Evolution of the COPD Assessment Test score during chronic obstructive pulmonary disease exacerbations: determinants and prognostic value

Physical status, symptoms and health-related quality of life during a severe exacerbation of COPD: Recovery and discriminative capacity for future events

OBJECTIVE

Severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can have a negative impact on functional capacity, symptoms and health-related quality of life (HRQOL). This study aimed to i) investigate the recovery of muscle strength, functional capacity, symptoms, and HRQOL in patients after a severe AECOPD; ii) compare with matched patients with stable COPD (SCOPD); and iii) assess whether these assessments at hospital discharge could discriminate patients' risk for future events.

METHODS

This observational study assessed patients with AECOPD during hospital discharge (T1) and one month after discharge (T2). Patients with SCOPD were assessed once. Quadriceps force, handgrip strength, short physical performance battery (SPPB), 6-min walk distance (6 MWD), COPD assessment test (CAT), London chest activity of daily living (LCADL), modified medical research council, checklist individual strength-fatigue, patient health questionnaire, and physical activity (Actigraph) were measured. Exacerbation-related readmission and mortality within six months and 1-year were collected.

RESULTS

Forty-four patients with AECOPD were matched with 44 patients with SCOPD. At T2, a significant improvement was found for the SPPB total score, 6 MWD, CAT score, and LCADL score. Compared to patients with SCOPD, a worse LCADL score was found at T2 in patients with AECOPD. Patients with AECOPD that were readmitted or died had a worse SPPB classification and five-repetition sit-to-stand test at T1.

CONCLUSION

Patients after severe AECOPD improved in functional capacity and HRQOL one month after hospital discharge, but ADL performance was still worse compared to SCOPD. Patients who were readmitted or died had significantly worse scores on functional tests at hospital discharge.

ICS/Ultra LABA in the Treatment of Obstructive Airway Diseases: A Consensus of Indian Experts

Inhaled corticosteroid and ultra-long-acting beta-agonist (ICS/uLABA) combination is a recent advancement in the armamentarium against obstructive airways diseases (OADs). The combination of ICS/uLABA has several advantages, creating a favorable landscape for its utilization. Fluticasone furoate/vilanterol trifenatate (FF/Vi) is one such example of an ICS/uLABA. It offers several benefits from both drugs, such as a convenient once daily dosing schedule; high lipophilicity; high receptor affinity of fluticasone furoate along with high functional selectivity and a quick onset of action of vilanterol. However, the Global Initiative for Asthma (GINA) as well as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines do not clearly define the positioning of ICS/uLABA compared to conventional ICS/LABAs. There are a few areas of uncertainty especially around the appropriate reliever strategy with ICS/uLABA in Asthma. The current consensus was planned with a group of Indian pulmonology experts to provide more clarity on the potential use of FF/Vi in Asthma and COPD. The clinical statements highlighted in this consensus manuscript address crucial clinical questions revolving around the efficacy and safety of FF/Vi as compared to conventional ICS/LABAs and identify the ideal patient profile for its use. This consensus paper also sheds light upon the appropriate reliever to be used along with FF/Vi in Asthma and the utilization of FF/Vi-based triple therapy in OADs. Expert recommendations mentioned in this paper will serve as guidance to pulmonologists as well as consultant physicians who are involved in providing care to OAD patients and will help them weigh the various factors that need to be taken into account while prescribing ICS/uLABA combination.

Higher COPD Assessment Test Score Associated With Greater Exacerbations Risk: A Post Hoc Analysis of the IMPACT Trial

BACKGROUND

In the InforMing the PAthway of COPD Treatment (IMPACT) trial, single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) reduced moderate/severe exacerbation rates versus FF/VI and UMEC/VI in patients with chronic obstructive pulmonary disease (COPD). This post hoc analysis tested the relationship between baseline health status, risk of future exacerbations, and efficacy outcomes.

METHODS

IMPACT was a Phase 3, double-blind, 52-week trial in patients with symptomatic COPD (COPD Assessment Test [CAT] score ≥10) and ≥1 moderate/severe exacerbation in the prior year randomized 2:2:1 to FF/UMEC/VI 100/62.5/25mcg, FF/VI 100/25mcg, or UMEC/VI 62.5/25mcg. Annual rate of on-treatment moderate/severe exacerbations, lung function, and safety were analyzed by continuous baseline CAT score.

