Analysis of comorbid factors that increase the COPD assessment test scores

Exploring the pathophysiology of anemia in COPD: Insights from chest CT and longitudinal clinical data

BACKGROUND

Although anemia has been associated with chronic obstructive pulmonary disease (COPD) severity, the underlying risk factors, such as chest imaging indicators, remain poorly understood. In this study, we aimed to investigate the relationship between anemia and clinical features, including pulmonary and extrapulmonary indicators on chest computed tomography (CT), and to clarify the pathophysiology of anemia in COPD.

METHODS

A total of 400 patients with COPD were prospectively followed for 3 years. Anemia was defined as hemoglobin <13 g/dl in males and <12 g/dl in females. Patients were categorized into the anemia and non-anemia groups, and their clinical characteristics were compared.

RESULTS

The anemia group exhibited lower percentage of predicted forced expiratory volume in 1 s (%FEV1) and body mass index (BMI) measurements, worse COPD assessment test (CAT) scores, and more frequent exacerbations. Imaging revealed more severe emphysema, lower cross-sectional areas of the pectoralis and erector spinae muscles, decreased subcutaneous fat, and more severe coronary artery calcification in this group. Additionally, echocardiography demonstrated a higher prevalence of pulmonary hypertension and reduced left ventricular ejection fraction in patients with anemia. Three-year longitudinal data analysis further showed that declining hemoglobin levels correlated with the worsening of nutritional status, a deterioration in bone mineral density (BMD), and an increase in CAT scores.

CONCLUSION

Anemia in COPD is a multifactorial comorbidity resulting in emphysema, decreased fat and muscle mass, and reduced BMD.

Current perspectives on the rehabilitation of COPD patients with comorbidities

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is frequently accompanied by a variety of comorbidities, complicating management and rehabilitation efforts. Understanding this interplay is crucial for optimizing patient outcomes.

AREAS COVERED

This review, based on the MEDLINE, Embase and Cochrane Library databases, summarizes the main research on the rehabilitation of patients with COPD, with an emphasis on relevant comorbidities, such as cardiovascular diseases, pulmonary hypertension, lung cancer, metabolic, musculoskeletal, and gastrointestinal disorders. anxiety/depression and cognitive disorders. The study highlights the importance of pre-participation assessments, ongoing monitoring and personalized rehabilitation programs. A review includes a comprehensive literature search to assess the scientific evidence on these interventions and their impact.

EXPERT OPINION

The integration of cardiorespiratory rehabilitation program is essential for improving physical capacity and quality of life in COPD patients with comorbidities. While existing studies highlight positive outcomes, challenges such as interdisciplinary collaboration and access to rehabilitation services remain. Future strategies must prioritize personalized and integrated approaches programs combining pharmacological optimization and a close monitoring during cardiopulmonary rehabilitation to significantly reduce hospital readmissions and mortality, even in patients with complex multimorbidities. Continued research is necessary to refine rehabilitation protocols and better understand the complexities of managing COPD alongside cardiac conditions.

Unravelling the Information Contained in the Single Items of the COPD Assessment Test for Different Outcomes and Smoking Status in Patients with COPD: Results from COSYCONET

Background

The COPD Assessment Test (CAT) comprises eight questions. We evaluated the information that each of the questions and the total score contributed to outcomes and characteristics of chronic obstructive lung disease (COPD), including their dependence on smoking status.

Methods

Patients with COPD of the COSYCONET cohort with Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 1-4 and the former grade 0 were included. The evaluated outcomes included mortality, exacerbation risk, the comorbidities asthma, cardiac disease (coronary artery disease/heart failure), osteoporosis, and emphysema, for which a reduction in carbon monoxide transfer coefficient (KCO) <55% predicted was considered as marker. Analyses were performed by Cox proportional hazard or logistic multiple regression analyses separately for smokers and nonsmokers.

Results

In total, 2509 patients had complete data, among them 1884 nonsmokers (ex or never; 38.4% female; mean age±SD 66.1±8.5 years) and 625 current smokers (45.1% female, 61.6±7.9 years). The pattern of responses to the single questions of the CAT differed between outcome variables, as well as between smokers and nonsmokers, but in most cases the total score was superior to the single items. The CAT total score was associated with mortality (p<0.05) only in nonsmokers, while for exacerbation frequency/severity, it was of about equal importance in smokers and nonsmokers. Regarding KCO, the total score was indicative (p<0.05) only in nonsmokers. Particularly in smokers, single items could show opposite signs of their coefficients which therefore largely cancelled in the total score.

Conclusion

Our results show in detail for which outcomes single items are informative in nonsmokers and current smokers with COPD, overall being more informative in nonsmokers. Only regarding exacerbation risk, the predictive value was similar in both groups. These results might be helpful to extract as much as possible information from a COPD questionnaire that is often part of routine assessment.

Trial Registration

NCT01245933.

The effects of music therapy on patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

Inconsistent findings concerning the effects of music therapy on patients with chronic obstructive pulmonary disease (COPD) have been reported.

OBJECTIVE

To systematically evaluate the effects of music therapy on patients with COPD.

METHODS

Database search was conducted in Cochrane Library, Web of Science, PubMed, Embase, CINAHL, CNKI, CBM, WanFang Data, and VIP databases, from database inception to June 2024. Two researchers independently reviewed and assessed the methodological quality of the included studies using the Version 2 of the Cochrane tool. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the overall quality. Review Manager (v 5.4) software was used for the meta-analysis.

RESULTS

Eleven studies with 947 patients were included. Standardized mean differences (SMD) and 95% confidence intervals (CI) were observed in favor of music therapy for quality of life (SMD = 0.92, 95% CI [0.39, 1.46]) and exercise endurance (SMD = 0.77, 95% CI [0.05, 1.49]). Meanwhile, the results of subgroup analyses indicated that passive music therapy had significant effects on quality of life (SMD = -0.83, 95% CI [-1.23, -0.44]), anxiety (SMD = -0.67, 95% CI [-1.11, -0.24]) and exercise endurance (SMD = 1.54, 95% CI [0.55, 2.54]). When intervention duration was more than 3 months, music therapy could significantly improve quality of life (SMD = -1.32, 95% CI [-2.17, -0.47]), reduce depression (SMD = -3.94, 95% CI [-5.20, -2.67]) and increase exercise endurance (SMD = 0.96, 95% CI [0.41, 1.51]).

CONCLUSION

Music therapy is effective for quality of life and exercise endurance of patients with COPD; however, its impact on dyspnea, anxiety, and depression is still uncertain. More high-quality randomized control trials are warranted to confirm these conclusions.

Increased Risk of Severe Cardiovascular Events Following Exacerbations of Chronic Obstructive Pulmonary Disease: Results of the EXACOS-CV Study in Japan

INTRODUCTION

Severe exacerbations of chronic obstructive pulmonary disease (COPD) are known to increase the risk of cardiovascular events. However, this association has not been investigated specifically in patients with COPD in Japan, whose characteristics may differ from those of Western patients (i.e., western Europe, the US, and Canada).

METHODS

This longitudinal retrospective cohort study analyzed secondary claims data and included patients aged ≥ 40 years with COPD (International Classification of Diseases-10 codes J41-J44). All exacerbations occurring during follow-up were measured. Time-dependent Cox models were used to estimate hazard ratios (HRs) for the association between time periods following an exacerbation of COPD (vs. time prior to a first exacerbation) and occurrence of a first hospitalization for a severe fatal or non-fatal cardiovascular event.

RESULTS

The analysis included 152,712 patients with COPD with a mean age of 73.8 years and 37.6% of whom were female. During a median follow-up of 37 months, 63,182 (41.4%) patients experienced ≥ 1 exacerbation and 13,314 (8.7%) patients experienced ≥ 1 severe cardiovascular event. Following an exacerbation of COPD, the risk of a severe cardiovascular event was increased in the first 30 days [adjusted HR (aHR) 1.44, 95% confidence interval (CI) 1.33-1.55] and remained elevated for 365 days post-exacerbation (aHR 1.13, 95% CI 1.04-1.23). Specifically, the risks of acute coronary syndrome or arrhythmias remained significantly increased for up to 180 days, and the risk of decompensated heart failure for 1 year.

CONCLUSION

Among Japanese patients with COPD, the risk of experiencing a severe cardiovascular event increased following a COPD exacerbation and remained elevated for 365 days, emphasizing the need to prevent exacerbations.

