What is a COPD exacerbation? Current definitions, pitfalls, challenges and opportunities for improvement

Understanding the Gaps in the Reporting of COPD Exacerbations by Patients: A Review

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with loss of lung function, poor quality of life, loss of exercise capacity, risk of serious cardiovascular events, hospitalization, and death. However, patients underreport exacerbations, and evidence suggests that unreported exacerbations have similar negative health implications for patients as those that are reported. Whilst there is guidance for physicians to identify patients who are at risk of exacerbations, they do not help patients recognise and report them. Newly developed tools, such as the COPD Exacerbation Recognition Tool (CERT) have been designed to achieve this objective. This review focuses on the underreporting of COPD exacerbations by patients, the factors associated with this, the consequences of underreporting, and potential solutions.

Comprehensive comorbidity assessment for the ECOPD: a long-term multi-centre retrospective study

BACKGROUND

Exacerbation of chronic obstructive pulmonary disease (ECOPD) results in severe adverse outcomes and mortality. It is often associated with increased local and systemic inflammation. However, individual susceptibility to exacerbations remains largely unknown. Our study aimed to investigate the association between comorbidities and exacerbation outcomes.

METHODS

We included patients with the primary discharge diagnosis of exacerbation for more 10 years in China. Data on all comorbidities were collected and analysed to determine the impact of the comorbidities on 1-year exacerbation readmission, length of hospital stay, and hospital cost. Univariable and multivariable logistic regression analyses were performed, and predictive models were developed.

RESULTS

This extensive investigation evaluated a total of 15,708 individuals from five prominent locations in China, revealing notable variations in the prevalence of comorbidities and healthcare expenses among different regions. The study shows that there is a high rate of readmission within one year, namely 15.8%. The most common conditions among readmitted patients are hypertension (38.6%), ischemic heart disease (16.9%), and diabetes mellitus (16.6%). An extensive multivariable study revealed that age, gender, and particular comorbidities such as malnutrition and hyperlipidemia are important factors that can significantly predict greater readmission rates, longer hospital stays or increased healthcare costs. The multivariable models show a moderate to good ability to predict patient outcomes, with concordance index ranging from 0.701 to 0.752. This suggests that targeted interventions in these areas could improve patient outcomes and make better use of healthcare resources.

CONCLUSIONS

The results regarding the association between severe exacerbations and systemic disease status support the integration of systematic evaluation of comorbidities into the management of exacerbations and the intensification of treatment of important comorbidities as a appropriate measure for prevention of further exacerbations. Our models also provide a novel tool for clinicians to determine the risk of the 1-year recurrence of severe ECOPD in hospitalised patients.

PD-L1: From cancer immunotherapy to therapeutic implications in multiple disorders

The PD-L1/PD-1 signaling pathway is the gold standard for cancer immunotherapy. Therapeutic antibodies targeting PD-1, such as nivolumab (Opdivo) and pembrolizumab (Keytruda), and PD-L1, including atezolizumab (Tecentriq), durvalumab (Imfinzi), and avelumab (Bavencio) have received Food and Drug Administration approval and are currently being used to treat various cancers. Traditionally, PD-L1 is known as an immune checkpoint protein that binds to the PD-1 receptor on its surface to inhibit the activity of T cells, which are the primary effector cells in antitumor immunity. However, it also plays a role in cancer progression, which goes beyond traditional understanding. Here, we highlight the multifaceted mechanisms of action of PD-L1 in cancer cell proliferation, transcriptional regulation, and systemic immune suppression. Moreover, we consider the potential role of PD-L1 in the development and pathogenesis of diseases other than cancer, explore PD-L1-focused therapeutic approaches for these diseases, and assess their clinical relevance. Through this review, we hope to provide deeper insights into the PD-L1/PD-1 signaling pathway and present a broad perspective on potential therapeutic approaches for cancer and other diseases.

A comprehensive review of Mycoplasma pneumoniae infection in chronic lung diseases: recent advances in understanding asthma, COPD, and bronchiectasis

This review summarizes the research progress over the past 30 years on the relationship between Mycoplasma pneumoniae infection and chronic respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), and bronchiectasis. Mycoplasma pneumoniae is a common cause of community-acquired pneumonia, particularly in children and young adults. Key findings from recent studies indicate that M. pneumoniae infection is associated with a higher risk of asthma exacerbations and may contribute to the development of bronchiectasis in susceptible individuals. Additionally, emerging evidence suggests that M. pneumoniae-induced immune dysregulation plays a crucial role in the pathogenesis of chronic lung diseases. This review aims to summarize the current understanding of the potential links between M. pneumoniae pneumonia and various chronic respiratory conditions, including asthma, chronic obstructive pulmonary disease (COPD), and bronchiectasis. We discuss the epidemiological data, pathogenic mechanisms, clinical manifestations, and long-term consequences of M. pneumoniae-related respiratory illnesses. Additionally, we highlight the challenges in diagnosis and treatment, as well as future research directions in this field.

The malnutrition in AECOPD and its association with unfavorable outcomes by comparing PNI, GNRI with the GLIM criteria: a retrospective cohort study

Introduction

The management of nutritional risk has garnered significant attention in individuals diagnosed with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) due to the high prevalence of malnutrition and its correlation with unfavorable outcomes. While numerous rating scales exist to assist in assessment for both clinical and research purposes, there is considerable variability in the selection of scales based on the characteristics of the study participants and the study design. The objective of this study was to examine the efficacy of the Geriatric Nutritional Risk Index (GNRI) and Prognostic Nutritional Index (PNI) in identifying malnutrition and predicting prognosis in elderly AECOPD patients.

Methods

From January 2022 to December 2022, a consecutive inclusion of elderly AECOPD patients admitted to the First Affiliated Hospital of Zhengzhou University was conducted. Diagnosing malnutrition in patients using PNI and GNRI, comparing the results with the diagnostic outcomes based on the Global Leadership Initiative on Malnutrition (GLIM) criteria through Receiver Operating Characteristic curves. Logistic regression analysis was employed to assess the risks associated with length of stay (LOS), hospitalization costs, and Charlson Comorbidity Index (CCI) based on GLIM, GNRI, or PNI.

Results

A total of 839 elderly AECOPD patients were investigated in the study. The GNRI and PNI demonstrated a sensitivity of 89.5 and 74.1%, specificity of 77.2 and 66.4%, and an area under the curve of 0.834 and 0.702, respectively. The identification of high malnutrition-risk cases using the GLIM, GNRI and PNI were associated with a significant increase in the risk of LOS over 7 days [odds ratio (95% CI) for GLIM, GNRI, PNI: 1.376 (1.033-1.833); 1.405 (1.070-1.846); 1.875 (1.425-2.468)] and higher hospitalization expenses [OR (95% CI) for GLIM, GNRI: 1.498 (1.080-2.080); 1.510 (1.097-2.079)], but not with the CCI.

Conclusion

According to our study, it is possible to use GNRI and PNI as alternatives to GLIM in the context of AECOPD, which makes it easier to identify malnutrition. The utilization of GNRI and PNI as alternatives to GLIM in the context of AECOPD enables the identification of malnutrition. The presence of malnourished individuals experiencing AECOPD is correlated with higher probabilities of extended hospital stays and escalated in-hospital expenses.

The Biomarker Potential of the Neutrophil-to-Lymphocyte Ratio in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background Chronic obstructive pulmonary disease (COPD) is characterized by periods of exacerbations and seasonal variations due to the recruitment of inflammatory cells. Various cells, such as neutrophils, lymphocytes, and the inflammatory mediators released by them, play a role in its pathogenesis. The current study was conducted to determine the role of the neutrophil-to-lymphocyte ratio (NLR) as a marker in acute exacerbation of COPD (AECOPD). Materials and methods We conducted a cross-sectional observational study at a tertiary care center in Western Maharashtra over six months after receiving approval from the institutional ethics committee. The study included 50 patients with AECOPD and 30 age and gender-matched controls without COPD. The patients were examined with a detailed history, complete blood count, and spirometry. The NLR was calculated and patients' disease severity was assessed using Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging. Results The mean age in the AECOPD group was 67.5 ± 12.5 years, whereas it was 46.2 ± 18.5 years in the control group. There was a male predominance in the AECOPD group (32/50). The majority of patients were in the GOLD stage 2 (42/50), followed by GOLD stage 3 (7/50). A total of 28 out of 50 AECOPD patients required admission to the medical intensive care unit. In the AECOPD group, 39 were smokers, and 11 were nonsmokers. Smoking was significantly associated with AECOPD when compared with controls. The mean NLR was 10.9 ± 10.2 in AECOPD patients and 4.3 ± 3.1 in the controls. Among cases with high NLR (≥5), seven required mechanical ventilation, 13 required noninvasive ventilation (NIV), and six succumbed to death. The mean duration of mechanical ventilation in this group was 12.5 ± 4.5 days, and for NIV, it was 7.5 ± 5.5 days. Conversely, patients with lower NLR (≤5) were more likely to avoid artificial ventilation and had a better in-hospital outcome. Conclusion COPD exacerbations can harm a patient's health, lead to disease progression, and increase mortality rates. Predicting exacerbations in advance can aid in early detection and treatment. NLR is an inexpensive, noninvasive, and easily available marker of inflammation and a predictor of outcome in AECOPD patients and hence should be calculated routinely in all patients with COPD.

