosis can be involved in respiratory diseases. Emphysema is a chronic inflammatory disease, but it is unclear whether dysbiosis caused by antibiotics can affect disease progression. Here, we tried to elucidate the effect of systemic antibiotics on smoking-exposed emphysema models. In this study, the antibiotic mixture caused more alveolar destruction and airspace expansion in the smoking group than in the smoking only or control groups. This emphysema aggravation as a result of antibiotic exposure was associated with increased levels of inflammatory cells, IL-6, IFNγ and protein concentrations in bronchoalveolar lavage fluid. Proteomics analysis indicated that autophagy could be involved in antibiotic-associated emphysema aggravation, and increased protein levels of LC3B, atg3, and atg7 were identified by Western blotting. In microbiome and metabolome analyses, the composition of the gut microbiota was different with smoking and antibiotic exposure, and the levels of short-chain fatty acids (SCFAs), including acetate and propionate, were reduced by antibiotic exposure. SCFA administration restored emphysema development with reduced inflammatory cells, IL-6, and IFNγ and decreased LC3B, atg3, and atg7 levels. In conclusion, antibiotics can aggravate emphysema, and inflammation and autophagy may be associated with this aggravation. This study provides important insight into the systemic impact of microbial dysbiosis and the therapeutic potential of utilizing the gut microbiota in emphysema.

Flip focus and emphasise patient resources in person-centred care over the telephone-A retrospective descriptive study

AIM

The study aim was to describe the content of person-centred health plans, formulated via telephone conversations between registered nurses and patients with chronic obstructive pulmonary disease and/or chronic heart failure.

METHOD

Patients who had been hospitalised due to worsening chronic obstructive pulmonary disease and/or chronic heart failure were enrolled. After hospital discharge, the patients received a person-centred telephone support where a health plan was co-created with registered nurses who had received training in the theory and practice of person-centred care. A retrospective descriptive review of 95 health plans using content analysis was conducted.

RESULTS

The health plan content revealed personal resources such as optimism and motivation in patients with chronic obstructive pulmonary disease and/or chronic heart failure. Although patients reported severe dyspnoea symptoms, the most common goals were to engage in physical activity and to be able to manage social life and leisure activities. Additionally, the health plans illustrated that patients were capable of using their own interventions to reach their goals rather than accessing municipal and health care support.

CONCLUSION

The focus on listening, that person-centred telephone care affords, promotes the patient's own goals, interventions, and resources, which can be used to tailor support and engage the patient as an active partner in their care. The flipped focus from patient to person highlights the person's own resources, which in turn may contribute to a reduced need for hospital care.

Recent Advances (2015-2020) in Drug Discovery for Attenuation of Pulmonary Fibrosis and COPD

A condition of scarring of lung tissue due to a wide range of causes (such as environmental pollution, cigarette smoking (CS), lung diseases, some medications, etc.) has been reported as pulmonary fibrosis (PF). This has become a serious problem all over the world due to the lack of efficient drugs for treatment or cure. To date, no drug has been designed that could inhibit fibrosis. However, few medications have been reported to reduce the rate of fibrosis. Meanwhile, ongoing research indicates pulmonary fibrosis can be treated in its initial stages when symptoms are mild. Here, an attempt is made to summarize the recent studies on the effects of various chemical drugs that attenuate PF and increase patients' quality of life. The review is classified based on the nature of the drug molecules, e.g., natural/biomolecule-based, synthetic-molecule-based PF inhibitors, etc. Here, the mechanisms through which the drug molecules attenuate PF are discussed. It is shown that inhibitory molecules can significantly decrease the TGF-β1, profibrotic factors, proteins responsible for inflammation, pro-fibrogenic cytokines, etc., thereby ameliorating the progress of PF. This review may be useful in designing better drugs that could reduce the fibrosis process drastically or even cure the disease to some extent.

Evaluation of Ocular Microvascular Characteristics in Smokers and Patients with Chronic Obstructive Pulmonary Disease Using an Optical Coherence Tomography Angiography

PURPOSE

To investigate retinal microvascular changes in patients with chronic obstructive pulmonary disease (COPD) using optical coherence tomography angiography (OCTA) and to compare these values with those of smokers and healthy non-smokers.

METHODS

This study was performed on 38 eyes of 38 patients with COPD, 30 eyes of 30 smokers, and 31 eyes of 31 healthy non-smokers. Foveal avascular zone (FAZ) area, superficial (SCP) and deep (DCP) capillary plexus (whole image, fovea, parafovea, and perifovea) and radial peripapillary capillary (RPC) vessel densities (whole image, peripapillary, and inside disc) were evaluated via OCTA device (Optovue, Fremont, CA, USA). The forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) ratio and FEV1 values of patients with COPD were recorded.

RESULTS

There were statistically similar values in smoking pack-years between the smoker and COPD groups (p = 0.059). Entire SCP and DCP vessel densities were significantly different among the all groups (p < 0.05); for these parameters, the control group had the highest and the COPD group had the lowest vessel density values. Significantly decreased RPC vessel densities in all regions were detected in the COPD group compared with the other groups. Multiple regression analysis showed significant positive correlations between the FEV1 and the SCP, DCP, and RPC vessel densities (for all, p < 0.05).

CONCLUSIONS

This study detected lower vessel densities in patients with COPD than in smokers and healthy controls and reported decreased vessel density measurements with increasing COPD severity. COPD patients with or without a history of smoking may benefit from higher prioritization in terms of ophthalmic screening to prevent ocular complications.

Pulmonary rehabilitation after severe exacerbation of COPD: a nationwide population study

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (COPD) lead to a significant reduction in quality of life and an increased mortality risk. Current guidelines strongly recommend pulmonary rehabilitation (PR) after a severe exacerbation. Studies reporting referral for PR are scarce, with no report to date in Europe. Therefore, we assessed the proportion of French patients receiving PR after hospitalization for COPD exacerbation and factors associated with referral.

METHODS

This was a national retrospective study based on the French health insurance database. Patients hospitalized in 2017 with COPD exacerbation were identified from the exhaustive French medico-administrative database of hospitalizations. In France, referral to PR has required as a stay in a specialized PR center or unit accredited to provide multidisciplinary care (exercise training, education, etc.) and admission within 90 days after discharge was assessed. Multivariate logistic regression was used to assess the association between patients' characteristics, comorbidities according to the Charlson index, treatment, and PR uptake.

