Exacerbation frequency and course of COPD

Dupilumab for COPD with Blood Eosinophil Evidence of Type 2 Inflammation

BACKGROUND

Dupilumab, a fully human monoclonal antibody that blocks the shared receptor component for interleukin-4 and interleukin-13, key and central drivers of type 2 inflammation, has shown efficacy and safety in a phase 3 trial involving patients with chronic obstructive pulmonary disease (COPD) and type 2 inflammation and an elevated risk of exacerbation. Whether the findings would be confirmed in a second phase 3 trial was unclear.

METHODS

In a phase 3, double-blind, randomized trial, we assigned patients with COPD who had a blood eosinophil count of 300 cells per microliter or higher to receive subcutaneous dupilumab (300 mg) or placebo every 2 weeks. The primary end point was the annualized rate of moderate or severe exacerbations. Key secondary end points, analyzed in a hierarchical manner to adjust for multiplicity, included the changes from baseline in the prebronchodilator forced expiratory volume in 1 second (FEV1) at weeks 12 and 52 and in the St. George's Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better quality of life) total score at week 52.

RESULTS

A total of 935 patients underwent randomization: 470 were assigned to the dupilumab group and 465 to the placebo group. As prespecified, the primary analysis was performed after a positive interim analysis and included all available data for the 935 participants, 721 of whom were included in the analysis at week 52. The annualized rate of moderate or severe exacerbations was 0.86 (95% confidence interval [CI], 0.70 to 1.06) with dupilumab and 1.30 (95% CI, 1.05 to 1.60) with placebo; the rate ratio as compared with placebo was 0.66 (95% CI, 0.54 to 0.82; P<0.001). The prebronchodilator FEV1 increased from baseline to week 12 with dupilumab (least-squares mean change, 139 ml [95% CI, 105 to 173]) as compared with placebo (least-squares mean change, 57 ml [95% CI, 23 to 91]), with a significant least-squares mean difference at week 12 of 82 ml (P<0.001) and at week 52 of 62 ml (P = 0.02). No significant between-group difference was observed in the change in SGRQ scores from baseline to 52 weeks. The incidence of adverse events was similar in the two groups and consistent with the established profile of dupilumab.

CONCLUSIONS

In patients with COPD and type 2 inflammation as indicated by elevated blood eosinophil counts, dupilumab was associated with fewer exacerbations and better lung function than placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; NOTUS ClinicalTrials.gov number, NCT04456673.).

Joint clinical and molecular subtyping of COPD with variational autoencoders

Chronic Obstructive Pulmonary Disease (COPD) is a complex, heterogeneous disease. Traditional subtyping methods generally focus on either the clinical manifestations or the molecular endotypes of the disease, resulting in classifications that do not fully capture the disease's complexity. Here, we bridge this gap by introducing a subtyping pipeline that integrates clinical and gene expression data with variational autoencoders. We apply this methodology to the COPDGene study, a large study of current and former smoking individuals with and without COPD. Our approach generates a set of vector embeddings, called Personalized Integrated Profiles (PIPs), that recapitulate the joint clinical and molecular state of the subjects in the study. Prediction experiments show that the PIPs have a predictive accuracy comparable to or better than other embedding approaches. Using trajectory learning approaches, we analyze the main trajectories of variation in the PIP space and identify five well-separated subtypes with distinct clinical phenotypes, expression signatures, and disease outcomes. Notably, these subtypes are more robust to data resampling compared to those identified using traditional clustering approaches. Overall, our findings provide new avenues to establish fine-grained associations between the clinical characteristics, molecular processes, and disease outcomes of COPD.

Inhaled corticosteroids with combination inhaled long-acting beta2-agonists and long-acting muscarinic antagonists for chronic obstructive pulmonary disease

BACKGROUND

Management of chronic obstructive pulmonary disease (COPD) commonly involves a combination of long-acting bronchodilators including beta2-agonists (LABA) and muscarinic antagonists (LAMA). LABA and LAMA bronchodilators are now available in single-combination inhalers. In individuals with persistent symptoms or frequent exacerbations, inhaled corticosteroids (ICS) are also used with combination LABA and LAMA inhalers. However, the benefits and risks of adding ICS to combination LABA/LAMA inhalers as a triple therapy remain unclear.

OBJECTIVES

To assess the effects of adding an ICS to combination LABA/LAMA inhalers for the treatment of stable COPD.

SEARCH METHODS

We searched the Cochrane Airways Group Register of Trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase up to 30 November 2022. We also searched ClinicalTrials.gov and the WHO ICTRP up to 30 November 2022.

SELECTION CRITERIA

We included parallel-group randomised controlled trials of three weeks' duration or longer that compared the treatment of stable COPD with ICS in addition to combination LABA/LAMA inhalers against combination LABA/LAMA inhalers alone.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The primary outcomes were acute exacerbations of COPD, respiratory health-related quality of life, pneumonia and other serious adverse events. The secondary outcomes were symptom scores, lung function, physical capacity, and mortality. We used GRADE to assess certainty of evidence for studies that contributed data to our prespecified outcomes.