Components of the Chronic Obstructive Pulmonary Disease Assessment Test Associated with the Exacerbation of Severe Chronic Obstructive Pulmonary Disease Patients

INTRODUCTION

The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) score is widely used for evaluating the health status of patients diagnosed with COPD. The aim of this study was to identify which components of the CAT are associated with exacerbations in severe COPD patients.

METHODS

Using data from the Korean COPD Subgroup Study (KOCOSS), we identified 3,440 COPD patients, among which 1,027 patients are classified as having severe COPD based on spirometry results. The CAT scores on 8 items were evaluated and classified into respiratory and non-respiratory categories. We analyzed the association between CAT item scores and moderate-to-severe exacerbations during study enrollment and the following years.

RESULTS

Patients with a history of moderate-to-severe exacerbations had higher scores on non-respiratory CAT components. Longitudinal CAT scores on all items after enrollment were higher in the moderate-to-severe exacerbation group. Additionally, the frequency of severe exacerbations was associated with specific CAT components related to limited activities, confidence leaving home, sleeplessness, and energy.

CONCLUSIONS

This study revealed that the non-respiratory CAT component scores were statistically significant factors for predicting the moderate-to-severe exacerbation of severe COPD patients. Non-respiratory symptoms and functional limitations should be considered in patients with severe COPD. Interventions, such as pulmonary rehabilitation, may be needed to improve patients' overall well-being and prevent exacerbations.

Impact of comorbidities in COPD clinical control criteria. The CLAVE study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) frequently coexists with other chronic diseases, namely comorbidities. They negatively impact prognosis, exacerbations and quality of life in COPD patients. However, no studies have been performed to explore the impact of these comorbidities on COPD clinical control criteria.

RESEARCH QUESTION

Determine the relationship between individualized comorbidities and COPD clinical control criteria.

STUDY DESIGN AND METHODS

Observational, multicenter, cross-sectional study performed in Spain involving 4801 patients with severe COPD (< 50 predicted forced expiratory volume in the first second [FEV1%]). Clinical control criteria were defined by the combination of COPD assessment test (CAT) scores (≤16 vs ≥17) and exacerbations in the previous three months (none vs ≥1). Binary logistic regression adjusted by age and FEV1% was performed to identify comorbidities potentially associated with the lack of control of COPD. Secondary endpoints were the relationship between individualized comorbidities with COPD assessment test and exacerbations within the last three months.

RESULTS

Most frequent comorbidities were arterial hypertension (51.2%), dyslipidemia (36.0%), diabetes (24.9%), obstructive sleep apnea-hypopnea syndrome (14.9%), anxiety (14.1%), heart failure (11.6%), depression (11.8%), atrial fibrillation (11.5%), peripheral arterial vascular disease (10.4%) and ischemic heart disease (10.1%). After age and FEV1% adjustment, comorbidities related to lack of clinical control were cardiovascular diseases (heart failure, peripheral vascular disease and atrial fibrillation; p < 0.0001), psychologic disorders (anxiety and depression; all p < 0.0001), metabolic diseases (diabetes, arterial hypertension and abdominal obesity; all p < 0.001), sleep disorders (p < 0.0001), anemia (p = 0.015) and gastroesophageal reflux (p < 0.0001). These comorbidities were also related to previous exacerbations and COPD assessment test scores.

INTERPRETATION

Comorbidities are frequent in patients with severe COPD, negatively impacting COPD clinical control criteria. They are related to health-related quality of life measured by the COPD assessment test. Our results suggest that comorbidities should be investigated and treated in these patients to improve their clinical control.

TAKE-HOME POINTS

Study question: What is the impact of comorbidities on COPD clinical control criteria?

RESULTS

Among 4801 patients with severe COPD (27.5% controlled and 72.5% uncontrolled), after adjustment by age and FEV1%, comorbidities related to lack of clinical control were cardiovascular diseases (heart failure, peripheral vascular disease and atrial fibrillation; p < 0.0001), psychologic disorders (anxiety and depression; p < 0.0001), metabolic diseases (diabetes, arterial hypertension and abdominal obesity; p < 0.001), obstructive sleep apnea-hypopnea syndrome (p < 0.0001), anaemia (p = 0.015) and gastroesophageal reflux (p < 0.0001), which were related to previous exacerbations and COPD assessment test scores.

INTERPRETATION

Comorbidities are related to health-related quality of life measured by the COPD assessment test scores and history of exacerbations in the previous three months.

Non-exercise Activity Thermogenesis Correlated With Clinical Parameters in Patients With or At-Risk for Chronic Obstructive Pulmonary Disease (COPD): A Pilot Study

BACKGROUND

Attention to physical activity has grown in patients with chronic obstructive pulmonary disease (COPD), as it serves as a robust indicator for mortality associated with COPD. Non-exercise activity thermogenesis (NEAT) is the energy expenditure due to physical activities besides active sports-like exercises and resistance training in daily life, and decreased NEAT may be related to physical inactivity in patients with COPD. We examined whether NEAT assessed using a questionnaire reflects clinical parameters in patients with or at risk for COPD.

METHODS

The study participants consisted of 36 male patients (COPD=28; stage1=6, stage2=14, stage3/4=8, and at-risk for COPD=8) older than 50 years of age. The participants underwent anthropometric measurements, lung function testing, a six-minute walk test, muscle strength testing, and questionnaires, e.g., the COPD assessment test (CAT), modified Medical Research Council (mMRC) dyspnea scale, and Hospital Anxiety and Depression Scale. Image analysis with chest computed tomography (CT) included the number of trunk muscles, bronchial wall thickening, and emphysema (percentage of the lung field occupied by low attenuation area <-950 HU). We evaluated the relationship between these clinical parameters and NEAT questionnaire scores using Pearson correlation analysis and the Tukey-Kramer test.

RESULTS

The NEAT score was correlated with the severity of airflow limitation and airway wall thickness measured by chest CT, symptoms evaluated by the mMRC dyspnea scale and CAT, and inspiratory muscle strength and pectoralis muscle area assessed by CT.

CONCLUSION

Our study revealed the significance of NEAT as a valuable indicator in assessing the health status of patients with or at risk for COPD. The NEAT score was correlated with various clinical traits, suggesting that incorporating NEAT assessments using a questionnaire can contribute to a comprehensive understanding of the clinical condition in these patients. Further large-scale studies are warranted to validate and generalize these findings across diverse COPD populations.

Differential impacts between fat mass index and fat-free mass index on patients with COPD

BACKGROUND

Differences in the clinical impacts of fat mass index (FMI) and fat-free mass index (FFMI) remain unclear in patients with chronic obstructive pulmonary disease (COPD). We hypothesized that FMI and FFMI have different impacts on 1) emphysema and 2) pulmonary function and health-related quality of life of COPD patients.

METHODS

Patients with COPD (n = 228), enrolled in a multicenter prospective 3-year cohort were classified into four groups based on baseline median FMI and FFMI values. Emphysema assessed as the ratio of low attenuation area to total lung volume (LAA%) on computed tomography, pulmonary function, and health-related quality of life assessed using the St. George's Respiratory Questionnaire (SGRQ) were compared.

RESULTS

The four groups had statistically significant differences in LAA%, pulmonary function, and SGRQ scores. The Low FMI Low FFMI group exhibited the highest LAA%, lowest pulmonary function, and worst SGRQ scores among the four groups. In addition, these differences were consistent over 3 years. Multivariate analysis showed that low FMI was associated with high LAA%, low inspiratory capacity/total lung capacity (IC/TLC), and carbon monoxide transfer coefficient (KCO). In contrast, low FFMI was associated with these factors as well as worse SGRQ scores.

CONCLUSION

FMI and FFMI have different effects on the clinical manifestations of COPD. Both low fat and muscle mass contributed to severe emphysema, whereas only low muscle mass contributed to worse health-related quality of life in patients with COPD.

The COPD Assessment Test (CAT) and Depression: A Longitudinal Analysis During the COVID-19 Pandemic

Purpose

Chronic obstructive pulmonary disease (COPD) is multifaceted, with some patients experiencing anxiety and depression. Depression in COPD has been associated with worse total scores for the COPD assessment test (CAT). Also, CAT score worsening has been observed during the COVID-19 pandemic. The relationship between the Center for Epidemiologic Studies Depression Scale (CES-D) score and CAT sub-component scores has not been evaluated. We investigated the relationship between CES-D score and CAT component scores during the COVD-19 pandemic.

Patients and Methods

Sixty-five patients were recruited. Pre-pandemic (baseline) was defined as 23rd March 2019-23rd March 2020, CAT scores and information related to exacerbations were collected via telephone at 8-week intervals between 23rd March 2020-23rd March 2021.