RESULTS

Among 48,638 patients aged ≥ 40 years admitted for a COPD exacerbation, 4,182 (8.6%) received PR within 90 days after discharge. General practitioner's (GP) density (number of GPs for the population at regional level) and PR center facilities (number of beds for the population at regional level) were significantly correlated with PR uptake (respectively r = 0.64 and r = 0.71). In multivariate analysis, variables independently associated with PR uptake were female gender (aOR 1.36 [1.28-1.45], p < 0.0001), age (p < 0.0001), comorbidities (p = 0.0013), use of non-invasive ventilation and/or oxygen therapy (aOR 1.52 [1.41-1.64], p < 0.0001) and administration of long-acting bronchodilators (p = 0.0038).

CONCLUSION

This study using the French nationally exhaustive health insurance database shows that PR uptake after a severe COPD exacerbation is dramatically low and must become a high-priority management strategy.

Cost-Effectiveness of Humidified High-Flow Therapy (HHFT) for COPD Patients on Long-Term Oxygen Therapy

Purpose

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality, and is associated with significant respiratory impairment, decreased quality of life, and high health care costs. Recent evidence indicates significant clinical benefit results from adding humidified high-flow therapy (HHFT) to standard long-term oxygen therapy (LTOT) as a home-based therapy in persons with severe COPD. The objective was to evaluate the cost-effectiveness of adding HHFT to standard treatment of COPD patients using LTOT with US healthcare cost estimates.

Patients and Methods

A Markov state-transition model was developed using data from a prospective clinical trial of adding HHFT to standard therapy for persons with severe COPD using LTOT. The analysis was conducted from the US health care system perspective using a 5-year time horizon and 3% discount rate. QALYs and downstream healthcare costs were modeled. One-way and probabilistic sensitivity analyses were used to examine the impact of input parameters on the incremental net monetary benefit (NMB).

Results

Incremental QALYs accrued were 0.058 (2.047 vs 1.989 QALYs for HHFT and standard therapy groups respectively). Incremental total costs were -$3939 ($47,516 vs $51,455 for HHFT and standard therapy groups respectively). Thus, HHFT was the dominant treatment in the analysis, resulting on both better health and lower total costs. Varying utility and cost inputs individually never resulted in NMB approaching 0. Probabilistic analyses indicate that HHFT is cost-effective in 84% of simulations.

Conclusion

Our results indicate that the reductions in acute exacerbations of COPD (AECOPDs) that result from adding HHFT for persons with COPD on LTOT will produce both health benefit (QALYs) and cost savings. Cost savings occur because the HHFT device costs are more than offset by reductions in costly COPD exacerbations. Health care systems and payors can benefit from wider implementation of HHFT with existing treatments.

Muscle Power in Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis

This study aimed to review the impact of training on muscle power in patients with chronic obstructive pulmonary disease (COPD). Randomized controlled trials evaluating the effects of exercise-based interventions on limbs muscle power and rate of force development in COPD patients were investigated. Five international databases were searched until October 2022. Meta-analyses were performed calculating the mean difference or standardized mean difference. Risk of bias in studies was assessed using Cochrane Risk of Bias tool 2.0. A total of nine studies were included in the analysis. There were concerns about risk of bias in seven out of nine studies. Comparison of exercising and non-exercising groups showed a significant effect of exercise in improving muscle power (P=0.0004) and rate of force development (P<0.001), in five and three trials, respectively. Four studies comparing different trainings showed no significant results on muscle power (P=0.45). Eight to 16 weeks of exercise-based intervention versus no intervention might be beneficial to enhance upper and lower limbs muscle power and rate of force development in people with COPD. In contrast, muscle power did not improve when different training modalities were compared. Future studies performing power training in COPD patients are encouraged.

Changes in Blood Markers of Oxidative Stress, Inflammation and Cardiometabolic Patients with COPD after Eccentric and Concentric Cycling Training

Chronic obstructive pulmonary disease (COPD) patients manifest muscle dysfunction and impaired muscle oxidative capacity, which result in reduced exercise capacity and poor health status. This study examined the effects of 12-week eccentric (ECC) and concentric (CONC) cycling training on plasma markers of cardiometabolic health, oxidative stress, and inflammation in COPD patients. A randomized trial in which moderate COPD was allocated to ECC (n = 10; 68.2 ± 10.0 year) or CONC (n = 10; 71.1 ± 10.3 year) training groups. Participants performed 12-week ECC or CONC training, 2-3 sessions per week, 10 to 30 min per session. Before and after training, peak oxygen consumption, maximal power output (VO_2peak and PO_max), and time-to-exhaustion (TTE) tests were performed. Plasma antioxidant and oxidative markers, insulin resistance, lipid profile, and systemic inflammation markers were measured before and after training at rest. VO_2peak, PO_max and TTE remained unchanged after ECC and CONC. CONC induced an increase in antioxidants (p = 0.01), while ECC decreased antioxidant (p = 0.02) markers measured at rest. CONC induced lesser increase in oxidative stress following TTE (p = 0.04), and a decrease in insulin resistance (p = 0.0006) compared to baseline. These results suggest that CONC training induced an increase in insulin sensitivity, antioxidant capacity at rest, and lesser exercise-induced oxidative stress in patients with moderate COPD.

Predicting severe chronic obstructive pulmonary disease exacerbations using quantitative CT: a retrospective model development and external validation study

BACKGROUND

Quantitative CT is becoming increasingly common for the characterisation of lung disease; however, its added potential as a clinical tool for predicting severe exacerbations remains understudied. We aimed to develop and validate quantitative CT-based models for predicting severe chronic obstructive pulmonary disease (COPD) exacerbations.

METHODS

We analysed the Subpopulations and Intermediate Outcome Measures In COPD Study (SPIROMICS) cohort, a multicentre study done at 12 clinical sites across the USA, of individuals aged 40-80 years from four strata: individuals who never smoked, individuals who smoked but had normal spirometry, individuals who smoked and had mild to moderate COPD, and individuals who smoked and had severe COPD. We used 3-year follow-up data to develop logistic regression classifiers for predicting severe exacerbations. Predictors included age, sex, race, BMI, pulmonary function, exacerbation history, smoking status, respiratory quality of life, and CT-based measures of density gradient texture and airway structure. We externally validated our models in a subset from the Genetic Epidemiology of COPD (COPDGene) cohort. Discriminative model performance was assessed using the area under the receiver operating characteristic curve (AUC), which was also compared with other predictors, including exacerbation history and the BMI, airflow obstruction, dyspnoea, and exercise capacity (BODE) index. We evaluated model calibration using calibration plots and Brier scores.

