COPD in Nonsmokers: Reports from the Tunisian Population-Based Burden of Obstructive Lung Disease Study

Prevalence and Risk Factors of Chronic Obstructive Pulmonary Disease Among Users of Primary Health Care Facilities in Morocco

Background

Chronic obstructive pulmonary disease (COPD) is a major public health problem. In Morocco, few studies have focused on COPD in primary health care facilities, whose main mission is prevention. The aim of our work is thus to assess the prevalence of COPD and to study the factors associated with this silent disease among users of health care facilities in Morocco.

Methods

This is a cross-sectional observational study of participants aged 40 and over. Data were collected by questionnaire. Pulmonary function testing was conducted using a spirometer before and after administration of a bronchodilator. COPD was defined as fixed ratio of the post-bronchodilator forced expiratory volume in 1 second / forced vital capacity less than 0.7. Logistic regression models were applied to define factors associated with COPD.

Results

From 550 participants aged 40 and over, we selected only 477 patients with exploitable spirometry results for inclusion in the final analysis. The mean age of participants was 54.91±11.92 years, and the female/male ratio was 1.59. The prevalence of COPD was 6.7% (95% CI; 4.6 to 9.3%), and was higher in men than in women (11.4% vs 3.8%, p=0.002). The prevalence of COPD increased significantly with age, from 3.3% in those aged 40 to 49 to 16.9% in those aged 70 and over (p=0.001). Current smokers had a higher prevalence of COPD than former and never smokers. Age, smoking, asthma diagnosis and childhood hospitalization for lung disease were risk factors associated with the development of COPD. Only 6.25% of participants identified as having COPD had previously been diagnosed with COPD.

Conclusion

COPD remains largely under-diagnosed among primary care consultants in Morocco. Efforts for early detection and promotion of prevention of the main risk factors need to be intensified in order to reduce the burden of this silent pathology on a national scale.

Estimating the global prevalence of chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major public health problem. The present study aims to provide a global and regional estimate of the prevalence of COPD based on spirometry according to the two most widely used diagnostic criteria of COPD: fixed ratio (FR) and lower limit of normal (LLN).

METHODS

We conducted a systematic review of the literature according to PRISMA guidelines. MEDLINE, Web of Sciences, and Scopus databases were searched to identify studies on the spirometry-based prevalence of COPD in individuals aged 40 years and older. The meta-analysis was performed using MedCalc 19 software.

RESULTS

In total, 42 of the 3393 studies reviewed were eligible for inclusion. The overall prevalence of COPD in people aged 40 years and older was 12.64% (95% CI 10.75%-14.65%) and 7.38% (95% CI 5.47% - 9.55%) based on FR and LLN criteria, respectively. By gender, men had a higher prevalence of COPD compared to women (15.47%; 95% CI 12.22%-19.02% for men versus 8.79%; 95% CI 6.94%-10.82% for women). Using the LLN criteria, the prevalence of COPD in both sexes was almost identical (8.67%; 95% CI 8.44%- 8.90% for men and 8.00%; 95% CI 6.42% - 9.73% for women). We reported a high prevalence of COPD among smokers and the elderly by both definitions of airway obstruction. Regional prevalence estimates using the FR definition indicate that the highest COPD prevalence was recorded in the Americas and the lowest was recorded in the Eastern Mediterranean region. Using the LLN definition, the highest prevalence was recorded in the Southeast Asian region and the lowest prevalence was recorded in the American region. The most common COPD stage was stage II, with a prevalence of 50.46%. The results indicate a huge lack of prevalence data in the African and Eastern Mediterranean region. The results were given using a random-effect model due to the high heterogeneity between studies.

CONCLUSION

Results show that the prevalence of COPD differs according to the diagnostic criteria used. In addition, management and prevention strategies targeting risk factors for COPD are certainly needed to reduce the global burden of this chronic respiratory disease.

COPD in Never-Smokers: BOLD Australia Study

Purpose

Tobacco smoking is the major risk factor for COPD, and it is common for other risk factors in never-smokers to be overlooked. We examined the prevalence of COPD among never-smokers in Australia and identified associated risk factors.

Methods

We used data from the Australia Burden of Obstructive Lung Disease (BOLD) study, a cross-section of people aged ≥40 years from six sites. Participants completed interviews and post-bronchodilator spirometry. COPD was primarily defined as an FEV1/FVC ratio <0.70 and secondarily as the ratio less than the lower limit of normal (LLN).

Results

The prevalence of COPD in the 1656 never-smokers who completed the study was 10.5% (95% CI: 9.1-12.1%) [ratio

Conclusion

COPD was prevalent in this population of never-smokers aged 40 years and over. This finding highlights the significance of risk factors other than smoking in the development of COPD.

