Acute bronchodilator responsiveness and health outcomes in COPD patients in the UPLIFT trial

Chronic obstructive pulmonary disease (COPD) and COPD-like phenotypes

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease. Historically, two COPD phenotypes have been described: chronic bronchitis and emphysema. Although these phenotypes may provide additional characterization of the pathophysiology of the disease, they are not extensive enough to reflect the heterogeneity of COPD and do not provide granular categorization that indicates specific treatment, perhaps with the exception of adding inhaled glucocorticoids (ICS) in patients with chronic bronchitis. In this review, we describe COPD phenotypes that provide prognostication and/or indicate specific treatment. We also describe COPD-like phenotypes that do not necessarily meet the current diagnostic criteria for COPD but provide additional prognostication and may be the targets for future clinical trials.

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.

Bronchodilator Responsiveness in Tobacco-Exposed People With or Without COPD

BACKGROUND

Bronchodilator responsiveness (BDR) in obstructive lung disease varies over time and may be associated with distinct clinical features.

RESEARCH QUESTION

Is consistent BDR over time (always present) differentially associated with obstructive lung disease features relative to inconsistent (sometimes present) or never (never present) BDR in tobacco-exposed people with or without COPD?

STUDY DESIGN AND METHODS

We retrospectively analyzed data from 2,269 tobacco-exposed participants in the Subpopulations and Intermediate Outcome Measures in COPD Study with or without COPD. We used various BDR definitions: change of ≥ 200 mL and ≥ 12% in FEV1 (FEV1-BDR), change in FVC (FVC-BDR), and change in in FEV1, FVC or both (ATS-BDR). Using generalized linear models adjusted for demographics, smoking history, FEV1 % predicted after bronchodilator administration, and number of visits that the participant completed, we assessed the association of BDR group: (1) consistent BDR, (2) inconsistent BDR, and (3) never BDR with asthma, CT scan features, blood eosinophil levels, and FEV1 decline in participants without COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 0) and the entire cohort (participants with or without COPD).

RESULTS

Both consistent and inconsistent ATS-BDR were associated with asthma history and greater small airways disease (%parametric response mapping functional small airways disease) relative to never ATS-BDR in participants with GOLD stage 0 disease and the entire cohort. We observed similar findings using FEV1-BDR and FVC-BDR definitions. Eosinophils did not vary consistently among BDR groups. Consistent BDR was associated with FEV1 decline over time relative to never BDR in the entire cohort. In participants with GOLD stage 0 disease, both the inconsistent ATS-BDR group (OR, 3.20; 95% CI, 2.21-4.66; P < .001) and consistent ATS-BDR group (OR, 9.48; 95% CI, 3.77-29.12; P < .001) were associated with progression to COPD relative to the never ATS-BDR group.

INTERPRETATION

Demonstration of BDR, even once, describes an obstructive lung disease phenotype with a history of asthma and greater small airways disease. Consistent demonstration of BDR indicated a high risk of lung function decline over time in the entire cohort and was associated with higher risk of progression to COPD in patients with GOLD stage 0 disease.

Differences in clinical significance of bronchodilator responses measured by forced expiratory volume in 1 second and forced vital capacity

BACKGROUND

The clinical implication of bronchodilator response (BDR) is not fully understood. However, BDR is frequently present in patients with chronic obstructive pulmonary disease (COPD). We identified the differences in clinical features regarding BDR. In addition, we divided BDR into BDR for forced expiratory volume in 1 s (FEV1) and BDR for forced vital capacity (FVC; i.e., BDR-FEV1 and BDR-FVC, respectively) and analyzed clinical significance.

METHODS

We used data from the Korea COPD Subgroup Study, a multicenter cohort study of COPD patients recruited from 54 centers in South Korea since April 2012. We analyzed differences in baseline characteristics, 1-year exacerbation rate, and 3-year FEV1 decline between BDR negative and positive patients. Moreover, we analyzed the differences in clinical features between BDR-FEV1 positive and negative patients and between BDR-FVC positive and negative patients.

RESULTS

Of the 2,181 patients enrolled in this study, 366 (16.8%) were BDR positive. BDR positive patients were more likely to be ever-smokers and to have a lower body mass index and higher symptom scores compared to BDR negative patients. Baseline FEV1 and FEV1/FVC were lower in the BDR positive compared to the BDR negative group (1.7 ± 0.6 and 1.6 ± 0.5, respectively, p < 0.01; 50.9 ± 12.1 and 46.5 ± 14.8, respectively, p < 0.01). BDR positive patients were more likely to have been diagnosed with asthma-COPD overlap and to receive inhaled corticosteroids (ICS) than BDR negative patients. BDR-FVC patients were more likely to be smokers, suffer from worse symptoms and have lower lung function than those with no BDR-FVC. BDR had no significant effect on 1-year moderate to severe or severe exacerbation rates or 3-year annual FEV1 decline. Interactive effects of ICS and BDR on the exacerbation rate were not significant in any group.

CONCLUSIONS

In this study, BDR positive patients were more likely to be ever-smokers and to have worse symptoms and lung function than BDR negative patients. BDR-FVC was associated with worse symptom control and lung function compared to BDR-FEV1. However, there were no significant differences in exacerbation rate or decline in lung function in any BDR group. In addition, the effects of ICS on exacerbations were not significant in any group.

Bronchodilator Responsiveness Defined by the 2005 and 2021 ERS/ATS Criteria in Patients with Asthma as Well as Chronic Obstructive Pulmonary Disease

Background

In the 2021 ERS/ATS interpretive strategies for routine lung function tests, a positive bronchodilator response (BDR) was updated as a change of >10% relative to the predicted value in forced expiratory volume in 1 second (FEV₁) or forced vital capacity (FVC). We aimed to explore the differences between the 2005 and 2021 ERS/ATS criteria applied to patients with asthma as well as chronic obstructive pulmonary disease (COPD).

Methods

BDR test data about asthma patients aged 6–80 years and COPD patients aged 18–80 years were derived from the National Respiratory Medicine Center, First Affiliated Hospital of Guangzhou Medical University, from January 2017 to March 2022. BDR results defined by the 2005 and 2021 ERS/ATS criteria were named 2005-BDR and 2021-BDR, respectively. We compared differences between 2005-BDR and 2021-BDR and analyzed the trend in the proportion of positive BDR (BDR+) with the level of airflow obstruction.

Results

A total of 4457 patients with asthma and 7764 patients with COPD were included in the analysis. The percentages of 2005-BDR+ and 2021-BDR+ were 63.32% and 52.84% for asthma, 30.92% and 22.94% for COPD, respectively. Of patients with 2005-BDR+, 81.86% for asthma and 70.18% for COPD showed 2021-BDR+ results, and these patients had higher FEV₁%pred, FVC%pred (all P<0.05). Whichever BDR criterion was adopted, the proportion of BDR+ had an upward linear trend with the increased degree of airflow obstruction in COPD, but exhibited an approximate inverted U-shaped curve in asthma. In COPD, the proportion of BDR_FEV1 was negatively associated with the degree of airflow obstruction, while BDR_FVC was positively associated (all P<0.05).

Conclusion

Compared with 2005-BDR+, the proportion of 2021-BDR+ reduced markedly in patients with asthma and COPD, but their trends with the degree of airflow obstruction did not change. Patients with consistent BDR+ had higher initial FEV₁%pred and FVC%pred.

ERS/ATS technical standard on interpretive strategies for routine lung function tests

BACKGROUND

Appropriate interpretation of pulmonary function tests (PFTs) involves the classification of observed values as within/outside the normal range based on a reference population of healthy individuals, integrating knowledge of physiological determinants of test results into functional classifications and integrating patterns with other clinical data to estimate prognosis. In 2005, the American Thoracic Society (ATS) and European Respiratory Society (ERS) jointly adopted technical standards for the interpretation of PFTs. We aimed to update the 2005 recommendations and incorporate evidence from recent literature to establish new standards for PFT interpretation.

METHODS

This technical standards document was developed by an international joint Task Force, appointed by the ERS/ATS with multidisciplinary expertise in conducting and interpreting PFTs and developing international standards. A comprehensive literature review was conducted and published evidence was reviewed.

