Implementation of a targeted screening program to detect airflow obstruction suggestive of chronic obstructive pulmonary disease within a presurgical screening clinic

Pulmonary function testing in preoperative high-risk patients

BACKGROUND

Postoperative respiratory failure is the most frequent complication in postsurgical patients. The purpose of this study is to assess whether pulmonary function testing in high-risk patients during preoperative assessment detects previously unknown respiratory impairments which may influence patient outcomes.

METHODS

A targeted patient screening by spirometry and the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) was implemented in the anesthesia department of a tertiary university hospital. Patients of all surgical disciplines who were at least 75 years old or exhibited reduced exercise tolerance with the metabolic equivalent of task less than four (MET < 4) were examined. Clinical characteristics, history of lung diseases, and smoking status were also recorded. The statistical analysis entailed t-tests, one-way ANOVA, and multiple linear regression with backward elimination for group comparisons.

RESULTS

Among 256 included patients, 230 fulfilled the test quality criteria. Eighty-one (35.2%) patients presented obstructive ventilatory disorders, out of which 65 were previously unknown. 38 of the newly diagnosed obstructive disorders were mild, 18 moderate, and 9 severe. One hundred forty-five DLCO measurements revealed 40 (27.6%) previously unknown gas exchange impairments; 21 were mild, 17 moderate, and 2 severe. The pulmonary function parameters of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and DLCO were significantly lower than the international reference values of a healthy population. Patients with a lower ASA class and no history of smoking exhibited higher FVC, FEV1, and DLCO values. Reduced exercise tolerance with MET < 4 was strongly associated with lower spirometry values.

CONCLUSIONS

Our screening program detected a relevant number of patients with previously unknown obstructive ventilatory disorders and impaired pulmonary gas exchange. This newly discovered sickness is associated with low metabolic equivalents and may influence perioperative outcomes. Whether optimized management of patients with previously unknown impaired lung function leads to a better outcome should be evaluated in multicenter studies.

TRIAL REGISTRATION

German Registry of Clinical Studies (DRKS00029337), registered on: June 22nd, 2022.

Smoking, e-cigarettes and the effect on respiratory symptoms among a population sample of youth: Retrospective cohort study

INTRODUCTION

E-cigarettes have been steadily increasing in popularity, both as cessation methods for smoking and for recreational and social reasons. This increase in vaping may pose cardiovascular and respiratory risks. We aimed to assess respiratory symptoms in youth users of e-cigarettes and cigarettes.

METHODS

A retrospective survey design was utilized to assess Canadian youth aged 16-25 years. Participants were recruited from the Ontario Tobacco Research Unit Youth and Young Adult Research Registration Panel November 2020 to March 2021. A total of 3082 subjects completed the baseline survey. Of these, 2660 individuals who did not have asthma were included in the analysis. The exposure of interest was pack-equivalent years, a novel measure of vaping exposure equivalent conceptually to cigarette pack years incorporating number of puffs per day, number of days vaped per month, and number of years vaped. Respiratory symptoms were measured using the five-item Canadian Lung Health Test. Poisson regression analyses were performed while adjusting for demographic confounders, stratified by smoking status. A non-stratified model tested the interaction of status and vaping dose and the effect of vaping device used was assessed among ever vapers. Analyses controlled for demographic characteristics, use of cannabis and alcohol, and survey date.

RESULTS

Each additional puff year increased the rate ratio (RR) of respiratory symptoms by a factor of 11.36 (95% CI: 4.61-28.00; p<0.001) for never smokers, but among current daily smokers higher pack-equivalent years were not associated with more respiratory symptoms (RR=0.83; 95% CI: 0.23-3.11). Among current vapers, those using pod-style devices were more likely to have more respiratory symptoms (RR=1.25; 95% CI: 1.08-1.45) after adjusting for dose.

CONCLUSIONS

Vaping is associated with an increased risk of reporting respiratory symptoms among never smoking youth and non-daily ever cigarette smokers. Use of e-cigarettes among non-smokers should be discouraged.