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Key Words

• BOLD
• LLN
• burden of obstructive lung disease
• lower limit of normal
• non-smokers
• prevalence
• spirometry

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MESH Headings

• Female
• Male
• Humans
• Adult
• Middle Aged
• Child
• Smokers
• Pulmonary Disease, Chronic Obstructive/diagnosis
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Asthma
• Odds Ratio
• Australia/epidemiology

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Grants

• National Health and Medical Research Council (NHMRC) of Australia
• Thoracic Society of Australia and New Zealand
• Robert Pierce Grant-in-Aid for Indigenous Lung Health
• Air Liquide, AstraZeneca; GlaxoSmithKline; and Boehringer Ingelheim

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Affiliation(s)

Marsha A Ivey School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia School of Medicine, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago
Sheree M Smith School of Nursing and Midwifery, Campbelltown Campus, Western Sydney University, Penrith, NSW, 2751, Australia Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
Geza Benke School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
Brett G Toelle Respiratory and Environmental Epidemiology Group, Woolcock Institute of Medical Research, Sydney, NSW, 2037, Australia Sydney Local Health District, Sydney, NSW, 2050, Australia
Michael L Hunter School of Population and Global Health, University of Western Australia, Perth, WA, 6009, Australia
Alan L James Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital and Medical School, University of Western Australia, Perth, WA, 6009, Australia
Graeme P Maguire Curtin Medical School, Curtin University, Perth, WA, 6102, Australia
Richard Wood-Baker School of Medicine, University of Tasmania, Hobart, TAS, 7000, Australia
David P Johns Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
Guy B Marks Respiratory and Environmental Epidemiology Group, Woolcock Institute of Medical Research, Sydney, NSW, 2037, Australia School of Clinical Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
Michael J Abramson School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia

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Prevalence of chronic obstructive pulmonary disease in Indian nonsmokers: a systematic review & meta-analysis

INTRODUCTION

Nonsmokers with chronic obstructive pulmonary disease (COPD) are neglected despite constituting half of all cases in studies from the developed world. Herein, we systematically reviewed the prevalence of COPD among nonsmokers in India.

CONTENT

We searched Embase, Scopus, and PubMed databases for studies examining the prevalence of COPD among nonsmokers in India. We used the Joanna Briggs Institute (JBI) checklist to assess included studies' quality. Meta-analysis was performed using random-effects model.

SUMMARY

Seven studies comprising 6,903 subjects were included. The quality of the studies ranged from 5/9 to 8/9. The prevalence of COPD varied between 1.6 and 26.6 %. Studies differed considerably in demographics and biomass exposure profiles of subjects. Among the four studies that enrolled both middle-aged and elderly Indian nonsmokers not screened based on biomass fuel exposure, the pooled prevalence of COPD was 3 % (95 % CI, 2-3 %; I2=50.52 %, p=0.11). The pooled prevalence of COPD among biomass fuel-exposed individuals was 10 % (95 % CI, 2-18 %; I2=98.8 %, p<0.001).

OUTLOOK

Limited evidence suggests a sizable burden of COPD among nonsmokers and biomass fuel-exposed individuals in India. More epidemiological studies of COPD in nonsmokers are needed from low and middle-income countries.

Value of inferior vena cava collapsibility index as marker of heart failure in chronic obstructive pulmonary disease exacerbation

INTRODUCTION

Inferior vena cava (IVC) diameter variability with respiration measured by ultrasound was found to be useful for the diagnosis of heart failure (HF) in ED patients with acute dyspnea. Its value in identifying HF in acute exacerbation of chronic obstructive pulmonary disease exacerbation (AECOPD) was not specifically demonstrated.

OBJECTIVE

To determine the value of ΔIVC in the diagnosis of HF patients with AECOPD.

METHODS

This is a prospective study conducted in the ED of three Tunisian university hospitals including patients with AECOPD. During this period, 401 patients met the inclusion criteria. The final diagnosis of HF is based on the opinion of two emergency experts after consulting the data from clinical examination, cardiac echocardiography, and BNP level. The ΔIVC was calculated by two experienced emergency physicians who were blinded from the patient's clinical and laboratory data. A cut off of 15% was used to define the presence (< 15%) or absence of HF (≥ 15%). Left ventricular ejection fraction (LVEF) was also measured. The area under the ROC curve, sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic and predictive accuracy of the ΔIVC in predicting HF.

RESULTS

The study population included 401 patients with AECOPD, mean age 67.2 years with male (68.9%) predominance. HF was diagnosed in 165 (41.1%) patients (HF group) and in 236 patients (58.9%) HF was excluded (non HF group). The assessment of the performance of the ΔIVC in the diagnosis of HF showed a sensitivity of 37.4% and a specificity of 89.7% using the threshold of 15%. The positive predictive value was 70.9% and the negative predictive value was 66.7%. The area under the ROC curve was 0.71(95%, CI 0.65-0.76). ΔIVC values were not different between HF patients with reduced LVEF and those with preserved LVEF.

CONCLUSION

Our results showed that ΔIVC has a good value for ruling out HF in ED patients consulting for AECOPD.

Association of mannose binding lectin with chronic obstructive pulmonary disease susceptibility and its clinical outcomes

BACKGROUND

The physiological interactions of MBL suggest its contribution towards the pathogenesis of COPD.