RESULTS

Recommendations for the choice of reference equations and limits of normal of the healthy population to identify individuals with unusually low or high results are discussed. Interpretation strategies for bronchodilator responsiveness testing, limits of natural changes over time and severity are also updated. Interpretation of measurements made by spirometry, lung volumes and gas transfer are described as they relate to underlying pathophysiology with updated classification protocols of common impairments.

CONCLUSIONS

Interpretation of PFTs must be complemented with clinical expertise and consideration of the inherent biological variability of the test and the uncertainty of the test result to ensure appropriate interpretation of an individual's lung function measurements.

Efficacy of umeclidinium/vilanterol according to the degree of reversibility of airflow limitation at screening: a post hoc analysis of the EMAX trial

Background

In patients with chronic obstructive pulmonary disease (COPD), the relationship between short-term bronchodilator reversibility and longer-term response to bronchodilators is unclear. Here, we investigated whether the efficacy of long-acting bronchodilators is associated with reversibility of airflow limitation in patients with COPD with a low exacerbation risk not receiving inhaled corticosteroids.

Methods

The double-blind, double-dummy EMAX trial randomised patients to umeclidinium/vilanterol 62.5/25 µg once daily, umeclidinium 62.5 µg once daily, or salmeterol 50 µg twice daily. Bronchodilator reversibility to salbutamol was measured once at screening and defined as an increase in forced expiratory volume in 1 s (FEV₁) of ≥ 12% and ≥ 200 mL 10−30 min post salbutamol. Post hoc, fractional polynomial (FP) modelling was conducted using the degree of reversibility (mL) at screening as a continuous variable to investigate its relationship to mean change from baseline in trough FEV₁ and self-administered computerised-Transition Dyspnoea Index (SAC-TDI) at Week 24, Evaluating Respiratory Symptoms-COPD (E-RS) at Weeks 21–24, and rescue medication use (puffs/day) over Weeks 1–24. Analyses were conducted across the full range of reversibility (−850–896 mL); however, results are presented for the range −100–400 mL because there were few participants with values outside this range.

Results

The mean (standard deviation) reversibility was 130 mL (156) and the median was 113 mL; 625/2425 (26%) patients were reversible. There was a trend towards greater improvements in trough FEV₁, SAC-TDI, E-RS and rescue medication use with umeclidinium/vilanterol with higher reversibility. Improvements in trough FEV₁ and reductions in rescue medication use were greater with umeclidinium/vilanterol compared with either monotherapy across the range of reversibility. Greater improvements in SAC-TDI and E-RS total scores were observed with umeclidinium/vilanterol versus monotherapy in the middle of the reversibility range.

Conclusions

FP analyses suggest that patients with higher levels of reversibility have greater improvements in lung function and symptoms in response to bronchodilators. Improvements in lung function and rescue medication use were greater with umeclidinium/vilanterol versus monotherapy across the full range of reversibility, suggesting that the dual bronchodilator umeclidinium/vilanterol may be an appropriate treatment for patients with symptomatic COPD, regardless of their level of reversibility.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01859-w.

Upper airway symptoms associate with the eosinophilic phenotype of COPD

BACKGROUND

There is growing evidence that upper airway symptoms coexist with lower airway symptoms in COPD. Still, the prevalence and impact of upper airway disease on the nature and course of COPD remain unclear. We aimed to describe this in a cross-sectional study.

METHODS

We examined a cohort of COPD patients with pulmonary function tests, induced sputum, blood eosinophils, atopy tests and computed tomography (CT) of the paranasal sinuses. Lower airway symptoms were assessed using the COPD Assessment Test (CAT), and upper airway symptoms were assessed using the nasal subdomain of the 22-item Sino Nasal Outcome Test (SNOT22nasal). We recruited patients from five sites in Denmark and Sweden. We excluded patients with a history of asthma.

FINDINGS

In total, 180 patients (female 55%, age 67±8 years, forced expiratory volume in 1 s (FEV1 %) 52.4±16.6, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage: A: 18%, B: 54%, C: 3%, D: 25%) were included in the study. Seventy-four patients (41%) reported high upper airway symptoms (UAS, defined as SNOT22nasal≥6) with a median score of 10 (IQR 8-13). Patients with high UAS reported higher CAT scores (17.4±7.5 versus 14.9±6.6, p<0.05) and displayed higher fractions of eosinophils in blood (median 3.0% (IQR 1.6-4.2%) versus 2.3% (IQR 1.4-3.1%), p<0.05) and in induced sputum (median 1.8% (IQR 0.3-7.1%) versus median 0.5% (IQR 0-1.7%), p<0.05). No differences in atopy, CT findings or exacerbation rates were observed.

CONCLUSION

COPD patients with upper airway disease showed increased evidence of eosinophilic disease and increased lower airway symptom burden.

What Is Asthma Chronic Obstructive Pulmonary Disease Overlap?

The term asthma chronic obstructive pulmonary disease (COPD) overlap (ACO) has been popularized to describe people who simultaneously have features of both diseases. Analysis of the basis of disease classification and comparison of the clinical, pathophysiological, and therapeutic features of asthma and COPD concludes that it is not useful to use the term ACO. Rather, it is important to make the individual diagnoses, recognizing that both diseases may coexist. If a concurrent diagnosis of COPD is suspected in people with asthma, pharmacotherapy should primarily follow asthma guidelines, but pharmacologic and nonpharmacologic approaches also may be needed for COPD.

Combined Forced Expiratory Volume in 1 Second and Forced Vital Capacity Bronchodilator Response, Exacerbations, and Mortality in Chronic Obstructive Pulmonary Disease

Rationale: The American Thoracic Society (ATS)/European Respiratory Society defines a positive bronchodilator response (BDR) by a composite of BDR in either forced expiratory volume in 1 second (FEV₁) and/or forced vital capacity (FVC) greater than or equal to 12% and 200 ml (ATS-BDR). We hypothesized that ATS-BDR components would be differentially associated with important chronic obstructive pulmonary disease (COPD) outcomes. Objectives: To examine whether ATS-BDR components are differentially associated with clinical, functional, and radiographic features in COPD. Methods: We included subjects with COPD enrolled in the COPDGene study. In the main analysis, we excluded subjects with self-reported asthma. We categorized BDR into the following: 1) No-BDR, no BDR in either FEV₁ or FVC; 2) FEV₁-BDR, BDR in FEV₁ but no BDR in FVC; 3) FVC-BDR, BDR in FVC but no BDR in FEV₁; and 4) Combined-BDR, BDR in both FEV₁ and FVC. We constructed multivariable logistic, linear, zero-inflated negative binomial, and Cox hazards models to examine the association of BDR categories with symptoms, computed tomography findings, change in FEV₁ over time, respiratory exacerbations, and mortality. We also created models using the ATS BDR definition (ATS-BDR) as the main independent variable. Results: Of 3,340 COPD subjects included in the analysis, 1,083 (32.43%) had ATS-BDR, 182 (5.45%) had FEV₁-BDR, 522 (15.63%) had FVC-BDR, and 379 (11.34%) had Combined-BDR. All BDR categories were associated with FEV₁ decline compared with No-BDR. Compared with No-BDR, both ATS-BDR and Combined-BDR were associated with higher functional residual capacity %predicted, greater internal perimeter of 10 mm, and greater 6-minute-walk distance. In contrast to ATS-BDR, Combined-BDR was independently associated with less emphysema (adjusted beta regression coefficient, -1.67; 95% confidence interval [CI], -2.68 to -0.65; P = 0.001), more frequent respiratory exacerbations (incidence rate ratio, 1.25; 95% CI, 1.03-1.50; P = 0.02) and severe exacerbations (incidence rate ratio, 1.34; 95% CI, 1.05-1.71; P = 0.02), and lower mortality (adjusted hazards ratio, 0.76; 95% CI, 0.58-0.99; P = 0.046). Sensitivity analysis that included subjects with self-reported history of asthma showed similar findings. Conclusions: BDR in both FEV₁ and FVC indicates a COPD phenotype with asthma-like characteristics, and provides clinically more meaningful information than current definitions of BDR.

