Daily Peak Expiratory Flow Rate and Disease Instability in Chronic Obstructive Pulmonary Disease

Screening performance of COPD-PS scale, COPD-SQ scale, peak expiratory flow, and their combinations for chronic obstructive pulmonary disease in the primary healthcare in Haicang District, Xiamen City

Objectives

This study aimed to evaluate the screening performance of COPD-PS questionnaire, COPD-SQ questionnaire, peak expiratory flow (PEF), COPD-PS questionnaire combined with PEF, and COPD-SQ questionnaire combined with PEF for chronic obstructive pulmonary disease (COPD).

Methods

This was a cross-sectional study. We distributed self-designed surveys and COPD screening scales (COPD-PS questionnaire and COPD-SQ questionnaire) to residents who underwent physical examination in five community health centers in Haicang District, Xiamen City, from February 2023 to May 2023, and measured their lung function and PEF with a portable device. We used logistic regression to obtain the coefficients of COPD-PS questionnaire, COPD-SQ questionnaire, and PEF, and plotted the receiver operating characteristic curves of each tool for diagnosing COPD and moderate-to-severe COPD. We evaluated and compared the optimal cut-off points and scores of sensitivity, specificity, Youden index, and area under the curve (AUC) values, and assessed the screening efficiency of different methods.

Results

Of the 3,537 residents who completed the COPD-SQ questionnaire, COPD-PS questionnaire, and spirometry, 840 were diagnosed with COPD. We obtained the coefficients of COPD-PS questionnaire combined with peak expiratory flow (PEF), and COPD-SQ questionnaire combined with PEF, by logistic regression as -0.479-0.358 × PEF +0.321 × COPD-PS score and - 1.286-0.315 × PEF +0.125 × COPD-SQ score, respectively. The sensitivity of diagnosing COPD by COPD-SQ questionnaire, COPD-PS questionnaire, PEF, COPD-PS questionnaire combined with PEF, and COPD-SQ questionnaire combined with PEF were 0.439, 0.586, 0.519, 0.586, 0.612 respectively, and the specificity were 0.725, 0.621, 0.688, 0.689, 0.663 respectively, with ROC values of 0.606 (95%CI: 0.586-0.626), 0.640 (0.619-0.661), 0.641 (0.619-0.663), 0.678 (0.657-0.699), 0.685 (0.664-0.706) respectively. The sensitivity of diagnosing GOLD II and above by COPD-SQ questionnaire, COPD-PS questionnaire, PEF, COPD-PS questionnaire combined with PEF, and COPD-SQ questionnaire combined with PEF were 0.489, 0.620, 0.665, 0.630, 0.781 respectively, and the specificity were 0.714, 0.603, 0.700, 0.811, 0.629 respectively, with ROC values of 0.631 (95%CI: 0.606-0.655), 0.653 (0.626-0.679), 0.753 (0.730-0.777), 0.784 (0.762-0.806), 0.766 (0.744-0.789) respectively.

Conclusion

Our study found that the accuracy of COPD screening by COPD-SQ questionnaire and COPD-PS questionnaire can be improved by combining the results of PEF. The screening performance of COPD-SQ questionnaire combined with PEF is relatively better. In future research, further studies are needed to optimize the performance of screening tools and understand whether their use will affect clinical outcomes.

How can we identify subglottic stenosis in patients with suspected obstructive disease?

PURPOSE

Subglottic stenosis, a rare condition of the upper airway, is frequently misdiagnosed as obstructive lung disease. The aim of this study was to investigate whether subglottic stenosis could be identified and distinguished from asthma and chronic obstructive pulmonary disease (COPD) using spirometry or the dyspnea index (DI).

METHODS

The study population included 43 patients with asthma, 31 patients with COPD and 50 patients with subglottic stenosis planned to undergo endoscopic intervention. All patients completed the DI and underwent dynamic spirometry registering both inspiratory and expiratory volumes and flows, including the expiratory disproportion index (EDI), the ratio of forced expiratory volume in 1 s to peak expiratory flow. One-way analysis of variance assessed the discrepancy of the variables among the study groups, and receiver operating curve (ROC) analysis determined the measurement with the best discriminatory power providing a cutoff value, maximizing both sensitivity and specificity.

RESULTS

The only statistically significant variables differing between all three groups were the EDI and the DI. The EDI showed an excellent area under the ROC curve (0.99, p < 0.001) with a cutoff value of 0.39 (98% sensitivity, 96% specificity), followed by DI (0.87, p < 0.001) with a cutoff score of > 25 (83% sensitivity and 78% specificity).