MAIN RESULTS

Four studies with a total of 15,412 participants met the inclusion criteria. The mean age of study participants ranged from 64.4 to 65.3 years; the proportion of female participants ranged from 28% to 40%. Most participants had symptomatic COPD (COPD Assessment Test Score ≥ 10) with severe to very severe airflow limitation (forced expiratory volume in one second (FEV1) < 50% predicted) and one or more moderate-to-severe COPD exacerbations in the last 12 months. Trial medications differed amongst studies. The duration of follow-up was 52 weeks in three studies and 24 weeks in one study. We assessed the risk of selection, performance, and detection bias to be low in the included studies; one study was at high risk of attrition bias, and one study was at high risk of reporting bias. Triple therapy may reduce rates of moderate-to-severe COPD exacerbations compared to combination LABA/LAMA inhalers (rate ratio (RR) 0.74, 95% confidence interval (CI) 0.67 to 0.81; n = 15,397; low-certainty evidence). Subgroup analysis stratifying by blood eosinophil counts showed there may be a greater reduction in rate of moderate-to-severe COPD exacerbations with triple therapy in participants with high-eosinophils (RR 0.67, 95% CI 0.60 to 0.75) compared to low-eosinophils (RR 0.87, 95% CI 0.81 to 0.93) (test for subgroup differences: P < 0.01) (high/low cut-offs: 150 eosinophils/µL in three studies; 200 eosinophils/µL in one study). However, moderate-to-substantial heterogeneity was observed in both high- and low-eosinophil subgroups. These subgroup analyses are observational by nature and thus results should be interpreted with caution. Triple therapy may be associated with reduced rates of severe COPD exacerbations (RR 0.75, 95% CI 0.67 to 0.84; n = 14,131; low-certainty evidence). Triple therapy improved health-related quality of life assessed using the St George's Respiratory Questionnaire (SGRQ) by the minimal clinically important difference (MCID) threshold (4-point decrease) (35.3% versus 42.4%, odds ratio (OR) 1.35, 95% CI 1.26 to 1.45; n = 14,070; high-certainty evidence). Triple therapy may result in fewer symptoms measured using the Transition Dyspnoea Index (TDI) (OR 1.33, 95% CI 1.13 to 1.57; n = 3044; moderate-certainty evidence) and improved lung function as measured by change in trough FEV1 (mean difference 38.68 mL, 95% CI 22.58 to 54.77; n = 11,352; low-certainty evidence). However, these benefits fell below MCID thresholds for TDI (1-unit decrease) and trough FEV1 (100 mL), respectively. Triple therapy is probably associated with a higher risk of pneumonia as a serious adverse event compared to combination LABA/LAMA inhalers (3.3% versus 1.9%, OR 1.74, 95% CI 1.39 to 2.18; n = 15,412; moderate-certainty evidence). In contrast, all-cause serious adverse events may be similar between groups (19.7% versus 19.7%, OR 0.95, 95% CI 0.87 to 1.03; n = 15,412; low-certainty evidence). All-cause mortality may be lower with triple therapy (1.4% versus 2.0%, OR 0.70, 95% CI 0.54 to 0.90; n = 15,397; low-certainty evidence).

AUTHORS' CONCLUSIONS

The available evidence suggests that triple therapy may reduce rates of COPD exacerbations (low-certainty evidence) and results in an improvement in health-related quality of life (high-certainty evidence) compared to combination LABA/LAMA inhalers, but probably confers an increased pneumonia risk as a serious adverse event (moderate-certainty evidence). Triple therapy probably improves respiratory symptoms and may improve lung function (moderate- and low-certainty evidence, respectively); however, these benefits do not appear to be clinically significant. Triple therapy may reduce the risk of all-cause mortality compared to combination LABA/LAMA inhalers (low-certainty evidence). The certainty of the evidence was downgraded most frequently for inconsistency or indirectness. Across the four included studies, there were important differences in inclusion criteria, trial medications, and duration of follow-up. Investigation of heterogeneity was limited due to the small number of included studies. We found limited data on the effects of triple therapy compared to combination LABA/LAMA inhalers in patients with mild-moderate COPD and those without a recent exacerbation history.

Monocyte related haematological indices in acute exacerbations of COPD - a new biomarker?

C-reactive protein (CRP) and leukocyte count are standard tools for recognising inflammation in COPD patients. This study aimed to find if there is a pattern in monocyte related haematological indices - monocyte to neutrophil ratio (MNR) and monocyte to lymphocyte ratio (MLR) - which could be helpful in differentiating COPD patients in need for hospitalization due to acute exacerbation of COPD or differentiating frequent COPD exacerbators from non-frequent COPD exacerbators. The study included 119 patients with COPD and 35 control subjects, recruited at the Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Croatia. Complete blood count was performed on Sysmex XN-1000, CRP on Cobas c501, and Fbg on BCS XP analyser. Data were analysed with MedCalc statistical software. The COPD patients were divided into three groups - frequent exacerbators (FE), non-frequent exacerbators (NFE), patients hospitalized for acute COPD exacerbations (HAE) and the control group were healthy smokers (HS). A statistically significant difference was found in the values of MNR while comparing these groups of patients: FE vs HAE (p<0.000), NFE vs HAE (p<0.000) and HS vs HAE (p<0.001); and for the values of MLR: FE vs HAE (p<0.022), NFE vs HAE (p<0.000) and HS vs HAE (p<0.000). As MLR and MNR have shown the statistical difference comparing the group of HAE to NFE, FE and HS, MLR and MNR could be valuable and available markers of acute COPD exacerbations and need for hospitalization.

Hospital Admission Rates in Patients with COPD Throughout the COVID-19 Pandemic

Purpose

Several studies report decreased hospital admissions for acute exacerbations of COPD (AECOPD) during the COVID-19 pandemic. However, there are no studies that compare AECOPD admissions with admissions for respiratory infections, including COVID-19. This study aimed to examine hospital admission rates for AECOPD, pneumonia, influenza, and COVID-19 among COPD patients, before and during the COVID-19 pandemic.

Patients and Methods

We obtained anonymized data on hospital admissions of patients with COPD and a primary diagnosis code for AECOPD, pneumonia, influenza, or COVID-19, from the hospital patient admission register at a large Swedish hospital. The study compared the pandemic period (February 2020-March 2022) to a period before the pandemic (June 2017-January 2020). Sequential phases of the pandemic were evaluated separately. Monthly admission rates were compared using Poisson regression, controlling for admission month.

Results

Comparing monthly admission rates during the pandemic with the prepandemic period, incidence rate ratios were 0.72 for AECOPD (95% CI 0.67-0.77; p<0.001), 0.56 for pneumonia (95% CI 0.49-0.62; p<0.001), 0.18 for influenza during the winter period (95% CI 0.10-0.30; p<0.001) and 0.79 for total COPD admissions, including COVID-19 (95% CI 0.75-0.84; p<0.001). The study showed significantly lower rate ratios for AECOPD, pneumonia, and total COPD admissions during the first, second, third, and fifth (Omicron) waves. No significant effect on admissions was seen after the withdrawal of restriction measures.

Conclusion

There was a significant reduction in the overall rate of hospital admissions among COPD patients for AECOPD, pneumonia, and respiratory viral infections during the pandemic despite the rise in COVID-19 admissions. However, prepandemic admission levels returned in the post-restriction period.

