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Naharro-González S, Lorente-Sorolla C, Rodrigo-Muñoz JM, Valverde-Monge M, Pinillos-Robles EJ, Betancor D, Fernández-Nieto M, Sánchez-Mellado D, Gil-Martínez M, Santillán-Coello JM, Villacampa-Aubá JM, Mahillo-Fernandez I, Herrero-González A, Perez-González A, Rodríguez-Nieto MJ, del Pozo V. Moderate-High Blood Eosinophilia Is Associated with Increased Hospitalization and Other Asthma Comorbidities. Biomolecules 2024; 14:126. [PMID: 38254726 PMCID: PMC10813157 DOI: 10.3390/biom14010126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Background: Eosinophilia has traditionally been linked to eosinophilic asthma, for which it is the gold-standard prognostic biomarker. However, the association between eosinophilia and the presence of other diseases and comorbidities is yet unclear. (2) Methods: For this retrospective study, we reviewed the electronic medical records of 49,909 subjects with blood eosinophilia to gather data on the presence of asthma, COPD, sleep apnea, tuberculosis, dyslipidemia, hypertension, and other cardiovascular diseases and severe CRSwNP among these subjects. Demographic features including age, sex, and smoking habits were collected, as well as the number of hospitalizations and emergency department visits. T-tests, ANOVA, Fisher test, and logistic regression models were used. (3) Results: For all age groups studied, eosinophilia was significantly more prevalent among asthmatic subjects than nonasthmatics, especially in patients also presenting CRSwNP, hypertension, and dyslipidemia. The likelihood of developing asthma, COPD, and CRSwNP, and hospitalization, was increased when BEC was above 600 eosinophils/μL. The association between asthma, CRSwNP, and BEC was corroborated by multiple logistic regressions models. (4) Conclusions: We demonstrated the association of having over 600 blood eosinophils/μL with a higher number of hospitalizations and comorbidities (CRSwNP and COPD), which proves that BEC is a highly useful parameter to consider in subjects who present blood eosinophilia.
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Affiliation(s)
- Sara Naharro-González
- Immunoallergy Laboratory, Immunology Department, Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), 28040 Madrid, Spain; (S.N.-G.); (C.L.-S.); (J.M.R.-M.); (M.G.-M.)
| | - Clara Lorente-Sorolla
- Immunoallergy Laboratory, Immunology Department, Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), 28040 Madrid, Spain; (S.N.-G.); (C.L.-S.); (J.M.R.-M.); (M.G.-M.)
| | - José Manuel Rodrigo-Muñoz
- Immunoallergy Laboratory, Immunology Department, Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), 28040 Madrid, Spain; (S.N.-G.); (C.L.-S.); (J.M.R.-M.); (M.G.-M.)
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (M.V.-M.); (D.B.)
| | - Marcela Valverde-Monge
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (M.V.-M.); (D.B.)
- Allergy Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain;
| | - Erwin Javier Pinillos-Robles
- Pulmonology Unit, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (E.J.P.-R.); (D.S.-M.); (M.J.R.-N.)
| | - Diana Betancor
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (M.V.-M.); (D.B.)
- Allergy Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain;
| | - Mar Fernández-Nieto
- Allergy Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain;
| | - Diana Sánchez-Mellado
- Pulmonology Unit, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (E.J.P.-R.); (D.S.-M.); (M.J.R.-N.)
| | - Marta Gil-Martínez
- Immunoallergy Laboratory, Immunology Department, Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), 28040 Madrid, Spain; (S.N.-G.); (C.L.-S.); (J.M.R.-M.); (M.G.-M.)