Clinical Significance of Bronchodilator Responsiveness Evaluated by Forced Vital Capacity in COPD: SPIROMICS Cohort Analysis

Objective

Bronchodilator responsiveness (BDR) is prevalent in COPD, but its clinical implications remain unclear. We explored the significance of BDR, defined by post-bronchodilator change in FEV₁ (BDR_FEV1) as a measure reflecting the change in flow and in FVC (BDR_FVC) reflecting the change in volume.

Methods

We analyzed 2974 participants from a multicenter observational study designed to identify varying COPD phenotypes (SPIROMICS). We evaluated the association of BDR with baseline clinical characteristics, rate of prospective exacerbations and mortality using negative binomial regression and Cox proportional hazards models.

Results

A majority of COPD participants exhibited BDR (52.7%). BDR_FEV1 occurred more often in earlier stages of COPD, while BDR_FVC occurred more frequently in more advanced disease. When defined by increases in either FEV₁ or FVC, BDR was associated with a self-reported history of asthma, but not with blood eosinophil counts. BDR_FVC was more prevalent in subjects with greater emphysema and small airway disease on CT. In a univariate analysis, BDR_FVC was associated with increased exacerbations and mortality, although no significance was found in a model adjusted for post-bronchodilator FEV₁.

Conclusion

With advanced airflow obstruction in COPD, BDR_FVC is more prevalent in comparison to BDR_FEV1 and correlates with the extent of emphysema and degree of small airway disease. Since these associations appear to be related to the impairment of FEV₁, BDR_FVC itself does not define a distinct phenotype nor can it be more predictive of outcomes, but it can offer additional insights into the pathophysiologic mechanism in advanced COPD.

Clinical trials registration

ClinicalTrials.gov: NCT01969344T4.

A New Bronchodilator Response Grading Strategy Identifies Distinct Patient Populations

Rationale: A positive bronchodilator response (BDR) according to American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines require both 200 ml and 12% increase in forced expiratory volume in 1 second (FEV1) or forced vital capacity (FVC) after bronchodilator inhalation. This dual criterion is insensitive in those with high or low FEV1.Objectives: To establish BDR criteria with volume or percentage FEV1 change.Methods: The largest FEV1 and FVC were identified from three pre- and three post-bronchodilator maneuvers in COPDGene (Genetic Epidemiology of COPD) participants. A total of 7,741 individuals with coefficient of variation less than 15% for both FEV1 and FVC formed bronchodilator categories of FEV1 response: negative (≤0.00% or ≤0.00 L), minimal (>0.00% to ≤9.00% or >0.00 L to ≤0.09 L), mild (>9.00% to ≤16.00% or >0.09 L to ≤0.16 L), moderate (>16.00% to ≤26.00% or >0.16 L to ≤0.26 L), and marked (>26.00% or >0.26 L). These response size categories are based on empirical limits considering average FEV1 increase of approximately 160 ml and the clinically important difference for FEV1. To compare flow and volume response characteristics, BDR-FEV1 category assignments were applied for the BDR-FVC response.Results: Twenty percent met mild and 31% met moderate or marked BDR-FEV1 criteria, whereas 12% met mild and 33% met moderate or marked BDR-FVC criteria. In contrast, only 20.6% met ATS/ERS positive criteria. Compared with the negative BDR-FEV1 category, the minimal, mild, moderate, and marked BDR-FEV1 categories were associated with greater 6-minute-walk distance and lower St. George's Respiratory Questionnaire and modified Medical Research Council dyspnea scale scores. Compared with negative BDR, moderate and marked BDR-FEV1 categories were associated with fewer exacerbations, and minimal BDR was associated with lower computed tomography airway wall thickness. Compared with the negative category, all BDR-FVC categories were associated with increasing emphysema percentage and gas trapping percentage. Moderate and marked BDR-FVC categories were associated with higher St. George's Respiratory Questionnaire scores but fewer exacerbations and lower dyspnea scores.Conclusions: BDR grading by FEV1 volume or percentage response identified subjects otherwise missed by ATS/ERS criteria. BDR grades were associated with functional exercise performance, quality of life, exacerbation frequency, dyspnea, and radiological airway measures. BDR grades in FEV1 and FVC indicate different clinical and radiological characteristics.

Efficacy of Indacaterol/Glycopyrrolate in Patients with COPD by Airway Reversibility at Baseline: A Pooled Analysis of the FLIGHT1 and FLIGHT2 12-Week Studies

Bronchodilator reversibility occurs in patients with COPD. Pooled analysis of two 12-week, placebo-controlled randomised studies (FLIGHT1 [NCT01727141]; FLIGHT2 [NCT01712516]) assessed the effect of bronchodilator reversibility on lung function, patient-reported outcomes, and safety in 2,043 patients with moderate-to-severe COPD treated with indacaterol/glycopyrrolate (IND/GLY) 27.5/15.6 µg twice daily. Reversibility was defined as post-bronchodilator increase in forced expiratory volume in one second (FEV₁) of ≥12% and ≥0.200 L. Overall, mean reversibility (mean post-bronchodilator FEV₁ increase) was 22.8%, and 54.5% of patients met reversibility criteria. IND/GLY resulted in significant (p < 0.05) placebo-adjusted improvements from baseline at Week 12 in reversible and non-reversible patients in FEV₁ area under the curve from 0 to 12 hours (0.308 L and 0.170 L, respectively), trough FEV₁ (0.260 L and 0.174 L), St. George's Respiratory Questionnaire total score (-6.3 and -3.5), COPD Assessment Test total score (-2.3 and -1.2), daily rescue medication use (-1.52 and -0.79), and daily total symptom score (-0.86 and -0.63); Transition Dyspnoea Index focal score also showed improvements (1.93 and 1.29) at Week 12, irrespective of reversibility status. Improvements in lung function and rescue medication use were significantly (p < 0.05) greater in IND/GLY patients in the reversible subgroup compared with the non-reversible subgroup. The safety profile was similar across treatment groups and reversibility subgroups. Overall, treatment with IND/GLY led to significant improvements in lung function and PROs in patients with moderate-to-severe COPD, regardless of reversibility status, with greater improvements in the reversible subgroup. Safety profile was not affected by reversibility status.

Factors Associated with Indacaterol Response in Tuberculosis-Destroyed Lung with Airflow Limitation

Background

Pulmonary tuberculosis can result in anatomical sequelae, and cause airflow limitation. However, there are no treatment guidelines for patients with a tuberculosis-destroyed lung. Recently, indacaterol effectiveness in chronic obstructive pulmonary disease (COPD) patients with Tuberculosis history (INFINITY) study revealed indacaterol provided bronchodilation and symptom improvement in COPD patients with a tuberculosis-destroyed lung.

Methods

We conducted a post-hoc subgroup analysis of the randomized controlled trial, the INFINITY study, to determine factors associated with indacaterol response in a tuberculosis-destroyed lung with airflow limitation. Data from 68 patients treated with inhaled indacaterol, were extracted and analyzed. Factors associated with the response of forced expiratory volume in one second (FEV₁) to indacaterol treatment, were determined using linear regression analysis.

Results

Of 62 patients included, 68% were male, and 52% had history of cigarette smoking. Patients revealed mean FEV₁ of 50.5% of predicted value with mean improvement of 81.3 mL in FEV₁ after indacaterol treatment for 8 weeks. Linear regression analysis revealed factors associated with response of FEV₁ to indacaterol included a short duration of smoking history, and high short-acting bronchodilator response. When patients with history of smoking were excluded, factors associated with response of FEV₁ to indacaterol included high short-acting bronchodilator response, and poor healthrelated quality of life score as measured by St. George's Respiratory Questionnaire for COPD.

Conclusion

In a tuberculosis-destroyed lung with airflow limitation, short-acting bronchodilator response and smoking history can play a critical role in predicting outcomes of indacaterol treatment.

[Personalised COPD care: Where are we going?]

