Determinants of chronic obstructive pulmonary disease severity in the late-elderly differ from those in younger patients

Quantitative CT parameters correlate with lung function in chronic obstructive pulmonary disease: A systematic review and meta-analysis

Objective

This study aimed to analyze the correlation between quantitative computed tomography (CT) parameters and airflow obstruction in patients with COPD.

Methods

PubMed, Embase, Cochrane and Web of Knowledge were searched by two investigators from inception to July 2022, using a combination of pertinent items to discover articles that investigated the relationship between CT measurements and lung function parameters in patients with COPD. Five reviewers independently extracted data, and evaluated it for quality and bias. The correlation coefficient was calculated, and heterogeneity was explored. The following CT measurements were extracted: percentage of lung attenuation area <-950 Hounsfield Units (HU), mean lung density, percentage of airway wall area, air trapping index, and airway wall thickness. Two airflow obstruction parameters were extracted: forced expiratory volume in the first second as a percentage of prediction (FEV₁%pred) and FEV₁ divided by forced expiratory volume lung capacity.

Results

A total of 141 studies (25,214 participants) were identified, which 64 (6,341 participants) were suitable for our meta-analysis. Results from our analysis demonstrated that there was a significant correlation between quantitative CT parameters and lung function. The absolute pooled correlation coefficients ranged from 0.26 (95% CI, 0.18 to 0.33) to 0.70 (95% CI, 0.65 to 0.75) for inspiratory CT and 0.56 (95% CI, 0.51 to 0.60) to 0.74 (95% CI, 0.68 to 0.80) for expiratory CT.

Conclusions

Results from this analysis demonstrated that quantitative CT parameters are significantly correlated with lung function in patients with COPD. With recent advances in chest CT, we can evaluate morphological features in the lungs that cannot be obtained by other clinical indices, such as pulmonary function tests. Therefore, CT can provide a quantitative method to advance the development and testing of new interventions and therapies for patients with COPD.

The impact of anemia on the mortality of COPD patients hospitalized for acute exacerbation resulting in respiratory failure

Anemia increases mortality in patients with chronic obstructive pulmonary disease (COPD), but its effects on mortality and survival time for different levels of airflow limitation severity are unclear. Our goal was to investigate the effects of anemia on survival time and mortality in COPD patients with varying degrees of airflow limitation. We looked at 300 consecutive COPD patients in the past. Their demographic information, Charlson comorbidity index, previous early (30 days) and late (>30 days) hospitalizations, blood counts, and post-bronchodilator spirometric values were all recorded. They were contacted by phone to check on their vital status, and their mortality rates were calculated. Anemic patients had a mean overall survival time of 31.9 2.8 months and normal patients had a mean overall survival time of 41.7 2.1 months (p=0.001). Their 1-year and 2-year mortality rates are higher. Age, Charlson comorbidity index, BMI, FEV1%, anemia, MCV, hemoglobin, serum creatinin, and early and late hospitalizations all had an impact on mortality. BMI, anemia, and FEV1% remained risk factors for death. Anemic group 2 patients had a higher mortality rate than groups 3 and 4. Anemic patients in groups 2 and 4 had shorter survival times. Anemic COPD patients have higher 1-year and 2-year mortality rates. Mortality is affected by age, Charlson comorbidity index, BMI, FEV1%, anemia, MCV, hemoglobin, serum creatinin, and early and late hospitalizations. BMI, anemia, and FEV1% remained risk factors for death. Anemic group 2 patients have a higher mortality rate than groups 3 and 4. Anemic patients in groups 2 and 4 have shorter survival times.

The Paradigm Shift from Polycythemia to Anemia in COPD: The Critical Role of the Renin-Angiotensin System Inhibitors

INTRODUCTION

Although polycythemia has been considered a common adverse event in COPD, anemia is reported more often and has gained more importance than polycythemia over the last thirty years.

AREAS COVERED

Factors considered to be associated with the development of anemia in COPD have included: Aging and kidney dysfunction with erythropoietin deficiency and bone marrow suppression due to uremic toxins; heart failure (HF), which is often encountered in COPD and is accompanied by anemia in one third of the cases; Low-grade chronic inflammation, which can directly suppresses the bone marrow and diminish iron absorption and utilization via increased hepcidin levels; long-term oxygen therapy (LTOT), which ameliorates chronic hypoxia, and most important, RAS inhibitors, which are widely used for the co-morbidities associated with COPD (hypertension, HF, CKD, diabetes) and have previously been shown to lower hematocrit values or cause anemia in various clinical conditions.

