Prevalence of COPD in five Colombian cities situated at low, medium, and high altitude (PREPOCOL study)

Association between biomass exposure and COPD occurrence in Fez, Morocco: results from the BOLD study

OBJECTIVE

To investigate the association between biomass exposure and chronic obstructive pulmonary disease (COPD) in a representative sample of adults from the Moroccan population METHODS: A cross-sectional study was conducted in Fez as part of the Burden of Obstructive Lung Disease (BOLD) study, which included apparently healthy subjects aged 40 years and above. Biomass exposure was defined as self-report use of various biomass types for heating or cooking. The Wood Heating Exposure Index, and the Cooking Biomass Exposure Index were used to assess biomass exposure. Participants underwent post-bronchodilator spirometry and COPD was defined as having a forced expiratory volume in 1 s/forced vital capacity ratio <0.7. Descriptive, univariate and multivariable statistical analyses adjusting for potential confounders including age, sex, smoking, education level, Mokken scale (wealth index) and occupational dust exposure were performed for the general population and separately for men and women.

RESULTS

A total of 760 subjects were included, comprising 350 men and 410 women. In the multivariable analyses, we found a statistically significant association between a higher Wood Heating Exposure Index and COPD in men (adjusted OR=3.8; 95% CI: 1.4 to 10.4). While for women, a high Cooking Biomass Exposure Index was the main factor potentially linked to the increased risk of COPD (adjusted OR=7.2; 95% CI: 1.7 to 30.0).

CONCLUSION

This study suggests that biomass exposure is a significant risk factor for COPD development in both men and women, independently of the smoking status which is known as its main risk factor.

Factors related to mortality in patients with chronic obstructive pulmonary disease in Colombian population

Introduction. Data in low- and middle-income countries on mortality and its related risk factors in patients with chronic obstructive pulmonary disease are limited. Objective. To identify the incidence of death and its relationship with variables in a Colombian population during 12 months of follow-up. Materials and methods. We carried out a retrospective study in subjects diagnosed with chronic obstructive pulmonary disease in a third-level hospital in Colombia. Odds ratios were calculated using multivariable logistic regression analysis with the outcome variable “mortality at 12 months”. Results. We included 524 patients, 18.1% (95 / 524) died. The average age was 69.7 (SD = 8.92), and 59.2% (310 / 524) were women. The variables associated with mortality were age (OR = 6.54; 95% CI = 3.65-11.36; p < 0.001), years of exposure to wood smoke (OR = 4.59; 95% CI = 1.64-2.82; p = 0.002), chronic heart failure (OR = 1.81; 95% CI = 1.13-2.91; p = 0.014), cerebrovascular disease (OR = 3.35; 95% CI = 1.04-10.75; p = 0.032), and chronic kidney disease (OR = 6.96; 95% CI = 1.15-41.67; p=0.015). When adjusting the variables in the multivariate analysis, only an association was found for sex (OR = 1.55; 95% CI = 0.95-2.54; p = 0.008) and age (OR = 5.94; 95% CI = 3.3-10.69; p < 0.001). Conclusion. Age, years of exposure to wood smoke, chronic heart failure, and cerebrovascular and chronic kidney disease were the clinical variables associated with a fatal outcome. However, age and sex were the only variables related to mortality when adjusted for confounding factors.

Blood eosinophils levels in a Colombian cohort of biomass-and tobacco-related COPD patients

Introduction

Chronic obstructive pulmonary disease (COPD) is a major cause of illness and death among adults. In 2019, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy incorporated blood eosinophils as a biomarker to identify patients at increased risk of exacerbations which, with the history of exacerbations during the previous year, allows identification of patients who would benefit from anti-inflammatory treatment to reduce the risk of future exacerbations. The aim of this study was to describe demographic and clinical characteristics, eosinophil counts, and exacerbations in a cohort of COPD patients stratified by clinical phenotypes (non-exacerbator, frequent exacerbator, asthma-COPD overlap) in a Colombian cohort at 2600 meters above sea level.

Methods

A descriptive analysis of a historical cohort of patients with a confirmed diagnosis of moderate to severe COPD (FEV1/FVC < 0.7 and at least one risk factor for COPD) from two specialized centers with comprehensive disease management programs was performed from January 2015 to March 2019. Data were extracted from medical records 1 year before and after the index date.

Results

200 patients were included (GOLD B: 156, GOLD E: 44; 2023 GOLD classification); mean age was 77.9 (SD 7.9) years; 48% were women, and 52% had biomass exposure as a COPD risk factor. The mean FEV1/FVC was 53.4% (SD 9.8), with an FEV1 of 52.7% (20.7). No differences were observed between clinical phenotypes in terms of airflow limitation. The geometric mean of absolute blood eosinophils was 197.58 (SD 2.09) cells/μL (range 0 to 3,020). Mean blood eosinophil count was higher in patients with smoking history and frequent exacerbators. At least one moderate and one severe exacerbation occurred in the previous year in 44 and 8% of patients, respectively; during the follow-up year 152 exacerbations were registered, 122 (80%) moderate and 30 (20%) severe. The highest rate of exacerbations in the follow-up year occurred in the subgroup of patients with the frequent exacerbator phenotype and eosinophils ≥300 cells/μL.

Discussion

In this cohort, the frequency of biomass exposure as a risk factor is considerable. High blood eosinophil count was related to smoking, and to the frequent exacerbator phenotype.

Prevalence of pulmonary hypertension in COPD patients living at high altitude

BACKGROUND

Pulmonary hypertension (PH) is associated with poor prognosis for patients with chronic obstructive pulmonary disease (COPD). Most of the knowledge about PH in COPD has been generated at sea level, with limited information associated with high altitude (HA).

OBJECTIVES

To assess the prevalence and severity of PH in COPD patients living in a HA city (2,640 m).

METHODS

Cross-sectional study in COPD patients with forced expiratory volume in the first second / forced vital capacity ratio (FEV1/FVC) post-bronchodilator <0,7. Transthoracic echocardiography (TTE), spirometry, carbon monoxide diffusing capacity, and arterial blood gasses tests were performed. Patients were classified according to the severity of airflow limitation. PH was defined by TTE as an estimated systolic pulmonary artery pressure (sPAP) > 36 mmHg or indirect PH signs; severe PH as sPAP > 60 mmHg; and disproportionate PH as an sPAP > 60 mmHg with non-severe airflow limitation (FEV1 > 50% predicted).

RESULTS

We included 176 COPD patients. The overall estimated prevalence of PH was 56.3% and the likelihood of having PH increased according to airflow-limitation severity: mild (31.6%), moderate (54.9%), severe (59.6%) and very severe (77.8%) (p = 0.038). The PH was severe in 7.3% and disproportionate in 3.4% of patients.

CONCLUSIONS

The estimated prevalence of PH in patients with COPD at HA is high, particularly in patients with mild to moderate airflow limitation, and greater than that described for COPD patients at low altitude. These results suggest a higher risk of developing PH for COPD patients living at HA compared to COPD patients with similar airflow limitation living at low altitude.

Proposing the potential of utilizing the CAT score for early detection of COPD in asymptomatic patients, shifting towards a patient-centered approach: A review

Chronic obstructive pulmonary disease (COPD) constitutes a significant public health challenge, with delayed diagnosis and underdiagnosis being pervasive issues. The United States Preventive Service Task Force recommends restricting COPD screening to symptomatic smokers, a focus that has exhibited limitations, leading to delayed diagnoses, and imposing a substantial burden on patients, their families, and the healthcare system. This paper explores an alternative approach, highlighting the potential utility of the COPD assessment test (CAT) score as a prescreening tool. A CAT score of 10 or higher could serve as an appropriate threshold for further diagnostic procedures, given its robust correlation with pulmonary function test parameters and is valuable capacity to quantify patients' symptoms. The utilization of CAT as a prescreening tool in primary care signifies a transition towards a more patient-centered and comprehensive approach to COPD diagnosis and care.

Chronic obstructive pulmonary disease related to wood smoke and impact of the combined exposure to tobacco

BACKGROUND

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 highlights the need to explore aetiotypes of chronic obstructive pulmonary disease (COPD) beyond the tobacco-smoking COPD. Exposure to wood smoke (WS) is a risk factor for COPD in women, but the effect of the combined exposure to tobacco smoke (TS) in the general population and among COPD patients, and the characteristics of WS-COPD are unclear.

METHOD

This was an analysis of data from PREPOCOL (Prevalence of COPD in Five Colombian Cities Situated at Low, Medium, and High Altitude), a random cross-sectional population-based study (n = 5,539) focusing on the effect of combined WS and TS exposure and WS-COPD characterisation.

RESULTS

Prevalence of COPD was significantly higher in those exposed to both WS and TS (16.0%) than in those exposed to WS (6.7%) or TS (7.8%) only (P < 0.001). Exposure to WS was associated with COPD in men (OR 1.53, P = 0.017). WS-COPD individuals were more frequently female, older, shorter and had higher forced expiratory volume in 1 sec (FEV1) (all P < 0.05). Those exposed to both WS and TS had more symptoms and worse airflow limitation (P < 0.001).

CONCLUSIONS

This was the first random population-based study showing that WS is an associated risk factor for COPD also in men, and that people exposed to both WS and TS have a significantly higher prevalence of COPD. Similarly, COPD subjects exposed to both types of smoke have more symptoms and greater airflow obstruction. This suggests an additive effect of WS and TS.

