Acute exacerbations of COPD: risk factors for failure and relapse

Treatment pathways, economic burden and clinical outcomes in new users of inhaled corticosteroid/long-acting B2-agonist dual therapy with chronic obstructive pulmonary disease in a primary care setting in England: a retrospective cohort study

OBJECTIVE

Management of chronic obstructive pulmonary disease (COPD) with inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) improves lung function and health status and reduces COPD exacerbation risk versus monotherapy. This study described treatment use, healthcare resource utilisation (HCRU), healthcare costs and outcomes following initiation of single-device ICS/LABA as initial maintenance therapy (IMT).

DESIGN

Retrospective cohort study.

SETTING

Primary care, England.

DATA SOURCES

Linked data from the Clinical Practice Research Datalink Aurum and Hospital Episode Statistics datasets.

PARTICIPANTS

Patients with COPD and ≥1 single-device ICS/LABA prescription between July 2015 and December 2018 were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Treatment pathways, COPD-related HCRU and healthcare costs, COPD exacerbations, time to triple therapy, medication adherence (proportion of days covered ≥80%) and indexed treatment time to discontinuation. Data for patients without prior maintenance therapy history (IMT users) and non-triple users were assessed over a 12-month follow-up period.

RESULTS

Of 13 451 new ICS/LABA users, 5162 were IMT users (budesonide/formoterol, n=1056; beclomethasone dipropionate/formoterol, n=2427; other ICS/LABA, n=1679), for whom at 3 and 12 months post-index, 45.6% and 39.4% were still receiving any ICS/LABA. At >6 to ≤12 months, the proportion of IMT users with ≥1 outpatient visit (10.1%) and proportion with ≥1 inpatient stay (12.6%) had increased from those at 3 months (9.0% and 7.4%, respectively). Inpatient stays contributed most to total COPD-related healthcare costs. For non-triple IMT users, at 3 and 12 months post-index, 4.5% and 13.7% had ≥1 moderate-to-severe COPD exacerbation. Time to triple therapy initiation and time to discontinuation of index medication ranged from 45.9 to 50.2 months and 2.3 to 2.8 months between treatments. Adherence was low across all time points (21.5-27.6%). Results were similar across indexed therapies.

CONCLUSIONS

In the year following treatment initiation, ICS/LABA adherence was poor and many patients discontinued or switched therapies, suggesting that more consideration and optimisation of treatment is required in England for patients initiating single-device ICS/LABA therapy.

Association Between Rome Classification Among Hospitalized Patients With COPD Exacerbations and Short-Term and Intermediate-Term Outcomes

BACKGROUND

Recently, the Rome proposal updated the definition of exacerbation of COPD (ECOPD). However, such severity grade has not yet demonstrated intermediate-term clinical relevance.

RESEARCH QUESTION

What is the association between the Rome severity classification and short-term and intermediate-term clinical outcomes?

STUDY DESIGN AND METHODS

We retrospectively grouped hospitalized patients with ECOPD according to the Rome severity classification (ie, mild, moderate, severe). Baseline, clinical, microbiologic, gas analysis, and laboratory variables were collected. In addition, data about the length of hospital stay and mortality (in-hospital and a follow-up time line from 6 months until 3 years) were assessed.

RESULTS

Of the 347 hospitalized patients, 39% were categorized as mild, 31% were categorized as moderate, and 30% were categorized as severe. Overall, patients with severe ECOPD had an extended length of hospital stay. Although in-hospital mortality was similar among groups, patients with severe ECOPD presented a worse prognosis in all follow-up time points. The Kaplan-Meier curves show the role of the severe classification in the cumulative survival at 1 and 3 years (Gehan-Breslow-Wilcoxon test, P = .032 and P = .004, respectively). The multivariable Cox regression analysis showed a higher risk of death at 1 year when patients presented a severe (hazard ratio, 1.99; 95% CI, 1.49-2.65) or moderate grade (hazard ratio, 1.47; 95% CI, 1.10-1.97) compared with a mild grade. Older patients (aged ≥ 80 years), patients requiring long-term oxygen therapy, or patients reporting previous ECOPD episodes had a higher mortality risk. A BMI between 25 and 29 kg/m2 was associated with a lower risk.

INTERPRETATION

The Rome classification makes it possible to discriminate patients with a worse prognosis (severe or moderate) until a 3-year follow-up.

Endobronchial lung volume reduction with valves reduces exacerbations in severe emphysema patients

BACKGROUND AND OBJECTIVE

Exacerbations drive the progression of chronic obstructive pulmonary disease (COPD). Endoscopic lung volume reduction (ELVR) with valves is an established treatment option for patients with severe emphysema. Post-interventional exacerbations are observed in 8-17% of cases. Whether the exacerbation rate changes in the medium term after ELVR, is not known.

METHODS

This is a single-center retrospective analysis of severe emphysema patients with endobronchial valve implantation. The number of exacerbations before and after ELVR was compared, including lung function parameters, exercise capacity and degree of lung volume reduction. The primary endpoint of the study was the number of exacerbations one year after ELVR compared to one year before ELVR.

RESULTS

129 patients (mean age 64.1 ± 7.7 years, 57% female, mean FEV1 0.8 ± 0.2 l, mean RV 243.4 ± 54.9 %) with ELVR in the years 2016-2019 and complete exacerbation history were analyzed. Patients experienced a mean of 2.5 ± 2.2 moderate and severe exacerbations in the year before ELVR. The number of exacerbations decreased significantly to 1.8 ± 2.2 exacerbations in the first year after ELVR (p = 0.009). The decrease in exacerbation rate was associated with the development of complete lobar atelectasis (r = 0.228. p = 0.009). Accordingly, in 41 patients with complete lobar atelectasis, the decrease in exacerbation rate was higher from 2.8 ± 2.0 to 1.4 ± 1.8 exacerbations (p < 0.001).

CONCLUSIONS

ELVR with valves appears promising to reduce the exacerbation rate in COPD patients, especially when the full treatment benefit of complete lobar atelectasis is achieved.

Prognostic Value of Neutrophil to Lymphocyte Ratio for Predicting 90-Day Poor Outcomes in Hospitalized Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objective

This study aimed to evaluate the predictive value of neutrophil to lymphocyte ratio (NLR) for poor outcomes within 90-day in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

A retrospective study including 503 AECOPD patients was performed, and the subjects' clinical characteristics were collected. Binary logistic regression analysis was used to identify risk factors for 90-day poor outcomes in patients with AECOPD. Receiver-operating characteristic curves (ROC) and areas under the curves (AUC) were used to assess the ability of different biomarkers to predict the risk of 90-day mortality, readmission and re-exacerbation in patients with AECOPD.