OBJECTIVE

The present case-control study was undertaken to elucidate the role of MBL with COPD risk and clinical outcomes in north Indian cohort.

METHODS

Patients were enrolled as per GOLD criteria. MBL2 variants were selected based on the literature and their putative functional significance. Genotyping of six single nucleotide polymorphisms of MBL2 comprising of two coding (rs1800450, rs1800451) and four non-coding variants (rs11003125, rs7096206, rs11003123 and rs7095891) was done by using PCR-RFLP and ARMS-PCR. Serum MBL levels were analysed by sandwich ELISA.

RESULTS

Overall findings of the molecular genetic analysis of MBL2 indicated significant difference in frequency of three of the six studied variants, between patients and controls or among different disease severity stages. Heterozygous genotype of rs7095891 showed significant protective association towards severity of disease. Linkage disequilibrium (LD) analysis indicated a strong LD between rs1800450 and rs7095891 while intermediate LD was observed for rs11003123/rs11003125 and rs7096206/rs11003125. Haplotype analysis revealed 17.14-fold risk of developing exacerbations conferred by GGGTGG haplotype. Significantly low serum MBL levels observed in COPD patients as compared to controls. Significant difference in MBL deficiency levels were also observed for homozygous wild and variant genotypes of rs11003125 and rs7096206 respectively, as well as for all genotypes of rs11003123 than respective controls.

CONCLUSION

The present study reinforces the role played by MBL in the susceptibility, protection and clinical outcomes of COPD. Therefore, including the reported associations at diagnostic, prognostic and therapeutic interventions may prove helpful.

Prevalence and determinants of chronic respiratory diseases in adults in rural Sudan

BACKGROUND: Chronic respiratory diseases (CRDs) greatly contribute to worldwide mortality. Despite new data emerging from Africa, prevalence estimates and determinants of CRDs in rural settings are limited. This study sought to extend the existing research conducted in urban Sudan by conducting a rural comparison.METHODS: Participants aged ≥18 years (n = 1,850), living in rural Gezira State completed pre-and post-bronchodilator spirometry and a questionnaire. Prevalence of respiratory symptoms and spirometric abnormalities were reported. Regression analyses were used to identify risk factors for CRDs.RESULTS: Prevalence of chronic airflow obstruction (CAO) was 4.1% overall and 5.5% in those aged ≥40 years. Reversibility was seen in 6.4%. Low forced vital capacity (FVC) was seen in 58.5%, and at least one respiratory symptom was present in 40.7% of the participants. CAO was more common among people aged 60-69 years (OR 2.07, 95% CI 1.13-3.82) and less common among highly educated participants (OR 0.50, 95% CI 0.27-0.93). Being underweight was associated with lower FVC (OR 3.07, 95% CI 2.24-4.20).CONCLUSIONS: A substantial burden of CRD exists among adults in rural Sudan. Investment in CRD prevention and management strategies is needed.

Clinical characteristics of chronic obstructive pulmonary disease in never-smokers: A systematic review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is the third cause of death worldwide. While tobacco smoking is a key risk factor, COPD also occurs in never-smokers (NS). However, available evidence on risk factors, clinical characteristics, and natural history of the disease in NS is scarce. Here, we perform a systematic review of the literature to better describe the characteristics of COPD in NS.

METHODS

We searched different databases following the PRISMA guidelines with explicit inclusion and exclusion criteria. A purpose-designed quality scale was applied to the studies included in the analysis. It was not possible to pool the results due to the high heterogeneity of the studies included.

RESULTS

A total of 17 studies that met the selection criteria were included, albeit only 2 of them studied NS exclusively. The total number of participants in these studies were 57,146 subjects,25,047 of whom were NS and 2655 of the latter had NS-COPD. Compared to COPD in smokers, COPD in NS is more frequent in women and older ages, and is associated with a slightly higher prevalence of comorbidities. There are not enough studies to understand if COPD progression and clinical symptoms in NS are different to that of ever-smokers.

CONCLUSIONS

There is a significant knowledge gap on COPD in NS. Given that COPD in NS account for about a third of all COPD patients in the world, particularly in low-middle income countries, and the decrease in tobacco consumption in high income countries, understanding COPD in NS constitutes a public-health priority.

Early Origins of Chronic Obstructive Pulmonary Disease: Prenatal and Early Life Risk Factors

The main risk factor for chronic obstructive pulmonary disease (COPD) is active smoking. However, a considerable amount of people with COPD never smoked, and increasing evidence suggests that adult lung disease can have its origins in prenatal and early life. This article reviews some of the factors that can potentially affect lung development and lung function trajectories throughout the lifespan from genetics and prematurity to respiratory tract infections and childhood asthma. Maternal smoking and air pollution exposure were also analyzed among the environmental factors. The adoption of preventive strategies to avoid these risk factors since the prenatal period may be crucial to prevent, delay the onset or modify the progression of COPD lung disease throughout life.

COPD in Africa: risk factors, hospitalisation, readmission and associated outcomes-a systematic review and meta-analysis

BACKGROUND

This review aims to synthesise available evidence on the prevalence of chronic obstructive pulmonary disease (COPD), associated risk factors, hospitalisations and COPD readmissions in Africa.