EXPERT OPINION

Introduction of LTOT in COPD and especially the established use of RAS inhibitors form the basis for the shift from polycythemia to anemia in COPD. Interestingly, when the SGLT2 inhibitors are introduced for cardiorenal protection in COPD, one could anticipate correction of anemia or even reemergence of polycythemia, since this new class of drugs can augment erythropoietin secretion and increase hematocrit values.

Relationship between Multimorbidity and Quality of Life in a Primary Care Setting: The Mediating Role of Dyspnea

Multimorbidity is known to impair Quality of Life (QoL) in patients in a primary setting. Poor QoL is associated with higher dyspnea perception. How multimorbidity and dyspnea perception are related to QoL needs clarification. The aim of the present study is to evaluate the mediating role of dyspnea perception in the relationship between multimorbidity and QoL in adults with and without airflow obstruction in a primary care setting. Seventeen general practitioners participated in the study: a total of 912 adult patients attending the practitioner’s surgery for a generic consultation completed a preliminary respiratory screening; 566 of them answered a respiratory questionnaire between January and June 2014, and 259 of the latter (148 M, aged 40–88) agreed to go through all the of procedures including spirometry, the IMCA and QoL (SF-36 through Physical Health “PCS” and Mental Health components) questionnaires, evaluation of comorbidities and the mMRC Dyspnea Scale. For screening purpose, a cut-off of FEV₁/FVC < 70% was considered a marker of airflow obstruction (AO). Of the sample, 25% showed airflow obstruction (AO). No significant difference in mMRC score regarding the number of comorbidities and the PCS was found between subjects with and without AO. Multimorbidity and PCS were inversely related in subjects with (p < 0.001) and without AO (p < 0.001); mMRC and PCS were inversely related in subjects with (p = 0.001) and without AO (p < 0.001). A mediation analysis showed that the relation between number of comorbidities and PCS was totally mediated by mMRC in subjects with AO and partially in subjects without AO. We conclude that the effect of multimorbidity on PCS is totally mediated by mMRC only in AO. Detecting and monitoring mMRC in a primary care setting may be a useful indicator for evaluating a patient’s global health.

Effect of different salivary glucose concentrations on dual-species biofilms of Candida albicans and Streptococcus mutans

Diabetes mellitus is one of the most prevalent diseases worldwide. The glucose levels found in the blood of diabetic patients can be reflected in the saliva, which can favor biofilm growth and predispose denture wearers to oral candidiasis. This study aimed to evaluate the effect of different salivary glucose concentrations on dual-species biofilms of Candida albicans and Streptococcus mutans. A 96-h biofilm was developed on acrylic resin specimens exposed to 'feast' (10% sucrose) and 'famine' periods. Biofilms were constantly exposed to salivary glucose concentrations equivalent to 0, 20, 60 and 100 mM. Higher salivary glucose concentrations resulted in increased counts of C. albicans and a higher quantity of insoluble extracellular polysaccharides. All biofilms presented high phospholipase activity. The biofilms were characterized by the predominance of yeast cells and microcolonies in all the groups analyzed with co-localization of both species. Higher salivary glucose concentrations formed more robust and potentially virulent biofilms.

Beyond price: the effects of non-financial barriers on access to drugs and health outcomes

OBJECTIVES

We study the impact of the pharmacy dispensing channel (as a proxy for access to drugs) on the drug purchases, health outcomes, and health care utilization (emergency room visits or hospitalizations) of chronically ill patients in Liguria, Italy, in 2017.

METHODS

We use the coarsened exact matching algorithm to compare the health outcomes for a treated group of patients living in a local health authority (LHA) where drug distribution through community pharmacies was restricted. These patients were matched to a control group of patients living in other LHAs, where drugs were also dispensed through a broad network of community pharmacies. We exploit a unique administrative dataset with information on the socio-demographic characteristics and health care services utilization of Ligurian patients with chronic cardiovascular and respiratory ailments. We restrict our analysis to patients 65 years of age or older who were admitted to hospitals from 2013 to 2016 with either a principal or secondary diagnosis connected to chronic cardiovascular and respiratory diseases.