Identification of Patients With COPD in a Cardiac Rehabilitation Setting: THE COnCuR STUDY

PURPOSE

To examine the feasibility of screening for chronic obstructive pulmonary disease (COPD) in an outpatient cardiac rehabilitation (CR) setting and to evaluate the detection rate of COPD using a targeted screening protocol.

METHODS

A total of 95 patients (62.5 ± 10.0 yr; men, n = 77), >40-yr old with a history of smoking were included in the study sample. Each participant answered the 5-item Canadian Lung Health Test (CLHT) questionnaire assessing symptoms such as coughing, phlegm, wheezing, shortness of breath, and frequent colds. Endorsing ≥1 item was indicative of potential COPD and warranted pulmonary function testing (PFT) and/or spirometry to diagnose or rule out COPD.

RESULTS

The CLHT questionnaire identified 44 patients at risk for COPD, with an average of 1.9 ± 1.2 items endorsed. Of the patients who underwent PFT, 6 new cases of mild COPD were diagnosed, resulting in a true positive rate with CLHT screening of 19% and a false-positive rate of 81%.

CONCLUSIONS

Implementing the CLHT to patients referred to CR correctly identified COPD in <20% of cases. Using the CLHT to screen for COPD prior to starting CR may not be optimal, due to disparities between true- and false-positive rates.

Active screening for COPD among hospitalized smokers - a feasibility study

BACKGROUND

Spirometry is a primary tool for early chronic obstructive pulmonary disease (COPD) detection in patients with risk factors, for example, cigarette smoking. The aim of this study was to evaluate the strategy of an active screening for COPD among smokers admitted to the pulmonary and cardiology department.

METHODS

This prospective study was conducted between February and March 2019. All hospitalized smokers aged 40 years and older completed an original questionnaire and had spirometry measurement with a bronchial reversibility test (if applicable) performed by medical students using a portable spirometer.

RESULTS

One hundred and eighty-eight patients were eligible to participate in the study. Seventy (37%) subjects refused to participate. Eventually, 116 (62%) patients were included in the final analysis and 94 (81%) performed spirometry correctly. In total, 32 (34 %) patients were found to have COPD. Nine (28%) of these patients were newly diagnosed, 89% of them had mild-to-moderate airway obstruction. Patients with newly diagnosed COPD were significantly younger [age 63 (56-64) versus 69 (64-78) years], had a longer smoking-free period [17 (13-20) versus 9 (2-12) years], had fewer symptoms and had a better lung function compared with patients with a previous diagnosis of COPD (p < 0.05 for all comparisons).

CONCLUSION

The proposed diagnostic strategy can be successfully used to improve COPD detection in the inpatient setting. The majority of the newly diagnosed COPD patients had mild-to-moderate airway obstruction. Patients who should be particularly screened for COPD include ex-smokers with less pronounced respiratory symptoms.

Diagnosing Chronic Obstructive Airway Disease on a Smartphone Using Patient-Reported Symptoms and Cough Analysis: Diagnostic Accuracy Study

Background

Rapid and accurate diagnosis of chronic obstructive pulmonary disease (COPD) is problematic in acute care settings, particularly in the presence of infective comorbidities.

Objective

The aim of this study was to develop a rapid smartphone-based algorithm for the detection of COPD in the presence or absence of acute respiratory infection and evaluate diagnostic accuracy on an independent validation set.

Methods

Participants aged 40 to 75 years with or without symptoms of respiratory disease who had no chronic respiratory condition apart from COPD, chronic bronchitis, or emphysema were recruited into the study. The algorithm analyzed 5 cough sounds and 4 patient-reported clinical symptoms, providing a diagnosis in less than 1 minute. Clinical diagnoses were determined by a specialist physician using all available case notes, including spirometry where available.