RESULTS

Moderate/severe exacerbation rates increased with increasing baseline CAT scores in FF/UMEC/VI and UMEC/VI arms. There was a very small increase in on-treatment pneumonia rates at higher baseline CAT scores across all treatment arms. FF/UMEC/VI reduced moderate/severe exacerbation rates versus UMEC/VI (i.e., the inhaled corticosteroid effect) consistently across the range of CAT scores. The reduction with FF/UMEC/VI versus FF/VI (i.e., the long-acting muscarinic antagonist effect) was greatest at lower CAT scores and appeared lesser at higher CAT scores. Improvements in lung function were observed with FF/UMEC/VI versus FF/VI and UMEC/VI, regardless of baseline CAT score.

CONCLUSIONS

The CAT score was predictive of exacerbation risk. Worse baseline health status was associated with higher moderate/severe exacerbation and pneumonia rates. Irrespective of baseline CAT score, FF/UMEC/VI improved lung function, and reduced the annual moderate/severe exacerbation rates versus dual therapy. Results indicate an overall favorable benefit-risk profile of triple versus dual therapy, irrespective of CAT score. Clinical Trial Registration:GSK (CTT116855/NCT02164513).

A Systematic Literature Review of the Humanistic Burden of COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide, causing substantial economic and social burden.

OBJECTIVE

This review assessed the patient-reported humanistic burden associated with moderate to very severe COPD, specifically the impact on health-related quality of life (HRQoL), symptoms, limitations in daily life, and emotional implications, through the use of HRQoL instruments.

METHODS

A systematic review was conducted to retrieve relevant clinical data from published literature using a representative sample of countries where healthcare systems provide wide availability of COPD medications and/or universal coverage includes respiratory medicines (Australia, Canada, China, France, Germany, Italy, Spain, the UK, and the USA). The primary inclusion criteria were patients with moderate to very severe COPD. HRQoL was quantified with non-disease-specific and disease-specific questionnaires.

RESULTS

In total, 82 studies from 95 publications presented HRQoL data from patients with moderate to very severe COPD. Patient-reported HRQoL declined with worsening airflow limitation, advancing GOLD group, and increasing exacerbation frequency. Both increasing frequency of hospitalization for COPD exacerbations and recurrent hospitalization adversely impacted HRQoL. Comorbidity incidence was higher in patients with increased airflow limitation. It was associated with a further decline in HRQoL and increased depression and anxiety, particularly as disease-associated pain worsened. Physical activity improved HRQoL over time.

CONCLUSION

This review highlighted the impact of exacerbations and associated hospitalizations on the humanistic burden of COPD. These findings underline the importance of managing COPD actively, including prompt and appropriate use of pharmacological and non-pharmacological therapies that can improve symptoms and reduce the risk of exacerbations, thereby lessening the humanistic burden. Future reviews could consider a broader range of countries and publications to further assess the humanistic impact of COPD in low- and middle-income economies.

Clinical Role of the Chronic Obstructive Pulmonary Disease Assessment Test in Prediction of the Response to Treatment for Exacerbations

BACKGROUND

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is a validated, eight-item questionnaire used to quantify the health status of patients. The aim of this study was to evaluate the usefulness of the CAT questionnaire as a tool to assess the response to treatment in acute exacerbations of COPD in an outpatient setting.

METHODS

A multicenter, phase 3 randomized controlled trial was conducted previously to examine the efficacy and safety of oral zabofloxacin for the treatment of COPD exacerbations. In the present post hoc analysis of the original study, patients with COPD exacerbation were categorized as responders or non-responders according to the respiratory symptoms persisting on day 10 (visit 3) of treatment. The CAT questionnaire was completed daily by patients at home from the initial visit to the second visit on day 5. Subsequently, the questionnaire was completed in the presence of a physician on days 10 (visit 3) and 36 (visit 4). Multivariate regression analysis was performed to determine the association between CAT scores and the therapeutic response.

RESULTS

The CAT scores decreased more rapidly in responders compared to non-responders during the first 5 days (23.3-20.4 vs. 23.5-22). Among responders, patients with higher severity of illness also revealed higher CAT scores on the first day of an exacerbation (mild, 19.8; moderate, 21.4; severe, 23.8; very severe, 28.6). Multivariate analysis revealed that a change in the CAT score during the first 3 days influenced the therapeutic response. A significant decrease in scores in the domains of sputum production, chest tightness, and activities of daily living was seen among responders.