Estimated burden of fungal infections in Panama

Data published on Panamanian fungal disease are scarce, mostly case reports. To date, there is no paper that compiles the burden of fungal disease Here we estimate for the first time the incidence and prevalence of fungal diseases in Panama. Data on fungal disease were obtained from different search engines: PubMed, Google Scholar, Scielo and Lilacs. For population and at risk diseases, we used statistics from worldometer, UNAIDS, and WHO. Incidence, prevalence, and absolute numbers were calculated based on the population at risk. Panamanian population in 2022 was 4,429,739. We estimated that 85,530 (1.93 %) people suffer from fungal diseases. The most frequent fungal infection was recurrent Candida vaginitis (3285/100,000). There are 31,000 HIV-infected people in Panama and based on the number of cases not receiving anti-retroviral therapy (14,570), and previous reports of prevalence of opportunistic infections, we estimated annual incidences of 4.0/100,000 for cryptococcal meningitis, 29.5/100,000 for oral candidiasis, 23.1/100,000 for esophageal candidiasis, 29.5/100,000 for Pneumocystis pneumonia, 15.1/100,000, and for histoplasmosis. For chronic pulmonary aspergillosis (CPA) and fungal asthma we used data from Guatemala and Colombia to estimate COPD and asthma prevalence and WHO report for tuberculosis. We estimated annual incidences of 6.1/100,000 for invasive aspergillosis and prevalence of 31.5/100,000 for CPA, 60.2/100,000 for allergic bronchopulmonary aspergillosis, and 79.5/100,000 for severe asthma with fungal sensitisation. Other incidence estimates were 5.0/100,000 for candidaemia, 0.20/100,000 for mucormycosis, and 4.97/100,000 for fungal keratitis. Even though this report on burden of fungal disease is a forward step, more epidemiological studies to validate these estimates are needed.

Sputum Biomarkers in Wood and Tobacco Smoke Etiotypes of Chronic Obstructive Pulmonary Disease

Introduction

There is a need to better understand the etiotypes of chronic obstructive pulmonary disease (COPD) beyond the tobacco-smoke (TS-COPD). Wood smoke COPD (WS-COPD) is characterized by greater airway compromise, milder emphysema, and slower rate of lung function decline than TS-COPD. However, it is unclear if these two etiotypes of COPD have differences in sputum biomarker concentrations. Objective was to compare sputum levels of selected sputum biomarkers between WS-COPD and TS-COPD, and healthy controls.

Methods

Eighty-eight women (69±12 years) were recruited and classified into: WS-COPD (n=31), TS-COPD (n=29) and controls (n=28). Using ELISA, we determined induced sputum levels of metalloproteinase 9 (MMP-9), chemokine ligand 5 (CCL5), interleukin-8 (IL-8), chemokine ligand 16 (CCL16/HCC-4) and vascular endothelial growth factor (VEGF-1). Differences were analyzed by Kruskal-Wallis and Mann-Whitney-U tests and correlation between airflow limitation and biomarkers by Spearman's test.

Results

At similar degree of airflow obstruction, anthropometrics and medications use, the level of sputum CCL5 was higher in TS-COPD than WS-COPD (p=0.03) without differences in MMP-9, IL-8, CCL16/HCC-4, and VEGF-1. Women with WS-COPD and TS-COPD showed significantly higher sputum levels of MMP-9, IL-8 and CCL5 compared with controls (p<0.001). FEV1% predicted correlated negatively with levels of MMP-9 (rho:-0.26; P=0.016), CCL5 (rho:-0.37; P=0.001), IL-8 (rho:-0.42; P<0.001) and VEGF (rho:-0.22; P=0.04).

Conclusion

While sputum concentrations of MMP-9, IL-8, and CCL5 were higher in COPD women compared with controls, women with TS-COPD had higher levels of CCL5 compared with those with WS-COPD. Whether this finding relates to differences in pathobiological pathways remains to be determined.

Comparison of the Diagnostic Performance of Five Clinical Questionnaires for Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) remains one of the most prevalent pathologies in the world and is among the leading causes of mortality and morbidity, partially due to underdiagnosis. The use of clinical questionnaires to identify high-risk individuals to take them to further diagnostic procedures has emerged as a strategy to address this problem.

Objective

To compare the performance of the COULD IT BE COPD, CDQ, COPD-PS, LFQ, and PUMA questionnaires for COPD diagnosis.

Methods

A cross-sectional study was carried out on subjects who underwent spirometry in the third-level center. Data were collected between January 2015 and March 2020. Bivariate analysis was performed between the study variables and the presence of COPD. The area under the receiver operating characteristics curve (AUC-ROC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for each questionnaire were calculated. The AUC-ROCs were compared with the DeLong test, considering a p value <0.05 statistically significant.

Results

681 subjects met the inclusion criteria and were taken to the final analysis. The prevalence of COPD was 27.5% (187/681). The mean age of the subjects was 65.9 years (SD ± 11.79); 46.3% (315/681) were female, and 83.6% (569/681) reported respiratory symptoms. Statistically significant relationship was found for COPD diagnosis with male sex, older age, respiratory symptoms, and exposure to wood smoke (p value <0.05). The AUC-ROCs of the questionnaires were between 0.581 and 0.681. The COULD IT BE COPD questionnaire had a lower discriminatory capacity AUC-ROC of 0.581, concerning the other scores (DeLong test, p = 0.0002).

Conclusion

The CDQ, COPD-PS, LFQ, PUMA, and COULD IT BE COPD questionnaires have acceptable performance for the diagnosis of COPD together with low sensitivity and specificity. Therefore, its use must be complemented with other diagnostic tests or techniques such as pulmonary function tests.

COPD Risk Factor Profiles in General Population and Referred Patients: Potential Etiotypes

Purpose

To identify the risk factors for chronic obstructive pulmonary disease (COPD) in view of potential etiotypes in a general population and referred COPD patients.

Patients and Methods

We performed a cross-sectional observational study utilizing two distinct datasets: a dataset of a general population including 2430 subjects with COPD from the Korea National Health and Nutrition Examination Survey (KNHANES) and another dataset of referral clinics including 579 patients with COPD from the Korean Obstructive Lung Disease (KOLD).

Results

The mean age of both groups was 67 years, and 71.2% and 93.8% were male in the COPD subjects from the KNHANES and the KOLD, respectively. The mean forced expiratory volume in 1 second of predicted value was 79.1% (KNHANES) and 55.4% (KOLD). The frequency of risk factors of cigarette smoking (C), infection (I), pollution (P), and asthma (A) was 54.6%, 9.4%, 10.7%, and 7.9%, respectively, in the KNHANES COPD subjects, and 88.4%, 26.6%, 41.6%, and 35.2%, respectively, in the KOLD COPD subjects. Risk factors were unidentified in 32.6% (KNHANES) and 3.1% (KOLD) of COPD subjects. Additionally, 14.1% and 66.2% of subjects with COPD had two or more risk factors in the KNHANES and KOLD, respectively.

Conclusion

The profiles of risk factors C, I, P, and A were identified and appeared to be different among the two COPD groups from a general population or referral clinics. In some of the COPD subjects, risk factors were not identified, so we should endeavour to find out unidentified COPD risk factors, especially in the general population.

Knowledge of Vaccination Against Influenza and Pneumococcus in Patients with Chronic Obstructive Pulmonary Disease in an Integrated Care Program

Purpose

To compare the level of knowledge in vaccination against influenza and pneumococcus of patients with chronic obstructive pulmonary disease (COPD) who are managed in an Integrated Care Program (ICP) with those who receive usual care (UC).

Methods

A telephone survey of patients diagnosed with COPD registered in public care networks or private institutions was done. A descriptive and comparative analysis of the characteristics of the ICP and UC groups was carried out. The relationship between belonging to an ICP and the level of knowledge about vaccination was evaluated using Propensity Score Matching (PSM) and multivariate logistic and ordinal regression models.

Results

Of 674 study participants, 27.2% were from the ICP group. ICP patients were older, more frequently men, from a higher socioeconomic stratum and a higher educational level (p<0.05). 75.5% of the patients in the ICP group had a high level of vaccination knowledge compared to 42.7% in the UC group (p<0.001). In the multivariate analysis, adjusting for sociodemographic variables, years of COPD diagnosis, and comorbidities, belonging to the ICP was associated with a higher probability of answering questions about vaccination correctly and having a high level of knowledge (OR 3.397, IC 95% 2.058-5.608, p<0.001).

Conclusion

Patients with COPD managed in an ICP have a higher level of knowledge in vaccination against influenza and pneumococcus, compared to patients in usual care.

Chronic Obstructive Pulmonary Disease in Cameroon: Prevalence and Predictors-A Multisetting Community-Based Study

Objective

Little is known concerning chronic obstructive pulmonary disease (COPD) in Sub-Saharan Africa (SSA), where the disease remains underdiagnosed. We aimed to estimate its prevalence in Cameroon and look for its predictors.

Methods

Adults aged 19 years and older were randomly selected in 4 regions of Cameroon to participate in a cross-sectional community-based study. Data were collected in the participant's home or place of work. Spirometry was performed on selected participants. COPD was defined as the postbronchodilator forced expiratory volume in 1 second/forced vital capacity ratio (FEV1/FVC) < lower limit of normal, using the global lung initiative (GLI) equations for Black people. Binomial logistic regression was used to seek COPD-associated factors. The strength of the association was measured using the adjusted odds ratio (aOR).