Results

The algorithm demonstrated high positive percent agreement (PPA) and negative percent agreement (NPA) with clinical diagnosis for COPD in the total cohort (N=252; PPA=93.8%, NPA=77.0%, area under the curve [AUC]=0.95), in participants with pneumonia or infective exacerbations of COPD (n=117; PPA=86.7%, NPA=80.5%, AUC=0.93), and in participants without an infective comorbidity (n=135; PPA=100.0%, NPA=74.0%, AUC=0.97). In those who had their COPD confirmed by spirometry (n=229), PPA was 100.0% and NPA was 77.0%, with an AUC of 0.97.

Conclusions

The algorithm demonstrated high agreement with clinical diagnosis and rapidly detected COPD in participants presenting with or without other infective lung illnesses. The algorithm can be installed on a smartphone to provide bedside diagnosis of COPD in acute care settings, inform treatment regimens, and identify those at increased risk of mortality due to seasonal or other respiratory ailments.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618001521213; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375939

Identification of Risk Factors for Readmission in Patients Undergoing Anterior Cervical Discectomy Fusion: A Predictive Risk Scale

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to analyze readmission rates among patients undergoing anterior cervical discectomy and fusion (ACDF), determine which factors were associated with higher readmission rates, and develop a scale for utilization during surgical planning.

SUMMARY OF BACKGROUND DATA

ACDF is the most common surgical treatment for many cervical disk pathologies. With the Centers for Medicare and Medicaid Services selecting readmissions as a measure of health care quality, there has been an increased focus on reducing readmissions.

MATERIALS AND METHODS

There were 114,174 recorded ACDF surgeries in the derivation cohort, the State Inpatient Database (SID) of New York and California between 2006 and 2014. There were 115,829 ACDF surgeries recorded in the validation cohort, the SID from Florida and Washington over the same time period. After identification of risk factors using univariate and multivariate analysis of the derivation cohort, a predictive scale was generated and tested utilizing the validation cohort.

RESULTS

Overall, readmission rates within 30 days of discharge were 5.87% and 5.52% in the derivation and validation cohorts, respectively. On multivariate analysis of the derivation cohort, age older than 80 years [odds ratio (OR), 1.67] male sex (OR, 1.16), Medicaid insurance (OR, 1.90), Medicare insurance (OR, 1.64), revision ACDF (OR, 1.43), anemia (OR, 1.45), chronic lung disease (OR, 1.23), coagulopathy (OR, 1.42), congestive heart failure (OR, 1.31), diabetes (OR, 1.23), fluid and electrolyte disorder (OR, 1.56), liver disease (OR, 1.37), renal failure (OR, 1.59), and myelopathy (OR, 1.19) were found to be statistically significant predictors for readmission. These factors were incorporated into a numeric scale that, that when tested on the validation cohort, could explain 97.1% of the variability in readmission rate.

CONCLUSIONS

Overall, 30-day readmission following ACDF surgery was 5%-6%. A novel risk scale based on factors associated with increased readmission rates may be helpful in identifying patients who require additional optimization to reduce perioperative morbidity.

LEVEL OF EVIDENCE

Level III-prognostic.

Undiagnosed chronic obstructive pulmonary disease in patients admitted to an acute assessment unit

Introduction: Chronic obstructive pulmonary disease (COPD) is very prevalent worldwide, yet underdiagnosed. Aim: This study investigates feasibility of performing spirometry in patients in need of acute hospital admission as well as the prevalence of undiagnosed COPD in the same cohort. Methods: During a two-week period, all patients admitted to three large acute assessment units were evaluated. Patients ≥ 18 years, able to perform spirometry, with no surgery to the thorax or abdomen within the last weeks and no known COPD was included. Patients with FEV1/FEV6 ≤ 0.7 or FEV1 < 80% or FEV6 < 80% were offered follow-up visit after 6 weeks. Results: Of the 1145 admitted patients, 46% were eligible: 28% of those had an abnormal spirometry. The offered follow-up visit was attended by 51% and in this group 17% were diagnosed with lung disease. COPD was the most prevalent diagnosis (73%), and 2/3 was in GOLD group A. In total, 75% of the patients with airflow obstruction at the initial examination remained obstructive. Conclusion: Performing spirometry in patients in need of acute hospital admission is feasible, abnormal findings are common, and COPD is the most prevalent diagnosis.