The concept of personalised medicine is recent but the underlying notions are not new: knowing how to adapt care to patients' characteristics is one of the components of the "art of medicine". The advances of science allow to refine considerably the applications of the concept in many fields of medicine including COPD: research has identified phenotypes, endotypes and treatable traits. Personalisation can be applied to all components of care. For instance, the decision to perform screening spirometry relies not only on risk factors (age, smoking, other exposures) but also on symptoms. Assessment of comorbidities often associated with COPD is based on risk factors and their combinations, variable between individuals. Rehabilitation and its components are in essence highly individualised, which a major condition for their success. Last but not least, personalisation of pharmacological therapy, which has long been rather poor, could not benefit from biomarkers of interest (predictive of response), such as blood eosinophil count. Practical strategies using these still need to be established, and new biomarkers may usefully enrich the collection!

Efficacy and safety of the direct switch to indacaterol/glycopyrronium from salmeterol/fluticasone in non-frequently exacerbating COPD patients: The FLASH randomized controlled trial

BACKGROUND AND OBJECTIVE

Combination long-acting β₂ -agonist/long-acting muscarinic antagonist (LABA/LAMA) has demonstrated superior clinical outcomes over LABA/inhaled corticosteroid (ICS) in chronic obstructive pulmonary disease (COPD) patients; however, data from blinded randomized controlled trials on direct switching from LABA/ICS to LABA/LAMA are lacking. FLASH (Assessment of switching salmeterol/Fluticasone to indacateroL/glycopyrronium in A Symptomatic COPD patient coHort) investigated if direct switch, without a washout period, from salmeterol/fluticasone (SFC) to indacaterol/glycopyrronium (IND/GLY) in COPD patients improves lung function and is well tolerated.

METHODS

In this 12-week, multicentre, double-blind study, patients with moderate-to-severe COPD and up to one exacerbation in previous year, receiving SFC for ≥3 months, were randomized to continue SFC 50/500 μg twice daily (bd) or switch to IND/GLY 110/50 μg once daily (od). Primary endpoint was pre-dose trough forced expiratory volume in 1 s (FEV₁ ) at Week 12.

RESULTS

In total, 502 patients were randomized (1:1) to IND/GLY or SFC. Patients switched to IND/GLY demonstrated superior lung function (pre-dose trough FEV₁ ) versus SFC at Week 12 (treatment difference (Δ) = 45 mL; P = 0.028). IND/GLY provided significant improvements in pre-dose trough forced vital capacity (FVC; Δ = 102 mL; P = 0.002) and numerical improvements in transition dyspnoea index (TDI; Δ = 0.46; P = 0.063). Rescue medication use and COPD assessment test (CAT) scores were comparable between groups. Both treatments had similar safety profiles.

CONCLUSION

FLASH demonstrated that a direct switch to IND/GLY from SFC improved pre-dose FEV₁ and FVC in COPD patients with up to one exacerbation in the previous year. No new safety signals were identified.

Asthma-like Features and Clinical Course of Chronic Obstructive Pulmonary Disease. An Analysis from the Hokkaido COPD Cohort Study

RATIONALE

Some patients with chronic obstructive pulmonary disease (COPD) have asthma-like features, such as significant bronchodilator reversibility, blood eosinophilia, and/or atopy, even if they are not clinically diagnosed as having asthma. However, the clinical significance of asthma-like features overlapping with COPD remains unclear.

OBJECTIVES

The aim of this study was to assess the effect of asthma-like features on the clinical course of patients with COPD who were adequately treated and followed-up over 10 years.

METHODS

A total of 268 patients with COPD who had been clinically considered as not having asthma by respiratory specialists were included in this study. The asthma-like features included in this study were bronchodilator reversibility (ΔFEV₁, ≥12% and ≥200 ml), blood eosinophilia (≥300 cells/μl), and atopy (positive specific IgE for any inhaled antigen). The annual changes in post-bronchodilator FEV₁ and COPD exacerbations were monitored during the first 5 years, and mortality was followed during the entire 10 years of the study.

MEASUREMENTS AND MAIN RESULTS

Fifty-seven subjects (21%) had bronchodilator reversibility, 52 (19%) had blood eosinophilia, and 67 (25%) had atopy. Subjects with blood eosinophilia had significantly slower annual post-bronchodilator FEV₁ decline; bronchodilator reversibility and atopy did not affect the annual post-bronchodilator FEV₁ decline, and none of the asthma-like features was associated with development of COPD exacerbation. Even if subjects had two or more asthma-like features, they displayed annual post-bronchodilator FEV₁ declines and exacerbation rates similar to those of subjects with one or zero asthma-like features, as well as a lower 10-year mortality rate (P = 0.02).

CONCLUSIONS

The presence of asthma-like features was associated with better clinical course in patients with COPD receiving appropriate treatment.

Immediate salbutamol responsiveness does not predict long-term benefits of indacaterol in patients with chronic obstructive pulmonary disease

BACKGROUND

The purpose of this study was to evaluate the correlation between immediate responsiveness with the short-acting β2-agonist salbutamol and effects of treatment with the ultra-long-acting β2-agonist indacaterol in patients with chronic obstructive pulmonary disease (COPD).

METHODS

The REVERBREZ study was a phase IV, multicentre, open-label study in which patients with moderate-to-severe COPD received indacaterol 150 μg once-daily for 5 months. The primary endpoint was the correlation between immediate response of forced expiratory volume in 1 s (FEV1) post-inhalation of salbutamol (400 μg) at study entry and the change from baseline in trough FEV1 after 1 month of indacaterol. Secondary endpoints included dyspnoea measured by the modified Medical Research Council (mMRC) grade and health-related quality of life measured by the clinical COPD questionnaire (CCQ).

RESULTS

Of the 602 patients enrolled from 177 centres in France, 543 patients received at least one indacaterol dose, 512 patients completed 1 month of indacaterol treatment (primary endpoint), and 400 patients completed 5 months of treatment. At study entry, mean FEV1 values before and after salbutamol inhalation were 1.54 ± 0.50 L and 1.65 ± 0.53 L, respectively. Based on the magnitude of an immediate response of FEV1 after salbutamol inhalation at study entry, patients were classified into reversible (Rv, ≥12% and ≥200 mL from pre-salbutamol value; n = 106) and non-reversible (NRv, <12% or <200 mL from pre-salbutamol value; n = 431) groups. After 1 month of indacaterol treatment, mean absolute and relative difference in trough FEV1 were 100 mL and 9%, respectively. No significant correlation was found between the immediate FEV1 response to salbutamol at study entry and change from baseline in trough FEV1 after 1 month of indacaterol treatment (correlation coefficient = 0.056 [95% CI;-0.032, 0.144] for absolute response and 0.028 [95% CI;-0.06, 0.116] for relative response). At all subsequent visits, mMRC and CCQ scores, and FEV1 improved from baseline with no significant difference between the Rv and NRv groups.

CONCLUSIONS

Immediate FEV1 response to salbutamol did not predict the long-term benefits observed with indacaterol treatment in patients with COPD. Patients considered reversible or non-reversible to salbutamol showed comparable improvements in lung function, dyspnoea and health-related quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01272362 . Date: January 5, 2011.

Asthma-chronic obstructive pulmonary disease overlap syndrome - Literature review and contributions towards a Portuguese consensus

INTRODUCTION

Phenotypic overlap between the two main chronic airway pulmonary diseases, asthma and chronic obstructive pulmonary disease (COPD), has been the subject of debate for decades, and recently the nomenclature of asthma-COPD overlap syndrome (ACOS) was adopted for this condition. The definition of this entity in the literature is, however, very heterogeneous, it is therefore important to define how it applies to Portugal.

METHODS

A literature review of ACOS was made in a first phase resulting in the drawing up of a document that was later submitted for discussion among a panel of chronic lung diseases experts, resulting in reflexions about diagnosis, treatment and clinical guidance for ACOS patients.