Results

A total of 5055 participants (median age (25th-75th percentile) = 43 (30-56) years, 54.9% of women) were enrolled. COPD prevalence (95% confidence interval (95% CI)) was 2.9% (2.4, 3.3)%. Independent predictors of COPD (aOR (95% CI)) were a high educational level (4.7 (2.0, 11.1)), living in semiurban or rural locality (1.7 (1.4, 3.0)), tobacco smoking (1.7 (1.1, 2.5)), biomass fuel exposure (1.9 (1.1, 3.3)), experience of dyspnea (2.2 (1.4, 3.5)), history of tuberculosis (3.6 (1.9, 6.7)), and history of asthma (6.3 (3.4, 11.6)). Obesity was protective factor (aOR (95%CI) = 0.3 (0.2, 0.5)).

Conclusion

The prevalence of COPD was relatively low. Alternative risk factors such as biomass fuel exposure, history of tuberculosis, and asthma were confirmed as predictors.

Characteristics of Inhaler Technique in COPD Patients in a Specialized Center in Armenia, Colombia: A Cross-Sectional Study

Purpose

The aim of this research was to evaluate the technique of using inhaled drugs in patients with a confirmed history of COPD and describe errors in inhaler technique.

Patients and Methods

Descriptive cross-sectional study was conducted in patients with a history of COPD using inhalation therapy, attending pulmonology consultation between August 2020 and April 2021 in Armenia, Colombia. A non-probabilistic sample of 80 adult participants was calculated, and the inhalation technique was evaluated (depending on the device used) using a scale validated for Colombia. Descriptive analysis of the qualitative variables was performed using frequencies and percentages. The Chi-Square test and Fisher's exact test (in corresponding cases) were used to look for association relationships between categorical variables.

Results

A total of 80 participants were evaluated, of which 66.3% (n = 53) were male, and 32.5% were older than 80 years. Clinically, 30.0% (n = 24) were classified as Modified Medical Research Council Dyspnea Scale (mMRC) grade 3, and 51.2% (n = 41) had at least one exacerbation per year. The main comorbidity was hypertension (40.3%). Pressurized metered-dose inhalers with spacer were the most used device at 22.7% (n = 39). Incorrect technique (at least one error in the steps of the inhalation technique used) was found in 48.7%. The most frequent error among all the techniques was the failure to perform pre-inspiratory exhalation. No significant differences were observed between the development of the technique and the characteristics of the participants.

Conclusion

Nearly half of the patients who use inhalation devices make errors in the technique. Patient education and training of healthcare personnel represent a fundamental pillar in mitigating the incorrect use of these devices.

Patterns and Trends in the Use of Medications for COPD Control in a Cohort of 9476 Colombian Patients, 2017-2019

Purpose

Chronic obstructive pulmonary disease (COPD) affects approximately 174 million people worldwide. The objective was to determine the trends of COPD medication use in a group of Colombian patients.

Patients and Methods

This was a retrospective study on prescription patterns of bronchodilators and other medications used in COPD from a population database with follow-up at 12 and 24 months. Patients older than 18 years of age of any sex with a COPD diagnostic code between 2017 and 2019 were included. Sociodemographic variables, medications, treatment schedules for COPD, comorbidities, comedications, and the specialty of the prescriber were considered.

Results

Data from 9476 people with COPD was evaluated. The mean age was 75.9 ± 10.7 years, 50.1% were male, and 86.8% were prescribed by a general practitioner. A total of 57.9% had comorbidities, most often hypertension (44.4%). At the baseline measurement, on average, they received 1.6 medications/patient, mainly short-acting antimuscarinics (3784; 39.9%), followed by short-acting β-agonists (2997, 31.6%) and inhaled corticosteroids (ICS) (2239, 23.6%); more than half (5083, 53.6%) received a long-acting bronchodilator. Prescription of triple therapy (antimuscarinic, β-agonist, and ICS) went from 645 (6.8%) at baseline to 1388 (20.6%) at the 12-month mark.

Conclusion

This group of patients with COPD treated in Colombia frequently received short-acting bronchodilators and ICS, but a growing proportion are undergoing controlled therapy with long-acting bronchodilators, a situation that can improve the indicators of morbidity, exacerbations, and hospitalization.

Mechanisms of lung damage in tuberculosis: implications for chronic obstructive pulmonary disease

Pulmonary tuberculosis is increasingly recognized as a risk factor for COPD. Severe lung function impairment has been reported in post-TB patients. Despite increasing evidence to support the association between TB and COPD, only a few studies describe the immunological basis of COPD among TB patients following successful treatment completion. In this review, we draw on well-elaborated Mycobacterium tuberculosis-induced immune mechanisms in the lungs to highlight shared mechanisms for COPD pathogenesis in the setting of tuberculosis disease. We further examine how such mechanisms could be exploited to guide COPD therapeutics.

Investigation and Analysis of Risk Factors and Psychological Status of Chronic Obstructive Pulmonary Disease in Permanent Residents Aged 40 or Older in Hongyuan County, Aba Prefecture, Sichuan Province

Background

COPD is an important public health problem worldwide, and there is a lack of epidemiological data on COPD in high-altitude areas in Sichuan province. Thus, we aimed to investigate the prevalence, risk factors and psychological status of COPD in Hongyuan County, Aba Prefecture, Sichuan Province, which is located at an average altitude of 3507 meters.

Methods

The 40 years old or greater permanent residents of Hongyuan County were selected by random sampling method, and the lung function test and questionnaires were conducted to determine the disease situation of COPD. The prevalence of COPD was compared among different factors of investigation, and multivariate logistic regression analysis was used for different factors to determine the independent influencing factors of COPD disease.

Results

A total of 456 permanent residents aged 40 years or older in Hongyuan County, 436 qualified for quality control, among which 53 cases confirmed COPD, the total prevalence was 12.16%, among which the prevalence was 14.55% for men and it was 8.07% for women. There were significant differences in different gender, ethnicity, age, smoking status, smoking years, educational level, heating style, history of tuberculosis, and prevalence of BMI (P <0.05). Binary logistic regression analysis showed that age ≥60 years (OR = 2.810, 95% CI: 1.0457.557), Han Nationality (OR: 3.238, 95% CI: 1.290-8.127), the heating method including biofuels (OR: 18.119, 95% CI: 4.140-79.303) and coals (OR: 6.973, 95% CI: 1.856-26.200), medical history of pulmonary tuberculosis (OR: 2.670, 95% CI: 1.278-5.578), the education level including junior high school (OR: 3.336, 95% CI: 1.2259.075), high school and above (OR: 5.910, 95% CI: 1.796-19.450), and smoking (OR: 10.774, 95% CI: 3.622-32.051) were independent risk factors for COPD disease. The prevalence of anxiety was 16.98%, and the prevalence of depression was 13.2%.

Conclusion

The prevalence of COPD in Hongyuan County was higher than the national level; age, ethnic group, education, smoking, heating method, and history of tuberculosis are the independent influencing factors of COPD in Hongyuan County. The prevalence of anxiety and depression is low.

Usability of a mobile application for the clinical follow-up of patients with chronic obstructive pulmonary disease and home oxygen therapy

BACKGROUND

Technological health tools (e-Health) may potentially facilitate the treatment of patients with chronic diseases through development of self-management and -care skills in patients and caregivers. However, these tools are usually marketed without prior analysis and without providing any context to final users, which frequently results in low adherence to their use.

PURPOSE

To determine the usability of and satisfaction toward a mobile app for the clinical monitoring of patients with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at home.

METHODS

This was a participative-qualitative study focused on final users-with direct intervention by patients and professionals-consisting of three phases as follows: (i) medium-fidelity mockups design, (ii) development of a usability test for each user profile, and (iii) assessment of the satisfaction level regarding the usability of the mobile app. A sample was established and selected through non-probability convenience sampling and was divided into two groups as follows: healthcare professionals (n = 13) and patients (n = 7). Each participant received a smartphone with mockup designs. The "think-aloud" method was applied in the usability test. Participants were audio recorded and the anonymous transcriptions were analyzed, highlighting fragments about mockups characteristics and the usability test. The difficulty level of the tasks was assessed with a scale from 1 (very easy) to 5 (too difficult), and task non-completion was considered a critical mistake. The satisfaction level related to test usability was assessed with a 4-score Likert scale ranging from 4 (totally agree) to 1 (totally disagree).

RESULTS

Regarding the difficulty level, >60% of professionals described most tasks as "very easy" and 70% of patients as "easy." No participant made critical mistakes and both groups reported a high satisfaction level regarding the usability variables. The patient and professionals group required 18 and 11 min to complete all tasks, respectively.

CONCLUSIONS

Participants described the app as intuitive and easy to use. The usability satisfaction results show a high level of satisfaction for both groups. This positive assessment and performance in user tests showed that the mobile application was able to be apprehended and used by participants in the circumstances of use in the usability tests. Usability evaluation through satisfaction surveys and qualitative data analysis allows for greater insight into the use of mobile applications in healthcare.

Airflow obstruction and small airway dysfunction following pulmonary tuberculosis: a cross-sectional survey

OBJECTIVES

Pulmonary function impairment and chronic respiratory symptoms after tuberculosis are relatively common in low-income and middle-income countries. We aimed to estimate the impact of post-tuberculosis (post-TB) on pulmonary function.

METHODS

This large cross-sectional, population-based study included subjects aged 15 years or older with technically acceptable postbronchodilator spirometry measurements. Post-TB was diagnosed on the basis of radiological evidence and/or medical history. Airflow obstruction was defined as a postbronchodilator forced expiratory volume in 1 s/forced vital capacity ratio below the lower limit of normal of Global Lung Function Initiative (GLI) lung function equations. Small airway dysfunction was diagnosed if at least two of the following indicators were less than 65% of predicted: maximal mid-expiratory flow, forced expiratory flow (FEF) 50% or FEF 75%.

