Risk Factors for Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Industrial Regions of China: A Multicenter Cross-Sectional Study

Factors Associated with Non-Adherence to Self-Management Among Patients with Chronic Obstructive Pulmonary Disease: A Survey Using the Delphi Technique and Analytic Hierarchy Process

Background

The relevant factors and patterns of non-adherence to self-management among patients with chronic obstructive pulmonary disease (COPD) need to be elucidated to improve self-management.

Purpose

This study was a survey to prioritize the relevance of factors associated with non-adherence to COPD self-management using the Delphi technique and analytic hierarchy process (AHP).

Patients and Methods

A total of 15 expert panels were established to determine the priority of relevant factors in a three-round Delphi survey and an AHP. To develop the preliminary conceptual framework for non-adherence to COPD self-management, findings from a systematic literature review, a qualitative study using in-depth interviews with COPD patients, and the first round of the Delphi survey were integrated. Based on the preliminary framework, the content validity ratio (CVR) was analyzed to examine the consensus among expert panels in the second and third rounds of the Delphi survey, and the relative weight was determined by pairwise comparisons between alternative factors in the AHP.

Results

In developing the preliminary conceptual framework, 8 factor categories and 53 factors were identified as relevant to non-adherence to COPD self-management. Of the 53 factors, 22 factors with a CVR of 0.49 or higher were identified in the Delphi survey. A total of 14 of the 53 factors were common to both the Delphi survey and AHP with high weights. The most notable factors were prolonged treatment, experience of treatment failure, and unknown effects of medication.

Conclusion

Through consensus decision-making by experts, 14 factors were identified as relevant factors associated with non-adherence to COPD self-management. A hierarchical and systematic framework incorporating factors associated with non-adherence to COPD self-management was developed in this study. Further research is needed to develop intervention strategies based on factors associated with non-adherence to COPD self-management.

Clinical Utility of Chest Sonography in Chronic Obstructive Pulmonary Disease Patients Focusing on Diaphragmatic Measurements

BACKGROUND

There are many methods of evaluating diaphragmatic function, including trans-diaphragmatic pressure measurements, which are considered the key rule of diagnosis. We studied the clinical usefulness of chest ultrasonography in evaluating stable chronic obstructive pulmonary disease (COPD) patients and those in exacerbation, focusing on diaphragmatic measurements and their correlation with spirometry and other clinical parameters.

METHODS

In a prospective case-control study, we enrolled 100 COPD patients divided into 40 stable COPD patients and 60 patients with exacerbation. The analysis included 20 age-matched controls. In addition to the clinical assessment of the study population, radiological evaluation included chest radiographs and chest computed tomography. Transthoracic ultrasonography (TUS) was performed for all included subjects.

RESULTS

Multiple A lines (more than 3) were more frequent in COPD exacerbation than in stable patients, as was the case for B-lines. TUS significantly showed high specificity, negative predictive value, positive predictive value, and accuracy in detecting pleural effusion, consolidation, pneumothorax, and lung mass. Diaphragmatic measurements were significantly lower among stable COPD subjects than healthy controls. Diaphragmatic thickness and excursion displayed a significant negative correlation with body mass index and the dyspnea scale, and a positive correlation with spirometry measures. Patients in Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D showed lower diaphragmatic measurements (thickness and excursion).

CONCLUSION

The TUS of COPD patients both in stable and exacerbated conditions and the assessment of diaphragm excursion and thickness by TUS in COPD patients and their correlations to disease-related factors proved informative and paved the way for the better management of COPD patients.

