Physiological and radiological characterisation of patients diagnosed with chronic obstructive pulmonary disease in primary care

Clinical Significance of Preserving Pulmonary Function After Lung Resection in Early-Stage Non-Small-Cell Lung Cancer

INTRODUCTION

To determine the association between changes in pulmonary function before and after surgery, and the subsequent prognosis, of patients with early-stage non-small-cell lung cancer (NSCLC).

METHODS

A total of 485 patients who underwent lobectomy or segmentectomy for NSCLC with whole tumor size ≤2 cm and clinical stage IA at 2 institutions were retrospectively reviewed. The relationship between the postoperative reduction rate in vital capacity (VC), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) and overall survival (OS) was investigated. OS determined the cut-off value of the reduction rate, according to the reduction rate of every 10% in pulmonary function.

RESULTS

Multivariable Cox regression analysis showed that a reduction rate in VC at 12 months postoperatively was an independent prognostic factor for OS (hazard ratio, 1.05; 95% confidence interval [CI], 1.02-1.07; P < .001) but those in FVC and FEV1 were not. OS was classified into good and poor with 20% reduction rate in VC. OS and recurrence-free survival (RFS) in a higher than 20% reduction rate in VC were worse than those in ≤20% reduction rate in VC (5 year-OS; 82.0% vs. 93.4%; P = .0004. Five year-RFS; 80.3% vs. 89.8%; P = .0018, respectively). Multivariable logistic analysis showed that lobectomy was a risk factor for the higher than 20% reduction rate in VC (odds ratio, 1.61; 95% CI, 1.01-2.56; P = .045).

CONCLUSIONS

Postoperative decrease in VC was significantly associated with the prognosis. Preserving pulmonary function is important for survival of patients with early-stage NSCLC.

Correlating Reiff scores with clinical, functional, and prognostic factors: characterizing noncystic fibrosis bronchiectasis severity: validation from a nationwide multicenter study in Taiwan

BACKGROUND

Our study aimed to confirm a simplified radiological scoring system, derived from a modified Reiff score, to evaluate its relationship with clinical symptoms and predictive outcomes in Taiwanese patients with noncystic fibrosis bronchiectasis (NCFB).

METHODS

This extensive multicenter retrospective study, performed in Taiwan, concentrated on patients diagnosed with NCFB verified through high-resolution computed tomography (HRCT) scans. We not only compared the clinical features of various types of bronchiectasis (cylindrical, varicose, and cystic). Furthermore, we established relationships between the severity of clinical factors, including symptom scores, pulmonary function, pseudomonas aeruginosa colonization, exacerbation and admission rates, and HRCT parameters using modified Reiff scores.

RESULTS

Data from 2,753 patients were classified based on HRCT patterns (cylindrical, varicose, and cystic) and severity, assessed by modified Reiff scores (mild, moderate, and severe). With increasing HRCT severity, a significant correlation was found with decreased forced expiratory volume in the first second (FEV1) (p < 0.001), heightened clinical symptoms (p < 0.001), elevated pathogen colonization (pseudomonas aeruginosa) (p < 0.001), and an increased annual hospitalization rate (p < 0.001). In the following multivariate analysis, elderly age, pseudomonas aeruginosa pneumonia, and hospitalizations per year emerged as the only independent predictors of mortality.

CONCLUSION

Based on our large cohort study, the simplified CT scoring system (Reiff score) can serve as a useful adjunct to clinical factors in predicting disease severity and prognosis among Taiwanese patients with NCFB.

The role of Neutrophil counts, infections and Smoking in mediating the Effect of Bronchiectasis on Chronic Obstructive Pulmonary Disease: a mendelian randomization study

BACKGROUND

The causality of the relationship between bronchiectasis and chronic obstructive pulmonary disease (COPD) remains unclear. This study aims to investigate the potential causal relationship between them, with a specific focus on the role of airway inflammation, infections, smoking as the mediators in the development of COPD.

METHODS

We conducted a two-sample Mendelian randomization (MR) analysis to assess: (1) the causal impact of bronchiectasis on COPD, sex, smoking status, infections, eosinophil and neutrophil counts, as well as the causal impact of COPD on bronchiectasis; (2) the causal effect of smoking status, infections and neutrophil counts on COPD; and (3) the extent to which the smoking status, infections and neutrophil counts might mediate any influence of bronchiectasis on the development of COPD.

RESULTS

COPD was associated with a higher risk of bronchiectasis (OR 1.28 [95% CI 1.05, 1.56]). Bronchiectasis was associated with a higher risk of COPD (OR 1.08 [95% CI 1.04, 1.13]), higher levels of neutrophil (OR 1.01 [95% CI 1.00, 1.01]), higher risk of respiratory infections (OR 1.04 [95% CI 1.02, 1.06]) and lower risk of smoking. The causal associations of higher neutrophil cells, respiratory infections and smoking with higher COPD risk remained after performing sensitivity analyses that considered different models of horizontal pleiotropy, with OR 1.17, 1.69 and 95.13, respectively. The bronchiectasis-COPD effect was 0.99, 0.85 and 122.79 with genetic adjustment for neutrophils, respiratory infections and smoking.

CONCLUSION

COPD and bronchiectasis are mutually causal. And increased neutrophil cell count and respiratory infections appears to mediate much of the effect of bronchiectasis on COPD.

Comorbidities in COPD: Current and Future Treatment Challenges

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition, primarily characterized by the presence of a limited airflow, due to abnormalities of the airways and/or alveoli, that often coexists with other chronic diseases such as lung cancer, cardiovascular diseases, and metabolic disorders. Comorbidities are known to pose a challenge in the assessment and effective management of COPD and are also acknowledged to have an important health and economic burden. Local and systemic inflammation have been proposed as having a potential role in explaining the association between COPD and these comorbidities. Considering that the number of patients with COPD is expected to rise, understanding the mechanisms linking COPD with its comorbidities may help to identify new targets for therapeutic purposes based on multi-dimensional assessments.

Sociodemographic correlates with prevalence of comorbidities in patients with chronic obstructive pulmonary disease: a study from a Chinese National Survey

Background

An increase in the prevalence of comorbidities has been reported in patients with chronic obstructive pulmonary disease (COPD). However, contemporary estimates of the overall prevalence of the sociodemographic correlates of COPD comorbidities are scarce and inconsistent in China. This study aimed to investigate the prevalence of sociodemographic correlates of comorbidities in patients with COPD across China.

Methods

This was a cross-sectional study. We used data from the Enjoying Breathing Program between May 2020 and April 2022. Participants with COPD from 17 provinces (or equivalent) were included. Comorbidity clusters were stratified based on the number of comorbidities per person. Univariable and multivariable analyses were used to determine the sociodemographic associations of patients with COPD with specific clusters of comorbidities after adjusting for age, sex, and other prespecified covariates. Tetrachoric correlation analyses were performed to determine the associations between specific comorbidities.