METHOD

Using the Met-Analyses and Systematic Reviews of Observational Studies guideline, electronic databases were searched from inception to 1 October 2021. The quality of studies was assessed using the Newcastle-Ottawa Scale. Evidence from retrieved articles was synthesised, and a random-effect model meta-analysis was conducted. The protocol was registered on PROSPERO.

RESULTS

Thirty-nine studies met the inclusion criteria, with 13 included in the meta-analysis. The prevalence of COPD varied between the Global Initiative for Chronic Obstructive Lung Disease (2%-24%), American Thoracic Society/European Respiratory Society (1%-17%) and Medical Research Council chronic bronchitis (2%-11%) criteria, respectively. Increasing age, wheezing and asthma were consistent risk factors for COPD from studies included in the narrative synthesis. Our meta-analysis indicated that prior tuberculosis ((OR 5.98, 95% CI 4.18 to 8.56), smoking (OR 2.80, 95% CI: 2.19 to 3.59) and use of biomass fuel (OR 1.52, 95% CI: 1.39 to 1.67)) were significant risk factors for COPD. Long-term oxygen therapy (HR 4.97, 95% CI (1.04 to 23.74)) and frequent hospitalisation (≥3 per year) (HR 11.48, 95% CI (1.31 to 100.79)) were risk factors associated with 30-day COPD readmission.

CONCLUSION

This study not only highlights specific risk factors for COPD risk in Africa but also demonstrates the paucity and absence of research in several countries in a continent with substantial COPD-related mortality. Our findings contribute towards the development of evidence-based clinical guidelines for COPD in Africa.PROSPERO registration numberCRD42020210581.

Clinical Characteristics of Non-Smoking Chronic Obstructive Pulmonary Disease Patients: Findings from the KOCOSS Cohort

Chronic obstructive pulmonary disease (COPD) has been regarded as a disease of smokers, but the prevalence of non-smoking COPD patients have been reported to be considerable. We investigated differences in clinical characteristics between smoking and non-smoking COPD patients. We used data from the Korea COPD Subgroup Study (KOCOSS) database, which is a multicenter cohort that recruits patients from 54 medical centres in Korea. Comprehensive comparisons of smoking and non-smoking COPD patients were performed based on general characteristics, exacerbations, symptom scores, radiological findings, and lung-function tests. Of the 2477 patients included in the study, 8.1% were non-smokers and 91.9% were smokers. Non-smoking COPD patients were more likely to be female and to have a higher body mass index and lower level of education. Non-smoking COPD patients had more comorbidities, including hypertension, osteoporosis, and gastroesophageal reflux disease, and experienced more respiratory and allergic diseases. No significant differences in exacerbation rates, symptom scores, or exercise capacity scores were observed between the two groups. Smoking COPD patients had more emphysematous lung according to the radiological findings, and non-smoking patients had more tuberculosis-destroyed lung and bronchiectasis. Lung-function testing revealed no significant difference in the forced expiratory capacity in 1 sec between the two groups, but smokers had more rapid lung-function decline in the 5 years of follow-up data. We found differences in general characteristics and radiological findings between smoking and non-smoking COPD patients. No significant differences in exacerbation or symptom scores were observed, but decline in lung function was less steep in non-smoking patients.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2022.2053088 .

Risk factors for chronic obstructive pulmonary disease in never‐smokers: A systematic review

Introduction

Relatively little is known about the risk factors for chronic obstructive pulmonary disease (COPD) in never‐smokers, and these factors have not yet been fully characterised. This study therefore sought to analyse COPD risk factors in never‐smokers by conducting a systematic review of the literature on the topic.

Materials and methods

We performed a search in PubMed (Medline) and Embase from 2000 onwards, to locate studies on COPD in never‐smokers. For literature search and evidence synthesis purposes, we used the PRISMA guidelines and drew up a specific quality scale to quantify the evidence of each study included.

Results

The bibliographic search retrieved a total of 557 papers, 20 of which fulfilled the designated inclusion criteria (two case–control studies, four cohort studies and 14 cross‐sectional studies). These studies were undertaken in Europe, the United States, Latin America, Asia and Africa. The risk factors for never‐smokers were varied and ranged from exposure to biomass, occupational exposure and passive smoking to having a history of asthma, tuberculosis or respiratory infections during childhood. The effect of residential radon was unclear. The highest risk was obtained for previous respiratory diseases of any type, with a magnitude much higher than that observed for other risk factors.

Conclusions

There are few studies on COPD risk factors in never‐smokers. More purpose‐designed studies in this subpopulation are thus called for, including well‐designed studies to specifically assess if indoor radon has any role on COPD onset.

Comparison of demographic, clinical, spirometry, and radiological parameters between smoking and non-smoking COPD patients in rural Gujarat, India

Context:

A total of 20% of Chronic Obstructive Pulmonary Disease(COPD) patients are non-smokers due to preventable causes, such as biomass fuel exposure, post tuberculous sequelae, occupational exposure, air pollution, persistent chronic asthma, and genetic predisposition.