FINDINGS

Participants in SPIROMICS were enrolled between Nov 12, 2010, and July 31, 2015. Participants in COPDGene were enrolled between Jan 10, 2008, and April 15, 2011. We included 1956 participants from the SPIROMICS cohort who had complete 3-year follow-up data: the mean age of the cohort was 63·1 years (SD 9·2) and 1017 (52%) were men and 939 (48%) were women. Among the 1956 participants, 434 (22%) had a history of at least one severe exacerbation. For the CT-based models, the AUC was 0·854 (95% CI 0·852-0·855) for at least one severe exacerbation within 3 years and 0·931 (0·930-0·933) for consistent exacerbations (defined as ≥1 acute episode in each of the 3 years). Models were well calibrated with low Brier scores (0·121 for at least one severe exacerbation; 0·039 for consistent exacerbations). For the prediction of at least one severe event during 3-year follow-up, AUCs were significantly higher with CT biomarkers (0·854 [0·852-0·855]) than exacerbation history (0·823 [0·822-0·825]) and BODE index 0·812 [0·811-0·814]). 6965 participants were included in the external validation cohort, with a mean age of 60·5 years (SD 8·9). In this cohort, AUC for at least one severe exacerbation was 0·768 (0·767-0·769; Brier score 0·088).

INTERPRETATION

CT-based prediction models can be used for identification of patients with COPD who are at high risk of severe exacerbations. The newly identified CT biomarkers could potentially enable investigation into underlying disease mechanisms responsible for exacerbations.

FUNDING

National Institutes of Health and the National Heart, Lung, and Blood Institute.

Prevalence of and factors associated with alexithymia among patients with chronic obstructive pulmonary disease in China: a cross-sectional study

BACKGROUND

Alexithymia is a common psychological disorder. However, few studies have investigated its prevalence and predictors in patients with chronic obstructive pulmonary disease (COPD). Therefore, we aimed to determine the prevalence and predictors of alexithymia in Chinese patients.

METHODS

This cross-sectional study included 842 COPD patients to assess the prevalence and predictors of alexithymia using the 20-item Toronto Alexithymia Scale (TAS-20). We used the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression, the modified British Medical Research Council dyspnea Rating Scale (mMRC) to assess dyspnea, St. George's Respiratory Questionnaire (SGRQ) to assess quality of life, and the age-adjusted Charlson comorbidity index (ACCI) to assess comorbidities. Alexithymia-related predictors were identified using univariate and multivariate logistic regression analyses.

RESULTS

The prevalence of alexithymia in COPD patients was 23.6% (199/842). Multivariate analysis showed that age [odds ratio (OR) 0.886; 95% confidence interval (CI) 0.794-0.998], body mass index (OR 0.879; 95% CI 0.781-0.989), HADS-anxiety (OR 1.238; 95% CI 1.097-1.396), HADS-depression (OR 1.178; 95% CI 1.034-1.340), mMRC (OR 1.297; 95% CI 1.274-1.320), SGRQ (OR 1.627; 95% CI 1.401-1.890), ACCI (OR 1.165; 95% CI 1.051-1.280), and GOLD grade (OR 1.296; 95% CI 1.256-1.337) were independent predictors for alexithymia in patients with COPD.

CONCLUSIONS

The prevalence of alexithymia was high in Chinese COPD patients. Anxiety, depression, dyspnea, quality of life, comorbidities, and disease severity are independent risk factors, and age and BMI are predictive factors for alexithymia in COPD patients.

Conscious sedation versus general anesthesia for transcatheter aortic valve implantation in patients with severe chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is considered a major risk factor for postoperative complications after transcatheter aortic valve implantation (TAVI). To date, there is no clear consensus on the best anesthesia management for these patients. We aimed to investigate the effects of types of anesthesia on clinical outcomes in patients with severe COPD undergoing TAVI.

METHODS

This is a single-center, retrospective study comparing conscious sedation (CS) versus general anesthesia (GA) in 72 patients with severe COPD who underwent TAVI. The primary endpoints were 30-day all-cause mortality and postoperative pulmonary complications.

RESULTS

The main outcome of interest of this study was that the frequency of pulmonary complications was statistically higher in the GA group (21.4% vs 3.3%, p = 0.038). These differences are most likely attributed to the GA because of prolonged mechanical ventilation, and longer ICU stay (2 (1.2-3) vs 2.5 (2-4) days, p = 0.029) associated with an increased risk of nosocomial infections. There were no significant differences in procedure complications and 30-day mortality between the two groups (GA; 19% vs CS; 13.3%, p = 0.521). One-year survival rates, compared by Kaplan-Meier analysis, were similar between groups (log-rank p = 0.733).

CONCLUSION

In aortic stenosis patients with severe COPD undergoing TAVI, the use of GA compared with CS was associated with higher incidences of respiratory-related complications, and longer ICU length of stay. CS is a safe and viable option for these patients and should be considered the favored approach.

Ultrasonographic evaluation of diaphragm function in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

Some studies have reported using ultrasonic evaluations to assess diaphragm function in patients with chronic obstructive pulmonary disease (COPD). However, they have limitations and thus cannot provide strong evidence to support ultrasound evaluations for diaphragm function and dysfunction severity assessments in this patient population. Additionally, quantitative studies on the relationship between ultrasound evaluations and diaphragm function do not exist. Therefore, we performed a systematic review and meta-analysis to explore the usefulness of ultrasonography for evaluating diaphragm function in patients with COPD.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, Chinese Biomedical Literature Database, Wanfang Data, China National Knowledge Network, and Chinese Scientific Journal Database (i.e., VIP) databases were searched for literature about ultrasonic evaluations of diaphragm function in patients with COPD for systematic review. We extracted patient demographic, diaphragm mobility, diaphragm thickness, diaphragm thickening score, and other related parameter data using RevMan 5.3 software for the meta-analysis.