The care cascade of chronic obstructive pulmonary disease in China: a cross-sectional study of individual-level data at enrolment into the national 'Happy Breathing' Programme

Background

Understanding the chronic obstructive pulmonary disease (COPD) care cascade is crucial for identifying where and when to intervene to improve COPD outcomes. We aimed to determine the proportion of patients with COPD seeking care in China's health system who are lost at each stage of the COPD care cascade and how the patterns of loss vary across geographical regions and population groups.

Methods

From November 3, 2018, to April 22, 2021, we used individual-level patient data from the national Chinese 'Happy Breathing' Programme, which aims to identify patients with COPD and provide appropriate care. COPD was defined as a post-bronchodilator ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) <0.70. We calculated the proportions of individuals who, at enrolment into the 'Happy Breathing' Programme, (i) had ever undergone a pulmonary function test, (ii) had been diagnosed with COPD in the past, (iii) were currently on treatment for COPD, and (iv) had achieved control of their COPD. We examined the association between reaching each stage of the care cascade and individual patient characteristics as well as regional-level economic development and available resources in the health system using multilevel regression.

Findings

Among the 29,201 patients with COPD in the 'Happy Breathing' Programme, 41.0% (95% confidence interval [CI]: 40.4-41.6%) had ever been tested for COPD, 17.6% (95% CI: 17.1-18.0%) had previously been diagnosed with COPD, 8.5% (95% CI: 8.2-8.8%) were currently on treatment for COPD, 4.6% (95% CI: 4.3-4.8%) of patients had mild or no exacerbations in the prior year, and 3.9% (95% CI: 3.7-4.2%) of patients had suffered no exacerbations in the prior year. On average, patients living in the cities of Beijing, Wuhan, and Yinchuan had progressed further along the COPD care cascade than patients living in Daqing and Luoyang. Using multilevel regression, we found that young age, rural residence, and low regional per-capita GDP were significantly associated with larger losses at each stage of the COPD care cascade.

Interpretation

Substantial proportions of patients with COPD are lost at each stage of the COPD care cascade in the Chinese health system. The largest losses occur during the initial stages of the cascade, when diagnosis first occurs. New policies and interventions are required to boost COPD care, especially screening and diagnosis, in the Chinese health system to reduce this large disease burden.

Funding

This work was supported by Major Programme of National Natural Science Foundation of China (82090011), CAMS Innovation Fund for Medical Sciences (CIFMS) (2021-I2M-1-049), and Horizon Europe (HORIZON-MSCA-2021-SE-01; project number 101086139-PoPMeD-SuSDeV). TB was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt professorship award.

New markers in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), a global healthcare and socioeconomic burden, is a multifaceted respiratory disorder that results in substantial decline in health status and life quality. Acute exacerbations of the disease contribute significantly to increased morbidity and mortality. Consequently, the identification of reliable and effective biomarkers for rapid diagnosis, prediction, and prognosis of exacerbations is imperative. In addition, biomarkers play a crucial role in monitoring responses to therapeutic interventions and exploring innovative treatment strategies. Although established markers such as CRP, fibrinogen and neutrophil count are routinely used, a universal marker is lacking. Fortunately, an increasing number of studies based on next generation analytics have explored potential biomarkers in COPD. Here we review those advances and the need for standardized validation studies in the appropriate clinical setting.

Lack of Association between Inhaled Corticosteroid Use Based on the Exhaled Nitric Oxide and Acute Exacerbation of Chronic Obstructive Pulmonary Disease

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is known to useful biomarker for detecting eosinophilic airway inflammation. However, there is a lack of evidence regarding the role of FeNO in chronic obstructive pulmonary disease (COPD). We aimed to assess whether elevated FeNO and its impact on treatment change into an inhaled corticosteroid (ICS)-containing regimen and association with acute exacerbation (AE) in patients with COPD.

METHODS

We retrospectively analyzed 107 COPD patients without a history of asthma from March 2016 to December 2019. The patients whose FeNO value was more than 50 parts per billion (ppb) were defined into the high FeNO group. Multivariable analysis with logistic regression was used to identify factors associated with AE in COPD.

RESULTS

The median FeNO value was 32 ppb (interquartile range, 19 to 45) and 34 (20.0%) patients were classified as high FeNO group (median 74 ppb). In the high FeNO group, changes in inhaler treatment into an ICS-containing regimen occurred in 23 of 34 patients after the measurement of FeNO. In multivariate analysis, high FeNO was not a contributing factor for AE, but only the high blood eosinophil count (≥300 cells/μL) was associated with AE (adjusted odds ratio, 2.63; 95% confidence interval, 1.01 to 6.91; p=0.049).

CONCLUSION

High FeNO value had a significant impact on the prescription of ICSs in COPD patients, but it did not show a significant association with AE either on its own or with changes in treatment.

Associations Between Air Pollution and the Onset of Acute Exacerbations of COPD: A Time-Stratified Case-Crossover Study in China

BACKGROUND

Associations between air pollution and the acute exacerbations (AEs) of COPD have been established primarily in time-series studies in which exposure and case data were at the aggregate level, limiting the identification of susceptible populations.

RESEARCH QUESTION

Are air pollutants associated with the onset of AEs of COPD in China? Who is more susceptible to the effects of air pollutants?

STUDY DESIGN AND METHODS

Data regarding AEs of COPD were obtained from the Acute Exacerbation of Chronic Obstructive Pulmonary Disease Registry study, and air pollution data were assigned to individuals based on their residential address. We adopted a time-stratified case-crossover study design combined with conditional logistic regression models to estimate the associations between six air pollutants and AEs of COPD. Stratified analyses were performed by individual characteristics, disease severity, COPD types, and the season of exacerbations.

RESULTS

A total of 5,746 patients were included. At a 2-day lag, for each interquartile range increase in fine particulate matter (PM2.5) and inhalable particulate matter (PM10) concentrations, ORs for AEs of COPD were 1.054 (95% CI, 1.012-1.097) and 1.050 (95% CI, 1.009-1.092), respectively. The associations were more pronounced in participants who were younger than 65 years, had experienced at least one severe AE of COPD in the past year, received a diagnosis of COPD between 20 and 50 years of age, and experienced AEs of COPD in the cool seasons. By contrast, significant associations for nitrogen dioxide, sulfur dioxide, and carbon monoxide lost significance when excluding patients collected before 2020 or with larger distance from the monitoring station, and no significant association was observed for ozone.

INTERPRETATION

This study provides robust evidence that short-term exposure to PM2.5 and PM10 was associated with higher odds of AEs of COPD onset. Individuals who are young, have severe COPD, or whose first diagnosis of COPD was made when they were between 20 and 50 years of age and experience an exacerbation during the cooler seasons may be particularly susceptible.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT2657525; URL: www.

CLINICALTRIALS

gov.

Development and validation of a prediction score to assess the risk of incurring in COPD-related exacerbations: a population-based study in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the fourth most important cause of death in high-income countries. Inappropriate use of COPD inhaled therapy, including the low adherence (only 10 %-40 % of patients reporting an adequate compliance) may shrink or even nullify the proven benefits of these medications. As such, an accurate prediction algorithm to assess at national level the risk of COPD exacerbation might be relevant for general practictioners (GPs) to improve patient's therapy.

METHODS

We formed a cohort of patients aged 45 years or older being diagnosed with COPD in the period between January 2013 to December 2021. Each patient was followed until occurrence of COPD exacerbation up to the end of 2021. Sixteen determinants were adopted to assemble the CopdEX(CEX)-Health Search(HS)core, which was therefore developed and validated through the related two sub-cohorts.

RESULTS

We idenfied 63763 patients aged 45 years or older being diagnosed with COPD (mean age: 67.8 (SD:11.7); 57.7 % males).When the risk of COPD exacerbation was estimated via CEX-HScore, its predicted value was equal to 14.22 % over a 6-month event horizon. Discrimination accuracy and explained variation were equal to 66 % (95 % CI: 65-67 %) and 10 % (95 % CI: 9-11 %), respectively. The calibration slope did not significantly differ from the unit (p = 0.514).

CONCLUSIONS

The CEX-HScore was featured by fair accuracy for prediction of COPD-related exacerbations over a 6-month follow-up. Such a tool might therefore support GPs to enhance COPD patients' care, and improve their outcomes by facilitating personalized approaches through a score-based decision support system.

Risk Factors Associated with Misuse of Soft Mist Inhaler in Patients with Chronic Obstructive Pulmonary Disease

Purpose

The use of inhaled bronchodilators is the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Although the soft mist inhaler (SMI) was developed to overcome the disadvantages of pressurized metered dose and drug powder inhalers, misuse during handling has been frequently observed in many studies. However, few studies have focused on SMI misuse among patients with COPD. Thus, we aimed to assess and identify the risk factors associated with SMI misuse among patients with COPD.

Patient and Methods

In this prospective, observational, cross-sectional study, we enrolled patients with COPD who were undergoing SMI treatment between January 2018 and March 2020. An advanced nurse practitioner assessed the participants' handling of the device by using a check list.

Results

Among 159 participants, 136 (85.5%) reported inhaler misuse. Duration of COPD and COPD assessment test (CAT) scores were positively associated with inhaler misuse; adherence and education level were negatively associated with inhaler misuse. In the multivariable analysis, a low educational level (less than high school), high CAT score (≥ 10), and short duration of COPD (≤ 2 years) were identified as risk factors for SMI misuse.