Results

During the follow-up, 188 patients (38.4%) redeveloped exacerbations, 112 patients (22.9%) were readmitted, and 20 patients (4.1%) died directly resulted from COPD or COPD-related causes. Multivariate analysis demonstrated that age>72 years (OR: 14.817, 95% CI: 1.561-140.647), NLR>14.17 (OR: 9.611, 95% CI: 2.303-40.113), EOS<0.15% (OR: 8.621, 95% CI: 3.465-34.913) and BNP>2840ng/L (OR: 5.291, 95% CI: 1.367-20.474) at discharge were independent risk factors for 90-day mortality in AECOPD patients. NLR was the optimal biomarker for predicting 90-day mortality with an AUC of 0.802 (95% CI: 0.631-0.973). Using 14.17 as the critical value of NLR, the sensitivity was 76.7%, and the specificity was 88.9%. Compared with mortality, NLR had no significant advantage in predicting risk of short-term re-exacerbation (AUC=0.580, 95% CI:0.529-0.632, p=0.001) and readmission (AUC=0.555, 95% CI:0.497-0.614, p=0.045), with AUCs less than 0.6. In contrast, the predictive value of EOS (AUC=0.561, 95% CI:0.502-0.621, p=0.038) was slightly better than NLR in terms of readmission within 90 days. CRP did not serve as a well predictive biomarker for the risk of readmission and re-deterioration (p>0.05).

Conclusion

NLR is of great value in predicting the risk of poor outcomes, especially COPD associated mortality, in hospitalized patients with AECOPD within 90 days after discharge.

Association between cadmium exposure and pulmonary function reduction: Potential mediating role of telomere attrition in chronic obstructive pulmonary disease patients

BACKGROUND

Environmental cadmium (Cd) exposure is linked to pulmonary function injury in the general population. But, the association between blood Cd concentration and pulmonary function has not been investigated thoroughly in chronic obstructive pulmonary disease (COPD) patients, and the potential mechanisms are unclear.

METHODS

All eligible 789 COPD patients were enrolled from Anhui COPD cohort. Blood specimens and clinical information were collected. Pulmonary function test was conducted. The subunit of telomerase, telomerase reverse transcriptase (TERT), was determined through enzyme linked immunosorbent assay (ELISA). Blood Cd was measured via inductively coupled-mass spectrometer (ICP-MS).

RESULTS

Blood Cd was negatively and dose-dependently associated with pulmonary function. Each 1-unit increase of blood Cd was associated with 0.861 L decline in FVC, 0.648 L decline in FEV1, 5.938 % decline in FEV1/FVC %, and 22.098 % decline in FEV1 % among COPD patients, respectively. Age, current-smoking, self-cooking and higher smoking amount aggravated Cd-evoked pulmonary function decrease. Additionally, there was an inversely dose-response association between Cd concentration and TERT in COPD patients. Elevated TERT obviously mediated 29.53 %, 37.50 % and 19.48 % of Cd-evoked FVC, FEV1, and FEV1 % declines in COPD patients, respectively.

CONCLUSION

Blood Cd concentration is strongly associated with the decline of pulmonary function and telomerase activity among COPD patients. Telomere attrition partially mediates Cd-induced pulmonary function decline, suggesting an underlying mechanistic role of telomere attrition in pulmonary function decline from Cd exposure in COPD patients.

Factors Associated with the Non-Exacerbator Phenotype of Chronic Obstructive Pulmonary Disease

Background

Patients with chronic obstructive pulmonary disease (COPD) and no exacerbations may need less maintenance treatment and follow-up. The aim was to identify factors associated with a non-exacerbator COPD phenotype.

Methods

Cross-sectional analysis of 1354 patients from primary and secondary care, with a doctor's diagnosis of COPD. In 2014, data on demographics, exacerbation frequency and symptoms using COPD Assessment Test (CAT) were collected using questionnaires and on spirometry and comorbid conditions by record review. The non-exacerbator phenotype was defined as having reported no exacerbations the previous six months. Multivariable logistic regression with the non-exacerbator phenotype as dependent variable was performed, including stratification and interaction analyses by sex.

Results

The non-exacerbator phenotype was found in 891 (66%) patients and was independently associated with COPD stage 1 (OR [95% CI] 5.72 [3.30-9.92]), stage 2 (3.42 [2.13-5.51]) and stage 3 (2.38 [1.46-3.88]) compared with stage 4, and with CAT score <10 (3.35 [2.34-4.80]). Chronic bronchitis and underweight were inversely associated with the non-exacerbator phenotype (0.47 [0.28-0.79]) and (0.68 [0.48-0.97]), respectively. The proportion of non-exacerbators was higher among patients with no maintenance treatment or a single bronchodilator. The association of COPD stage 1 compared with stage 4 with the non-exacerbator phenotype was stronger in men (p for interaction 0.048). In women, underweight and obesity were both inversely associated with the non-exacerbator phenotype (p for interaction 0.033 and 0.046 respectively), and in men heart failure was inversely associated with the non-exacerbator phenotype (p for interaction 0.030).

Conclusion

The non-exacerbator phenotype is common, especially in patients with no maintenance treatment or a single bronchodilator, and is characterized by preserved lung function, low symptom burden, and by absence of chronic bronchitis, underweight and obesity and heart failure. We suggest these patients may need less treatment and follow-up, but that management of comorbid conditions is important to avoid exacerbations.

Prevention of Re-Hospitalization for Acute Exacerbations: Perspectives of People with Chronic Obstructive Pulmonary Disease: A Qualitative Study

Purpose

Current guidelines for prevention of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) reflect clinical understanding of the causes of exacerbations but with a limited recognition of person-specific contributing factors. As part of a randomized trial of a person-centered intervention aiming to promote self-determination, we describe personal perspectives of those with chronic obstructive pulmonary disease (COPD) on what they saw as the causes and best ways to stay well and prevent rehospitalization after an AECOPD.

Patients and Methods

Twelve participants (mean age 69.3 years, six female, six male; eight New Zealand European, two Māori, one Pacific, and one other) were interviewed about their experiences of staying well and out of hospital. Data were collected via individual semi-structured interviews one year following an index hospital admission for AECOPD and focused on the participants' views and experiences of their health condition, their beliefs about staying well, and the causes of and factors preventing further exacerbations and hospitalizations. Data were analyzed using constructivist grounded theory methods.