The clinical characteristics and treatment response of patients with chronic obstructive pulmonary disease with low body mass index

Background: This study aimed to analyze the clinical characteristics and treatment response of patients with chronic obstructive pulmonary disease (COPD) with low body mass index (BMI). Methods: In this cross-sectional study, we enrolled patients with stable COPD from the database setup by the Second Xiangya Hospital of Central South University. We classified the patients into three groups based on BMI: low-BMI (<18.5 kg/m²), normal-BMI (≥18.5 and <24.0 kg/m²), and high-BMI (≥24 kg/m²) groups. We defined clinically important deterioration (CID) as a COPD Assessment Test (CAT) score increase of ≥2 and minimum clinically important difference (MCID) as a CAT score decrease of ≥2 during 6 months of follow-up. We recorded the number of exacerbations and mortality during 1 year of follow-up. Results: A total of 910 COPD patients were included with 144 (15.8%) patients in low-BMI, 475 (52.2%) in normal-BMI, and 291 (32.0%) in high-BMI groups. Patients with low BMI had worse pulmonary function, higher symptom scores, and exacerbations in the past year compared with normal- and high-BMI groups (p < 0.05). Logistic regression analysis revealed that age, Global Initiative for Chronic Obstructive Lung Disease grades 3 and 4, and hospitalizations in the past year were independent risk factors for patients with low BMI (p < 0.05). After 1 year of follow-up, patients with low BMI had higher mortality and number of hospitalizations. Patients with low BMI were more likely to attain CID and less likely to attain MCID compared with patients with high BMI (p < 0.05). In addition, patients with low BMI treated with long-acting β2-agonist (LABA)+long-acting muscarinic antagonist (LAMA) and LABA+LAMA+inhaled corticosteroid (ICS) were more likely to attain MCID than those treated with LABA+ICS and LAMA (p < 0.05). Conclusion: COPD patients with low BMI had worse pulmonary function, higher symptom scores, and higher risk of future hospitalizations and mortality and were less likely to attain MCID and more likely to attain CID. It is worth noting that patients with low BMI treated with LABA+LAMA and LABA+LAMA+ICS were more likely to attain MCID than those treated with LABA+ICS and LAMA.

EXAcerbations of COPD and their OutcomeS on CardioVascular diseases (EXACOS-CV) Programme: protocol of multicountry observational cohort studies

INTRODUCTION

In patients with chronic obstructive pulmonary disease (COPD), the risk of certain cardiovascular (CV) events is increased by threefold to fivefold in the year following acute exacerbation of COPD (AECOPD), compared with a non-exacerbation period. While the effect of severe AECOPD is well established, the relationship of moderate exacerbation or prior exacerbation to elevated risk of CV events is less clear. We will conduct cohort studies in multiple countries to further characterise the association between AECOPD and CV events.

METHODS AND ANALYSIS

Retrospective longitudinal cohort studies will be conducted within routinely collected electronic healthcare records or claims databases. The study cohorts will include patients meeting inclusion criteria for COPD between 1 January 2014 and 31 December 2018. Moderate exacerbation is defined as an outpatient visit and/or medication dispensation/prescription for exacerbation; severe exacerbation is defined as hospitalisation for COPD. The primary outcomes of interest are the time to (1) first hospitalisation for a CV event (including acute coronary syndrome, heart failure, arrhythmias or cerebral ischaemia) since cohort entry or (2) death. Time-dependent Cox proportional hazards models will compare the hazard of a CV event between exposed periods following exacerbation (split into these periods: 1-7, 8-14, 15-30, 31-180 and 181-365 days) and the unexposed reference time period, adjusted on time-fixed and time-varying confounders.

ETHICS AND DISSEMINATION

Studies have been approved in Canada, Japan, the Netherlands, Spain and the UK, where an institutional review board is mandated. For each study, the results will be published in peer-reviewed journals.

Clinical-functional characteristics and risk of exacerbation and mortality among more symptomatic patients with chronic obstructive pulmonary disease: a retrospective cohort study

OBJECTIVES

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 classified chronic obstructive pulmonary disease (COPD) patients into more and less symptomatic groups. This study aimed to analyze the clinical characteristics, risk of future exacerbation and mortality among patients in more symptomatic group.

DESIGN

A retrospective cohort study.

SETTING

Data were obtained from patients enrolled in a database setup by Second Xiangya Hospital of Central South University.

PARTICIPANTS

1729 stable COPD patients listed from September 2017 to December 2019 in the database. The patients were classified into more and less symptomatic groups based on GOLD 2017 report.