Conclusion

SMI misuse remains common among patients with COPD. Therefore, clinicians should pay close attention to their patients using SMIs, especially in the early period after the diagnosis of COPD.

The use of antibiotics in the early stage of acute exacerbation of chronic obstructive pulmonary disease in patients without obvious signs of infection: a multicenter, randomized, parallel-controlled study

Introduction

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with high prevalence and mortality. In some acute exacerbations of COPD (AECOPD) in patients with no obvious signs of infection, early antibiotic treatment seems to clinically improve the disease, but more studies are needed to determine the prognostic impact of antibiotic treatment in AECOPD patients with no obvious signs of infection.

Purpose

To clarify the impact of antibiotic treatment on the short-term and long-term prognoses of AECOPD patients without obvious signs of infection.

Methods

The impact of the two treatment methods on the prognosis of patients was compared at 30, 90, 180, and 360 days after discharge. A multicenter, randomized, parallel-controlled clinical trial was conducted in a department of respiratory and critical care medicine in Central China. All patients met the inclusion criteria for AECOPD, and the patients were randomly assigned to the antibiotic group or the nonantibiotic group at a 1:1 ratio. Patients in the antibiotic group were given moxifloxacin 400 mg/day intravenously for 7 days. Patients in the nonantibiotic group were intravenously injected with the same amount of normal saline as the amount of moxifloxacin given to those in the antibiotic group for 7 days.

Results

There were 406 patients in the antibiotic group and 410 patients in the nonantibiotic group. During the short-term and long-term follow-ups, the acute exacerbation frequency, intensive care unit (ICU) treatment rate, mortality, and mMRC and CAT scores were not significantly different between the two groups (p > 0.05). At the 180- and 360-day follow-ups, the forced expiratory volume in 1 s (FEV1%) and peak expiratory flow (PEF) were not significantly different between the two groups (p > 0.05). The 30-day readmission rate was significantly lower in the antibiotic group than in the nonantibiotic group (p < 0.05). The time from discharge to the first acute exacerbation was not significantly different between the two groups (p > 0.05). The length of the first hospital stay after discharge was significantly lower in the antibiotic group (5.84 days) than in the nonantibiotic group (6.75 days) (p < 0.05). At the 30-day follow-up, the acute exacerbation frequency, age, C-reactive protein (CRP) level, and sputum viscosity were significantly greater in the nonantibiotic group than in the antibiotic group (p < 0.05). In addition, according to the receiver operating characteristic (ROC) analysis, the frequency of acute exacerbations at the 30-day follow-up was significantly greater in COPD patients aged >62.5 years, with a CRP level >12.56 mg/L or with a sputum viscosity >III, in the nonantibiotic group than in those in the antibiotic group, suggesting that the short-term prognosis was poor.

Conclusion

Patients who are >62.5 years of age, have a CRP concentration >12.56 mg/L, or have a sputum viscosity >III without obvious signs of infection should be treated with antibiotics to improve their short-term prognosis.

Clinical Trial Registration

(https://www.chictr.org.cn), (ChiCTR1800018921).

Clinical characterization and outcomes of impulse oscillometry-defined bronchodilator response: an ECOPD cohort-based study

BACKGROUND

The clinical significance of the impulse oscillometry-defined small airway bronchodilator response (IOS-BDR) is not well-known. Accordingly, this study investigated the clinical characteristics of IOS-BDR and explored the association between lung function decline, acute respiratory exacerbations, and IOS-BDR.

METHODS

Participants were recruited from an Early Chronic Obstructive Pulmonary Disease (ECOPD) cohort subset and were followed up for two years with visits at baseline, 12 months, and 24 months. Chronic obstructive pulmonary disease (COPD) was defined as a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio < 0.70. IOS-BDR was defined as meeting any one of the following criteria: an absolute change in respiratory system resistance at 5 Hz ≤ - 0.137 kPa/L/s, an absolute change in respiratory system reactance at 5 Hz ≥ 0.055 kPa/L/s, or an absolute change in reactance area ≤ - 0.390 kPa/L. The association between IOS-BDR and a decline in lung function was explored with linear mixed-effects model. The association between IOS-BDR and the risk of acute respiratory exacerbations at the two-year follow-up was analyzed with the logistic regression model.

RESULTS

This study involved 466 participants (92 participants with IOS-BDR and 374 participants without IOS-BDR). Participants with IOS-BDR had higher COPD assessment test and modified Medical Research Council dyspnea scale scores, more severe emphysema, air trapping, and rapid decline in FVC than those without IOS-BDR over 2-year follow-up. IOS-BDR was not associated with the risk of acute respiratory exacerbations at the 2-year follow-up.

CONCLUSIONS

The participants with IOS-BDR had more respiratory symptoms, radiographic structural changes, and had an increase in decline in lung function than those without IOS-BDR.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900024643. Registered on 19 July, 2019.

Predicting Response to In-Hospital Pulmonary Rehabilitation in Individuals Recovering From Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

Predicting the response to pulmonary rehabilitation (PR) could be valuable in defining admission priorities. We aimed to investigate whether the response of individuals recovering from a COPD exacerbation (ECOPD) could be forecasted using machine learning approaches.

METHOD

This multicenter, retrospective study recorded data on anthropometrics, demographics, physiological characteristics, post-PR changes in six-minute walking distance test (6MWT), Medical Research Council scale for dyspnea (MRC), Barthel Index dyspnea (BId), COPD assessment test (CAT) and proportion of participants reaching the minimal clinically important difference (MCID). The ability of multivariate approaches (linear regression, quantile regression, regression trees, and conditional inference trees) in predicting changes in each outcome measure has been assessed.

RESULTS

Individuals with lower baseline 6MWT, as well as those with less severe airway obstruction or admitted from acute care hospitals, exhibited greater improvements in 6MWT, whereas older as well as more dyspnoeic individuals had a lower forecasted improvement. Individuals with more severe CAT and dyspnea, and lower 6MWT had a greater potential improvement in CAT. More dyspnoeic individuals were also more likely to show improvement in BId and MRC. The Mean Absolute Error estimates of change prediction were 44.70m, 3.22 points, 5.35 points, and 0.32 points for 6MWT, CAT, BId, and MRC respectively. Sensitivity and specificity in discriminating individuals reaching the MCID of outcomes ranged from 61.78% to 98.99% and from 14.00% to 71.20%, respectively.

CONCLUSION

While the assessed models were not entirely satisfactory, predictive equations derived from clinical practice data might help in forecasting the response to PR in individuals recovering from an ECOPD. Future larger studies will be essential to confirm the methodology, variables, and utility.

Effectiveness of a new "focused pulse" high-frequency chest wall oscillation in patients with moderate to severe COPD

BACKGROUND

Chest physiotherapy plays a crucial role in the treatment of COPD, although the optimal techniques for airway clearance have not been definitively established. Among the different techniques, high-frequency chest wall oscillation (HFCWO) has gained attention for its potential to create a widespread lung percussion, facilitating the removal of secretions and potentially clearing the peripheral bronchial tree. This study aims to assess the effectiveness of a novel "focused pulse" HFCWO in patients with moderate to severe COPD.

METHODS

Sixty patients were randomized to three groups: a group treated with the PEP technique, a group with "focused pulse "HFCWO" and a group with pharmacological therapy alone (control group). The primary outcomes were changes in respiratory function parameters, changes in dyspnea and quality of life scores as well as daily life activity and health status assessment. The secondary outcomes were the number of exacerbations and the number of practitioner or emergency department (ED) visits after 1, 3, and 6 months.

RESULTS

Sixty patients concluded the study with 20 patients allocated to each group. The two devices improved respiratory function tests, quality of life and health scores and dyspnea compared to the control group. Maximal expiratory pressure and diffusing lung carbon oxide were significantly improved in the focused pulse HFCWO group compared to the PEP group. Only pulse-focused HFCWO showed a statistically significant lower number of exacerbations and visits to ED or practitioner compared to the control group.

CONCLUSIONS

The focused pulse HFCWO technique improves daily life activities and lung function in patients with stable COPD. The device demonstrated significantly greater effectiveness in lowering COPD exacerbations as well as visits to ED or practitioner.

Moderate-High Blood Eosinophilia Is Associated with Increased Hospitalization and Other Asthma Comorbidities

(1) Background: Eosinophilia has traditionally been linked to eosinophilic asthma, for which it is the gold-standard prognostic biomarker. However, the association between eosinophilia and the presence of other diseases and comorbidities is yet unclear. (2) Methods: For this retrospective study, we reviewed the electronic medical records of 49,909 subjects with blood eosinophilia to gather data on the presence of asthma, COPD, sleep apnea, tuberculosis, dyslipidemia, hypertension, and other cardiovascular diseases and severe CRSwNP among these subjects. Demographic features including age, sex, and smoking habits were collected, as well as the number of hospitalizations and emergency department visits. T-tests, ANOVA, Fisher test, and logistic regression models were used. (3) Results: For all age groups studied, eosinophilia was significantly more prevalent among asthmatic subjects than nonasthmatics, especially in patients also presenting CRSwNP, hypertension, and dyslipidemia. The likelihood of developing asthma, COPD, and CRSwNP, and hospitalization, was increased when BEC was above 600 eosinophils/μL. The association between asthma, CRSwNP, and BEC was corroborated by multiple logistic regressions models. (4) Conclusions: We demonstrated the association of having over 600 blood eosinophils/μL with a higher number of hospitalizations and comorbidities (CRSwNP and COPD), which proves that BEC is a highly useful parameter to consider in subjects who present blood eosinophilia.

