Hospital admissions and mortality in patients with COPD exacerbations and vertebral body compression fractures

Mechanisms of osteoporosis associated with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a disease characterized by chronic respiratory symptoms due to inflammatory and destructive changes of the lung leading to progressive airflow obstruction. Fragility fractures associated with osteoporosis are among major comorbidities and have significant impacts on quality of life and prognosis of patients with COPD. Evidence suggests that both decreased bone mineral density (BMD) and impaired bone quality contribute to bone fragility and resultant fractures in COPD. Although various clinical risk factors of osteoporosis have been described, mechanisms of COPD-associated osteoporosis are still largely unknown. In addition, its specific treatment has not been established, either. Previous studies have suggested involvement of low BMI and sarcopenia in the pathogenesis of COPD-associated osteoporosis. In this narrative review, we will propose critical roles of vitamin D deficiency and inflammation, both of which are often present in COPD and may underlie the development of osteosarcopenia and impaired bone quality, ultimately causing fractures in COPD patients.

Lung Function Impairment, Associating Hyperinflation with Impaired Diffusion Capacity and Transfer Coefficient, Is a Risk Factor for Hip Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a risk factor for osteoporosis. Our objective is to determine if functional indices associated with emphysema on pulmonary function tests (DLCO—diffusion capacity of the lung for CO-; DLCO/AV—DLCO corrected for alveolar volume- and TLC—total lung capacity), considered alone or together, can identify COPD patients with osteoporosis. Methods: 90 COPD patients underwent dual-energy X-ray absorptiometry (DEXA) and pulmonary function tests. Results: 26% of the COPD patients were osteoporotic. In univariate analysis, each functional parameter associated with emphysema, analyzed separately, was not associated with osteoporosis. In contrast, patients with hyperinflation associated with impaired diffusion capacity and transfer coefficient, defined by the association of the three functional indices (DLCO < 70%, DLCO/AV < 80% and CPT > 115%), had significantly more osteoporosis at the total hip (OR: 5.9, CI: 1.5–23.8, p = 0.013). In multivariate analysis, this phenotype was confirmed as an independent factor associated with hip osteoporosis. In contrast, COPD airway obstruction severity, based on FEV1 (%), was not associated with osteoporosis. A lower BMI, female gender and age were also identified as osteoporosis risk factors. Conclusions: COPD patients with hyperinflation associated with impaired diffusion capacity and transfer coefficient are at higher risk for osteoporosis. Pulmonary function tests associated with emphysema detection can help to identify COPD patients with osteoporosis, in addition to the classical risk factors.

High rate of abdominal aortic calcification in COPD patients and its relationship with musculoskeletal fragility

A very high rate of abdominal aortic calcification was observed in patients with COPD. Vascular calcification severity was associated with older age and lower bone mass at the femur in women.

INTRODUCTION

Osteoporosis, sarcopenia, and cardiovascular disease are frequent comorbidities in COPD. Considering routine x-ray as a simple tool to access vertebral fractures and vascular calcification, the rate and severity of abdominal aortic calcification (AAC) and its association with musculoskeletal outcomes were investigated in COPD patients.

METHODS

Ninety-six COPD patients (44 men and 52 women, 65.8 (51-83) and 64.3 (44-85) years-old, respectively) underwent spirometry, laboratory workout, bone mineral density (BMD) measurements with body composition analysis, and thoracolumbar spine radiography. Vertebral fractures (VFs) and AAC were defined using Genant semiquantitative approach and Kauppila score, respectively.

RESULTS

Densitometric osteoporosis and VFs grades 2-3 were detected in almost 40% and 23% of the participants, respectively. Two-thirds of the participants had AAC ≥ 1 while significant atherosclerotic burden (extended AAC, Kauppila score ≥ 5) was seen in 40.6% of the sample. Women with significant atherosclerotic burden were older (P = 0.044) and had lower femoral neck BMD (P = 0.012) when compared to those with an AAC score < 5. Multivariate logistic regression analyses showed that body fat tended to be associated with increased odds of extended AAC in men (OR = 1.06, 95% CI 0.99-1.13, P = 0.099) while femoral neck BMD (0.01 g/cm²) was found to be significantly associated with extended AAC in women (OR = 0.95, 95% CI 0.92-0.99; P = 0.018).