CONCLUSION

Early improvement in CAT scores may be associated with a more favorable response to the treatment of COPD exacerbations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01658020.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0000532.

Social and clinical predictors associated with prolonged hospital stays for patients with severe exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To determine whether there are social factors that affect the prolonged hospital stay (PHS) of patients with severe chronic obstructive pulmonary disease exacerbation (COPDE), as well as clinical-demographic factors.

METHODOLOGY

We conducted a prospective cohort study that consecutively included patients who were admitted to a Pneumology department for COPDE. We recorded demographic, clinical (tobacco use, exacerbations and infections, dyspnoea, impact according to CAT questionnaire, pulmonary function, comorbidities, oxygen therapy and noninvasive ventilation) and social (financial status, caregiver availability and overload, dependence for basic and instrumental activities, social risk and use of social services) variables, employing questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber and Gijón. We performed a univariate and multivariate analysis using a logistic regression model.

RESULTS

The study included 253 patients, with a mean age of 68.9±9.8years; 77.1% of whom were men. The logistic regression model included active tobacco use, FEV₁ value, CAT score >10, dyspnoea 3-4 on the MMRC, the presence of bacteria in sputum cultures, cardiovascular comorbidity, anaemia, home oxygen therapy, living alone, rural residence, caregiver overload and detecting social-family risks/problems. The variables independently associated with the possibility of PHS were a CAT score >10 (OR, 8.9; P=.04) and detecting a social-family risk/problem (OR, 2.6; P=.04). Active smoking was a predictor of shorter stays (OR, 0.15; P=.002).

CONCLUSIONS

Variables related to the social sphere play a relevant role in hospital stays, as do the impact of the disease and the persistent use of tobacco by patients with severe COPD exacerbation.

Enhancing our understanding of the time course of acute exacerbations of COPD managed on an outpatient basis

Purpose

Acute exacerbations of COPD (AECOPD) are associated with pulmonary/systemic changes; however, quantification of those changes during AECOPD managed on an outpatient basis and factors influencing recovery are lacking. This study aimed to characterize patients’ changes during AECOPD and identify factors influencing their recovery.

Methods

Body mass index, the modified British Medical Research Council questionnaire, number of exacerbations in the previous year, and the Charlson comorbidity index (independent variables) were collected within 24–48 hours of hospital presentation (T0). Peripheral oxygen saturation (SpO₂), forced expiratory volume in one second, percentage predicted (FEV₁% predicted), maximum inspiratory pressure, quadriceps muscle strength, 5 times sit-to-stand, and COPD assessment test (CAT) (dependent variables) were collected at T0 and approximately at days 8 (T1), 15 (T2), and 45 (T3) after T0.

Results

A total of 44 outpatients with AECOPD (31♂; 68.2±9.1 years; 51.1±20.3 FEV₁% predicted) were enrolled. All variables improved overtime (P<0.05); however, at day 8, only SpO₂ and CAT (P≤0.001) showed significant improvements. Changes in FEV₁% predicted and SpO₂ were not influenced by any independent measure, while changes in other outcome measures were influenced by at least one of the independent measures. Independently of the time of data collection, being underweight or overweight and having increased dyspnea, previous exacerbations, and severe comorbidities negatively affected patients’ outcomes.

Conclusion

FEV₁% predicted and SpO₂ were not influenced by any independent measure and, thus, seem to be robust measures to follow-up outpatients with AECOPD. No single indicator was able to predict patients’ recovery for all measures; thus, a comprehensive assessment at the onset of the AECOPD is required to personalize interventions.

Digital Delivery of Meditative Movement Training Improved Health of Cigarette-Smoke-Exposed Subjects