Results

Three main themes were identified that described participants' views on what helped or hindered them to stay well and out of hospital: 1) Being Positive: The importance of having a positive mindset; 2) Being Proactive: Practical steps to reduce the risk of, and consequences from, episodes of AECOPD; and 3) Being in Control: Feeling in command of one's life and health. Each of these was affected by Being Connected: The influence of significant others, particularly close family.

Conclusion

This research expands our understanding of how patients manage COPD and adds patient perspectives to current knowledge on how to prevent recurrent AECOPD. Programs which promote self-efficacy and positivity would be beneficial additions to AECOPD prevention strategies, as could the inclusion of family or significant others in wellbeing plans.

The Significance of Implementing Bilevel Positive Airway Pressure under Cluster Nursing in Improving the Survival Possibility of Patients with Severe Pulmonary Infection Complicated by Respiratory Failure

Objective. To explore the significance of bilevel positive airway pressure (BIPAP) under cluster nursing in improving the survival probability of patients with severe pulmonary infection (SPI) complicated by respiratory failure (RF). Methods. This research included 153 SPI patients complicated by RF ( $\text{SPI}+\text{RF}$ ) admitted between January 2020 and March 2022, including 55 cases in group A who were treated with BIPAP under cluster care during hospitalization, 47 cases in group B receiving invasive continuous mechanical ventilation during hospitalization, and 51 cases in group C treated with BIPAP under routine care during hospitalization. The three cohorts were compared regarding pre- and posttreatment serum inflammatory factors (IFs), blood gas (BG) parameters, heart rate (HR), and respiratory rate (RR). Besides, the cumulative time of ventilator use, successful ventilator weaning rate, mortality, and incidence of adverse events were counted. Finally, patients were scored for their psychological state using the Hamilton Anxiety/Depression Scale (HAMA/HAMD). Results. The posttreatment TNF-α, IL-6, PCT, WBC, and PaCO2 reduced statistically in all the three groups, with the lowest levels found in group A and the highest in group B ( $P<0.05$ ); while PaO2 and SpO2 increased, with the highest values found in group A and the lowest in group B ( $P<0.05$ ). Among the three groups, group A had the shortest duration of ventilator use, the highest successful weaning rate, and the lowest incidence of adverse events ( $P<0.05$ ). Besides, HAMA and HAMD scores were the lowest in group A among the three groups, while those in group B were higher compared with group C ( $P<0.05$ ). Conclusion. The implementation of BIPAP under cluster nursing can effectively reduce inflammatory responses of $\text{SPI}+\text{RF}$ patients, improve their vital signs, and enhance their psychological state, which has extremely high clinical application value.

Mortality outcomes associated with invasive aspergillosis among acute exacerbation of chronic obstructive pulmonary disease patient population

BACKGROUND

Literature regarding trends of mortality, and complications of aspergillosis infection among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is limited.

METHODS

Data from the National Readmissions Database (NRD) that constitutes 49.1% of the stratified sample of all hospitals in the United States (US), representing more than 95% of the national population were analyzed for hospitalizations with aspergillosis among AECOPD. Predictors and trends related to aspergillosis in AECOPD were evaluated. A Linear p-trend was used to assess the trends.

RESULTS

Out of the total 7,282,644 index hospitalizations for AECOPD (mean age 69.17 ± 12.04years, 55.3% females), 8209 (11.2/10,000) with primary diagnosis of invasive aspergillosis were recorded in the NRD for 2013-2018. Invasive aspergillosis was strongly associated with mortality (OR 4.47, 95%CI 4.02-4.97, p < 0.001) among AECOPD patients. Malignancy and organ transplant status were predominant predictors of developing aspergillosis among AECOPD patients. The IA-AECOPD group had higher rates of multi-organ manifestations including ACS (3.7% vs 0.44%; p-value0.001), AF (20% vs 18.4%; p-value0.001), PE (4.79% vs1.87%; p-value0.001), AKI (22.3% vs17.5%; p-value0.001), ICU admission (16.5% vs11.9%; p-value0.001), and MV (22.3% vs7.31%; p-value0.001) than the AECOPD group. The absolute yearly trend for mortality of aspergillosis was steady (linear p-trend 0.22) while the yearly rate of IA-AECOPD had decreased from 15/10,000 in 2013 to 9/10,000 in 2018 (linear p-trend 0.02).

INTERPRETATION

Aspergillosis was related with high mortality among AECOD hospitalizations. There has been a significant improvement in the yearly rates of aspergillosis while the mortality trend was steady among aspergillosis subgroups. Improved risk factor management through goal-directed approach may improve clinical outcomes.

Circulating JNK pathway-associated phosphatase: A novel biomarker correlates with Th17 cells, acute exacerbation risk, and severity in chronic obstructive pulmonary disease patients

Background

JNK pathway‐associated phosphatase (JKAP) involves in the regulation of inflammation, immunity, and lung injury. The current study aimed to investigate correlation of JKAP with Th1, Th17 cells, acute exacerbation risk, and disease severity in chronic obstructive pulmonary disease (COPD) patients.

Methods

Totally, 45 stable COPD (SCOPD) patients, 45 acute exacerbation COPD (AECOPD) patients, and 45 controls were enrolled. Serum was collected for JKAP, interferon‐gamma (IFN‐γ) (Th1 cytokine), and interleukin 17 (IL‐17) (Th17 cytokine) detection. Besides, peripheral blood mononuclear cell from COPD patients was collected for evaluating Th1 and Th17 cells.

Results

JKAP was highest in controls followed by SCOPD patients and lowest in AECOPD patients (median: 105.673 vs. 75.374 vs. 41.807 pg/ml, p < 0.001). Meanwhile, receiver operating characteristic (ROC) curves revealed that JKAP differentiated the AECOPD patients from the controls (area under curve (AUC): 0.910 (95% confidence interval (CI): 0.849–0.970)) and AECOPD patients from SCOPD patients (AUC: 0.726 (95% CI: 0.622–0.830)). Moreover, JKAP positively correlated with FEV₁ (%predicted) in AECOPD patients (r = 0.347 p = 0.019). Additionally, JKAP was negatively correlated with the GOLD stage in AECOPD patients (r = −0.344, p = 0.021) and SCOPD patients (r = −0.357, p = 0.016). Whereas, JKAP was not associated with other clinical features (all p > 0.05). Besides, JKAP was negatively linked with Th17 cells (r = −0.378, p = 0.010), IFN‐γ (r = −0.358, p = 0.016), IL‐17 (r = −0.414, p = 0.005) in AECOPD patients and Th17 cells (r = −0.342, p = 0.022), IL‐17 (r = −0.299, p = 0.046) in SCOPD patients.