Validation of the Rome Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbation: A Multicenter Cohort Study

Background

The Rome severity classification is an objective assessment tool for the severity of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) based on readily measurable variables but has not been widely validated. The aim of this study is to evaluate the validity of the Rome classification in distinguishing the severity of AECOPD based on short-term mortality and other adverse outcomes.

Methods

The Rome severity classification was applied to a large multicenter cohort of inpatients with AECOPD. Differences in clinical features, in-hospital and 60-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) and invasive mechanical ventilation (IMV) usage were compared among the mild, moderate and severe AECOPD according to the Rome proposal. Moreover, univariate logistic analysis and Kaplan Meier survival analysis were also performed to find the association between the Rome severity classification and those adverse outcomes.

Results

A total of 7712 patients hospitalized for AECOPD were included and classified into mild (41.88%), moderate (40.33%), or severe (17.79%) group according to the Rome proposal. The rate of ICU admission (6.4% vs 12.0% vs 14.9%, P <0.001), MV (11.7% vs 33.7% vs 45.3%, P <0.001) and IMV (1.4% vs 6.8% vs 8.9%, P <0.001) increased significantly with the increase of severity classification from mild to moderate to severe AECOPD. The 60-day mortality was higher in the moderate or severe group than in the mild group (3.5% vs 1.9%, 4.3% vs 1.9%, respectively, P <0.05) but showed no difference between the moderate and severe groups (2.6% vs 2.5%, P >0.05), results for in-hospital mortality showed the same trends. Similar findings were observed by univariate logistic analysis and survival analysis.

Conclusion

Rome severity classification demonstrated excellent performance in predicting ICU admission and the need for MV or IMV, but how it performs in differentiating short-term mortality still needs to be confirmed.

Predictive Role of White Blood Cell Differential Count for the Development of Acute Exacerbation in Korean Chronic Obstructive Pulmonary Disease

Purpose

Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterized by chronic inflammation. Acute exacerbation of COPD (AECOPD) manifests as acute worsening of respiratory symptoms and is associated with high morbidity and mortality. The aim of the present study was to evaluate the predictive value of white blood count (WBC) and its derived inflammatory biomarkers for AECOPD.

Methods

From the Korean COPD Subgroup Study cohort, a prospective and multicenter observational study, 826 patients who had baseline complete blood count (CBC) and 3-year AECOPD data were included. Follow-up CBC data at 1 (n = 385), 2 (n = 294), and 3 (n = 231) years were collected for available patients. The primary outcome was the occurrence of AECOPD at 3 years. The risk of AECOPD was evaluated using a binary logistic analysis.

Results

The cumulative incidences of 12-, 24-, and 36-month AECOPD were 47.6%, 60.5%, and 67.6%, respectively. Patients with AECOPD at 3 years had higher baseline WBC counts, neutrophil counts, neutrophil/lymphocyte ratio (NLR), and neutrophil/monocyte ratio than those without AECOPD. Higher WBC count, neutrophil count, and NLR were associated with the 3-year occurrence of AECOPD in the univariate analysis, but only the higher neutrophil count was a significant risk factor (odds ratio [OR] = 1.468; 95% confidence interval [CI]: 1.024-2.104) in the covariates-adjusted analysis. In the analysis of changes in inflammatory parameters, a decrease in the platelet count (OR = 0.502; 95% CI: 0.280-0.902) and NLR (OR = 0.535; 95% CI: 0.294-0.974) at 2 years and an increase in the eosinophil count (OR = 2.130; 95% CI: 1.027-4.416) at 3 years were significantly associated with AECOPD in the adjusted analysis.

Conclusion

Our data suggest that a high baseline WBC count, particularly neutrophil count, was associated with a higher incidence of long-term AECOPD.

The short- and long-term effects of lower limb endurance training on outpatients with chronic obstructive pulmonary disease

OBJECTIVE

To explore the short- and long-term effects of lower-limb endurance training on chronic obstructive pulmonary disease outpatients.

DESIGN

Prospective quasi-experimental study.

SETTING

1383-bed teaching hospital in Taiwan.

PARTICIPANTS

Overall, 69 outpatients diagnosed with chronic obstructive pulmonary disease were enrolled. A total of 60 patients completed the study.

INTERVENTION

Training group: Lower-limb endurance training; control group: Education only.

MAIN MEASURES

The modified medical research council score, chronic obstructive pulmonary disease assessment test score, pulmonary function test, and number of acute exacerbation within a year.

RESULTS

The training group showed significant improvement in the chronic obstructive pulmonary disease assessment test total score, modified medical research council score (both P < 0.001) at third month sustaining to 12th month (P < 0.001) and presented less events of acute exacerbation (P = 0.011) at 12th month. The chronic obstructive pulmonary disease assessment test decreased by 8 points sustaining to 12th month. The training group presented significant post-training functional capacity improvements in 6-min walking distance, lowest oxygen saturation during 6-min walking test, peak workload, maximum inspiratory/ expiratory pressures, and calf circumference.

CONCLUSIONS

The lower-limb endurance training improved perceived dyspnea in daily activity and health status after completion of training and sustaining for a year. The lower-limb endurance training alleviated disease impacted on reduced acute exacerbations.

Systematic Review and Meta-Analysis of Psychological Distress and Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Consequences

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) occasionally develop acute exacerbation of COPD-a potentially fatal condition. Psychological distress was associated with acute exacerbation of COPD. However, the evidence on the effect of psychological distress on acute exacerbation of COPD remains unclear.

OBJECTIVE

The aim of this study was to explore the influence of psychological distress on acute exacerbation of COPD and its consequences.

METHODS

The current review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, CINAHL, and PsyINFO) that were searched to identify relevant articles. Pooled risk ratios and 95% confidential interval were calculated from the included studies' data with random-effect methods to estimate the effect of psychological distress on acute exacerbation of COPD and its consequences.

RESULTS

Nineteen articles were included in the review. Most revealed that psychological distress was significantly associated with increased risk of acute exacerbation of COPD and its consequences. The meta-analyses showed that psychological distress increased risk of acute exacerbation of COPD, COPD-related hospitalization, and death.

CONCLUSION

Psychological distress had negative effects on acute exacerbation of COPD and its consequences. The results of the meta-analyses show that persons with COPD and psychological distress had a greater risk of acute exacerbation of COPD, hospitalization, and death.

The Management of Acute Exacerbations in COPD: A Retrospective Observational Study and Clinical Audit

(1) Background: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are not only associated with increased patient morbidity and mortality, but with extensive healthcare costs. Thus, adequate clinical management is crucial. The aim of this project was to evaluate the management of acute COPD exacerbations in a public teaching hospital in Switzerland. (2) Methods: We retrospectively analyzed clinical routine data of patients presenting with an acute exacerbation of COPD at the emergency department of a Swiss hospital between January 2019 and February 2020. Management was evaluated against recommendations from the GOLD 2019 report and previous audits. (3) Results: The data of 184 patients (mean age 73.5 years, range 41-95 years, 53% male) with 226 visits were included. While the documentation of GOLD stage (I-IV) and smoking status was consistent (81.0% and 91.6%), GOLD risk category (A-D) was only documented in 36% of the cases. Patients' respiratory rate upon presentation was measured in 73%, and blood gas analysis was performed in 70%. A total of 94% of the patients received a chest imaging; spirometry was performed in 10%. Initial symptomatic therapy with short acting bronchodilators was applied in 56%. Systemic steroid treatment was installed in 86%. Antibiotics were given in 56%, but in one fourth the indication was not clear. Non-invasive ventilation was applied in 25% of the indicated cases. Smoking cessation was recommended to 26% of the current smokers and referral to pulmonary rehabilitation was given in 16%. (4) Conclusion: GOLD recommendations were not comprehensively implemented, especially with regard to the assessment of severity, initial symptomatic therapy, and non-invasive ventilation. These results show the importance of the frequent revision of routine practice and may help to create awareness among practitioners and ultimately improve the quality of COPD management.

Short- and Long-Term Impact of Prior Chronic Obstructive Pulmonary Disease Exacerbations on Healthcare Resource Utilization and Related Costs: An Observational Study (SHERLOCK)

The observational retrospective cohort Study on HEalthcare Resource utiLization (HCRU) related to exacerbatiOns in patients with COPD (SHERLOCK; D5980R00014) evaluated exacerbation-related HCRU and costs using the U.K. National Health Service Greater Glasgow and Clyde Health Board data. Patients (≥40 years) with COPD were stratified by exacerbations one year before the index date: Group A (none), B (1 moderate), C (1 severe) and D (≥2 moderate and/or severe). All-cause and COPD-related HCRU and costs were assessed over 36 months. Adjusted rate ratios (RRs) or relative costs versus Group A were estimated using generalized linear models with appropriate distributions and link functions. The study included 22 462 patients (Group A, n = 7788; B, n = 5151; C, n = 250 and D, n = 9273). At 12 months, RRs (95% CI) versus Group A for all-cause and COPD-related HCRU, respectively, were highest in Groups C (1.28 [1.18, 1.39] and 1.18 [1.09, 1.29]) and D (1.26 [1.23, 1.28] and 1.29 [1.26, 1.31]). General practitioner and outpatient visits, and general ward stays/days accounted for the greatest COPD-related HCRU. All-cause and COPD-related relative costs (95% CI) versus Group A at 12 months, respectively, were 1.03 (0.94, 1.12) and 1.06 (0.99, 1.13) in Group B; 1.47 (1.07, 2.01) and 1.54 (1.20, 1.97) in Group C; 1.47 (1.36, 1.58) and 1.63 (1.54, 1.73) in Group D. Increased HCRU and costs in patients with exacerbation histories persisted at 36 months, demonstrating the sustained impact of exacerbations. The study suggests the importance of management and prevention of exacerbations through intervention optimization and budgeting by payers for exacerbation-related costs.

