Differences in the risk of mood disorders in patients with asthma-COPD overlap and in patients with COPD alone: a nationwide population-based retrospective cohort study in Korea

Epidemiological characteristics of asthma-COPD overlap, its association with all-cause mortality, and the mediating role of depressive symptoms: evidence from NHANES 2005-2018

BACKGROUND

Asthma-COPD overlap (ACO) is a distinct and intricate respiratory condition that requires specific attention and management. The objective of this cohort study was to examine the epidemiological characteristics of ACO, explore the association between ACO and all-cause mortality, and investigate the potential mediating role of depressive symptoms in this association.

METHODS

This retrospective cohort study used data from the National Health and Nutrition Examination Survey (NHANES) 2005-2018 and National Death Index (NDI) 2019. A total of 22,745 participants were included: 705 with ACO, 2352 with asthma-only, 853 with COPD-only, and 18,835 without asthma or COPD. The non-ACO group (N = 22,040) referred to the individuals without ACO. Statistical tests were employed to assess differences in some characteristics between the ACO group and the other groups. Cox proportional hazards models were applied to evaluate the relationship between ACO and all-cause mortality, estimating hazard ratios (HR) with 95% confidence intervals. Mediation analysis was conducted to investigate the potential mediating effects of depressive symptoms on the association of ACO with all-cause mortality.

RESULTS

The prevalence of ACO was 3.10% in our study population. Compared to the non-ACO participants, the ACO participants exhibited significantly different characteristics, including higher age, a lower family income-to-poverty ratio, a higher body mass index, higher rates of comorbidities i.e., hypertension, diabetes, hyperlipidemia, cardiovascular disease, and cancer, poorer dietary habits, and a higher rate of depressive disorders. Compared to the participants without ACO, the participants with ACO exhibited a significant increase in all-cause mortality (HR = 1.908, 95%CI 1.578-1.307, p < 0.001). The proportions mediated by depressive symptoms for ACO -associated all-cause mortality were 8.13% (CI: 4.22%-14.00%, p < 0.001).

CONCLUSIONS

This study revealed a strong relationship between ACO and all-cause mortality and uncovered a potential psychological mechanism underlying this relationship. Our study indicates the possible necessity of offering comprehensive care to ACO patients, encompassing early detection, lifestyle guidance, and mental health support. Nevertheless, due to the limitations in the study design and the dataset, the results should be interpreted with caution.

Current Status of Studies Investigating Asthma-Chronic Obstructive Pulmonary Disease Overlap in Korea: A Review

There is a considerable number of individuals who exhibit features of both asthma and chronic obstructive pulmonary disease (COPD), defined as asthma-COPD overlap (ACO). Many studies have reported that these patients have a greater burden of symptoms, including cough and dyspnea, and experience more exacerbations and hospitalizations than those with non-ACO COPD or asthma. Although diagnostic criteria for ACO have not yet been clearly established, their clinical significance remains to be determined. As interest in ACO grows, related studies have been conducted in South Korea as well. The present review summarizes ACO-related studies in South Korea to better understand Korean ACO patients and guide further research. Several cohort studies of asthma and COPD and population-based studies for ACO were reviewed and the key results from demographics, clinical features, lung function, biomarkers, treatment, and prognosis were summarized.

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective

OBJECTIVES

Emergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.

METHODS

We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005-2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.

RESULTS

From 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20-109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056-0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31-0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12-0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091-0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31-0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23-0.93).

CONCLUSIONS

ACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.

Comorbidity profile of patients with concurrent diagnoses of asthma and COPD in Germany

The aim of this study was to estimate the prevalence of concurrent diagnoses of asthma/COPD and examine its full spectrum of comorbid disorders in Germany. We used nationwide outpatient claims data comprising diagnoses of all statutory health insurees (40+ years) in 2017 (N = 40,477,745). The ICD-10 codes J44 (COPD) and J45 (asthma) were used to identify patients. The odds of 1,060 comorbid disorders were examined in a case-control study design. Of all insurees, 4,632,295 (11%) were diagnosed with either asthma or COPD. Of them, 43% had asthma only, 44% COPD only and 13% both diseases. The prevalence of concurrent asthma/COPD was 1.5% with a slightly higher estimate among females than males (1.6% vs. 1.4%) and constant increase by age in both sexes. Comorbid disorders were very common among these patients. 31 disorders were associated with a strong effect size (odds ratio > 10), including other respiratory diseases, but also bacterial (e.g., mycobacteria, including tuberculosis) and fungal infections (e.g., sporotrichosis and aspergillosis). Patients with concurrent asthma/COPD suffer from comorbid disorders involving various body systems, which points to the need of a multidisciplinary care approach. Regular screening for common comorbid disorders may result in better clinical course and prognosis as well as improvement of patients' quality of life.

Integrating Comorbidities and Phenotype-Based Medicine in Patient-Centered Medicine in COPD

Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy.

Application of mindfulness techniques in patients with asthma or COPD

OBJECTIVE

Mindfulness is the ability to pay attention to the present moment without judgment. Mindfulness interventions have proved to be effective in improving the management of psychological symptoms of chronic patients. The objective of this work is to update the evidence about the effects of mindfulness interventions on psychological symptoms in patients with asthma and chronic obstructive pulmonary disease (COPD).

METHODOLOGY

Data sources were PubMed and PsycInfo. From a first set of 109 articles, 12 about mindfulness-interventions in adult populations with asthma or COPD were finally included in the review.

RESULTS

Of the total of 12 studies included, 5 were qualitative and 6 quantitative (5 randomized controlled trials). One quantitative study reported long-term psychological effects in asthma patients, two studies reported short-term psychological effects in COPD patients. Relevant themes identified in qualitative studies included increased awareness, development of new relationships with dyspnea, including new cognitive strategies, and slowing down.

CONCLUSIONS

Mindfulness interventions could increase psychological resources in situations related to asthma and COPD symptoms. More randomized control trials are needed.

Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis

Background

Asthma-COPD overlap (ACO) is a term that encompasses patients with features of both asthma and COPD. To date, the global prevalence of ACO in the general population remains unknown. The objective of this study was to estimate the prevalence of ACO in the general population using a systematic review and meta-analysis.

Methods

A systematic search of ISI Web of Knowledge, MEDLINE/PubMed, and Scopus was performed up to May 2019 to identify studies reporting the prevalence of ACO. Reference lists from identified studies and relevant review articles were also searched. Eligibility criteria were studies reporting the prevalence of ACO, performed in general population, and published in English language. Pooled prevalence of ACO with 95% confidence interval (CI) was calculated using random effects Meta-analysis.

Results

A total of 27 studies were included in this meta-analysis. The Cochran Q test and I² statistics revealed substantial heterogeneity among studies. Based on the random-effects model, the pooled prevalence of ACO was 2.0% (95% CI: 1.4–2.6%) in the general population, 26.5% (95% CI: 19.5–33.6%) among patients with asthma, and 29.6% (95% CI: 19.3–39.9%) among patients with COPD. In addition, for included studies, the global prevalence of asthma-only was 6.2% (95% CI: 5.0–7.4%) and COPD-only was 4.9% (95% CI: 4.3–5.5%).

Conclusion

We estimated the global prevalence of ACO based on population-based studies and found that 2.0% of the general population is affected. However, the prevalence of ACO depends on its diagnostic criteria. Therefore, there is a vital need to better define the ACO diagnostic criteria, management and treatment. It is worth noting that the limitations of the present study include lack of studies in some region of the world and small number of studies included in the subgroup analyses.