Many FA who flew prior to the ban on smoking in commercial aircraft exhibit an unusual pattern of long-term pulmonary dysfunction. This randomized controlled study tested the hypothesis that digitally delivered meditative movement (MM) training improves chronic obstructive pulmonary disease (COPD)-related symptoms in flight attendants (FA) who were exposed to second-hand cigarette smoke (SHCS) while flying. Phase I of this two-phase clinical trial was a single-arm non-randomized pilot study that developed and tested methods for MM intervention; we now report on Phase II, a randomized controlled trial comparing MM to a control group of similar FA receiving health education (HE) videos. Primary outcomes were the 6-min walk test and blood levels of high sensitivity C-reactive protein (hs-CRP). Pulmonary, cardiovascular, autonomic and affective measures were also taken. There were significant improvements in the 6-min walk test, the Multidimensional Assessment of Interoceptive Awareness (MAIA) score, and the COPD Assessment Test. Non-significant trends were observed for increased dehydroepiandrosterone sulfate (DHEAS) levels, decreased anxiety scores and reduced blood hs-CRP levels, and increased peak expiratory flow (PEF). In a Survey Monkey questionnaire, 81% of participants who completed pre and post-testing expressed mild to strong positive opinions of the study contents, delivery, or impact, while 16% expressed mild negative opinions. Over the course of the year including the study, participant adoption of the MM practices showed a significant and moderately large correlation with overall health improvement; Pearson's R = 0.62, p < 0.005. These results support the hypothesized benefits of video-based MM training for this population. No adverse effects were reported.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02612389

The role of CAT in evaluating the response to treatment of patients with AECOPD

Background

The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) questionnaire is a short patient-completed questionnaire, which is used to assess the health status of patients with stable COPD. However, whether it is a good tool to evaluate the response to treatment in acute exacerbation of COPD (AECOPD) has been less studied.

Methods

The patients were assessed at two visits, at admission and on the seventh day. Anthropometric variables were collected at admission. CAT and lung function were measured twice at the above time points. At the second visit, the health status of the patients were divided into five groups based on a 5-point Likert scale, ranging from 1 to 5, which represents "much better," "slightly better," "no change," "slightly worse," and "much worse." Responders were those who reported "much better" or "slightly better," and nonresponders were those who claimed "no change," "worse," or "much worse."

Results

In total, 225 patients were recruited. The average CAT score at admission was 24.82±7.41, which declined to 17.41±7.35 on the seventh day. There were 81.33% responders, whose improvement in CAT score (9.37±5.24) was much higher than that of the nonresponders (-1.36±4.35). A moderate correlation was observed between the changes in CAT score and improvement in FEV1, FEV1%, and the length of hospital stay. There was a strong correlation between the changes in CAT score and health status. A 3.5-unit improvement in the CAT score, with highest area under the curve, was the cutoff to differentiate responders from nonresponders.

Conclusion

The evolution of CAT scores during exacerbation can provide useful information to assess the health status of patients with AECOPD. A 3.5-unit improvement in CAT score is the best cutoff to differentiate between patients who have a response or no response to treatment, which offers a convenient and easy way for clinicians to monitor the health status of patients with an AECOPD.

Current Approaches for Phenotyping as a Target for Precision Medicine in COPD Management

The study of airway diseases continues to present several challenges for modern medicine. The different disease presentations with variables and overlapping features may result in a real challenge for the clinician. In this context, the concept of precision medicine has started to emerge in order to give answers to some of these challenges from a diagnostic and therapeutic point of view. The main reasons to target for precision medicine in chronic obstructive pulmonary disease (COPD) include that there is variability in the clinical presentation, there is no correlation between the different clinical variables at the patient level, there are a number of relevant clinical variables associated with outcomes, we do have specific therapies for specific patient types, and that there is variability in the clinical response to different therapies. To bring precision medicine into clinical practice several approaches have been used, including the use of independent variables to identify subjects, the use of multidimensional indexes, the so-called clinical phenotypes, and the approximation by the so-called treatable traits. All these approaches have their strengths and weaknesses which are reviewed in the present document. Although there is no universally accepted proposal, the available initiatives provide us with a framework on which to start working and move toward precision medicine in COPD, with the ultimate goal of bringing the best possible medicine to each patient in particular.

Evaluation of clinical variables according to follow-up times in COPD: results from ON-SINT cohort

Background: COPD is a chronic disease traditionally associated with increased symptoms as lung function deteriorates. Follow-up times in previous cohort studies were limited to a few years. Interestingly, newer longer observational studies show a more comprehensive picture on disease progression over time. Therefore, the question on the relevancy of the follow-up time in cohort studies remains open.

Methods: The ON-SINT study is an observational, retrospective, nationwide, real-life cohort study, in which patients diagnosed with COPD were recruited between December 2011 and April 2013 by primary care (PC) and secondary care (SC) physicians. Patients were evaluated at the inclusion visit and at the initial visit when the diagnosis of COPD was first established. Distribution of lung function decline over the years was studied comparing those cases with longer follow-up times, with the median of the distribution as the cutoff point.