Findings

A total of 3913 participants with COPD were included, of whom 1744 (44.7%) had at least one comorbidity; 25.4% had one comorbid disease, 12.9% had two, and 6.4% had three or more concurrent diseases. The most common comorbidities were hypertension (17.8%), asthma (9.9%), bronchiectasis (8.2%), diabetes (8.2%), and coronary artery disease (7.7%). In the logistic regression models adjusted for a broad set of factors, patients with COPD residing in the east region of China and having health insurance experienced a decreased likelihood of comorbidities (from OR = 0.70 [95% confidence interval [CI], 0.53-0.93] to OR = 0.50 [95% CI, 0.25-0.99]). However, patients over 80 years had increased risk (OR 1.43 [95% CI 1.01-2.03]), as did those in all Modified Medical Research Council (mMRC) grade categories (grade 1: OR = 1.30 [95% CI, 1.02-1.65]; grade 2: OR = 1.39 [95% CI, 1.07-1.8]; grade 3: OR = 1.67 [95% CI, 1.23-2.26]; and grade 4: OR = 1.81 [95% CI, 1.00-3.28]) and in Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2 classification (OR = 1.30 [95% CI, 1.03-1.65]) relative to their respective references. The associations observed in these subgroups were consistent regardless of the number of comorbidities per person. Tetrachoric correlations demonstrated negative associations in pairwise comparisons of the top five comorbidities, ranging from -0.03 to -0.31 (p < 0.001 in all groups).

Interpretation

In China, comorbidities are highly prevalent among patients with COPD, with older age, higher mMRC grade, and lung function decline being the major risk factors. Studies with larger sample sizes are required to elucidate the complex mechanisms underlying COPD comorbidities.

Funding

This study was funded by CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-049 and 2022-I2M-C&T-B-107).

Artificial Intelligence-based CT Assessment of Bronchiectasis: The COPDGene Study

Background CT is the standard method used to assess bronchiectasis. A higher airway-to-artery diameter ratio (AAR) is typically used to identify enlarged bronchi and bronchiectasis; however, current imaging methods are limited in assessing the extent of this metric in CT scans. Purpose To determine the extent of AARs using an artificial intelligence-based chest CT and assess the association of AARs with exacerbations over time. Materials and Methods In a secondary analysis of ever-smokers from the prospective, observational, multicenter COPDGene study, AARs were quantified using an artificial intelligence tool. The percentage of airways with AAR greater than 1 (a measure of airway dilatation) in each participant on chest CT scans was determined. Pulmonary exacerbations were prospectively determined through biannual follow-up (from July 2009 to September 2021). Multivariable zero-inflated regression models were used to assess the association between the percentage of airways with AAR greater than 1 and the total number of pulmonary exacerbations over follow-up. Covariates included demographics, lung function, and conventional CT parameters. Results Among 4192 participants (median age, 59 years; IQR, 52-67 years; 1878 men [45%]), 1834 had chronic obstructive pulmonary disease (COPD). During a 10-year follow-up and in adjusted models, the percentage of airways with AARs greater than 1 (quartile 4 vs 1) was associated with a higher total number of exacerbations (risk ratio [RR], 1.08; 95% CI: 1.02, 1.15; P = .01). In participants meeting clinical and imaging criteria of bronchiectasis (ie, clinical manifestations with ≥3% of AARs >1) versus those who did not, the RR was 1.37 (95% CI: 1.31, 1.43; P < .001). Among participants with COPD, the corresponding RRs were 1.10 (95% CI: 1.02, 1.18; P = .02) and 1.32 (95% CI: 1.26, 1.39; P < .001), respectively. Conclusion In ever-smokers with chronic obstructive pulmonary disease, artificial intelligence-based CT measures of bronchiectasis were associated with more exacerbations over time. Clinical trial registration no. NCT00608764 © RSNA, 2022 Supplemental material is available for this article. See also the editorial by Schiebler and Seo in this issue.

The Airway Microbiome-IL-17 Axis: a Critical Regulator of Chronic Inflammatory Disease

The respiratory tract is home to a diverse microbial community whose influence on local and systemic immune responses is only beginning to be appreciated. Increasing reports have linked changes in this microbiome to a range of pulmonary and extrapulmonary disorders, including asthma, chronic obstructive pulmonary disease and rheumatoid arthritis. Central to many of these findings is the role of IL-17-type immunity as an important driver of inflammation. Despite the crucial role played by IL-17-mediated immune responses in protection against infection, overt Th17 cell responses have been implicated in the pathogenesis of several chronic inflammatory diseases. However, our knowledge of the influence of bacteria that commonly colonise the respiratory tract on IL-17-driven inflammatory responses remains sparse. In this article, we review the current knowledge on the role of specific members of the airway microbiota in the modulation of IL-17-type immunity and discuss how this line of research may support the testing of susceptible individuals and targeting of inflammation at its earliest stages in the hope of preventing the development of chronic disease.

How and when to manage respiratory infections out of hospital

Lower respiratory infections include acute bronchitis, influenza, community-acquired pneumonia, acute exacerbation of COPD and acute exacerbation of bronchiectasis. They are a major cause of death worldwide and often affect the most vulnerable: children, elderly and the impoverished. In this paper, we review the clinical presentation, diagnosis, severity assessment and treatment of adult outpatients with lower respiratory infections. The paper is divided into sections on specific lower respiratory infections, but we also dedicate a section to COVID-19 given the importance of the ongoing pandemic. Lower respiratory infections are heterogeneous entities, carry different risks for adverse events, and require different management strategies. For instance, while patients with acute bronchitis are rarely admitted to hospital and generally do not require antimicrobials, approximately 40% of patients seen for community-acquired pneumonia require admission. Clinicians caring for patients with lower respiratory infections face several challenges, including an increasing population of patients with immunosuppression, potential need for diagnostic tests that may not be readily available, antibiotic resistance and social aspects that place these patients at higher risk. Management principles for patients with lower respiratory infections include knowledge of local surveillance data, strategic use of diagnostic tests according to surveillance data, and judicious use of antimicrobials.

Bronchiectasis associated with severe COPD: Clinical, functional, microbiological and tomographic features

Background

Bronchiectasis is frequently identified in patients with COPD, especially in severe patients, but the relevance of this finding remains unclear. We aimed to investigate the factors that would increase the chance of having bronchiectasis in patients with severe COPD.

Methods

This is an analytical, observational, cross-sectional study. Patients with severe COPD with (BC group) and without bronchiectasis (NBC group) were clinically evaluated and performed spirometry, 6-minute walk test (6MWT), volumetric capnography (VCap) and high resolution computed tomography (CT). CT was scored for the findings, and multiple linear regression was performed to identify variables related to the score's severity and logistic regression in order to identify factors that could be associated with the presence of bronchiectasis.

Results

There was no significant difference between BC and NBC groups regarding clinical variables, except in the smoking load, which was lower in the BC group. In functional evaluation, NBC patients walked shorter distances in 6MWT (P < 0.005). In the BC group the distribution of CT findings was mostly bilateral and in lower lobes. Using the multiple linear regression analysis within the BC group, we found that the higher the bronchiectasis score, the higher ΔSpO2 during the 6MWT and the lower the FVC. The chance of having bronchiectasis was 4.78 times higher in the presence of positive isolates (sputum) (CI 1.35-16.865; P = 0.023). The higher the distance covered (6MWT) and Slp3 (VCap), (OR 1.01, CI 1.004; 1.0202, P = 0.0036; OR 1.04, CI 1.003; 1.077; P = 0.036), the greater are likelihood of bronchiectasis.

Conclusions

In patients with COPD and bronchiectasis, higher CT scores were associated with worse lung function and a greater drop in oxygenation during exercise.