RESULTS

We included 13 articles in the systematic review, 8 of which (494 participants) were included in the meta-analysis. The degree of diaphragm offset in patients with COPD was significantly lower than that in healthy controls (weighted mean difference [WMD] = -1.34; 95% confidence interval [CI]: -2.15, 0.53; P < .05). The diaphragm deviation was lower in the severe COPD group than in the mild-to-moderate COPD group (WMD = 0.50; 95% CI: -0.01, 1.01; P = .06), but the difference was not significant.

CONCLUSION

Ultrasonography effectively evaluates diaphragm function in patients with COPD. The diaphragm offset can be used as an auxiliary diagnostic index for COPD, which is also related to disease severity.

Impact of Chronic Obstructive Pulmonary Disease on Outcomes After Total Joint Arthroplasty: A Meta-analysis and Systematic Review

Background

Comorbid chronic obstructive pulmonary disease (COPD) is increasingly common and may have an adverse impact on outcomes in patients undergoing total joint arthroplasty (TJA) of lower extremity. The purpose of this meta-analysis is to compare the postoperative complications between COPD and non-COPD patients undergoing primary TJA including total hip and knee arthroplasty.

Methods

PubMed, EMBASE, and Cochrane Library were systematically searched for relevant studies published before December 2021. Postoperative outcomes were compared between patients with COPD versus those without COPD as controls. The outcomes were mortality, re-admission, pulmonary, cardiac, renal, thromboembolic complications, surgical site infection (SSI), periprosthetic joint infection (PJI), and sepsis.

Results

A total of 1,002,779 patients from nine studies were finally included in this meta-analysis. Patients with COPD had an increased risk of mortality (OR [odds ratio] = 1.69, 95% confidence interval [CI] 1.42-2.02), re-admission (OR = 1.54, 95% CI 1.38-1.71), pulmonary complications (OR = 2.73, 95% CI 2.26-3.30), cardiac complications (OR = 1.40, 95% CI 1.15-1.69), thromboembolic complications (OR = 1.21, 95% CI 1.15-1.28), renal complications (OR = 1.50, 95% CI 1.14-1.26), SSI (OR = 1.23, 95% CI 1.18-1.30), PJI (OR = 1.26, 95% CI 1.15-1.38), and sepsis (OR = 1.36, 95% CI 1.22-1.52).

Conclusion

Patients with comorbid COPD showed an increased risk of mortality and postoperative complications following TJA compared with patients without COPD. Therefore, orthopedic surgeons can use the study to adequately educate these potential complications when obtaining informed consent. Furthermore, preoperative evaluation and medical optimization are crucial to minimizing postoperative complications from arising in this difficult-to-treat population.

Level of evidence

Level III.

Registration

None.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00794-2.

MRI-assessed diaphragmatic function can predict frequent acute exacerbation of COPD: a prospective observational study based on telehealth-based monitoring system

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have considerably high mortality and re-hospitalisation rate. Diaphragmatic dysfunction (DD) is common in COPD patients. However, whether diaphragmatic dysfunction is related to acute exacerbation is yet to be elucidated. This study aimed to evaluate the diaphragm function by magnetic resonance imaging (MRI) in COPD patients and assess whether the impact of DD may help predict AECOPD.

METHODS

20 healthy adult volunteers and 80 COPD patients were enrolled. The diaphragms function parameters were accessed by MRI. Patients were guided to start self-management by the Telehealth-based monitoring system following the enrolment. Events of acute exacerbation of COPD were recorded by the system and confirmed by healthcare providers. Binary univariate and multivariate logistic regression analyses were performed to investigate the factors associated with the frequency of AECOPD. Receiver operating characteristic (ROC) curves were further used to assess the value of prediction indexes.

RESULTS

Fifty-nine COPD patients completed a one-year follow-up based on the Telehealth-based monitoring system. The clinical outcomes showed that the diaphragm function parameters at the end of maximal breathing were lower in the COPD group than in the healthy control group (P < 0.05). ANOVA showed significant differences among Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages for diaphragm function parameters, including chest wall motion, lung area, upper-lower diameter, and the diaphragm thickening fraction at the end of maximal breathing (P < 0.05). Moreover, significant differences in diaphragm function parameters were observed between patients with infrequent AECOPD (n = 28) and frequent AECOPD (n = 31) based on the frequency of AECOPD (P < 0.05). The diaphragm thickening fraction and the chest wall motion were associated with AECOPD after adjusting for age, sex, BMI, and lung functions, and the combination of predictions showed better accuracy in predicting the frequency of AECOPD.

CONCLUSIONS

In COPD patients, diaphragm function parameters correlate with the severity of airflow limitation. The diaphragm thickening fraction and the chest wall motion were associated with the frequency of AECOPD and can predict it.

The role of muscle-specific MicroRNAs in patients with chronic obstructive pulmonary disease and skeletal muscle dysfunction

Skeletal muscle dysfunction is a systematic manifestation of chronic obstructive pulmonary disease (COPD), which is manifested through the changes in the respiratory and peripheral muscle fiber types, reducing muscle strength and endurance, and muscle atrophy. Muscle dysfunction limits the daily mobility, negatively affects the quality of life, and may increase the patient’s risk of mortality. MicroRNAs (miRNAs) as the regulators of gene expression, plays an important role in modulating skeletal muscle dysfunction in COPD by regulating skeletal muscle development (proliferation, differentiation), protein synthesis and degradation, inflammatory response, and metabolism. In particular, muscle-specific miRNAs (myomiRs) may play an important role in this process, although the different expression levels of myomiRs in COPD and skeletal muscle dysfunction and the mechanisms underlying their role remain unclear. In this paper, we review the differential expression of the myomiRs in COPD to identify myomiRs that play a role in skeletal muscle dysfunction in COPD. We further explore their possible mechanisms and action in order to provide new ideas for the prevention and treatment of the skeletal muscle dysfunction in COPD.

The association of chronic bronchitis and airflow obstruction with lifetime and current farm activities in a sample of rural adults in Iowa

OBJECTIVE

Farmers have an increased risk for chronic bronchitis and airflow obstruction. The objective of this study was to investigate the association of these health outcomes with farm activities.

METHODS

We evaluated the Keokuk County Rural Health Study (KCRHS) enrollment data for farm activities and the two health outcomes chronic bronchitis based on self-reported symptoms and airflow obstruction based on spirometry. We used logistic regression to model the health outcomes, yielding an odds ratio (OR) and 95% confidence interval (95% CI) for farm activities while adjusting for potential confounders and other risk factors.