CONCLUSION

In patients with dyspnea of unknown cause, an increase in EDI should arouse a suspicion of extrathoracic airway obstruction, advocating for further evaluation with laryngotracheoscopy.

The Role of Pulmonary Function Testing in the Diagnosis and Management of COPD

Pulmonary function testing (PFT) has a long and rich history in the definition, diagnosis, and management of COPD. For decades, spirometry has been regarded as the standard for diagnosing COPD; however, numerous studies have shown that COPD symptoms, pathology, and associated poor outcomes can occur, despite normal spirometry. Diffusing capacity and imaging studies have called into question the need for spirometry to put the "O" (obstruction) in COPD. The role of exercise testing and the ability of PFTs to phenotype COPD are reviewed. Although PFTs play an important role in diagnosis, treatment decisions are primarily determined by symptom intensity and exacerbation history. Although a seminal study positioned FEV1 as the primary predictor of survival, numerous studies have shown that tests other than spirometry are superior predictors of mortality. In years past, using spirometry to screen for COPD was promulgated; however, this only seems appropriate for individuals who are symptomatic and at risk for developing COPD.

Accuracy of portable spirometers in the diagnosis of chronic obstructive pulmonary disease A meta-analysis

Portable spirometers has been approved for diagnosing chronic obstructive pulmonary disease (COPD). However, their diagnostic accuracy has not been reviewed. Therefore, the purpose of this study was to systematically evaluate the diagnostic value of portable spirometers in detecting COPD. A comprehensive literature search for relevant studies was conducted in PubMed, Embase, CNKI, Wan Fang, and Web of Science databases. Pooled sensitivity, specificity, summary receiver operating characteristic (SROC), area under the curve (AUC), and other related indices were calculated using the bivariate mixed-effect model. Subgroup analysis was performed to explore the source of heterogeneity. Thirty one studies were included in the meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic ratio (DOR), SROC, and AUC of the SROC of portable spirometers were 0.85 (0.81–0.88), 0.85 (0.81–0.88), 5.6 (4.4–7.3), 0.18 (0.15–0.22), 31 (21–46) and 0.91 (0.89–0.94), respectively. Among the three commonly used types of portable spirometers, the accuracy of PIKO-6 was higher (0.95) than that of COPD-6 (0.91) and PEF (0.82). Subgroup analysis indicated that the accuracy of a multi-indices portable spirometer was higher than that of a single-index one (P < 0.05). In addition, portable spirometry performed by professional technicians in tertiary hospitals was more accurate than for those conducted by trained technicians in primary care facilities and communities (P < 0.05). Moreover, the accuracy of studies conducted in developing country was superior to developed country (P < 0.05). Portable spirometers have high accuracy in the diagnosis of COPD. Multi-index COPD-6 and PIKO-6 displayed higher accuracy than others. Standardized training of instrument operators should be considered to achieve reliable results.

Chronic Low-dose Exposure to Highly Toxic Gas Phosgene and Its Effect on Peak Expiratory Flow Rate

INTRODUCTION

Phosgene is a highly toxic gas causing irritation of the airways and eyes though at high dose exposure. The effect on airways can be assessed by peak expiratory flow rate (PEFR) which is a cheaper, simple, and easy to perform test under field conditions and routine monitoring. Thus, this study is undertaken to understand the effect of chronic low-dose phosgene exposure on PEFR and the associated factors.

METHODS

This study included 287 workers of phosgene production and captive units. After recording the demographic, occupational, and clinical history on a questionnaire, every participant was subjected to clinical examination, chest radiography, and measurement of PEFR using Spirovit SP-10.

RESULTS

The mean age and mean duration of the job of participants was 42.8 ± 10.4 years and 18.9 ± 9.6 years, respectively. The PEFR was significantly reduced with increasing age, increasing duration in the job, and those having direct exposure.

CONCLUSION

PEFR is affected by chronic low-dose exposure to phosgene.