Inhaled Corticosteroids in Adults with Non-cystic Fibrosis Bronchiectasis: From Bench to Bedside. A Narrative Review

Due to their potent anti-inflammatory capacity (particularly in predominantly eosinophilic inflammation) and immunosuppressive properties, inhaled corticosteroids (ICSs) are widely used in asthmatic patients and also in individuals with chronic obstructive pulmonary disease (COPD) who suffer multiple exacerbations or have peripheral eosinophilia. However, there is little evidence for their use in non-cystic fibrosis bronchiectasis (hereafter, bronchiectasis). According to data extracted from large databases of bronchiectasis in adults, ICSs are used in more than 50% of patients without any scientific evidence to justify their efficacy and contrary to the recommendations of international guidelines on bronchiectasis that generally advise against their use. Indeed, bronchiectasis is a disease with predominantly neutrophilic inflammation and a high likelihood of chronic bacterial bronchial infection. Furthermore, it is known that due to their immunosuppressive properties, ICSs can induce an increase in bacterial infections. This manuscript aims to review the basic properties of ICSs, how they impact bronchiectasis in adults, the current position of international guidelines on this treatment, and the current indications and future challenges related to ICS use in bronchiectasis.

Kronik Obstrüktif Akciğer Hastalığı Olan Hastalarda Komorbid Bronşektazinin Yaşam Kalitesine Etkisinin Değerlendirilmesi

Objective: The objective of this study was to evaluate the effect of comorbid bronchiectasis on quality-of-life in patients with Chronic Obstructive Pulmonary Disease (COPD). Method: 103 patients were diagnosed with COPD were included in our study. Spirometric measurements were made. The following measurement tools were used to collect data: 6-Minute Walk Test (6MWT), Modified Medical Research Council (mMRC) dyspnea scale, COPD Assessment Test (CAT), St. George Respiratory Questionnaire (SGRQ), and Short Form 36 (SF-36) quality-of-life questionnaire. Furthermore, all the patients’ high Resolution Computed Tomography (HRCT) images for the last three years were included in the study. Result: 93.2% of the patients were male, with a mean age of 64.79±9.35 years. It was found that SGRQ and SF-36 quality-of-life scores decreased by half in all the patients compared to normal ones. The volume/forced vital capacity (FEV1/FVC) values in the first second of forced expiration were significantly lower in the group with bronchiectasis. A significant correlation was found to exist between the patients’ mMRC dyspnea scale and CAT scores, 6MWT distances, and all subscales of SGRQ and SF-36. In addition, a significant correlation was also found to exist between FEV1 values and all subscales of SGRQ, and between subscales of SF-36. Conclusion: In our study, when we compared the quality-of-life scores of the patients with COPD and bronchiectasis with those with COPD alone, we found that the quality-of-life of both groups was impaired, but there was no significant difference between them.

Increased hospitalizations and economic burden in COPD with bronchiectasis: a nationwide representative study

With the increasing use of computed tomography, bronchiectasis has become a common finding in patients with chronic obstructive pulmonary disease (COPD). However, the clinical aspects and medical utilization of COPD with bronchiectasis (BE) remain unclear. We aimed to investigate the BE effect on prognosis and medical utilization in patients with COPD. Among 263,747 COPD patients, we excluded patients lacking chest X-ray, CT, or pulmonary function test codes and classified 2583 GOLD-C/D patients matched according to age, sex, and medical aid as having COPD-BE (447 [17.3%]) and COPD without BE (2136 [82.7%]). Patients with COPD-BE showed a higher rate of acute exacerbation requiring antibiotics than those without BE. Moreover, multivariable analysis showed that BE co-existence was a crucial factor for moderate-to-severe exacerbation (incidence rate ratio [IRR] 1.071; 95% CI 1.012-1.134; p = 0.019). Patients with COPD-BE had a significantly higher rate of exacerbations requiring antibiotics, as well as treatment cost and duration (meant as number of days using hospitalization plus outpatient appointment), than those with COPD without BE (52.64 ± 65.29 vs. 40.19 ± 50.02 days, p < 0.001; 5984.08 ± 8316.96 vs. 4453.40 ± 7291.03 USD, p < 0.001). Compared with patients with COPD without BE, patients with COPD-BE experienced more exacerbations requiring antibiotics, more hospitalizations, and a higher medical cost.

Qualitative and Quantitative Assessment of Emphysema Using Dark-Field Chest Radiography

Background Dark-field chest radiography allows for assessment of lung alveolar structure by exploiting wave optical properties of x-rays. Purpose To evaluate the qualitative and quantitative features of dark-field chest radiography in participants with pulmonary emphysema as compared with those in healthy control subjects. Materials and Methods In this prospective study conducted from October 2018 to October 2020, participants aged at least 18 years who underwent clinically indicated chest CT were screened for participation. Inclusion criteria were an ability to consent to the procedure and stand upright without help. Exclusion criteria were pregnancy, serious medical conditions, and any lung condition besides emphysema that was visible on CT images. Participants were examined with a clinical dark-field chest radiography prototype that simultaneously acquired both attenuation-based radiographs and dark-field chest radiographs. Dark-field coefficients were tested for correlation with each participant's CT-based emphysema index using the Spearman correlation test. Dark-field coefficients of adjacent groups in the semiquantitative Fleischner Society emphysema grading system were compared using a Wilcoxon Mann-Whitney U test. The capability of the dark-field coefficient to enable detection of emphysema was evaluated with receiver operating characteristics curve analysis. Results A total of 83 participants (mean age, 65 years ± 12 [standard deviation]; 52 men) were studied. When compared with images from healthy participants, dark-field chest radiographs in participants with emphysema had a lower and inhomogeneous dark-field signal intensity. The locations of focal signal intensity loss on dark-field images corresponded well with emphysematous areas found on CT images. The dark-field coefficient was negatively correlated with the quantitative CT-based emphysema index (r = -0.54, P < .001). Participants with Fleischner Society grades of mild, moderate, confluent, or advanced destructive emphysema exhibited a lower dark-field coefficient than those without emphysema (eg, 1.3 m^-1 ± 0.6 for participants with confluent or advanced destructive emphysema vs 2.6 m^-1 ± 0.4 for participants without emphysema; P < .001). The area under the receiver operating characteristic curve for detection of mild emphysema was 0.79. Conclusion Pulmonary emphysema leads to reduced signal intensity on dark-field chest radiographs, showing the technique has potential as a diagnostic tool in the assessment of lung diseases. © RSNA, 2022 See also the editorial by Hatabu and Madore in this issue.

Effects of Non-intubated Video-Assisted Thoracic Surgery on Patients With Pulmonary Dysfunction

Background: Non-intubated video-assisted thoracic surgery (NIVATS) can be safely performed in lung volume reduction surgery for patients with severe pulmonary dysfunction. However, there is still no cohort observation on the effects of NIVATS on patients with pulmonary dysfunction undergoing different types of thoracic procedures. This retrospective study aimed to observe the effects of NIVATS for this kind of patients.

Methods: Three hundred and twenty-eight patients with moderate to severe obstructive pulmonary dysfunction, who underwent video-assisted thoracic surgery (VATS), were retrospectively collected from June 1st, 2017 to September 30th, 2019. Patients in NIVATS were case-matched with those in intubated video-assisted thoracic surgery (IVATS) by a propensity score-matched analysis. The primary outcome was the comparison of perioperative values, the secondary outcome was the risk factors for postoperative clinical complications (PCP) which were identified by binary logistic regression analysis.

