Impact of current cough on health-related quality of life in patients with COPD

Characteristics associated with SF-36 in alpha-1 antitrypsin deficiency-associated COPD: a cross-sectional analysis

BACKGROUND

Generic measures of health-related quality of life (HRQoL), such as the 36-Item Short Form Survey (SF-36), are widely used in assessing chronic conditions. These tools have an advantage over disease-specific instruments, as they allow comparisons across different health conditions and with the general population. In alpha-1 antitrypsin deficiency (AATD)-associated chronic obstructive pulmonary disease (COPD), HRQoL research remains scarce. This cross-sectional study evaluates the factors associated with HRQoL in a cohort of patients with AATD-associated COPD.

METHODS

Our study included participants of AlphaNet (2008-2019), a health management organization for people with AATD in the US who are prescribed augmentation therapy. Norm-based SF-36 scores for the mental and physical component summary scores (MCS and PCS, mean of 50 ± 10 in the general US population) and 8 individual scales were evaluated. Individuals with lung disease and data available on ≥1 measurement on any SF-36 scale and clinically relevant characteristics such as modified Medical Research Council (mMRC) scale, exacerbation frequency, productive cough, and use of oxygen were included in these analyses. Generalized linear regression models were fit to examine the association of baseline characteristics with MCS and PCS scores. Age, sex, regular use of oxygen, exacerbation frequency, mMRC, and productive cough were included in these models.

RESULTS

Participants (n=4398, mean age 57.6 [SD=10.6] years, 45.4% female) had a mean MCS score of 51.2 ± 10.8 and PCS of 36.3 ± 9.8. The average mMRC score was 2.4 ± 1.3, and 56.4% had 2 or more exacerbations per year. Overall, the physical component of SF-36 was more severely impacted compared to the mental component. In multivariable regression analyses, PCS scores were significantly associated with exacerbation frequency, mMRC, regular use of oxygen, and productive cough; MCS was associated with age, sex, exacerbation frequency, mMRC, and productive cough.

CONCLUSIONS

These findings demonstrate that patient-perceived physical health is significantly impaired in this cohort of people with AATD-associated COPD compared to mental health. Longitudinal studies are needed to evaluate the change in physical and mental health status over time in this population.

The clinical characteristics and outcomes of different inhaled therapies in chronic obstructive pulmonary disease patients with frequent cough

BACKGROUND

Cough is a common symptom in patients with chronic obstructive pulmonary disease (COPD). Patients with cough may exhibit various clinical characteristics and experience varying outcomes based on inhaled therapies they receive.

OBJECTIVES

This study aimed to explore the clinical characteristics and outcomes of various inhaled therapies in COPD patients with frequent cough.

METHODS

This was a multicenter, prospective cohort study. Of these patients, the median cough score in COPD assessment test (CAT) was two. Patients were classified into frequent cough group if they scored two or over in the first item of CAT and infrequent cough group otherwise. Patients with frequent cough were then divided into long-acting antimuscarinic (LAMA), long-acting beta2-agonist (LABA)/LAMA, inhaled corticosteroids (ICS)/LABA and ICS/LABA/LAMA groups. Minimum clinically important difference (MCID) (CAT scores decreased ≥2 from baseline) and the improvement of cough (cough score decreased ≥1 from baseline) were collected in the six-month follow-up. Frequent exacerbations (experiencing at least two exacerbations) were collected in the one-year follow-up.

RESULTS

Of 906 patients, 581 (64.1%) patients reported frequent cough at the initial visit. Frequent cough was associated with the current smokers and CAT scores (p < 0.05). The MCID showed no significant difference between frequent cough and infrequent cough groups in the follow-up. More patients with frequent cough experienced future frequent exacerbations compared to those with infrequent cough. After receiving inhaled therapies, 62% of patients with frequent cough got the cough improved. More patients with frequent cough treated with LABA/LAMA or ICS/LABA/LAMA attained MCID and fewer experienced exacerbations than those treated with LAMA or ICS/LABA (p < 0.05). The change in cough score showed no difference among various inhaled therapies in patients with frequent cough.

CONCLUSION

COPD patients with frequent cough were related to current smokers and higher CAT scores. These patients had a higher incidence of frequent exacerbations than those with infrequent cough. Patients with frequent cough who were treated with LABA/LAMA or ICS/LABA/LAMA were more likely to attain MCID and at a lower risk of exacerbation than those treated with LAMA or ICS/LABA.

Chronic cough associated with COPD exacerbation, pneumonia and death in the general population

Background

Chronic cough affects up to 10% of the general population and was previously perceived as a comorbidity of underlying conditions, but is nowadays classified as a disease in its own entity that could confer increased risk of morbidity and mortality. We tested the hypothesis that chronic cough is associated with increased risk of COPD exacerbation, pneumonia and all-cause mortality in the general population.

Methods

We identified 2801 individuals with chronic cough, defined as cough lasting >8 weeks, among 44 756 randomly selected individuals from the Copenhagen General Population Study, and recorded COPD exacerbations, pneumonia and all-cause mortality during follow-up.

Results

During up to 5.9 years of follow-up (median 3.4 years), 173 individuals experienced COPD exacerbation, 767 experienced pneumonia and 894 individuals died. Individuals with chronic cough versus those without had cumulative incidences at age 80 years of 12% versus 3% for COPD exacerbation, 30% versus 15% for pneumonia, and 25% versus 13% for death from all causes. After adjustment for age, sex and smoking, individuals with chronic cough versus those without had adjusted hazard ratios of 4.6 (95% CI 2.9-7.2) for COPD exacerbation, 2.2 (1.7-2.7) for pneumonia and 1.7 (1.4-2.0) for all-cause mortality. Among current smokers aged >60 years with airflow limitation, those with versus without chronic cough had an absolute 5-year risk of 10% versus 4% for COPD exacerbation, 16% versus 8% for pneumonia and 19% versus 12% for all-cause mortality.

Conclusion

Chronic cough is associated with higher risks of COPD exacerbation, pneumonia and death, independent of airflow limitation and smoking.

Current cough and sputum assessed by the cough and sputum assessment-questionnaire (CASA-Q) is associated with quality of life impairment in cystic fibrosis

BACKGROUND

Cough and sputum are major symptoms in cystic fibrosis (CF) that contribute to the impairment of quality of life.

METHODS

This prospective single centre cross-sectional pilot study aimed to evaluate the results of a self-administered questionnaire assessing cough and sputum symptoms (2 domains), and their impact (2 domains) on daily activities in the previous week, named the Cough and Sputum Assessment Questionnaire (CASA-Q) in CF adult patients at stable state, and to analyse associations with clinical, functional, microbiological, radiological data, and two quality of life scales: the Cystic Fibrosis Questionnaire Revised (CFQ-R) and the Saint George Respiratory Questionnaire (SGRQ).