Therapeutic potential of Lianhua Qingke in airway mucus hypersecretion of acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Lianhua Qingke (LHQK) is an effective traditional Chinese medicine used for treating acute tracheobronchitis. In this study, we evaluated the effectiveness of LHQK in managing airway mucus hypersecretion in the acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

The AECOPD model was established by subjecting male Wistar rats to 12 weeks of cigarette smoke (CS) exposure (80 cigarettes/day, 5 days/week for 12 weeks) and intratracheal lipopolysaccharide (LPS) exposure (200 μg, on days 1, 14, and 84). The rats were divided into six groups: control (room air exposure), model (CS + LPS exposure), LHQK (LHQK-L, LHQK-M, and LHQK-H), and a positive control group (Ambroxol). H&E staining, and AB-PAS staining were used to evaluate lung tissue pathology, inflammatory responses, and goblet cell hyperplasia. RT-qPCR, immunohistochemistry, immunofluorescence and ELISA were utilized to analyze the transcription, expression and secretion of proteins related to mucus production in vivo and in the human airway epithelial cell line NCI-H292 in vitro. To predict and screen the active ingredients of LHQK, network pharmacology analysis and NF-κB reporter system analysis were employed.

RESULTS

LHQK treatment could ameliorate AECOPD-triggered pulmonary structure damage, inflammatory cell infiltration, and pro-inflammatory cytokine production. AB-PAS and immunofluorescence staining with CCSP and Muc5ac antibodies showed that LHQK reduced goblet cell hyperplasia, probably by inhibiting the transdifferentiation of Club cells into goblet cells. RT-qPCR and immunohistochemistry of Muc5ac and APQ5 showed that LHQK modulated mucus homeostasis by suppressing Muc5ac transcription and hypersecretion in vivo and in vitro, and maintaining the balance between Muc5ac and AQP5 expression. Network pharmacology analysis and NF-κB luciferase reporter system analysis provided insights into the active ingredients of LHQK that may help control airway mucus hypersecretion and regulate inflammation.

CONCLUSION

LHQK demonstrated therapeutic effects in AECOPD by reducing inflammation, suppressing goblet cell hyperplasia, preventing Club cell transdifferentiation, reducing Muc5ac hypersecretion, and modulating airway mucus homeostasis. These findings support the clinical use of LHQK as a potential treatment for AECOPD.

Controlling Nutritional Status Score as a Predictor for Chronic Obstructive Pulmonary Disease Exacerbation Risk in Elderly Patients

The Controlling Nutritional Status (CONUT) score is a simple screening tool able to assess poor nutritional status as well as to predict clinical adverse outcomes in different clinical settings. No data are available in older patients with chronic obstructive pulmonary disease (COPD). This study aimed to investigate the CONUT score as a predictor of frequent exacerbations. We retrospectively enrolled 222 patients aged 65 years or older, classified in two groups according to the number of exacerbations (or hospitalizations because AECOPD) during the previous year. The two groups were further divided according to low (<5) or high (≥5) CONUT scores. A total of 67.2% of frequent exacerbators had a high CONUT score. These patients exhibited a significantly higher CAT score, lower FEV1 percentage value, and higher prevalence of severe GOLD stages compared to those with low CONUT. Multivariate analysis showed that a CONUT score ≥ 5 was the best independent predictor (OR 20.740, p < 0.001) of the occurrence of ≥2 exacerbations (or 1 hospitalization) during the previous year. The CONUT score seemed to have a high prognostic value for frequent exacerbations for COPD in older patients. The predictive role of different CONUT score cut-off values needs to be validated in larger COPD populations in future multi-center, prospective clinical studies.

Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review

This scoping review summarized the evidence regarding the impact of acute exacerbations of COPD (AECOPD) on patients' health status beyond pulmonary function. PubMed, Embase, and Web of Science were searched. Prospective cohort studies assessing the health status of patients with COPD in a stable phase of the disease and after a follow-up period (where at least one AECOPD occurred) were included. An integrated assessment framework of health status (i.e., physiological functioning, complaints, functional impairment, quality of life) was used. Twenty-two studies were included. AECOPD acutely affected exercise tolerance, quadriceps muscle strength, physical activity levels, symptoms of dyspnoea and fatigue, and impact of the disease. Long-term effects on quadriceps muscle strength, symptoms of dyspnoea and depression, and quality of life were found. Repeated exacerbations negatively impacted the fat-free mass, levels of dyspnoea, impact of the disease and quality of life. Conflicting evidence was found regarding the impact of repeated exacerbations on exercise tolerance and physical activity levels. AECOPD have well-established acute and long-term adverse effects on health status beyond pulmonary function; nevertheless, the recovery trajectory and the impact of repeated exacerbations are still poorly studied. Further prospective research is recommended to draw firm conclusions on these aspects.

Beta-blockers reduce severe exacerbation in patients with mild chronic obstructive pulmonary disease with atrial fibrillation: a population-based cohort study

BACKGROUND AND OBJECTIVE

Beta-blockers (BBs) decrease mortality and acute exacerbation (AE) rates in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular disease; however, information on their effects in patients with COPD and atrial fibrillation (AF) is limited. We aimed to assess the AE risk in patients with different severities of COPD and AF receiving BBs compared with that in patients receiving calcium channel blockers (CCBs).

METHODS

This retrospective cohort study used data from the Taiwan National Health Insurance Database from 2009 to 2018. Outcomes included AE-related emergency room visits and hospitalisation. HRs and 95% CIs were estimated using the Cox proportional hazards model. COPD severity was classified as mild or severe based on exacerbation history. Sensitivity analyses included treatment and subgroup analyses, and competing risk adjustment.

RESULTS

After propensity score matching, 4486 pairs of BB and CCB users from 13 462 eligible patients were included. The exacerbation risk for BB users was lower (HR 0.80; 95% CI 0.72 to 0.89) than that of CCB users. After stratification, BB benefits persisted in the mild COPD group (HR 0.75; 95% CI 0.66 to 0.85), unlike the severe COPD group (HR 0.95; 95% CI 0.75 to 1.20). The results of the subgroup analysis showed consistent protective effects even in patients without heart failure or myocardial infarction (adjusted HR 0.82; 95% CI 0.71 to 0.94).

CONCLUSION

We found that BB use in patients with mild COPD and AF was associated with a lower exacerbation risk than CCB use, and that close monitoring of BB use in patients with severe COPD and AF is warranted.

Pulmonary rehabilitation for acute exacerbations of COPD: A systematic review

INTRODUCTION AND OBJECTIVES

This systematic review summarized the evidence on the effects (benefits and harms) of pulmonary rehabilitation for individuals with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

MATERIAL AND METHODS

We included randomized controlled trials comparing pulmonary rehabilitation to either active interventions or usual care regardless of setting. In March 2022, we searched MEDLINE, Scopus, CENTRAL, CINAHL and Web of Sciences, and trial registries. Record screening, data extraction and risk of bias assessment were undertaken by two reviewers. We assessed the certainty of the evidence using the GRADE approach.

RESULTS

This systematic review included 18 studies (n = 1465), involving a combination of mixed settings (8 studies), inpatient settings (8 studies), and outpatient settings (2 studies). The studies were at high risk of performance, detection, and reporting biases. Compared to usual care, pulmonary rehabilitation probably improves AECOPD-related hospital readmissions (relative risk 0.56, 95% CI 0.36 to 0.86; moderate certainty evidence) and cardiovascular submaximal capacity (standardized mean difference 0.73, 95% CI 0.48 to 0.99; moderate certainty evidence). Low certainty evidence suggests that pulmonary rehabilitation may be beneficial on re-exacerbations, dyspnoea, and impact of disease. The evidence regarding the effects of pulmonary rehabilitation on health-related quality of life and mortality is very uncertain (very low certainty evidence).

CONCLUSION

Our results indicate that pulmonary rehabilitation may be an effective treatment option for individuals with AECOPD, irrespective of setting. Our certainty in this evidence base was limited due to small studies, heterogeneous rehabilitation programs, numerous methodological weaknesses, and a poor reporting of findings that were inconsistent with each other. Trialists should adhere to the latest reporting standards to strengthen this body of evidence.

REGISTRATION

The study protocol was registered in Open Science Framework (https://osf.io/amgbz/).