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (M.V.-M.); (D.B.)
| | - Jessica Mireya Santillán-Coello
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (J.M.S.-C.); (J.M.V.-A.)
| | - José Miguel Villacampa-Aubá
- ENT and Cervicofacial Surgery Department, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (J.M.S.-C.); (J.M.V.-A.)
| | | | - Antonio Herrero-González
- Data Analysis Department, I Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (A.H.-G.); (A.P.-G.)
| | - Alejandro Perez-González
- Data Analysis Department, I Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (A.H.-G.); (A.P.-G.)
| | - María Jesús Rodríguez-Nieto
- Pulmonology Unit, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (E.J.P.-R.); (D.S.-M.); (M.J.R.-N.)
- Villalba General University Hospital, 28400 Madrid, Spain
| | - Victoria del Pozo
- Immunoallergy Laboratory, Immunology Department, Fundación Jimenez Díaz Health Research Institute (IIS-FJD, UAM), 28040 Madrid, Spain; (S.N.-G.); (C.L.-S.); (J.M.R.-M.); (M.G.-M.)
- CIBER of Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain; (M.V.-M.); (D.B.)
- Department of Medicine, Autonomous University of Madrid, 28049 Madrid, Spain
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Zhang Y, Zheng SP, Hou YF, Jie XY, Wang D, Da HJ, Li HX, He J, Zhao HY, Liu JH, Ma Y, Qiang ZH, Li W, Zhang M, Shan H, Wu YY, Shi HY, Zeng L, Sun X, Liu Y. A predictive model for frequent exacerbator phenotype of acute exacerbations of chronic obstructive pulmonary disease. J Thorac Dis 2023; 15:6502-6514. [PMID: 38249857 PMCID: PMC10797373 DOI: 10.21037/jtd-23-931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/27/2023] [Indexed: 01/23/2024]
Abstract
Background The frequent exacerbator phenotype of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is characterized by experiencing at least two exacerbations per year, leading to a significant economic burden on healthcare systems worldwide. Although several biomarkers have been shown to be effective in assessing AECOPD severity in recent years, there is a lack of studies on markers to predict the frequent exacerbator phenotype of AECOPD. The current study aimed to develop a new predictive model for the frequent exacerbator phenotype of AECOPD based on rapid, inexpensive, and easily obtained routine markers. Methods This was a single-center, retrospective study that enrolled a total of 2,236 AECOPD patients. The participants were divided into two groups based on the frequency of exacerbations: infrequent group (n=1,827) and frequent group (n=409). They underwent a complete blood count, as well as blood biochemistry, blood lipid and coagulation testing, and general characteristics were also recorded. Univariate analysis and binary multivariate logistic regression analyses were used to explore independent risk factors for the frequent exacerbator phenotype of AECOPD, which could be used as components of a new predictive model. The receiver operator characteristic (ROC) curve was used to assess the predictive value of the new model, which consisted of all significant risk factors predicting the primary outcome. The nomogram risk prediction model was established using R software. Results Age, gender, length of stay (LOS), neutrophils, monocytes, eosinophils, direct bilirubin (DBil), gamma-glutamyl transferase (GGT), and the glucose-to-lymphocyte ratio (GLR) were independent risk factors for the frequent exacerbator phenotype of AECOPD. The area under the curve (AUC) of the new predictive model was 0.681 [95% confidence interval (CI): 0.653-0.708], and the sensitivity was 63.6% (95% CI: 58.9-68.2%) and the specificity was 65.0% (95% CI: 60.3-69.6%). Conclusions A new predictive model based on demographic characteristics and blood parameters can be used to predict the frequency of acute exacerbations in the management of chronic obstructive pulmonary disease (COPD).