RESULTS

Of the 1234 farmers, 104 (8.4%) had chronic bronchitis, 75 (6.1%) fulfilled the criteria for airflow obstruction, and the two outcomes overlapped by 18 participants. Chronic bronchitis without airflow obstruction (n = 86) had a statistically significant association with crop storage insecticides (OR 3.1, 95% CI 1.6, 6.1) and a low number of years (≤ 3) worked with turkeys (OR 3.3, 95% CI 1.2, 9.4). The latter result should be interpreted with caution because it is based on a small number of cases (n = 5). Airflow obstruction with or without chronic bronchitis (n = 75) was significantly associated with ever working in a hog or chicken confinement setting (OR 2.2, 95% CI 1.0, 4.5).

CONCLUSIONS

These results suggest that work with crop storage insecticides or turkeys may increase the risk for chronic bronchitis and work in hog or chicken confinement may increase the risk for airflow obstruction.

Muscle function and functional performance after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a prospective observational study

This study aimed to measure changes in different properties of skeletal muscles and evaluate their contribution and relationship to changes in functional performance after pulmonary rehabilitation (PR) in patients with chronic obstructive pulmonary disease (COPD). COPD outpatients attending 5 weeks of conventional PR were recruited. Functional performance [5-repetitions sit-to-stand (5STS), and 4-m gait speed (4mGS)], and muscle function (maximal isometric strength, power, force control, and relative concentric and eccentric activation during 5STS) were assessed after PR and 3 months of follow-up. Twenty patients (71 years; 52% of predicted FEV₁) completed the study. 4mGS and relative concentric activation during 5STS decreased respectively by 7.7% and 26% between the beginning of PR and follow-up. Quadriceps strength, power, and force control improved by 10.4%, 27.3%, and 15.2%, respectively, from the beginning of PR to follow-up the relative eccentric activation during 5STS explained 31% of the variance in 4mGS changes. In conclusion, functional performance appeared to decline after conventional PR, whereas several properties of skeletal muscles were maintained at follow-up in COPD outpatients. Of note, eccentric contractions might play a role in the improvement of functional performance. Therefore, future studies with interventional design should include eccentric training in PR programs during clinical COPD practice.

The clinical relevance of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in chronic obstructive pulmonary disease with lung cancer

Background

Chronic obstructive pulmonary disease (COPD) coexisting with lung cancer is associated with severe mortality and a worse prognosis. Inflammation plays an important role in common pathogenic pathways and disease progression. However, a few studies have identified the clinical value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in COPD with lung cancer, which are systemic inflammatory response markers in the blood. This study aimed to determine the association of the NLR or PLR with clinical characteristics and whether NLR or PLR can be diagnostic markers for COPD with lung cancer.

Methods

Between 2015 and 2021, we conducted a retrospective analysis of 236 COPD patients with lung cancer and 500 patients without lung cancer (control group). Clinical information, blood routine examination, and spirometry results were collected and analyzed. The receiver operating characteristic (ROC) curve was used to identify the best cutoff point of NLR or PLR. Multivariate logistic regression analysis was performed to evaluate the association of NLR or PLR with the diagnosis and prognosis of COPD with lung cancer.

Results

Compared to patients in the COPD-only group, patients in the lung cancer group had a higher percentage of current smoking and emphysema, and it was found that NLR or PLR was significantly higher in the lung cancer group. Multivariate analysis showed that age, smoking status, FEV1%pred, emphysema, NLR, and PLR were independent risk factors for lung cancer development in COPD. Furthermore, the high level of NLR or PLR was associated with age over 70 years old, current smoking status, and ineligible surgery treatment. The level of PLR or NLR markedly increased with hypercoagulation status, the severity of airflow limitation, and advanced progression of lung cancer. Additionally, the ROC analysis also revealed that elevated NLR or PLR was an independent predictor of COPD in lung cancer patients, TNM stages IIIB–IV at first diagnosis in lung cancer, and ineligible surgery in lung cancer patients.

Conclusion

Increased NLR or PLR values might be an important and easily measurable inflammation biomarker to predict the diagnosis and severity of lung cancer with COPD.

The relationship between glycated hemoglobin A1c levels and exacerbation status in the patients with chronic obstructive pulmonary disease

OBJECTIVE

This study was performed in Razi Hospital, Rasht, Iran, between March 2016 and August 2018 on a population of chronic obstructive pulmonary disease (COPD) patients (56 as COPD exacerbation group and 56 as COPD stable group). Study variables include age, sex, occupation, body mass index (BMI), cigarette consumption, duration of COPD, annual hospitalization, dyspnea, glycated hemoglobin (HbA1c), FEV1, and FEV1/FVC indices.

RESULT

The mean age of the participants was 63.92 ± 10.75 years. There was a significant difference in the hospitalization between the patients with both exacerbation and normal state of COPD (P ≤ 0.001). HbA1c in the patients with exacerbation of COPD was significantly higher than stable status (P = 0.001). Logistic regression showed that HbA1c levels and hospitalization were predictors of exacerbation of COPD. HbA1c levels were statistically significant in terms of hospitalization in patients with COPD exacerbation. There was a significant difference between the HbA1c levels and MMRC in patients with COPD. The percentage of HbA1c was associated with exacerbation of COPD and HbA1c is a good predictor of disease severity in patients with COPD. It also shows that patients with COPD exacerbation and severe COPD are at the higher risk of hyperglycemia.

Measurement of Procalcitonin as an Indicator of Severity in Patients With Chronic Obstructive Pulmonary Disease Admitted With Respiratory Illness

Introduction

Exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent reason for hospital admission and a major cause of morbidity and mortality. A useful biomarker or indicator of disease severity at the time of presentation could help guide treatment and identify those with poor prognosis who need early aggressive intervention. We hypothesized that patients who present to the hospital with COPD exacerbations who are found to have elevated procalcitonin (PCT) levels will have worse outcomes such as longer admissions, increased intensive care unit (ICU) utilization, and more frequent readmissions than those with normal levels, regardless of presence or absence of infiltrate on initial chest X-ray (CXR).