Results

There were no differences in CAT scores pre- compared to during the pandemic (ANOVA p = 0.97). Total CAT scores were higher in patients with symptoms of depression compared to those without both pre- (p < 0.001) and during-pandemic (eg, at 12 months 21.2 versus 12.9, mean difference = 8.3 (95% CI = 2.3-14.2), p = 0.02). Individual CAT component scores showed significantly higher chest tightness, breathlessness, activity limitation, confidence, sleep and energy scores in patients with symptoms of depression at most time points (p < 0.05). Significantly fewer exacerbations were observed during- compared to pre-pandemic (p = 0.04). We observed that COPD patients with symptoms of depression had higher CAT scores both pre- and during the COVID-19 pandemic.

Conclusion

Presence of depressive symptoms was selectively associated with individual component scores. Symptoms of depression may potentially influence total CAT scores.

Patient-Reported Outcome Measurements in Patients with COPD-Obstructive Sleep Apnea Overlap Syndrome: Time for Action?

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea syndrome (OSA) are common conditions that often coexist [Overlap syndrome (OS)]. OS has important implications in the diagnosis, treatment, and patient outcome of both disorders. Patient-reported outcomes (PROs) are essential to evaluate symptoms, impact of symptoms on activities of daily living, and treatment response. The present review aims to display the potential usefulness of PROs measurements (PROMs) regarding the initial evaluation and treatment of both conditions (COPD and OSA) in OS patients. More specifically, we review PROMs regarding symptoms, mental health indices and health-related quality of life in patients with OS. These PROMs have the potential to add value to clinical research and daily practice in certain aspects that are important to patients.

Impact of non-exercise activity thermogenesis on physical activity in patients with COPD

Physical inactivity is associated with comorbidities and mortality in chronic obstructive pulmonary disease (COPD) patients. Although non-exercise activity thermogenesis (NEAT) is important for evaluating the physical activity level (PAL) of patients with chronic diseases, it has not yet been assessed in COPD patients. This study included male patients with COPD (n = 28) and high risk for COPD (n = 8). Total energy expenditure (TEE) and basal metabolic rate (BMR) were measured using the doubly labeled water (DLW) method and indirect calorimetry, respectively. PAL was calculated as TEE/BMR, while the NEAT was obtained from a questionnaire. Physical activity was also assessed using an accelerometer. The total NEAT score was correlated with PAL (r = 0.534, P < 0.001), while PAL was correlated more strongly with the non-locomotive NEAT score (r = 0.548, P < 0.001) than the locomotive NEAT score (r = 0.278, P = 0.10). Regarding accelerometer-obtained data, this questionnaire mainly reflected steps/day and the duration of light locomotive and non-locomotive daily activities. The NEAT score is a possible option for evaluating PAL in daily clinical practice. The present results indicated that non-locomotive activity may have a greater impact on PAL than locomotive activity in COPD patients.

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

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

Real-world Safety and Efficacy of Indacaterol/Glycopyrronium in Japanese Patients with Chronic Obstructive Pulmonary Disease: A 52-week Post-marketing Surveillance

Objective To evaluate the long-term safety and efficacy of indacaterol/glycopyrronium (IND/GLY) in patients with chronic obstructive pulmorary disease (COPD) in a real-world setting in Japan. Methods This 52-week, multicentre, post-marketing surveillance conducted in Japan between December 2013 and August 2019 included patients using IND/GLY for the first time to relieve airway obstructive disorder-related symptoms. Safety outcomes included the incidence of adverse events (AEs), serious AEs (SAEs), adverse drug reactions (ADRs), and serious ADRs during the 52-week period. The incidence of priority variables, including cardiovascular/cerebrovascular (CCV) AEs, β-adrenergic-related or anticholinergic AEs and cough, was also assessed. Safety outcomes were also evaluated in elderly patients. Efficacy outcomes included a physician's global assessment, COPD assessment test (CAT) and lung function test. Results Of the 1,167 patients registered, 1,108 were included in the safety and efficacy analysis. In the safety analysis population, the incidence of AEs was 13.54%, that of SAEs was 4.69%, that of ADR was 3.61%, and that of serious ADRs was 0.36% over 52 weeks. CCV AEs, β-adrenergic-related and anticholinergic AEs and cough were reported as 2.62%, 1.99% and 0.63%, respectively. The physician's global assessment showed that the overall response rate at the last assessment was 74.19%. The mean (95% confidence interval) CAT scores decreased from the start of treatment to Week 52 with IND/GLY [-6.9 (-7.8 to -6.1)]. The lung function (FEV₁ and FVC) improved over time from the start of IND/GLY to Week 52. Conclusion IND/GLY demonstrated a good long-term safety profile in a real-world setting in Japanese patients with COPD, with beneficial effects in terms of the lung function and symptoms in clinical use.

Real-World Safety and Efficacy of Glycopyrronium Bromide in Japanese Patients with COPD: A 52-Week Post-Marketing Surveillance

Objective:

To evaluate the long-term safety and efficacy of glycopyrronium (GLY) in patients with COPD in a real-world setting in Japan.

Methods:

This 52-week, multicentre, post-marketing surveillance conducted in Japan, between February 2013 and August 2019, included patients using GLY for the first time for the relief of airway obstructive disorder-related symptoms. Safety outcomes included incidence of adverse events (AEs), serious AEs (SAEs), adverse drug reactions (ADRs), serious ADRs (SADRs) and priority variables included cardiovascular/cerebrovascular (CCV) AEs and anticholinergic AEs during the 52-week period. Safety outcomes were also assessed in elderly patients. Efficacy outcomes included physician’s global assessment, COPD assessment test (CAT) and lung function test.

Results and Discussion:

Of the 1,331 patients registered for this surveillance, safety and efficacy outcomes were evaluated in 1,277 patients. In the safety analysis population, the incidence of AEs was 15.51%, SAEs 4.70%, ADRs 5.01% and SADRs 0.31%. The CCV AEs and anticholinergic AEs were reported by 0.70% and 2.58% patients, respectively. Physician’s global assessment showed that the overall response rate at the last assessment was 70%. The mean (95% CI) CAT scores decreased from the start of treatment to Week 52 with GLY, (−6.2 [−7.0 to −5.4]). Lung function in terms of trough FEV1 and FVC improved over time from the start of GLY to Week 52.

Conclusion:

GLY demonstrated an acceptable long-term safety profile with no new safety concerns in a real-life setting. It demonstrated improvement in lung function and symptom control in Japanese COPD patients.

Change in individual chronic obstructive pulmonary disease assessment test item scores after short-term bronchodilator therapy and its impact on exacerbation in treatment-naïve patients with chronic obstructive pulmonary disease

Background:

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) measures the health status of patients with COPD. We aimed to investigate the change in individual CAT scores after short-term bronchodilator therapy among treatment-naïve patients with COPD.

Methods:

Data from 148 patients newly diagnosed with COPD between January 2016 and April 2020 were retrospectively analyzed. We compared the CAT score, modified Medical Research Council (mMRC) dyspnea grade, and forced expiratory volume in 1 s (FEV1) before and after short-term (6 ± 2 months) bronchodilator therapy. We analyzed the change trends using generalized estimating equations.

Results:

The mean patient age was 70.9 years, and 92.6% were male. The total CAT score did not significantly improve. However, among the CAT items, phlegm [adjusted difference: –0.22 (–0.48, –0.002)], chest tightness [–0.30 (–0.56, –0.05)], and breathlessness [–0.45 (–0.66, –0.23)] scores significantly improved after bronchodilator therapy. The patients were divided into two groups: CAT score improved ( n = 69) and not improved group ( n = 79). The development of moderate-to-severe exacerbations during follow-up was significantly lower (2.9% versus 17.7%, p = 0.004) in the CAT score improved group.

Conclusion:

The improvement in CAT items indicating respiratory symptoms was more evident than the CAT total score after short-term bronchodilator therapy. Despite the significant increase in FEV1 after bronchodilator therapy, fewer than half of the patients achieved meaningful improvement in CAT, and this group showed significantly lower development of exacerbation during follow-up.

Clinical Utility of the Electrocardiographic P-Wave Axis in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

The vertical P-wave axis on electrocardiography (ECG) is a useful criterion for screening patients with chronic obstructive pulmonary disease (COPD). This study aimed to investigate the clinical characteristics of patients with COPD with a vertical P-wave axis as they have not yet been elucidated.

METHODS

Keio University and its affiliated hospitals conducted an observational COPD cohort study over 3 years. We analyzed 201 patients using ECG and chest computed tomography.