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Affiliation(s)
- Yan Zhang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shu-Ping Zheng
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yang-Fan Hou
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xue-Yan Jie
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Dan Wang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hong-Ju Da
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hong-Xin Li
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jin He
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hong-Yan Zhao
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jiang-Hao Liu
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yu Ma
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zhi-Hui Qiang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Wei Li
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Ming Zhang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hu Shan
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yuan-Yuan Wu
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hong-Yang Shi
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Liang Zeng
- Chongqing Nanpeng Artificial Intelligence Technology Research Institute Co., Ltd., Chongqing, China
| | - Xin Sun
- Chongqing Nanpeng Artificial Intelligence Technology Research Institute Co., Ltd., Chongqing, China
| | - Yun Liu
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
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Chow R, So OW, Im JHB, Chapman KR, Orchanian-Cheff A, Gershon AS, Wu R. Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review. Int J Chron Obstruct Pulmon Dis 2023; 18:2581-2617. [PMID: 38022828 PMCID: PMC10664718 DOI: 10.2147/copd.s418295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD. Methods A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035). Results In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility. Conclusion The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.
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Affiliation(s)
- Ronald Chow
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Olivia W So
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - James H B Im
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Kenneth R Chapman
- University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Andrea S Gershon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Robert Wu
- University Health Network, University of Toronto, Toronto, ON, Canada
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4
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Li J, Liang L, Feng L, Cao S, Cai YS, Li X, Qian Z, Brightling CE, Tong Z. The Prognostic Value of Blood Eosinophil Level in AECOPD is Influenced by Corticosteroid Treatment During Hospitalization. J Inflamm Res 2023; 16:3233-3243. [PMID: 37555013 PMCID: PMC10404713 DOI: 10.2147/jir.s421605] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023] Open
Abstract
PURPOSE Blood eosinophil is a promising biomarker for phenotyping patients with acute exacerbation of COPD (AECOPD). We aimed to evaluate the prognostic value of eosinophil on short- and long-term outcomes stratified by corticosteroid treatment among AECOPD inpatients. PATIENTS AND METHODS In this retrospective cohort study, we included patients hospitalized for AECOPD from July 2013 to June 2021 in Beijing, China. Clinical data were collected from electronic medical records. The blood eosinophil count was measured within 24h after admission. Eosinophilic AECOPD was defined as having an eosinophil percentage ≥ 2%. The study outcomes were length of stay (LOS), treatment failure, and AECOPD readmission risk within 3 years of discharge. Multivariable models were used to analyze the associations between blood eosinophil count and outcomes stratified by corticosteroid treatment during hospitalization. RESULTS A total of 2406 AECOPD patients were included. The median LOS of AECOPD patients was 10 (interquartile range: 8-14) days. The eosinophil percentage was negatively associated with LOS (P-trend=0.014). Compared with the non-eosinophilic AECOPD group, the eosinophilic group had a 58% lower risk of treatment failure (OR=0.42, 95% CI: 0.20-0.89) in patients treated with systemic corticosteroids, but no association was observed in those treated with inhaled corticosteroids (ICS) only (OR=0.95, 95% CI: 0.60-1.52). The eosinophilic group had an increased risk of 90-day re-admission in patients treated with ICS only (HR=1.51, 95% CI: 1.00-2.29), but not in patients treated with systemic corticosteroids during hospitalization (HR=0.67, 95% CI: 0.39-1.15). No statistically significant results were found for 180-day, 1-year, or 3-year readmission risk. CONCLUSION Elevated blood eosinophils in AECOPD were associated with shorter length of stay and improved response to treatment with systemic corticosteroids, but not inhaled corticosteroids. Our study suggested that a therapeutic approach of using systemic corticosteroid may benefit patients present with eosinophilic AECOPD.