Results: The sample included 1214 patients of which 857 (70.6%) were recruited by PC and 357 (29.4%) by SC physicians. Median follow-up time was 6.26 years. Mean annual change in the complete cohort were –4.5 (222) ml year^–1 for FVC and 5.5 (134) ml year^–1 for FEV₁. We confirm the variable distribution of FEV₁ decline and found that longer follow-up periods reduce this variability. Of note, FEV₁ decline was different between groups (shorter: 19.7 [180.4] vs longer: –9.7 [46.9]; p = 0.018). Further, our data revealed differences in the clinical presentation according to follow-up times, with special emphasis on dyspnea (OR: 1.035; 95%CI: 1.014–1.056), exacerbations (OR 1.172; 95%CI 1.045–1.315) and CAT scores (OR 1.047; 95%CI 1.019–1.075) being associated with longer follow-up times.

Conclusions: This study describes the impact of follow-up periods on lung function variability, and reveals differences in clinical presentation according to follow-up times, with special emphasis on dyspnea, exacerbations and CAT scores.

Clinical characteristics of chronic bronchitic, emphysematous and ACOS phenotypes in COPD patients with frequent exacerbations

Purpose

Chronic bronchitis (CB), emphysematous (EM) and asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) phenotypes in COPD are well recognized. This study aimed to investigate distinguishing characteristics of these phenotypes in COPD patients with frequent exacerbations (FE).

Patients and methods

A retrospective study was carried out. COPD patients with acute exacerbations were consecutively reviewed from November 2015 to October 2016. Patients were divided into FE and infrequent exacerbations (iFE) subgroups.

Results

A total of 142 eligible COPD subjects were reviewed. In the CB phenotype subgroup, age, body mass index, forced expiratory volume in 1 second (FEV₁) % predicted, COPD assessment test (CAT), modified Medical Research Council breathlessness measurement (mMRC) dyspnea scale, emphysema scores and arterial carbon dioxide pressure (PaCO₂) were significantly different in subjects with FE when compared to those in subjects with iFE of CB. In the EM phenotype subgroup, age, CAT, mMRC scores and history of COPD were different in subjects with FE when compared to those in CB subjects with iFE. Multivariate analysis indicated that FEV₁% predicted (odds ratio [OR] =0.90, P=0.04) and PaCO₂ (OR =1.22, P=0.02) were independent risk factors for FE in COPD with CB phenotype, and CAT (OR =2.601, P=0.001) was the independent risk factor for FE in COPD with EM phenotype. No significant differences in characteristics were observed in ACOS phenotype subgroups with FE or iFE.

Conclusion

In CB or EM phenotypes, COPD patients with FE present several differential clinical characteristics compared to patients with iFE, while the characteristics of ACOS phenotype in patients with FE need more investigation.

Effectiveness of a Novel Qigong Meditative Movement Practice for Impaired Health in Flight Attendants Exposed to Second-Hand Cigarette Smoke

This single-arm non-randomized pilot study explores an intervention to improve the health of flight attendants (FA) exposed to second-hand cigarette smoke prior to the smoking ban on commercial airlines. This group exhibits an unusual pattern of long-term pulmonary dysfunction. We report on Phase I of a two-phase clinical trial; the second Phase will be a randomized controlled trial testing digital delivery of the intervention. Subjects were recruited in the Northeastern US; testing and intervention were administered in 4 major cities. The intervention involved 12 h of training in Meditative Movement practices. Based on recent research on the effects of nicotine on fear learning, and the influence of the autonomic nervous system on immune function, our hypothesis was that this training would improve autonomic function and thus benefit a range of health measures. Primary outcomes were the 6-min walk test and blood levels of C-reactive protein. Pulmonary, cardiovascular, autonomic, and affective measures were also taken. Fourteen participants completed the training and post-testing. There was a 53% decrease in high sensitivity C-Reactive Protein (p ≤ 0.05), a 7% reduction in systolic blood pressure (p ≤ 0.05), a 13% increase in the 6-min walk test (p ≤ 0.005), and significant positive changes in several other outcomes. These results tend to confirm the hypothesized benefits of MM training for this population, and indicate that autonomic function may be important in the etiology and treatment of their symptoms. No adverse effects were reported. This trial is registered at ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT02612389/), and is supported by a grant from the Flight Attendant Medical Research Institute (FAMRI).