Determinants of Self-Rated Health Among Middle-Aged and Elderly Patients with COPD: The China Health and Retirement Longitudinal Study

This study aimed to assess self-rated health (SRH) status and its determinants in patients with chronic obstructive pulmonary disease (COPD). Participants aged at least 45 years were included from a nationally representative investigation in 2015. The SRH assessment was divided into two groups: "good" and "not good." Independent samples t-tests, chi-square tests, and Fisher's exact tests were used to determine differences in patient characteristics between the two groups. Multiple logistic models were used to determine factors influencing SRH. A total of 1,215 patients with COPD were included in the final analysis, of whom 21.2% reported favorable SRH status. The results indicated that female gender, non-smoking, and elevated peak expiratory flow correlated with better SRH, while nighttime sleep duration less than 7 hours, asthma, and disability, negatively impacted SRH. Our findings provide new evidence for the development of effective health promotion programs for the well-being of patients with COPD.

Going beyond the mean in examining relationships of adolescent non-cognitive skills with health-related quality of life and biomarkers in later-life

Several studies have established associations between early-life non-cognitive skills and later-life health and health behaviours. However, no study addresses the more important policy concern about how this relationship varies along the health distribution. We use unconditional quantile regression to analyse the effects of adolescent non-cognitive skills across the distributions of the health-related quality of life at age 50 and biomarkers at age 45 years. We examine the effects of measures of conscientiousness, agreeableness and neuroticism recorded at age 16 for 3585 individuals from the National Child Development Study. Adolescent conscientiousness is positively associated with ability to cope with stress and negatively associated with risk of cardiovascular disease in middle-age. Adolescent agreeableness is associated with higher health-related quality of life and lower physiological 'wear and tear', but negatively associated with ability to cope with stress in middle-age. Adolescent neuroticism is associated with lower health-related quality of life, higher physiological 'wear and tear', and a higher risk of cardiovascular disease in middle-age. All of these associations are stronger at the lower end of the health distribution except for the cardiovascular risk biomarkers. These associations are robust to correcting for attrition using inverse probability weighting and consistent with causal bounds assuming proportional selection on observables and unobservables. They suggest policies that improve non-cognitive skills in adolescence could offer most long-term health benefit to those with the poorest health.

Clinical, laboratory, and functional characteristics of asthma-COPD overlap in patients with a primary diagnosis of COPD

OBJECTIVE

To evaluate the frequency of asthma-COPD overlap (ACO) in patients with COPD and to compare, from a clinical, laboratory, and functional point of view, patients with and without ACO, according to different diagnostic criteria.

METHODS

The participants underwent evaluation by a pulmonologist, together with spirometry and blood tests. All of the patients were instructed to record their PEF twice a day. The diagnosis of ACO was based on the Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar (PLATINO, Latin American Project for the Investigation of Obstructive Lung Disease) criteria, the American Thoracic Society (ATS) Roundtable criteria, and the Spanish criteria. We investigated patient histories of exacerbations and hospitalizations, after which we applied the COPD Assessment Test and the modified Medical Research Council scale, to classify risk and symptoms in accordance with the GOLD criteria.

RESULTS

Of the 51 COPD patients, 14 (27.5%), 8 (12.2%), and 18 (40.0) were diagnosed with ACO on the basis of the PLATINO, ATS Roundtable, and Spanish criteria, respectively. The values for pre-bronchodilator FVC, post-bronchodilator FVC, and pre-bronchodilator FEV1 were significantly lower among the patients with ACO than among those with COPD only (1.9 ± 0.4 L vs. 2.4 ± 0.7 L, 2.1 ± 0.5 L vs. 2.5 ± 0.8 L, and 1.0 ± 0.3 L vs. 1.3 ± 0.5 L, respectively). When the Spanish criteria were applied, IgE levels were significantly higher among the patients with ACO than among those with COPD only (363.7 ± 525.9 kU/L vs. 58.2 ± 81.6 kU/L). A history of asthma was more common among the patients with ACO (p < 0.001 for all criteria).

CONCLUSIONS

In our sample, patients with ACO were more likely to report previous episodes of asthma and had worse lung function than did those with COPD only. The ATS Roundtable criteria appear to be the most judicious, although concordance was greatest between the PLATINO and the Spanish criteria.

Remote Patient Monitoring for the Detection of COPD Exacerbations

Background

COPD exacerbations occur more frequently with disease progression and are associated with worse prognosis and higher healthcare expenditure.

Purpose

To utilize a networked system, optimized with statistical process control (SPC), for remote patient monitoring (RPM) and to identify potential predictors of COPD exacerbations.

Methods

Seventeen subjects, mean (SD) age of 69.7 (7.2) years, with moderate to severe COPD received RPM. Over 2618 patient-days (7.17 patient-years) of monitoring, we obtained daily symptom scores, treatment adherence, self-reported activity levels, daily spirometry (SVC, FEV₁, FVC, PEF), inspiratory capacity (IC), and oxygenation (SpO₂). These data were used to identify predictors of exacerbations defined using Anthonisen and other criteria.