RESULTS

Forty-eight patients were included in this analysis (69% men; median age of 27.8 ± 8.1 years; median body mass index of 21.8 + 3.3 kg/m²; mean FEV1 of 64 ± 30% of the predicted value). The mean values of the CASA-Q domains were 58 ± 23 for cough symptoms, 77 ± 24 for cough impact, 62 ± 25 for sputum symptoms and 84 ± 21 for sputum impact. Impairment in CASA-Q cough and sputum domains was associated with dyspnea mMRC scale (p < 0.005 for all 4 domains of CASA-Q) and exacerbations in the previous year (p < 0.05 for CASA-Q symptoms domains). We also found correlations between all domains of the CASA-Q and quality of life questionnaires including SGRQ (p < 0.001) and to a lesser extend CFQ-R. We identified a clinical phenotype (female gender, ΔF508 heterozygous mutation, dyspnea mMRC scale) associated with an impairment of CASA-Q score and quality of life using a 2-step cluster analysis.

CONCLUSIONS

CASA-Q allows the assessment of cough and sputum in CF adult patients and is associated with quality of life impairment. This simple easy-to-use tool could be used in routine clinical practice and in clinical studies to assess cough and sputum in CF patients.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov (NCT02924818, first posted on 5th October 2016).

[Bronchoscopic COPD treatments]

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is associated with disabling respiratory symptoms including dyspnea, frequent exacerbations and chronic bronchitis. The currently available pharmacological and non-pharmacological therapies have limited efficacy, necessitating the development of interventional strategies, many of them endoscopic.

STATE OF THE ART

Endoscopic lung volume reduction has markedly increased over recent years, principally as regards the endobronchial valves currently used in routine care. Indeed, multiple randomized trials have demonstrated a significant clinical benefit in a selected population identifiable due to the absence of interlobar collateral ventilation. Other endoscopic volume reduction techniques (polymers, thermal vapor, spirals) shall require additional studies before being considered as options in routine care. Targeted lung denervation (TLD) has aroused interest as a means of reducing exacerbations in the early phases of relevant studies. Endobronchial techniques (bronchoscopic cryospray, bronchial rheoplasty) are still at a very early stage of development, which is aimed at reducing the symptoms of chronic bronchitis.

OUTLOOK

Aside from endobronchial valves, which are currently employed in routine care, all the above-mentioned endoscopic techniques require additional studies in order to determine their benefit/risk balance and to identify the population that would benefit the most.

CONCLUSIONS

Endoscopic treatments constitute a major avenue of research and innovation in the therapeutic management of COPD. Inclusion of patients in disease registries and clinical trials remains essential, the objective being to gauge the interest of these treatments and their future role in everyday COPD management.

COPD exacerbations and patient-reported outcomes according to post-bronchodilator FEV1 - a post-hoc analysis of pooled data

BACKGROUND

Management strategies of chronic obstructive pulmonary disease (COPD) need to be tailored to the forced expiratory volume in one second (FEV₁₎, exacerbations, and patient-reported outcomes (PROs) of individual patients. In this study, we analyzed the association and correlation between the FEV₁, exacerbations, and PROs of patients with stable COPD.

METHODS

This was a post-hoc analysis of pooled data from two cross-sectional studies that were previously conducted in Malaysia from 2017 to 2019, the results of which had been published separately. The parameters measured included post-bronchodilator FEV₁ (PB-FEV₁), exacerbations, and scores of modified Medical Research Council (mMRC), COPD Assessment Test (CAT), and St George's Respiratory Questionnaire for COPD (SGRQ-c). Descriptive, association, and correlation statistics were used.

RESULTS

Three hundred seventy-four patients were included in the analysis. The PB-FEV₁ predicted was < 30% in 85 (22.7%), 30-49% in 142 (38.0%), 50-79% in 111 (29.7%), and ≥ 80% in 36 (9.6%) patients. Patients with PB-FEV₁ < 30% predicted had significantly more COPD exacerbations than those with PB-FEV₁ 30-49% predicted (p < 0.001), 50-79% predicted (p < 0.001), and ≥ 80% predicted (p = 0.002). The scores of mMRC, CAT, and SGRQ-c were not significantly higher in patients with more severe airflow limitation based on PB-FEV₁ (p = 0.121-0.271). The PB-FEV₁ predicted had significant weak negative correlations with exacerbations (r = - 0.182, p < 0.001), mMRC (r = - 0.121, p = 0.020), and SGRQ-c scores (r = - 0.114, p = 0.028). There was a moderate positive correlation between COPD exacerbations and scores of mMRC, CAT, and SGRQ-c (r = 0.407-0.482, all p < 0.001). There were significant strong positive correlations between mMRC score with CAT (r = 0.727) and SGRQ-c scores (r = 0.847), and CAT score with SGRQ-c score (r = 0.851) (all p < 0.001).

CONCLUSIONS

In COPD patients, different severity of airflow limitation was not associated with significant differences in the mMRC, CAT, and SGRQ-c scores. Exacerbations were significantly more frequent in patients with very severe airflow limitation only. The correlation between airflow limitation with exacerbations, mMRC, and SGRQ-c was weak.

Sputum-Rheology-Based Strategy for Guiding Azithromycin Prescription in COPD Patients with Frequent Exacerbations: A Randomized, Controlled Study (“COPD CARhE”)

(1) Background: We have previously shown that sputum rheology can discriminate between patients with COPD and other muco-obstructive lung diseases, and that it is correlated with mucin content and sputum eosinophilia. We now hypothesize that it could be a more-accurate guide than clinical evaluation for the prescription of azithromycin to prevent exacerbations of COPD and to reduce exposure to antibiotics; (2) Methods: “COPD CaRhe” is a multicentric, randomized, controlled trial comparing outcomes in two parallel arms (36 vs. 36 patients). Patients will be recruited in the university hospitals of Montpellier, Bordeaux, and Toulouse, in France, and they should have a diagnosis of COPD with frequent exacerbations (≥3/year). Enrollment will occur during a routine visit to a respiratory department, and follow-up visits will occur every 3 months for a period of 1 year. At each visit, a 3-month prescription of azithromycin will be provided to those patients who obtain a score of <70 on the Cough and Sputum Assessment Questionnaire (CASA-Q) or a critical stress score of σc > 39 on a rheological assessment of sputum, depending upon their randomization group. The primary outcome will be the number of exacerbations of COPD; (3) Discussion: By using sputum rheology, the COPD CaRhe study may provide clinicians with an objective biomarker to guide the prescription of azithromycin while reducing the cumulative exposure to macrolides.

Performance of the Cough and Sputum Assessment Questionnaire (CASA-Q) in COPD: Evidence from Clinical and Online Patient Interaction Studies

Introduction

Patient perception of the burden of chronic bronchitis symptoms in chronic obstructive pulmonary disease (COPD) can be assessed using patient-reported outcome measures (PROMs). The Cough and Sputum Assessment Questionnaire (CASA-Q) was developed and tested for this purpose. This study reviewed the performance of the CASA-Q in published online studies and tested a novel approach to complement traditional methods of qualitative content validation.