Prulifloxacin vs Levofloxacin for Exacerbation of COPD after Failure of Other Antibiotics

The chronic course and evolution of chronic obstructive pulmonary disease (COPD) is often characterized by periods of exacerbation of symptoms, which have a negative impact on the quality of life of patients, as well as on the evolution of COPD, and represent a significant cause of medical intervention and hospitalization. Very few data are available on the efficacy of rescue antibiotics in patients with acute exacerbation of COPD (AECOPD) unresponsive to previous treatment. The aim of this study was to evaluate the efficacy of two fluoroquinolones in AECOPD previously treated without success. The FADOI-FLOR study is a randomized, single-blind, non-inferiority comparison between levofloxacin and prulifloxacin. Primary end-point was "therapeutic success" at Day 10 of treatment, defined as disappearance of signs/symptoms or decrease of at least three points of a global score of symptomatology (maximum score = 15). 258 patients were enrolled (128 levofloxacin and 130 prulifloxacin), in 25 centers. A very high proportion of patients in the two groups had therapeutic success at Day-10 (levofloxacin 93.0% vs prulifloxacin 96.7%, population intention-to-treat; 94.6% vs 99.1%, population per-protocol). Earlier therapeutic success (within 7 days) was achieved in 32.0% and 36.2% of patients receiving levofloxacin or prulifloxacin, respectively. At 3-month follow-up, re-exacerbations occurred in 17.8% of patients treated with levofloxacin and 14.2% of those receiving prulifloxacin (p = 0.44). In conclusion, fluoroquinolones are very effective in the treatment of AECOPD resistant to other antibiotics.

The chronic obstructive pulmonary disease assessment test improves the predictive value of previous exacerbations for poor outcomes in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) exacerbations have a negative impact on the quality of life of patients and the evolution of the disease. We have investigated the prognostic value of several health-related quality of life questionnaires to predict the appearance of a composite event (new ambulatory or emergency exacerbation, hospitalization, or death) over a 1-year follow-up.

METHODS

This was a multicenter, prospective, observational study. Patients completed four questionnaires after recovering from an exacerbation (COPD Assessment Test [CAT], a Clinical COPD Questionnaire [CCQ], COPD Severity Score [COPDSS], and Airways Questionnaire [AQ20]). Patients were followed-up until the appearance of the composite event or for 1 year, whichever came first.

RESULTS

A total of 497 patients were included in the study. The majority of them were men (89.7%), with a mean age of 68.7 (SD 9.2) years, and a forced expiratory volume in 1 second of 47.1% (SD 17.5%). A total of 303 (61%) patients experienced a composite event. Patients with an event had worse mean scores of all questionnaires at baseline compared to patients without event: CAT=12.5 vs 11.3 (P=0.028); CCQ=2.2 vs 1.9 (P=0.013); COPDSS=12.3 vs 10.9 (P=0.001); AQ20=8.3 vs 7.5 (P=0.048). In the multivariate analysis, only previous history of exacerbations and CAT score ≥13.5 were significant risk factors for the composite event. A CAT score ≥13.5 increased the predictive value of previous exacerbations with an area under the receiver operating characteristic curve of 0.864 (95% CI: 0.829-0.899; P=0.001).

CONCLUSION

The predictive value of previous exacerbations significantly increased only in one of the four trialled questionnaires, namely in the CAT questionnaire. However, previous history of exacerbations was the strongest predictor of the composite event.

Evaluation of the Persian Transcript of the COPD Assessment Test in the Measurement of COPD Health Status in Iranian COPD Patients

AIM

Chronic obstructive pulmonary disease is a completely irreversible obstructive airway disease. The COPD assessment test (CAT) is one of the standard methods for the clinical assessment of the disease, which is translated into Persian. This study investigated the reliability of the test and its relationship with the severity of the disease.

METHODS

In this cross-sectional study, 120 patients filled out the Persian transcript of the test. After two weeks, the patients filled out the CAT test again. Obstruction severity was determined for all the patients using spirometry, and the patients were categorized into four groups according to the Global Initiative for Chronic Obstructive Lung Disease criteria. The relationship between the test scores and the disease severity wan validated.