RESULTS

There was a consensus among the experts that the diagnosis of ACOS should be considered in the concomitant presence of: clinical manifestations characteristic of both asthma and COPD, persistent airway obstruction (post-bronchodilator FEV₁/FVC<0.7), positive response to bronchodilator test (increase in FEV₁ of ≥200mL and ≥12% from baseline) and current or past history of smoking or biomass exposure. In reaching diagnosis, the presence of peripheral eosinophilia (>300eosinophils/μL or >5% of leukocytes) and previous history of atopy should also be considered. The recommended first line pharmacological treatment in these patients is the ICS/LABA association; if symptomatic control is not achieved or in case of clinical severity, triple therapy with ICS/LABA/LAMA may be used. An effective control of the exposure to risk factors, vaccination, respiratory rehabilitation and treatment of comorbidities is also important.

CONCLUSIONS

The creation of initial guidelines on ACOS, which can be applied in the Portuguese context, has an important role in the generation of a broad nationwide consensus. This will give, in the near future, a far better clinical, functional and epidemiological characterization of ACOS patients, with the ultimate goal of achieving better therapeutic guidance.

Bronchodilator reversibility in patients with COPD revisited: short-term reproducibility

Categorization of patients with COPD as reversible or nonreversible to a bronchodilator may change over time. This post hoc analysis aimed to determine if an individual's reversibility, when treated as a continuous variable, could predict his/her future response to two short-acting bronchodilators: albuterol and ipratropium. The analysis was completed using data from a 4-week, randomized, open-label, two-period crossover study (NCT01691482; GSK study DB2114956). Patients received albuterol (doses: UK =4×100 μg/puff; US =4×90 μg/puff) followed 1 hour later by ipratropium (4×20 μg/puff) or vice versa during treatment Period 1. The order of treatments was reversed during Period 2. Predefined efficacy end points included pre- and post-bronchodilator forced expiratory volume in 1 second. The correlation coefficient between bronchodilator response on Days 1 and 10 was investigated, as well as the correlation between treatment response on Day 1 and the mean treatment response on Days 5-10, for each individual patient. Bronchodilator response to albuterol on Day 1 was strongly correlated with that on Day 10 (r=0.64; n=53). The correlation coefficient of bronchodilator treatment response on Day 1 and Days 5-10 was 0.78 (P<0.001; n=53) and 0.76 (P<0.001; n=54) for albuterol and ipratropium, respectively. A single measurement of the initial bronchodilator response to albuterol or ipratropium was, therefore, highly correlated with the subsequent mean bronchodilator response over 5-10 days, demonstrating its potential usefulness for future treatment decisions.

What is asthma-COPD overlap syndrome? Towards a consensus definition from a round table discussion

Patients with asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) have been largely excluded from pivotal therapeutic trials and, as a result, its treatment remains poorly defined and lacking firm evidence. To date, there is no universally accepted definition of ACOS, which has made it difficult to understand its epidemiology or pathophysiology. Despite many uncertainties, there is emerging agreement that some of the key features of ACOS include persistent airflow limitation in symptomatic individuals 40 years of age and older, a well-documented history of asthma in childhood or early adulthood and a significant exposure history to cigarette or biomass smoke. In this perspective, we propose a case definition of ACOS that incorporates these key features in a parsimonious algorithm that may enable clinicians to better diagnose patients with ACOS and most importantly enable researchers to design therapeutic and clinical studies to elucidate its epidemiology and pathophysiology and to ascertain its optimal management strategies.

Bronchodilator responsiveness of peripheral airways in smokers with normal spirometry

BACKGROUND AND OBJECTIVE

Cigarette smoke exposure increases airway smooth muscle (ASM) contractility. Abnormalities in peripheral airway function in smokers with normal spirometry could be due to the effects of ASM tone. We aimed to determine the contribution of ASM tone to peripheral airway function in smokers with normal spirometry from the response to bronchodilator (BD).

METHODS

Ventilation heterogeneity in peripheral conductive (Scond) and acinar (Sacin) airways were measured in 50 asymptomatic smokers and 20 never-smokers using multiple breath nitrogen washout, before and 20 min after inhalation of 200 µg salbutamol and 80 µg ipratropium bromide. Z-scores were calculated to define abnormality in Sacin and Scond.

RESULTS

Nineteen smokers had abnormal Sacin, and 12 had abnormal Scond; 7 had abnormalities in both. After BD, Sacin improved in smokers with normal Sacin (6.5 ± 15.9%, P = 0.02), smokers with abnormal Sacin (9.2 ± 16.9%, P = 0.03) and in control subjects (11.7 ± 18.2%, P = 0.01), with no differences in improvements between groups. Sacin remained abnormal in 15/19 smokers and their post-BD values correlated with smoking exposure (r = 0.53, P = 0.02). After BD, Scond improved in smokers with abnormal Scond (28.3 ± 15.9%, P = 0.002) and normalized in 9/12 subjects, but not in those with normal Scond (0.25 ± 32.7%, P = 0.44) or control subjects (-1.7 ± 21.2%, P = 0.64).

CONCLUSION

In smokers with normal spirometry, abnormal conductive airway function could be attributed to increased bronchomotor tone. In contrast, bronchomotor tone in acinar airways is unaffected by smoking and functional abnormality. There may be different causal mechanisms underlying acinar and conductive airway abnormalities in smokers with normal spirometry.

Effect of tiotropium on COPD exacerbations: A systematic review

BACKGROUND

Exacerbation frequency is related to disease progression, quality of life, and prognosis in COPD. Earlier diagnosis, along with interventions aimed at preventing exacerbations and delaying progression, may help reduce the global burden of disease. Long-acting inhaled bronchodilators are effective at maintaining symptom relief and are recommended as first-choice therapy for more symptomatic patients and those at risk of exacerbation.

METHODS

As prevention of exacerbations is a priority goal in COPD management and a number of different long-acting bronchodilators are available, we conducted a systematic review of exacerbation data from randomized controlled trials (published January 2000 to May 2014) comparing the effect of tiotropium versus placebo and/or other maintenance therapies.

RESULTS

Exacerbations were a primary endpoint in 12 publications (five studies: four comparing tiotropium with placebo; one with active comparator) and a secondary endpoint in 17 publications (seven studies: six comparing tiotropium with placebo; one with active comparator). Overall, tiotropium was associated with a longer time to first exacerbation event and fewer exacerbations (including severe exacerbations/hospitalizations) compared with placebo and long-acting β2-agonists. Tiotropium also showed similar efficacy to glycopyrronium and a fixed long-acting muscarinic antagonist/long-acting β2-agonist combination (glycopyrronium/indacaterol), although not all studies were powered to demonstrate differences in exacerbation outcomes. Exacerbation outcomes were comparable with both formulations of tiotropium (HandiHaler(®) 18 μg/Respimat(®) 5 μg).

CONCLUSIONS

The results of this comprehensive systematic review demonstrate tiotropium is beneficial in reducing exacerbation risk versus placebo or other maintenance treatments.

Treatment of overlapping asthma-chronic obstructive pulmonary disease: Can guidelines contribute in an evidence-free zone?

In their most typical forms, asthma and chronic obstructive pulmonary disease (COPD) are clearly distinguishable, but many patients with chronic airflow limitation demonstrate features of both conditions and have worse health outcomes than those with either disease alone. This has been called the asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS), but as yet, it lacks a precise definition. However, given the different pathways by which a patient can come to demonstrate features of both asthma and COPD, ACOS is not thought to represent a single disease but to include several heterogeneous phenotypes with different underlying mechanisms. These issues have important implications for guidelines because some existing treatment recommendations for asthma and COPD are in conflict, and patients with both asthma and COPD have specifically been excluded from major pharmacologic trials. As a result, there is little evidence at present to support specific treatment recommendations for ACOS on the basis of efficacy or effectiveness, yet these patients continue to present for diagnosis and management, mainly in primary care. This article highlights the need for clinical guidance about ACOS, summarizes recommendations about its diagnosis and treatment from a sample of national asthma and COPD guidelines, and proposes a way forward, as suggested in a collaborative Global Initiative for Asthma/Global Initiative for Chronic Obstructive Lung Disease report, to provide health professionals with interim recommendations about syndromic recognition and initial treatment based on both potential effectiveness and potential risk. Additional research in broad populations is urgently needed to develop a precise definition for ACOS, characterize its phenotypes, and identify opportunities for targeted treatment.

The asthma-COPD overlap syndrome: towards a revised taxonomy of chronic airways diseases?