Respiratory Care Management of COPD Exacerbations

A COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks. Exacerbations are common. Respiratory therapists and physicians in an acute care setting often treat these patients. Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92%. Arterial blood gases remain the standard approach to assessing gas exchange in patients with COPD exacerbation. The limitations of arterial blood gas surrogates (pulse oximetry, capnography, transcutaneous monitoring, peripheral venous blood gases) should be appreciated so that they can be used wisely. Inhaled short-acting bronchodilators can be provided by nebulizer (jet or mesh), pressurized metered-dose inhaler (pMDI), pMDI with spacer or valved holding chamber, soft mist inhaler, or dry powder inhaler. The available evidence for the use of heliox for COPD exacerbation is weak. Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines. Robust high-level evidence with patient important outcomes is lacking for the use of high-flow nasal cannula in patients with COPD exacerbation. Management of auto-PEEP is the priority in mechanically ventilated patients with COPD. This is achieved by reducing airway resistance and decreasing minute ventilation. Trigger asynchrony and cycle asynchrony are addressed to improve patient-ventilator interaction. Patients with COPD should be extubated to NIV. Additional high-level evidence is needed before widespread use of extracorporeal CO2 removal. Care coordination can improve the effectiveness of care for patients with COPD exacerbation. Evidence-based practices improve outcomes in patients with COPD exacerbation.

The Complex Association between COPD and COVID-19

Chronic obstructive pulmonary disease (COPD) is significant cause of morbidity and mortality worldwide. There is mounting evidence suggesting that COPD patients are at increased risk of severe COVID-19 outcomes; however, it remains unclear whether they are more susceptible to acquiring SARS-CoV-2 infection. In this comprehensive review, we aim to provide an up-to-date perspective of the intricate relationship between COPD and COVID-19. We conducted a thorough review of the literature to examine the evidence regarding the susceptibility of COPD patients to COVID-19 infection and the severity of their disease outcomes. While most studies have found that pre-existing COPD is associated with worse COVID-19 outcomes, some have yielded conflicting results. We also discuss confounding factors such as cigarette smoking, inhaled corticosteroids, and socioeconomic and genetic factors that may influence this association. Furthermore, we review acute COVID-19 management, treatment, rehabilitation, and recovery in COPD patients and how public health measures impact their care. In conclusion, while the association between COPD and COVID-19 is complex and requires further investigation, this review highlights the need for careful management of COPD patients during the pandemic to minimize the risk of severe COVID-19 outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

COVID-19 vaccination coverage in patients with chronic obstructive pulmonary disease - A cross-sectional study in Hungary

INTRODUCTION

Coronavirus infection is a particular risk for patients with chronic obstructive pulmonary disease (COPD), because they are much more likely to become severely ill due to oxygen supply problems. Primary prevention, including COVID-19 vaccination is of paramount importance in this disease group. The aim of our study was to assess COVID-19 vaccination coverage in COPD patients during the first vaccination campaign of the COVID-19 pandemic.

METHODS

A cross-sectional observational study (CHANCE) has been conducted in COPD patients in the eastern, western and central regions of Hungary from 15th November 2021. The anthropometric, respiratory function test results and vaccination status of 1,511 randomly selected patients were recorded who were aged 35 years and older.

RESULTS

The median age was 67 (61-72) years, for men: 67 (62-73) and for women: 66 (60-72) years, with 47.98 % men and 52.02 % women in our sample. The prevalence of vaccination coverage for the first COVID-19 vaccine dose was 88.62 %, whereas 86.57 % of the patients received the second vaccine dose. When unvaccinated (n = 172) and double vaccinated (n = 1308) patients were compared, the difference was significant both in quality of life (CAT: 17 (12-23) vs 14 (10-19); p < 0.001) and severity of dyspnea (mMRC: 2 (2-2) vs 2 (1-2); p = 0.048). The COVID-19 infection rate between double vaccinated and unvaccinated patients was 1.61 % vs 22.67 %; p < 0.001 six months after vaccination. The difference between unvaccinated and vaccinated patients was significant (8.14 % vs 0.08 %; p < 0.001) among those with acute COVID-19 infection hospitalized. In terms of post-COVID symptoms, single or double vaccinated patients had significantly fewer outpatient hospital admissions than unvaccinated patients (7.56 vs 0 %; p < 0.001).

CONCLUSION

The COVID-19 vaccination coverage was satisfactory in our sample. The uptake of COVID-19 vaccines by patients with COPD is of utmost importance because they are much more likely to develop severe complications.

Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables

OBJECTIVE

To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations.

METHODS

People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR).

RESULTS

Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective.

CONCLUSIONS

Variables recorded at the bedside or in clinic provided information on hospitalisation risk.

Use of Remote Cardiorespiratory Monitoring is Associated with a Reduction in Hospitalizations for Subjects with COPD

Background

Chronic obstructive pulmonary disease (COPD) is prevalent and results in high healthcare resource utilization. The largest impact on health status and proportion of healthcare costs in COPD are related to hospitalizations for acute exacerbations. Accordingly, the Centers for Medicare & Medicaid Services have advocated for remote patient monitoring (RPM) to aid in chronic disease management. However, there has been a lack of evidence for the effectiveness of RPM in reducing the need for unplanned hospitalizations for patients with COPD.

Methods

This pre/post study was a retrospective analysis of unplanned hospitalizations in a cohort of COPD subjects started on RPM at a large, outpatient pulmonary practice. The study included all subjects with at least one unplanned, all-cause hospitalization or emergency room visit in the prior year, who had elected to enroll in an RPM service for assistance with clinical management. Additional inclusion criteria included being on RPM for at least 12 months and a patient of the practice for at least two years (12 months pre- and post-initiation of RPM).

Results

The study included 126 subjects. RPM was associated with a significantly lower rate of unplanned hospitalizations per patient per year (1.09 ± 0.07 versus 0.38 ± 0.06, P<0.001).

Conclusion

Unplanned, all-cause hospitalization rates were lower in subjects started on RPM for COPD when compared to their prior year. These results support the potential of RPM to improve the long-term management of COPD.