RESULTS

The severity of airflow limitation was higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. Patients with a P-wave axis >75° exhibited significantly higher total COPD assessment test scores and increased St. George's Respiratory Questionnaire total, activity, and impact scores than those with a P-wave axis ≤75°. The incidence of exacerbations over 1 and 3 years was significantly higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. The optimal cutoff for the P-wave axis for a percentage of the predicted forced expiratory volume in 1 s <50% and future exacerbations over 3 years was 70° (the areas under the curve [AUC]: 0.788; sensitivity: 65.3%; specificity: 78.3%) and 79° (AUC: 0.642; sensitivity: 36.7%; specificity: 92.6%). The ratio of the low attenuation area was also significantly higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. However, the ratio of the airway wall area did not differ between the 2 groups.

CONCLUSIONS

Patients with COPD with a vertical P-wave axis exhibited severe airflow limitation and emphysema, a worse health status, and more frequent exacerbation than patients without a vertical P-wave. Detection of the vertical P-wave axis by ECG is beneficial for the management of patients with COPD.

Comorbid Anxiety and Depression, Though Underdiagnosed, Are Not Associated with High Rates of Low-Value Care in Patients with Chronic Obstructive Pulmonary Disease

Rationale: Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients.Objectives: To determine whether diagnosed anxiety and depression, as well as significant anxiety and depression symptoms, are associated with underuse and overuse of appropriate COPD therapies.Methods: We analyzed data from a multicenter prospective cohort study of 2,376 participants (smokers and control subjects) enrolled between 2010 and 2015. We identified two subgroups of participants, one at risk for inhaled corticosteroid (ICS) overuse and one at risk for long-acting bronchodilator (LABD) underuse based on the 2011 Global Initiative for Chronic Obstructive Lung Disease statement. Our primary outcomes were self-reported overuse and underuse. Our primary exposures of interest were self-reported anxiety and depression and significant anxiety and depression symptoms. We adopted a propensity-score method with inverse probability of treatment weighting adjusting for differences in prevalence of confounders and performed inverse probability of treatment weighting logistic regression to evaluate all associations between the exposures and outcomes.Results: Among the 1,783 study participants with COPD confirmed by spirometry, 667 (37.4%) did not have an indication for ICS use, whereas 985 (55.2%) had an indication for LABD use. Twenty-five percent (n = 167) of patients reported ICS use, and 72% (n = 709) denied LABD use in each subgroup, respectively. Neither self-reported anxiety and depression nor significant anxiety and depression symptoms were associated with overuse or underuse. At least 50% of patients in both subgroups with significant symptoms of anxiety or depression did not report a preexisting mental health diagnosis.Conclusions: Underuse of LABDs and overuse of ICSs are common but are not associated with comorbid anxiety or depression diagnosis or symptoms. Approximately one-third of individuals with COPD experience anxiety or depression, and most are undiagnosed. There are significant opportunities to improve disease-specific and patient-centered treatment for individuals with COPD.

Utility of Self-Administered Questionnaires for Identifying Individuals at Risk of COPD in Japan: The OCEAN (Okinawa COPD casE finding AssessmeNt) Study

Purpose

A considerable proportion of patients with chronic obstructive pulmonary disease (COPD) remain undiagnosed and untreated even though they may have a burden of respiratory symptoms that impact quality of life. The OCEAN study assessed the ability of screening questionnaires to identify individuals with, or at risk of, COPD by comparing questionnaire outcomes with spirometric measures of lung function.

Methods

This observational study included participants ≥40 years of age presenting for their annual health examination at a single medical center in Okinawa, Japan. Participants completed COPD screening questionnaires (CAPTURE and COPD-Q), the Chronic Airways Assessment Test (CAAT), and general demographic and health-related questionnaires. The performance characteristics of CAPTURE and COPD-Q were compared with spirometry-based airflow limitation by calculating the area under the receiver operating characteristic (ROC-AUC) curve.

Results

A total of 2518 participants were included in the study; 79% of whom were <60 years of age (mean 52.0 years). A total of 52 (2.1%) participants had airflow limitation defined as forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) <0.7, and 420 (16.7%) participants were classified as Preserved Ratio Impaired Spirometry (PRISm). Among participants with PRISm, 75 (17.9%) had a CAAT total score ≥10. Airflow limitation and PRISm were more prevalent in current smokers versus past smokers. For the CAPTURE questionnaire, ROC-AUC for screening airflow limitation, PRISm, and PRISm with a CAAT total score ≥10 were 0.59, 0.55, and 0.69, respectively; for COPD-Q, these three clinical features were 0.67, 0.58 and 0.68, respectively.

Conclusion

This study demonstrated that CAPTURE and COPD-Q appear to be effective screening tools for identifying symptomatic individuals with undiagnosed, or at risk of developing COPD in adults ≥40 years of age in Okinawa. Furthermore, early diagnosis and management of PRISm is important to improve future outcomes and the societal burden of disease.

Clinical Characteristics of COPD Patients According to COPD Assessment Test (CAT) Score Level: Cross-Sectional Study

PURPOSE

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is widely used to assess the impact of COPD symptoms on health status. Whilst the CAT consists of eight different items, details on the distribution of each item are limited. This study aimed to investigate the distribution and clinical implication of each CAT item, stratified by CAT severity group, in stable COPD patients.

PATIENTS AND METHODS

This was a cross-sectional study at a single referral hospital in South Korea. Spirometry confirmed COPD patients with CAT measured at the first clinical visit were retrospectively identified. Patients were categorized into three groups: low (0 ≤ CAT < 10), medium (10 ≤ CAT < 20), and high (20 ≤ CAT ≤ 40) impact group. For the purpose of this analysis, the first four items (cough, sputum, chest tightness, and dyspnea) and the remaining four items (activities, confidence, sleep and energy) were also grouped as "pulmonary" and "extra-pulmonary", respectively.

RESULTS

A total of 815 patients were included, and mean (SD) forced expiratory volume in 1 s (FEV1) was 62.8 (17.4) % pred. Among them, 300 patients (36.8%) were in the high impact group and had a greater exacerbation history and lower lung function. The proportion of "extra-pulmonary" items score was greater in patients with higher total CAT scores, with the activity and confidence items showing higher scores.

CONCLUSION

In our study, in addition to dyspnea, activity limitation is a particular problem in individual patients with higher CAT total scores, for which physicians need to pay more attention. Our study suggests that whilst CAT total score captures the overall impact of COPD, each item of the CAT contains potentially useful information in understanding the patient's symptom burden.

Characteristics of chronic obstructive pulmonary disease patients with robust progression of emphysematous change

Emphysema is a major pathological change in chronic obstructive pulmonary disease (COPD). However, the annual changes in the progression of emphysematous have not been investigated. We aimed to determine possible baseline predicting factors of the change in emphysematous progression in a subgroup of COPD patients who demonstrated rapid progression. In this observational study, we analyzed patients with COPD who were followed up by computed tomography (CT) at least two times over a 3-year period (n = 217). We divided the annual change in the low attenuation area percentage (LAA%) into quartiles and defined a rapid progression group (n = 54) and a non-progression group (n = 163). Predictors of future changes in emphysematous progression differed from predictors of high LAA% at baseline. On multivariate logistic regression analysis, low blood eosinophilic count (odds ratio [OR], 3.22; P = 0.04) and having osteoporosis (OR, 2.13; P = 0.03) were related to rapid changes in emphysematous progression. There was no difference in baseline nutritional parameters, but nutritional parameters deteriorated in parallel with changes in emphysematous progression. Herein, we clarified the predictors of changes in emphysematous progression and concomitant deterioration of nutritional status in COPD patients.

"SingStrong": Singing for better lung health in COPD - A pilot study

Background: Chronic Obstructive Pulmonary Disease (COPD) affects up to 440,000 people in Ireland. Multiple domains of biopsychosocial health are affected. Community-based interventions supporting behavioral change and self-management are advocated. The aim of this pilot study was to evaluate the efficacy of an 8-week singing intervention, "SingStrong", to improve biopsychosocial wellness in persons with COPD. Methods: Seventy-eight adults with COPD were recruited from three COPD Support groups in the Irish Mid-west. Pre and post-intervention testing performed by physiotherapy and nursing staff comprised Six-Minute Walk Test (6MWT), COPD Assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), and Spirometry: FEV1, FVC, FEV1/FVC. The intervention was a weekly one-hour group class for eight weeks led by a trained choir leader at each site. This included physical and vocal warm-up, breathing exercises and singing. Participants were given a songbook based on their song preferences and a CD with vocal, breathing exercises and songs, and encouraged to practice daily. Semi-structured focus groups were conducted post intervention. Parametric or non-parametric t-tests were conducted to establish significance. Results: Fifty-eight (74%) participants who attended at least 4/8 session were re-tested. There was a statistically significant improvement in 6MWT (p = .02), non-significant improvements in CAT (p = .24) and HADS Depression (p = .238), and non-significant worsening in HADS Anxiety (p = .34). All qualitative feedback was positive, including improvements in breathing, quality of life and intervention enjoyment. Principal Conclusions: Singing for lung health has positive implications for persons with COPD. Future longer studies should examine outcomes of exacerbation level, hospitalization and medication use.