Combined Pulmonary Fibrosis and Emphysema: A Narrative Review

Combined pulmonary fibrosis and emphysema (CPFE) syndrome refers to co-occurrence of two disease processes in the lung that can be difficult to diagnose but is associated with high morbidity and mortality burden. Diagnosis of CPFE is challenging because the two diseases can counterbalance respective impairments resulting in deceivingly normal-appearing chest radiography and spirometry in a dyspneic patient. Although an international committee published the terminology and definitions of CPFE in 2022, consensus on exact diagnostic criteria and optimal management strategy is yet to be determined. Herein, we provide a narrative review summarizing the literature on CPFE from 1990 to 2022, including historical background, epidemiology, pathogenesis, clinical features, imaging and pulmonary function findings, diagnosis, prognosis, complications, and treatment. Although CPFE was initially conceived as a variant presentation of idiopathic pulmonary fibrosis, it has been recognized to occur in patients with a wide variety of interstitial lung diseases, including connective tissue disease-associated interstitial lung diseases, and hypersensitivity pneumonitis. The affected patients have a heightened risk for pulmonary hypertension and lung cancer. Clinicians need to recognize the characteristic presenting features of CPFE along with prognostic implications of this entity.

Risk Factors for Recurrent Exacerbations in the General-Practitioner-Based Swiss Chronic Obstructive Pulmonary Disease (COPD) Cohort

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often suffer from acute exacerbations. Our objective was to describe recurrent exacerbations in a GP-based Swiss COPD cohort and develop a statistical model for predicting exacerbation.

METHODS

COPD cohort demographic and medical data were recorded for 24 months, by means of a questionnaire-based COPD cohort. The data were split into training (75%) and validation (25%) datasets. A negative binomial regression model was developed using the training dataset to predict the exacerbation rate within 1 year. An exacerbation prediction model was developed, and its overall performance was validated. A nomogram was created to facilitate the clinical use of the model.

RESULTS

Of the 229 COPD patients analyzed, 77% of the patients did not experience exacerbation during the follow-up. The best subset in the training dataset revealed that lower forced expiratory volume, high scores on the MRC dyspnea scale, exacerbation history, and being on a combination therapy of LABA + ICS (long-acting beta-agonists + Inhaled Corticosteroids) or LAMA + LABA (Long-acting muscarinic receptor antagonists + long-acting beta-agonists) at baseline were associated with a higher rate of exacerbation. When validated, the area-under-curve (AUC) value was 0.75 for one or more exacerbations. The calibration was accurate (0.34 predicted exacerbations vs 0.28 observed exacerbations).

CONCLUSION

Nomograms built from these models can assist clinicians in the decision-making process of COPD care.

Lung microbiota and potential treatment of respiratory diseases

The unique microbiome found in the lungs has been studied and shown to be associated with both pulmonary homeostasis and lung diseases. The lung microbiome has the potential to produce metabolites that modulate host-microbe interactions. Specifically, short-chain fatty acids (SCFAs) produced by certain strains of the lung microbiota have been shown to regulate immune function and maintain gut mucosal health. In response, this review described the distribution and composition of the microbiota in lung diseases and discussed the impact of the lung microbiota on health and lung disease. In addition, the review further elaborated on the mechanism of microbial metabolites in microbial-host interaction and their application in the treatment of lung diseases. A better understanding of the interaction between the microbiota, metabolites, and host will provide potential strategies for the development of novel methods for the treatment of pulmonary microbial induced lung diseases.

Clinical and Functional Effects of Inhaled Dual Therapy Umeclidinium/Vilanterol in Patients with Chronic Obstructive Pulmonary Disease: A Real-Life Study

Background

The pharmacological association umeclidinium/vilanterol (UMEC/VI) allows to implement a very effective dual bronchodilation in chronic obstructive pulmonary disease (COPD), thus optimizing bronchodilating therapy.

Methods

The main purpose of our real-world observational study was to evaluate in COPD patients the effects of UMEC/VI on lung function and respiratory symptoms. Functional and clinical parameters were assessed at baseline, and after 52 weeks of treatment with this combined double inhaled therapy.

Results

We enrolled 110 subjects suffering from COPD. A 12-month UMEC/VI treatment induced significant improvements in total lung capacity (TLC) (p < 0.05), and residual volume (RV) (p < 0.0001). Pulmonary deflation was paralleled by significant increases of forced expiratory volume in one second (FEV₁) (p < 0.0001), forced vital capacity (FVC) (p < 0.01), forced expiratory flow between 25% and 75% of FVC (FEF_25-75) (p < 0.0001) and diffusion capacity of the lung (DLCOcSB) (p < 0.05). In addition, in the same period, we also observed significant reductions of airway resistance including total resistance (R_tot) (p < 0.0001) and specific effective resistance (sR_eff) (p < 0.0001). Other improvements were detected with regard to modified British Medical Research Council (mMRC) questionnaire score (p < 0.0001), COPD Assessment Test (CAT) score (p < 0.0001), and COPD exacerbation rate (p < 0.0001). In particular, the reported changes of mMRC/CAT scores and COPD exacerbation numbers were significantly correlated with UMEC/VI-induced modifications of TLC, RV, FVC and FEV₁.

Conclusion

In conclusion, our study corroborates in a real-life context the effectiveness of UMEC/VI in COPD treatment. Indeed, our broad investigational strategy has allowed to better characterize the functional mechanisms underpinning the therapeutic properties of UMEC/VI association.

Long-term Telerehabilitation or Unsupervised Training at Home for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Rationale: Despite the benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD), many patients do not access or complete pulmonary rehabilitation, and long-term maintenance of exercise is difficult. Objectives: To compare long-term telerehabilitation or unsupervised treadmill training at home with standard care. Methods: In an international randomized controlled trial, patients with COPD were assigned to three groups (telerehabilitation, unsupervised training, or control) and followed up for 2 years. Telerehabilitation consisted of individualized treadmill training at home supervised by a physiotherapist and self-management. The unsupervised training group performed unsupervised treadmill exercise at home. The control group received standard care. The primary outcome was the combined number of hospitalizations and emergency department presentations. Secondary outcomes included time free from the first event; exercise capacity; dyspnea; health status; quality of life; anxiety; depression; self-efficacy; and subjective impression of change. Measurements and Main Results: A total of 120 participants were randomized. The incidence rate of hospitalizations and emergency department presentations was lower in telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94-1.46) and unsupervised training group (1.14; 95% CI, 0.92-1.41) than in the control group (1.88; 95% CI, 1.58-2.21; P < 0.001 compared with intervention groups). Telerehabilitation and unsupervised training groups experienced better health status for 1 year. Intervention participants reached and maintained clinically significant improvements in exercise capacity. Conclusions: Long-term telerehabilitation and unsupervised training at home in COPD are both successful in reducing hospital readmissions and can broaden the availability of pulmonary rehabilitation and maintenance strategies.

Implementation of offering choice of pulmonary rehabilitation location to people with COPD: a protocol for the process evaluation of a cluster randomised controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) is a core component of management people with chronic obstructive pulmonary disease (COPD); yet, people with COPD face significant barriers to attending centre-based PR programs. The emergence of new models of PR, remotely delivered directly into people's homes, has the potential to improve rehabilitation access and completion by providing patients with a choice of rehabilitation location (centre or home). However, offering patients a choice of rehabilitation model is not usual practice. We are undertaking a 14-site cluster randomised controlled trial to determine whether offering choice of PR location improves rehabilitation completion rates resulting in reduced all-cause unplanned hospitalisation over 12 months. The aim of this paper is to describe the protocol for the process evaluation of the HomeBase2 trial.

METHODS

A mixed methods process evaluation, to be undertaken in real time, has been developed in accordance with UK Medical Research Council (MRC) recommendations on process evaluation of complex interventions. This protocol describes the intended use of two theoretical frameworks (RE-AIM framework (Reach; Effectiveness; Adoption; Implementation; Maintenance) and Theoretical Domains Framework (TDF)) to synthesise findings and interpret data from a combination of qualitative (semi-structured interviews) and quantitative (questionnaires, clinical outcome data, intervention fidelity) methodologies. Data will be collected at an intervention, patient and clinician level. Qualitative and quantitative data will be used to derive context-specific potential and actual barriers and facilitators to offering patients choice of rehabilitation location. Acceptability and sustainability of the intervention will be evaluated for future scale-up.

DISCUSSION

The process evaluation described here will appraise the clinical implementation of offering a choice of rehabilitation program location for people with COPD. It will identify and evaluate key factors for future scale-up and sustainability and scale-up of offering choice of pulmonary rehabilitation program model for people.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04217330 Registration date: January 3 2020.

Adiponectin Increase in Patients Affected by Chronic Obstructive Pulmonary Disease with Overlap of Bronchiectasis

Chronic obstructive pulmonary disease (COPD) is characterized by respiratory symptoms and non-reversible airflow limitation with recurrent episodes of acute exacerbations. The concurrent presence of bronchiectasis in patients with COPD is associated with reduced respiratory function as well as increased exacerbation risk. Adiponectin is a promising biomarker in COPD, as greater high molecular weight (HMW) oligomer levels have been observed among COPD patients. Here, we investigate adiponectin levels in two groups of COPD patients characterized by the presence or absence of bronchiectasis (BCO), comparing both groups to healthy controls. We evaluated serum adiponectin levels in COPD patients, those with BCO, and healthy subjects and characterized the pattern of circulating adiponectin oligomers. We found that forced volume capacity % (FVC%) and forced expiratory volume % (FEV1%) were lower for BCO patients than for COPD patients. COPD patients had higher levels of adiponectin and its HMW oligomers than healthy controls. Interestingly, BCO patients had higher levels of adiponectin than COPD patients. We showed that expression levels of IL-2, -4, and -8, IFN-γ, and GM-CSF were significantly higher in BCO patients than in healthy controls. Conversely, IL-10 expression levels were lower in BCO patients. Our data suggest that the increased levels of adiponectin detected in the cohort of BCO patients compared to those in COPD patients without bronchiectasis might be determined by their worse airway inflammatory state. This hypothesis suggests that adiponectin could be considered as a biomarker to recognize advanced COPD patients with bronchiectasis.