Lung Cancer in the Course of COPD-Emerging Problems Today

Tobacco smoking remains the main cause of tobacco-dependent diseases like lung cancer, chronic obstructive pulmonary disease (COPD), in addition to cardiovascular diseases and other cancers. Whilst the majority of smokers will not develop either COPD or lung cancer, they are closely related diseases, occurring as co-morbidities at a higher rate than if they were independently triggered by smoking. A patient with COPD has a four- to six-fold greater risk of developing lung cancer independent of smoking exposure, when compared to matched smokers with normal lung function. The 10 year risk is about 8.8% in the COPD group and only 2% in patients with normal lung function. COPD is not a uniform disorder: there are different phenotypes. One of them is manifested by the prevalence of emphysema and this is complicated by malignant processes most often. Here, we present and discuss the clinical problems of COPD in patients with lung cancer and against lung cancer in the course of COPD. There are common pathological pathways in both diseases. These are inflammation with participation of macrophages and neutrophils and proteases. It is known that anticancer immune regulation is distorted towards immunosuppression, while in COPD the elements of autoimmunity are described. Cytotoxic T cells, lymphocytes B and regulatory T cells with the important role of check point molecules are involved in both processes. A growing number of lung cancer patients are treated with immune check point inhibitors (ICIs), and it was found that COPD patients may have benefits from this treatment. Altogether, the data point to the necessity for deeper analysis and intensive research studies to limit the burden of these serious diseases by prevention and by elaboration of specific therapeutic options.

More than a random association between chronic obstructive pulmonary disease and psoriatic arthritis: shared pathogenic features and implications for treatment

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory condition characterized by skin and joints involvement, and with a great burden of comorbidity that could affect the choice of treatment. Chronic obstructive pulmonary disease (COPD) is one of the primary causes of morbidity and mortality. Medical therapy can improve symptoms and the frequency and severity of exacerbations. A variety of evidence showed an increasing association between COPD and PsA.

AREAS COVERED

Psoriatic disease and COPD appear to have a possible pathophysiologic link. The inhibition of intracellular molecules responsible for pro-inflammatory responses could be a therapeutic approach for both psoriatic diseases and COPD. Inhibitors of phosphodiesterase 4 (PDE-4) were developed to treat chronic inflammatory conditions such as psoriasis, PsA and COPD. Roflumilast has been used to treat COPD and asthma, while Apremilast to treat psoriasis and PsA. Given the efficacy and safety of these treatments, we can speculate that blocking PDE-4 might also provide clinical benefits in patients with co-existing COPD and PsA.

EXPERT OPINION

This hypothesis could offer the opportunity to screen patients for both diseases. Furthermore, this approach would increase the involvement of other specialists in the management of PsA, and it would improve the use of a tailored treatment for each patient.

Effectiveness of remote home monitoring for patients with Chronic Obstructive Pulmonary Disease (COPD): systematic review

Background

Although remote home monitoring (RHM) has the capacity to prevent exacerbations in patients with chronic obstructive pulmonary disease (COPD), evidence regarding its effectiveness remains unclear. The objective of this study was to determine the effectiveness of RHM in patients with COPD.

Methods

A systematic review of the scholarly literature published within the last 10 years was conducted using internationally recognized guidelines. Search strategies were applied to several electronic databases and clinical trial registries through March 2020 to identify studies comparing RHM to ‘no remote home monitoring’ (no RHM) or comparing RHM with provider’s feedback to RHM without feedback. To critically appraise the included randomized studies, the Cochrane Collaboration risk of bias tool (ROB) was used. The quality of included non-randomized interventional and comparative observational studies was evaluated using the ACROBAT-NRSI tool from the Cochrane Collaboration. The quality of evidence relating to key outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) on the following: health-related quality of life (HRQoL), patient experience and number of exacerbations, number of emergency room (ER) visits, COPD-related hospital admissions, and adherence as the proportion of patients who completed the study. Three independent reviewers assessed methodologic quality and reviewed the studies.

Results

Seventeen randomized controlled trials (RCTs) and two comparative observational studies were included in the review. The primary finding of this systematic review is that a considerable amount of evidence relating to the efficacy/effectiveness of RHM exists, but its quality is low. Although RHM is safe, it does not appear to improve HRQoL (regardless of the type of RHM), lung function or self-efficacy, or to reduce depression, anxiety, or healthcare resource utilization. The inclusion of regular feedback from providers may reduce COPD-related hospital admissions. Though adherence RHM remains unclear, both patient and provider satisfaction were high with the intervention.

Conclusions

Although a considerable amount of evidence to the effectiveness of RHM exists, due to heterogeneity of care settings and the low-quality evidence, they should be interpreted with caution.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07938-y.

Mortality of COVID-19 is associated with comorbidity in patients with chronic obstructive pulmonary disease

BACKGROUND

The aim of this study was to compare the outcome of coronavirus disease 2019 (COVID-19) in hospitalised patients with chronic obstructive pulmonary disease (COPD) with the outcome in matched COVID-19 patients without COPD.

METHODS

Sixty-three COPD patients hospitalised for acute COVID-19 from March through August 2020 were retrospectively identified and 63 hospitalised COVID-19 patients without COPD were selected and matched for age, gender and month of hospital admission.

RESULTS

COPD patients had a higher rate of comorbidities, especially cardiovascular disease, and a trend towards a higher 30-day mortality than control patients (35% vs. 22%). In the COPD group, high Charlson comorbidity index (p = 0.03) and previous cerebrovascular disease (p = 0.04) were associated with 30-day mortality in univariate analysis. Inhaled corticosteroids maintenance therapy was not associated with lower mortality.

CONCLUSION

COPD patients hospitalised for acute COVID-19 disease had significantly more comorbidities and a high risk of severe outcome and death within 30 days. Comorbidity, especially cardiovascular diseases, was associated with mortality among COPD patients.

COPD - do the right thing

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

Clinical Practice Patterns of Speech-Language Pathologists Delivering Dysphagia Services to Persons with COPD: Analysis of Survey Outcomes

Swallowing impairments co-occur with chronic obstructive pulmonary disease (COPD) leading to aspiration, disease exacerbations, and malnutrition. This pilot survey study aimed to identify current clinical practice patterns for swallowing evaluation and treatment in persons with COPD. A 35-question Qualtrics survey was deployed to medical speech-language pathology (SLP) social media sites and professional boards; flyers were distributed at a professional conference. Forty-eight SLPs completed the study. SLPs routinely include a clinical swallow examination (96%), videofluoroscopic swallowing study (79%), adjunctive respiratory measures (respiratory rate [83%], and pulse oximetry [67%], respiratory-swallow pattern [77%]) but less frequently include fiberoptic endoscopic evaluation of swallowing (23%). Self-reported advanced clinical experience and expert respiratory analysis skills were associated with adjunctive respiratory measure (respiratory rate, pulse oximetry) inclusion during assessment. Compensatory strategy training (77%) is a preferred treatment for dysphagia in COPD; however, respiratory-swallow pattern training and expiratory muscle strength training are increasing in use. SLPs self-report a comprehensive, individualized patient-centered care approach with inclusion of adjunctive respiratory-focused methods in dysphagia evaluation and treatment practice in persons with COPD. Advances in the identification of the integral role of respiratory function in swallowing integrity may be translating to clinical practice methods for dysphagia management in persons with COPD.