Conclusion

Downregulated JKAP correlates with Th17 cells, higher acute exacerbation risk, and severity in COPD patients, indicating its underlying potency as a biomarker for COPD.

Overcoming Therapeutic Inertia to Reduce the Risk of COPD Exacerbations: Four Action Points for Healthcare Professionals

Background

Therapeutic inertia, defined as failure to escalate or initiate adequate therapy when treatment goals are not met, contributes to poor management of COPD exacerbations.

Methods

A multidisciplinary panel of five expert clinicians actively managing COPD and representative of UK practice developed action points to reduce exacerbation risk, based on evidence, clinical expertise, and experience. The action points are applicable despite changing circumstances (eg, virtual clinics). The panel agreed areas where further evidence is needed.

Results

The four action points were (1) an experienced HCP, such as a GP or member of the multi-professional COPD team should review patients within one month of every exacerbation that requires oral steroids, antibiotics, or hospitalization to address modifiable risk factors, optimize non-pharmacological measures, and evaluate pharmacological therapy. (2) Presenting to hospital with an exacerbation defines an important window of opportunity to reduce the risk of further exacerbations. Follow-up by a GP, or member of the multi-professional specialist COPD team within one month of discharge with a full management review and appropriate escalation of pharmacological treatment is essential. (3) Healthcare professionals (HCPs) in all healthcare settings should be able to recognize COPD exacerbations, refer as appropriate and document the episode accurately in medical records across service boundaries. HCPs should support patients to recognize and report exacerbations. (4) HCPs should intervene proactively based on risk assessments, disease activity and any treatable traits at or as soon as possible after diagnosis and annually thereafter. Delivering these action points needs coordinated action with policymakers, funders, and service providers.

Conclusion

These action points should be a fundamental part of clinical practice to determine if a change in management is necessary to reduce the risk of exacerbations. Policymakers should use these action points to develop systems and initiatives that reduce the risk of further exacerbations.

Predicting treatment outcomes following an exacerbation of airways disease

Background

COPD and asthma exacerbations result in many emergency department admissions. Not all treatments are successful, often leading to hospital readmissions.

Aims

We sought to develop predictive models for exacerbation treatment outcome in a cohort of exacerbating asthma and COPD patients presenting to the emergency department.

Methods

Treatment failure was defined as the need for additional systemic corticosteroids (SCS) and/or antibiotics, hospital readmissison or death within 30 days of initial emergency department visit. We performed univariate analysis comparing characteristics of patients either given or not given SCS at exacerbation and of patients who succeeded versus failed treatment. Patient demographics, medications and exacerbation symptoms, physiology and biology were available. We developed multivariate random forest models to identify predictors of SCS prescription and for predicting treatment failure.

Results

Data were available for 81 patients, 43 (53%) of whom failed treatment. 64 (79%) of patients were given SCS. A random forest model using presence of wheeze at exacerbation and blood eosinophil percentage predicted SCS prescription with area under receiver operating characteristic curve (AUC) 0.69. An 11 variable random forest model (which included medication, previous exacerbations, symptoms and quality of life scores) could predict treatment failure with AUC 0.81. A random forest model using just the two best predictors of treatment failure, namely, visual analogue scale for breathlessness and sputum purulence, predicted treatment failure with AUC 0.68.

Conclusion

Prediction of exacerbation treatment outcome can be achieved via supervised machine learning combining different predictors at exacerbation. Validation of our predictive models in separate, larger patient cohorts is required.

Distribution of COPD Comorbidities and Creation of Acute Exacerbation Risk Score: Results from SCICP

Background

Chronic obstructive pulmonary disease (COPD) often coexists with multiple comorbidities which may have a significant impact on acute exacerbations of patients. At present, what kind of comorbidities affects acute exacerbations and how comorbidities lead to poor prognosis are still controversial. The purpose of our study is to determine the impact of comorbidities on COPD exacerbation and establish an acute exacerbation risk assessment system related to comorbidities.

Methods

A total of 742 COPD patients participated in the Shanghai COPD Investigation on Comorbidity Program (SCICP, ChiCTR2000030911). Finally, the baseline information of 415 participants and one-year follow-up data were involved in the analysis. We collected hemogram indices, pulmonary function tests and acute exacerbation of COPD with regular medical follow-up. Q-type cluster analysis was used to determine the clusters of participants. Receiver operating characteristic (ROC) analysis was constructed to assess the ability of indicators in predicting acute exacerbations.

Results

Almost 65% of the population we investigated had at least one comorbidity. The distribution and incidence of comorbidities differed between exacerbation group and non-exacerbation group. Three comorbidity clusters were identified: (1) respiratory, metabolic, immune and psychologic disease (non-severe cases); (2) cardiovascular and neoplastic disease (severe cases); (3) less comorbidity. Different sub-phenotypes of COPD patients showed significant distinction in health status. Anxiety (OR=5.936, P=0.001), angina (OR=10.155, P=0.025) and hypertension (OR=3.142, P=0.001) were found to be independent risk factors of exacerbation in a year. The novel risk score containing BODEx and four diseases showed great prognostic value of COPD exacerbation in developing sample.

Conclusion

Our study detailed the major interaction between comorbidities and exacerbation in COPD. Noteworthily, a novel risk score using comprehensive index – BODEx – and comorbidity parameters can identify patients at high risk of acute exacerbation.