CONCLUSION

COPD patients present a very high rate of AAC and its extended phenotype. Easily measured by conventional spine radiography, AAC severity in women with COPD is associated with low bone mass at the femoral neck, a surrogate marker for musculoskeletal fragility.

Predictors of mortality in chronic obstructive pulmonary disease: a systematic review and meta-analysis

Background

Better insight in patients’ prognosis can help physicians to timely initiate advance care planning (ACP) discussions with patients with chronic obstructive pulmonary disease (COPD). We aimed to identify predictors of mortality.

Methods

We systematically searched databases Embase, PubMed, MEDLINE, Web of Science, and Cochrane Central in April 2020. Papers reporting on predictors or prognostic models for mortality at 3 months and up to 24 months were assessed on risk-of-bias. We performed a meta-analysis with a fixed or random-effects model, and evaluated the discriminative ability of multivariable prognostic models.

Results

We included 42 studies (49–418,251 patients); 18 studies were included in the meta-analysis. Significant predictors of mortality within 3–24 months in the random-effects model were: previous hospitalization for acute exacerbation (hazard ratio [HR] 1.97; 95% confidence interval [CI] 1.32–2.95), hospital readmission within 30 days (HR 5.01; 95% CI 2.16–11.63), cardiovascular comorbidity (HR 1.89; 95% CI 1.25–2.87), age (HR 1.48; 95% CI 1.38–1.59), male sex (HR 1.68; 95% CI 1.38–1.59), and long-term oxygen therapy (HR 1.74; 95% CI 1.10–2.73). Nineteen previously developed multicomponent prognostic models, as examined in 11 studies, mostly had moderate discriminate ability.

Conclusion

Identified predictors of mortality may aid physicians in selecting COPD patients who may benefit from ACP. However, better discriminative ability of prognostic models or development of a new prognostic model is needed for further large-scale implementation.

Registration: PROSPERO (CRD42016038494), https://www.crd.york.ac.uk/prospero/.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01911-5.

Treatable Traits in COPD - A Proposed Approach

The well-recognized individual heterogeneity within COPD patients has led to a growing interest in greater personalization in the approach of these patients. Thus, the treatable traits strategy has been proposed as a further step towards precision medicine in the management of chronic airway disease, both in stable phase and acute exacerbations. The aim of this paper is to perform a critical review on the treatable traits strategy and propose a guide to approach COPD patients in the light of this new concept. An innovative stepwise approach is proposed - a multidisciplinary model based on two distinct phases, with the potential to be implemented in both primary care and hospital settings. The first phase is the initial and focused assessment of a selected subset of treatable traits, which should be addressed in all COPD patients in both settings (primary care and hospital). As some patients may present with advanced disease at diagnosis or may progress despite this initial treatment requiring a more specialized assessment, they should progress to a second phase, in which a broader approach is recommended. Beyond stable COPD, we explore how the treatable traits strategy may be applied to reduce the risk of future exacerbations and improve the management of COPD exacerbations. Since many treatable traits have already been related to exacerbation risk, the strategy proposed here represents an opportunity to be proactive. Although it still lacks prospective validation, we believe this is the way forward for the future of the COPD approach.

The impact of osteoporosis and vertebral compression fractures on mortality and association with pulmonary function in COPD: A meta-analysis

OBJECTIVE

Osteoporosis is highly prevalent among patients with chronic obstructive pulmonary disease (COPD) and most commonly presents as a vertebral compression fracture (VCF). Our objective was to quantify the effect of osteoporosis and VCFs on the mortality and pulmonary function tests (PFTs), such as forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC), of patients with COPD.

METHODS

A PubMed/Medline search was conducted using the search terms "chronic obstructive pulmonary disease", "osteoporosis" and "vertebral compression fracture". Meta-analyses were conducted to evaluate the differences in mortality and PFTs between patients with COPD with and without osteoporosis or VCFs, according to PRISMA guidelines. PROSPERO registration: CRD42019120335.