Most research of treatments for airways diseases has been restricted to patients who meet standard definitions of either chronic obstructive pulmonary disease (COPD) or asthma, yet to distinguish COPD from asthma in adult patients who have clinical features of both can be challenging. Treatment guidelines provide scant advice on how such patients should be managed. With increasing recognition that asthma and COPD are heterogeneous diseases, attention has been directed to the needs of a group of patients with what is now termed asthma-COPD overlap syndrome (ACOS), particularly in view of the high morbidity in this population. This Review considers the epidemiology, mechanisms of disease, current attempts to define and diagnose ACOS, existing and potential treatment options, and new approaches to the phenotyping and taxonomy of airway diseases.

Misdiagnosis Among Frequent Exacerbators of Clinically Diagnosed Asthma and COPD in Absence of Confirmation of Airflow Obstruction

PURPOSE

Clinical diagnosis of severe asthma and chronic obstructive lung disease (COPD) remains a challenge and often flawed with lack of objective confirmation of airflow obstruction (AO). Misdiagnosis of asthma and COPD has been reported in stable disease, data are non-existent in frequent exacerbators. We investigated misdiagnosis and its predictors in frequent exacerbators.

METHODS

The cohort comprised of frequent severe exacerbators (requiring ≥2 emergency room (ER) visits or hospitalizations) of physician diagnosed (PD)-asthma and PD-COPD. All patients underwent a rigorous diagnostic algorithm over a follow-up period of 10 ± 6 months. Two board-certified pulmonologists ascertained final diagnosis. Patients with persistent absence of AO were identified to have misdiagnosis. Multivariate logistic regression analyses were used to identify predictors of misdiagnoses.

RESULTS

Among 333 frequent exacerbators analyzed (171 patients with PD-asthma, 162 with PD-COPD, mean annual exacerbations 3.4 ± 2.8), 24 % of patients had a baseline post-bronchodilator spirometry. Misdiagnosis was found in 26 % (87 of 333) of patients. Another 12 % (41 of 333) of patients had obstructive lung diseases other than asthma and COPD. Independent risk factors for misdiagnosis were spirometry underutilization (PD-asthma: OR = 2.8, 95 % CI 1.16-6.78, p = 0.02 and PD-COPD: OR = 10.7, 95 % CI 2.05-56.27, p = 0.005) and pack years of smoking (PD-COPD: OR = 1.05, 95 % CI 1.01-1.11, p = 0.03).

CONCLUSIONS

Objective confirmation of AO is essential in preventing misdiagnosis in frequent severe exacerbators of clinically diagnosed asthma and COPD, a third of whom have neither. Spirometry utilization is strongly associated with a reduced risk of misdiagnosis. Smoking is associated with increased risk of misdiagnosis in severe COPD, but not asthma.

Detection of COPD in a high-risk population: should the diagnostic work-up include bronchodilator reversibility testing?

Background

Underdiagnosis of chronic obstructive pulmonary disease (COPD) is widespread. Early detection of COPD may improve the outcome by timely smoking cessation, a change in lifestyle, and treatment with an inhaled bronchodilator (BD). The objective of this study was to evaluate the diagnostic role of BD reversibility testing in early COPD case finding.

Methods

General practitioners (n=241) consecutively recruited subjects aged ≥35 years with relevant exposure (history of smoking, and/or occupational exposure) and at least one respiratory symptom. Information on age, smoking status, body mass index, dyspnea score (Medical Research Council scale), and spirometry was obtained. Individuals with airway obstruction (forced expiratory volume in one second [FEV₁]/forced vital capacity [FVC] <0.70) underwent a BD test with an inhaled β₂ agonist, which was considered positive if ΔFEV₁ was >0.20 L and >12%. Asthma and COPD were, respectively, defined as an FEV₁ increase >0.50 L and a post-BD FEV₁/FVC <0.70.

Results

In total, 4,049 subjects (51% male) were included (mean age 58 years, body mass index 27, 32 pack-years of smoking). A significant BD response was found in 143 (15%) of the 937 subjects (23%) with airway obstruction at screening spirometry. In 59% of these subjects, the post-BD FEV₁/FVC remained <0.70. In 24% of the subjects with pre-BD airway obstruction, the post-BD FEV₁/FVC ratio was within the reference range. In subjects with confirmed COPD, the mean increase in FEV₁ following BD was 0.11 L±0.10 L. The subjects with COPD and a significant BD response were characterized by a higher prevalence of dyspnea (72% versus 57%, P=0.02) but less cough (55% versus 75%, P=0.001) when compared with COPD subjects without BD reversibility.

Conclusion

Administration of a BD in COPD case finding is important in order to determine the post-BD FEV₁/FVC ratio. Exclusion of subjects with a significant BD response may result in underdiagnosis of COPD, and we question the need for the BD reversibility test in the diagnostic screening algorithm in early COPD case finding.

Feasibility and effectiveness of an asthma/COPD service for primary care: a cross-sectional baseline description and longitudinal results

BACKGROUND

In 2007, an Asthma/chronic obstructive pulmonary disease (COPD) (AC) service was implemented in the North of the Netherlands to support General Practitioners (GPs) by providing advice from pulmonologists on a systematic basis.

AIMS

To evaluate the feasibility and effectiveness of this service on patient-related outcomes.

METHODS

We report baseline data on 11,401 patients and follow-up data from 2,556 patients. GPs can refer all patients with possible obstructive airway disease (OAD) to the service, which is conducted by the local laboratory. Patients are assessed in the laboratory using questionnaires and spirometry. Pulmonologists inspect the data through the internet and send the GP diagnosis and management advice.

RESULTS

A total of 11,401 patients were assessed by the service, covering almost 60% of all adult patients with projected asthma or COPD in the area. In all, 46% (n = 5,268) of the patients were diagnosed with asthma, 18% (n = 2,019) with COPD and 7% (n = 788) with the overlap syndrome. A total of 740 (7%) patients were followed up after 3 months because the GP advised them to change medication. In this group, the proportion of unstable COPD patients (Clinical COPD Questionnaire (CCQ) ⩾ 1) decreased from 63% (n = 92) at baseline to 49% (n = 72). The proportion of patients with uncontrolled asthma (Asthma Control Questionnaire (ACQ) ⩾ 1.5) decreased from 41% (n = 204) to 23% (n = 115). In all, 938 (8%) patients were followed up after 12 months. From these patients, the proportion of unstable COPD patients (CCQ ⩾ 1) decreased from 47% (n = 115) to 44% (n = 107). The proportion of patients with uncontrolled asthma (ACQ⩾1.5) decreased from 16% (n = 95) to 14% (n = 85).

CONCLUSION

The AC service assessed a considerable proportion of patients with OAD in the area, improved patients' outcomes, and is considered to be feasible and effective.

[Long-term treatment strategy in chronic obstructive pulmonary disease: how to change the course of the disease]

COPD is a pulmonary disease with a systemic impact. The goals of COPD assessment are to determine the severity of the disease to guide management. Smoking cessation is a prime objective at all the stages of the disease to modify the long-term decline in lung function, reduce the COPD symptoms, and the frequency of exacerbations, improve health status and reduce mortality. The bronchodilators are central in the pharmacologic management of COPD. Long-acting bronchodilators are indicated as maintenance treatment to relieve COPD symptoms (particularly dyspnea) despite regular use of short-acting bronchodilators. Long-acting bronchodilators reduce the exacerbation rate. The choice between a long-acting β2-adrenergic and an anticholinergic depends on the patient's perception of symptom relief. The inhaled corticoids are only indicated in COPD combined with long-acting β2-adrenergic in patients with severe COPD and a history of repeated exacerbations, who have significant symptoms despite therapy with bronchodilators. The combination of an inhaled corticosteroid with a long-acting β2-agonist reduces the exacerbation rate. The rehabilitation should be offered to all patients with dyspnea, exercise intolerance, or limitation in everyday activities related to COPD despite optimal pharmacological therapy and management of co-morbidities. Pulmonary rehabilitation is a multidisciplinary and tailored management of the COPD patients which enable to optimize exercise capacity, social reintegration, autonomy, reduce health care costs by decreasing the exacerbation rate, urgent visits and duration of hospitalisation. The rehabilitation is not just focusing on the improvement of exercise capacity, but also seeks sustained behavioural changes that are needed to achieve real improvement in health status and quality of life. Pulmonary rehabilitation is also an excellent opportunity for education which is critical in the healthcare pathway.