Results: After being matched, there were no differences in demographics and preoperative values of pulmonary function between NIVATS and IVATS groups. The duration of surgery and anesthesia had no difference (P = 0.091 and P = 0.467). As for the postoperative recovery, except for the mean intensive care unit (ICU) stay was longer in the IVATS group than in the NIVATS group (P = 0.015), the chest tube removal time and the postoperative hospital stay had no difference (P = 0.394 and P = 0.453), and the incidence of PCP also had no difference (P = 0.121). The binary logistic regression analysis revealed that the history of pulmonary disease, anesthesia method, and surgical location were risk factors of PCP.

Conclusion: For patients with pulmonary dysfunction when undergoing different types of thoracic procedures, the NIVATS can be performed as effectively and safely as the IVATS, and can reduce the ICU stay.

Clinical Impact of the Bronchiectasis with Chronic Bronchitis Symptoms in COPD: Analysis of a Longitudinal Cohort

Purpose

Bronchiectasis (BE) is a poor prognostic factor in COPD. However, it is not clear whether the poor prognosis is a result of BE alone or accompanying chronic bronchitis symptoms. Therefore, we investigated the effect of chronic bronchitis symptoms on clinical outcomes in COPD patients with BE.

Patients and Methods

We analyzed data of COPD patients from the Korean Obstructive Lung Disease (KOLD) cohort. The presence of BE was verified by chest computed tomography. Chronic bronchitis symptoms were determined using items in the symptomatic domain of the SGRQ, which is also used as an alternative definition of chronic bronchitis (CB). Patients were divided into four groups according to the presence of BE and CB symptoms: BE/CB, BE-only, CB-only, and no BE/CB. Demographic features and clinical outcomes were compared among these groups.

Results

In total, 389 COPD patients were included in the analysis. BE was present in 148 (38%) patients and CB symptoms were found in 123 patients (33.2%). The patients were divided according to BE and CB symptoms, and the numbers and percentages of each group were as follows: BE/CB, 52 (13.4%); BE-only, 96 (24.7%); CB-only, 77 (19.8%); no BE/CB, 164 (42.2%). No significant differences were observed in baseline characteristics of lung function, radiological findings, and inflammatory markers among the four groups. The proportion of annual exacerbators was higher in the BE/CB and CB-only groups than the other two groups. After adjusting other parameters, the BE/CB group was significantly associated with acute exacerbation of COPD (AE-COPD) (OR = 2.110, p = 0.045).

Conclusion

BE accompanying CB symptoms is associated with AE-COPD, while BE alone was not significantly associated. This finding suggests that it is more important to examine chronic bronchitis symptoms of BE to predict acute exacerbation than simply to identify BE in COPD patients.

Chronic Obstructive Pulmonary Disease: Epidemiology, Biomarkers, and Paving the Way to Lung Cancer

Chronic obstructive pulmonary disease (COPD), the frequently fatal pathology of the respiratory tract, accounts for half a billion cases globally. COPD manifests via chronic inflammatory response to irritants, frequently to tobacco smoke. The progression of COPD from early onset to advanced disease leads to the loss of the alveolar wall, pulmonary hypertension, and fibrosis of the respiratory epithelium. Here, we focus on the epidemiology, progression, and biomarkers of COPD with a particular connection to lung cancer. Dissecting the cellular and molecular players in the progression of the disease, we aim to shed light on the role of smoking, which is responsible for the disease, or at least for the more severe symptoms and worse patient outcomes. We summarize the inflammatory conditions, as well as the role of EMT and fibroblasts in establishing a cancer-prone microenvironment, i.e., the soil for ‘COPD-derived’ lung cancer. We highlight that the major health problem of COPD can be alleviated via smoking cessation, early diagnosis, and abandonment of the usage of biomass fuels on a global basis.

Favorable Response to Long-Term Azithromycin Therapy in Bronchiectasis Patients with Chronic Airflow Obstruction Compared to Chronic Obstructive Pulmonary Disease Patients without Bronchiectasis

PURPOSE

Long-term macrolide treatment is recommended for patients with chronic obstructive pulmonary disease (COPD) with frequent exacerbations. Bronchiectasis is a common comorbid condition in patients with COPD, for which long-term azithromycin is effective in preventing exacerbation. This study aimed to compare the effect of long-term azithromycin between bronchiectasis patients with chronic airflow obstruction (CAO) and COPD patients without bronchiectasis.

PATIENTS AND METHODS

Patients with CAO who received azithromycin for more than 12 weeks were retrospectively identified at a single referral hospital. CAO was defined as a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.7, and bronchiectasis was determined using computed tomography. The development of exacerbation and symptom improvement were compared between bronchiectasis patients with CAO and COPD patients without bronchiectasis.

RESULTS

A total of 59 patients (43 in bronchiectasis with CAO group vs 16 in COPD without bronchiectasis group) were included in this study. Compared to COPD patients without bronchiectasis, those in bronchiectasis with CAO group were younger, more likely to be female, and never smokers. There was no difference in the previous exacerbation history or FEV1 between the two groups. The median duration of azithromycin treatment was 15 months (interquartile range, 8-25 months). At the 12-month follow-up, the development of ≥2 moderate or ≥1 severe exacerbations was significantly lower in bronchiectasis with CAO group than in COPD without bronchiectasis group (46.5% vs 87.5%, P = 0.005). The proportion of patients with symptom improvement determined by the COPD assessment test score was also significantly higher in bronchiectasis with CAO group than COPD without bronchiectasis group at the 12-month follow-up (68.2% vs 16.7%, P = 0.004).

CONCLUSION

Bronchiectasis patients with CAO could benefit more from long-term azithromycin treatment than COPD patients without bronchiectasis.

Evolution and Comparative Analysis of Hospitalizations in Spain Due to COPD and Bronchiectasis between 2004 and 2015

Chronic obstructive pulmonary disease (COPD) is the leading cause of hospitalization for chronic respiratory illness in Spain. In recent years hospital admissions due to bronchiectasis have been increasing, although it is not known whether this is in proportion to COPD hospitalizations. Our main objective was to analyze the temporal evolution of discharges due to COPD, bronchiectasis, and their combination, and secondly, to assess their impact on in-hospital mortality and healthcare costs. We performed a retrospective study, based on the analysis of the Minimum Basic Data Set (MBDS) of hospital discharges using data from Spanish Ministry of Health with diagnostic codes of COPD or bronchiectasis between 2004 and 2015. We found 3 356 186 discharges with a diagnosis of COPD or bronchiectasis. After exclusions, 1 386 430 episodes were analyzed: 85.2% with COPD, 8.4% bronchiectasis, and 6.4% with both pathologies. Mean age of patients was 74.8 (10.9) years and with a male predominance of 80.1%. The increase in the annual number of discharges was greater in the two groups with bronchiectasis: 48.8% in the bronchiectasis group and 55.4% in the mixed group, compared to 6.6% in the COPD group. The mean length of stay was greater in both groups with bronchiectasis (p < 0.001), while in-hospital mortality was higher in the COPD group (p < 0.001). Similarly, the annual increase of costs was more evident in the two groups with bronchiectasis. Conclusions: Hospitalizations and health costs for bronchiectasis have increased in recent years significantly more than for COPD.Supplemental data for this aricle can be accessed here.

'It's not one size fits all': a qualitative study of patients' and healthcare professionals' views of self-management for bronchiectasis

BACKGROUND

Bronchiectasis is a chronic respiratory condition that impacts significantly on individuals and healthcare services. Self-management is recommended in clinical guidelines for bronchiectasis as an intervention to enable patients to manage their condition, yet there is little evidence to support it.