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Affiliation(s)
- Jiachen Li
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Lirong Liang
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Lin Feng
- Department of Clinical Epidemiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Siyu Cao
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yutong Samuel Cai
- Centre for Environmental Health and Sustainability, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Xiaobo Li
- Beijing Key Laboratory of Environmental Toxicology, School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Zhenbei Qian
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
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Ruan H, Zhang H, Wang J, Zhao H, Han W, Li J. Readmission rate for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis. Respir Med 2023; 206:107090. [PMID: 36528962 DOI: 10.1016/j.rmed.2022.107090] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/04/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The readmission rate following hospitalization for chronic obstructive pulmonary disease (COPD) exacerbations is extremely high and has become a common and challenging clinical problem. This study aimed to systematically summarize COPD readmission rates for acute exacerbations and their underlying risk factors. METHODS A comprehensive search was performed using PubMed, Embase, Cochrane Library, and Web of Science, published from database inception to April 2, 2022. Methodological quality was evaluated using the Newcastle-Ottawa Scale (NOS). We used a random-effects model or a fixed-effects model to estimate the pooled COPD readmission rate for acute exacerbations and underlying risk factors. RESULTS A total of 46 studies were included, of which 24, 7, 17, 7, and 20 summarized the COPD readmission rates for acute exacerbations within 30, 60, 90, 180, and 365 days, respectively. The pooled 30-, 60-, 90-, 180-, and 365-day readmission rates were 11%, 17%, 17%, 30%, and 37%, respectively. The study design type, age stage, WHO region, and length of stay (LOS) were initially considered to be sources of heterogeneity. We also identified potential risk factors for COPD readmission, including male sex, number of hospitalizations in the previous year, LOS, and comorbidities such as heart failure, tumor or cancer, and diabetes, whereas obesity was a protective factor. CONCLUSIONS Patients with COPD had a high readmission rate for acute exacerbations, and potential risk factors were identified. Therefore, we should propose clinical interventions and adjust or targeted the control of avoidable risk factors to prevent and reduce the negative impact of COPD readmission. SYSTEMATIC REVIEW REGISTRATION PROSPERO, identifier CRD42022333581.
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Affiliation(s)
- Huanrong Ruan
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China
| | - Hailong Zhang
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China.
| | - Jiajia Wang
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China
| | - Hulei Zhao
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China
| | - Weihong Han
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China
| | - Jiansheng Li
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China
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Soler-Cataluña JJ, Lopez-Campos JL. COPD Exacerbation Syndrome: The Spanish Perspective on an Old Dilemma. Int J Chron Obstruct Pulmon Dis 2022; 17:3139-3149. [PMID: 36601561 PMCID: PMC9807017 DOI: 10.2147/copd.s393535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 11/30/2022] [Indexed: 12/29/2022] Open
Abstract
The definition of exacerbation of COPD as a syndrome, as proposed by the Spanish COPD guidelines (GesEPOC) 2021 update, and the consequences that this implies, have direct implications on patient care. This review analyzes this novel vision of the COPD exacerbation syndrome, its rationale, and its clinical implications, as opposed to the traditional symptoms-based or event-based definitions. An exacerbation conceived as a syndrome provides us with an umbrella term to include a set of diverse alterations, which, either in isolation or more frequently in combination, are clinically expressed in a similar way in patients with COPD. In patients with COPD, this occurs as a consequence of worsening expiratory airflow limitation or the underlying inflammatory process, producing a worsening in symptoms with respect to the baseline situation. This definition therefore assumes a worsening in at least one of the two key physiopathological markers, lung function and inflammation. The main features of this new physiopathological proposal include a syndromic approach with narrower differential diagnosis, the use of several biomarkers, treatable traits to better guide treatment, and a new severity classification. Further research is needed to examine the role of eosinophils in this context, but currently, the early results are promising. The evaluation of severity is key in the multidimensional characterization of exacerbation and the GesEPOC 2021 proposes new approaches and also recommends the use of multidisciplinary scores for severity categorization in patients. Finally, another innovation in the GesEPOC 2021 refers to the recurrence of exacerbations, which has implications for disease prognosis or long-term clinical impact which need to be elucidated in further studies.