The correlation between quadriceps muscle strength and endurance and exercise performance in patients with COPD

To determine the association between quadriceps muscle strength (QMS) and endurance (QME) and exercise capacity in patients with COPD after stratification for sex and resting lung function (LF). Data were collected from 3,246 patients with COPD (60% men, 64 ± 9 yr), including measures of exercise capacity [peak aerobic capacity (peakV̇o₂), 6-min walk distance (6MWD)] and isokinetic QMS and QME. Patients were stratified for sex, forced expiratory volume in 1 s (>50/≤50% predicted), single breath carbon monoxide diffusing capacity (>50/≤50% predicted), and residual volume (>140/≤140% predicted). After stratification for resting LF, QMS and QME were significantly associated with peakV̇o₂ (r range: 0.47-0.61 and 0.49-0.65 for men and 0.53-0.66 and 0.48-0.67 for women, respectively) and 6MWD (r range: 0.29-0.42 and 0.44-0.55 for men and 0.25-0.54 and 0.34-0.55 for women, respectively) (P < 0.001). Regression models demonstrated that QMS and QME were significant determinants of peakV̇o₂ (explained variance R² range: 35.6%-48.8% for men and 36.8%-49.0% for women) and 6MWD (R² range: 24.3%-43.3% for men and 28.4%-40.3% for women), independent of age and fat-free mass. Quadriceps muscle function was significantly associated with peakV̇o₂ and 6MWD in male and female patients with COPD after stratification for resting LF, in which QME appear to be a more important determinant than QMS. This underlines the importance of systematically evaluating both quadriceps muscle strength and endurance in in all patients with COPD.NEW & NOTEWORTHY Our findings identified quadriceps muscle function as an important determinant of exercise capacity across a wide spectrum of lung function. Quadriceps muscle endurance appears to be a more important determinant than quadriceps muscle strength, underlining the importance of including both the measurement of quadriceps muscle strength and endurance in routine assessment for all patient with COPD.

Population Pharmacokinetics and Dose Optimization of Ceftazidime and Imipenem in Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Background: Ceftazidime and imipenem have been increasingly used to treat Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) due to their extended-spectrum covering Pseudomonas aeruginosa. This study aims to describe the population pharmacokinetic (PK) and pharmacodynamic (PD) target attainment for ceftazidime and imipenem in patients with AECOPD. Methods: We conducted a prospective PK study at Bach Mai Hospital (Viet Nam). A total of 50 (ceftazidime) and 44 (imipenem) patients with AECOPD were enrolled. Population PK analysis was performed using Monolix 2019R1 and Monte Carlo simulations were conducted to determine the optimal dose regimen with respect to the attainment of 60% and 40% fT>MIC for ceftazidime and imipenem, respectively. A dosing algorithm was developed to identify optimal treatment doses. Results: Ceftazidime and imipenem PK was best described by a one-compartment population model with a volume of distribution and clearance of 23.7 L and 8.74 L/h for ceftazidime and 15.1 L and 7.88 L/h for imipenem, respectively. Cockcroft–Gault creatinine clearance represented a significant covariate affecting the clearance of both drugs. Increased doses with prolonged infusion were found to cover pathogens with reduced susceptibility. Conclusions: This study describes a novel and versatile three-level dosing algorithm based on patients’ renal function and characteristic of the infective pathogen to explore ceftazidime and imipenem optimal regimen for AECOPD.

Elevated serum 4HNE plus decreased serum thioredoxin: Unique feature and implications for acute exacerbation of chronic obstructive pulmonary disease

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a global problem with high mortality. Its pathogenesis is not fully understood. To reveal new serum feature of AECOPD and their potential implications, we have analyzed 180 serum samples, and found that in the serum of AECOPD patients, 4-hydroxy-2-nonenal (4HNE)-protein adducts are dynamically increased as partial pressure of oxygen (PaO2) drops, which is accompanied by progressively decreasing thioredoxin reductase (TrxR1) and thioredoxin (Trx1), as compared with those of healthy people. This phenomenon is unique, because acute hypoxia patients have 1.1-fold or 1.7-fold higher serum TrxR1 or Trx1 activity, respectively, than healthy people, in keeping with low 4HNE level. Moreover, serum 4HNE-protein adducts may form disulfide-linked complexes with high-molecular-weight, the amount of which is significantly increased during AECOPD. Serum 4HNE-protein adducts include 4HNE-Trx1 adduct and 4HNE-TrxR1 adduct, but only the former is significantly increased during AECOPD. Through cell biology, biochemistry and proteomics methods, we have demonstrated that extracellular 4HNE and 4HNE-Trx1 adduct affect human bronchial epithelial cells via different mechanisms. 4HNE-Trx1 adduct may significantly alter the expression of proteins involved mainly in RNA metabolism, but it has no effect on TrxR1/Trx1 expression and cell viability. On the other hand, low levels of 4HNE promote TrxR1/Trx1 expression and cell viability, while high levels of 4HNE inhibit TrxR1/Trx1 expression and cell viability, during which Trx1, at least in part, mediate the 4HNE action. Our data suggest that increasing serum 4HNE and decreasing serum Trx1 in AECOPD patients are closely related to the pathological processes of the disease. This finding also provides a new basis for AECOPD patients to use antioxidant drugs.

The Proinflammatory Activity of Structurally Altered Elastic Fibers

The mechanisms responsible for the increased loss of pulmonary function following acute lung inflammation in chronic obstructive pulmonary disease remain poorly understood. To investigate this process, our laboratory developed a hamster model that uses a single intratracheal instillation of LPS to superimpose an inflammatory response on lungs treated with intratracheal elastase 1 week earlier. Parameters measured at 2 days after LPS included total leukocyte content and percent neutrophils in BAL fluid (BALF), and BALF levels of both total and peptide-free elastin-specific crosslinks, desmosine and isodesmosine (DID). Airspace enlargement, measured by the mean linear intercept method, and relative interstitial elastic fiber surface area were determined at 1 week after LPS. Compared with animals only treated with elastase, those receiving elastase/LPS showed statistically significant increases in mean linear intercept (156.2 vs. 85.5 μm), BALF leukocytes (187 vs. 37.3 × 10⁴ cells), neutrophils (39% vs. 3.4%), and free DID (182% vs. 97% of controls), which exceeded the sum of the individual effects of the two agents. Despite increased elastin breakdown, the elastase/LPS group had significantly greater elastic fiber surface area than controls (49% vs. 26%) owing to fragmentation and splaying of the fibers. Additional experiments showed that the combination of elastin peptides and LPS significantly enhanced their separate effects on BALF neutrophils and BALF DID in vivo and leukocyte chemotaxis in vitro. The results suggest that structural changes in elastic fibers have proinflammatory activity and may contribute to the decline in pulmonary function related to chronic obstructive pulmonary disease exacerbations.

Effects of an integrated respiratory service on Chronic Obstructive Pulmonary Disease hospital admissions in England: An interrupted time series analysis

OBJECTIVES

To investigate the effects of an admission avoidance pathway within a new integrated respiratory service on the number of Chronic Obstructive Pulmonary Disease (COPD)-related hospital admissions in England.