Methods

We conducted a retrospective chart review of patients admitted to our facility with a respiratory complaint and a diagnosis of COPD to examine the relation between PCT and disease severity. A total of 156 unique encounters were reviewed, with 87 included in the final data set. Data was collected on baseline medical conditions as well as clinical status at the time of presentation. Primary endpoints included the need for overnight ICU admission, hospital length of stay greater than seven days, and repeat visit within 30 days of discharge. Secondary endpoints included the need for intubation at the time of admission, in-hospital mortality or discharge to hospice, and ICU length of stay.

Results

Patients with elevated PCT levels (>0.25ng/mL) had a significantly increased likelihood of a need for ICU admission (odds ratio 3.18) and hospital length of stay greater than seven days (odds ratio 3.38). There was no statistically significant difference in the Emergency Department readmission rate or any of the secondary outcomes.

Conclusions

Our data suggests that PCT may be a useful early biomarker for patients with COPD presenting with an acute respiratory illness.

Cost-effectiveness of integrated disease management for high risk, exacerbation prone, patients with chronic obstructive pulmonary disease in a primary care setting

Background

We evaluate the cost-effectiveness of the ‘Best Care’ integrated disease management (IDM) program for high risk, exacerbation prone, patients with chronic obstructive pulmonary disease (COPD) compared to usual care (UC) within a primary care setting from the perspective of a publicly funded health system (i.e., Ontario, Canada).

Methods

We conducted a model-based, cost-utility analysis using a Markov model with expected values of costs and outcomes derived from a Monte-Carlo Simulation with 5000 replications. The target population included patients started in GOLD II with a starting age of 68 years in the trial-based analysis. Key input parameters were based on a randomized control trial of 143 patients (i.e., UC (n = 73) versus IDM program (n = 70)). Results were shown as incremental cost per quality-adjusted life year (QALY) gained.

Results

The IDM program for high risk, exacerbation prone, patients is dominant in comparison with the UC group. After one year, the IDM program demonstrated cost savings and improved QALYs (i.e., UC was dominated by IDM) with a positive net-benefit of $5360 (95% CI: ($5175, $5546) based on a willingness to pay of $50,000 (CAN) per QALY.

Conclusions

This study demonstrates that the IDM intervention for patients with COPD in a primary care setting is cost-effective in comparison to the standard of care. By demonstrating the cost-effectiveness of IDM, we confirm that investment in the delivery of evidence based best practices in primary care delivers better patient outcomes at a lower cost than UC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-022-00377-w.

I.

Interventions that can reduce the frequency and severity of exacerbations in patients who suffer from COPD have the potential to reduce the financial burden of COPD on the health system;

II.

This is the first study that demonstrates the cost-effectiveness of integrated disease management for patients who suffer from COPD within a primary care environment;

III.

This study makes the case for embedding Certified Respiratory Educators (CREs) within the primary care environment to improve the quality of life of patients who suffer from COPD, as well as alleviating unnecessary health services utilization and decreasing the overall financial burden of the disease on the health system.

Peitu Shengjin Recipe Attenuates Airway Inflammation via the TLR4/NF-kB Signaling Pathway on Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is a common respiratory disease, but there is no specific medicine for COPD. In this study, we aimed to evaluate the effects of Peitu Shengjin Recipe (PSR) and Biostime Probiotic Powder on COPD rats.

Methods

UPLC-Q/TOF-MS was used to detect the chemical constituents in PSR. The COPD rat model was established by cigarette smoke combined with tracheal injection of lipopolysaccharide. We assessed lung function by calculating FEV_0.3/FVC%, dynamic lung compliance (Cdyn), and resistance of inspiration (RI). Histological analysis was performed by HE staining. The levels of TNF-α, IFN-γ, IL-1β, IL-4, and IL-10 were detected by the ELISA. The mRNA and protein expressions of the TLR4/NF-kB signaling pathway were detected by the qRT-PCR and western blotting, respectively.

Results

There were 53 ESI⁺ and 50 ESI⁻ components in PSR. After high-dose PSR treatment, FEV_0.3/FVC% and Cdyn increased significantly, while RI decreased. Compared with the COPD model, the RI of the Biostime Probiotic Powder group was significantly lower. HE staining showed that the inflammatory cell infiltration was reduced to varying degrees, the bronchial tube wall was not thickened, and the alveoli were relatively intact after treatment with PSR and Biostime Probiotic Powder. Compared with the model group, the levels of TNF-α, IFN-γ, IL-1β, IL-4, and IL-10 in the PSR group and the Biostime Probiotic Powder group were reversed. The mRNA and protein expressions of TLR4 and NF-kB were significantly decreased after PSR and Biostime Probiotic Powder treatment.

Conclusion

Our findings suggest that PSR and Biostime Probiotic Powder have protective effects on COPD rats, which may be achieved by modulating the TLR4/NF-kB signaling pathway.

Risk factors for postoperative pneumonia in patients undergoing hip fracture surgery: a systematic review and meta-analysis

BACKGROUND

Postoperative pneumonia (POP) is a devastating complication that can frequently occur after hip fracture surgery. This study aimed to quantitatively and comprehensively summarize the risk factors for POP following hip fracture surgery.

METHODS

PubMed, Embase, and Cochrane Library were systematically searched for studies assessing risk factors for POP following hip fracture surgery. The pooled odds ratio (OR) and standardized mean difference (SMD) between patients with and without POP were calculated. Evidence was assessed using the Newcastle-Ottawa scale.

RESULTS

Ten studies including 37,130 patients with hip fractures were selected. POP occurred in 1768 cases with an accumulated incidence of 7.8% (95% confidence interval [CI]: 0.061-0.094). Advanced age (SMD: 0.50, 95% CI: 0.10-0.90), male sex (OR: 1.50, 95% CI: 1.12-2.01), American Society of Anesthesiologists physical status scale ≥3 (OR: 3.17, 95% CI: 1.25-8.05), chronic obstructive pulmonary disease (OR: 2.05, 95% CI: 1.43-2.94), coronary heart disease (OR: 1.82, 95% CI: 1.27-2.60), arrhythmia (OR: 1.49, 95% CI: 1.04-2.15), congestive heart failure (OR: 1.41, 95% CI: 1.14-1.75), chronic kidney disease (OR: 2.09, 95% CI: 1.28-3.41), and cerebrovascular accident (OR: 2.14, 95% CI: 1.60-2.85) were risk factors for POP. Hemoglobin (SMD: -0.14, 95% CI: - 0.25 to - 0.03), albumin (SMD: -0.97, 95% CI: - 1.54--0.41), blood urea nitrogen (SMD: 0.20, 95% CI: 0.03-0.37), alanine aminotransferase (SMD: 0.27, 95% CI: 0.10-0.44), arterial oxygen pressure (SMD: -0.49, 95% CI: - 0.71--0.27), time from injury to surgery (SMD: 0.13, 95% CI: 0.08-0.17), and surgery within 48 h (OR: 3.74, 95% CI: 2.40-5.85) were associated with the development of POP.