Methods

A targeted literature search was performed to identify published clinical studies of COPD using the CASA-Q as an endpoint. The performance of the questionnaire was examined in relation to other study endpoints, including clinical and functional measurements and other PROMs. Assessment of the content validity of the CASA-Q was carried out by comparing the content and structure of the questionnaire with published qualitative patient data from previously conducted online social media listening (SML) and online bulletin board (OBB) studies.

Results

In the interventional clinical trials, CASA-Q change scores were consistent with study objectives and other endpoints, including FEV₁ and other PROMs. Two observational studies showed cross-sectional correlations with other PROMs like the St.-George's Respiratory Questionnaire (SGRQ) and COPD assessment test (CAT) scores. Qualitative data from the SML and OBB patient studies were consistent with the content and structure of the CASA-Q, supporting the content validity of the measure.

Conclusion

Results suggest that the CASA-Q is appropriately responsive to changes in cough and sputum symptoms and clinical impact in trials of COPD. The mapping of qualitative findings from online SML and OBB studies to CASA-Q domains and items confirm the content validity of the instrument. These results suggest the CASA-Q can be a valuable tool for evaluating treatment effect in COPD trials.

Optimizing Pulmonary Outcomes After Total Laryngectomy: Crossover Study on New Heat and Moisture Exchangers

OBJECTIVE

To evaluate the effects of new devices-heat and moisture exchangers (HMEs) and adhesives-on pulmonary symptoms, subject adherence, quality of life, dermatologic symptoms, and patient satisfaction after laryngectomy.

STUDY DESIGN

Prospective crossover study.

SETTING

Between December 2020 and April 2021, 40 patients were enrolled who had undergone laryngectomy, routinely used HMEs and adhesive, and were followed in our Department of Otolaryngology-Head and Neck Surgery.

METHODS

Patients were allocated into group A (new products) or group B (usual care) for 6 weeks. Then the 2 groups reversed, and each patient acted as his or her own control. Patients kept a diary and cough tally sheet. At baseline and after each 6-week period, 2 questionnaires were administered: EQ-5D (European Quality of Life-5 Dimensions) and CASA-Q (Cough and Sputum Assessment Questionnaire).

RESULTS

Six weeks of using new products resulted in the following effects for both groups: (1) a significant reduction in daily forced expectoration and dry coughs, (2) a significant improvement in all domains of the CASA-Q, (3) an increase in adherence to HME use, (4) a significant reduction in shortness of breath and skin irritation, and (5) significantly better scores in the anxiety/depression domain of the EQ-5D.

CONCLUSION

Achieving this reduction in patients who were already highly adherent to HME use is clinically relevant and underscores the importance of using better-performing HMEs that can compensate for the humidification deficit. Improving pulmonary symptomatology could reduce patient restrictions in daily life and avoidance of social activity, with a consequent positive effect on quality of life.

Grupo de síntomas de enfermedad pulmonar obstructiva crónica y cuidados paliativos: una revisión sistemática

La enfermedad pulmonar obstructiva crónica (EPOC) es una entidad patológica que se caracteriza por una serie de manifestaciones físicas persistentes como tos, fatiga, disnea y producción de esputo; síntomas que generan malestar en el paciente desde el momento del diagnóstico y que, al ser una enfermedad irreversible por el daño tisular que causa, progresivamente va incidiendo de manera negativa en la calidad de vida. De otra parte, se ha reportado presencia de síntomas psicológicos como depresión, inseguridad, ansiedad y alteraciones emocionales en los pacientes diagnosticados con EPOC. Así mismo, los pacientes con este diagnóstico tienden a desarrollar comportamientos que alteran sus relaciones sociales familiares y laborales, por cuanto tienden a aislarse debido a la sintomatología, especialmente física. La situación planteada genera la necesidad de desarrollar un trabajo de investigación con el objetivo de reconocer el clúster de síntomas físicos, psicológicos y sociales de los pacientes diagnosticados con EPOC, e identificar si se plantea un abordaje desde la atención paliativa. El estudio se desarrolló mediante una revisión sistemática de literatura en la que se identificaron 1776 artículos, de los que se evaluaron 41 para la identificación del clúster de síntomas. Se identificó el binomio disnea y tos, fatiga y expectoración como el clúster de síntomas físicos; la depresión y la ansiedad constituyen el clúster de síntomas psicológicos, y el impacto en la calidad de vida y la percepción de aislamiento o exclusión social.

The impact of long-acting muscarinic antagonists on mucus hypersecretion and cough in chronic obstructive pulmonary disease: a systematic review

Patients suffering from chronic obstructive pulmonary disease (COPD) clinically manifest airway mucus hypersecretion as sputum expectoration and cough. Evidence accumulated in the past decade has shown that the cholinergic system not only regulates airway smooth muscle contraction but also the activity of inflammatory and airway epithelial cells, including goblet cells, and submucosal gland activity. Long-acting muscarinic antagonists (LAMAs) with the most favourable M₃/M₂ muscarinic acetylcholine (ACh) receptors residency properties are not only excellent bronchodilators but potentially also mucus-modifying agents, able to positively impact on mucus hypersecretion and cough. The aim of this systematic review was to investigate the impact of LAMAs on mucus hypersecretion and cough in COPD patients. The evidence confirmed that LAMAs, mainly tiotropium and aclidinium, improved sputum production and cough in moderate to severe COPD. Thus, LAMAs not only antagonise the ACh-induced bronchoconstriction of the airways but also appear to limit the production of mucus secreted in response to ACh by airway goblet cells and/or submucosal glands. Further clinical studies are necessary to evaluate the impact of LAMAs exclusively on sputum symptoms and cough as primary end-points and to investigate whether LAMAs have a modulatory action on the rheological properties of mucus.

People living with Moderate-to-Severe COPD Prefer Improvement of Daily Symptoms Over the Improvement of Exacerbations: A Multi-Country Patient Preference Study

Introduction

This patient preference study sought to quantify the preferences of people living with COPD regarding symptom improvement in the UK, USA, France, Australia and Japan.

Methods

The inclusion criteria were people living with COPD aged 40 years or older who experienced ≥1 exacerbation in the previous year with daily symptoms of cough and excess mucus production. The study design included: 1) development of an attributes and levels grid through qualitative patient interviews; and 2) implementation of the main online quantitative survey, which included a discrete choice experiment (DCE) to allow assessment of attributes and levels using hypothetical health state profiles. Preference weights (utilities) were derived from the DCE using hierarchical Bayesian analysis. A preference simulator was developed that enabled different health state scenarios to be evaluated based on the predicted patient preferences.

Results

1050 people living with moderate-to-severe COPD completed the survey. All attributes were considered important when patients determined their preferences in the DCE. In a health state preference simulation, two hypothetical health states (comprising attribute levels) with qualitatively equivalent improvements in A) cough and mucus and B) shortness of breath (SOB) resulted in a clear preference for cough and mucus improved profile. When comparing two profiles with C) daily symptoms improved and D) exacerbations improved, there was a clear preference for the daily symptoms improved profile.