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Affiliation(s)
- Juan Jose Soler-Cataluña
- Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, Departamento de Medicina, Universitat de València, Valencia, Spain,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jose Luis Lopez-Campos
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain,Correspondence: Jose Luis Lopez-Campos, Hospital Universitario Virgen del Rocío, Avda, Manuel Siurot, s/n, Seville, 41013, Spain, Tel +34 955013166, Email
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7
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Wei T, Wang X, Lang K, Chen C, Song Y, Luo J, Gu Z, Hu X, Yang D. Low Eosinophil Phenotype Predicts Noninvasive Mechanical Ventilation Use in Patients with Hospitalized Exacerbations of COPD. J Inflamm Res 2022; 15:1259-1271. [PMID: 35237060 PMCID: PMC8884709 DOI: 10.2147/jir.s343918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/26/2022] [Indexed: 11/23/2022] Open
Abstract
Rationale Objective Methods Results Conclusion
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Affiliation(s)
- Tingting Wei
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Xiaocen Wang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Ke Lang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Cuicui Chen
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yansha Song
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jinlong Luo
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Zhaolin Gu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Xianglin Hu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Dong Yang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- Correspondence: Dong Yang; Xianglin Hu, Email ;
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8
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Mathioudakis AG, Ananth S, Bradbury T, Csoma B, Sivapalan P, Stovold E, Fernandez-Romero G, Lazar Z, Criner GJ, Jenkins C, Papi A, Jensen JU, Vestbo J. Assessing Treatment Success or Failure as an Outcome in Randomised Clinical Trials of COPD Exacerbations. A Meta-Epidemiological Study. Biomedicines 2021; 9:biomedicines9121837. [PMID: 34944653 PMCID: PMC8698292 DOI: 10.3390/biomedicines9121837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
A recently published ERS core outcome set recommends that all trials of COPD exacerbation management should assess the treatment success (or “cure” of the exacerbation), defined as a dichotomous measure of the overall outcome of an exacerbation. This methodological systematic review describes and compares the instruments that were used to assess treatment success or failure in 54 such RCTs, published between 2006–2020. Twenty-three RCTs used composite measures consisting of several undesirable outcomes of an exacerbation, together defining an overall unfavourable outcome, to define treatment failure. Thirty-four RCTs used descriptive instruments that used qualitative or semi-quantitative descriptions to define cure, marked improvement, improvement of the exacerbation, or treatment failure. Treatment success and failure rates among patients receiving guidelines-directed treatments at different settings and timepoints are described and could be used to inform power calculations in future trials. Descriptive instruments appeared more sensitive to treatment effects compared to composite instruments. Further methodological studies are needed to optimise the evaluation of treatment success/failure. In the meantime, based on the findings of this systematic review, the ERS core outcome set recommends that cure should be defined as sufficient improvement of the signs and symptoms of the exacerbation such that no additional systemic treatments are required.
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Affiliation(s)
- Alexander G. Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester M23 9LT, UK;
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
- Correspondence:
| | - Sachin Ananth
- West Hertfordshire Hospital NHS Trust, Watford WD18 0HB, UK;
| | - Thomas Bradbury
- The George Institute for Global Health, University of New South Wales, Sydney 1466, Australia; (T.B.); (C.J.)
| | - Balazs Csoma
- Department of Pulmonology, Faculty of Medicine, Semmelweis University, 1085 Budapest, Hungary; (B.C.); (Z.L.)
| | - Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev-Gentofte Hospital, 2900 Hellerup, Denmark; (P.S.); (J.-U.J.)
- Department of Internal Medicine, Zealand University Hospital, 4000 Roskilde, Denmark
| | - Elizabeth Stovold
- Cochrane Airways Group, Population Health Research Institute, St George’s University of London, London SW17 0RE, UK;
| | - Gustavo Fernandez-Romero
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (G.F.-R.); (G.J.C.)
| | - Zsofia Lazar
- Department of Pulmonology, Faculty of Medicine, Semmelweis University, 1085 Budapest, Hungary; (B.C.); (Z.L.)