CONCLUSION

Patients with the aforementioned risk factors should be identified preoperatively, and related prophylaxis strategies should be implemented to prevent POP following hip fracture surgery.

Relationship between concavity of the flow-volume loop and small airway measures in smokers with normal spirometry

Background

There is increasing evidence of small airway abnormalities in smokers despite normal spirometry. The concavity in the descending limb of the maximum expiratory flow curve (MEFV) is a recognised feature of obstruction and can provide information beyond FEV₁, and potentially early smoking-related damage. We aimed to evaluate concavity measures compared to known small airway measurements.

Methods

Eighty smokers with normal spirometry had small airway function assessed: multiple breath nitrogen washout (MBNW) from which ventilation heterogeneity in the diffusion-dependent acinar (Sacin) and convection-dependent conductive (Scond) airways were assessed, and impulse oscillometry system (IOS) from which respiratory resistance and reactance at 5 Hz (R5 and X5) were measured. Concavity measures were calculated from the MEFV, partitioned into global and peripheral concavity.

Results

We found abnormal peripheral and global concavity as well as acinar ventilation heterogeneity are common in “normal” smokers. Concavity measures were not related to either MBNW or IOS measurements.

Conclusion

Abnormalities in concavity indices and MBNW or oscillometry parameters are common in smokers despite normal spirometry. However, these measures likely reflect different mechanisms of peripheral airway dysfunction.

Association between body composition, sarcopenia and pulmonary function in chronic obstructive pulmonary disease

Background

Chronic Obstructive Pulmonary Disease (COPD) is characterized by progressive and irreversible airflow limitation. Different factors that modify pulmonary function include age, sex, muscular strength, and a history of exposure to toxic agents. However, the impact of body composition compartments and sarcopenia on pulmonary function is not well-established. This study aimed to evaluate how body composition compartments and sarcopenia affect pulmonary function in COPD patients.

Methods

In a cross-sectional study, patients with a confirmed diagnosis of COPD, > 40 years old, and forced expiratory volume in the first second /forced vital capacity ratio (FEV₁/FVC) < 0.70 post-bronchodilator were included. Patients with cancer, HIV, and asthma were excluded. Body composition was measured with bioelectrical impedance. Sarcopenia was defined according to EWGSOP2, and pulmonary function was assessed by spirometry.

Results

185 patients were studied. The mean age was 72.20 ± 8.39 years; 55.14% were men. A linear regression adjusted model showed associations between body mass index, fat-free mass, skeletal muscle mass index, appendicular skeletal muscle mass index, and phase angle (PhA), and sarcopenia with FEV₁ (%). As regards FVC (%), PhA and exercise tolerance had positive associations.

Conclusion

Body composition, especially PhA, SMMI, ASMMI, and sarcopenia, has a significant impact on pulmonary function. Early detection of disturbances of these indexes enables the early application of such therapeutic strategies in COPD patients.

Derivation and Validation of the UCAP-Q Case-finding Questionnaire to Detect Undiagnosed Asthma and COPD

BACKGROUND

Many people with asthma and COPD remain undiagnosed. We developed and validated a new case-finding questionnaire to identify symptomatic adults with undiagnosed obstructive lung disease.

METHODS

Adults in the community with no prior history of physician-diagnosed lung disease who self-reported respiratory symptoms were contacted via random-digit dialing. Pre- and post-bronchodilator spirometry was used to confirm asthma or COPD. Predictive questions were selected using multinomial logistic regression with backward elimination. Questionnaire performance was assessed using sensitivity, predictive values, and area under the receiver operating curve (AUC). The questionnaire was assessed for test-retest reliability, acceptability, and readability. External validation was prospectively conducted in an independent sample and predictive performance re-evaluated.

RESULTS

A 13-item UCAP-Q case-finding questionnaire to predict undiagnosed asthma or COPD was developed. The most appropriate risk cut-off was determined to be 6% for either disease. Applied to the derivation sample (N=1615), the questionnaire yielded a sensitivity of 92% for asthma and 97% for COPD, specificity of 17%, with an AUC of 0.69 (95% CI: 0.64-0.74) for asthma and 0.82 (95% CI: 0.78-0.86) for COPD. Prospective validation using an independent sample (n=471) showed sensitivities of 93% and 92% for asthma and COPD, respectively, specificity of 19%, with AUC's of 0.70 (95% CI: 0.62-0.79) for asthma and 0.81 (95% CI: 0.74-0.87) for COPD. AUC's for UCAP-Q were higher compared to AUC's for currently recommended case-finding questionnaires for asthma or COPD.Conclusions:The UCAP-Q demonstrated high sensitivities and AUC's for identifying undiagnosed asthma or COPD. A web-based calculator allows for easy calculation of risk probabilities for each disease.

The Indices of Instantaneous Pulse Rate Variability Are Indicators for Daily Life Quality Assessment in Patients with COPD

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory illness. Questionnaires such as modified Medical Research Council (mMRC) dyspnea scale and COPD assessment test (CAT) are useful for COPD condition and life quality assessment. These questionnaires reflect how respiratory disorder affects daily life. Breathing and autonomic nervous system (ANS) usually regulate each other. Few studies discussed the ANS activity and daily life quality in patients with COPD. Therefore, this study aimed to find the relationship between daily life quality assessed by mMRC or CAT and ANS assessed by a novel method, instantaneous pulse rate variability (iPRV), a method indicating not only the ANS activity but also the peripheral response. The result showed that the change in mMRC and the change in low frequency power to high frequency power ratio, which usually represents the sympathetic activity in conventional heart rate variability analysis, had significant correlation (r = 0.63; p < 0.05). The change in CAT and the change in high frequency power (regulated by vagal nervous and respiratory system) or very high frequency power (new frequency band can be indicated in iPRV spectrum) had significant negative correlation (r = -0.64 and -0.55, respectively; p < 0.05 for both). This study showed the change in iPRV indices when the condition of COPD was improvement or exacerbation. This study presents a possible way to show how cardiovascular activity affects daily life quality in patients with COPD. Increase in LF or decrease in HF and VHF would cause poorer quality of daily life in patients with COPD. The result can also be a reference for patients with COPD to choose the breathing type to adjust rehabilitation and therapy program for ANS regulation to indicate or improve their daily life quality.