RESULTS

In this population sample (N=8680, mean age: 40.1 years), 610 (7.0% (95% CI 6.5 to 7.6) participants were post-TB. Post-TB subjects had more frequent respiratory symptoms (46.8% vs 28.3%). Among post-TB subjects, 130 (21.3% (95% CI 18.1 to 24.8)) had airflow obstruction; OR of airflow obstruction was significantly associated with post-TB after adjustment for other confounding factors (OR 1.31, 95% CI 1.05 to 1.62). Post-TB was also associated with small airway dysfunction (OR 1.28, 95% CI1.07 to 1.53), which was present in 297 (48.9% (95% CI 33.9 to 53.0)) post-TB subjects.

CONCLUSIONS

Our findings support existing knowledge that post-TB is positively associated with pulmonary function impairment and make for frequent respiratory symptoms. Post-TB should be considered as a potentially important cause of airflow obstruction and respiratory symptoms in patients originating from countries with a high burden of tuberculosis.

[Lung cancer mortality trends in Colombia, 1985-2018Tendências na mortalidade por câncer de pulmão na Colômbia de 1985 a 2018]

Objetivo.

Determinar la evolución de la mortalidad por cáncer de pulmón en Colombia en el período 1985-2018 en la población de 35 años y más e identificar cambios en la tendencia.

Métodos.

Análisis de series temporales de mortalidad. Se calcularon las tasas específicas y estandarizadas por sexo y grupos de edad. Mediante la regresión joinpoint se estimó el porcentaje de cambio anual de las tasas y se identificaron puntos de cambio.

Resultados.

En el período 1985-2018 se registraron 105 553 muertes por cáncer de pulmón en la población de 35 años y más. Las tasas estandarizadas muestran una tendencia decreciente en el período 1985-2005, excepto en mayores de 64 años.

Conclusiones.

La tendencia de las tasas de mortalidad por cáncer de pulmón es decreciente en Colombia. Es necesario potenciar medidas de prevención primaria y secundaria sobre el consumo de tabaco y vigilar otros factores de riesgo como el radón residencial o la ocupación.

Patients, caregivers, and healthcare professionals' needs when designing the content of a mobile application for the clinical monitoring of patients with chronic obstructive pulmonary disease and home oxygen therapy: A user-centered design

Background

Patients with chronic respiratory diseases require oxygen supply in a considerable amount to reduce their symptoms and increase their survival. The development of abilities for the self-management of chronic diseases has been shown to be essential to decrease exacerbation of symptoms. Therefore, the design and development of health mobile applications (apps) that aid in educating and training for disease self-management are cost-effective strategies.

Objective

The purpose of this research was to describe the main characteristics that, according to final users, should be included in a mobile application for monitoring patients prescribed home oxygen therapy.

Methods

A participative-qualitative design was used, involving direct participation of patients, caregivers, and healthcare professionals. Focus groups were conducted to identify the needs and perspectives related to the app. A card sorting method was used to determine the contents and basic architecture of the app.

Results

By means of the focus groups, we could identify nine basic functions of the app for the clinical monitoring of patients under home oxygen therapy. For both profiles, the app structure was determined by identifying the most frequent contents among participants.

Conclusions

The implementation of a user-centered design allowed for the detection of the functions, contents, and basic architecture of the app by identifying healthcare professionals and patients' needs and preferences regarding the self-management and monitoring of home oxygen prescriptions.

Trial Registration

The study is registered in ClinicalTrials.gov: NCT04820790.

Lung health after tuberculosis: clinical and functional assessment in post-pulmonary tuberculosis Egyptian patients

Background

Some of the pulmonary tuberculous patients who completed their medication course experience lung function impairment which may influence their quality of life. However, the pattern and nature of post-tuberculosis lung impairment are still not identified. Thus, the aim of this study was to determine the type and degree of lung physiology changes in previously treated tuberculous patients which latter may affect their quality of life, thus helping clinicians for early diagnosis of lung impairment, especially in tuberculous endemic areas.

Results

Adults (≥18 years) who were treated from first attack pulmonary tuberculosis were included in the study. Demographic data, respiratory symptoms, smoking history, comorbidities, Medical Research Council dyspnea score (MRC), spirometry, chest radiography, and oxygen saturation were collected. One hundred ninety-seven participants were finally included in the study. The mean age was 49.50±13.26 years with males representing 75.6% of total patients. MRC dyspnea scale grading showed that about 13.2% and 5.1% of patients suffer from dyspnea grade II and grade III, respectively. Main respiratory symptoms were cough in 38.1%, sputum production in 24.9%, and hemoptysis in 6.6% cases. Normal spirometry was documented in 53.3%, obstructive pattern in 31.98%, and mixed pattern in 7.11%, whereas 7.61% cases had a restrictive pattern. According to ATS staging of obstructive pattern, 27 patients (42.8%) had mild obstruction, 22 (34.9%) patients had moderate obstruction, 13 (20.6%) patients had moderate to severe obstruction, and one patient (1.6%) had severe obstruction.

Conclusions

Impairment of respiratory function after tuberculosis is one of the causes of chronic lung disease that is underestimated, especially in endemic countries. This impairment in function occurs early in the course of the diseases and even without symptoms, affecting the quality of life. Thus, clinicians should encourage patients for an earlier visit to a respiratory clinic for follow-up and further management if needed. Guidelines for the management of cured tuberculous patients are urgently needed.

Trial registration

ClinicalTrials.gov, NCT05097638. Registered on October 28, 2021—retrospectively registered

Is pulmonary tuberculosis a true risk-factor for chronic obstructive pulmonary disease?

This viewpoint discusses the possible relationship of tuberculosis with chronic obstructive pulmonary disease. Pulmonary tuberculosis as a risk factor and/or complication of COPD is reported in several reports from African and Asian countries. History of TB seems to have an important role in the natural history of COPD. It is difficult to conclude whether this is a true causal relationship or merely an incidental observation due to the concurrent presence of the two commonly prevalent diseases and their risk factors. Many of these disease and treatment-related factors can promote and/or aggravate disease condition.

Revamping of Chronic Respiratory Diseases in Low- and Middle-Income Countries

Low- and middle-income countries (LMICs) endure an asymmetrically high burden of worldwide disease and death caused by chronic respiratory diseases (CRDs), i.e., asthma, emphysema, bronchiectasis, and post-tuberculosis lung disease (PTLD). CRDs are firmly related with indigence, infectious diseases, and other non-communicable diseases (NCDs) and add to complex multi-disease with great impact on the lives and livelihood of those affected. The pertinence of CRDs to health and demographic wellbeing is relied upon to increment in the long time ahead, as expectations of life rise and the contending dangers of right on time youth mortality and irresistible infections level. The WHO has distinguished the counteraction and control of NCDs as an earnest improvement issue and crucial for the sustainable development goals (SDSs) by 2030. In this review, we center on CRDs in LMICs. We examine the early life roots of CRDs, challenges in their avoidance, identification and administration in LMICs, and the pathways to resolve for accomplish valid widespread wellbeing inclusion.

Disease burden and vaccination priorities in Colombia

Introduction

In the context of the COVID-19 pandemic, vaccination is considered a potentially effective strategy for controlling the disease. The objective of this study is to estimate the number of people with a high risk of morbidity and those who should be prioritized in immunization planning in Colombia.

Materials and methods

The population at risk by age was identified from the national census data of 2018. Various sources were identified to obtain information on the number of patients with different comorbidities, including heart failure, diabetes, chronic kidney failure, cancers, HIV infection, and obesity. Sources were also identified to estimate the number of health workers, teachers and military and police force personnel.

Results

By 2021, Colombia is estimated to have a total of 51,049,498 inhabitants, of whom 14% will be people over 60 years of age. Additionally, of the people with comorbidities younger than 60 years old, 5,233,241 inhabitants are expected to be obese, 592,726 are expected to have diabetes mellitus, 216,389 are expected to have chronic kidney disease, and 521,263 are expected to have heart failure, totaling 15,055,697 individuals. Combining the high-priority groups and health workers, a projected 20 million people will have mortality risk factors.

Conclusions

For Colombia’s vaccination strategy to have an impact on reducing mortality, population groups with risk factors, corresponding to approximately 15 million inhabitants, as well as essential workers should be prioritized.

Validación Cuestionario FSI-10 y grado de satisfacción con dispositivos de inhaloterapia

Introducción. El tratamiento farmacológico de la EPOC se realiza progresiva y escalonadamente de acuerdo a la gravedad y puede ser modificado en función de la respuesta al mismo, por lo cual se han desarrollado instrumentos con el fin de evaluar la satisfacción del paciente con los distintos sistemas de inhalación; sin embargo, estos instrumentos han sido diseñados en su mayoría para pacientes con Asma. Objetivo. Validar el instrumento FSI-10 y determinar el nivel de satisfacción de los dispositivos de inhaloterapia en pacientes con EPOC. Materiales y métodos. Estudio transversal prospectivo y de validación de contenido, muestreo probabilístico estratificado con afijación proporcional; población de 337 pacientes con diagnóstico EPOC de la provincia Centro del departamento de Boyacá, Colombia. Se evaluó el cuestionario FSI-10 mediante la prueba de esfericidad de Bartlett, Kaiser-Meyer-Olkin y alfa de Cronbach. Resultados. La prueba de esfericidad resultó estadísticamente significativa, sugiriendo la existencia de correlaciones dentro de la matriz de diez preguntas. La variación total explicable de las diez preguntas que corresponden a la versión del FSI 10 dio cuenta del 81 % de variabilidad. Los pacientes evaluados reportaron un nivel de satisfacción entre bastante a algo con los dispositivos de inhaloterapia. Conclusiones. Las propiedades psicométricas permiten su utilización en la satisfacción del paciente con dispositivos de medicación inhalada, sin presentar diferencias en la comprensión y teniendo resultado fiables. La satisfacción con los dispositivos de inhaloterapia no es muy alta en la mayoría de la población evaluada.