Healthcare, Medication Utilization and Outcomes of Patients with COPD by GOLD Classification in England

Background

Available data on the relationship between COPD symptoms, disease outcomes, and mortality are currently limited. This study investigated the clinical characteristics, outcomes, healthcare utilization, and prescribing practices across GOLD 2017 groups (A, B, C, and D) in a large-scale, population-based cohort of COPD patients managed in an English primary care setting.

Patients and Methods

This retrospective analysis included patients aged ≥35 years, with a confirmed diagnosis of COPD and ≥1 record of pulmonary function testing in their medical history. Medical Research Council dyspnea score and exacerbation history were used to define patients’ GOLD 2017 classification. Patients were identified using the UK Clinical Practice Research Database and were followed for 12 months.

Results

Eligible COPD patients’ (N=42,331; mean [SD] age, 69.5 [10.7] years; 54% males), GOLD 2017 categorizations were: Group A: 49.1%, Group B: 30.5%, Group C: 8.2%, Group D: 12.1%. Overall, 37.7% of patients experienced ≥1 moderate COPD exacerbation. The rate of moderate exacerbations per person per year (PPPY) was highest in GOLD group D (0.72), followed by C (0.53), B (0.22), and A (0.15), while the rate of exacerbations leading to hospitalization PPPY was much higher in D (0.27) than in B (0.10), C (0.08), or A (0.03). Overall, 56.4% of patients visited their general practitioner ≥5 times in the 12 months of follow-up. Time-to-event analysis suggested that breathlessness contributed to exacerbation severity and frequency. One-year mortality was highest in GOLD groups D and B. The most frequent prescribed maintenance therapies were inhaled corticosteroids with long-acting β₂-agonists, multiple-inhaler triple therapy, or long-acting muscarinic antagonist, irrespective of GOLD classification.

Conclusion

The burden of COPD remains substantial in England. Stratification of this large primary care population according to GOLD criteria predicted the risk of COPD exacerbations. Understanding populations of patients with COPD may enable the optimization of patient care.

Future concepts in bronchodilation for COPD: dual- versus monotherapy

Most patients with COPD are recommended to initiate maintenance therapy with a single long-acting bronchodilator, such as a long-acting muscarinic antagonist or long-acting β₂-agonist. However, many patients receiving mono-bronchodilation continue to experience high symptom burden, suggesting that patients are frequently not receiving optimal treatment. Treatment goals for COPD are often broad and not individually tailored, making initial treatment response assessments difficult. A personalised approach to initial maintenance therapy, based upon an individual's symptom burden and exacerbation risk, may be more appropriate.An alternative approach would be to maximise bronchodilation early in the disease course of all patients with COPD. Evidence suggests that dual bronchodilation has greater and consistent efficacy for lung function and symptoms than mono-bronchodilation, whilst potentially reducing the risk of exacerbations and disease deterioration, with a similar safety profile to mono-bronchodilators. Improvements in lung function and symptoms between dual- and mono-bronchodilation have also been demonstrated in maintenance-naïve patients, who are most likely to resemble those at first presentation in a clinical setting. Despite promising results, there are several evidence gaps that need to be addressed to allow decision makers to evaluate the merits of a widespread earlier introduction of dual bronchodilation.

Chronic Obstructive Pulmonary Disease: Epidemiology, Biomarkers, and Paving the Way to Lung Cancer

Chronic obstructive pulmonary disease (COPD), the frequently fatal pathology of the respiratory tract, accounts for half a billion cases globally. COPD manifests via chronic inflammatory response to irritants, frequently to tobacco smoke. The progression of COPD from early onset to advanced disease leads to the loss of the alveolar wall, pulmonary hypertension, and fibrosis of the respiratory epithelium. Here, we focus on the epidemiology, progression, and biomarkers of COPD with a particular connection to lung cancer. Dissecting the cellular and molecular players in the progression of the disease, we aim to shed light on the role of smoking, which is responsible for the disease, or at least for the more severe symptoms and worse patient outcomes. We summarize the inflammatory conditions, as well as the role of EMT and fibroblasts in establishing a cancer-prone microenvironment, i.e., the soil for ‘COPD-derived’ lung cancer. We highlight that the major health problem of COPD can be alleviated via smoking cessation, early diagnosis, and abandonment of the usage of biomass fuels on a global basis.

Effects of cigarette smoke exposure on pulmonary physiology, muscle strength and exercise capacity in a retrospective cohort with 30,000 subjects

BACKGROUND

The effects of long-term cigarette smoke exposure on pulmonary physiology and how those effects lead to reduced exercise capacity are not well established.

METHODS

We retrospectively analyzed the spirometry, single-breath gas transfer (DLCO), peripheral muscle strength, and maximum exercise capacity data in patients referred to McMaster University Medical Centre for cardiopulmonary exercise testing between 2000 and 2012.

RESULTS

29,441 subjects underwent CPET and had a recorded smoking history [58% male, mean age 51.1 years (S.D.±19.6), BMI 27.4 kg/m2(±5.8)]. 7081 (24%) were current or former smokers and were divided into 4 categories by packs years (mean ±S.D.): <10 (5.8±3.3), 10-20 (17.1±2.9), 20-30 (27.1±2.8), 30-40 (37.3±2.8), and >40 (53.9±12.8). Patients with greater cigarette smoke exposure had lower expiratory flow rates (FEV1, FEF50, FEF75, PEFR), DLCO, and maximum power output (MPO) during exercise. There was no association between smoke exposure and muscle strength. Modeling MPO (kpm/min) output as a function of demographic and physiologic variables showed that the data are well explained by muscle strength (kg), FEV1 (L), and DLCO (mmHg/min/mL) in similar magnitude (MPO = 42.7*Quads0.34*FEV10.34 * DLCO0.43; r = 0.84).