RESULTS

The mean age of the patients was 51.5 years. The Cronbach's alpha coefficient of the Persian transcript of the test was 0.872 in the first time, and 0.885 in the second time. Intragroup reliability, test re-test and intragroup correlations were significant for all the questions (<0.001). The relationship between the test mean score and obstruction severity was significant, and the correlation between disease categorization in accordance with obstruction severity and categorization according to the test score was significant as well.

CONCLUSION

The Persian transcript of the assessment test for COPD was reliable and is directly related to the disease severity according to airflow limitation.

Evaluation of the COPD Assessment Test and GOLD patient types: a cross-sectional analysis

Background

The COPD Assessment Test (CAT) has been recently developed to quantify COPD impact in routine practice. However, no relationship with other measures in the Global Initiative for Obstructive Lung Disease (GOLD) strategy has been evaluated. The present study aimed to evaluate the relationship of the CAT with other GOLD multidimensional axes, patient types, and the number of comorbidities.

Methods

This was a cross-sectional analysis of the Clinical presentation, diagnosis, and course of chronic obstructive pulmonary disease (On-Sint) study. The CAT score was administered to all participants at the inclusion visit. A GOLD 2011 strategy consisting of modified Medical Research Council scale (MRC) scores was devised to study the relationship between the CAT, and GOLD 2011 axes and patient types. The relationship with comorbidities was assessed using the Charlson comorbidity index, grouped as zero, one to two, and three or more.

Results

The CAT questionnaire was completed by 1,212 patients with COPD. The CAT maintained a relationship with all the three axes, with a ceiling effect for dyspnea and no distinction between mild and moderate functional impairment. The CAT score increased across GOLD 2011 patient types A–D, with similar scores for types B and C. Within each GOLD 2011 patient type, there was a considerably wide distribution of CAT values.

Conclusion

Our study indicates a correlation between CAT and the GOLD 2011 classification axes as well as the number of comorbidities. The CAT score can help clinicians, as a complementary tool to evaluate patients with COPD within the different GOLD patient types.

Course of COPD Assessment Test (CAT) Scores During Bacterial Exacerbations of Chronic Obstructive Pulmonary Disease Treated in Outpatient Setting

Introduction :

COPD Assessment Test (CAT) is an 8-items questionnaire for assessment of health status in patients with chronic obstructive pulmonary disease (COPD).

Objective :

To evaluate the course of CAT scores during bacterial exacerbations of COPD treated in outpatient setting.

Methods :

We performed an observational, prospective study including 81 outpatients (57 males and 24 females, aged 43 to 74 years) with bacterial exacerbation of COPD. All participants completed CAT at initial visit (i.e. at the time of diagnosis of exacerbation and beginning of its treatment), 10 and 30 days after initial visit. Mean scores of each item, as well as the overall mean score, at these time points were compared.

Results :

The mean scores for each CAT question at initial visit varied from 2.6 to 3.5, whereas the mean scores for each CAT question 10 days after initial visit varied from 1.7 to 2.6. We registered significant reduction of the mean overall CAT score 10 days after initial visit as compared to its value at initial visit of 6.9 ± 2.7 points (16.8 vs 23.7; P < 0.001). The mean scores for each CAT question 30 days after initial visit varied from 1.3 to 2.4. We registered reduction of mean overall CAT score 30 days after initial visit as compared to its score 10 days after initial visit of 2.9 ± 1.2 points (13.9 vs 16.8; P < 0.005). The mean overall CAT score 30 days after initial visit was reduced for 9.8 ± 4.5 points as compared to its value at initial visit (13.9 vs 23.7; P < 0.001).

Conclusion :

We found significant improvement in the patient’s health status during recovery from exacerbation as compared to their health status at the time of exacerbation confirming the CAT as an effective tool to measure health status in patients with COPD.

Detection of acute deterioration in health status visit among COPD patients by monitoring COPD assessment test score

Background

The Chronic Obstructive Pulmonary Disease Assessment Test (CAT) could play a role in detecting acute deterioration in health status during monitoring visits in routine clinical practice.

Objective

To evaluate the discriminative property of a change in CAT score from a stable baseline visit for detecting acute deterioration in health status visits of chronic obstructive pulmonary disease (COPD) patients.

Methods

The CAT questionnaire was administered to stable COPD patients routinely attending the chest clinic of Chiang Mai University Hospital who were monitored using the CAT score every 1–3 months for 15 months. Acute deterioration in health status was defined as worsening or exacerbation. CAT scores at baseline, and subsequent visits with acute deterioration in health status were analyzed using the t-test. The receiver operating characteristic curve was performed to evaluate the discriminative property of change in CAT score for detecting acute deterioration during a health status visit.