METHODS

Three face to face focus groups (17 adults with bronchiectasis) were conducted at three National Health Service (NHS) sites in North West England. Additionally, semi-structured telephone interviews were undertaken with 11 healthcare professionals (HCPs), including doctors, nurses and physiotherapists. Thematic analysis identified common themes and occurrences verified by independent audit.

FINDINGS

Four common overarching themes were identified: the meaning of self-management; benefits; barriers and influencers to self-management; subthemes varied. Both groups recognised component interventions. Patients highlighted that self-management enabled them to learn what works and moderate behaviour. Aspects of delivery and structure were important to HCPs but a 'make do' culture was evident. Benefits for both groups included empowering patients. Common barriers for patients were time, mood and lack of access to support which could mitigate engagement with self-management. HCPs identified barriers including patient characteristics and lack of resources. Influencers for patients were peer, carer and psychosocial support, for HCPs influencers were individual patient attributes, including ability and motivation, and HCP characteristics such as knowledge and understanding about bronchiectasis.

SUMMARY

This is the first study to explore patients' and HCPs' views of self-management for bronchiectasis. The need for an individual, flexible and responsive self-management programme specific to bronchiectasis was evident. Personal characteristics of patients and HCPs could affect the uptake and engagement with self-management and HCPs knowledge of the disease is a recognised precursor to effective self-management. The study identified key aspects for consideration during development, delivery and sustainability of self-management programmes and findings suggest that patients' psychosocial and socioeconomic circumstances may affect adoption and activation of self-management behaviours.

Risk factors for bronchiectasis in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

The risk factors of bronchiectasis in patients with chronic obstructive pulmonary disease have not yet been established. This systematic review and meta-analysis aimed to investigate and identify potential risk factors for patients with chronic obstructive pulmonary disease accompanied by bronchiectasis. We reviewed eight electronic journal databases from their inception to November 2019 for observational studies with no language restrictions. The Newcastle-Ottawa Scale was applied to evaluate the quality of the literature. Binary variables were pooled using odds ratios and continuous variables using the standardized mean difference with 95% confidence intervals. The confidence of evidence was assessed according to the grading of the recommendations assessment, development, and evaluation method. Eight case-control studies met the inclusion criteria. Tuberculosis history, smoking history, hospitalization stays, admissions in the past year, and duration of symptoms were considered risk factors. In addition, the ratio between the forced expiratory volume in 1s and forced vital capacity, the percentage of forced expiratory volume in 1s, the forced expiratory volume in 1s as a percentage of the predicted value, purulent sputum, purulent mucus sputum, positive sputum culture, Pseudomonas aeruginosa infection, arterial oxygen pressure, daily dyspnea, C-reactive protein, leukocytes, and the percentage of neutrophils were found to be closely related to bronchiectasis. However, these were not considered risk factors. The evidence of all outcomes was judged as "low" or "very low." Additional prospective studies are required to elucidate the underlying risk factors and identify effective preventive interventions.

Relationship between clinical and radiological signs of bronchiectasis in COPD patients: Results from COSYCONET

Bronchiectasis (BE) might be frequently present in COPD but masked by COPD symptoms. We studied the relationship of clinical signs of bronchiectasis to the presence and extent of its radiological signs in patients of different COPD severity. Visit 4 data (GOLD grades 1-4) of the COSYCONET cohort was used. Chest CT scans were evaluated for bronchiectasis in 6 lobes using a 3-point scale (0: absence, 1: ≤50%, 2: >50% BE-involvement for each lobe). 1176 patients were included (61%male, age 67.3y), among them 38 (3.2%) with reported physicians' diagnosis of bronchiectasis and 76 (6.5%) with alpha1-antitrypsin deficiency (AA1D). CT scans were obtained in 429 patients. Within this group, any signs of bronchiectasis were found in 46.6% of patients, whereby ≤50% BE occurred in 18.6% in ≤2 lobes, in 10.0% in 3-4 lobes, in 15.9% in 5-6 lobes; >50% bronchiectasis in at least 1 lobe was observed in 2.1%. Scores ≥4 correlated with an elevated ratio FRC/RV. The clinical diagnosis of bronchiectasis correlated with phlegm and cough and with radiological scores of at least 3, optimally ≥5. In COPD patients, clinical diagnosis and radiological signs of BE showed only weak correlations. Correlations became significant with increasing BE-severity implying radiological alterations in several lobes. This indicates the importance of reporting both presence and extent of bronchiectasis on CT. Further research is warranted to refine the criteria for CT scoring of bronchiectasis and to determine the relevance of radiologically but not clinically detectible bronchiectasis and their possible implications for therapy in COPD patients.

Bronchiectasis Information and Education: a randomised, controlled feasibility trial

Background

There has been comparatively little patient information about bronchiectasis, a chronic lung disease with rising prevalence. Patients want more information, which could improve their understanding and self-management. A novel information resource meeting identified needs has been co-developed in prior work. We sought to establish the feasibility of conducting a multi-centre randomised controlled trial to determine effect of the information resource on understanding, self-management and health outcomes.

Methods/design

We conducted an unblinded, single-centre, randomised controlled feasibility trial with two parallel groups (1:1 ratio), comparing a novel patient information resource with usual care in adults with bronchiectasis. Integrated qualitative methods allowed further evaluation of the intervention and trial process. The setting was two teaching hospitals in North East England. Participants randomised to the intervention group received the information resource (website and booklet) and instructions on its use. Feasibility outcome measures included willingness to enter the trial, in addition to recruitment and retention rates. Secondary outcome measures (resource use and satisfaction, quality of life, unscheduled healthcare presentations, exacerbation frequency, bronchiectasis knowledge and lung function) were recorded at baseline, 2 weeks and 12 weeks.

Results

Sixty-two participants were randomised (control group = 30; intervention group = 32). Thirty-eight (61%) were female, and the participants’ median age was 65 years (range 15–81). Median forced expiratory volume in 1 s percent predicted was 68% (range 10–120). Sixty-two of 124 (50%; 95% CI, 41–59%) of potentially eligible participants approached were recruited. Sixty (97%) of 62 participants completed the study (control group, 29 of 30 [97%]; 95% CI, 83–99%; 1 unrelated death; intervention group, 31 [97%] of 32; 95% CI, 84–99%; 1 withdrawal). In the intervention group, 27 (84%) of 32 reported using the information provided, and 25 (93%) of 27 of users found it useful, particularly the video content. Qualitative data analysis revealed acceptability of the trial and intervention. Web analytics recorded over 20,000 page views during the 16-month study period.

Conclusion

The successful recruitment process, high retention rate and study form completion rates indicate that it appears feasible to conduct a full trial based on this study design. Worldwide demand for online access to the information resource was high.

Trial registration

ISRCTN Registry, ISRCTN84229105. Registered on 25 July 2014.

Correlation of quantitative and qualitative parameters of high-resolution computed tomography with pulmonary function test for diagnosing and assessing the severity of obstructive pulmonary disease

PURPOSE

The aim of the study was to evaluate the role of high-resolution computed tomography (HRCT) in the prediction of presence and severity of chronic obstructive pulmonary disease (COPD), based on the pulmonary function test (PFT), to correlate the various quantitative and qualitative indices of COPD in HRCT with PFT values, and to derive at the threshold values for various quantitative HRCT indices of COPD.

MATERIAL AND METHODS

A one-year retrospective and prospective evaluation of the HRCTs of 90 cases and 38 controls was performed. Quantitative and qualitative parameters of COPD were assessed in HRCT and were correlated with PFT.