RESULTS

Reduced access to drugs leads to lowered drug consumption, a higher probability of adverse health outcomes including mortality, and a higher consumption of medical services in terms of hospitalizations and emergency room visits. These effects increase with patients' age.

CONCLUSION

The pharmacy dispensing channel significantly affects drug consumption and acts as a proxy for adherence among chronically ill patients. Thus, health outcomes and health care utilization should be carefully evaluated when comparing the costs of alternative dispensing channels.

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.

Meta-analysis of the Effect of a Pulmonary Rehabilitation Program on Respiratory Muscle Strength in Patients with Chronic Obstructive Pulmonary Disease

PURPOSE

Pulmonary rehabilitation (PR) programs are important in the treatment of patients with chronic obstructive pulmonary disease (COPD) but vary widely in type, duration, and efficacy. This meta-analysis investigated the effect of PR programs on respiratory muscle strength in patients with COPD.

METHODS

PubMed, Embase, and CINAHL were searched. The primary outcome variables were maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP). The secondary outcome variables were the modified Borg score after the 6-min walking test, percent predicted forced expiratory volume in 1 second (FEV₁%pred), and percent FEV₁/forced volume capacity (FVC). Comprehensive Meta-Analysis, version 3.0, was used to analyze the data. The effect size was calculated using the standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

Twenty randomized controlled trials (with 992 participants) were included in the analysis. The PR programs had a significant effect on the MEP (SMD, 0.87; 95% CI, 0.42-1.32; p < .001), MIP (SMD, 0.53; 95% CI, 0.13-0.93; p = .009), and modified Borg score (SMD, -0.37; 95% CI, -0.52 to -0.22; p < .001) in patients with COPD. There was no effect on FEV₁%pred (SMD, 0.09; 95% CI, -0.12 to 0.30; p = .406) or FEV₁/FVC% (SMD, 0.04; 95% CI, -0.17 to 0.26; p = .702).

CONCLUSION

PR programs improve respiratory muscle strength in patients with COPD. Strategies for selecting a suitable PR program need to be developed, and future studies should evaluate the long-term effects of such programs on pulmonary function.

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.

Efficacy of Umeclidinium/Vilanterol in Elderly Patients with COPD: A Pooled Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this pooled analysis was to assess the efficacy and safety of umeclidinium/vilanterol (UMEC/VI) 62.5/25 µg dual bronchodilation versus placebo in elderly symptomatic patients with chronic obstructive pulmonary disease (COPD).

METHODS

We conducted a post hoc pooled analysis of data from 10 randomized controlled trials (RCTs). Change from baseline (CFB) in trough forced expiratory volume in 1 s (FEV1), proportion of FEV1 responders (≥ 100-mL increase from baseline), and safety were analyzed in patients aged < 65, ≥ 65, and ≥ 75 years on Days 28, 56, and 84 (12-week analysis of parallel-group design studies), Days 28, 56, 84, 112, 140, 168, and 169 (24-week analysis of parallel-group design studies), and Days 2, 42, and 84 (12-week analysis of crossover design studies).

RESULTS

The UMEC/VI intent-to-treat (ITT) populations comprised 2246, 1296, and 472 patients in the 12-week parallel-group, 24-week parallel-group, and 12-week crossover analysis, respectively (≥ 65 years: 36-44%; ≥ 75 years: 7-11%). The placebo ITT populations comprised 528, 280, and 505 patients, respectively (≥ 65 years: 37-41%; ≥ 75 years: 5-11%). Significant improvements in trough FEV1 and significantly greater proportions of FEV1 responders were seen with UMEC/VI compared with placebo in all analyses regardless of patient age or timepoint considered (p ≤ 0.023), except Day 84 trough FEV1 CFB in the 12-week crossover analysis in patients aged ≥ 75 years (p = 0.064). UMEC/VI safety profile was similar to placebo in all age groups.

CONCLUSIONS

In this pooled analysis of RCT data, once-daily UMEC/VI was well tolerated and provided clinically significant lung function benefits compared with placebo in younger and older patients with COPD.

FUNDING

GlaxoSmithKline (study 208125).