RESULTS

Of the 896 abstracts identified, 27 studies describing 7662 patients with COPD of which 1883 (24.6%) had osteoporosis or VCFs, were included. Random effects model analysis demonstrated that patients with COPD and osteoporosis or VCFs had an increased OR for mortality of 2.40 (95% CI: 1.24; 4.64, I²=89%, P<0.01), decreased FEV₁/FVC with a mean difference of -4.80% (95% CI: -6.69; -2.90, I²=83%, P<0.01) and decreased FEV₁, with a mean difference of -4.91% (95% CI: -6.51; -3.31, I²=95%, P<0.01) and -0.41 L (95% CI: -0.59; -0.24, I²=97%, P<0.01), compared to control subjects. Apart from FEV₁ (liters) in subgroup 1 (P=0.06), all subgroup analyses found significant differences between groups, as did sensitivity analysis of low risk of bias studies.

CONCLUSION

Osteoporosis and VCFs are associated with a significant reduction in survival and pulmonary function among patients with COPD.

[Osteoporosis in pneumological diseases : Joint guideline of the Austrian Society for Bone and Mineral Research (ÖGKM) and the Austrian Society for Pneumology (ÖGP)]

Chronic inflammation induces proinflammatory cytokine cascades. In addition to systemic inflammation, hypoxemia, hypercapnia, a catabolic metabolism, gonadal or thyroid dysfunction, musculoskeletal dysfunction and inactivity as well as vitamin D deficiency contribute to an increased risk of fragility fractures. Iatrogenic causes of osteoporosis are long-term use of inhaled or systemic glucocorticoids (GC). Inhalative GC application in asthma is often indicated in childhood and adolescence, but interstitial lung diseases such as chronic organizing pneumonia, COPD, sarcoid or rheumatic diseases with lung involvement are also treated with inhalative or oral GC. In patients with cystic fibrosis, malabsorption in the context of pancreatic insufficiency, hypogonadism and chronic inflammation with increased bone resorption lead to a decrease in bone structure. After lung transplantation, immunosuppression with GC is a risk factor.The underlying pneumological diseases lead to a change in the trabecular and cortical bone microarchitecture and to a reduction in osteological formation and resorption markers. Hypercapnia, acidosis and vitamin D deficiency can accelerate this process and thus increase the individual risk of osteoporotic fragility fractures.A bone mineral density measurement with a T‑Score < -2.5 is a threshold value for the diagnosis of osteoporosis; in contrast the vast majority of all osteoporotic fractures occur with a T‑Score > -2.5. A history of low-trauma fracture indicates osteological therapy.All antiresorptive or anabolic drugs approved in Austria for the treatment of osteoporosis are also indicated for pneumological patients with an increased fragility fracture risk of bone fractures in accordance with the national reimbursement criteria.

Muscle-Bone Crosstalk in Chronic Obstructive Pulmonary Disease

Sarcopenia and osteoporosis are common musculoskeletal comorbidities of chronic obstructive pulmonary disease (COPD) that seriously affect the quality of life and prognosis of the patient. In addition to spatially mechanical interactions, muscle and bone can also serve as endocrine organs by producing myokines and osteokines to regulate muscle and bone functions, respectively. As positive and negative regulators of skeletal muscles, the myokines irisin and myostatin not only promote/inhibit the differentiation and growth of skeletal muscles, but also regulate bone metabolism. Both irisin and myostatin have been shown to be dysregulated and associated with exercise and skeletal muscle dysfunction in COPD. During exercise, skeletal muscles produce a large amount of IL-6 which acts as a myokine, exerting at least two different conflicting functions depending on physiological or pathological conditions. Remarkably, IL-6 is highly expressed in COPD, and considered to be a biomarker of systemic inflammation, which is associated with both sarcopenia and bone loss. For osteokines, receptor activator of nuclear factor kappa-B ligand (RANKL), a classical regulator of bone metabolism, was recently found to play a critical role in skeletal muscle atrophy induced by chronic cigarette smoke (CS) exposure. In this focused review, we described evidence for myokines and osteokines in the pathogenesis of skeletal muscle dysfunction/sarcopenia and osteoporosis in COPD, and proposed muscle-bone crosstalk as an important mechanism underlying the coexistence of muscle and bone diseases in COPD.