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (G.F.-R.); (G.J.C.)
| | - Christine Jenkins
- The George Institute for Global Health, University of New South Wales, Sydney 1466, Australia; (T.B.); (C.J.)
| | - Alberto Papi
- Research Center on Asthma and COPD, Faculty of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Jens-Ulrik Jensen
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev-Gentofte Hospital, 2900 Hellerup, Denmark; (P.S.); (J.-U.J.)
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, 1165 Copenhagen, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester M23 9LT, UK;
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M23 9LT, UK
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Papaporfyriou A, Bakakos P, Hillas G, Papaioannou AI, Loukides S. Blood eosinophils in COPD: friend or foe? Expert Rev Respir Med 2021; 16:35-41. [PMID: 34821191 DOI: 10.1080/17476348.2021.2011219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The pathogenesis of chronic obstructive pulmonary disease (COPD) is highly complex and the underlying cellular and molecular mechanisms remain poorly understood. AREAS COVERED COPD has been traditionally associated with neutrophilic inflammation of the bronchi, but in the last decade, studies have demonstrated that eosinophils may also migrate into the lower airways of patients with COPD and their increased numbers can be noticed during exacerbations as well as stable disease. In this review, we present clinical characteristics of eosinophilic COPD, as well as the role of eosinophils as a biomarker-guided therapy in COPD. A systematic research using the database of Pubmed up to February 2021 was performed. The terms we searched were eosinophilic inflammation, COPD, COPD phenotypes, COPD exacerbations, corticosteroids in COPD, and monoclonal antibodies in COPD. EXPERT OPINION Blood eosinophil levels show strong potential as a prognostic and theragnostic biomarker in the clinical management of COPD being at the moment the most reliable biomarker. The lack of a certain cutoff value of blood eosinophils as guidance for treatment with ICS and biologic therapies and the uncertainty regarding the stability of eosinophilia and eosinophilic phenotype through the course of COPD remain as unmet dilemmas and problems.
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Affiliation(s)
| | - Petros Bakakos
- 1st Respiratory Medicine Department, University of Athens Medical School Sotiria' Chest Hospital,'Athens, Greece
| | - Georgios Hillas
- 5th Pulmonary Department, "Sotiria" Chest Diseases Hospital, Athens, Greece
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, University of Athens Medical School 'Attikon' Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, University of Athens Medical School 'Attikon' Hospital, Athens, Greece
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Stability of blood eosinophils in acute exacerbation of chronic obstructive pulmonary disease and its relationship to clinical outcomes: a prospective cohort study. Respir Res 2021; 22:301. [PMID: 34819051 PMCID: PMC8611944 DOI: 10.1186/s12931-021-01888-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The clinical value of blood eosinophils and their stability in chronic obstructive pulmonary disease (COPD) remains controversial. There are limited studies on association between the stability of blood eosinophils in acute exacerbation of COPD (AECOPD) and clinical outcomes. This study aimed to evaluate the stability of blood eosinophils in hospitalized AECOPD and its relationship to clinical outcomes. METHODS This prospective observational study recruited patients hospitalized with AECOPD from November 2016 to July 2020. The eligible patients were divided into four groups according to their blood eosinophil counts at admission and discharge: persistently < 300 cells/μl (LL), < 300 cells/μl at admission but ≥ 300 cells/µl at discharge (LH), ≥ 300 cells/μl at admission but < 300 cells/µl at discharge (HL), and persistently ≥ 300 cells/μl (HH). Cox hazard analyses were used to study the association between eosinophil changes and exacerbations or mortality. RESULTS In 530 patients included, 90 (17.0%) had a high blood eosinophil count (BEC) ≥ 300 cells/µl at admission but 32 (35.6%) of them showed a decreased BEC at discharge. The proportions and distribution for group LL, LH, HL, and HH were 381 (71.9%), 59 (11.1%), 32 (6.0%), and 58 (10.9%), respectively. During hospitalization, the LH group had a higher C-reactive protein level, higher rate of intensive care unit (ICU) admission, and higher total cost. The length of hospital stay of the LH group was longer compared with group LL, HL, or HH (P = 0.002, 0.017, and 0.001, respectively). During a follow-up of 12 months, the HH group was associated with a higher risk of moderate-to-severe exacerbations compared to the LL group (hazard ratio 2.00, 95% confidence interval 1.30-3.08, P = 0.002). Eosinophil changes had no significant association with mortality at 12 months. Sensitivity analyses in patients without asthma and without use of systemic corticosteroids prior to admission did not alter the results. CONCLUSIONS More attention should be paid to the LH group when evaluating the short-term prognosis of AECOPD. A persistently high BEC was a risk factor for long-term exacerbations. Eosinophil changes during hospitalization could help to predict outcomes.