Epidemiological evidence relating risk factors to chronic obstructive pulmonary disease in China: A systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD), the most common chronic respiratory disease worldwide, not only leads to the decline of pulmonary function and quality of life consecutively, but also has become a major economic burden on individuals, families, and society in China. The purpose of this meta-analysis was to explore the risk factors for developing COPD in the Chinese population that resides in China and to provide a theoretical basis for the early prevention of COPD.

METHODS

A total of 2457 cross-sectional, case-control, and cohort studies published related to risk factors for COPD in China were searched. Based on the inclusion and exclusion criteria, 20 articles were selected. Stata 11.0 was used for meta-analysis. After merging the data, the pooled effect and 95% confidence intervals (CIs) were calculated to assess the association between risk factors and COPD. Heterogeneity between studies was assessed using I2 and Cochran's Q tests. Begg's test was used to assess publication bias.

RESULTS

Exposure to particulate matter less than 2.5 μm in diameter (PM2.5) (pooled effect = 1.73; 95%CI: 1.16~2.58; P <0.01), smoking history (pooled effect = 2.58; 95%CI: 2.00~3.32; P <0.01), passive smoking history (pooled effect = 1.39; 95%CI: 1.03~1.87; P = 0.03), male sex(pooled effect = 1.70; 95%CI: 1.31~2.22; P <0.01), body mass index (BMI) <18.5 kg/m2 (pooled effect = 1.73; 95%CI: 1.32~2.25; P <0.01), exposure to biomass burning emissions (pooled effect = 1.65; 95%CI: 1.32~2.06; P <0.01), childhood respiratory infections (pooled effect = 3.44; 95%CI: 1.33~8.90; P = 0.01), residence (pooled effect = 1.24; 95%CI: 1.09~1.42; P <0.01), and a family history of respiratory diseases (pooled effect = 2.04; 95%CI: 1.53~2.71; P <0.01) were risk factors for COPD in the Chinese population.

CONCLUSION

Early prevention of COPD could be accomplished by quitting smoking, reducing exposure to air pollutants and biomass burning emissions, maintaining body mass index between 18.5 kg/m2 and 28 kg/m2, protecting children from respiratory infections, adopting active treatments to children with respiratory diseases, and conducting regular screening for those with family history of respiratory diseases.

Variabilidad de síntomas en pacientes ambulatorios con EPOC y validación del Instrumento colombiano de variabilidad de síntomas en EPOC (CoVaSy)

Introducción. Se considera que la variabilidad de los síntomas respiratorios de la enfermedad pulmonar obstructiva crónica (EPOC) es baja o inexistente. Sin embargo, algunos autores afirman que se pueden presentar fluctuaciones. Objetivos. Describir la variabilidad de síntomas en pacientes con EPOC a lo largo del día y la noche durante cuatro semanas mediante un diario de paciente y validar un cuestionario desarrollado para tal fin (el Instrumento Colombiano Autoadministrado de Variabilidad de Síntomas en EPOC - EPOC-CoVaSy) Materiales y métodos. Estudio de cohorte realizado en 96 pacientes con EPOC atendidos entre junio y diciembre de 2016 en el Centro de Atención Pulmonar - CAP, en Barranquilla, Colombia, quienes diligenciaron un diario de paciente durante cuatro semanas y, luego de este periodo, el instrumento auto administrado EPOC-CoVaSy. La independencia y comparación de frecuencias de las variables categóricas y continuas se establecieron mediante las pruebas χ² y exacta de Fisher y el coeficiente de correlación de Pearson, respectivamente. Se realizó un MANOVA, utilizando modelos de regresión lineal, para determinar las correlaciones entre los resultados del diario y el instrumento. Resultados. La edad promedio de los participantes fue 73.3±8.3 años y 71.87% eran hombres. Según el análisis de los diarios, los puntajes promedio (escala visual analógica) para todos los síntomas y desempeño de actividades diarias oscilaron entre 0.5 y 2.5 siendo más altos en la mañana (puntajes promedio entre 1.5 y 2.5) que en la tarde y noche (puntajes promedio entre 0.5 y 1.5), sin embargo esta variabilidad fue mínima, lo que coincidió con los resultados obtenidos en el EPOC-CoVaSy, evidenciándose una alta correlación entre ambos instrumentos, lo que permitió confirmar que la herramienta diseñada es útil para medir dicha variabilidad. Conclusiones. Con base en los hallazgos del presente estudio, se puede concluir que existe una leve variabilidad en los síntomas de EPOC a lo largo del día, la cual debe considerarse a la hora de establecer esquemas de tratamiento para esta enfermedad. Asimismo, se estableció que el EPOC-CoVaSy es válido para medir dicha variabilidad en la población colombiana con EPOC.

Exercise Capacity, Ventilatory Response, and Gas Exchange in COPD Patients With Mild to Severe Obstruction Residing at High Altitude

Background

Exercise intolerance, desaturation, and dyspnea are common features in patients with chronic obstructive pulmonary disease (COPD). At altitude, the barometric pressure (BP) decreases, and therefore the inspired oxygen pressure and the partial pressure of arterial oxygen (PaO₂) also decrease in healthy subjects and even more in patients with COPD. Most of the studies evaluating ventilation and arterial blood gas (ABG) during exercise in COPD patients have been conducted at sea level and in small populations of people ascending to high altitudes. Our objective was to compare exercise capacity, gas exchange, ventilatory alterations, and symptoms in COPD patients at the altitude of Bogotá (2,640 m), of all degrees of severity.

Methods

Measurement during a cardiopulmonary exercise test of oxygen consumption (VO₂), minute ventilation (VE), tidal volume (VT), heart rate (HR), ventilatory equivalents of CO₂ (VE/VCO₂), inspiratory capacity (IC), end-tidal carbon dioxide tension (PETCO₂), and ABG. For the comparison of the variables between the control subjects and the patients according to the GOLD stages, the non-parametric Kruskal–Wallis test or the one-way analysis of variance test was used.

Results

Eighty-one controls and 525 patients with COPD aged 67.5 ± 9.1 years were included. Compared with controls, COPD patients had lower VO₂ and VE (p < 0.001) and higher VE/VCO₂ (p = 0.001), A-aPO₂, and V_D/V_T (p < 0.001). In COPD patients, PaO₂ and saturation decreased, and delta IC (p = 0.004) and VT/IC increased (p = 0.002). These alterations were also seen in mild COPD and progressed with increasing severity of the obstruction.

Conclusion

The main findings of this study in COPD patients residing at high altitude were a progressive decrease in exercise capacity, increased dyspnea, dynamic hyperinflation, restrictive mechanical constraints, and gas exchange abnormalities during exercise, across GOLD stages 1–4. In patients with mild COPD, there were also lower exercise capacity and gas exchange alterations, with significant differences from controls. Compared with studies at sea level, because of the lower inspired oxygen pressure and the compensatory increase in ventilation, hypoxemia at rest and during exercise was more severe; PaCO₂ and PETCO₂ were lower; and VE/VO₂ was higher.

Mobile application for monitoring patients under home oxygen therapy: a protocol for a randomized controlled trial

BACKGROUND

Mobile technologies have become capable of changing the paradigm of healthcare services. A clear example is that, nowadays, these technologies are an important instrument for data collection processes, epidemiologic surveillance, health promotion and disease prevention. Therefore, technological tools should be exploited to optimize the monitoring of patients with chronic diseases, including patients who require home oxygen therapy.

PURPOSE

The purpose of this study is to determine the efficacy of a mobile application in the clinical monitoring of patients under home oxygen therapy.

METHODS

This is a randomized controlled trial includes subjects of 18 years or older diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who are under home oxygen therapy. Subjects will be divided into two arms: the intervention group will include patients who will be monitored with a mobile application, and the control group will include patients monitored by conventional follow-up methods (periodic visits of a respiratory therapist). The following outcome variables will be considered to measure the effect of the intervention: identification of dyspnea self-management, number of acute exacerbations associated with oxygen therapy, and the occurrence of oxygen supply underuse.

DISCUSSION

This study is expected to assess the efficacy of a mobile application in the follow up of patients under home oxygen therapy. It will also determine whether the monitoring of a six-month intervention by a team comprising a physician, a nurse and respiratory therapists can decrease acute exacerbations, determine the most appropriate oxygen dose, and identify the underuse of oxygen systems and supplies.

TRIAL REGISTRATION

The study has been registered at ClinicalTrials.gov ( NCT04820790 ; date of registration: March 29, 2021).

Quality of life and depression in COPD patients in the Colombian Caribbean

OBJECTIVE

To establish the association between quality of life and depression among COPD patients of the Colombian Caribbean.