Associated Factors and Comorbidities of Airflow Limitation in Subjects Undergoing Comprehensive Health Examination in Japan - Survey of Chronic Obstructive Pulmonary Disease Patients Epidemiology in Japan (SCOPE- J)

Purpose

To identify associated factors of having at least one of the airflow limitation, chronic cough/phlegm, and currently treated respiratory diseases in health examinees, and to describe the characteristics of each subgroup classified by comorbidities.

Subjects and Methods

This was an observational cross-sectional survey carried out in multiple regions of Japan. Subjects aged 40 years older, undergoing comprehensive health examination, were recruited. Airflow limitation was defined as having forced expiratory volume in 1 s/forced vital capacity lower than 70%. Associated factors of having at least one of the airflow limitation, chronic cough/phlegm, and currently treated respiratory diseases were examined by logistic regression analysis. Subgroup classification by comorbidity patterns was conducted by hierarchical cluster analysis.

Results

In a total of 22,293 subjects, 1520 (6.8%) had at least one of the airflow limitation, chronic cough/phlegm, and currently treated respiratory diseases. With this objective variable, the following explanatory variables were significantly associated: older age, higher total score in the chronic obstructive pulmonary disease assessment test (CAT) and coexistence of lung cancer (common in ever-smokers and never-smokers), higher pack-years, lower body mass index, higher C-reactive protein, without coexistence of diabetes mellitus (specific in ever-smokers), male sex, coexistence of anxiety, and sleep disorder (specific in never-smokers). Among the 1520 subjects, 1512 subjects with smoking history data were classified by comorbidity patterns into subgroups of "no comorbidities," "mixed comorbidities," "inflammatory comorbidities," "overweight," "underweight," and "chronic kidney disease." "Inflammatory comorbidities" were specific in ever-smokers, and "underweight" was specific in never-smokers.

Conclusion

Several factors were identified as associated factors of having at least one of airflow limitation, chronic cough/phlegm, and currently treated respiratory diseases and they were different between ever-smokers and never-smokers. Different comorbidity patterns were observed by smoking history. These findings could provide information to assist the management of subjects with COPD or at risk for COPD in the general population.

Multimorbidity networks of chronic obstructive pulmonary disease and heart failure in men and women: Evidence from the EpiChron Cohort

Patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD) constitute a complex population with different phenotypes based on pathophysiology, comorbidity, sex and age. We aimed to compare the multimorbidity patterns of HF and COPD in men and women using network analysis. Individuals aged 40 years or older on 2015 of the EpiChron Cohort (Aragon, Spain) were stratified by sex and as having COPD (n = 28,608), HF (n = 13,414), or COPD and HF (n = 3952). We constructed one network per group by obtaining age-adjusted phi correlations between comorbidities. For each sex, networks differed between the three study groups; between sexes, similarities were found for the two HF groups. We detected some specific diseases highly connected in all networks (e.g., cardio-metabolic, respiratory diseases, and chronic kidney failure), and some others that were group-specific that would require further study. We identified common clusters (i.e., cardio-metabolic, cardiovascular, cancer, and neuro-psychiatric) and others specific and clinically relevant in COPD patients (e.g., behavioral risk disorders were systematically associated with psychiatric diseases in women and cancer in men). Network analysis represents a powerful tool to analyze, visualize, and compare the multimorbidity patterns of COPD and HF, also facilitated by developing an ad hoc website.

Management of cardiovascular comorbidities in chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) is а highly prevalent, complex and heterogeneous clinical condition which is associated with significant concomitant diseases. COPD and cardiovascular diseases (CVDs) often coexist due to the high prevalence of each of these pathological conditions separately as well as the common risk factors (particularly smoking), mechanisms of interaction and influence of systemic inflammation. In addition, decreased pulmonary function in COPD is closely associated with an increased risk of congestive CVDs. One of the most important pathophysiological markers of COPD—lung hyperinflation—plays a significant role in the appearance of functional limitations of the pumping function of the heart, creating unfavorable conditions by exerting a compression effect on the heart muscle. The latter was confirmed by significant correlation between the COPD severity according to GOLD classification and the basic dimensions of the heart chambers. Several decades ago, the term “microcardia” was commonly used and indicated a radiological sign of emphysema. Some studies demonstrated a close relationship between the chance of occurrence of CVD and the severity of pulmonary dysfunction. Such an association has been demonstrated for the whole spectrum of CVD—including cerebrovascular disease, congestive heart failure (CHF) and rhythm disturbances—and was detected in the early stages of the disease. A large proportion of patients with mild and moderate COPD die due to CVD, which is much more likely than deaths in the same group due to respiratory insufficiency. COPD patients have a higher rate of hospitalization and death, the cause of which are coronary heart disease (CHD), stroke and CHF. Treatment of COPD today is mainly determined by national and international clinical guidelines, which should pay more attention to the problems of the treatment of COPD patients with comorbid conditions.

Malnutrition, Airflow Limitation and Severe Emphysema are Risks for Exacerbation of Chronic Obstructive Pulmonary Disease in Japanese Subjects: A Retrospective Single-Center Study

Background

Different characteristics of patients with chronic obstructive pulmonary disease (COPD) between Western and Japanese populations have been reported. Risk factors for COPD exacerbation have been reported in Western countries but have not been studied in Japan.

Patients and Methods

We retrospectively examined risk factors for COPD exacerbation. A total of 156 Japanese patients were enrolled, and the records of 136 patients were analyzed.

Results

In the exacerbation group (n=60), body mass index, forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), the FEV₁/FVC ratio (FEV₁/FVC), the percent predicted values of FEV₁ (%FEV₁), and serum total protein (TP) and albumin concentrations were lower, and age, mortality rate, frequency of common cold and pneumonia, COPD severity rankings, modified Medical Research Council (mMRC) dyspnea score, and proportions of patients with severe emphysema (>50% of low attenuation area) and receiving long-term oxygen therapy were higher than those in the nonexacerbation group (n=76). However, the proportion of patients with a greater number of eosinophils (≥200/μL and/or ≥2%) and the exhaled nitric oxide concentration did not differ between the two groups. In the univariate analysis, the risk factors for exacerbation were age; long-term oxygen therapy; low FVC, FEV₁, FEV₁/FVC and %FEV₁; high COPD severity ranking and mMRC score; severe emphysema; hypoproteinemia (<6.5 g/dL); hypoalbuminemia (<3.5 g/dL); leukocytosis; lymphocytopenia; and anemia. In the multivariate analysis, the risk factors were hypoalbuminemia, hypoproteinemia and low FEV₁. Additionally, in patients in the exacerbation-induced mortality subgroup, age, exacerbation frequency, mMRC score and the proportion of patients with lymphocytopenia were higher, and FVC, %FVC, FEV₁, serum TP concentration and the lymphocyte number were lower than those in the exacerbation survival subgroup.

Conclusion

Malnutrition, airflow limitation and severe emphysema were risks for exacerbation and mortality associated with infection in Japanese patients with COPD.

Characteristics of Chronic Obstructive Pulmonary Disease Patients with Pulmonary Hypertension Assessed by Echocardiography in a Three-Year Observational Cohort Study

Background

Pulmonary hypertension (PH) is a major comorbidity of chronic obstructive pulmonary disease (COPD). However, the association of PH detected by echocardiography and COPD-related outcome in longitudinal follow-up has not been elucidated. In this study, we aimed to investigate the relationship between clinical characteristics of COPD patients with PH detected by echocardiography and various outcome parameters such as COPD exacerbation and health status over a three-year observation period.

Methods

In this observational study, we analyzed patients with COPD who underwent chest computed tomography and echocardiography at baseline (n = 183).