METHODS

We used interrupted time series analysis to estimate the effects of the admission avoidance pathway on COPD hospital admissions, length of stay, and 30-day readmissions. We included all unplanned admissions with COPD as primary diagnosis using Hospital Episode Statistics, comparing the intervention region with a demographically similar control region in the two years before and one year after the implementation of the new service.

RESULTS

Unplanned hospital admissions for COPD exacerbations followed a clear seasonal pattern, peaking in early winter. We found no evidence that the admission avoidance pathway influenced the rate of hospital admissions or 30-day readmissions. We found weak evidence of a trend change in length of stay following the launch of the admission avoidance pathway.

CONCLUSIONS

Our study adds to the growing body of evidence that suggests that additional admission avoidance capacity alone does not lead to a measurable reduction in admissions or length of stay. Further investigation is required to understand the reasons why. A longer follow-up may be required to see some of the potential benefits.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) impose a significant burden on patients and the emergency health care system. Patients with COPD who present to the emergency department (ED) often have comorbidities that can complicate their management.

OBJECTIVE

To discuss strategies for the management of acute exacerbations in the ED, from initial assessment through disposition, to enable effective patient care and minimize the risk of treatment failure and prevent hospital readmissions.

DISCUSSION

Establishing a correct diagnosis early on is critical; therefore, initial evaluations should be aimed at differentiating COPD exacerbations from other life-threatening conditions. Disposition decisions are based on the intensity of symptoms, presence of comorbidities, severity of the disease, and response to therapy. Patients who are appropriate for discharge from the ED should be prescribed evidence-based treatments and smoking cessation to prevent disease progression. A patient-centric discharge care plan should include medication reconciliation; bedside "teach-back," wherein patients demonstrate proper inhaler usage; and prompt follow-up.

CONCLUSIONS

An effective assessment, accurate diagnosis, and appropriate discharge plan for patients with AECOPD could improve treatment outcomes, reduce hospitalization, and decrease unplanned repeat visits to the ED.

Clinical and spirometric variables are better predictors of COPD exacerbations than routine blood biomarkers

BACKGROUND

Understanding the risk factors for exacerbations of COPD may help provide a more personalised approach to exacerbation prevention.

METHOD

Observational, prospective, international, multicentre study aimed at identifying risk factors for exacerbations of COPD. Clinical variables, lung function and CAT scores were collected at baseline. In addition, routine blood biomarkers were also obtained, and patients were followed for 12 months.

RESULTS

A total of 326 patients were included. Of these, 155 (47.5%) presented at least one exacerbation. The median time to the first exacerbation was 147 days. Exacerbators had more respiratory symptoms, more impairment in FEV1(%), FVC(%) and a worse CAT score. Regarding biomarkers, only C-reactive protein was significantly higher in exacerbators (2.8 (standard deviation (SD):3.8) mg/dL vs. 1.9 (SD:2.6) mg/dL; p = 0.037). In multivariate analysis, only CAT scores, FEV1(%) and previous exacerbations were significantly associated with having an exacerbation during follow-up. In the equation of risk, patients with a CAT score ≥15, FEV1(%) <55% and at least one exacerbation the previous year had a probability of 76% of having an exacerbation during the next year, compared with 17% in patients who had none of the previous variables. No biomarkers showed a significant association in multivariate analysis.

CONCLUSIONS

Less than half of the patients presented an exacerbation during the one-year follow-up. CAT scores, FEV1(%) and previous exacerbations were the only variables associated with increased risk of exacerbations. Routine biomarkers did not provide additional information to evaluate the risk of exacerbations.

Pharmacotherapeutic management of bronchial infections in adults: non-cystic fibrosis bronchiectasis and chronic obstructive pulmonary disease

INTRODUCTION

Effective management of both acute and chronic bronchial infections is mandatory due to their high frequency rate, the relevant morbidity and mortality and the significant burden to health care systems, especially with the aging of population. Bacteria are the main causative pathogens, followed by viruses, and less commonly by fungi. The clinical evaluation of new therapeutic associations is mandatory to cope with the increases in resistance, in association with better infection control and antimicrobial policies.

AREAS COVERED

The authors searched Medline for any article published in English language up until March 1, 2020 that concerns the treatment of acute exacerbations and chronic infections in chronic obstructive respiratory disease and bronchiectasis.

EXPERT OPINION

As acute exacerbations are a main common and detrimental event in patients with COPD and bronchiectasis, effective antimicrobial therapies and regimens should be optimized. The development of new molecules or combination regimens is vital to patients with severe and/or difficult-to-treat infections. Moreover, chronic infection control is mandatory in these patients to their improve quality of life, respiratory function and prognosis as well as for reducing health care costs.

Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) often suffer acute exacerbations (AECOPD) and community-acquired pneumonia (CAP), named nonpneumonic and pneumonic exacerbations of COPD, respectively. Abnormal host defense mechanisms may play a role in the specificity of the systemic inflammatory response. Given the association of this aspect to some biomarkers at admission (e.g., C-reactive protein), it can be used to help to discriminate AECOPD and CAP, especially in cases with doubtful infiltrates and advanced lung impairment. Fever, sputum purulence, chills, and pleuritic pain are typical clinical features of CAP in a patient with COPD, whereas isolated dyspnea at admission has been reported to predict AECOPD. Although CAP may have a worse outcome in terms of mortality (in hospital and short term), length of hospitalization, and early readmission rates, this has only been confirmed in a few prospective studies. There is a lack of methodologically sound research confirming the impact of severe AECOPD and COPD + CAP. Here, we review studies reporting head-to-head comparisons between AECOPD and CAP + COPD in hospitalized patients. We focus on the epidemiology, risk factors, systemic inflammatory response, clinical and microbiological characteristics, outcomes, and treatment approaches. Finally, we briefly discuss some proposals on how we should orient research in the future.