METHOD

A cross-sectional study was carried out with the participation of adult COPD patients. COPD-related quality of life was quantified with the COPD Assessment Test (CAT) and depression using the Zung 10-item Self-rating Depression Scale (SDS-10). The relationship between COPD-related quality of life and depression with odds ratios (OR), crude and adjusted, was determined.

RESULTS

408 patients participated in the study. They were aged between 40 and 102 years (mean = 72.9, SD = 10.2) and 58.8% men. Two hundred eighty-four patients (69.6%) reported worse health status (CAT ≥10), and 114 patients (27.9%) scored for depression (SDS-10). Patients with worse health status presented more depression (OR = 5.85, 95% CI 3.01-11.36) and after adjusting for gender (OR = 5.70, 95% CI 2.92-11.13).

CONCLUSIONS

In patients with COPD and CAT ≥10, there is a five times greater risk of depression than patients with CAT <10. However, the relationship may be bidirectional. It is essential to specify the direction of causality in future investigations.

Biomarkers as a Prognostic Factor in COPD Exacerbation: A Cohort Study

The acute exacerbations of COPD (AECOPD) are one of the main causes of hospitalization and morbimortality in the adult population. There are not many tools available to predict the clinical course of these patients during exacerbations. Our goal was to estimate the clinical utility of C Reactive Protein (CRP), Mean Platelet Volume (MPV), eosinophil count and neutrophil/lymphocyte ratio (NLR) as in-hospital prognostic factors in patients with AECOPD. A prospective cohort study was conducted in patients who consulted three reference hospitals in the city of Medellín for AECOPD and who required hospitalization between 2017 and 2020. A multivariate analysis was performed to estimate the effect of biomarkers in the two primary outcomes: the composite outcome of in-hospital death and/or admission to the ICU and hospital length-of-stay. A total of 610 patients with a median age of 74 years were included; 15% were admitted to the ICU and 3.9% died in the hospital. In the multivariate analysis adjusted for confounding variables, the only marker significantly associated with the risk of dying or being admitted to the ICU was the NLR > 5 (OR: 3; CI95%: 1.5; 6). Similarly, the NLR > 5 was also associated to a lower probability of being discharged alive from the institution (SHR: 0.73; CI95%: 0.57; 0.94) and, therefore, a longer hospital stay. It was found that a neutrophil/lymphocyte ratio greater than 5 is a strong predictor of mortality or ICU admissions and a longer hospital stay in patients hospitalized with AECOPD.

Pulmonary hypertension in majority countries: opportunities amidst challenges

PURPOSE OF REVIEW

Pulmonary hypertension is a deadly disease, the causes of which vary between geographical regions. Eighty four percentage of the world's population lives in majority countries (also called low-income and middle-income countries), yet data on pulmonary hypertension in these settings are proportionally scarce. This article provides a review of pulmonary hypertension in majority countries, focusing in detail on the most common causes in these regions, and highlights contextual challenges faced.

RECENT FINDINGS

Epidemiological data confirms a complex and overlapping array of causes, with pulmonary hypertension because of conditions such as rheumatic heart disease, HIV, schistosomiasis, chronic lung disease and sickle cell disease. Delayed pulmonary hypertension diagnosis remains a concern and is ascribed to a lack of resources and lack of pulmonary hypertension awareness by health professionals. Pulmonary hypertension diagnosis is frequently considered once signs of right heart failure emerge, while echocardiography and right heart catheterization are unavailable in many settings. Accurate data on the prevalence of pulmonary hypertension in many of these regions are needed and could be achieved by establishing and frequent review of national databases where the incident and prevalent pulmonary hypertension cases are captured.

SUMMARY

There is urgent need for pulmonary hypertension advocacy among clinicians in the primary, secondary and tertiary healthcare sectors of majority countries, and validated noninvasive diagnostic algorithms are needed. Increased awareness and early diagnosis are likely to improve outcomes of pulmonary hypertension patients in these regions, and potentially stimulate locally relevant research.

Factors Associated with Chronic Obstructive Pulmonary Diseases in Nepal: Evidence from a Nationally Representative Population-Based Study

Background

The Global Burden of Diseases Study 2017 predicted that chronic obstructive pulmonary disease (COPD) is the second leading cause of death, the fourth leading cause of premature death, and the third cause for DALYs lost in Nepal. However, data on the population-based prevalence of COPD in Nepal are very limited. This study aims to assess the prevalence of COPD and factors associated with the occurrence of COPD in Nepal.

Methods

From a nationally representative, population-based cross-sectional study on chronic non-communicable diseases, the prevalence of COPD and its associated factors was determined. Of 12,557 participants aged over 20 years, 8945 participants completed a questionnaire and spirometry. Eligible participants were also asked to answer a COPD diagnostic questionnaire for screening COPD cases, and if needed underwent pre-bronchodilator and post-bronchodilator spirometry. COPD was defined as a post-bronchodilator FEV1/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio of <0.70. Multivariate logistic regression was performed to identify factors associated with COPD. Sampling weights were used for all data analyses.

Results

The prevalence of COPD in Nepal was 11.7% (95% CI: 10.5% to 12.9 %), which increased with age, and higher in those with a low educational level, those who had smoked ≥50 pack-years, persons having a low body mass index (BMI), and residents of Karnali province. Multivariate analysis revealed that being aged 60 years and above, having a low BMI, low educational status, having smoked more than 50 pack-years, provincial distribution, and ethnicity were independent predictors of COPD.

Conclusion

COPD is a growing and serious public health issue in Nepal. Factor such as old age, cigarette smoking, low educational attainment, low BMI, ethnicity, and locality of residence (province-level variation) plays a vital role in the occurrence of COPD. Strategies aimed at targeting these risk factors through health promotion and education interventions are needed to decrease the burden of COPD.

Effects of Pulmonary Rehabilitation in Men Compared to Women with Chronic Obstructive Pulmonary Disease in Colombia

Objective: To determine the effects of pulmonary rehabilitation in men and women with a COPD diagnosis in a Colombian clinic. Method: A longitudinal and descriptive study was conducted with 75 COPD patients who entered a pulmonary rehabilitation program during 2018 and 2019. The population was divided into groups according to gender and some sociodemographic characteristics were assessed, such as spirometry expressed in percentage of the predicted value, body mass index, mMRC dyspnea, and capacity for physical exercise, as well as some physiological variables with the six-minute walk test, anxiety-depression (HADS) and quality of life (SGRQ). A p-value<0.05 was considered statistically significant. Results: The cigarette packs smoked per year index was higher in men, 34±29.11 (p<0.001), whereas the exposure to firewood smoke was five times higher in women (p=0.037). All the variables related to the capacity for physical exercise improved significantly (p<0.021), with distance covered standing out: 63.26±60.03 vs. 51.53±61.02 in favor of women. mMRC dyspnea was initially higher in women when compared to men, 0.709±0.287, and presented a greater change in women with 1.294±0.415 when compared to men, 0.736±0.880, at the end of pulmonary rehabilitation. Conclusion: Pulmonary rehabilitation in women shows an increase of 63.26 meters in the distance covered and a 1.294-point reduction in dyspnea; while, for men, these figures were 51.53 meters and 0.736 points, respectively, as well as an improvement in quality of life in men by 11.47 SGRQ points when compared to women: 0.600.

Profile and preliminary results of Iranian sub cohort chronic obstructive pulmonary disease (COPD) in Shahrekord PERSIAN cohort in southwest Iran

Background

Chronic obstructive pulmonary disease (COPD) is a chronic and complex respiratory disorder associated with airflow limitation and increased inflammatory response of the lungs to harmful particles. The purpose of this original study was to describe the results and profile of the Shahrekord Prospective Epidemiological Research Studies in IrAN (PERSIAN) regarding COPD in southwestern Iran.

Methods

This study of asthma and respiratory diseases is a subcohort of the more extensive cohort study, i.e., Shahrekord PERSIAN cohort, a population-based prospective study on people aged 35–70 years in southwestern Iran (n = 10,075). The sample size of the subcohort was 8500 people. Annual follow-ups (person-year) of the cohort were designed to be conducted up to 2036. The instruments to collect data on various exposures were derived from the questionnaires previously developed in extensive multinational studies (occupational exposures, smoking, housing status, and fuel consumption, history of respiratory and chronic diseases, comorbidity, etc.). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the lower limit of normal (LLN) spirometric criteria were used to confirm COPD diagnosis.

Results

The response rate was 93.85%. The mean age of the participants was 49.48 ± 9.32; 47.9% were male, and 52.9% were female; nearly 16% of the population was current smokers; the fuel used by most of the participants for heating the house and cooking was gas. The most common comorbidity among participants was dyslipidemia; 30% of people have three or more comorbidities. According to GOLD and LLN criteria, the Prevalence of COPD was 3.6% and 8.4%, respectively. 4.3% of the participants had a history of chronic lung disease. The group of subjects with COPD had higher mean age, fewer years of schooling, a higher percentage of smokers with a smoking history of 10 or more pack years. 4.6% of patients had a history of chronic lung disease, 17.6% had a history of asthma in childhood, and 5.2% had a family history of respiratory and pulmonary diseases.

Conclusion

Epidemiological research is necessary to create an appropriate framework to fight COPD. This framework requires a better description of men and women at risk of developing COPD and describing people with early-stage illnesses.