Aims:

To compare smokers and non-smokers with COPD.

Settings and Design:

An observational study was conducted at a tertiary care hospital on 60 patients diagnosed with COPD, (GOLD criteria), who were divided into smoker and non-smoker groups.

Subjects and Methods:

Demographic data, clinical profile, smoking history, and radiological data were collected and compared. Exclusion criteria were individuals having active pulmonary tuberculosis and reversible air flow limitations.

Statistical Analysis Used:

Using STATA 14.2, quantitative and qualitative data were presented using descriptive statistics.

Results:

A total of 100% of smokers were male, whereas 70% of non-smokers were female. Compared to non-smokers (16.67%), smokers (26.6%) presented with higher grade of dyspnea. A statistically significant difference was seen with more smokers diagnosed as severe (40%) and very severe (30%) COPD compared to non-smokers with mild (16.67%) and moderate (46.67%) COPD (P < 0.012), Post bronchodilator FEV₁ among smokers (42.63) compared to non-smokers (56.63) (P < 0.01) and decrease in FEV₁ as the grade of dyspnea increased (P < 0.002). Compared to 36.67% in non-smokers, 70% smokers showed emphysematous x-rays.

Conclusions:

In our study we found majority of non-smokers to be female, and smokers had a higher grade of dyspnea, more severe COPD, lower post bronchodilator FEV₁, and more emphysematous changes on x-rays.

Unmet need in the management of chronic obstructive pulmonary disease in the Middle East and Africa region: An expert panel consensus

Chronic obstructive pulmonary disease (COPD) has a significant impact on healthcare systems and health-related quality of life. Increased prevalence of smoking is an important factor contributing to high burden of COPD in the Middle East and Africa (MEA). Several other factors including sedentary lifestyle, urbanization, second-hand smoke, air pollution, and occupational exposure are also responsible for the upsurge of COPD in the MEA. Frequent COPD exacerbations accelerate disease progression, progressively deteriorate the lung function, and negatively affect quality of life. This consensus is based on review of the published evidence, international and regional guidelines, and insights provided by the expert committee members from the MEA region. Spirometry, though the gold standard for diagnosis, is often unavailable and/or underutilized leading to underdiagnosis of COPD in primary care settings. Low adherence to the treatment guidelines and delayed use of appropriate combination therapy including triple therapy are additional barriers in management of COPD in MEA. It is necessary to recognize COPD as a screenable condition and develop easy and simple screening tools to facilitate early diagnosis. Knowledge of the disease symptomatology at patient and physician level and adherence to the international or regional guidelines are important to create awareness about harmful effects of smoking and develop national guidelines to focus on prevention on COPD. Implementation of vaccination program and pulmonary rehabilitation are equally valuable to manage patients with COPD at local and regional level. We present recommendations made by the expert panel for improved screening, diagnosis, and management of COPD in MEA.

Oscillococcinum® for upper respiratory tract infections and exacerbations in COPD: an observational, prospective study (OXITUNIS)

BACKGROUND

Upper respiratory tract infections (URTIs) are a major cause of exacerbations in patients with chronic obstructive pulmonary disease (COPD). We assessed the effectiveness of Oscillococcinum® in the protection from URTIs in patients with COPD who had been vaccinated against influenza infection over the 2018-2019 winter season.

METHODS

Patients (n=106; mean ± standard deviation age: 66.0 ± 10.3 years; 89.6% men) were randomized into two groups: group V received influenza vaccination only and group OV received influenza vaccination plus Oscillococcinum® (one oral dose per week from inclusion in the study until the end of follow-up, with a maximum of 6 months follow-up over the winter season). The primary endpoint was the incidence rate of URTIs (number of URTIs/1000 patient-treatment exposure days) during follow-up compared between the two groups.

RESULTS

There was no significant difference in any of the demographic characteristics, baseline COPD, or clinical data between the two treatment groups (OV and V). The URTI incidence rate was significantly higher in group V than in group OV (2.9 versus 1.2 episodes/1000 treatment days, difference OV-V = -1.7; p=0.0312). There was a significant delay in occurrence of an URTI episode in the OV group versus the V group (mean ± standard error: 48.7 ± 3.0 versus 67.0 ± 2.8 days, respectively; p=0.0158). Limitations to this study include its small population size and the self-recording by patients of the number and duration of URTIs and exacerbations.

CONCLUSION

Oscillococcinum may decrease the incidence rate and delay the appearance of URTIs in patients with COPD.

COPD in Biomass exposed nonsmokers: a different phenotype

INTRODUCTION

Chronic obstructive pulmonary disease, most commonly caused by tobacco smoking, is increasingly reported in nonsmoking patients exposed to domestic combustion of biomass fuels. This is particularly common among rural women in the low- and middle-income countries. It is highly likely that the disease in these patients is a different clinical phenotype.

AREAS COVERED

This manuscript covers epidemiological and clinical aspects of biomass-exposed COPD and also dwells upon its different phenotypic characteristics.