RESULTS

Among the qualitative parameters, significant correlation with spirometry was found with the qualitative scoring for emphysema and presence and inhomogeneous attenuation. Among the quantitative indices, anterior junction line length, thoracic cage ratio at both aortic arch and inferior pulmonary vein level, thoracic cross-sectional area/[height]² at the aortic arch were found to have good correlation with spirometry. There was significant strong correlation of anterior junction line length and tracheal index with residual volume/total lung capacity (RV/TLC). The threshold values of chest X-ray and HRCT quantitative parameters were calculated and were found to be lower than those of the western population.

CONCLUSION

HRCT has a definite role in the diagnosis of COPD and can be used to predict the severity of emphysema.

Time To Revise COPD Treatment Algorithm

In 2017, a new two-step algorithm for the treatment of COPD was proposed. This algorithm was based on the severity of symptoms and phenotypes or treatable traits, and patient-specialised assessment targeting eosinophilic inflammation, chronic bronchitis, and frequent infections is recommended after exacerbation occurs despite maximal bronchodilation therapy. However, recent studies have revealed the clinical characteristics of patients who should have second controllers added, such as ICS. We again realized that treatable traits should be assessed and intervened for as early as possible. Moreover, the treatment algorithm is necessary to be adapted to the situation of clinical practice, taking into account the characteristics of the patients. The time to revise COPD treatment algorithm has come and we propose a new 3-step parallel approach for initial COPD treatment. After the diagnosis of COPD, the first assessment is to divide into two categories based on the usual clinical characteristics for patients with COPD and the specific clinical characteristics for each patient with concomitant disease. In the former, the assessment should be based on the level of dyspnea and the frequency of exacerbations. After the assessment, mono- or dual bronchodilator should be selected. In the latter, the assessment should be based on asthma characteristics, chronic bronchitis, and chronic heart failure. After the assessment, patients with asthmatic characteristics may consider treatment with ICS, while patients with chronic bronchitis may consider treatment with roflumilast and/or macrolide, while patients with chronic heart failure may consider treatment with selective β1-blocker. The 3-step parallel approach is completed by adding an additional therapy for patients with concomitant disease to essential therapy for patients with COPD. In addition, it is important to review the response around 4 weeks after the initial therapy. This COPD management proposal might be considered as an approach based on patients’ clinical characteristics and on personalized therapy.

Assessing pulmonary hypertension in COPD. Is there a role for computed tomography?

Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD) and is associated with increased morbidity and mortality. Reference standard method to diagnose PH is right heart catheterization. Several non-invasive imaging techniques have been employed in the detection of PH. Among them, computed tomography (CT) is the most commonly used for phenotyping and detecting complications of COPD. Several CT findings have also been described in patients with severe PH. Nevertheless, CT analysis is currently based on visual findings which can lead to reproducibility failure. Therefore, there is a need for quantification in order to assess objective criteria. In this review, progresses in automated analyses of CT parameters and their values in predicting PH and COPD outcomes are presented.

Phthalates Exposure and Occupational Symptoms among Slovakian Hairdressing Apprentices

The objectives of the study were to examine occupational exposure to phthalates of hairdressing apprentices from Slovakia (n = 74, 89.2% females; 10.8% males), outcomes related to body composition and pulmonary functions. We used high-performance liquid chromatography and tandem mass spectrometry to the quantified urinary concentration of phthalates. Pulmonary function test (PFT), anthropometric measurements, and questionnaire were also conducted. We observed a decrease of % of predicted values of forced vital capacity (FVC% of PV) related exposure to mono(2-ethyl-5-oxohexyl) phthalate (MEOHP; p = 0.054) and sum of bis(2-ethylhexyl) phthalate metabolites (∑DEHP; p = 0.037), and a decrease of % of predicted values of vital capacity (VC% of PV) related to exposure to MEOHP, ∑DEHP (p = 0.008), and mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP; p = 0.014) in females. We detected associations between forced vital capacity (FVC) with weight (p = 0.002) and fat-free mass index (FFMI, p = 0.010). Vital capacity (VC) and VC% of PV increased with weight, body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-hip ratio (WHR), the waist-height ratio (WHtR), fat mass index (FMI) and FFMI in females (p ≤ 0.014). Results of multivariate regression between PFT and anthropometric parameters adjusted to phthalates indicated exposure to MnBP and MEHP, changing body structure (BMI and FMI), subsequently affecting values of FEV1/FVC.

Brazilian consensus on non-cystic fibrosis bronchiectasis

Bronchiectasis is a condition that has been increasingly diagnosed by chest HRCT. In the literature, bronchiectasis is divided into bronchiectasis secondary to cystic fibrosis and bronchiectasis not associated with cystic fibrosis, which is termed non-cystic fibrosis bronchiectasis. Many causes can lead to the development of bronchiectasis, and patients usually have chronic airway symptoms, recurrent infections, and CT abnormalities consistent with the condition. The first international guideline on the diagnosis and treatment of non-cystic fibrosis bronchiectasis was published in 2010. In Brazil, this is the first review document aimed at systematizing the knowledge that has been accumulated on the subject to date. Because there is insufficient evidence on which to base recommendations for various treatment topics, here the decision was made to prepare an expert consensus document. The Brazilian Thoracic Association Committee on Respiratory Infections summoned 10 pulmonologists with expertise in bronchiectasis in Brazil to conduct a critical assessment of the available scientific evidence and international guidelines, as well as to identify aspects that are relevant to the understanding of the heterogeneity of bronchiectasis and to its diagnostic and therapeutic management. Five broad topics were established (pathophysiology, diagnosis, monitoring of stable patients, treatment of stable patients, and management of exacerbations). After this subdivision, the topics were distributed among the authors, who conducted a nonsystematic review of the literature, giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. The authors reviewed and commented on all topics, producing a single final document that was approved by consensus.

Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019

The British Thoracic Society (BTS) Guidelines for Bronchiectasis in adults were published in January 2019, and comprise recommendations for treatment from primary to tertiary care. Here, we outline the practical implications of these guidelines for primary care practitioners. A diagnosis of bronchiectasis should be considered when a patient presents with a recurrent or persistent (>8 weeks) productive cough. A definitive diagnosis is made by using thin-section chest computed tomography (CT). Once diagnosed, patients should be initially assessed by a specialist respiratory team and a shared management plan formulated with the patient, the specialist and primary care teams. The cornerstone of primary care management is physiotherapy to improve airway sputum clearance and maximise exercise capacity, with prompt treatment of acute exacerbations with antibiotics.

Postoperative pulmonary function changes according to the resected lobe: a 1-year follow-up study of lobectomized patients

Background

Pulmonary function and patient complaints appear to improve up to 12 months after lobectomy but long-term prospective studies based on clinical data are scarce. Improvement in pulmonary function may depend on the area and extent of the resection and the time from the operation. This prospective study aimed to determine pulmonary function changes according to the resected lobe.

Methods

This prospective study included 59 patients requiring single lobectomy. Total volume and low-attenuation volume (LAV) for each lobe and the entire lungs were calculated based on helical computed tomography images. Vital capacity (VC), forced expiratory volume in one second (FEV₁), percent FEV₁ (%FEV₁), percent lung diffusion capacity for carbon monoxide (%DL_co), %DL_co divided by the alveolar volume (%DL_co/V_A), modified Medical Research Council (mMRC) grades, and COPD Assessment Test (CAT) scores were compared at 3, 6, and 12 months after surgery.