Airway wall thickness is increased in COPD patients with bronchodilator responsiveness

RATIONALE

Bronchodilator responsiveness (BDR) is a common but variable phenomenon in COPD. The CT characteristics of airway dimensions that differentiate COPD subjects with BDR from those without BDR have not been well described. We aimed to assess airway dimensions in COPD subjects with and without BDR.

METHODS

We analyzed subjects with GOLD 1-4 disease in the COPDGene® study who had CT airway analysis. We divided patients into two groups: BDR + (post bronchodilator ΔFEV1 ≥ 10%) and BDR-(post bronchodilator ΔFEV1 < 10%). The mean wall area percent (WA%) of six segmental bronchi in each subject was quantified using VIDA. Using 3D SLICER, airway wall thickness was also expressed as the square root wall area of an airway of 10 mm (Pi10) and 15 mm (Pi15) diameter. %Emphysema and %gas trapping were also calculated.

RESULTS

2355 subjects in the BDR-group and 1306 in the BDR + group formed our analysis. The BDR + group had a greater Pi10, Pi15, and mean segmental WA% compared to the BDR-group. In multivariate logistic regression using gender, race, current smoking, history of asthma, %emphysema, %gas trapping, %predicted FEV1, and %predicted FVC, airway wall measures remained independent predictors of BDR. Using a threshold change in FEV1 ≥ 15% and FEV1 ≥ 12% and 200 mL to divide patients into groups, the results were similar.

CONCLUSION

BDR in COPD is independently associated with CT evidence of airway pathology. This study provides us with greater evidence of changes in lung structure that correlate with physiologic manifestations of airflow obstruction in COPD.

Tiotropium versus placebo for chronic obstructive pulmonary disease

BACKGROUND

Tiotropium is an anticholinergic agent which has gained widespread acceptance as a once daily maintenance therapy for symptoms and exacerbations of stable chronic obstructive pulmonary disease (COPD). In the past few years there have been several systematic reviews of the efficacy of tiotropium, however, several new trials have compared tiotropium treatment with placebo, including those of a soft mist inhaler, making an update necessary.

OBJECTIVES

To evaluate data from randomised controlled trials (RCTs) comparing the efficacy of tiotropium and placebo in patients with COPD, upon clinically important endpoints.

SEARCH METHODS

We searched the Cochrane Airways Group's Specialised Register of Trials (CAGR) and ClinicalTrials.gov up to February 2012.

SELECTION CRITERIA

We included parallel group RCTs of three months or longer comparing treatment with tiotropium against placebo for patients with COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and then extracted data on study quality and the outcome results. We contacted study authors and trial sponsors for additional information, and collected information on adverse effects from all trials. We analysed the data using Cochrane Review Manager 5, RevMan 5.2.

MAIN RESULTS

This review included 22 studies of good methodological quality that had enrolled 23,309 participants with COPD. The studies used similar designs, however, the duration varied from three months to four years. In 19 of the studies, 18 mcg tiotropium once daily via the Handihaler dry powder inhaler was evaluated, and in three studies, 5 or 10 mcg tiotropium once daily via the Respimat soft mist inhaler was evaluated. Compared to placebo, tiotropium treatment significantly improved the mean quality of life (mean difference (MD) -2.89; 95% confidence interval (CI) -3.35 to -2.44), increased the number of participants with a clinically significant improvement (odds ratio (OR) 1.52; 95% CI 1.38 to 1.68), and reduced the number of participants with a clinically significant deterioration (OR 0.65; 95% CI 0.59 to 0.72) in quality of life (measured by the St George's Respiratory Questionnaire (SGRQ)). Tiotropium treatment significantly reduced the number of participants suffering from exacerbations (OR 0.78; 95% CI 0.70 to 0.87). This corresponds to a need to treat 16 patients (95% CI 10 to 36) with tiotropium for a year in order to avoid one additional patient suffering exacerbations, based on the average placebo event rate of 44% from one-year studies. Tiotropium treatment led to fewer hospitalisations due to exacerbations (OR 0.85; 95% CI 0.72 to 1.00), but there was no statistically significant difference in all-cause hospitalisations (OR 1.00; 95% CI 0.88 to 1.13) or non-fatal serious adverse events (OR 1.03; 95% CI 0.97 to 1.10). Additionally, there was no statistically significant difference in all-cause mortality between the tiotropium and placebo groups (Peto OR 0.98; 95% CI 0.86 to 1.11). However, subgroup analysis found a significant difference between the studies using a dry powder inhaler and those with a soft mist inhaler (test for subgroup differences: P = 0.01). With the dry powder inhaler there were fewer deaths in the tiotropium group (Peto OR 0.92; 95% CI 0.80 to 1.05) than in the placebo group (yearly rate 2.8%), but with the soft mist inhaler there were significantly more deaths in the tiotropium group (Peto OR 1.47; 95% CI 1.04 to 2.08) than in the placebo group (yearly rate 1.8%). It is noted that the rates of patients discontinuing study treatment were uneven, with significantly fewer participants withdrawing from tiotropium treatment than from placebo treatment (OR 0.66; 95% CI 0.59 to 0.73). Participants on tiotropium had improved lung function at the end of the study compared with those on placebo (trough forced expiratory volume in one second (FEV1) MD 118.92 mL; 95% CI 113.07 to 124.77).

AUTHORS' CONCLUSIONS

This review shows that tiotropium treatment was associated with a significant improvement in patients' quality of life and it reduced the risk of exacerbations, with a number needed to treat to benefit (NNTB) of 16 to prevent one exacerbation. Tiotropium also reduced exacerbations leading to hospitalisation but no significant difference was found for hospitalisation of any cause or mortality. Thus, tiotropium appears to be a reasonable choice for the management of patients with stable COPD, as proposed in guidelines. The trials included in this review showed a difference in the risk of mortality when compared with placebo depending on the type of tiotropium delivery device used. However, these results have not been confirmed in a recent trial when 2.5 mcg or 5 mcg of tiotropium via Respimat was used in a direct comparison to the 18 mcg Handihaler.

Determinants of 1-year changes in disease-specific health status in patients with advanced chronic obstructive pulmonary disease: A 1-year observational study

We aimed to identify baseline and longitudinal determinants of change in disease-specific health status in patients with advanced chronic obstructive pulmonary disease (COPD). Demographic and clinical characteristics as well as disease-specific health status (St George's Respiratory Questionnaire, SGRQ) were assessed in 105 outpatients with advanced COPD at baseline and at 4, 8 and 12 months. Eighty-five patients (81.0%) had complete SGRQ data at baseline and 12 months and were included in analyses. Stepwise multiple regression analysis revealed that lower SGRQ total score, higher depression scores and longer time needed to complete the Timed Up and Go (TUG) test at baseline, as well as increase in time needed to complete the TUG test and increase in dyspnoea during the 1-year follow-up period, were predictors of deterioration in disease-specific health status. The current study reinforces the stimulation of physical mobility and the targeting of dyspnoea as components for treatment programs to optimize disease-specific health status in patients with advanced COPD.

Long-acting inhaled therapy (beta-agonists, anticholinergics and steroids) for COPD: a network meta-analysis

BACKGROUND

Pharmacological therapy for chronic obstructive pulmonary disease (COPD) is aimed at relieving symptoms, improving quality of life and preventing or treating exacerbations.Treatment tends to begin with one inhaler, and additional therapies are introduced as necessary. For persistent or worsening symptoms, long-acting inhaled therapies taken once or twice daily are preferred over short-acting inhalers. Several Cochrane reviews have looked at the risks and benefits of specific long-acting inhaled therapies compared with placebo or other treatments. However for patients and clinicians, it is important to understand the merits of these treatments relative to each other, and whether a particular class of inhaled therapies is more beneficial than the others.