OUTCOMES

All patients were followed up for 18 months. We collected baseline data and recorded the number of exacerbations and mortality during follow-up.

RESULTS

The more symptomatic patients were older, had higher Clinical COPD Questionnaire (CCQ) scores, more severe airflow limitation and higher number of exacerbations and hospitalizations in the past year (P < 0.05). Logistic regression showed that having more symptoms correlated with the CCQ scores and exacerbations in the past year (P < 0.05). After patients were followed up, there were higher numbers of exacerbations, hospitalizations and mortality rates in more symptomatic patients (P < 0.05). The multivariate model showed that age more than 65 years (OR = 2.047, 95% CI = 1.020-4.107) and COPD assessment test scores more than 30 (OR = 2.609, 95% CI = 1.339-5.085) were independent risk factors for mortality, whereas current smoker (OR = 1.565, 95% CI = 1.052-2.328), modified Medical Research Council scores (OR = 1.274, 95% CI = 1.073-1.512) and exacerbations in the past year (OR = 1.061, 95% CI = 1.013-1.112) were independent risk factors for exacerbation in more symptomatic patients (P < 0.05).

CONCLUSIONS

More symptomatic COPD patients have worse outcomes. In addition, several independent risk factors for exacerbation and mortality were identified. Therefore, clinicians should be aware of these risk factors and take them into account during interventions.

The Role of Early Warning Scoring Systems NEWS and MEWS in the Acute Exacerbation of COPD

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are the most devastating events in the course of the disease. Our aim was to investigate the value of early warning scoring systems: National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) in AECOPD. This is a prospective observational study of patients with AECOPD who were admitted at hospital. The NEWS and MEWS scores were registered at admission (NEWS-d1, MEWS-d1) and on the second day (NEWS-d2, MEWS-d2). A nasopharyngeal and sputum sample was taken for culture. Follow-up was done at 3 and 6 months after hospitalization. Any possible correlations between NEWS and MEWS and other parameters of COPD were explored. A cohort of 64 patients were included. In-hospital mortality was 4.7% while total mortality at 6 months was 26%. We did not find any significant correlation between in-hospital mortality and any of the scores but we could show a higher mortality and more frequent AECOPD at 6 months of follow-up for those with higher NEWS-d2. NEWS-d2 was associated with higher pCO₂ at presentation and a more frequent use of NIV. Higher NEWS-d1 and NEWS-d2 were predictive of a longer hospital stay. The presence of pathogens in the nasopharyngeal sample was related with a higher reduction of both scores on the second day. We therefore support the superiority of NEWS in the evaluation of hospitalized patients with AECOPD. A remaining high NEWS at the second day of hospital stay signals a high risk of hypercapnia and need of NIV but also higher mortality and more frequent exacerbations at 6 months after AECOPD.

Adherence to Long-Acting Inhaler Use for Initial Treatment and Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study

We aimed to determine the effect of long-acting inhaler use adherence on acute exacerbations in treatment-naïve patients with chronic obstructive pulmonary disease (COPD) using claims data from the Korean Health Insurance Review and Assessment Service from July 2015−December 2016. Patients with COPD aged ≥ 40 years who used long-acting inhalers were enrolled and observed for 6 months. Medication adherence was determined by the medication possession ratio (MPR); patients were categorized to adherence (MPR ≥ 80%) and non-adherence (MPR < 80%) groups. Ultimately, 3959 patients were enrolled: 60.4% and 39.6% in the adherence and non-adherence groups, respectively. The relative risk of acute exacerbation in the non-adherence group was 1.58 (95% confidence interval [CI] 1.25−1.99) compared with the adherence group. The adjusted logistic regression analysis revealed a relative risk of acute exacerbation in the non-adherence vs. adherence group of 1.68 (95% CI 1.32−2.14) regarding the number of inhalers used. Poor adherence to long-acting inhalers influenced increased acute exacerbation rates among patients with COPD. The acute exacerbation of COPD risk requiring hospitalization or ED visits was high in the non-adherence group, suggesting that efforts to improve medication adherence may help reduce COPD exacerbations even in the initial management of treatment-naïve patients.