Quantitative Vertebral Bone Density Seen on Chest CT in Chronic Obstructive Pulmonary Disease Patients: Association with Mortality in the Korean Obstructive Lung Disease Cohort

Objective

Patients with chronic obstructive pulmonary disease (COPD) are known to be at risk of osteoporosis. The purpose of this study was to evaluate the association between thoracic vertebral bone density measured on chest CT (D_Thorax) and clinical variables, including survival, in patients with COPD.

Materials and Methods

A total of 322 patients with COPD were selected from the Korean Obstructive Lung Disease (KOLD) cohort. D_Thorax was measured by averaging the CT values of three consecutive vertebral bodies at the level of the left main coronary artery with a round region of interest as large as possible within the anterior column of each vertebral body using an in-house software. Associations between D_Thorax and clinical variables, including survival, pulmonary function test (PFT) results, and CT densitometry, were evaluated.

Results

The median follow-up time was 7.3 years (range: 0.1–12.4 years). Fifty-six patients (17.4%) died. D_Throax differed significantly between the different Global Initiative for Chronic Obstructive Lung Disease stages. D_Throax correlated positively with body mass index (BMI), some PFT results, and the six-minute walk distance, and correlated negatively with the emphysema index (EI) (all p < 0.05). In the univariate Cox analysis, older age (hazard ratio [HR], 3.617; 95% confidence interval [CI], 2.119–6.173, p < 0.001), lower BMI (HR, 3.589; 95% CI, 2.122–6.071, p < 0.001), lower forced expiratory volume in one second (FEV₁) (HR, 2.975; 95% CI, 1.682–5.262, p < 0.001), lower diffusing capacity of the lung for carbon monoxide corrected with hemoglobin (DL_CO) (HR, 4.595; 95% CI, 2.665–7.924, p < 0.001), higher EI (HR, 3.722; 95% CI, 2.192–6.319, p < 0.001), presence of vertebral fractures (HR, 2.062; 95% CI, 1.154–3.683, p = 0.015), and lower D_Thorax (HR, 2.773; 95% CI, 1.620–4.746, p < 0.001) were significantly associated with all-cause mortality and lung-related mortality. In the multivariate Cox analysis, lower D_Thorax (HR, 1.957; 95% CI, 1.075–3.563, p = 0.028) along with older age, lower BMI, lower FEV₁, and lower DL_CO were independent predictors of all-cause mortality.

Conclusion

The thoracic vertebral bone density measured on chest CT demonstrated significant associations with the patients' mortality and clinical variables of disease severity in the COPD patients included in KOLD cohort.

COPD and Osteoporosis: Associated Factors in Patients Treated with Inhaled Corticosteroids

Purpose

Osteoporosis is a systemic skeletal disease with a consequent increase in fractures rates. Osteoporosis may be primary which is related with normal aging, or secondary which occurs in the presence of an underlying disease or medication. Osteoporosis is one of the significant comorbidities in chronic obstructive pulmonary disease (COPD). In this study, we aimed to investigate the presence of osteoporosis and the influencing factors in COPD patients.

Patients and Methods

This is a two-group comparison study that was conducted among 30 COPD patients on inhaled corticosteroid (ICS) and 33 controls. It was conducted in the outpatient clinics at the Departments of Physical Medicine and Rehabilitation and Pulmonary Diseases in Bursa Uludag University Hospital, a tertiary reference center, in the northwest region of Turkey. For both groups, demographic variables, osteoporosis risk questioning, body mass index (BMI), bone mineral density (BMD), biochemical blood tests, vertebral fractures on lumbar and thoracic x-rays were recorded. COPD patients were also evaluated for lung functions via spirometry.