CONCLUSIONS

Long-term cigarette smoke exposure is associated with small airway narrowing and impaired diffusion capacity but not with peripheral muscle weakness. The effects of smoking, age, and gender on maximum power output are mediated by reductions in FEV1, muscle strength and DLCO. Exercise capacity in smokers may benefit from therapies targeting all 3 variables.

Reduced All-Cause Mortality in the ETHOS Trial of Budesonide/Glycopyrrolate/Formoterol for Chronic Obstructive Pulmonary Disease. A Randomized, Double-Blind, Multicenter, Parallel-Group Study

Rationale: In the phase III, 52-week ETHOS (Efficacy and Safety of Triple Therapy in Obstructive Lung Disease) trial in chronic obstructive pulmonary disease (COPD) (NCT02465567), triple therapy with budesonide/glycopyrrolate/formoterol fumarate (BGF) significantly reduced all-cause mortality compared with glycopyrrolate/formoterol fumarate (GFF). However, 384 of 8,509 patients were missing vital status at Week 52 in the original analyses.Objectives: To assess the robustness of the ETHOS mortality findings after additional data retrieval for patients missing Week 52 vital status in the original analyses.Methods: Patients with moderate to very severe COPD and prior history of exacerbation received twice-daily dosing with 320/18/9.6 μg of BGF (BGF 320), 160/18/9.6 μg of BGF (BGF 160), 18/9.6 μg of GFF, or 320/9.6 μg of budesonide/formoterol fumarate (BFF) (all delivered via a single metered-dose Aerosphere inhaler). Time to death (all-cause) was a prespecified secondary endpoint.Measurements and Main Results: In the final retrieved dataset, which included Week 52 vital status for 99.6% of the intent-to-treat population, risk of death with BGF 320 was significantly lower than GFF (hazard ratio, 0.51; 95% confidence interval, 0.33-0.80; unadjusted P = 0.0035). There were no significant differences in mortality when comparing BGF 320 with BFF (hazard ratio, 0.72; 95% confidence interval, 0.44-1.16; P = 0.1721), nor were significant differences observed when comparing BGF 160 against either dual comparator. Results were similar when the first 30, 60, or 90 days of treatment were excluded from the analysis. Deaths from cardiovascular causes occurred in 0.5%, 0.8%, 1.4%, and 0.5% of patients in the BGF 320, BGF 160, GFF, and BFF groups, respectively.Conclusions: Using final retrieved vital status data, triple therapy with BGF 320 reduced the risk of death compared with GFF, but was not shown to significantly reduce the risk of death compared with BFF, in patients with COPD. Triple therapy containing a lower dose of inhaled corticosteroid (BGF 160) was not shown to significantly reduce the risk of death compared with the dual therapy comparators.

Benefit/Risk Profile of Single-Inhaler Triple Therapy in COPD

Chronic obstructive pulmonary disease (COPD) is associated with major healthcare and socioeconomic burdens. International consortia recommend a personalized approach to treatment and management that aims to reduce both symptom burden and the risk of exacerbations. Recent clinical trials have investigated single-inhaler triple therapy (SITT) with a long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA), and inhaled corticosteroid (ICS) for patients with symptomatic COPD. Here, we review evidence from randomized controlled trials showing the benefits of SITT and weigh these against the reported risk of pneumonia with ICS use. We highlight the challenges associated with cross-trial comparisons of benefit/risk, discuss blood eosinophils as a marker of ICS responsiveness, and summarize current treatment recommendations and the position of SITT in the management of COPD, including potential advantages in terms of improving patient adherence. Evidence from trials of SITT versus dual therapies in symptomatic patients with moderate to very severe airflow limitation and increased risk of exacerbations shows benefits in lung function and patient-reported outcomes. Moreover, the key benefits reported with SITT are significant reductions in exacerbations and hospitalizations, with data also suggesting reduced all-cause mortality. These benefits outweigh the ICS-class effect of higher incidence of study-reported pneumonia compared with LAMA/LABA. Important differences in trial design, baseline population characteristics, such as exacerbation history, and assessment of outcomes, have significant implications for interpreting data from cross-trial comparisons. Current understanding interprets the blood eosinophil count as a continuum that can help predict response to ICS and has utility alongside other clinical factors to aid treatment decision-making. We conclude that treatment decisions in COPD should be guided by an approach that considers benefit versus risk, with early optimization of treatment essential for maximizing long-term benefits and patient outcomes.

Safety of denervation following targeted lung denervation therapy for COPD: AIRFLOW-1 3-year outcomes

Background

Targeted lung denervation (TLD) is a novel bronchoscopic therapy that disrupts parasympathetic pulmonary nerve input to the lung reducing clinical consequences of cholinergic hyperactivity. The AIRFLOW-1 study assessed safety and TLD dose in patients with moderate-to-severe, symptomatic COPD. This analysis evaluated the long-term impact of TLD on COPD exacerbations, pulmonary function, and quality of life over 3 years of follow up.

Methods

TLD was performed in a prospective, energy-level randomized (29 W vs 32 W power), multicenter study (NCT02058459). Additional patients were enrolled in an open label confirmation phase to confirm improved gastrointestinal safety after procedural modifications. Durability of TLD was evaluated at 1, 2, and 3 years post-treatment and assessed through analysis of COPD exacerbations, pulmonary lung function, and quality of life.

Results

Three-year follow-up data were available for 73.9% of patients (n = 34). The annualized rate of moderate to severe COPD exacerbations remained stable over the duration of the study. Lung function (FEV₁, FVC, RV, and TLC) and quality of life (SGRQ-C and CAT) remained stable over 3 years of follow-up. No new gastrointestinal adverse events and no unexpected serious adverse events were observed.

Conclusion

TLD in COPD patients demonstrated a positive safety profile out to 3 years, with no late-onset serious adverse events related to denervation therapy. Clinical stability in lung function, quality of life, and exacerbations were observed in TLD treated patients over 3 years of follow up.

Clinical features of Japanese patients with exacerbations of chronic obstructive pulmonary disease

Background

Exacerbations are critical events in chronic pulmonary obstructive disease (COPD). The frequency of COPD exacerbations is associated with the prognosis, including mortality, but no useful biomarker has been established.