OBJECTIVES

To assess the efficacy of treatment options for patients whose chronic obstructive pulmonary disease cannot be controlled by short-acting therapies alone. The review will not look at combination therapies usually considered later in the course of the disease.As part of this network meta-analysis, we will address the following issues.1. How does long-term efficacy compare between different pharmacological treatments for COPD?2. Are there limitations in the current evidence base that may compromise the conclusions drawn by this network meta-analysis? If so, what are the implications for future research?

SEARCH METHODS

We identified randomised controlled trials (RCTs) in existing Cochrane reviews by searching the Cochrane Database of Systematic Reviews (CDSR). In addition, we ran a comprehensive citation search on the Cochrane Airways Group Register of trials (CAGR) and checked manufacturer websites and reference lists of other reviews. The most recent searches were conducted in September 2013.

SELECTION CRITERIA

We included parallel-group RCTs of at least 6 months' duration recruiting people with COPD. Studies were included if they compared any of the following treatments versus any other: long-acting beta2-agonists (LABAs; formoterol, indacaterol, salmeterol); long-acting muscarinic antagonists (LAMAs; aclidinium, glycopyrronium, tiotropium); inhaled corticosteroids (ICSs; budesonide, fluticasone, mometasone); combination long-acting beta2-agonist (LABA) and inhaled corticosteroid (LABA/ICS) (formoterol/budesonide, formoterol/mometasone, salmeterol/fluticasone); and placebo.

DATA COLLECTION AND ANALYSIS

We conducted a network meta-analysis using Markov chain Monte Carlo methods for two efficacy outcomes: St George's Respiratory Questionnaire (SGRQ) total score and trough forced expiratory volume in one second (FEV1). We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (placebo). We assumed that treatment effects were similar within treatment classes (LAMA, LABA, ICS, LABA/ICS). We present estimates of class effects, variability between treatments within each class and individual treatment effects compared with every other.To justify the analyses, we assessed the trials for clinical and methodological transitivity across comparisons. We tested the robustness of our analyses by performing sensitivity analyses for lack of blinding and by considering six- and 12-month data separately.

MAIN RESULTS

We identified 71 RCTs randomly assigning 73,062 people with COPD to 184 treatment arms of interest. Trials were similar with regards to methodology, inclusion and exclusion criteria and key baseline characteristics. Participants were more often male, aged in their mid sixties, with FEV1 predicted normal between 40% and 50% and with substantial smoking histories (40+ pack-years). The risk of bias was generally low, although missing information made it hard to judge risk of selection bias and selective outcome reporting. Fixed effects were used for SGRQ analyses, and random effects for Trough FEV1 analyses, based on model fit statistics and deviance information criteria (DIC). SGRQ SGRQ data were available in 42 studies (n = 54,613). At six months, 39 pairwise comparisons were made between 18 treatments in 25 studies (n = 27,024). Combination LABA/ICS was the highest ranked intervention, with a mean improvement over placebo of -3.89 units at six months (95% credible interval (CrI) -4.70 to -2.97) and -3.60 at 12 months (95% CrI -4.63 to -2.34). LAMAs and LABAs were ranked second and third at six months, with mean differences of -2.63 (95% CrI -3.53 to -1.97) and -2.29 (95% CrI -3.18 to -1.53), respectively. Inhaled corticosteroids were ranked fourth (MD -2.00, 95% CrI -3.06 to -0.87). Class differences between LABA, LAMA and ICS were less prominent at 12 months. Indacaterol and aclidinium were ranked somewhat higher than other members of their classes, and formoterol 12 mcg, budesonide 400 mcg and formoterol/mometasone combination were ranked lower within their classes. There was considerable overlap in credible intervals and rankings for both classes and individual treatments. Trough FEV1 Trough FEV1 data were available in 46 studies (n = 47,409). At six months, 41 pairwise comparisons were made between 20 treatments in 31 studies (n = 29,271). As for SGRQ, combination LABA/ICS was the highest ranked class, with a mean improvement over placebo of 133.3 mL at six months (95% CrI 100.6 to 164.0) and slightly less at 12 months (mean difference (MD) 100, 95% CrI 55.5 to 140.1). LAMAs (MD 103.5, 95% CrI 81.8 to 124.9) and LABAs (MD 99.4, 95% CrI 72.0 to 127.8) showed roughly equivalent results at six months, and ICSs were the fourth ranked class (MD 65.4, 95% CrI 33.1 to 96.9). As with SGRQ, initial differences between classes were not so prominent at 12 months. Indacaterol and salmeterol/fluticasone were ranked slightly better than others in their class, and formoterol 12, aclidinium, budesonide and formoterol/budesonide combination were ranked lower within their classes. All credible intervals for individual rankings were wide.

AUTHORS' CONCLUSIONS

This network meta-analysis compares four different classes of long-acting inhalers for people with COPD who need more than short-acting bronchodilators. Quality of life and lung function were improved most on combination inhalers (LABA and ICS) and least on ICS alone at 6 and at 12 months. Overall LAMA and LABA inhalers had similar effects, particularly at 12 months. The network has demonstrated the benefit of ICS when added to LABA for these outcomes in participants who largely had an FEV1 that was less than 50% predicted, but the additional expense of combination inhalers and any potential for increased adverse events (which has been established by other reviews) require consideration. Our findings are in keeping with current National Institute for Health and Care Excellence (NICE) guidelines.

Which is the optimal bronchodilator therapy for chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease is an inflammatory disorder characterized by airflow limitation. Its cardinal symptom is dyspnea, which develops gradually with even low levels of exercise. Bronchodilators (BDs) are the most effective drugs for relieving dyspnea. Two main types of BD are currently available, β-mimetics and anticholinergics, with different subtypes according to their duration of action. The most useful agents are those administered once daily, also called 'ultralong-acting' BDs. As a high proportion of patients remain insufficiently controlled with only one BD, all guidelines currently recommend the combination of two long-acting agents. A number of studies have demonstrated that combination therapy is functionally and, in general, clinically superior to individual drugs. Although various combinations have been assessed, the current trend is to use ultralong-acting agents due to their more convenient dosing schedule and, probably, their greater efficacy. In the research setting, some of these agents are combined in a single device, an approach that may become the standard treatment for many patients with chronic obstructive pulmonary disease.

What is the difference between FEV1 change in percentage predicted value and change over baseline in the assessment of bronchodilator responsiveness in patients with COPD?

BACKGROUND

Several criteria are clinically applied in the assessment of significant bronchodilator responsiveness in chronic obstructive pulmonary disease (COPD). The present study aimed to investigate the differences in various degree of severity of COPD among these criteria.

METHODS

After 400 micrograms of salbutamol administered via spacer by metered dose inhaler (MDI), forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) changes (including percentage change, absolute change and absolute change in percentage predicted value) were retrospectively analysed in 933 stable patients with mild-to-very-severe COPD. Significant bronchodilator responsiveness was assessed using American Thoracic Society and European Respiratory Society (ATS-ERS) criterion based on FEV1 or/and FVC (both ≥12% increase over baseline and ≥200 mL) and FEV1 percentage predicted criterion (≥10% absolute increase in percentage predicted FEV1) in different grades of COPD.

RESULTS

Of the patients [age 66.8 years, baseline FEV1 974 mL (39.3% predicted) and FVC 2,242 mL], mean improvements were 126 mL in FEV1 and 265 mL in FVC; 21.4% and 45.3% met ATS-ERS criterion based on FEV1 and FVC, respectively; and 13.5% met FEV1 percentage predicted criterion. The responsive ratios of ATS-ERS criterion based on FEV1 to FEV1 percentage predicted criterion in grade I, II, III and IV of COPD were 0.95(:)1.26(:)2.53(:)6.00, respectively (P<0.01 in grade II and P<0.001 in grade III). As the degree of severity increased, the mean improvement of FEV1 was reduced; on the contrary, that of FVC was increased.

CONCLUSIONS

Compared with FEV1 percentage predicted criterion, ATS-ERS criterion based on FEV1 as well as FVC, the later in particular, detected a larger percentage of patients with significant responsiveness. The increasing difference was relevant as a function of the severity of airflow obstruction.