Results

Thirty patients with COPD (Group 1) and 33 controls (Group 2) were included in the study. Comparing the demographic and biochemical data, no difference was found between the groups except smoking (pack/year) (p<0.001) and erythrocyte sedimentation rate (p<0.001), which were significantly high in COPD group. BMD in the COPD group was significantly lower in both hip and lumbar regions compared with the controls. There were significant correlations between L2 BMD values and pulmonary function tests. BMI was significantly low in osteoporotic COPD patients when compared with the non-osteoporotic COPD patients (p=0.002).

Conclusion

In patients with COPD using inhaled corticosteroids, BMD was significantly low compared with the controls. Osteoporotic COPD patients had significantly lower BMI than non-osteoporotic. These findings suggest that pulmonary dysfunction and low BMI are associated with osteoporosis in COPD patients.

Association of sarcopenia with osteoporosis in patients with chronic obstructive pulmonary disease

Objectives

Systemic consequence of Chronic Obstructive Pulmonary Disease (COPD) is associated with progressive loss of muscle mass and function. Preliminary studies showed presence of sarcopenia in COPD leads to reduced pulmonary function and quality of life; studies on whether this condition results in consequent loss of bone mineral density (BMD) is still inconsistent. This study aims to examine the association of sarcopenia in COPD with osteoporosis.

Methods

This is a post-hoc analysis of a study on forty-one (n = 41) participants with COPD seen in a tertiary public hospital in Manila, Philippines who underwent pulmonary function test and dual-energy x-ray absorptiometry. Sarcopenia was defined using a Philippine-based criteria of low fat free mass index (FFMI) and low muscle strength - hand grip strength, and osteoporosis using World Health Organization T-score diagnostic criteria.

Results

The prevalence of osteoporosis among COPD is 44%, and 63% in COPD with sarcopenia. There was no statistical difference seen in pulmonary function variables between COPD with and without osteoporosis. Significant positive correlations were observed between Forced Expiratory Volume in 1 s, FFMI, and appendicular lean muscle with total body BMD. Sarcopenia in COPD was associated with significantly increased risk for osteoporosis.

Conclusions

High prevalence rate of osteoporosis, and even higher among sarcopenic Filipino COPD patients should be further studied. The findings also suggest that sarcopenia in COPD is associated with increased risk of osteoporosis, and osteoporosis alone does not seem to affect lung function.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Back Pain-Inducing Test, a Novel and Sensitive Screening Test for Painful Osteoporotic Vertebral Fractures: A Prospective Clinical Study

To detect painful vertebral fractures (VFs) in back pain populations at risk of osteoporosis, we designed a physical examination test (the Back Pain-Inducing Test [BPIT]) that included three movements: lying supine, rolling over, and sitting up. If back pain is induced during any of these movements, the result is defined as positive, thereby establishing a presumptive diagnosis of painful VFs. Pain severity is quantified using a self-reported numerical rating scale (NRS). The presence or absence of painful VFs is verified by whole-spine magnetic resonance imaging (MRI), the gold standard for final diagnosis. According to the standards for reporting diagnostic accuracy, a real-world, prospective, and observational study was performed on 510 back pain patients (enrolled from a single institute) at risk of osteoporosis. The sensitivity, specificity, and accuracy of the BPIT for identifying painful VFs were 99.1% (95% CI, 97.5% to 99.8%), 67.9% (95% CI, 60.4% to 74.5%), and 89.0%, respectively. The positive and negative predictive values were 86.6% (95% CI, 82.9% to 89.6%) and 97.4% (95% CI, 92.6% to 99.3%), respectively. Cutoff NRS scores for lying supine, rolling over, and sitting up were 3, 0, and 2, respectively. The corresponding area under the receiver operating characteristic curves (AUROCs) of each movement was 0.898 (95% CI, 0.868 to 0.922), 0.884 (95% CI, 0.854 to 0.911), and 0.910 (95% CI, 0.882 to 0.933), respectively. Although the high prevalence of VFs in the enrolled cohort partially limits the external validity of the predictive value in the general population, we conclude that the BPIT is potentially effective for detecting painful VFs in back pain populations at risk of osteoporosis. This test may be used as a stratification tool in decision-making on subsequent imaging procedures: a negative BPIT rules out painful VFs and indicates that an MRI should be spared, whereas a positive BPIT means that an MRI is necessary and is likely to identify painful VFs. © 2019 American Society for Bone and Mineral Research.