Methods

The present retrospective study investigated 481 COPD patients. Clinical features in the stable period were compared between patients who experienced severe exacerbation (n = 88, 18.3%) and those who never experienced severe exacerbation (n = 393, 81.7%). In the patients who experienced exacerbations, clinical features were also compared between frequent exacerbators (exacerbation rate ≥ 2 times/year, n = 27, 30.7%) and infrequent exacerbators (1 time/year, n = 61, 69.3%).

Results

Compared to COPD patients who never experienced exacerbations, body mass index (BMI), serum albumin, and pulmonary functions were significantly lower, and the cardiovascular disease comorbidity rate, COPD assessment test score, modified Medical Research Council dyspnea scale, and use of long-term oxygen therapy, long-acting β₂ adrenergic agonist therapy, inhaled corticosteroid therapy, and macrolide therapy were significantly higher in COPD patients with exacerbations (all p < 0.01). In patients who experienced exacerbations, frequent exacerbators had significantly lower % forced expiratory volume in 1.0 s and a higher risk of critical exacerbations, percentage of blood eosinophils, history of mechanical ventilation use, and use of long-term oxygen therapy and of macrolide therapy than infrequent exacerbators (all p < 0.01). On multivariate analysis, the percentage of blood eosinophils was the parameter most correlated with exacerbation frequency (β value [95% confidence interval] 1.45 [1.12–1.88], p < 0.01).

Conclusion

Blood eosinophil in the stable period is the factor most correlated with the frequency of severe exacerbations.

Trial registration: The patients in this study was registered retrospectively

COVID-19 and COPD: a narrative review of the basic science and clinical outcomes

The 2019 coronavirus disease (COVID-19) pandemic is caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Clinical outcomes, including mortality, are worse in males, older individuals and patients with comorbidities. COPD patients are included in shielding strategies due to their susceptibility to virus-induced exacerbations, compromised pulmonary function and high prevalence of associated comorbidities. Using evidence from basic science and cohort studies, this review addresses key questions concerning COVID-19 and COPD. First, are there mechanisms by which COPD patients are more susceptible to SARS-CoV-2 infection? Secondly, do inhaled corticosteroids offer protection against COVID-19? And, thirdly, what is the evidence regarding clinical outcomes from COVID-19 in COPD patients? This up-to-date review tackles some of the key issues which have significant impact on the long-term outlook for COPD patients in the context of COVID-19.

This up-to-date review tackles some of the key issues which have significant impact on the long-term outlook for COPD patients in the context of COVID-19https://bit.ly/36PKzEO

Possible Protective Effect of Omalizumab on Lung Function Decline in Patients Experiencing Asthma Exacerbations

BACKGROUND

Frequent exacerbations are associated with greater FEV₁ decline in patients with asthma. The effect of omalizumab versus placebo on lung function in patients experiencing asthma exacerbations has not been previously examined.

OBJECTIVE

To evaluate the relationship between postbaseline (treatment phase) exacerbation status and lung function decline in children, adolescents, and adults treated with omalizumab versus placebo using data from 3 pediatric and adolescent/adult studies.

METHODS

Changes in percent predicted FEV₁ (ppFEV₁) and FEV₁ by treatment (omalizumab/placebo) and postbaseline exacerbation status (exacerbators/nonexacerbators) were assessed in patients aged 6 to 11 years (IA05, n = 576) and 12 to 75 years (EXTRA/INNOVATE pooled, n = 1202). Pediatric patients were examined at treatment weeks 12, 24, 28, 40, and 52, and adolescent/adult data at weeks 4, 12, 20, and 28.

RESULTS

Omalizumab-treated patients experienced larger increases in ppFEV₁ and FEV₁ compared with placebo-treated patients in the pediatric and pooled adolescent/adult populations. The response was observed in pediatric exacerbators, with significantly larger increases in ppFEV₁ and FEV₁ at week 12 (mean difference [95% CI], 4.11% [0.93%-7.30%], P = .011 for ppFEV₁; 80 [10-140] mL, P = .017 for FEV₁) and week 28 (mean difference [95% CI], 3.65% [0.11%-7.19%], P = .043 for ppFEV₁; 100 [30-170] mL, P = .007 for FEV₁). In the adolescent/adult population, both exacerbators and nonexacerbators derived similar benefit with omalizumab compared with placebo.

CONCLUSIONS

Findings from this post hoc analysis suggest that omalizumab may confer some protection against lung function decline among patients who experienced exacerbations during treatment.

Remote Patient Monitoring for the Detection of COPD Exacerbations

Background

COPD exacerbations occur more frequently with disease progression and are associated with worse prognosis and higher healthcare expenditure.

Purpose

To utilize a networked system, optimized with statistical process control (SPC), for remote patient monitoring (RPM) and to identify potential predictors of COPD exacerbations.

Methods

Seventeen subjects, mean (SD) age of 69.7 (7.2) years, with moderate to severe COPD received RPM. Over 2618 patient-days (7.17 patient-years) of monitoring, we obtained daily symptom scores, treatment adherence, self-reported activity levels, daily spirometry (SVC, FEV₁, FVC, PEF), inspiratory capacity (IC), and oxygenation (SpO₂). These data were used to identify predictors of exacerbations defined using Anthonisen and other criteria.

Results

After implementation of SPC, concordance analysis showed substantial agreement between FVC (decrease below the 7-day rolling average minus 1.645 SD) and self-reported healthcare utilization events (κ=0.747, P<0.001) as well as between increased use of inhaled short-acting bronchodilators and exacerbations defined by two Anthonisen criteria (κ=0.611, P<0.001) or modified Anthonisen criteria (κ=0.622, P<0.001). There was a moderate agreement between FEV₁ (decrease >1.645 SD below the 7-day rolling average) and self-reported healthcare utilization events (κ=0.475, P<0.001) and between SpO₂ less than 90% and exacerbations defined by two Anthonisen criteria (κ=0.474, P<0.001) or modified Anthonisen criteria (κ=0.564, P<0.001).

Conclusion

Exacerbations were best predicted by FVC and FEV₁ below the one-sided 95% confidence interval derived from SPC but also by increased use of inhaled short-acting bronchodilators and fall in oxygen saturation. An RPM program that captures these parameters may be used to guide appropriate interventions aimed at reducing healthcare utilization in COPD patients.