Results

VC was higher at 12 months than at 3 months after right upper lobectomy (RUL) or right lower lobectomy (RLL). FEV₁ and %FEV₁ were higher at 12 months than at 6 months after left lower lobectomy (LLL). %DL_co was higher at 12 months than at 3 months after RUL or left upper lobectomy (LUL). DL_co/V_A, mMRC grades, and CAT scores did not change significantly in the period from 3 to 12 months after any lobectomy procedure. Compared to the predicted postoperative values, the observed values of VC for RUL, RLL, and LUL; FEV₁ for RLL; %FEV₁ for RLL and LUL; %DL_co for LUL; and %DL_co/V_A for all lobectomy procedures were higher at 12 months.

Conclusions

Improvements in pulmonary function and symptoms varied according to the resected lobe. Some of the observed pulmonary function values were higher than the predicted postoperative values. Pulmonary function changes may be related to the location, volume, and extent of emphysematous changes.

Revised (2018) COPD Clinical Practice Guideline of the Korean Academy of Tuberculosis and Respiratory Disease: A Summary

Chronic obstructive pulmonary disease (COPD) results in high morbidity and mortality among patients nationally and globally. The Korean clinical practice guideline for COPD was revised in 2018. The guideline was drafted by the members of the Korean Academy of Tuberculosis and Respiratory Diseases as well as the participating members of the Health Insurance Review and Assessment Service, Korean Physicians' Association, and Korea Respiration Trouble Association. The revised guideline encompasses a wide range of topics, including the epidemiology, diagnosis, assessment, monitoring, management, exacerbation, and comorbidities of COPD in Korea. We performed systematic reviews assisted by an expert in meta-analysis to draft a guideline on COPD management. We expect this guideline to facilitate the treatment of patients with respiratory conditions by physicians as well other health care professionals and government personnel in South Korea.

The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions

Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.

Risk of Bacterial Transmission in Bronchiectasis Outpatient Clinics

Purpose of Review

The purpose of this review is to discuss the risk of bacterial cross-infection for bronchiectasis patients in the outpatient setting. Cross-infection has primarily been a matter of concern in cystic fibrosis (CF). There is considerable evidence of transmission of pathogens between CF patients, and this has led to guideline recommendations advocating strict segregation policies. Guidelines in bronchiectasis do not specifically address the issue of cross-infection. If cross-infection is prevalent, it may have significant implications for patients and the practical running of specialist care.

Recent Findings

Multiple UK-based studies have now published evidence of cross-infection with Pseudomonas aeruginosa within cohorts of bronchiectasis patients; however, the risk does not appear to be high. There is also evidence suggesting cross-infection from CF patients to bronchiectasis patients.

Summary

The current evidence for cross-infection in bronchiectasis is limited, but suggests a small risk with Pseudomonas aeruginosa. Longitudinal studies looking at Pseudomonas aeruginosa and other pathogens are now required.

Patient information, education and self-management in bronchiectasis: facilitating improvements to optimise health outcomes

BACKGROUND

Bronchiectasis is an incurable lung disease characterised by irreversible airway dilatation. It causes symptoms including chronic productive cough, dyspnoea, and recurrent respiratory infections often requiring hospital admission. Fatigue and reductions in quality of life are also reported in bronchiectasis. Patients often require multi-modal treatments that can be burdensome, leading to issues with adherence. In this article we review the provision of, and requirement for, education and information in bronchiectasis.

DISCUSSION

To date, little research has been undertaken to improve self-management in bronchiectasis in comparison to other chronic conditions, such as COPD, for which there has been a wealth of recent developments. Qualitative work has begun to establish that information deficit is one of the potential barriers to self-management, and that patients feel having credible information is fundamental when learning to live with and manage bronchiectasis. Emerging research offers some insights into ways of improving treatment adherence and approaches to self-management education; highlighting ways of addressing the specific unmet information needs of patients and their families who are living with bronchiectasis.

CONCLUSIONS

We propose non-pharmacological recommendations to optimise patient self-management and symptom recognition; with the aim of facilitating measurable improvements in health outcomes for patients with bronchiectasis.

Quantitative computed tomography features and clinical manifestations associated with the extent of bronchiectasis in patients with moderate-to-severe COPD

Background

Few studies have investigated the quantitative computed tomography (CT) features associated with the severity of bronchiectasis in COPD patients. The purpose of this study was to identify the quantitative CT features and clinical values to determine the extent of bronchiectasis in moderate-to-severe COPD patients.

Methods

A total of 127 moderate-to-severe COPD patients were selected from the cohort of COPD in Dusty Areas (CODA). The study subjects were classified into three groups according to the extent of bronchiectasis on CT: no bronchiectasis, mild bronchiectasis, and moderate-to-severe bronchiectasis. The three groups were compared with respect to demographic data, symptoms, medical history, serum inflammatory markers, pulmonary function, and quantitative CT values.

Results

Among 127 moderate-to-severe COPD subjects, 73 patients (57.5%) were detected to have bronchiectasis, 51 patients (40.2%) to have mild bronchiectasis, and 22 patients (17.3%) to have moderate-to-severe bronchiectasis. Compared with COPD patients without bronchiectasis, those with bronchiectasis were older and had higher frequency of prior tuberculosis, lower prevalence of bronchodilator reversibility (BDR), and more severe air trapping (P < 0.05). Moderate-to-severe bronchiectasis patients had lower body mass index (BMI), higher frequency of prior tuberculosis, lower prevalence of BDR, worse pulmonary function, and more severe air trapping (P < 0.05) than those in the mild bronchiectasis group.

Conclusion

Moderate-to-severe bronchiectasis was associated with a history of pulmonary tuberculosis, lower BMI, severe airflow obstruction, and lower BDR in moderate-to-severe COPD patients. Quantitative analysis of CT showed that severe air trapping was associated with the extent of bronchiectasis in these patients.

The Role of the Immune Response in the Pathogenesis of Bronchiectasis

Bronchiectasis is a prevalent respiratory condition characterised by permanent and abnormal dilation of the lung airways (bronchi). There are a large variety of causative factors that have been identified for bronchiectasis; all of these compromise the function of the immune response to fight infection. A triggering factor may lead to the establishment of chronic infection in the lower respiratory tract. The bacteria responsible for the lower respiratory tract infection are usually found as commensals in the upper respiratory tract microbiome. The consequent inflammatory response to infection is largely responsible for the pathology of this condition. Both innate and adaptive immune responses are activated. The literature has highlighted the central role of neutrophils in the pathogenesis of bronchiectasis. Proteases produced in the lung by the inflammatory response damage the airways and lead to the pathological dilation that is the pathognomonic feature of bronchiectasis. The small airways demonstrate infiltration with lymphoid follicles that may contribute to localised small airway obstruction. Despite aggressive treatment, most patients will have persistent disease. Manipulating the immune response in bronchiectasis may potentially have therapeutic potential.

Co-existence of COPD and bronchiectasis: a risk factor for a high ratio of main pulmonary artery to aorta diameter (PA:A) from computed tomography in COPD patients

Background

Pulmonary vascular disease, especially pulmonary hypertension, is an important complication of COPD. Bronchiectasis is considered not only a comorbidity of COPD, but also a risk factor for vascular diseases. The main pulmonary artery to aorta diameter ratio (PA:A ratio) has been found to be a reliable indicator of pulmonary vascular disease. It is hypothesized that the co-existence of COPD and bronchiectasis may be associated with relative pulmonary artery enlargement (PA:A ratio >1).