Conclusions

People living with moderate-to-severe COPD prefer to reduce cough and mucus production together over improvement of SOB and would prefer to reduce combined daily symptoms over an improvement in exacerbations.

There is a need for symptom-focused therapies to deliver meaningful outcomes for people living with COPDhttps://bit.ly/3KqcSur

Methods of Sputum and Mucus Assessment for Muco-Obstructive Lung Diseases in 2022: Time to “Unplug” from Our Daily Routine!

Obstructive lung diseases, such as chronic obstructive pulmonary disease, asthma, or non-cystic fibrosis bronchiectasis, share some major pathophysiological features: small airway involvement, dysregulation of adaptive and innate pulmonary immune homeostasis, mucus hyperproduction, and/or hyperconcentration. Mucus regulation is particularly valuable from a therapeutic perspective given it contributes to airflow obstruction, symptom intensity, disease severity, and to some extent, disease prognosis in these diseases. It is therefore crucial to understand the mucus constitution of our patients, its behavior in a stable state and during exacerbation, and its regulatory mechanisms. These are all elements representing potential therapeutic targets, especially in the era of biologics. Here, we first briefly discuss the composition and characteristics of sputum. We focus on mucus and mucins, and then elaborate on the different sample collection procedures and how their quality is ensured. We then give an overview of the different direct analytical techniques available in both clinical routine and more experimental settings, giving their advantages and limitations. We also report on indirect mucus assessment procedures (questionnaires, high-resolution computed tomography scanning of the chest, lung function tests). Finally, we consider ways of integrating these techniques with current and future therapeutic options. Cystic fibrosis will not be discussed given its monogenic nature.

Extended Bacteria Culture-Based Clustering Identifies a Phenotype Associating Increased Cough and Enterobacterales in Stable Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by airflow limitation. This chronic respiratory disease represents the third leading cause of death worldwide. Alteration of the airway microbiota has been reported to be associated with exacerbation frequency in COPD, but its role on the symptoms in patients at stable state is still incompletely described. This study aimed to determine whether bacteria isolated in sputum can be associated with the clinical features of COPD patients within stable state. Our study highlights, for the first time, that altered microbiota with Enterobacterales is associated with pejorative clinical symptoms in stable COPD patients. The airway microbiota of 38 patients was analyzed using an extended culture approach and mass spectrometry identification. Cluster analysis by principal coordinate analysis of the bacterial communities showed that the patients could be classified into three distinct clusters in our cohort. The clusters showed no differences in proportions of the phylum, but one of them was associated with a high prevalence of Enterobacterales (71.4% in cluster 1 vs. 0% in cluster 3), loss of microbiota diversity, and higher bacterial load (10⁷ vs. 10⁵ CFU/ml, respectively) and characterized by predominant cough and impact on mental health. These novel findings, supported by further studies, could lead to modifying the processing of COPD sputum in the everyday practice of clinical microbiology laboratories.

Lung microbiome of stable and exacerbated COPD patients in Tshwane, South Africa

Chronic obstructive pulmonary disease (COPD) is characterised by the occurrence of exacerbations triggered by infections. The aim of this study was to determine the composition of the lung microbiome and lung virome in patients with COPD in an African setting and to compare their composition between the stable and exacerbated states. Twenty-four adult COPD patients were recruited from three hospitals. Sputum was collected and bacterial DNA was extracted. Targeted metagenomics was performed to determine the microbiome composition. Viral DNA and RNA were extracted from selected samples followed by cDNA conversion. Shotgun metagenomics sequencing was performed on pooled DNA and RNA. The most abundant phyla across all samples were Firmicutes and Proteobacteria. The following genera were most prevalent: Haemophilus and Streptococcus. There were no considerable differences for alpha and beta diversity measures between the disease states. However, a difference in the abundances between disease states was observed for: (i) Serratia (3% lower abundance in exacerbated state), (ii) Granulicatella (2.2% higher abundance in exacerbated state), (iii) Haemophilus (5.7% higher abundance in exacerbated state) and (iv) Veillonella (2.5% higher abundance in exacerbated state). Virome analysis showed a high abundance of the BeAn 58058 virus, a member of the Poxviridae family, in all six samples (90% to 94%). This study is among the first to report lung microbiome composition in COPD patients from Africa. In this small sample set, no differences in alpha or beta diversity between stable and exacerbated disease state was observed, but an unexpectedly high frequency of BeAn 58058 virus was observed. These observations highlight the need for further research of the lung microbiome of COPD patients in African settings.

Comparative effects of capsaicin in chronic obstructive pulmonary disease and asthma (Review)

Chronic obstructive pulmonary disease (COPD) and asthma are chronic respiratory diseases with high prevalence and mortality that significantly alter the quality of life in affected patients. While the cellular and molecular mechanisms engaged in the development and evolution of these two conditions are different, COPD and asthma share a wide array of symptoms and clinical signs that may impede differential diagnosis. However, the distinct signaling pathways regulating cough and airway hyperresponsiveness employ the interaction of different cells, molecules, and receptors. Transient receptor potential cation channel subfamily V member 1 (TRPV1) plays a major role in cough and airway inflammation. Consequently, its agonist, capsaicin, is of substantial interest in exploring the cellular effects and regulatory pathways that mediate these respiratory conditions. Increasingly more studies emphasize the use of capsaicin for the inhalation cough challenge, yet the involvement of TRPV1 in cough, bronchoconstriction, and the initiation of inflammation has not been entirely revealed. This review outlines a comparative perspective on the effects of capsaicin and its receptor in the pathophysiology of COPD and asthma, underlying the complex entanglement of molecular signals that bridge the alteration of cellular function with the multitude of clinical effects.

Chronic cough is associated with depressive mood in women regardless of smoking status and lung function

BACKGROUND

Chronic cough is a common respiratory symptom, and, if persistent, the patient's quality of life can worsen and result in a depressive mood, or vice versa. Although previous reports suggest a relationship between chronic cough and depression, we further investigated this relationship according to smoking status and lung function.

METHODS

This observational study used cross-sectional data from the 6^th Korean National Health and Nutrition Examination Survey (2014 and 2016). Propensity score matching using age, sex, smoking status, and lung function was performed for participants with and without chronic cough to reduce the confounding effects associated with depressive mood. Questionnaires recorded coughs persisting for >3 months and the Patient Health Questionnaire-9 (PHQ-9) assessed the severity of depressive mood.

RESULTS

Among 12 494 participants who were >18 years old, 226 with chronic cough were matched with 226 with non-chronic cough. Overall, chronic cough participants showed higher PHQ-9 scores than the non-chronic cough participants (4.29 ± 5.23 vs. 2.63 ± 3.38, P < .001). When stratified by sex, the difference remained significant in women (5.69 ± 5.96 vs. 3.05 ± 3.97, P < .001) but not in men (3.18 ± 4.27 vs. 2.31 ± 3.65, P = .092). When stratified by lung function status, the difference remained significant for those with normal lung function (4.32 ± 5.32 vs. 2.78 ± 3.86, P = .003) and reduced lung function (4.19 ± 4.93 vs. 2.11 ± 3.55, P ≤ 0.001). Multivariate logistic regression analysis revealed that chronic cough was associated with PHQ-9 score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.014-1.27, P = .014), chronic obstructive pulmonary disease (OR, 4.87; 95% CI, 1.041-22.86, P = .044) and physician-diagnosed bronchial asthma (OR, 2.93; 95% CI, 1.162-7.435, P = .023).