EXPERT OPINION

Chronic obstructive pulmonary disease in biomass-exposed, nonsmoker patients which predominantly presents with features of chronic bronchitis is more likely a distinct phenotype with greater likelihood of small airway involvement.

COPD in the major nonsmoking adult: A systematic review and meta-analysis

Chronic Obstructive Pulmonary Disease (COPD) main cause is attributed to active smokers, but there's a small percentage that comes from risk factors that have been less considered. The aim of this research was to identify the risk factors and the clinical presentation of the population over 64 years of age that lead to the development of COPD. A systematic review and a meta-analysis was performed. From the 92 studies interpreted, we identified seven studies on the presence of COPD in nonsmokers older adults, having a universe of 14,920 patients. The primary risk factor to trigger the development of COPD was secondhand smoking. The study defined the most common risk factors that currently trigger COPD development among nonsmokers and provided an insight into the potential clinical differences between nonsmokers and smokers.

Assessment of comorbidities and prognosis in patients with COPD diagnosed with the fixed ratio and the lower limit of normal: a systematic review and meta-analysis

BACKGROUND

Currently, the diagnosis of chronic obstructive pulmonary disease (COPD) is not uniform, COPD guidelines recommend fixed ratio (FR), whereas ATS and ERS define airflow obstruction based on lower limit of normal (LLN). We aim to determine if there is difference between the two diagnostic criteria for morbidity, mortality, exacerbation.

METHODS

Four databases and all relevant studies from the references were searched from inception to June 25, 2019, to find studies that described the rate of comorbidity, the exacerbation rates, mortality in COPD patients. Data analysis was performed using STATA/SE 14.0 and followed the standard of Cochrane Collaboration. A sensitivity analysis was performed to find the source of heterogeneity.

RESULTS

Thirteen studies and 154,447 participants were finally included in this meta-analysis. The 11 cohort studies and 2 cross-sectional studies were all high-quality. Patients with airflow limitation according to either FR or LLN had higher mortality (HRFR+/LLN- = 1.27, 95% CI = 1.14-1.42; HRFR-/LLN+ = 1.83, 95% CI = 1.17-2.86) than those who met neither criteria. When compared with the FR-/LLN- criteria, those who met the FR criteria were more likely to exacerbate (HR FR+/LLN- = 1.64, 95% CI = 1.09-2.46; HR FR-/LLN+ = 1.58, 95% CI = 0.70-3.55). The meta-analysis for comorbidities showed no significant difference between patients who met neither criteria and those who met LLN or FR criteria.

CONCLUSION

The patients with airflow limitations according to FR were more likely to exacerbate than those with LLN only. Patients that met either FR or LLN were more likely to have higher mortality than FR-/LLN-. There was no difference between the FR+/LLN- and FR-/LLN+ groups for the occurrence of comorbidities.

Exposure to Air Pollution Exacerbates Inflammation in Rats with Preexisting COPD

Particulate matter with an aerodynamic diameter equal or less than 2.5 micrometers (PM2.5) is associated with the development of chronic obstructive pulmonary disease (COPD). The mechanisms by which PM2.5 accelerates disease progression in COPD are poorly understood. In this study, we aimed to investigate the effect of PM2.5 on lung injury in rats with hallmark features of COPD. Cardinal features of human COPD were induced in a rat model by repeated cigarette smoke inhalation and bacterial infection for 8 weeks. Then, from week 9 to week 16, some of these rats with COPD were subjected to real-time concentrated atmospheric PM2.5. Lung function, pathology, inflammatory cytokines, oxidative stress, and mucus and collagen production were measured. As expected, the COPD rats had developed emphysema, inflammation, and deterioration in lung function. PM2.5 exposure resulted in greater lung function decline and histopathological changes, as reflected by increased Mucin (MUC) 5ac, MUC5b, Collagen I, Collagen III, and the profibrotic cytokine α-smooth muscle-actin (SMA), transforming growth factor- (TGF-) β1 in lung tissues. PM2.5 also aggravated inflammation, increasing neutrophils and eosinophils in bronchoalveolar lavage fluid (BALF) and cytokines including Interleukin- (IL-) 1β, granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-4. The likely mechanism is through oxidative stress as antioxidants levels were decreased, whereas oxidants were increased, indicating a detrimental shift in the oxidant-antioxidant balance. Altogether, these results suggest that PM2.5 exposure could promote the development of COPD by impairing lung function and exacerbating pulmonary injury, and the potential mechanisms are related to inflammatory response and oxidative stress.

COPD: How can evidence from randomised controlled trials apply to patients treated in everyday clinical practice?

OBJECTIVES

To evaluate the degree to which evidence from large clinical trials can be applied to patients treated in a local hospital cohort of COPD outpatients.

METHODS

The authors selected seventeen RCTs identified in a systematic way from GOLD 2019 consensus document, and applied their inclusion and exclusion criteria to a real-world cohort of a previous cross-sectional study of 303 COPD outpatients included consecutively.