Results

A total of 354 follow-up visits were made by 140 patients, aged 71.1±8.4 years, with a forced expiratory volume in 1 second of 47.49%±18.2% predicted, who were monitored for 15 months. The mean CAT score change between stable baseline visits, by patients’ and physicians’ global assessments, were 0.05 (95% confidence interval [CI], −0.37–0.46) and 0.18 (95% CI, −0.23–0.60), respectively. At worsening visits, as assessed by patients, there was significant increase in CAT score (6.07; 95% CI, 4.95–7.19). There were also significant increases in CAT scores at visits with mild and moderate exacerbation (5.51 [95% CI, 4.39–6.63] and 8.84 [95% CI, 6.29–11.39], respectively), as assessed by physicians. The area under the receiver operating characteristic curve of CAT score change for the detection of acute deterioration in health status was 0.89 (95% CI, 0.84–0.94), and the optimum cut-off point score was at 4, with a sensitivity, specificity, and accuracy of 76.8%, 83.6%, and 82.4%, respectively.

Conclusions

Change in CAT score during monitoring visits is useful for detecting acute deterioration in health status, and a change of 4 units could make a moderate prediction of acute deterioration in health status.

The COPD assessment test: a systematic review

The COPD assessment test (CAT) is a self-administered questionnaire that measures health-related quality of life. We aimed to systematically evaluate the literature for reliability, validity, responsiveness and minimum clinically important difference (MCID) of the CAT. Multiple databases were searched for studies analysing the psychometric properties of the CAT in adults with chronic obstructive pulmonary disease. Two reviewers independently screened, selected and extracted data, and assessed methodological quality of relevant studies using the COSMIN checklist. From 792 records identified, 36 studies were included. The number of participants ranged from 45 to 6469, mean age from 56 to 73 years, and mean forced expiratory volume in 1 s from 39% to 98% predicted. Internal consistency (reliability) was 0.85-0.98, and test-retest reliability was 0.80-0.96. Convergent and longitudinal validity using Pearson's correlation coefficient were: SGRQ-C 0.69-0.82 and 0.63, CCQ 0.68-0.78 and 0.60, and mMRC 0.29-0.61 and 0.20, respectively. Scores differed with GOLD stages, exacerbation and mMRC grades. Mean scores decreased with pulmonary rehabilitation (2.2-3 units) and increased at exacerbation onset (4.7 units). Only one study with adequate methodology reported an MCID of 2 units and 3.3-3.8 units using the anchor-based approach and distribution-based approach, respectively. Most studies had fair methodological quality. We conclude that the studies support the reliability and validity of the CAT and that the tool is responsive to interventions, although the MCID remains debatable.

COPD assessment tests scores are associated with exacerbated chronic obstructive pulmonary disease in Japanese patients

BACKGROUND

Guidelines recommend chronic obstructive pulmonary disease (COPD) assessment tests (CATs) for evaluation of symptoms and management risks. To investigate whether CAT can predict moderate or severe exacerbations in Japanese COPD patients, a single-blinded prospective study was performed.

METHODS

A 123 Japanese COPD patients were classified into high-CAT (n=64) and low-CAT (n=59) groups. The frequencies and periods of moderate or severe exacerbation and hospitalization were compared between the two groups. Multivariate logistic regression analysis was performed to investigate whether CAT could predict exacerbations. A receiver operating characteristic (ROC) curve analysis was employed to find an appropriate CAT score for exacerbation.

RESULTS

The high-CAT group was significantly older, had a lower body mass index, and had a lower airflow obstruction as compared to the low CAT group. The frequency of moderate or severe exacerbation (1.3±1.3 events per patient per year, p<0.0001) and hospitalizations (0.2±0.4, p=0.0202) in the high-CAT group was significantly higher than in the low-CAT group (0.4±0.7 and 0.0±0.1, respectively). Multivariate logistic regression analysis showed that both high CAT score and low airflow obstruction were independently predictive of frequent moderate or severe COPD exacerbation. ROC analysis showed that the best cut-off CAT score for moderate or severe COPD exacerbation was 8 points.

CONCLUSION

Our present results indicate that COPD Japanese patients showing high CAT scores have a poor prognosis, and that the CAT score is able to predict exacerbation in Japanese COPD.