CONCLUSIONS

Depressive mood is significantly correlated with chronic cough in females.

Is the Symptom of Cough in Chronic Obstructive Pulmonary Disease Important?

Chronic obstructive pulmonary disease (COPD) is a common disease and a significant burden worldwide. The clinical symptoms of this disease include progressive dyspnea, cough, expectoration, and wheezing, among others. At present, the primary focus has been on reducing the frequency of acute exacerbations and improving lung function and dyspnea symptoms, and limited attention has been paid to cough and expectoration symptoms, which may be associated with a decrease in lung function, more acute exacerbations, and hospitalizations. Therefore, this outcomes in patients with COPD.

Extra-pulmonary manifestations of COPD and the role of pulmonary rehabilitation: a symptom-centered approach

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogenous disease that is associated with a range of respiratory and non-respiratory symptoms, which highly contribute to the daily burden of the disease. Symptoms burden remains high despite optimal bronchodilator therapy, but pulmonary rehabilitation (PR) is an effective intervention to improve patients' symptoms. A comprehensive interdisciplinary approach within the framework of a PR program is warranted to tackle these complex symptoms and their consequences. Areas covered: This narrative review describes how symptoms of dyspnea, fatigue, cough, sputum, anxiety, depression, pain, sleep disturbances, and cognitive decline arise in COPD and can contribute to several non-pulmonary manifestations of the disease. It also describes evidence of the effectiveness of interdisciplinary PR programs to counteract these symptoms. A literature search was performed on PubMed and Scopus between June and July 2020. Expert opinion: Respiratory and non-respiratory symptoms are highly prevalent, often not comprehensively assessed, and result in several extra-pulmonary manifestations of the disease (physical, emotional and social). Interdisciplinary PR programs can improve these negative manifestations through different pathways, contributing for an effective symptoms' management. A thorough assessment of symptoms (beyond dyspnea) should be routinely performed and may support the identification of treatable traits, allowing the tailoring of PR interventions and assessment of their real-life impact.

Prevalence and Characteristics of Chronic Cough in Adults Identified by Administrative Data

CONTEXT

International Classification of Diseases-9/10 codes for chronic cough (CC) do not exist, limiting investigation.

OBJECTIVE

To develop a computerized algorithm to determine CC prevalence and its characteristics.

DESIGN

This observational study using administrative data identified hierarchically patients aged 18 to 85 years with CC from 2013 to 2016. First, a specialist-diagnosed CC group was identified using an internal CC encounter code during an outpatient visit to a pulmonologist, allergist, otolaryngologist, or gastroenterologist. Subsequently, an event-diagnosed CC group was identified based on clinical notes through natural language processing, ICD-9/ICD-10 cough codes, and dispensed antitussives.

MAIN OUTCOME MEASURES

Prevalence of CC and comparison of clinical characteristics between specialist-diagnosed and event-diagnosed CC subgroups.

RESULTS

A total of 50,163 patients with CC of more than 8 weeks were identified. Of these, 11,290 (22.5%) were specialist diagnosed, and 38,873 (77.5%) were event diagnosed. The CC cohort was 57.4 ± 16.5 years of age; 67.6% were female. The overall prevalence was 1.04% (95% confidence interval = 1.03-1.06) in 2016. Prevalence in 2016 was higher in female patients (1.21%) than in male patients (0.81%), higher in patients aged 65 to 85 years (2.2%) than in patients aged 18 to 44 years (0.43%), and higher in Blacks (1.38%) than in Whites (1.21%). Compared with patients with event-diagnosed CC, patients with specialist-diagnosed CC exhibited significantly higher frequencies of laboratory tests and respiratory and nonrespiratory comorbidities and dispensed medication and lower frequency of pneumonia, all-cause and respiratory-cause emergency department visits and hospitalizations, and dispensed antitussives.

CONCLUSIONS

We identified a CC cohort using electronic data in a managed care organization. Prevalences varied by sex, age, and ethnicity. Clinical characteristics varied between specialist-diagnosed and event-diagnosed CC.

Life-Threatening and Non-Life-Threatening Complications Associated With Coughing: A Scoping Review

BACKGROUND

This is an update of the section on complications that are associated with coughing in the 2006 CHEST cough guidelines that addresses two aims: (1) to systematically identify and thematically categorize the diverse complications of cough by providing a guide for future studies and (2) to identify gaps in the literature for future research.

RESEARCH QUESTION

What are the potential complications that are associated with the act of coughing that have been reported in infants, children, adolescents, and adults?

STUDY DESIGN AND METHODS

A scoping review was performed with the use of PubMed and SCOPUS databases that were searched from their beginning until September 6, 2019.

RESULTS

Two hundred forty-seven publications met our inclusion criteria. To these, we added 38 articles from the 2006 complications paper that were not identified in the literature search plus the paper itself for a final total of 286 publications that formed the basis of this review. Since 2006, three new categories of complications have been reported: ear, nose and throat; disease transmission; and laboratory testing. Multiple additional complications that fall outside of these three categories have also been identified and included in the following categories: cardiovascular, constitutional symptoms, dermatologic, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial/quality of life, and respiratory. Not previously highlighted is that some of the complications led to serious morbidity that included death, especially in patients with comorbid conditions, and potentially resulted in harm to others when cough resulted in a motor vehicle accident.

INTERPRETATION

Our work identified a large number of cough complications that we thematically categorized primarily by organ system so that future studies of each system or each complication can be conducted. The gap in the literature that future studies should address is to identify the frequency of the complications and the strength of their association with cough. Only then will one be able to describe the findings in a manner that allows specific recommendations for avoiding these complications. In the meantime, patients with cough should be evaluated and treated according to evidence-based guidelines to mitigate or prevent the myriad of potential complications that are associated with coughing.

Objective secondhand smoke exposure in chronic obstructive pulmonary disease patients without active smoking: the U.S. National Health and Nutrition Examination Survey (NHANES) 2007-2012

Background

Secondhand smoke (SHS) may be related to worse outcomes in chronic obstructive pulmonary disease (COPD), but the reported SHS prevalence in different studies varied from 27% to 65% and the effects of SHS are still questionable among these patients. The study aims were to estimate the objective SHS prevalence and explore the SHS impact on outcomes among COPD patients without active smoking.

Methods

A cross-sectional design combined with longitudinal death outcome. We selected COPD patients over 40 years old based on the spirometry from National Health and Nutrition Examination Survey (2007–2012), and used the tobacco-specific biomarkers [cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanonol] to determine exposure statuses (active smoking, SHS exposure, or no smoke exposure). Then we estimated the short-term (past 2–4 days) and medium-term (past 6–12 weeks) SHS prevalence among 334 patients without active smoking. Weighted multiple regressions were performed to assess the associations between medium-term SHS exposure and outcomes (symptoms, health status, medical institution visits, and death).