Improving lung health in low-income and middle-income countries: from challenges to solutions

Low-income and middle-income countries (LMICs) bear a disproportionately high burden of the global morbidity and mortality caused by chronic respiratory diseases (CRDs), including asthma, chronic obstructive pulmonary disease, bronchiectasis, and post-tuberculosis lung disease. CRDs are strongly associated with poverty, infectious diseases, and other non-communicable diseases (NCDs), and contribute to complex multi-morbidity, with major consequences for the lives and livelihoods of those affected. The relevance of CRDs to health and socioeconomic wellbeing is expected to increase in the decades ahead, as life expectancies rise and the competing risks of early childhood mortality and infectious diseases plateau. As such, the World Health Organization has identified the prevention and control of NCDs as an urgent development issue and essential to the achievement of the Sustainable Development Goals by 2030. In this Review, we focus on CRDs in LMICs. We discuss the early life origins of CRDs; challenges in their prevention, diagnosis, and management in LMICs; and pathways to solutions to achieve true universal health coverage.

Pulmonary tuberculosis as a risk factor for chronic obstructive pulmonary disease: a systematic review and meta-analysis

Background

Prior pulmonary tuberculosis (TB) can cause permanent changes in lung anatomy and is associated with lung function loss. However, it remains unclear whether pulmonary function impairment owing to TB is associated with airflow obstruction, the hallmark of chronic obstructive pulmonary disease (COPD). The aim of this systematic review and meta-analysis was to assess the association and quantify the magnitudes of association between pulmonary TB and COPD, and to evaluate the prevalence of COPD in patients with prior pulmonary TB.

Methods

We searched the PubMed, Embase, and Web of Science databases for studies published from inception to January 1, 2020. Pooled effect sizes were calculated according to a random effects model or fixed effect model depending on heterogeneity. Specific subgroups (different diagnostic criteria, smoking status, income level) were examined.

Results

A total of 23 articles were included in this study. Compared with controls, patients with pulmonary TB had an odds ratios (ORs) of 2.59 [95% confidence interval (CI): 2.12-3.15; P<0.001] for developing COPD. In jackknife sensitivity analyses, the increased risk of prior pulmonary TB remained consistent for COPD; when the meta-analysis was repeated and one study was omitted each time, the ORs and corresponding 95% CIs were greater than 2. Funnel plots of ORs with Egger's linear regression (t=2.00, P=0.058) and Begg's rank correlation (Z=0.75, P=0.455) showing no significant publication bias. Subgroup analysis showed that the same conclusion was still present in never smokers (ORs 2.41; 95% CI: 1.74-3.32; P<0.001), patients with pulmonary TB diagnosed using chest X-ray (ORs 2.47; 95% CI: 1.23-4.97; P<0.001), and low- and middle-income country (LMIC) settings (ORs 2.70; 95% CI: 2.08-3.51; P<0.001). The pooled prevalence of COPD in patients with prior pulmonary TB was 21% (95% CI: 16-25%; P<0.001).

Conclusions

Individuals with prior pulmonary TB have an increased risk and high prevalence of COPD. Future studies identifying the underlying mechanisms for TB-associated COPD and therapeutic strategies are required.

Post-Tuberculosis Lung Disease: Clinical Review of an Under-Recognised Global Challenge

An estimated 58 million people have survived tuberculosis since 2000, yet many of them will suffer from post-tuberculosis lung disease (PTLD). PTLD results from a complex interplay between organism, host, and environmental factors and affects long-term respiratory health. PTLD is an overlapping spectrum of disorders that affects large and small airways (bronchiectasis and obstructive lung disease), lung parenchyma, pulmonary vasculature, and pleura and may be complicated by co-infection and haemoptysis. People affected by PTLD have shortened life expectancy and increased risk of recurrent tuberculosis, but predictors of long-term outcomes are not known. No data are available on PTLD in children and on impact throughout the life course. Risk-factors for PTLD include multiple episodes of tuberculosis, drug-resistant tuberculosis, delays in diagnosis, and possibly smoking. Due to a lack of controlled trials in this population, no evidence-based recommendations for the investigation and management of PTLD are currently available. Empirical expert opinion advocates pulmonary rehabilitation, smoking cessation, and vaccinations (pneumococcal and influenza). Exacerbations in PTLD remain both poorly understood and under-recognised. Among people with PTLD, the probability of tuberculosis recurrence must be balanced against other causes of symptom worsening. Unnecessary courses of repeated empiric anti-tuberculosis chemotherapy should be avoided. PTLD is an important contributor to the global burden of chronic lung disease. Advocacy is needed to increase recognition for PTLD and its associated economic, social, and psychological consequences and to better understand how PTLD sequelae could be mitigated. Research is urgently needed to inform policy to guide clinical decision-making and preventative strategies for PTLD.

Prevalence and Risk Factors for COPD at High Altitude: A Large Cross-Sectional Survey of Subjects Living Between 2,100-4,700 m Above Sea Level

Aim of Study: Four hundred million people live at high altitude worldwide. Prevalence and risk factors for COPD in these populations are poorly documented. We examined the prevalence and risk factors for COPD in residents living at an altitude of 2,100–4,700 m.

Methods: We performed a cross-sectional survey in Xinjiang and Tibet autonomous region. A multistage stratified sampling procedure was used to select a representative population aged 15 years or older from eight high altitude regions. All participants underwent pre- and post-bronchodilator measurement of forced expiratory volumes. COPD was diagnosed according to 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria.

Results: Between June, 2015 and August 2016, 4,967 subjects were included. Median age was 38.0 years (range: 15–91 years; inter-quartile range: 28–49 years); 51.4% participants were female. Overall prevalence of spirometry-defined COPD was 8.2% (95% CI 7.4–8.9%): 9.3% in male (95% CI 8.2–10.4%), and 7.1% in female (95% CI 6.1–8.2%). By multivariable logistic regression analysis, COPD was significantly associated with being aged ≥40 years (odds ratio: 2.25 [95% CI 1.72–2.95], P < 0.0001), exposure to household air pollution (OR: 1.34 [95% CI 1.01–1.79], P = 0.043), and a history of tuberculosis (OR: 1.79 [95% CI 1.23–2.61], P = 0.030), while living at a higher altitude (OR: 0.45 [95% CI 0.33–0.61], P < 0.0001) and having a higher educational level (OR: 0.64 [95% CI 0.43–0.95], P = 0.025) were associated with a lower prevalence of COPD.

Conclusions: Our results show that the spirometry-defined COPD is a considerable health problem for residents living at high altitudes and COPD prevalence was inversely correlated with altitude. Preventing exposure to household air pollution and reducing the incidence of tuberculosis should be public health priorities for high altitude residents.

Validation of chronic obstructive pulmonary disease severity score (COPDSS) for primary care in a Colombian population

Introducción.

La enfermedad pulmonar obstructiva crónica (EPOC) es un importante problema de salud mundial con una alta morbimortalidad. Se requiere la medición de la gravedad de la enfermedad mediante una herramienta de fácil aplicación, bajo costo y fácil disponibilidad en áreas rurales.

Objetivo.

Evaluar la validez y contabilidad del puntaje de valoración de la gravedad de la EPOC (Chronic Obstructive Pulmonary Disease Severity Score, COPDSS) en una población de atención primaria en Colombia.

Materiales y métodos.

Se hizo un estudio de corte transversal en una muestra de 100 pacientes con diagnóstico de EPOC según las guías GOLD. La validez concurrente se evaluó correlacionando los resultados del COPDSS con otras variables de importancia como las del cuestionario sobre la enfermedad respiratoria crónica (Chronic Respiratory Disease Questionnaire, CRQ) y el volumen espiratorio forzado en el primer segundo (Forced Expiratory Volume in one second, FEV₁).

Resultados.

El COPDSS presentó una correlación significativa con el FEV₁ (r=-0,33), con el CRQ (r=-0,57) y sus dimensiones: disnea (r=0,51), fatiga (r=0,53), función emocional (r=0,43) y control de la enfermedad (r=0,50). En el análisis factorial se determinó un solo factor con una varianza acumulada de 59,1 %. El análisis de coherencia interna mostró un alfa de Cronbach de 0,76, valor este considerado adecuado.

Conclusiones.

Se observó que el uso del COPDSS como cuestionario de valoración de la gravedad de pacientes con EPOC en Colombia tenía validez y confiabilidad adecuadas y que es de fácil aplicación en la atención primaria.

Highlights of an Expert Advisory Board on Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AE-COPD) in Latin America

Background

Chronic obstructive pulmonary disease (COPD) is a preventable and usually progressive lung disease that affects millions of people worldwide and is the sixth leading cause of death in the Americas. Viral and bacterial respiratory tract infections and air pollution may cause acute exacerbations of COPD (AE-COPD) ranging from mild, moderate to severe. The greatest proportion of the overall COPD burden on the health system is due to disease exacerbations. There is limited evidence regarding the etiology and burden of AE-COPD in Latin America (LATAM).

Methods

To respond to this gap in evidence, an Advisory Board with regional pneumologists and infectious disease experts was convened in September 2018 in Panama City, Panama, to: 1) review the burden of AE-COPD in LATAM; 2) evaluate the etiology of AE-COPD in LATAM; and 3) assess and compare the local/regional guidelines to confirm the etiology, characterize, and manage AE-COPD.

Results

The results of the meeting showed that there is a high prevalence of AE-COPD in LATAM countries, limited evidence on etiology data, and discrepancies in the case definitions and symptomology (ie, severity) classifications used in LATAM.

Conclusion

The Advisory Board discussions further resulted in recommendations for future research on the impact on the epidemiology and burden of disease, on establishing standardized AE-COPD case definition guidelines, and on studying the etiology of both moderate and severe AE-COPD cases.