Prescription Synthetic Oral Cannabinoid use Among Older Adults with Chronic Obstructive Pulmonary Disease: A Population-Based Cohort Study

BACKGROUND

Synthetic oral cannabinoids (nabilone and dronabinol) may have adverse respiratory effects. Our purpose was to describe the scope, pattern, and patient characteristics associated with incident off-label synthetic oral cannabinoid use among older adults with chronic obstructive pulmonary disease (COPD) compared to older adults without COPD.

METHODS

This was a retrospective, population-based, cohort study using Ontario, Canada, heath administrative data. Individuals aged 66 years or older were included, and physician-diagnosed COPD was identified using a previously validated, highly specific algorithm. Incident off-label oral cannabinoid use was examined between April 1, 2005 and March 31, 2015. Descriptive statistics were used to describe drug use patterns. Multiple logistic regression was used to identify patient characteristics associated with incident drug use.

RESULTS

There were 172,282 older adults with COPD and 1,068,256 older adults without COPD identified between April 1, 2005 and March 31, 2015. Incident synthetic oral cannabinoid use during this period occurred with significantly greater (p < 0.001) frequency among older adults with COPD (0.6%) versus older adults without COPD (0.3%). Compared to those without COPD, older adults with COPD used synthetic cannabinoids for significantly longer durations and more frequently at higher doses.

CONCLUSIONS

Although incident off-label oral cannabinoid use was relatively low among all older Ontarian adults, this drug class was used with greater frequency and more often in potentially concerning ways among older adults with COPD. These findings raise possible safety concerns, but further research on the respiratory safety of oral cannabinoids among individuals with COPD is needed.

Prevalence and Risk Factors for Osteoporosis in Individuals With COPD: A Systematic Review and Meta-analysis

BACKGROUND

Osteoporosis is prevalent in individuals with COPD. Updated evidence is required to complement the previous systematic review on this topic to provide best practice. The aim of this systematic review and meta-analysis was to quantitatively synthesize data from studies with respect to the prevalence and risk factors for osteoporosis among individuals with COPD.

METHODS

EMBASE, CINAHL, MEDLINE, and PubMed databases were searched for articles containing the key words "COPD," "osteoporosis," "prevalence," and "risk factor." Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. Meta-analyses were performed to determine osteoporosis prevalence and risk factors in individuals with COPD. Meta-regression analyses were conducted to explore the sources of heterogeneity.

RESULTS

The pooled global prevalence from 58 studies was 38% (95% CI, 34-43). The presence of COPD increased the likelihood of having osteoporosis (OR, 2.83). Other significant risk factors for osteoporosis in COPD patients were BMI < 18.5 kg/m² (OR, 4.26) and the presence of sarcopenia (OR, 3.65).

CONCLUSIONS

Osteoporosis is prevalent in individuals with COPD, and the prevalence seems to be high and similar in many countries. Patients with COPD should be screened for osteoporosis and contributing risk factors.

Frequency of Osteoporosis and Vertebral Fractures in Chronic Obstructive Pulmonary Disease (COPD) Patients

BACKGROUND

Osteoporosis is a systemic skeletal disease characterized by low bone mass and/or microarchitectural deterioration of bone. Osteoporosis is a risk factor for fractures specially in patients with advanced COPD. The aim of this cross-sectional study was to determine the frequency of osteoporosis and vertebral fracture in COPD patients.

METHODS

We evaluated 91 COPD patients and compared to 82 healthy subjects (control group) matched for gender and age. We measured the bone mineral density by means of dual energy X-ray absorptiometry (DXA), evaluating the lumbar vertebra (L1-L4), proximal femur and total femur and evaluated vertebral fractures in thoracic and lumbar spine using X-ray. We questioned patients whether they had had any fall that resulted in any fracture in the past five years.