Clusters of individuals recovering from an exacerbation of chronic obstructive pulmonary disease and response to in-hospital pulmonary rehabilitation

INTRODUCTION AND OBJECTIVES

Due to the present low availability of pulmonary rehabilitation (PR) for individuals recovering from a COPD exacerbation (ECOPD), we need admission priority criteria. We tested the hypothesis that these individuals might be clustered according to baseline characteristics to identify subpopulations with different responses to PR.

METHODS

Multicentric retrospective analysis of individuals undergone in-hospital PR. Baseline characteristics and outcome measures (six-minute walking test - 6MWT, Medical Research Council scale for dyspnoea -MRC, COPD assessment test -CAT) were used for clustering analysis.

RESULTS

Data analysis of 1159 individuals showed that after program, the proportion of individuals reaching the minimal clinically important difference (MCID) was 85.0%, 86.3%, and 65.6% for CAT, MRC, and 6MWT respectively. Three clusters were found (C1-severe: 10.9%; C2-intermediate: 74.4%; C3-mild: 14.7% of cases respectively). Cluster C1-severe showed the worst conditions with the largest post PR improvements in outcome measures; C3-mild showed the least severe baseline conditions, but the smallest improvements. The proportion of participants reaching the MCID in ALL three outcome measures was significantly different among clusters, with C1-severe having the highest proportion of full success (69.0%) as compared to C2-intermediate (48.3%) and C3-mild (37.4%). Participants in C2-intermediate and C1-severe had 1.7- and 4.6-fold increases in the probability to reach the MCID in all three outcomes as compared to those in C3-mild (OR = 1.72, 95% confidence interval [95% CI] = 1.2 - 2.49, p = 0.0035 and OR = 4.57, 95% CI = 2.68 - 7.91, p < 0.0001 respectively).

CONCLUSIONS

Clustering analysis can identify subpopulations of individuals recovering from ECOPD associated with different responses to PR. Our results may help in defining priority criteria based on the probability of success of PR.

COPD Exacerbation Syndrome: The Spanish Perspective on an Old Dilemma

The definition of exacerbation of COPD as a syndrome, as proposed by the Spanish COPD guidelines (GesEPOC) 2021 update, and the consequences that this implies, have direct implications on patient care. This review analyzes this novel vision of the COPD exacerbation syndrome, its rationale, and its clinical implications, as opposed to the traditional symptoms-based or event-based definitions. An exacerbation conceived as a syndrome provides us with an umbrella term to include a set of diverse alterations, which, either in isolation or more frequently in combination, are clinically expressed in a similar way in patients with COPD. In patients with COPD, this occurs as a consequence of worsening expiratory airflow limitation or the underlying inflammatory process, producing a worsening in symptoms with respect to the baseline situation. This definition therefore assumes a worsening in at least one of the two key physiopathological markers, lung function and inflammation. The main features of this new physiopathological proposal include a syndromic approach with narrower differential diagnosis, the use of several biomarkers, treatable traits to better guide treatment, and a new severity classification. Further research is needed to examine the role of eosinophils in this context, but currently, the early results are promising. The evaluation of severity is key in the multidimensional characterization of exacerbation and the GesEPOC 2021 proposes new approaches and also recommends the use of multidisciplinary scores for severity categorization in patients. Finally, another innovation in the GesEPOC 2021 refers to the recurrence of exacerbations, which has implications for disease prognosis or long-term clinical impact which need to be elucidated in further studies.

Significant Interrelations among Serum Annexin A1, Soluble Receptor for Advanced Glycation End Products (sRAGE) and rs2070600 in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a major cause of death and morbidity; it may be accompanied by oxidative stress and inflammation with or without underlying genetic etiology. Finding circulating biomarkers for COPD that can help early diagnosis and predict exacerbation and association with respiratory functions has been challenging. There were 40 healthy participants and 60 COPD patients in this research. The rs2070600 gene variant was examined by PCR-RFLP. Circulating sRAGE and annexin A1 levels were determined by ELISA. GSH and MDA were determined by spectrophotometry. In COPD patients, sRAGE serum levels were substantially lower, but conversely, annexin A1 levels were much greater than in controls. The rs2070600 gene polymorphism's strong association with COPD was demonstrated by genotyping and allelic frequency distribution. The GA genotype was most distributed in COPD, and it was strongly linked to lower serum sRAGE levels. The interrelation between annexin A1, sRAGE, and COPD could be explained through effects on inflammatory mediators' pathways. The rs2070600 gene polymorphism was found to significantly enhance the risk of COPD. Serum sRAGE and annexin A1 may be considered potential diagnostic tools for COPD. Through impacts on GSH and MDA levels that alter the release of inflammatory factors and, therefore, lung damage, it is possible to explain the relationship between annexin A1, sRAGE, and COPD.

Changes in Serum Immunoglobulin G Subclasses during the Treatment of Patients with Chronic Obstructive Pulmonary Disease with Infectious Exacerbations

Introduction: Despite the theoretical importance of serum immunoglobulin (Ig) in the outcome of COPD exacerbations, the existing evidence for this has not been enough. This study was performed to evaluate changes in serum Ig levels and their relationship with outcomes of acute infectious exacerbations in patients with COPD. Methods: The prospective study was conducted at Military Hospital 103 from August 2017 to April 2019. Group D patients with COPD with infectious exacerbation were selected for participation in the study. The control group consisted of 30 healthy people. The patients were provided clinical examination and laboratory service; simultaneously, we measured their serum Ig levels (total IgG, IgG1, IgG2, IgG3, IgG4) at two time points: at admission (T1) and the final health outcome (T2). Results: The median levels of total IgG in patients at times T1 and T2 were significantly lower compared with those in the healthy group (1119.3 mg/dL and 1150.6 mg/dL compared with 2032.2 mg/dL) (p < 0.001). Regarding changes among IgG subclasses, the IgG1, IgG3, and IgG4 levels measured at T1 and T2 were reduced significantly compared with the control group (p < 0.05); the IgG3 levels at T1 were significantly higher than those at T2. IgG3 levels in patients with life-threatening exacerbations were significantly lower than the remaining ones (24.6 (26.8−155.5) mg/dL and 25.6 (29.5−161.2) mg/dL, respectively, p = 0.023). Conclusions: In group D patients with COPD with infectious exacerbations, there was a decrease in the serum IgG, IgG1, IgG3, and IgG4 levels. IgG3 levels were associated with the severity of COPD exacerbation.

Characteristics of 12-Month Readmission for Hospitalized Patients with COPD: A Propensity Score Matched Analysis of Prospective Multicenter Study

Purpose

Hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is considered as severe exacerbations. Readmission for severe exacerbations is a crucial event for COPD patients. However, factors associated with readmission for severe exacerbations are incomplete. The study aimed to investigate different characteristics between the severe and non-severe exacerbation groups.

Patients and Methods

Patients hospitalized for severe AECOPD were included in multi-centers, and their exacerbations in next 12 months after discharge were recorded. According to exacerbations, patients were separated into the severe-exacerbation group and the non-severe exacerbation group. Propensity-score matching (PSM) and multivariable analyses were performed to compare the baseline characteristics of two groups. The Hosmer-Lemeshow test and receiver operating characteristic curve were applied to evaluate how well the model could identify clusters.

Results

The cohort included 550 patients with severe AECOPD across 27 study centers in China, and 465 patients were finally analyzed. A total of 41.5% of patients underwent readmission for AECOPD within 1 year. There were no significant differences in baseline characteristics between groups after PSM. Severe exacerbations in the 12 months were related to some factors, eg, the duration of COPD (13 vs 8 years, P<0.001), the COPD Assessment Test (CAT) score (20 vs 17, P<0.001), the blood eosinophil percentage (1.5 vs 2.0, P<0.05), and their inhaler therapies. Patients readmitted with AECOPD had a longer time of diagnosis (≥9 years), more symptoms (CAT ≥10), and lower blood eosinophils (Eos <2%). A clinical model was derived to help identify patients at risk of readmission with severe exacerbations.

Conclusion

These analyses confirmed the relevance of COPD at admission with future severe exacerbations. A lower blood eosinophils percentage appears to be related to readmission when combined with clinical history. Further studies are needed to evaluate whether this study can predict the risk of exacerbations.

Serum Creatinine/Cystatin C Ratio as a Predictor of In-hospital Mortality in Patients Hospitalized with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

Low serum creatinine/cystatin C ratio (CCR) is associated with unfavorable characteristics in patients with chronic obstructive pulmonary disease (COPD); however, the relationship between CCR and in-hospital mortality of patients with acute exacerbation of COPD (AECOPD) is unexplored. Our objective was to assess the value of CCR for predicting in-hospital mortality of patients hospitalized with AECOPD.

Methods

Patients with AECOPD (n = 597) were retrospectively enrolled. Patient’s clinical characteristics and laboratory tests, including serum cystatin C and creatinine, were reviewed. The prediction value of CCR was evaluated using area under the receiver operating characteristic curve (AUC) values. Factors potentially impacting in-hospital mortality were investigated using univariate and multivariate logistic regression analyses.