Chest CT-assessed comorbidities and all-cause mortality risk in COPD patients in the BODE cohort

BACKGROUND AND OBJECTIVE

The availability of chest computed tomography (CT) imaging can help diagnose comorbidities associated with chronic obstructive pulmonary disease (COPD). Their systematic identification and relationship with all-cause mortality have not been explored. Furthermore, whether their CT-detected prevalence differs from clinical diagnosis is unknown.

METHODS

The prevalence of 10 CT-assessed comorbidities was retrospectively determined at baseline in 379 patients (71% men) with mild to severe COPD attending pulmonary clinics. Anthropometrics, smoking history, dyspnoea, lung function, exercise capacity, BODE (BMI, Obstruction, Dyspnoea and Exercise capacity) index and exacerbations rate were recorded. The prevalence of CT-determined comorbidities was compared with that recorded clinically. Over a median of 78 months of observation, the independent association with all-cause mortality was analysed. A 'CT-comorbidome' graphically expressed the strength of their association with mortality risk.

RESULTS

Coronary artery calcification, emphysema and bronchiectasis were the most prevalent comorbidities (79.8%, 62.7% and 33.9%, respectively). All were underdiagnosed before CT. Coronary artery calcium (hazard ratio [HR] 2.09; 95% CI 1.03-4.26, p = 0.042), bronchiectasis (HR 2.12; 95% CI 1.05-4.26, p = 0.036) and low psoas muscle density (HR 2.61; 95% CI 1.23-5.57, p = 0.010) were independently associated with all-cause mortality and helped define the 'CT-comorbidome'.

CONCLUSION

This study of COPD patients shows that systematic detection of 10 CT-diagnosed comorbidities, most of which were not detected clinically, provides information of potential use to patients and clinicians caring for them.

Global burden of chronic obstructive pulmonary disease attributable to ambient ozone in 204 countries and territories during 1990-2019

Ambient ozone becomes one of significant environmental threats to chronic obstructive pulmonary disease (COPD) in recent decades. To date, however, few systematic analyses have been performed to quantify ozone-attributable disease burden, globally and regionally. In this study, we aimed to comprehensively depict the global trend of ozone-related COPD premature deaths and disability-adjusted life years (DALYs). We derived estimates of COPD burden attributable to ambient ozone for 204 countries and territories during 1990-2019 from the Global Burden of Disease Study 2019. We examined the number of deaths and DALYs, as well as age-standardized mortality rate (ASMR) and DALYs rate (ASDR) by sex, socio-demographic index (SDI), countries, and regions. Population attributable fractions (PAFs) were adopted to identify age groups vulnerable to ozone-related COPD. Estimated annual percentage changes (EAPCs) were calculated to assess the temporal trend of ozone-attributable COPD burden (e.g., ASMR and ASDR) between 1990 and 2019, using generalized linear models. Spearman rank correlation was applied to measure the relationships of estimated ASMR, ASDR, and EAPC with SDI. In 2019, COPD attributable to ambient ozone gave rise to 365.22 (95% uncertainty interval: 174.93 to 564.27) thousand deaths and 6.21 (2.99 to 9.63) million DALYs globally, representing a corresponding increase of 76.11% and 56.37% versus 1990. During 1990-2019, however, a yearly decline of 1.07% (0.81 to 1.33) was observed for ASMR and 1.30% (1.07 to 1.52) for ASDR. Considerable gender inequality continues in ozone-attributable COPD burden, with much greater impacts among men, and the gap is enlarged with the increase of age. In all age groups, the fractional contribution of ozone to COPD burden exhibited an overall increasing trend globally for both deaths (8.22% in 1990 versus 11.13% in 2019) and DALYs (6.70% in 1990 versus 8.34% in 2019). The burden of COPD caused by ambient ozone varied substantially by geographical and socioeconomic regions. In 2019, the greatest ASMR and ASDR were seen in South Asia, followed by East Asia and Central Sub-Saharan Africa. Despite the clear drop of age-standardized rates (EAPC<0) in high, high-middle, and middle SDI regions, ASMR and ASDR in low and low-middle SDI regions continuously raised between 1990 and 2019. Higher SDI was found to be associated with lower EAPCs in ASMR (r_s=-0.4405, p<0.001) and ASDR (r_s=-0.4510, p<0.001). Although the global ASMR and ASDR of COPD attributable to ambient ozone have decreased from 1990 to 2019, there has been an unnegligible increase in some low and low-middle SDI regions such as Southeast Asia, South Asia, and Andean Latin America. Findings may have some implications for formulating targeted plans and policies for future COPD prevention and ambient ozone management in different regions.

Can COPD Exacerbations Be Picked Up Early via a Weekly Medication Question Through a Smartphone Application?

BACKGROUND

Exacerbations affect the disease trajectory of patients with COPD and result in an acute drop of functional status and physical activity. Timely detection of exacerbations by non-medical healthcare professionals is needed to counteract this decline. The use of digital health applications in patient interaction allows embedded detection of exacerbations. However, it is unknown if this is an effective way to pick up exacerbations.

METHOD

We investigated the detection of exacerbations in patients with COPD enrolled in a physical activity coaching program, by prompting a weekly question on changes in medication via the smartphone application. Data on response rate and occurrence of exacerbations were collected.

RESULTS

Response rate to the medication question, evaluated in 42 patients, was 72% (n = 497). A change in medication was reported through the smartphone application in 38 (7.6%) of the answered questions. The response rate was significantly lower at 6 months follow-up compared to the first month (p =0.03). When evaluating the occurrence of adverse events in a subset of patients who completed 6 months of follow-up (n = 27), 18 exacerbations were registered in eight patients, of which 10 of these exacerbations (56%) were picked up by the medication question in the coaching application.

CONCLUSION

Electronic interaction through a weekly medication question, embedded in a smartphone application, is feasible to support the detection of the occurrence of COPD exacerbations and can be used complementary to regular forms of detecting exacerbations. Compliance and smartphone literacy should be optimized when further using this method to report on COPD exacerbations.