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11
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Hansen MA, Hasbun R. US Hospitalizations and 60-Day Readmission Rates Associated with Herpes simplex virus Encephalitis: Analysis of All Cause Readmissions and Encephalopathy Associated Readmissions. Clin Infect Dis 2021; 74:1174-1182. [PMID: 34240104 DOI: 10.1093/cid/ciab613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) is the most common cause of encephalitis hospitalizations. We sought to describe and analyze features associated with all cause readmissions and encephalopathy associated readmissions amongst HSE cases. METHODS HSE hospitalizations and 60-day rehospitalizations were assessed in a retrospective cohort using linked hospitalizations from the Healthcare Utilization Project (HCUP) National Readmission Database (NRD) from 2010 through 2017. Risk factors for all-cause readmissions and encephalopathy associated readmissions were assessed with a weighted logistic regression model. RESULTS There were 10,272 HSE cases in the US between 2010 and 2017, resulting in a national rate of 4.95 per 100,000 hospitalizations. A total of 23.7% were readmitted at least once within 60-days. Patients that were readmitted were older (mean age 62.4 vs. 57.9, p<0.001), had a greater number of procedures at the index hospitalization (aOR 1.03, p<0.001) and have a higher Charlson comorbidity score (aOR 1.11, p<0.001). Amongst those readmitted, 465 (16.5%) had an encephalopathy related diagnosis. Over eight years, the rate of encephalopathy associated readmissions increased from 0.12 to 0.20. Encephalopathy specific readmissions were found to be associated with greater age (mean age 65.9 vs. 61.7, p = 0.004) and findings of cerebral edema at index hospitalization (aOR 2.16, p <0.001). CONCLUSIONS HSE readmissions are relatively common, particularly among older and sicker individuals. However, early signs and symptoms of neurological disease at index were correlated with encephalopathic specific readmissions.
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Affiliation(s)
- Michael A Hansen
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Rodrigo Hasbun
- Division of Infectious Disease, Department of Internal Medicine, UT Health McGovern Medical School, Houston, TX
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12
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Liu T, Xiang ZJ, Hou XM, Chai JJ, Yang YL, Zhang XT. Blood eosinophil count-guided corticosteroid therapy and as a prognostic biomarker of exacerbations of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Ther Adv Chronic Dis 2021; 12:20406223211028768. [PMID: 34285789 PMCID: PMC8267047 DOI: 10.1177/20406223211028768] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and dyspnea, as well as an increase in the number of leukocytes in the airways, lungs, and pulmonary vessels. A 'One size fits all' approach to COPD patients with different clinical features may be considered outdated. The following are the two major objectives of this meta-analysis: the first is to determine if blood eosinophil counts (BEC) can serve as a prognostic biomarker of COPD outcomes, and the second is to determine which level of BEC is effective for inhaled corticosteroid (ICS) treatment. METHODS We searched articles published before 15 May 2021 in the following four electronic databases: Web of Science, Cochrane Library, EMBASE, and PubMed. RESULTS A total of 42 studies, comprising a sampling of 188,710 subjects, were summarized and compared in this meta-analysis. The rate ratio (RR) of exacerbations of COPD (ECOPD) between ICS and non-ICS treatment was statistically significant for the COPD patients with a baseline BEC ⩾ 2% or ⩾ 200 cells/μl, RR = 0.82 (0.73, 0.93) or 0.79 (0.70, 0.89) respectively, while the RR of ECOPD between ICS and non-ICS treatment was statistically insignificant for the COPD patients with baseline BEC < 2% or <200 cells/μl, RR = 0.97 (0.87, 1.08) or 0.97 (0.86, 1.08), suggested that ICS therapy was beneficial to the improvement of ECOPD in patients with a baseline BEC ⩾ 2% or BEC ⩾ 200 cells/μl. CONCLUSION Our research shows that a BEC ⩾ 200 cells/μl or ⩾2% is likely to become the cutoff value of ICS treatment for ECOPD. Moreover, we believe that the baseline BEC can be used as a biomarker for predicting ECOPD. The stability of BEC requires special attention.