Results

Among the patients without active smoking, the objective prevalence rates of short-term and medium-term SHS were 66.65% [95% confidence interval (CI), 59.63–73.67%] and 34.91% (95% CI, 28.86%–40.96%), respectively. Medium-term SHS exposure showed a significant effect (odds ratio, 3.57; 95% CI, 1.22–10.40) on more chronic coughing after adjusting for the covariates and indicated a trend of unadjusted increasing death risk (log-rank test, P=0.01).

Conclusions

Among COPD patients without active smoking, both short-term and medium-term SHS exposure are prevalent. Chronic cough may be the most susceptible patient-centred outcome related to medium-term SHS exposure. The crude longitudinal trend of elevated death risk associated with medium-term SHS exposure deserves further study.

COPD Patients' Experience of Long-Term Domestic Oxygen-Enriched Nasal High Flow Treatment: A Qualitative Study

Little is known about chronic obstructive pulmonary disease (COPD) patients experience with home-based health treatments, which are currently rapidly evolving. A previous randomized controlled trial investigated the use of long-term oxygen enriched high flow nasal cannula (HFNC) treatment at home. The aim of this study was to explore COPD patients' experience using home HFNC treatment. Patients in this qualitative study were included from the previous RCT. All patients used long-term oxygen therapy and HFNC, the latter as a primarily nocturnal add-on. Data were collected using semi-structured interviews focused on four themes: 'Description of daily use', 'Experienced changes', 'Treatment benefits and disadvantages' and 'User-friendliness'. The interviewer played an encouraging, non-normative neutral facilitator role in order to give the participants possibility to explain themselves as fully as possible. Participants were recruited until themes were saturated. A total of 12 patients (5 males, 7 females) and 8 relatives participated. Six themes were identified as important to patient adherence: Perceived lower work of breathing; reduced symptoms; improved quality of sleep; increased activity of daily living; feeling safe; technology use. The results increase our knowledge of patient experience of using HFNC for home treatment, which improved the patients' experience through reducing symptoms and increase the activity of daily living. Furthermore, they substantiate the necessity of perceived usefulness and ease of use as important factors for adherence to treatment.

Minimal Clinically Important Differences for Patient-Reported Outcome Measures of Cough and Sputum in Patients with COPD

Background

Cough and sputum are highly prevalent in patients with chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation (PR) has shown to be effective in managing these symptoms. However, the interpretation of the magnitude of PR effects is hindered by the lack of minimal clinically important differences (MCIDs).

Purpose

This study established MCIDs for the Leicester cough questionnaire (LCQ) and the cough and sputum assessment questionnaire (CASA-Q), in patients with COPD after PR.

Patients and Methods

An observational prospective study was conducted in patients with COPD who participated in a 12-weeks community-based PR program. Anchor- (mean change, receiver operating characteristic curves and linear regression analysis) and distribution-based methods [0.5*standard deviation; standard error of measurement (SEM); 1.96*SEM; minimal detectable change and effect size] were used to compute the MCIDs. The anchors used were: i) patients and physiotherapists global rating of change scale, ii) COPD assessment test, iii) St. George's respiratory questionnaire and iv) occurrence of an exacerbation during PR. Pooled MCIDs were computed using the arithmetic weighted mean (2/3 for anchor- and 1/3 for distribution-based methods).

Results

Forty-nine patients with COPD (81.6% male, 69.8±7.4years, FEV150.4±19.4%predicted) were used in the analysis. The pooled MCIDs were 1.3 for LCQ and for CASA-Q domains were: 10.6 - cough symptoms; 10.1 - cough impact; 9.5 - sputum symptoms and 7.8 - sputum impact.

Conclusion

The MCIDs found in this study are potential estimates to interpret PR effects on cough and sputum, and may contribute to guide interventions.

Immune system in the pathogenesis of chronic cough

Chronic cough is a common symptom of various chronic diseases. However, the vast majority of individuals with conditions that are commonly associated with cough, such as asthma and GERD, do not have chronic cough. This implies that cough reflex sensitivities differ among individuals. It is known that in the pathogenesis of cough, the nervous system plays a vital role. Recently more information about the role of the immune system and its interaction with the nervous system in the pathogenesis of cough has appeared in the literature. The aim of this article is to review the most recent data about the role of the immune system in the pathogenesis of chronic cough.

Symptom Clusters and Health-related Quality of Life in Chinese patients with Chronic Obstructive Pulmonary Disease

This study aimed to identify symptom clusters of chronic obstructive pulmonary disease (COPD) and to examine the relationship between symptom clusters and health-related quality of life (HRQoL). It included 154 hospitalized patients with COPD. The majority of the participants (88.6%) were aged 60 years and above, and the numbers of men and women were approximately equal (men: 55.2%). The Charlson Comorbidity Index (CCI), the Memorial Symptom Assessment Scale (MSAS), and the Chinese version of the Clinical COPD Questionnaire (CCQ) were used to evaluate comorbidity, participant's symptoms, and HRQoL, respectively. Five symptom clusters were identified using exploratory factor analysis, and symptom clusters, especially the Psychological, Pain and Fatigue, GI, and Dyspnea-Sweat symptom clusters, had negative effects on HRQoL in patients with COPD. Understanding the patterns and occurrences of symptom clusters could be essential for developing effective interventions to manage COPD symptoms and improve the patients' HRQoL.

Impact of cough and mucus on COPD patients: primary insights from an exploratory study with an Online Patient Community

Background: Qualitative research provides real-life information on patients' condition and facilitates informed design of future clinical studies. Objective: We used Online Communities as a qualitative research tool to evaluate the effect of cough and mucus on COPD patients. Methods: Two 2-week Online Communities were run in parallel in the UK and in the USA, including COPD patients with persistent cough and excessive mucus. Patients anonymously posted their responses to pre-assigned tasks, supervised and guided by a trained moderator. Five themes around the impact of cough and mucus were explored with new questions posted every 2-3 days. On the final day, high-level conclusions were shared with patients for feedback. Data were analyzed following the principles of grounded theory. Results: Twenty COPD patients (UK, n=10; USA, n=10) participated in the Online Communities. We found that cough and mucus disrupted COPD patients' lives at functional, emotional, social and economic levels. Patients created daily rituals and adjusted their lifestyle to cope with the impact of these symptoms. Patients identified themselves with our conclusions and saw the Online Community as an effective forum to share their experiences. Conclusion: Findings of our study add to the body of evidence on the negative impact of COPD symptoms and unmet needs of these patients.