Results

After implementation of SPC, concordance analysis showed substantial agreement between FVC (decrease below the 7-day rolling average minus 1.645 SD) and self-reported healthcare utilization events (κ=0.747, P<0.001) as well as between increased use of inhaled short-acting bronchodilators and exacerbations defined by two Anthonisen criteria (κ=0.611, P<0.001) or modified Anthonisen criteria (κ=0.622, P<0.001). There was a moderate agreement between FEV₁ (decrease >1.645 SD below the 7-day rolling average) and self-reported healthcare utilization events (κ=0.475, P<0.001) and between SpO₂ less than 90% and exacerbations defined by two Anthonisen criteria (κ=0.474, P<0.001) or modified Anthonisen criteria (κ=0.564, P<0.001).

Conclusion

Exacerbations were best predicted by FVC and FEV₁ below the one-sided 95% confidence interval derived from SPC but also by increased use of inhaled short-acting bronchodilators and fall in oxygen saturation. An RPM program that captures these parameters may be used to guide appropriate interventions aimed at reducing healthcare utilization in COPD patients.

Body Composition of Filipino Chronic Obstructive Pulmonary Disease (COPD) Patients in Relation to Their Lung Function, Exercise Capacity and Quality of Life

Background and objectives

The loss of muscle or fat free mass (FFM) as a result of systemic inflammation and poor nutrition in Chronic Obstructive Pulmonary Disease (COPD), is recognized as an important factor that influences symptoms and disease-related outcomes. To date, there are no data on body composition among Filipino COPD patients and how it impacts COPD disease severity. This paper examined the relationship of Fat Free Mass Index (FFMI = FFM/height) and sarcopenia with COPD disease severity variables.

Methods

This was a cross-sectional analytic study comparing low and normal FFMI, sarcopenic and nonsarcopenic COPD patients, in terms of lung function, exercise capacity, and quality of life score. Filipino COPD patients older than 40 years were included. Patients performed six minute walking distance (6MWD), handgrip strength (HGS), and quality of life status evaluation using Filipino version of COPD Assessment Test (CAT). Body composition was measured using bioelectrical impedance analysis (BIA).

Results

A total of 41 patients were included. The mean age was 69.22 years. The prevalence of being underweight and having sarcopenia was 32% and 46%, respectively. Point biserial correlation showed that COPD patients with low FFMI had a statistically significant reduction in peak inspiratory flow (r= -0.5791, P value 0.0002), peak expiratory flow (r= -0.4475, P value 0.0055), and handgrip strength (r= -0.4560, P value 0.0027); and lower CAT score (r= -0.3422, P value 0.0285). Similar findings were observed among sarcopenic COPD patients.

Conclusion

The prevalence of being underweight and having sarcopenia was high. Low FFMI results in reduction of lung function and upper limb muscle strength among Filipino COPD patients.

Preventing clinically important deterioration with single-inhaler triple therapy in COPD

Clinically important deterioration (CID) is a novel composite end-point (lung function, health status, exacerbations) for assessing disease stability in patients with chronic obstructive pulmonary disease (COPD). We prospectively analysed CID in the FULFIL study. FULFIL (ClinicalTrials.gov NCT02345161; randomised, double-blind, double-dummy, multicentre study) compared 24 weeks of once daily, single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) 100/62.5/25 µg with twice daily budesonide/formoterol (BUD/FOR) 400/12 μg in patients aged ≥40 years with symptomatic advanced COPD (Global Initiative for Chronic Obstructive Lung Disease group D). A subset of patients received study treatment for up to 52 weeks. Time to first CID event was assessed over 24 and 52 weeks using two approaches for the health status component: St George's Respiratory Questionnaire and COPD assessment test. FF/UMEC/VI significantly reduced the risk of a first CID event by 47-52% versus BUD/FOR in the 24- and 52-week populations using both CID definitions (p<0.001). The median time to first CID event was ≥169 days and ≤31 days with FF/UMEC/VI and BUD/FOR, respectively. Only stable patients with no CID at 24 weeks demonstrated sustained clinically important improvements in lung function and health status at 52 weeks versus those who had experienced CID. Once daily, single-inhaler FF/UMEC/VI significantly reduced the risk of CID versus twice daily BUD/FOR with a five-fold longer period without deterioration.