Methods

This retrospective study enrolled COPD patients from 2012 through 2016. Demographic and clinical data were collected. Bhalla score was used to determine the severity of bronchiectasis. Patient characteristics were analyzed in two ways: the high (PA:A >1) and low (PA:A ≤1) ratio groups; and COPD with and without bronchiectasis groups. Logistic regression analysis was used to assess risk factors for high PA:A ratios.

Results

In this study, 480 COPD patients were included, of whom 168 had radiographic bronchiectasis. Patients with pulmonary artery enlargement presented with poorer nutrition (albumin, 35.6±5.1 vs 38.3±4.9, P<0.001), lower oxygen partial pressure (74.4±34.5 vs 81.3±25.4, P<0.001), more severe airflow obstruction (FEV1.0, 0.9±0.5 vs 1.1±0.6, P=0.004), and a higher frequency of bronchiectasis (60% vs 28.8%, P<0.001) than patients in the low ratio group. Patients with both COPD and bronchiectasis had higher levels of systemic inflammation (erythrocyte sedimentation rate, P<0.001 and fibrinogen, P=0.006) and PA:A ratios (P<0.001). A higher PA:A ratio was significantly closely correlated with a higher Bhalla score (r=0.412, P<0.001). Patients with both COPD and bronchiectasis with high ratios presented higher levels of NT-proBNP (P<0.001) and systolic pulmonary artery pressure (P<0.001). Multiple logistic analyses have indicated that bronchiectasis is an independent risk factor for high PA:A ratios in COPD patients (OR =3.707; 95% CI =1.888-7.278; P<0.001).

Conclusion

Bronchiectasis in COPD has been demonstrated to be independently associated with relative pulmonary artery enlargement.

Self-management for bronchiectasis

BACKGROUND

Bronchiectasis is a long term respiratory condition with an increasing rate of diagnosis. It is associated with persistent symptoms, repeated infective exacerbations, and reduced quality of life, imposing a burden on individuals and healthcare systems. The main aims of therapeutic management are to reduce exacerbations and improve quality of life. Self-management interventions are potentially important for empowering people with bronchiectasis to manage their condition more effectively and to seek care in a timely manner. Self-management interventions are beneficial in the management of other airways diseases such as asthma and COPD (chronic obstructive pulmonary disease) and have been identified as a research priority for bronchiectasis.

OBJECTIVES

To assess the efficacy, cost-effectiveness and adverse effects of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Specialised Register of trials, clinical trials registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 13 December 2017.

SELECTION CRITERIA

We included all randomised controlled trials of any duration that included adults or children with a diagnosis of non-cystic fibrosis bronchiectasis assessing self-management interventions delivered in any form. Self-management interventions included at least two of the following elements: patient education, airway clearance techniques, adherence to medication, exercise (including pulmonary rehabilitation) and action plans.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened searches, extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were, health-related quality of life, exacerbation frequency and serious adverse events. Secondary outcomes were the number of participants admitted to hospital on at least one occasion, lung function, symptoms, self-efficacy and economic costs. We used a random effects model for analyses and standard Cochrane methods throughout.

MAIN RESULTS

Two studies with a total of 84 participants were included: a 12-month RCT of early rehabilitation in adults of mean age 72 years conducted in two centres in England (UK) and a six-month proof-of-concept RCT of an expert patient programme (EPP) in adults of mean age 60 years in a single regional respiratory centre in Northern Ireland (UK). The EPP was delivered in group format once a week for eight weeks using standardised EPP materials plus disease-specific education including airway clearance techniques, dealing with symptoms, exacerbations, health promotion and available support. We did not find any studies that included children. Data aggregation was not possible and findings are reported narratively in the review.For the primary outcomes, both studies reported health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), but there was no clear evidence of benefit. In one study, the mean SGRQ total scores were not significantly different at 6 weeks', 3 months' and 12 months' follow-up (12 months mean difference (MD) -10.27, 95% confidence interval (CI) -45.15 to 24.61). In the second study there were no significant differences in SGRQ. Total scores were not significantly different between groups (six months, MD 3.20, 95% CI -6.64 to 13.04). We judged the evidence for this outcome as low or very low. Neither of the included studies reported data on exacerbations requiring antibiotics. For serious adverse events, one study reported more deaths in the intervention group compared to the control group, (intervention: 4 of 8, control: 2 of 12), though interpretation is limited by the low event rate and the small number of participants in each group.For our secondary outcomes, there was no evidence of benefit in terms of frequency of hospital admissions or FEV1 L, based on very low-quality evidence. One study reported self-efficacy using the Chronic Disease Self-Efficacy scale, which comprises 10 components. All scales showed significant benefit from the intervention but effects were only sustained to study endpoint on the Managing Depression scale. Further details are reported in the main review. Based on overall study quality, we judged this evidence as low quality. Neither study reported data on respiratory symptoms, economic costs or adverse events.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether self-management interventions benefit people with bronchiectasis. In the absence of high-quality evidence it is advisable that practitioners adhere to current international guidelines that advocate self-management for people with bronchiectasis.Future studies should aim to clearly define and justify the specific nature of self-management, measure clinically important outcomes and include children as well as adults.

Alpha-1 Antitrypsin Deficiency: Phenotypes and Quality of Life

Alpha-1 antitrypsin deficiency (AATD) is a recognized genetic cause of rapidly progressive loss of lung function conventionally assessed by the decline in FEV1. However, there is less information concerning other physiological measures and the impact on quality of life. Data derived predominantly from the UK national registry show that AATD presents with various physiological phenotypes with differing clinical impact and progression. In general, the decline in quality of life is surprisingly slow despite rapid loss of lung function, which may reflect the benefits of centralized services for patients with AATD. Use of the new GOLD classification identifies patient characteristics that relate to mortality and disparate symptomatology despite similar spirometric impairment.

Longitudinal modeling to predict vital capacity in amyotrophic lateral sclerosis

OBJECTIVES

Death in amyotrophic lateral sclerosis (ALS) patients is related to respiratory failure, which is assessed in clinical settings by measuring vital capacity. We developed ALS-VC, a modeling tool for longitudinal prediction of vital capacity in ALS patients.

METHODS

A gradient boosting machine (GBM) model was trained using the PRO-ACT (Pooled Resource Open-access ALS Clinical Trials) database of over 10,000 ALS patient records. We hypothesized that a reliable vital capacity predictive model could be developed using PRO-ACT.

RESULTS

The model was used to compare FVC predictions with a 30-day run-in period to predictions made from just baseline. The internal root mean square deviations (RMSD) of the run-in and baseline models were 0.534 and 0.539, respectively, across the 7L FVC range captured in PRO-ACT. The RMSDs of the run-in and baseline models using an unrelated, contemporary external validation dataset (0.553 and 0.538, respectively) were comparable to the internal validation. The model was shown to have similar accuracy for predicting SVC (RMSD = 0.562). The most important features for both run-in and baseline models were "Baseline forced vital capacity" and "Days since baseline."

CONCLUSIONS

We developed ALS-VC, a GBM model trained with the PRO-ACT ALS dataset that provides vital capacity predictions generalizable to external datasets. The ALS-VC model could be helpful in advising and counseling patients, and, in clinical trials, it could be used to generate virtual control arms against which observed outcomes could be compared, or used to stratify patients into slowly, average, and rapidly progressing subgroups.