Patients' perspectives on COPD: findings from a social media listening study

We utilised social media listening (SML) to obtain patients' perspectives on symptoms, diagnosis and comorbidities associated with chronic obstructive pulmonary disease (COPD) and its impact on patients' quality of life (QoL). A comprehensive search on social media platforms was performed for English language content posted between July 2016 and January 2018 using COPD-related terms. Social Studio, a social media data aggregator tool, was used to capture relevant records. The content was manually curated to analyse and map psychological aspects with descriptive statistics applied on aggregated findings. A total of 849 posts from patients or caregivers ("patient insights") were considered for the analysis, corresponding to postings of 695 unique individuals. Based on 734 mentions of symptoms from 849 posts by potential patients/caregivers, cough (27%), mucus (25%) and shortness of breath (21%) were the most frequent; analysis by perceived COPD severity indicated these to be common across all severities. Difficulty in mucus clearance (24% of 268 mentions) and sadness (40% of 129 mentions) were top among the aspects impacting physical and emotional QoL, respectively. SML from patients with COPD indicated that relief from cough, mucus production and shortness of breath would be the most desirable aspects of disease management from a patient's perspective.

Treatment of Chronic Obstructive Pulmonary Disease in the Primary Care Setting: How Can We Achieve More for Our Patients?

Chronic obstructive pulmonary disease is a debilitating and progressive disease that is both underdiagnosed and undertreated, affecting up to 1 in 10 older adults. Common symptoms, including dyspnea, productive cough, chest tightness, and fatigue, can reduce quality of life, the ability to participate in all types of activities, and overall health status in patients. Minimizing the impact of symptoms on patients' quality of life should be a key goal for physicians, and modest changes in current practice could make improvements in patients' lives. Here we review chronic obstructive pulmonary disease, its impact on patients, and how to improve symptom management.

Managing patients with chronic cough: challenges and solutions

Chronic cough is a common complaint and a frequent cause of medical consultation. Its management can be difficult. We present here an overview of the current guidelines for the management of chronic cough. Different steps are detailed, including the initial research of an obvious etiology and alert signs that should lead to further investigation of underlying condition. The diagnosis of the most frequent causes: asthma, non-asthmatic eosinophilic bronchitis, gastroesophageal reflux disease and upper airway cough syndrome should be considered, assessed and treated accordingly. Recent advances have been made in the comprehension of refractory chronic cough pathophysiology as well as its pharmacologic and non-pharmacologic treatment, especially speech pathology therapy.

Markers of Dental Health Correlate with Daily Respiratory Symptoms in COPD

Background: Poor dental health occurs in patients with chronic obstructive pulmonary disease (COPD); some evidence suggests that it may correlate with lower forced expiratory volume in 1 second (FEV1) and 6-minute walk distance, and an increased rate of exacerbations. However, there is no data that examines how dental health may impact the daily respiratory symptoms that COPD patients experience. We prospectively studied indices of dental health and hygiene in patients with COPD and determined their impact on daily respiratory symptoms. Methods: A total of 20 individuals with COPD (median [interquartile range (IQR)] % FEV1 37 [29-43]) and 10 healthy control individuals with no lung disease were recruited. Dental questionnaires, spirometry, and a dental examination were administered on their initial visit. COPD participants were given an electronic COPD daily diary to document peak expiratory flow and the presence and magnitude of daily breathlessness, cough, sputum production, and wheeze. Results: Compared to healthy controls, COPD participants had less teeth (median 16.5 versus 28, p=0.0001), a trend to a higher plaque index (median 2.2 versus 1.7, p=0.15), and worse oral health-related quality of life (median Oral Health Impact Profile score 12.0 versus 4.5, p=0.02). A greater number of teeth correlated with higher percentage of days with cough (r=0.48, p<0.05) and wheeze (r=0.47, p<0.05). Conclusion: Individuals with severe COPD have poor oral hygiene and oral health-related quality of life. In the setting of poor dentition, a greater number of teeth correlates with more daily respiratory symptoms. More teeth may create a larger reservoir for inflammatory proteins and pathogenic bacteria to be aspirated into the airways.

Risk Factors for Depression in Patients with Chronic Obstructive Pulmonary Disease

Background

Depression is a major comorbidity in patients with chronic obstructive pulmonary disease (COPD). The aim of this prospective study was to investigate socio-demographic and clinical factors and serum markers of inflammation, including cytokines that, may be a cause or an association with COPD-related depression.

Material/Methods

This study enrolled 53 patients who were hospitalized in the Department of Respiratory Medicine of Hefei First People’s Hospital, China between October 2015 and October 2016. Patients were consecutively recruited who were diagnosed with COPD and without lower respiratory tract disease, psychiatric disorders, or a family history of cognitive disorders. All patients were investigated for symptoms of depression. Lung function testing included forced expiratory volume in 1 second (FEV₁). Serum levels of C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α) were measured.

Results

Of the 53 patients with COPD, 40 (75.47%) patients had symptoms of depression. Univariate analysis showed that gender, smoking, a high level of education, duration of a cough, FEV₁, and serum CRP level were associated with depression. A multivariate logistic regression model identified two risk factors for depression in patients with COPD: serum CRP level and FEV₁.

Conclusions

The findings of this study showed that the risk factors for COPD-related depression included male gender, heavy smoking, higher academic qualifications, and duration of cough, but the two strongest risk factors were a high serum CRP level and low FEV₁.

The outcome and the influencing factors of the age of onset in post-mortem of chronic bronchitis patients: a retrospective study

Purpose

Chronic bronchitis is thought to occur in elderly patients, and smoking seems to be an important risk factor. The outcomes related to the age of onset in patients with chronic bronchitis are still unclear.

Patients and methods

A retrospective study was conducted on deceased patients whose diagnosis included bronchitis from 2010 to 2016. Patients were separated into two groups according to the age of onset (Group I, age ≤50 years old; Group II, age >50 years old). Information regarding disease course, smoking history, death age, number of admissions per year, Hugh Jones Index, and self-reported comorbidities of the patients was recorded.

Results

The courses of chronic cough and sputum were 33.38±7.73 years and 14.44±8.60 years in Group I and Group II, respectively (p<0.05). The death ages of Group I and Group II were 77.65±7.87 years and 84.69±6.67 years, respectively (p<0.05). There was a significant negative correlation between the number of hospital admissions per year and the age of onset. The age of onset was negatively associated with daily smoking count (r=−0.210) and total smoking count (r=−0.146). In Group I, there were fewer cases of coronary heart disease (OR =0.41 [0.24–0.71]), neurological diseases (OR =0.48 [0.24–0.97]), and total comorbidities (OR =0.67 [0.54–0.85]) than in Group II.

Conclusion

Patients with early onset chronic bronchitis had a longer history, younger death age, poorer health status, and lower incidence of comorbidities.

The contribution of symptoms and comorbidities to the economic impact of COPD: an analysis of the German COSYCONET cohort

Background

Although patients with COPD often have various comorbidities and symptoms, limited data are available on the contribution of these aspects to health care costs. This study analyzes the association of frequent comorbidities and common symptoms with the annual direct and indirect costs of patients with COPD.