RESULTS

When the inclusion criteria of the 17 RCTs were applied to a real-world cohort of COPD outpatients, only a small portion of them were eligible to participate in the referred trials, from 4.29% to 60.07%. However, when both the inclusion and the exclusion criteria were applied, only as little as 3.63% to as much as 40.59% of patients were eligible to participate. Hence, only a small fraction of patients from this cohort could benefit from the findings of these RCTs.

CONCLUSIONS

There is a need to complement the efficacy evidence provided by large RCTs according to the extent to which their results, designed to target significant patient populations, can be applied to typical patients treated in routine clinical practice.

Respiratory Symptoms and Lung Function among Ethiopian Women in Relation to Household Fuel Use

Exposure to household air pollution has been linked to chronic obstructive pulmonary disease, respiratory symptoms and reduced lung function. This study aims to assess respiratory symptoms and lung function among Ethiopian women in relation to exposure to HAP. We conducted a cross-sectional study among non-smoking women responsible for household cooking. Data was collected on socio-demographic characteristics, respiratory symptoms and risk factors using a validated questionnaire. Spirometry with reversibility testing was performed according to American Thoracic Society/European Respiratory Society guidelines. We used independent t-test and multivariable logistic regression to compare the means and measure association respectively. A total of 545 women participated in the study out of which 231 (42.3%) performed spirometry with at least three acceptable manoeuvres. Everyone in the rural group and 43% of the urban group were exposed to HAP from solid fuels during cooking. The odds of developing at least one respiratory symptom when compared with those using cleaner fuels are twice as high for women cooking within the living house. We also found significantly lower forced expiratory volume in the first second (FEV1) (L) among solid fuels users compared with cleaner energy users. Given the larger population settlement in the rural areas and the use of solid fuel as the only energy source, there is a higher risk of developing chronic respiratory health problems for those women in Ethiopia.

Randomized controlled trials of pharmacological treatments to prevent COPD exacerbations: applicability to real-life patients

BACKGROUND

In patients with chronic obstructive pulmonary disease, all efforts should be made to prevent exacerbations because each event modifies the trajectory of the disease. Treatment recommendations are mostly built on results from randomized controlled trials (RCTs) whose methodology ensure internal validity. However, their relevance may be compromised by the lack of generalizability, due to poor representability of study populations compared to real-life patients. In order to delimit to whom the results of studies on current and future treatments apply, we sought to identify and characterize the fraction of COPD population that would be eligible for inclusion into RCTs aiming at decreasing exacerbation risk.

METHODS

We used the Initiatives-BPCO database, a French cohort of 1309 real-life COPD patients monitored in academic centers. We identified industry-sponsored phase III and IV trials that enrolled more than 500 patients, lasted at least one year and used exacerbations related endpoints. Eligibility criteria were extracted from each trial and applied to the patients.

RESULTS

The eligibility criteria of 16 RCTs were applied to the 1309 patients. The most discriminating eligibility criteria were FEV1, minimum exacerbation rate in the previous year and smoking history, responsible for the exclusion of 39.9, 36.7 and 16.8% of patients, respectively. Altogether, 2.3 to 46.7% of our patients would have satisfied all eligibility criteria.

CONCLUSION

These analyses confirm that an important gap exists between real-life patients and clinical trials populations in COPD, which limits the relevance of results and therefore should be considered when grading levels of evidence and designing future studies.

Characterisation of morbidity in a COPD hospital cohort

OBJECTIVES

To characterise the morbidity of COPD out-patients based on symptoms, acute exacerbations, FEV₁ and comorbidities, and to explore the association between different patients' characteristics such as social, demographic, clinical history or exposure.

METHODS

Stable COPD outpatients over 40 years old diagnosed according to GOLD criteria were included consecutively; the exclusion criteria were only refusal to participate and inability to understand clinical questionnaires. A survey of demographic and clinical data was conducted. Symptoms were evaluated using the CAT and mMRC questionnaires. The number of COPD acute exacerbations reported in the previous year was assessed, and spirometry performed on all participants according to ATS/ERS recommendations. Different variables were collected and then related to each other.

RESULTS

We studied 303 COPD outpatients, all Caucasians, 79.5% males and mostly elderly. 65.7% of participants reported having low monthly income and 87.8% a low education level. Tobacco smoking was the most common exposure identified but a substantial proportion of COPD patients were non-smokers (26%). Frequent acute exacerbations were reported by 38.0% of patients. The mean post-bronchodilator FEV₁ was 53.2%. The distribution of patients according to GOLD 2017 stage and classification was respectively 9.9%, 41.9%, 35.0% and 13.2% from 1 to 4 and 23.1%, 39.6%, 2.3% and 35.0% from GOLD A to D. Only 29 patients (9.5%) presented no comorbid conditions, and the most common were hypertension, heart diseases and dyslipidaemia.