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Affiliation(s)
- Tao Liu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Jian Xiang
- Beijing Zhiyun Data Technology Co. LTD, Beijing, China
| | - Xiao-Meng Hou
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Jing Chai
- Department of Emergency Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Li Yang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Tong Zhang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
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13
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Cui Y, Zhan Z, Zeng Z, Huang K, Liang C, Mao X, Zhang Y, Ren X, Yang T, Chen Y. Blood Eosinophils and Clinical Outcomes in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Propensity Score Matching Analysis of Real-World Data in China. Front Med (Lausanne) 2021; 8:653777. [PMID: 34179040 PMCID: PMC8219875 DOI: 10.3389/fmed.2021.653777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022] Open
Abstract
Background and Objective: Elevated eosinophils in chronic obstructive pulmonary disease (COPD) are recognized as a biomarker to guide inhaled corticosteroids use, but the value of blood eosinophils in hospitalized exacerbations of COPD remains controversial. This study aimed to evaluate the accuracy of eosinophils in predicting clinical outcomes in acute exacerbation of COPD (AECOPD). Methods: We analyzed data from the acute exacerbation of chronic obstructive pulmonary disease inpatient registry (ACURE) study, which is an ongoing nationwide multicenter, observational real-world study in patients admitted for AECOPD. Data collected between January 2018 and December 2019 in 163 centers were first reviewed. The eligible patients were divided into eosinophilic and non-eosinophilic groups, according to blood eosinophil with 2% of the total leukocyte count as the threshold. Propensity score (PS) matching was performed to adjust for confounders. Results: A total of 1,566 patients (median age: 69 years; 80.3% male) were included and 42.7% had an eosinophilic AECOPD. Eosinophil count <2% was associated with the development of respiratory failure and pneumonia. After PS matching, 650 pairs in overall patients, 468 pairs in patients with smoking history and 177 pairs in patients without smoking were selected, respectively. Only in patients with smoking history, the non-eosinophilic AECOPD was associated with longer median hospital stays (9 vs. 8 days, P = 0.034), higher dosage of corticosteroid use, higher economic burden of hospitalization, and poorer response to corticosteroid therapy compared to the eosinophilic AECOPD. No significant difference was found in patients without smoking. Eosinophil levels had no relationship with the change of COPD Assessment Test scores and readmissions or death after 30 days. Conclusion: Elevated eosinophils were associated with better short-term outcomes only in patients with a smoking history. Eosinophil levels cannot be confidently used as a predictor alone for estimating prognosis.
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Affiliation(s)
- Yanan Cui
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zijie Zhan
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zihang Zeng
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ke Huang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Chen Liang
- Chinese Alliance for Respiratory Diseases in Primary Care, Beijing, China
| | - Xihua Mao
- Chinese Alliance for Respiratory Diseases in Primary Care, Beijing, China
| | - Yaowen Zhang
- Chinese Alliance for Respiratory Diseases in Primary Care, Beijing, China
| | - Xiaoxia Ren
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Ting Yang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Yan Chen
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
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