Mobility limitations related to reduced pulmonary function among aging people with chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is a major cause of disability. We aimed to analyse the impact of reduced pulmonary function on non-respiratory impairments and mobility activity limitations in an elderly population with COPD and to elucidate which specific limitations on mobility are related to reduced pulmonary function

Methods

Cross-sectional study of 110 patients with COPD, recruited from public and university hospital. The effect of impaired pulmonary function on the risk of non-respiratory impairments and mobility limitations was analysed using validated measures, including: the 6-Minute Walk Test (6MWT), skeletal muscle strength, the Short Physical Performance Battery (SPPB), and self-reported mobility questionnaire. Multivariate analysis was used to control for confounders such as age, sex, height, education, and cigarette smoking.

Results

Greater impairment of pulmonary function was associated with less distance walked during the 6MWT, poorer SPPB scores, and greater risk of self-reported mobility limitations (p<0.05). Lower forced expiratory volume in 1 s was also associated with a greater risk of limitations in carrying items under 10 pounds (4.54 kg), walking alone up and down a flight of stairs, and walking two or three neighbourhood blocks. There was no clear statistical relationship between pulmonary function impairment and skeletal muscle strength.

Conclusions

Impaired pulmonary function was associated with the 6MWT score and limitations on performance-based and self-reported mobility activities, but not with skeletal muscle strength among elderly COPD patients.

Octogenarian patients with chronic obstructive pulmonary disease: Characteristics and usefulness of prognostic indexes

BACKGROUND AND OBJECTIVE

Most studies on chronic obstructive pulmonary disease (COPD) exclude octogenarian patients. Therefore, the disease is not well characterized in this age group. The objective of this study is to analyze the clinical characteristics of octogenarian patients with COPD and the usefulness of the prognostic indexes used most frequently in this age group.

PATIENTS AND METHOD

Retrospective study of consecutive patients seen at a clinic between 2009 and 2017. The following variables were analyzed: lung function parameters, distribution of clinical phenotypes, income history, mortality, comorbidities and usefulness of the Charlson, BODEX, COTE and CODEX indexes to predict mortality.

RESULTS

The sample comprised 698 patients, 82 aged (11.7%)≥80 years old. Mean follow-up time was 47.9±21.8 months. In octogenarian patients, the severity of the COPD, assessed by means of the FEV₁% or BODEX index, was similar to that of younger patients, but dyspnea was worse in the elderly group. In these patients, the chronic bronchitis and frequent exacerbator phenotypes were the most frequent, whilst the emphysema phenotype was the least common. Octogenarians had a greater prevalence of cardiovascular comorbidities and renal diseases. Moreover, hospital admissions were more frequent and mortality was higher in these elderly patients. Most prognostic indexes were useful in predicting mortality in elderly patients. CODEX was the most useful index to predict mortality, both in octogenarian and younger patients.

CONCLUSION

Octogenarian patients with COPD have differential characteristics which could imply the need for different therapeutic approaches. Prognostic indexes are useful for predicting mortality in this population.

Radiologic features of precancerous areas of the lungs in chronic obstructive pulmonary disease

BACKGROUND

Only a few studies have evaluated the radiologic features of pre-existing structural abnormalities where lung cancer may develop. This study aimed to analyze the computed tomography (CT) images of lung areas where new cancer developed in chronic obstructive pulmonary disease (COPD) patients.

PATIENTS AND METHODS

We conducted a multicenter, longitudinal cohort study, called the Keio COPD Comorbidity Research, to assess the incidence of lung cancer. Emphysema and interstitial abnormalities were evaluated in 240 COPD patients who had baseline CT scans applicable for further digital analyses. For patients who developed lung cancer during the 3-year follow-up period, the local spherical lung density of the precancerous area was individually quantified.

RESULTS

Lung cancer was newly diagnosed in 21 participants (2.3% per year). The percent-age of low attenuation area in patients who developed lung cancer was higher than that of the other patients (20.0% vs 10.4%, P=0.014). The presence of emphysema (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.0-29.0, P=0.049) or interstitial lung abnormalities (OR 15.6, 95% CI 4.4-65.4, P<0.0001) independently increased the risk for lung cancer. Compared with the density of the entire lung, the local density of the precancerous area was almost the same in patients with heterogeneous emphysema, but it was higher in most patients with interstitial abnormalities.

CONCLUSION

The presence of emphysema or interstitial abnormalities or a combination of both were independent predictors of lung cancer development in COPD patients. Furthermore, lung cancer most often developed in non-emphysematous areas or in interstitial abnormalities.