Chronic Obstructive Pulmonary Disease: A Palliative Medicine Review of the Disease, Its Therapies, and Drug Interactions

Despite significant advances in treatment, chronic obstructive pulmonary disease (COPD) remains a chronic and progressive disease that frequently leads to premature mortality. COPD is associated with a constellation of significant symptoms, including dyspnea, cough, wheezing, pain, fatigue, anxiety, depression, and insomnia, and is associated with increased morbidity. Palliative care is appropriate to support these patients. However, historically, palliative care has focused on supporting patients with malignant disease, rather than progressive chronic diseases such as COPD. Therapies for COPD often result in functional and symptomatic improvements, including health-related quality of life (HRQL), and palliative care may further improve symptoms and HRQL. Provision of usual palliative care therapies for this patient population requires understanding the pathogenesis of COPD and common disease-targeted pharmacotherapies, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes COPD and current targeted therapies and their effects on symptoms, exercise tolerance, HRQL, and survival. It is important to note that medications commonly used for symptom management in palliative care can interact with COPD medications resulting in increased risk of adverse effects, enhanced toxicity, or changes in clearance of medications. To address this, we review pharmacologic interactions with and precautions related to use of COPD therapies in conjunction with commonly used palliative care medications.

Malnutrition, Airflow Limitation and Severe Emphysema are Risks for Exacerbation of Chronic Obstructive Pulmonary Disease in Japanese Subjects: A Retrospective Single-Center Study

Background

Different characteristics of patients with chronic obstructive pulmonary disease (COPD) between Western and Japanese populations have been reported. Risk factors for COPD exacerbation have been reported in Western countries but have not been studied in Japan.

Patients and Methods

We retrospectively examined risk factors for COPD exacerbation. A total of 156 Japanese patients were enrolled, and the records of 136 patients were analyzed.

Results

In the exacerbation group (n=60), body mass index, forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), the FEV₁/FVC ratio (FEV₁/FVC), the percent predicted values of FEV₁ (%FEV₁), and serum total protein (TP) and albumin concentrations were lower, and age, mortality rate, frequency of common cold and pneumonia, COPD severity rankings, modified Medical Research Council (mMRC) dyspnea score, and proportions of patients with severe emphysema (>50% of low attenuation area) and receiving long-term oxygen therapy were higher than those in the nonexacerbation group (n=76). However, the proportion of patients with a greater number of eosinophils (≥200/μL and/or ≥2%) and the exhaled nitric oxide concentration did not differ between the two groups. In the univariate analysis, the risk factors for exacerbation were age; long-term oxygen therapy; low FVC, FEV₁, FEV₁/FVC and %FEV₁; high COPD severity ranking and mMRC score; severe emphysema; hypoproteinemia (<6.5 g/dL); hypoalbuminemia (<3.5 g/dL); leukocytosis; lymphocytopenia; and anemia. In the multivariate analysis, the risk factors were hypoalbuminemia, hypoproteinemia and low FEV₁. Additionally, in patients in the exacerbation-induced mortality subgroup, age, exacerbation frequency, mMRC score and the proportion of patients with lymphocytopenia were higher, and FVC, %FVC, FEV₁, serum TP concentration and the lymphocyte number were lower than those in the exacerbation survival subgroup.

Conclusion

Malnutrition, airflow limitation and severe emphysema were risks for exacerbation and mortality associated with infection in Japanese patients with COPD.

Frequent Outpatient Visits Prevent Exacerbation of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory airway disease requiring frequent outpatient visits and lifelong management. We aimed to evaluate the roles of frequent outpatient visits in prognosis of COPD. We used claims data in the national medical insurance review system provided by the Health Insurance Review and Assessment Service of Korea from May 1, 2014 to April 30, 2015. A definition of COPD was used based on the diagnosis code and medication. Frequent visitors were defined as subjects who visited the outpatient clinic for COPD three or more times per year. Among 159,025 subjects, 117,483 (73.9%) were classified as frequent visitors. Frequent visitors underwent pulmonary function tests and used various inhalers more often than did infrequent visitors. The rates of COPD exacerbation requiring admission to a general ward, emergency room, or intensive care unit were significantly lower in frequent visitors than in infrequent visitors. In multivariable analysis, frequent visits were identified as an independent factor preventing COPD exacerbation that required admission to a ward (odds ratio [OR], 0.387), emergency room, (OR, 0.558), or intensive care unit (OR, 0.39) (all P < 0.001). In conclusion, we showed frequent outpatient visits reduce the risk of COPD exacerbation by 45-60%.

The Glasgow prognostic score can be a predictor of mortality in acute exacerbation of chronic obstructive pulmonary disease

Aim: To determine the prognostic value of Glasgow Prognostic Score (GPS) in acute exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) requiring hospitalization.Methods: Hospital electronic database of 129 patients with AECOPD was retrospectively searched and CRP levels, complete blood count, arterial blood gas (ABG) values and pulmonary function test (PFT) parameters of patients were recorded. Hospital mortality and need for ICU transfer were determined as adverse outcomes from files of cases.Results: 106 of 129 patients were male (82.2%) and rest of them were female (17.8%). GPS 0 was not observed in any patient, GPS 1 was observed in 101 patients, and GPS 2 was observed in 28 patients. The rate of adverse outcomes (ICU/Ex) was significantly increased in the GPS 2 group when compared to the GPS 1 group (X²:7.631, p < 0.01). Logistic regression analysis indicated that pH≤7.35 (p < 0.05, OR: 5.65, CI: 1.35-23.58%) and GPS 2 score (p < 0.05, OR: 5.52, CI: 1.45-20.97%) were independent predictors for adverse outcomes for AECOPD.Conclusion: Our results demonstrate that the GPS may have predictive value for adverse outcomes in patients with AECOPD.

Social and clinical predictors of short- and long-term readmission after a severe exacerbation of copd

INTRODUCTION AND OBJECTIVES

The aim of this study was to evaluate the predictive ability of multiple social, and clinical factors for readmission after a severe acute exacerbation of COPD (AECOPD) during various time periods.

METHODS

We performed a prospective cohort study in which recruited patients with AECOPD. We systematically collected numerous clinical (symptoms, pulmonary function, comorbidities, and treatment) and social (financial situation, housing situation, family support, caregiver overload, ability to perform activities, and risk of social exclusion) variables using several questionnaires and indices. The patients were followed closely for one year and readmissions at 30, 60, and 365 days were analysed.

RESULTS

253 patients were included, aged 68.9±9.8years, FEV1 = 42.1%±14.2%, and a Charlson's index = 1.8±0.9. Of these patients, 20.2%, 39.6%, and 63.7% were readmitted within the first 30, 90, and 365 days after discharge, respectively. In the multivariate model applied, the variables that were independently associated with readmission over all three periods of the analysis were dependence to perform basic activities of daily living (BADLs) (odds ratio [OR] = 2.10-4.10) and a history of two or more admissions within the previous year (OR = 2.78-3.78). At 90 days, a history of bacterial isolates in a previous sputum culture (OR = 2.39) and at 365 days, a high grade of dyspnoea (OR = 2.51) and obesity (OR = 2.38) were also identified as predictors of hospital readmission.