Methods

Self-reported information on 33 potential comorbidities and symptoms (dyspnea, cough, and sputum) of 2,139 participants from the baseline examination of the German COPD cohort COSYCONET was used. Direct and indirect costs were calculated based on self-reported health care utilization, work absence, and retirement. The association of comorbidities, symptoms, and COPD stage with annual direct/indirect costs was assessed by generalized linear regression models. Additional models analyzed possible interactions between COPD stage, the number of comorbidities, and dyspnea.

Results

Unadjusted mean annual direct costs were €7,263 per patient. Other than COPD stage, a high level of dyspnea showed the strongest driving effect on direct costs (+33%). Among the comorbidities, osteoporosis (+38%), psychiatric disorders (+36%), heart disease (+25%), cancer (+24%), and sleep apnea (+21%) were associated with the largest increase in direct costs (p<0.01). A sub-additive interaction between advanced COPD stage and a high number of comorbidities reduced the independent cost-driving effects of these factors. For indirect costs, besides dyspnea (+34%), only psychiatric disorders (+32%) and age (+62% per 10 years) were identified as significant drivers of costs (p<0.04). In the subsequent interaction analysis, a high number of comorbidities was found to be a more crucial factor for increased indirect costs than single comorbidities.

Conclusion

Detailed knowledge about comorbidities in COPD is useful not only for clinical purposes but also to identify relevant cost factors and their interactions and to establish a ranking of major cost drivers. This could help in focusing therapeutic efforts on both clinically and economically important comorbidities in COPD.

Cough and airway disease: The role of ion channels

Cough is the most common reason for patients to visit a primary care physician, yet it remains an unmet medical need. It can be idiopathic in nature but can also be a troublesome symptom across chronic lung diseases such as asthma, COPD and idiopathic pulmonary fibrosis (IPF). Chronic cough affects up to 12% of the population and yet there are no safe and effective therapies. The cough reflex is regulated by vagal, sensory afferent nerves which innervate the airway. The Transient Receptor Potential (TRP) family of ion channels are expressed on sensory nerve terminals, and when activated can evoke cough. This review focuses on the role of 4 TRP channels; TRP Vannilloid 1 (TRPV1), TRP Ankyrin 1 (TRPA1), TRP Vannilloid 4 (TRPV4) and TRP Melastatin 8 (TRPM8) and the purinergic P2X3 receptor and their possible role in chronic cough. We conclude that these ion channels, given their expression profile and their role in the activation of sensory afferents and the cough reflex, may represent excellent therapeutic targets for the treatment of respiratory symptoms in chronic lung disease.

Effect of Pingchuan Guben decoction on patients with chronic obstructive pulmonary disease: Results from a randomized comparative effectiveness research trial

Chronic obstructive pulmonary disease (COPD) is known to be a systemic low-grade ongoing inflammation exerting major health and economic burden worldwide. Complementary and alternative medicines, such as Traditional Chinese Medicine, are widely used for the treatment of patients with COPD. The present study was designed to investigate the efficacy of Pingchuan Guben decoction on patients with COPD through a double-blinded, open-labeled, randomized controlled trial. A total of 86 patients were randomly assigned to two groups, with 43 patients in the intervention group and 43 cases in the control group. The patients in the control group were treated with conventional western medicine, and the intervention group received a combination of conventional western medicine and Pingchuan Guben decoction. After 12 weeks of treatment, the mean 6-minute walking distance, forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC) and FEV1/FVC in the intervention group were significantly higher than those of the control group (P<0.05). The levels of inflammation factors and protease molecules were significantly ameliorated in the intervention group compared with the control group (P<0.05). The levels of Kelch-like ECH-associated protein 1 (Keap1), nuclear factor-E2-related factor-2 (Nrf2), superoxide anions, malondialdehyde, glutathione S-transferase and glutathione peroxidase were significantly more improved in the intervention group compared with those in the control group over the 12-week study period (P<0.05). Therefore, combinations of western medicine with Pingchuan Guben decoction may exert therapeutic effects on patients with COPD via modulations of inflammation factors and protease molecules, as well as the activation of the Keap1/Nrf2 signaling pathway.

Domestic solid fuel combustion in an adult population in Nigeria: A cross sectional analysis of association with respiratory symptoms, quality of life and lung function

BACKGROUND AND OBJECTIVES

We examined the association of respiratory symptoms, health status, and lung function with the use of solid fuel (wood, charcoal, coal or crop residue) for cooking or heating in a predominantly non-smoking population.

METHODS

Using the protocol of the Burden of Obstructive Lung Diseases (BOLD) initiative, we collected representative population data using questionnaires and spirometry tests. We categorized solid fuel use into 'never user', 'ex user' and 'current user' based on responses to the survey. We developed regression models to evaluate the relation between use of solid fuel and the prevalence of respiratory symptoms, quality of life and lung function adjusting for confounding variables.

RESULTS

Out of 1147 respondents with complete information on domestic fuel type, 33% were 'never-users', 19% were 'ex-users' while 48% reported current use of solid fuel for domestic cooking and/or indoor heating. Compared with never-users, current solid fuel users were more likely to report cough (OR: 1.7, 95% CI: 1.0, 2.9), cough or phlegm (OR: 1.6, 95% CI: 1.0, 2.5) and the association was stronger among women (OR: 3.0, 95% CI: 1.3, 7.1 and OR: 2.3, 95% CI: 1.1, 5.2, respectively). Current solid fuel users also had lower mental health status (coefficient: ?1.5, 95% CI: ?2.8, - 0.2) compared with the group of never-users. Current or previous domestic use of solid fuels for cooking or heating was not associated with higher prevalence of chronic airflow obstruction (FEV₁/FVC < LLN).

CONCLUSIONS

Using solid fuel for domestic cooking or heating was associated with a higher risk of cough or phlegm and a lower mental quality of life. However we found no significant effect in the prevalence of chronic airflow obstruction in Ife, Nigeria.

The variability of respiratory symptoms and associated factors in COPD

Few studies have investigated the variability of COPD-related symptoms or factors related to symptom variability. This observational, prospective, multicentre study was conducted to describe the number and intensity of morning and night-time respiratory symptoms and their variability over one week using the Night-time and Early Morning Symptoms of COPD Instruments (NiSCI and EMSCI) to evaluate stable COPD patients. Logistic regression analyses were performed to investigate factors associated with symptom variability. A total of 2669 patients were evaluated (mean age, 67.7 years; 80.9% men; mean FEV1 50.6%). Of these, 48% reported night-time symptoms and 71% reported morning symptoms. Of the 2293 patients who completed the NiSCI and EMSCI, 90% showed variability in either symptom number (89.6%) or symptom intensity (15.8%). More severe dyspnoea, more exacerbations during the previous year and the exacerbator or mixed COPD-asthma phenotypes were associated with variability in symptom number or intensity. Anxiety was significantly associated with variability in symptom number and intensity. Most COPD patients showed symptom variability over a weeklong period, especially in terms of symptom number. Several COPD-related factors, mainly factors related to more severe disease and more frequent exacerbations, were associated with increased symptom variability.