Results

The prevalence of PH was 21.9% (40 patients). The median estimated systolic pulmonary artery pressure in patients with PH was 38.8 mmHg. COPD patients with PH were older, had a lower body mass index, scored worse in the COPD Assessment Test and St. George's Respiratory Questionnaire, and exhibited a lower diffusing capacity of the lung for carbon monoxide in comparison to patients without PH. In computed tomography images, the percentages of low-attenuation areas (LAA%) and interstitial abnormalities were higher in COPD patients with PH than in those without PH. Higher values for LAA% (LAA ≥ 30%) and interstitial abnormalities independently increased the risk of PH. The ratio of main pulmonary diameter to aortic artery diameter was significantly correlated with estimated systolic pulmonary artery pressure. In the follow-up analysis, the frequency of exacerbations in three years was significantly higher in patients with PH compared to patients without PH.

Conclusion

In this study, we identified the clinical characteristics of COPD patients with PH detected by echocardiography. The presence of PH assessed by echocardiography was related to future COPD exacerbations and closely related to radiographical emphysema.

Characterization of low adherence population in asthma patients from Japan using Adherence Starts with Knowledge-12

BACKGROUND

Adherence Starts with Knowledge-12 (ASK-12) is a useful indicator of drug adherence. In this study, we analyzed patient background including social and psychological factors in a low-adherence group of patients with asthma defined using ASK-12.

METHODS

From a questionnaire survey for patients with asthma from the Niigata Prefecture, Japan, conducted in the fall of 2016, we enrolled patients who answered all ASK-12 items and underwent a measured respiratory function test within 1 year. The low-adherence group (ASK-12 ≥ 28) was compared with the control group (ASK-12 < 28), and we conducted a cluster analysis of the low-adherence group.

RESULTS

There were 170 patients in the low-adherence group and 402 patients in the control group. There was a significant difference between age, gender, working status, smoking history, the percentage of forced expiratory volume in one second (%FEV₁), asthma control test (ACT), and Patient Health Questionnaire-9 (PHQ-9) score between the two groups. Logistic analysis revealed that working status (working), % FEV₁ (<90%), and PHQ-9 score (>5) were independent factors for the low-adherence group. The cluster analysis identified three clusters in the low-adherence group. Among these, one cluster was characterized by elderly males with chronic obstructive pulmonary disease and another by middle-aged nonsmoking females with a depression tendency, had problems with asthma control.

CONCLUSIONS

Several factors were considered to be attributed to low drug-adherence. There were several phenotypes in the low-adherence population correlated with incomplete asthma control. Intervention with drug adherence should be a future goal for asthma treatment.

Predictors of Symptom Burden in Patients with COPD on LAMA Monotherapy: Multivariable Analysis of a Claims-Linked Survey Study

INTRODUCTION

Many patients with chronic obstructive pulmonary disease (COPD) prescribed long-acting muscarinic antagonist (LAMA) monotherapy remain symptomatic. This multivariable analysis of a previously reported claims-linked, cross-sectional survey assessed symptom burden measured by the COPD assessment test (CAT) in patients treated with LAMA monotherapy.

METHODS

Eligible patients aged ≥ 40 years with COPD (≥ 2 International Classification of Diseases-10th Revision-Clinical Modification [ICD-10-CM] diagnosis codes ≥ 30 days apart during the 12-month baseline period) and ≥ 2 claims for LAMA monotherapy in the latter half of the baseline period were identified using claims data from the Optum Research Database. Patients completed a survey and 7-day daily diary; baseline clinical characteristics and resource utilization were assessed from claims data. Association between symptom burden and baseline characteristics was assessed using generalized linear regression modeling with normal distribution and identity link.

RESULTS

Overall, 433 patients prescribed LAMA monotherapy with claims-linked survey and diary data were included in the analysis. Most patients (85.5%) had a mean CAT score ≥ 10; 39.0% had scores ≥ 21. Overall, the factors most related to a clinically meaningful increase in CAT score (≥ 2 points) were being diagnosed with COPD for > 5 years and being a current smoker (2.25 points, P = 0.003 and 2.22 points, P = 0.025, respectively).

CONCLUSIONS

Results demonstrate that many patients with COPD receiving LAMA monotherapy remain symptomatic, especially those diagnosed > 5 years ago or those who continue to smoke. Use of patient-reported outcomes such as the CAT should be considered part of routine visits for patients with COPD.

FUNDING

GlaxoSmithKline (GSK study number 205862 [HO-16-16642]).

[Chronic obstructive pulmonary disease and cardiovascular comorbidity]

In recent years, a greater understanding of the heterogeneity and complexity of chronic obstructive pulmonary disease (COPD) has come from the point of view of an integrated clinical assessment of severity, pathophysiology, and the relationship with other pathologies. A typical COPD patient suffers on average 4 or more concomitant diseases and every day about a third of patients take from 5 to 10 different drugs. The mechanisms of the interaction of COPD and cardiovascular disease (CVD) include the effects of systemic inflammation, hyperinflation (hyperinflation) of the lungs and bronchial obstruction. The risk of developing CVD in patients with COPD is on average 2-3 times higher than in people of a comparable age in the general population, even taking into account the risk of smoking. The prevalence of coronary heart disease, heart failure, and rhythm disturbances among COPD patients is significantly higher than in the general population. The article discusses in detail the safety of prescribing various groups of drugs for the treatment of CVD in patients with COPD. Achieving success in understanding and managing patients with COPD and CVD is possible using an integrated multidisciplinary approach.

Summary of the Japanese Respiratory Society statement for the treatment of lung cancer with comorbid interstitial pneumonia

Dramatic progress in targeted therapy and immunotherapy has been changing clinical practices in lung cancer. With the accumulation of clinical practice, it has become clear that pre-existing interstitial pneumonia (IP) could be a risk factor for drug-induced lung injury, which has enhanced awareness regarding the difficulty in treating lung cancer with comorbid IP. Unfortunately, there is only low-grade evidence in the field of lung cancer with comorbid IP, because almost all clinical trials exclude such patients. There have been very few specialized clinical trials for patients with lung cancer and underlying IPs thus far. Therefore, it is necessary to treat such cases empirically or to give up on the treatment itself. Considering these circumstances, establishing how to treat lung cancer with comorbid IP is an urgent issue. This paper is a summary of the official statement reported by the Diffuse Lung Disease/Thoracic Oncology Assembly and the Japanese Respiratory Society (JRS) in 2017, which attempts to approach lung cancer with comorbid IP systematically.

Patterns and Predictors of Recovery from Poor Health Status Measured with the Chronic Obstructive Pulmonary Disease (COPD) Assessment Test in Patients with Stable COPD: A Longitudinal Study

Recent recommendations for chronic obstructive pulmonary disease (COPD) suggest that evaluation and management should focus on patient health status. Despite the frequency of poor health status and its negative impact on patients with COPD, little is known about how poor or non-poor health status persists and/or remits over time or what factors might predict recovery from a poor health status. The aim was to determine the likelihood of transitioning between poor and non-poor health status in patients with stable COPD followed for 2 years and to investigate factors that might predict recovery from poor health status. We prospectively included 137 patients with stable COPD (mean age, 66.9 years ± 8.3). Health status was measured at baseline and after 1 and 2 years with the COPD assessment test (CAT). Higher scores indicated worse health status, and 10 was the cut-off score for discriminating between non-poor and poor health status. The likelihoods of annual transitions to new episodes and recovery were calculated. We evaluated demographic, non-respiratory, and respiratory variables as potential predictors with generalized estimating equations. At baseline, 37 patients (27%) reported non-poor health status. Within the group of patients displaying poor health status at the beginning of the year, 176 annual transitions were identified during the study period: 15.9% were transitions to recovery from poor health status. In contrast, of the 70 transitions from a starting non-poor health status, 32.4% worsened. Predictors of transitions to recovery were: current non-smoker status (odds ratio (OR) = 3.88; 95% confidence interval (CI): 0.64–5.54) and handgrip strength (OR = 1.08; 95% CI: 1.00–1.16). This study suggests that self-reported health status, measured with the CAT, has a dynamic nature in patients with COPD. Annual transitions towards recovery from poor health status are most likely among current non-smoking patients and those with high handgrip strength.

Implementation of a depression screening protocol among respiratory insufficiency patients

INTRODUCTION

Unnoticed and untreated depression is prevalent among patients with chronic respiratory insufficiency. Comorbid depression causes suffering and worsens patients' outcomes.

OBJECTIVES

The objective of this evaluation was to assess preliminary outcomes of a depression screening protocol among chronic respiratory insufficiency patients at a tertiary care pulmonary outpatient clinic.

METHODS

In the depression screening protocol, the patients filled the Depression Scale (DEPS) questionnaire. Patients whose scores suggested depression were offered the opportunity of a further evaluation of mood at a psychiatric outpatient clinic. The outcomes of the protocol were evaluated retrospectively from the patient records.