CONCLUSIONS

The patients' limitation to perform BADLs and their history of admissions for AECOPD were the best predictive variables for the likelihood of readmission when adjusted for many other social and clinical variables, regardless of the time period considered for such prediction.

How may we improve clinical outcomes for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease? A narrative review about possible therapeutic and preventive strategies

Introduction: In a subset of chronic obstructive pulmonary disease (COPD)patients the course of the disease is complicated by a severe acute exacerbations (AECOPD) that may require hospitalization, at which time negative outcomes may occur up to 30 days after discharge. Several predictors of negative outcomes have been documented.Areas covered: We considered five negative outcomes related to patients hospitalized with AECOPD: treatment failure, noninvasive mechanical ventilation (NIMV) failure, prolonged length of hospital stay (LHS), short-term mortality (≤ 90 days from admission and including the in-hospital mortality), and early readmission (≤30 days from discharge). Possible therapeutic and preventive strategies to improve these outcomes are outlined and discussed.Expert opinion: Several strategies have been proposed to improve outcomes. Among these, steroid or antibiotic use may reduce the risks of treatment failure or of prolonged hospital stay. We note that operator-related factors may influence the outcome of NIMV. However, little has been documented about the short-term mortality or early readmission rates. In general, few interventions consistently improve negative outcomes and prognosis of AECOPD.

Responsiveness of PROMIS® to change in chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease characterized by airflow obstruction that leads to shortness of breath and substantial negative impacts on health-related quality of life (HRQL). The course of COPD includes periodic acute exacerbations that require changes in treatment and/or hospitalizations. This study was designed to examine the responsiveness of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures to changes associated with COPD exacerbation recovery.

Methods

A longitudinal analysis using mixed-effects models was conducted of people who were enrolled while stable (n = 100) and those who experienced an acute exacerbation (n = 85). PROMIS (physical function, pain interference, pain behavior, fatigue, anxiety, depression, anger, social roles, discretionary social activities, Global Health, dyspnea severity and dyspnea functional limitations) and COPD-targeted HRQL measures were completed at baseline and at 12 weeks.

Results

We administered PROMIS measures using computer adaptive testing (CAT), followed by administration of any remaining short form (SF) items that had not yet been administered by CAT. Examination of the difference between group differences from baseline to 12 weeks in the stable and exacerbation groups revealed that the exacerbation group changed (improved) significantly more than the stable group in anxiety (p < .001 to p < .01; f² effect size [ES] = 0.023/0.021), fatigue (p < .0001; ES = 0.036/0.047) and social roles (p < .001 to p < .05; ES = 0.035/0.024). All effect sizes were small in magnitude and smaller than hypothesized. Depression was also statistically significant (p < .05, SF only) but the ES was trivial. For all other PROMIS domains, the differences were not significant and ES were trivial.

Conclusions

This longitudinal study provides some support for the validity of the PROMIS fatigue, anxiety, and social roles domains in COPD, but further evaluation of responsiveness is warranted.

Airflow limitation more than doubles the risk for hospitalization/mortality in patients with heart failure

BACKGROUND

Comorbid chronic obstructive pulmonary disease is found in approximately one-third of patients with heart failure. Survival in patients with chronic obstructive pulmonary disease generally decreases as lung function declines. However, the association between lung function, hospitalization and survival is less clear for patients with heart failure.

AIM

The purpose of this study was to determine the predictive power of spirometry measures for event-free survival (combined all-cause hospitalization and/or mortality) in patients with heart failure.

METHODS

In this secondary analysis of data from three prospective, longitudinal studies, we selected patients with a confirmed diagnosis of heart failure who completed airflow limitation assessment using spirometry measures ( n=137): forced vital capacity, forced expiratory volume/second, and forced expiratory volume/second/forced vital capacity. Cox proportional hazards modeling was used to determine the relationship between spirometry and all-cause hospitalization/mortality with and without adjusting for demographic and clinical covariates over a four-year follow-up period.

RESULTS

A majority (74%) exhibited some degree of airflow limitation (forced expiratory volume/second<80% predicted value) and 26 (19%) met the spirometric criterion for chronic obstructive pulmonary disease (forced expiratory volume/second/forced vital capacity⩽0.70). Cox proportional hazards regression models compared all-cause hospitalization/mortality between those with and without airflow limitation. Patients with airflow limitation were 2.2 times more likely to be hospitalized or die compared to those without airflow limitations (hazard ratio: 2.20, 95% confidence interval 1.06-4.53, p=0.03).

CONCLUSION

Patients with comorbid heart failure and airflow limitation were at more than double the risk for an event. Spirometric measures may be useful to patients with heart failure, as tailored management of airflow limitation may impact event-free survival.

Management of severe acute exacerbations of COPD: an updated narrative review

Background

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.

Main body

In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.

Conclusion

Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.

COPD transitions in health and self-management: service users' experiences from everyday life

Purpose

To explore how persons living with COPD experience transitions related to health, self-management, and follow-up from the healthcare services.

Patients and methods

This study is part of a participatory research project. Six males and five females living with COPD, with a COPD assessment test score of 21–29, participated; all the participants were living at home. Data were collected in qualitative research interviews and analyzed using qualitative content analysis highlighting the participants’ experiences.

Results

The findings showed two main themes: “The struggle to keep going” and “The need for continuity and competent facilitation”. The participants reported complex health transitions, with changes in roles and function, demanding exacerbations and critical events, and challenges with learning needed self-management. They expressed a great need for and had great benefit from, education, rehabilitation, and follow-up in their management of everyday life. Not all received offers in line with current guidelines.

Conclusion

In-depth knowledge of patients’ experienced COPD transitions offers clinicians guidance for the timing and quality of follow-up services. Life with COPD entails challenging transitions in health and self-management. Good rehabilitation and follow-up from the healthcare services are needed throughout the disease trajectory. Participation in self-management education and rehabilitation that include psychosocial aspects may facilitate health-enhancing transitions and improve self-management skills. Experienced lack of competence and flexibility among healthcare providers hinders trust and collaboration. Access to stable and competent follow-up in the primary health services may facilitate cohesive services and collaborative self-management.