Chronic moderate hypercapnia suppresses ventilatory responses to acute CO&lt;sub&gt;2&lt;/sub&gt; challenges

Chronic hypercapnia (CH) is a hallmark of chronic lung disease, and CH increases the risk for acute-on-chronic exacerbations leading to greater hypoxemia/hypercapnia and poor health outcomes. However, the role of hypercapnia per se (duration and severity) in determining an individual's ability to tolerate further hypercapnic exacerbations is unknown. Our primary objective herein was to test the hypothesis that mild-to-moderate CH (arterial [Formula: see text] ∼50-70 mmHg) increases susceptibility to pathophysiological responses to severe acute CO₂ challenges. Three groups (GR) of adult female goats were studied during 14 days of exposure to room air (<i>GR 1</i>; control) or 6% inspired CO₂ (<i>GR 2</i>; mild CH), or 7 days of 6% inspired CO₂ followed by 7 days of 8% inspired CO₂ (<i>GR 3</i>; moderate CH). Consistent with previous reports, there were no changes in physiological parameters in <i>GR 1</i> (RA control), but mild CH (<i>GR 2</i>) increased steady-state ventilation and transiently suppressed CO₂/[H⁺] chemosensitivity. Further increasing InCO₂ from 6% to 8% (<i>GR 3</i>) transiently increased ventilation and arterial [H⁺]. Similar to mild CH, moderate CH increased ventilation to levels greater than predicted. However, in contrast to mild CH, acute ventilatory chemosensitivity was suppressed throughout the duration of moderate CH, and the arterial - mixed expired CO₂ gradient became negative. These data suggest that moderate CH limits physiological responses to acute severe exacerbations and provide evidence of recruitment of extrapulmonary systems (i.e., gastric CO₂ elimination) during times of moderate-severe hypercapnia.<b>NEW &amp; NOTEWORTHY</b> Moderate levels of chronic hypercapnia (CH; ∼70 mmHg) in healthy adult female goats elicited similar steady-state physiological adaptations compared with mild CH (∼55 mmHg). However, unlike mild CH, moderate CH chronically suppressed acute CO₂/[H⁺] chemosensitivity and reversed the arterial to mixed expired CO₂ gradient. These findings suggest that moderate CH suppresses vital mechanisms of ventilatory control and recruits additional physiological systems (i.e., gastric CO₂ release) to help buffer excess CO₂.

Distribution of inflammatory phenotypes among patients with asthma in Jilin Province, China: a cross-sectional study

Background

The inflammatory phenotypes of asthma predict the treatment response and prognosis. The phenotype distributions differ depending on the geographical region. This study aimed to assess the distribution of different inflammatory phenotypes among asthma patients in Jilin Province, China.

Methods

A total of 255 patients with asthma were recruited from Jilin Province, China for this cross-sectional study. Each patient underwent sputum induction following clinical assessment and peripheral blood collection. Inflammatory phenotypes were classified according to the inflammatory cell counts in the sputum.

Results

Paucigranulocytic asthma (PGA) was the most common inflammatory phenotype (52.2%), followed by eosinophilic asthma (EA, 38.3%), mixed granulocytic asthma (MGA, 5.2%), and neutrophilic asthma (NA, 4.3%). NA was more common among patients over 45 years old and those who were treated with higher doses of inhaled corticosteroids (ICS), but was less common following antibiotics treatment (p < 0.05). The proportion of patients with EA decreased as the ICS treatment dose and time increased (p = 0.038). Patients with uncontrolled asthma had higher numbers of sputum eosinophils and neutrophils (p < 0.05). Patients with severe asthma had a higher percentage of sputum neutrophils (p < 0.05). A greater proportion of patients with NA had severe asthma (60%) compared to those with EA (18.2%) (p = 0.016).

Conclusions

The most common asthma inflammatory cell phenotype in Jilin Province, China is PGA, followed by EA, MGA, and NA. The low prevalence of NA in Jilin Province compared to other countries and also other regions in China might be due to excessive antibiotic use and irregular ICS treatment in this region.