Results

Mortality rate during hospitalization was 10.05%. CCR was lower in non-surviving vs. survived patients (41.67 vs. 61.52, P < 0.001). AUC value for CCR for in-hospital mortality prediction was 0.79 [95% confidence interval (CI) 0.73–0.85]. On multivariate logistic regression analysis, in-hospital mortality was strongly associated with CCR < 52.27 [odds ratio (OR) 6.23, 95% CI (3.00–12.92), P < 0.001], age ≥ 81 years [OR 2.97, 95% CI (1.20–7.37), P = 0.019], oxygenation index < 300 [OR 3.28, 95% CI (1.27–8.44), P = 0.014], CRP > 8 mg/L [OR 1.84, 95% CI (1.15–2.95), P = 0.012], and D-dimer > 500 ng/L [OR 5.19, 95% CI (1.51–17.79), P = 0.009].

Conclusions

CCR was significantly lower, and is a potential prognostic indicator, in patients with AECOPD who died during hospitalization.

Factors associated with poor long-term adherence after completing a pulmonary rehabilitation programme in patients with chronic obstructive pulmonary disease

BACKGROUND: Although pulmonary rehabilitation programmes (PRPs) benefit patients with chronic obstructive pulmonary disease (COPD), poor adherence to these programmes is common. OBJECTIVE: This study aimed to analyse the factors associated with poor long-term adherence after completing a PRP. METHOD: We conducted a retrospective study of 70 patients with COPD who performed an 8-week outpatient PRP that included 24 sessions of aerobic training, skeletal muscle resistance exercises, physiotherapy and COPD education. The study classified the patients into 2 groups: (1) long-term adherence and (2) long-term non-adherence to the PRP. We considered long-term non-adherence when the patient did not attend the 32 weeks follow-up visit after beginning the PRP. We measured the degree of dyspnoea, quality of life, physical activity, anxiety-depression status, submaximal exercise capacity and COPD exacerbations in both groups. RESULTS: The patients’ median age was 69.6 [63.8–75.0] years, and 71.4% were men. The median forced expiratory volume in 1 second was 60.0 [47.7–68.0] % of that predicted. We observed total COPD exacerbations and severe COPD exacerbations in the last year in 32 (45.7%) and 22 (31.4%) patients, respectively. Dyspnoea, physical activity and quality of life significantly improved after completing the PRP. Long-term non-adherence to the PRP was observed in 32 (45.7%) patients. In the single regression model, severe COPD exacerbations (p = 0.04) and dyspnoea (p = 0.03) were associated with long-term non-adherence to the PRP. In the multiple regression model, only severe COPD exacerbations remained as an associated factor (OR 2.7; 95% CI 1.1–8,1; p = 0.04). CONCLUSION: Approximately half of patients who complete PRPs present long-term non-adherence to the programme. Severe COPD exacerbations are associated with long-term non-adherence.

Predictive Value of Serum Markers SFRP1 and CC16 in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) patients are particularly vulnerable to acute exacerbation, resulting in a huge socioeconomic burden.

Objective

In this study, we evaluated the value of serum secreted frizzled-related protein 1 (SFRP1) and Clara cell-secreted protein (CC16) in predicting the risk of acute exacerbations in patients with COPD.

Methods

The study included 123 COPD patients admitted to our hospital from May 2020 to June 2021, including 65 patients in stable stage (STCOPD group), 58 patients in acute exacerbation stage (AECOPD group), and 60 healthy volunteers (control group). Serum SFRP1 and CC16 levels were detected by enzyme-linked immunosorbent assay (ELISA). The receiver operating characteristics curve (ROC) analysis was performed to evaluate the sensitivity and specificity of serum SFRP1 and CC16 for predicting the risk of acute exacerbation in COPD patients.

Results

The age among groups is significantly different, but there is no difference in the gender and body mass index (BMI). The level of serum SFRP1 in the AECOPD group was significantly higher than that in the STCOPD group and the control group, and the level of serum CC16 was lower than that in the STCOPD group and the control group. Serum SFRP1 was negatively correlated with forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) (r = −0.473, P < 0.001). Serum CC16 was positively correlated with FEV₁/FVC (r = 0.457, P < 0.001). The area under the curve (AUC), sensitivity, and specificity of SFRP1 for predicting the risk of exacerbation was 0.847 (95% CI: 0.775 to 0.920), 86.20%, and 80.00%. The AUC, sensitivity, and specificity of CC16 for predicting the risk of exacerbation were 0.795 (95% CI: 0.711 to 0.879), 74.10%, and 86.20%.

Conclusions

These findings suggest that SFRP1 and CC16 may be useful serum markers for predicting the risk of exacerbation in COPD patients.

Assessment of Antibiotic Pharmacokinetics, Molecular Biomarkers and Clinical Status in Critically Ill Adults Diagnosed with Community-Acquired Pneumonia and Receiving Intravenous Piperacillin/Tazobactam and Hydrocortisone over the First Five Days of Intensive Care: An Observational Study (STROBE Compliant)

Severe community-acquired pneumonia (CAP) is a condition that frequently requires intensive care and, eventually, can cause to death. Piperacillin/tazobactam antibiotic therapy is employed as an empiric intravenous regimen, in many cases supplemented with intravenous bolus hydrocortisone treatment. The individual and condition-dependent pharmacokinetic properties of these drugs may lead to therapeutic failure. The impact of systemic inflammation, as well as of hydrocortisone on the altered pharmacokinetics of piperacillin is largely unknown. The protocol of a clinical study aimed at the characterization of the pharmacokinetics of piperacillin and tazobactam and its association with the concentrations of inflammatory markers and adrenal steroids during CAP therapy will be investigated in up to 40 critically ill patients. The serum concentrations of piperacillin and tazobactam, cortisol, cortisone, corticosterone and 11-deoxycortisol and interleukin-6 levels, as well as routine clinical chemistry and hematology parameters will be monitored from the beginning of treatment for up to five days. Nonparametric population pharmacokinetic modeling and Monte-Carlo simulations will be performed to make estimates of the pharmacokinetics of piperacillin and tazobactam and the probability of pharmacokinetic-pharmacodynamic target attainment. The observed individual characteristics and changes will be correlated with clinical and laboratory findings. The protocol of the observational study will be designed following the STROBE guideline.

Grupo de síntomas de enfermedad pulmonar obstructiva crónica y cuidados paliativos: una revisión sistemática

La enfermedad pulmonar obstructiva crónica (EPOC) es una entidad patológica que se caracteriza por una serie de manifestaciones físicas persistentes como tos, fatiga, disnea y producción de esputo; síntomas que generan malestar en el paciente desde el momento del diagnóstico y que, al ser una enfermedad irreversible por el daño tisular que causa, progresivamente va incidiendo de manera negativa en la calidad de vida. De otra parte, se ha reportado presencia de síntomas psicológicos como depresión, inseguridad, ansiedad y alteraciones emocionales en los pacientes diagnosticados con EPOC. Así mismo, los pacientes con este diagnóstico tienden a desarrollar comportamientos que alteran sus relaciones sociales familiares y laborales, por cuanto tienden a aislarse debido a la sintomatología, especialmente física. La situación planteada genera la necesidad de desarrollar un trabajo de investigación con el objetivo de reconocer el clúster de síntomas físicos, psicológicos y sociales de los pacientes diagnosticados con EPOC, e identificar si se plantea un abordaje desde la atención paliativa. El estudio se desarrolló mediante una revisión sistemática de literatura en la que se identificaron 1776 artículos, de los que se evaluaron 41 para la identificación del clúster de síntomas. Se identificó el binomio disnea y tos, fatiga y expectoración como el clúster de síntomas físicos; la depresión y la ansiedad constituyen el clúster de síntomas psicológicos, y el impacto en la calidad de vida y la percepción de aislamiento o exclusión social.

Association between anticoagulant therapy, exacerbations and mortality in a Danish cohort of patients with Chronic Obstructive Pulmonary Disease

OBJECTIVES

Pulmonary Embolism has been frequently reported in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AE-COPD). The study aimed to determine whether COPD patients who receive anticoagulant (AC) therapy have a reduced risk of hospitalization due to AE-COPD and death.

METHODS

This nationwide population-based study was based on data from the Danish Register of COPD (DrCOPD), which contains complete data on COPD outpatients between 1st January 2010 and 31st December 2018. National registers were used to obtain information regarding comorbidities and vital status. Propensity-score matching and Cox proportional hazards models were used to assess AE-COPD and death after one year.

RESULTS

The study cohort consisted of 58,067 patients with COPD. Of these, 5194 patients were on AC therapy. The population was matched 1:1 based on clinical confounders and AC therapy, resulting in two groups of 5180 patients. We found no association between AC therapy and AE-COPD or all-cause mortality in the propensity-score matched population (HR 1.03, 95% CI 0.96-1.10, p = 0.37). These findings were confirmed in a competing risk analysis. In the sensitivity analysis, we performed an adjusted analysis of the complete cohort and found a slightly increased risk of AE-COPD or death in patients treated with AC therapy. This study found a low incidence of pulmonary embolisms and deep venous thrombosis in both groups.

CONCLUSIONS

AC therapy was not associated with the risk of hospitalization due to AE-COPD or all-cause mortality.