Prevalence of Chronic Bronchitis and Respiratory Health Profile of a Population Exposed to Wood Smoke in Nicaragua

BACKGROUND

Household air pollution (HAP) is one of the most important environmental risk factors worldwide associated with chronic respiratory diseases.

OBJECTIVES

The present study focused on respiratory health in a population with high wood smoke exposure in Nicaragua.

METHODS

We employed a cross-sectional study with 213 participants. Data on the prevalence of chronic bronchitis (chronic bronchitis), chronic obstructive pulmonary disease (COPD) and asthma, including respiratory scores and pulmonary function tests, were documented. The role of risk factors for chronic bronchitis was analyzed.

RESULTS

We found a high prevalence of chronic airway diseases in the population exposed to wood smoke. A higher prevalence of chronic bronchitis was found in persons serving as primary cooks in households. Further confounding factors for chronic bronchitis included age, a prior diagnosis of asthma, inhalational allergies and lower socioeconomic status. Respiratory scores were elevated in individuals with chronic bronchitis.

CONCLUSIONS

This is one of the first studies in a wood smoke-exposed population in Nicaragua showing a high prevalence of chronic bronchitis and COPD with an emphasis on the analysis of personal and environmental risk factors. Further studies are needed to address which combination of interventions is most efficient for ameliorating respiratory health hazards.

PARTICIPANT CONSENT

Obtained.

ETHICS APPROVAL

The study protocol was approved by the Ethics Committee of the University of Luebeck, Germany (reference number 12-214), and by the Ethics Committee of the Department of Medical Sciences at National Autonomous University of Nicaragua, Managua, Nicaragua.

COMPETING INTERESTS

The authors declare no competing financial interests.

Transition from Restrictive to Obstructive Lung Function Impairment During Treatment and Follow-Up of Active Tuberculosis

Background

Pulmonary tuberculosis (PTB) is associated with many forms of chronic lung disease including the development of chronic airflow obstruction (AFO). However, the nature, evolution and mechanisms responsible for the AFO after PTB are poorly understood. The aim of this study was to examine the progression of changes in lung physiology in patients treated for PTB.

Methods

Immunocompetent, previously healthy, adult patients receiving ambulatory treatment for a first episode of tuberculosis were prospectively followed up with serial lung physiology and quantitative computed tomography (CT) lung scans performed at diagnosis of tuberculosis, 2, 6, 12 and 18 months during and after the completion of treatment.

Results

Forty-nine patients (median age 26 years; 37.2% males) were included, and 43 were studied. During treatment, lung volumes improved and CT fibrosis scores decreased, but features of AFO and gas trapping emerged, while reduced diffusing capacity (DLco) seen in a majority of patients persisted. Significant increases in total lung capacity (TLC) by plethysmography were seen in the year following treatment completion (median change 5.9% pred., P<0.01) and were driven by large increases in residual volume (RV) (median change +19%pred., P<0.01) but not inspiratory capacity (IC; P=0.41). The change in RV/TLC correlated with significant progression of radiological gas trapping after treatment (P=0.04) but not with emphysema scores. One year after completing treatment, 18.6% of patients had residual restriction (total lung capacity, TLC <80%pred), 16.3% had AFO, 32.6% had gas trapping (RV/TLC>45%), and 78.6% had reduced DLco.

Conclusion

Simple spirometry alone does not fully reveal the residual respiratory impairments resulting after a first episode of PTB. Changes in physiology evolve after treatment completion, and these findings when taken together, suggest emergence of gas trapping after treatment likely caused by progression of small airway pathology during the healing process.

Prevalence of chronic obstructive pulmonary disease at high altitude: a systematic review and meta-analysis

Background and objective

Recently, several studies have investigated the prevalence of chronic obstructive pulmonary disease (COPD) at high altitude (>1,500 m). However, much remains to be understood about the correlation between altitude and COPD. We aimed to summarize the prevalence of COPD at high-altitudes and find out if altitude could be a risk factor for COPD.

Methods

We searched PubMed/Medline, Cochrane Library, Web of Science, SCOPUS, OVID, Chinese Biomedical Literature Database (CBM) and Embase databases from inception to April 30th, 2019, with no language restriction. We used STATA 14.0 to analyze the extracted data. A random-effect model was used to calculate the combined OR and 95% CI. Heterogeneity was assessed by the I² statistic versus P-value. We performed a subgroup analysis to analyze possible sources of heterogeneity. The Egger’s test and the Begg’s test were used to assess any publication bias.

Results

We retrieved 4,574 studies from seven databases and finally included 10 studies (54,578 participants). Males ranged from 18.8% to 49.3% and the population who smoked ranged from 3.3% to 53.3%. The overall prevalence of COPD at high-altitude was 10.0% (95% CI [0.08–0.12], P < 0.001). In a subgroup analysis, based on different regions, the results showed that the prevalence in Asia was higher than that in Europe and America. Seven studies compared the relationship between the prevalence of COPD at high-altitudes and the lowlands. The results showed that altitude was not an independent risk factor for the prevalence of COPD (OR_adj = 1.18, 95% CI [0.85–1.62], P = 0.321). There was no publication bias among the studies.

Conclusions

Our study found a higher prevalence of COPD at high-altitudes than those from average data. However, altitude was not found to be an independent risk factor for developing COPD (PROSPERO Identifier: CRD42019135012).

Spirometry results after treatment for pulmonary tuberculosis: comparison between patients with and without previous lung disease: a multicenter study

OBJECTIVE

To compare patients with and without previous lung disease, in terms of the spirometry results after they had been treated for pulmonary tuberculosis (PTB) and cured, as well as to analyze risk factors related to functional severity.

METHODS

This was a cross-sectional, multicenter study conducted at four referral centers in Brazil. Patients were divided into two groups: those with a history of lung disease or smoking (LDS+ group); and those with no such history (LDS- group). Patients underwent spirometry (at least six months after being cured). Sociodemographic and clinical data were collected.

RESULTS

A total of 378 patients were included: 174 (46.1%) in the LDS+ group and 204 (53.9%) in the LDS- group. In the sample as a whole, 238 patients (62.7%) had spirometric changes. In the LDS+ group, there was a predominance of obstructive lung disease (in 33.3%), whereas restrictive lung disease predominated in the LDS- group (in 24.7%). Radiological changes were less common in the LDS- group than in the LDS+ group (p < 0.01), as were functional changes (p < 0.05). However, of the 140 (79.1%) LDS- group patients with a normal or minimally altered chest X-ray, 76 (54%) had functional changes (p < 0.01). The risk factors associated with functional severity in the LDS- group were degree of dyspnea (p = 0.03) and moderate or severe radiological changes (p = 0.01).

CONCLUSIONS

Impaired pulmonary function is common after treatment for PTB, regardless of the history of lung disease or smoking. Spirometry should be suggested for patients who develop moderate/severe dyspnea or relevant radiological changes after treatment for PTB.

18-kDa Translocator Protein Ligands Protect H9C2 Cardiomyocytes from Cigarette Smoke-induced Cell Death: In Vitro Study

BACKGROUND

Cigarette smoke (CS) can induce cellular damage via alterations in 18 kDa translocator protein (TSPO)-related functions, leading to cardiovascular diseases. The current study focused on the possible protective effect of TSPO ligands against CS-induced damage to cardiac cells.

MATERIALS AND METHODS

H9C2 Cardiomyocyte cell line of rat origin was pre-treated with TSPO ligands. Cell death, TSPO binding, and TSPO protein expression levels were assessed following 30-min CS exposure with/without TSPO ligands.

RESULTS

CS exposure of H9C2 cells significantly incensed cell death (by 26%, p<0.001). Pre-treatment with TSPO ligands at two concentrations prevented cell death. Neither CS nor ligands affected TSPO protein expression in H9C2 cells. CS led to increased cell death and reduced TSPO binding.

CONCLUSION

Reduced TSPO binding may have a role in CS-induced cell death, and TSPO ligand MGV-1 can prevent suppression of TSPO binding and corresponding cell death. These results may be relevant to treatment of cardiovascular diseases associated with CS.

Risk of COPD due to indoor air pollution from biomass cooking fuel: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality in developing nations. In this meta-analysis, we aimed to determine the association between indoor air pollution and risk of COPD. Database searches were conducted using indoor air pollution, biomass and COPD related terms to identify relevant articles. The eligible studies were case-control, retrospective cohort, cross-sectional studies and conducted in adults that assessed COPD using any diagnostic criteria. A total of 35 studies with 73,122 participants were included. The pooled analysis showed that exposure to indoor air pollution due to solid biomass fuels increased risk of COPD by 2.65 (95% confidence interval [CI] 2.13-3.31; n = 73,122) and chronic bronchitis by 2.89 (95% CI 2.18-3.82) times more compared to non-biomass fuels. The risk of COPD was higher in Africa region (odds ratio [OR] 3.19), Asia (OR 2.88), South America (OR 2.15), Europe (OR 2.30) and North America (OR 2.14). The results of our meta-analysis indicated that exposure to indoor air pollution due to biomass smoke is strongly associated with COPD.Abbreviations: CS: cross-sectional; CC: case-control; NR: not reported; ATS: American Thoracic Society; BMRC: British Medical Research Council; GOLD: Global Initiative for Obstructive Lung Disease; IAP: indoor air pollution; BMF: biomass fuel; CB: chronic bronchitis; OR: odds ratio; UCI; upper confidence interval; LCI: lower confidence interval; COPD: chronic obstructive pulmonary disease.