CONCLUSIONS

Our data confirms COPD as a complex and heterogeneous disorder, with a significant morbidity due to the nature of symptoms, frequent comorbidities and exacerbations. A substantial proportion of COPD patients were never-smokers, mainly women, calling attention to the need for COPD recognition in these cases. COPD in women, in never-smokers and in patients with a previous diagnosis of asthma presented some specific characteristics. Some patient characteristics are associated with frequent acute exacerbations. FEV₁ was strongly related both to symptoms and exacerbations.

[Prevalence and characteristics of chronic obstructive pulmonary disease in non-smokers]

Objetivo

Conocer el perfil y las características de los enfermos diagnosticados de enfermedad pulmonar obstructiva crónica (EPOC) y que nunca han sido fumadores.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Área Básica de Salud del Pla d’Urgell (Atención Primaria de Lleida, España).

Participantes

Se incluyeron los 512 pacientes mayores de 40 años diagnosticados de EPOC del Área Básica de Salud con una espirometría compatible al inicio del estudio [cociente < 0,7 entre el volumen de espiración forzada en el primer segundo (FEV₁) y la capacidad vital forzada (FVC)].

Mediciones principales

La variable dependiente fue la EPOC en no fumadores y las independientes fueron variables recogidas a partir de la información sobre la historia clínica respiratoria, los factores de riesgo del enfermo y sobre calidad vida. Se diseñó un modelo predictor de padecer EPOC en no fumadores en comparación con los fumadores.

Resultados

El 33,2% de los pacientes EPOC nunca habían sido fumadores y de estos, el 59,4% eran mujeres. La media del FEV₁ de los no fumadores fue de 70,5 (DE = 17,1), superior a los 62,6 (DE = 18,5) en los fumadores/exfumadores (p < 0,001). La cobertura de la vacunación antineumocócica 23V era mejor en los no fumadores (75,3%), p < 0,001. Los EPOC en no fumadores (respecto a los fumadores/exfumadores) eran: mayormente mujeres (OR = 16,46), de mayor edad (OR = 1,1), con mejor FEV₁ (OR = 1,1), mejor percepción de calidad de vida, EuroQoL-5D (OR = 0,8), con menor prevalencia de diabetes (OR = 0,5), menor nivel de estudios (OR = 0,2), y con menos hospitalizaciones previas (OR = 0,3).

Conclusiones

El estudio evidencia una alta proporción de no fumadores en enfermos EPOC. Nuestro trabajo objetiva que las mujeres de mayor edad y con menor gravedad se asociarían a un mayor riesgo de EPOC en no fumadores. Parece indicar que la EPOC en no fumadores aparecería en edades más tardías y sería más leve que la EPOC relacionada con el tabaquismo.

Joint statement for the diagnosis, management, and prevention of chronic obstructive pulmonary disease for Gulf Cooperation Council countries and Middle East-North Africa region, 2017

Smoking and subsequent development of COPD is an ever-increasing epidemic in Arabian Gulf and Middle East countries, with no signs of decline. The important fact to be highlighted is that this COPD epidemic of increasing incidence and prevalence is mostly unrecognized by patients, due to the common attribution of symptoms to "smoker's cough", and the underdiagnosis and undertreatment by physicians because the common signs and symptoms masquerade as asthma. Consequently, there are long-term adverse effects of missing the diagnosis. The purpose of this review article is to focus upon the status of COPD in Arabian Gulf and Middle East countries, stressing the increasing burden of smoking and COPD, to emphasize the specific factors leading to rise in prevalence of COPD, to bring to light the underdiagnosis and undermanagement of COPD, and to treat COPD in conformity with standard guidelines with local and regional modifications. This review ends with suggestions and recommendations to the health department to formulate policies and to generate awareness among the general public about the side effects of smoking and consequences of COPD.

The epidemiology of noncommunicable respiratory disease in sub-Saharan Africa, the Middle East, and North Africa

Noncommunicable diseases (NCDs) are a major and increasing global health issue. The World Health Organization (WHO) estimates that NCDs represent 63% of all global deaths of which 3.9 million are due to chronic respiratory diseases (CRDs) and Chronic Obstructive Pulmonary Disease (COPD) in particular. COPD is now the third most common cause of death globally; 90% of these deaths occur in Low and Middle Income Countries (LMICs). COPD affects 329 million people, almost 5% of the world's population. In addition, asthma affects 334 million people, again representing almost 5% of the world's population. There is limited literature published on the epidemiology of COPD and Asthma from Sub-Saharan Africa (SSA) and Middle East and North Africa (MENA). Both diseases are under-diagnosed and underestimated in both SSA and MENA regions. The burden of COPD in sub-Saharan Africa is disputed and reports offer variable prevalence estimates, ranging from 4.1% to almost 22.2%. SSA and MENA countries report similar mortality rates from COPD of 18 per 100,000 population (2001 data). Asthma is a less common cause of death than COPD but is a major cause of morbidity; WHO estimates that there are 250,000 deaths per year from asthma, mainly in LMICs and it remains in the top twenty causes of disability in children globally. Risk factors for CRD are genetic and environmental; the latter dominated by air pollution exposures including tobacco smoke, household air pollution, outdoor air pollution and occupational exposures.