RESULTS

During the period of evaluation, 238 patients visited the outpatient clinic. DEPS was administered to 176 patients (74%), of whom 60 (34%) scored ≥9 (out of 30), thus exceeding the cut-off for referral. However, only 13 patients were referred, as the remainder declined the referral. Finally, seven patients were evaluated at the psychiatric clinic, and they all were deemed depressive. Symptoms of depression were most prevalent among patients with a long smoking history, refractory dyspnoea and a history of depression.

CONCLUSION

Depression screening was positive in a third of the patients. The depression screening protocol improved the detection of depression symptoms, but the effects on the patients' treatment and clinical course were small. Rather than referring patients to a psychiatric unit, the evaluation and management of depression should be undertaken at the pulmonary unit.

Influence of comorbidities in long-term survival of chronic obstructive pulmonary disease patients

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity around the world, with comorbidities in COPD being common and having a negative effect on survival. We investigate the effects of comorbidities on long-term survival of COPD patients.

Methods

The study included patients with COPD who were hospitalized with an exacerbation. The demographic characteristics, hematological and biochemical parameters, pulmonary function test parameters and comorbidities of the patients were obtained from the hospital database and patient records, and the mortality of the patients was assessed at two years. The parameters considered to be related to mortality were analyzed using the Cox regression method.

Results

A total of 826 patients with COPD were included in the study, and the rate of patients with at least one comorbidity was 84.5%. The most common comorbidities were hypertension (n=394, 47.7%), heart failure (n=244, 29.5%) and DM (n=173, 20.9%). In a Cox regression analysis, the Charlson Comorbidity Index was strongly associated with mortality (P=0.000). In Kaplan-Meier analysis, a significant association was noted between the increasing number of comorbidities and long-term mortality, when compared to the patients without comorbidity (comorbidity numbers 1, 2 and ≥3; HR: 1.37, P=0.032, HR: 1.40, P=0.028 and HR: 1.65, P=0.000, respectively).

Conclusions

Increasing number of comorbidities in COPD patients with severe exacerbation were found to negatively affect long-term survival. We consider both the evaluation and treatment of comorbidities to be important in the reduction of long-term mortality in patients with COPD.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) experiences among COPD patients with comorbid gastrooesophageal reflux disease

AIMS AND OBJECTIVES

To explore perceptions of experience exacerbations of chronic obstructive pulmonary disease among chronic obstructive pulmonary disease patients with comorbid gastrooesophageal reflux disease by focusing on unravelling how patients differentiate and react to symptoms of chronic obstructive pulmonary disease and gastrooesophageal reflux disease.

BACKGROUND

While gastrooesophageal reflux disease has been suggested to be a risk factor for chronic obstructive pulmonary disease exacerbations, no study has explored perceptions of the symptoms leading up to severe exacerbation of chronic obstructive pulmonary disease events among chronic obstructive pulmonary disease patients with comorbid gastrooesophageal reflux disease.

DESIGN

Qualitative design.

METHODS

The analysis was performed in accordance with principles of Grounded Theory methodology. Data were collected via semi-structured interviews from 12 chronic obstructive pulmonary disease patients with endoscopy-diagnosed gastrooesophageal reflux disease who had experienced a chronic obstructive pulmonary disease exacerbation with hospitalisation. Appraisal and analysis using consolidated criteria for reporting qualitative research (COREQ) checklist were undertaken.

RESULTS

The core category of this study was the ineffective management of exacerbation symptoms, which was associated with perceived symptoms pre-exacerbation which contained three overlapping categories of symptom presentation experienced, and chronic obstructive pulmonary disease-related coping strategies, high anxiety and a sense of helplessness in disease management.

CONCLUSIONS

Patients with severe chronic obstructive pulmonary disease with comorbid gastrooesophageal reflux disease presented with some distinctly different atypical symptoms yet used common respiratory symptom management strategies. Patients and practitioners alike need to be more aware of the possibility of other symptoms such as nonspecific symptoms being clues of exacerbation onset for a more effective intervention.

RELEVANCE TO CLINICAL PRACTICE

The medical community needs to educate patients to understand and manage not only chronic obstructive pulmonary disease but also gastrooesophageal reflux disease symptoms so that they are better able to identify the cause of their symptoms, treat them appropriately and seek out medical assistance when necessary.

Is the COPD Assessment Test sensitive for differentiating COPD patients from active smokers and nonsmokers without lung function impairment? A population-based study

OBJECTIVE

To assess COPD Assessment Test (CAT) scores in adults with and without COPD, as well as to compare the CAT scores for nonsmokers, former smokers, and smokers without COPD with those for patients with COPD.

METHODS

This was a cross-sectional population-based study (the Respira Floripa study). The study included adults ≥ 40 years of age residing in the city of Florianópolis, Brazil. A total of 846 households were surveyed. In addition to completing the Respira Floripa questionnaire and the CAT, participants underwent pulmonary function testing.

RESULTS

We analyzed data on 1,057 participants (88.1% of the predicted sample size). A functional diagnosis of COPD was made in 92 participants (8.7%). Of those, 72% were unaware that they had COPD. The mean CAT score was higher in the group of COPD patients than in that of individuals without COPD (10.6 [95% CI: 8.8-12.4] vs. 6.6 [95% CI: 6.1-7.0]; p < 0.01). Individual item scores were significantly higher in the patients with COPD than in the individuals without COPD (p < 0.001), the exception being the scores for the items related to sleep (p = 0.13) and energy (p = 0.08). The mean CAT score was higher in the group of COPD patients than in nonsmokers (5.8 [95% CI: 5.3-6.4]) and former smokers (6.4 [95% CI: 5.6-7.2]; p < 0.05). However, there were no significant differences in the mean CAT score between the group of COPD patients and smokers without COPD (9.5 [95% CI: 8.2-10.8]; p > 0.05), the exception being the mean scores for confidence leaving home (p = 0.02).

CONCLUSIONS

CAT scores were higher in the group of patients with COPD than in nonsmokers and former smokers without COPD. However, there were no significant differences in CAT scores between COPD patients and smokers without COPD. Smokers with an FEV1/FVC ratio > 0.70 have impaired health status and respiratory symptoms similar to those observed in COPD patients.

Predictive and modifying factors of bone mineral density decline in patients with COPD

RATIONALE

Various determinants of osteoporosis have been previously identified. However, only a few longitudinal studies have examined related factors. We aimed to investigate factors predicting and modifying rapid decline of bone mineral density in patients with chronic obstructive pulmonary disease.

METHODS

We analyzed patients with chronic obstructive pulmonary disease whose bone mineral density were measured at least three times over three years (n = 111). We divided annual per cent changes of bone mineral density in different body parts into tertiles. Rapid decliners (n = 33) were defined as those with the largest decline in at least two parts; all other participants were defined as non-rapid decliners (n = 78).

RESULTS

At enrollment, bone mineral density did not differ between the two groups. However, rapid decliners had a significantly greater rate of new vertebral fractures over 3 years compared with non-rapid decliners. On multivariate logistic regression analysis, age, moderate to severe emphysema, no daily exercise habits, and anemia increased the likelihood of rapid decliners. Furthermore, patients who newly started and continued bisphosphonate exhibited higher annual per cent changes of bone mineral density than did those without bisphosphonate use.

CONCLUSIONS

A rapid decline in bone mineral density correlates to a higher likelihood of vertebral fracture. We clarified the predictors of bone mineral density decline and demonstrated that bisphosphonate use might modify bone mineral density in patients with chronic obstructive pulmonary disease.

Impact of cataract on health-related quality of life in a longitudinal Japanese chronic obstructive pulmonary cohort

Cigarette smoking increases the risk of developing both cataract and chronic obstructive pulmonary disease (COPD). The prevalence of cataract and the clinical characteristics of COPD patients with cataract were retrospectively investigated in a 2-year observational COPD cohort. We analyzed 395 patients with complete data on ophthalmologic evaluation (319 subjects with COPD and 76 subjects at risk of COPD). There was no difference in the prevalence of cataract between COPD patients and those at risk (47.0% vs. 42.1%, p = 0.44). Age ≥ 75 years, low body mass index, and hypertension were independently associated with cataract as a comorbidity in COPD. The incidence of exacerbation within 2 years was significantly higher in COPD patients with cataract than those without cataract (36.6% vs. 18.3%, p = 0.0019). COPD patients with cataract exhibited significantly higher COPD assessment test score compared to those without cataract (13.7 ± 8.9 vs. 11.5 ± 7.2, p = 0.0240). Overall St George's Respiratory Questionnaire score and each component were significantly worse in COPD patients with cataract compared to those without cataract. COPD patients with cataract exhibited poor health-related quality of life and frequent exacerbations. The association between cataract and exacerbations of COPD deserves further attention.