RESULTS

Males comprised 60.4% of COPD group and 57.3% of the control group. Mean age was 66.2±9.2 years for COPD group and 64.2±8.8 for the control group. The frequency of osteoporosis in the COPD group was 29.7% and 18.3% in control group (p=0.007). The frequency of vertebral fractures was 18.6% in the COPD group and 9.0% in control group (p=0.06). The frequency of reported falls at resulting in any fracture was 36.3% in the COPD group and 7.3% in control group (p=0.001).

CONCLUSIONS

Our data indicate that COPD patients present a high frequency of osteoporosis and falls seem to be an important factor for vertebral fracture.

Increased rate of osteoporosis, low lean mass, and fragility fractures in COPD patients: association with disease severity

A very high rate of osteoporosis, fractures, and low lean mass was observed in patients with chronic obstructive pulmonary disease (COPD). Disease severity was associated with bone and muscle adverse outcomes, while age ≥ 63.5 years old, low lean mass, higher iPTH, and a T-score below - 2.5 were all associated with higher risk of fracture.

INTRODUCTION

Osteoporosis is frequently neglected in patients with COPD. We aimed at evaluating the rate of osteoporosis, fractures, and low lean mass in patients with COPD.

METHODS

Ninety-nine patients with COPD (53 women, 64.5 ± 9.6 years old, and 46 men, 65.9 ± 8.0 years old) underwent bone densitometry (DXA) with body composition analyses. Healthy individuals (N = 57) not exposed to tobacco matched by sex, age, and body mass index (BMI) were used as controls. Spirometry, routine laboratory workout, and conventional thoracolumbar radiography surveying for vertebral deformities were performed in all patients.

RESULTS

Osteoporosis was found in 40.4% of the COPD patients against only 13.0% of the healthy controls (p = 0.001). Vertebral fractures were seen in 24.4% of the men and 22.0% of the women with COPD. Disease severity (GOLD 3 and 4) was significantly associated with higher risk of vitamin D deficiency (p = 0.032), lower BMD (both men and women at all sites), higher frequency of osteoporosis (in women at all sites), lower skeletal mass index, and higher rate of low lean mass (in both men and women) than healthy controls and COPD patients with milder disease (GOLD 1 and 2). Age was a main predictor of vertebral fractures (OR = 1.164 (1.078-9.297); p < 0.001), while high plasma iPTH (OR = 1.045 (1.005-1.088); p = 0.029) and low ALM (OR = 0.99965 (0.99933-0.99997); p = 0.031) were predictors of non-vertebral fractures.

CONCLUSION

Highly prevalent in COPD, osteoporosis and low lean mass were associated with FEV_1% < 50%. Age, low lean mass, high iPTH, and low bone mass were all significantly associated with fractures in COPD patients.

GOLD Staging System is Appropriate to Predict Mortality in Older People With Chronic Obstructive Pulmonary Disease

INTRODUCTION

In the new GOLD classification the reduction of FEV1, expressed as percentage of predicted value (FEV1PP), is considered an important prognostic factor. However, the use of FEV1PP may introduce bias, especially if based on equations derived from populations different from the one under study. We evaluated how well the GOLD classification stratifies the mortality risk when FEV1PP is based on an equation developed in the same population that gave rise to cases, externally developed equations, or as FEV1 divided by cubed height (FEV1/Ht3).

METHODS

We studied 882 participants aged ≥65 years. Bronchial obstruction was defined using a fixed cut-off of 0.7 for FEV1/FVC. Predicted values of FEV1 were derived from equations based on the same sample of the cases included in this study and from the European Respiratory Society equations. Severity of bronchial obstruction was also classified according to quartiles of FEV1/Ht3.

RESULTS

All the classification systems showed a non-statistically significant linear tendency with 5-years mortality risk. For the 15-years mortality, the linear trend across severity stages is more evident for GOLD classifications, with significant increments in the hazard ratio. Stratification by FEV1/Ht3 could better discriminate the functional status of participants.

CONCLUSION

The severity of bronchial obstruction according to GOLD classes may stratify mortality risk better than quartiles of FEV1/Ht3, whereas the second seems to be more suited to stratify the risk of clinical outcomes. Concerns about the use of externally developed reference values to calculate FEV1PP do not seem confirmed, at least for GOLD classification.