COPD uncovered: a cross-sectional study to assess the socioeconomic burden of COPD in Japan

Background

COPD remains a major health problem in Japan. Patients with COPD experience a reduced quality of life (QoL) and have a higher chance of work impairment and productivity loss. However, there is a lack of data on the impact of COPD in terms of QoL and work activity impairment in Japan. This study assessed the socioeconomic burden of COPD in Japan and the impact it may have on the working age population.

Patients and methods

This was a 2-year retrospective chart review in COPD patients aged ≥40 years, with at least one health care visit to clinic or hospital in the previous 12 months. Patients were required to have available medical charts for at least the previous 24 months. Symptoms were assessed using COPD assessment test score; EuroQoL Group 5 Dimension (EQ-5D-5L) and work productivity and activity impairment general health questionnaires were used to evaluate health-related QoL and work productivity, and health care resource utilization data were obtained from clinical charts.

Results

In total, 71 patients aged <65 years, and 151 patients aged ≥65 years were included; the majority of patients had moderate or severe airflow limitation. Exacerbations (moderate or severe) were reported by ~35% of patients in both age groups; 52.1% and 62.9% of patients in the <65-year and ≥65-year age groups had COPD assessment test scores ≥10. EQ-5D-5L index scores in the <65-year and ≥65-year age groups were 0.79 and 0.77, respectively. Work productivity and activity impairment scores were higher in <65-year age group. Annual costs of health care resource use per patient in the <65-year and ≥65-year age groups were ¥438,975 (US$4,389) and ¥467,871 (US$4,678), respectively. Costs due to productivity loss were estimated to be ¥5,287,024 (US$52,870) in the <65-year age group and ¥3,018,974 (US$30,187) in the ≥65-year age group.

Conclusion

COPD represents a significant socioeconomic burden in Japan. Patients with COPD report significant use of health care resources. Higher impact on work impairment and productivity loss was observed frequently in the working age population.

Physical frailty characteristics have a differential impact on symptoms as measured by the CAT score: an observational study

BACKGROUND

The physical frailty status affects the health status of patients with chronic obstructive pulmonary disease (COPD). The objective was to determine if the individual physical frailty characteristics have a differential impact on the CAT score.

METHODS

This observational study included 137 patients with stable COPD. Physical frailty was measured with unintentional weight loss, low physical activity, exhaustion, slow walking speed and low grip strength and health status assessed with the COPD Assessment test (CAT). The following variables were evaluated as potential determinants of CAT: sex, age, body mass index, smoking, dyspnea, exacerbations, comorbidities, %FEV1, %FVC, anxiety and depression.

RESULTS

The prevalence of characteristics for individual frailty was as follows: low grip strength, 60.6%; low physical activity, 27.0%; exhaustion, 19.7%; slow walking speed, 9.5%; and unintentional weight loss, 7.3%. A total of 17.5% of the patients were non-frail, 73.7% were pre-frail and only 8.7% were frail. One of the five frailty characteristics, exhaustion (adjusted β coefficient 5.12 [standard error = 1.27], p = 0.001) was an independent determinant of CAT score in the final regression model which was adjusted by other independent determinants of CAT (dyspnea, exacerbations and anxiety).

CONCLUSIONS

Due to the fact that exhaustion is a frequent and relevant psychological symptom on CAT score of patients with COPD, interventions should reduce that stress. Future research should explore how exhaustion persists or remits over time.

Changes in the Burden of Comorbidities in Patients with COPD and Asthma-COPD Overlap According to the GOLD 2017 Recommendations

PURPOSE

Comorbidities associated with chronic obstructive pulmonary disease (COPD) affect quality of life and increase mortality. Asthma-COPD overlap (ACO) may express a different profile of comorbidities compared to COPD alone. It is unclear how recent changes in GOLD recommendations affect the profile of comorbidities in COPD and ACO.

METHODS

Eight hundred and thirty-four patients with COPD were recruited from 67 Hungarian secondary care outpatient clinics, 469 of them had ACO. Comorbidities were defined by respiratory specialists based on medical history, patient report, and medications. COPD grades were defined according to the old 2016 and the new 2017 GOLD document. Comorbidities were compared along COPD ABCD groups determined by the old and new GOLD.

RESULTS

66 and 72% of the COPD patients in groups C and D (GOLD 2016) were recategorized to groups A and B (GOLD 2017), respectively. There was no difference in the prevalence of disorders along the 2016 GOLD categories except for osteoporosis in ACO (p = 0.01). When the patients were categorized according to the 2017 GOLD criteria, the prevalence of osteoporosis (p = 0.01) was different among the four groups in all COPD patients. Subgroup analysis of non-ACO COPD patients revealed inter-group differences for cardiac arrhythmia (p < 0.01). No alteration was seen in the prevalence of coronary artery disease, hypertension, diabetes, or the total number of comorbidities.

CONCLUSION

A significant number of patients are recategorized according to the GOLD 2017 criteria. This change only marginally affects the profile of comorbidities; still this needs to be considered when assessing the patients in daily practice.

Clinical utility of blood neutrophil-lymphocyte ratio in Japanese COPD patients

Background

Neutrophil-to-lymphocyte ratio (NLR) is a biomarker of inflammation in chronic obstructive pulmonary disease (COPD) patients. But, a meaningful threshold and the longitudinal changes are unknown. We aimed to investigate the association between NLR and the clinical characteristics of COPD patients and to determine a meaningful threshold and the longitudinal changes for NLR.

Methods

Keio University and its affiliate hospitals conducted an observational COPD cohort study over 3 years. We performed a blood examination and a pulmonary function test. Blood examination was completed at baseline and annually thereafter, at a time when the disease was stable. Two hundred seventy-four patients who had at least 3 blood examinations over 3 years were included.

Results

Baseline NLR was correlated with baseline C-reactive protein (CRP) (r = 0.18, p = 0.003) and SAA (r = 0.34, p <  0.001). We defined an NLR score of 2.7 as the arbitrary cut-off value based on upper quartile points. COPD patients with NLR ≥ 2.7 were older (p = 0.037), had a lower BMI (p = 0.005) and a lower %FEV1 (p = 0.0003) compared to patients with NLR < 2.7. Receiver-operating-characteristic (ROC) curves showed the optimal cutoff for the baseline NLR in the predicting moderate/severe exacerbation to be 2.7, which was same as the upper quartile points. Follow-up analysis over 3 years revealed that the differences in the trends of NLR among the three groups based on the categories of exacerbations (moderate or severe, mild, no exacerbation) were significant (p = 0.006).

Conclusions

NLR is associated with COPD severity and exacerbations. For predicting exacerbations, we estimated the threshold of NLR to be 2.7 at baseline.

Trial registration

Clinical trial registered with the University Hospital Medication Information Network (UMIN000003470, April 10, 2010).

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0639-z) contains supplementary material, which is available to authorized users.

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

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

Depressive status explains a significant amount of the variance in COPD assessment test (CAT) scores

Background

COPD assessment test (CAT) is a short, easy-to-complete health status tool that has been incorporated into the multidimensional assessment of COPD in order to guide therapy; therefore, it is important to understand the factors determining CAT scores.

Methods

This is a post hoc analysis of a cross-sectional, observational study conducted in respiratory medicine departments and primary care centers in Spain with the aim of identifying the factors determining CAT scores, focusing particularly on the cognitive status measured by the Mini-Mental State Examination (MMSE) and levels of depression measured by the short Beck Depression Inventory (BDI).

Results

A total of 684 COPD patients were analyzed; 84.1% were men, the mean age of patients was 68.7 years, and the mean forced expiratory volume in 1 second (%) was 55.1%. Mean CAT score was 21.8. CAT scores correlated with the MMSE score (Pearson's coefficient r=-0.371) and the BDI (r=0.620), both p<0.001. In the multivariate analysis, the usual COPD severity variables (age, dyspnea, lung function, and comorbidity) together with MMSE and BDI scores were significantly associated with CAT scores and explained 45% of the variability. However, a model including only MMSE and BDI scores explained up to 40% and BDI alone explained 38% of the CAT variance.

Conclusion

CAT scores are associated with clinical variables of severity of COPD. However, cognitive status and, in particular, the level of depression explain a larger percentage of the variance in the CAT scores than the usual COPD clinical severity variables.

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

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

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

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

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