The Long-Term Burden of COPD Exacerbations During Maintenance Therapy and Lung Function Decline

Introduction

Early identification of preventable risk factors of COPD progression is important. Whether exacerbations have a negative impact on disease progression is largely unknown. We investigated whether the long-term occurrence of exacerbations is associated with lung function decline at early stages of COPD.

Methods

Patients diagnosed with mild/moderate COPD (obstruction and FEV₁% predicted 50–90%), aged ≥35 years, and a smoking history, who had ≥6 years of UK electronic medical records after initiation of maintenance therapy were studied. Multilevel mixed-effect linear regression was performed to determine the association between the count of any year in which the patient had ≥1 exacerbation over a 6-year period and FEV₁ decline, adjusted for sex, age, anthropometrics and smoking habits. Exacerbations were defined as any prescription for an acute oral corticosteroid course and/or lower respiratory-related antibiotics and/or any COPD-related emergency or inpatient hospitalization.

Results

Of 11,337 patients included (mean age 65 years; 49% female) 31.6%, 23.3%, 16.6%, 11.6%, 8.1%, 5.3% and 3.4% had 0, 1, 2, 3, 4, 5 and 6 years with ≥1 exacerbation. The mean annual FEV₁ decline accelerated by 1.50 mL/year (95% Confidence Interval 1.02; 1.98) with every additional year with ≥1 exacerbation from 31.0 mL/year in subjects without any exacerbation to 40.0 mL/year in patients experiencing ≥1 exacerbation every year. Patients with more years with ≥1 exacerbation had a lower mean FEV₁ at first diagnosis: 14.7 mL (11.7; 17.8) lower with every additional year with exacerbations. When counting years with ≥2 exacerbations, greater effects were observed (2.19 [1.50; 2.88]  mL/year excess decline per year with ≥2 exacerbations; 16.5 mL [12.1; 20.8] lower FEV₁ at diagnosis).

Conclusion

Patients who experienced a greater exacerbation burden after initiation of maintenance therapy had worse lung function at diagnosis and a more rapid lung function decline thereafter, which emphasizes the need for better treatment strategies.

Interstitial Lung Abnormalities and the Clinical Course in Patients With COPD

BACKGROUND

The presence and progression of interstitial lung abnormalities (ILAs) is known to be associated with a decline of lung function and increased risk of mortality.

RESEARCH QUESTION

We aimed to elucidate the clinical course according to ILAs in patients with COPD.

STUDY DESIGN AND METHODS

A retrospective study was conducted between January 2013 and December 2018 of COPD patients who underwent chest CT imaging and longitudinal pulmonary function tests. We evaluated radiologic findings, history of acute exacerbations of COPD, and lung function changes during the longitudinal follow-up.

RESULTS

Of 363 patients with COPD, 44 and 103 patients had equivocal and definite ILAs, respectively. Patients with ILAs were significantly older and had lower FEV₁ and FVC than patients without ILAs. During the mean follow-up period of 5.2 years, ILAs were associated significantly with the annual incidence of moderate to severe acute exacerbation of COPD (β ± SD, 0.38 ± 0.12; P = .002) and with the risk of frequent exacerbation (adjusted OR, 2.03; P = .045). Patients with progressive ILAs showed a significantly higher rate of annual decline in FEV₁ and FVC than those showing no change in, or improved, ILAs.

INTERPRETATION

ILAs were associated significantly with moderate to severe acute exacerbation in patients with COPD, and the progression of ILAs was associated with an accelerated decline in lung function.

Frailty in Chronic Obstructive Pulmonary Disease and Risk of Exacerbations and Hospitalizations

Background

Frailty is a complex clinical syndrome associated with vulnerability to adverse health outcomes. While frailty is thought to be common in chronic obstructive pulmonary disease (COPD), the relationship between frailty and COPD-related outcomes such as risk of acute exacerbations of COPD (AE-COPD) and hospitalizations is unclear.

Purpose

To examine the association between physical frailty and risk of acute exacerbations, hospitalizations, and mortality in patients with COPD.

Methods

A longitudinal analysis of data from a cohort of 280 participants was performed. Baseline frailty measures included exhaustion, weakness, low activity, slowness, and undernutrition. Outcome measures included AE-COPD, hospitalizations, and mortality over 2 years. Negative binomial regression and Cox proportional hazard modeling were used.

Results

Sixty-two percent of the study population met criteria for pre-frail and 23% were frail. In adjusted analyses, the frailty syndrome was not associated with COPD exacerbations. However, among the individual components of the frailty syndrome, weakness measured by handgrip strength was associated with increased risk of COPD exacerbations (IRR 1.46, 95% CI 1.09–1.97). The frailty phenotype was not associated with all-cause hospitalizations but was associated with increased risk of non-COPD-related hospitalizations.

Conclusion

This longitudinal cohort study shows that a high proportion of patients with COPD are pre-frail or frail. The frailty phenotype was associated with an increased risk of non-COPD hospitalizations but not with all-cause hospitalizations or COPD exacerbations. Among the individual frailty components, low handgrip strength was associated with increased risk of COPD exacerbations over a 2-year period. Measuring handgrip strength may identify COPD patients who could benefit from programs to reduce COPD exacerbations.

The Relationship Between Morning Symptoms and the Risk of Future Exacerbations in COPD

Background

The morning is the most troublesome time of day for patients with chronic obstructive pulmonary disease (COPD). However, the association of morning symptoms and COPD exacerbations in longitudinal follow-up has not been studied. In this study, we mainly aimed to investigate the relationship between morning symptoms and exacerbations over a one-year follow-up period. And the secondary aim was an investigation of the association between morning symptoms and baseline clinical features.

Patients and Methods

Ninety-two patients with stable COPD provided the baseline information. Morning symptoms were assessed with the Chinese version of Chronic Obstructive Pulmonary Disease Morning Symptom Diary (Ch-COPD-MSD); the median morning symptoms score was used as a cut-off to separate the study cohort in two groups. Modified Medical Research Council (mMRC), COPD assessment test (CAT), and Clinical COPD Questionnaire (CCQ) were used and exacerbation history of the previous year was recorded. Seventy-eight patients (84.8%) completed the longitudinal follow-up of exacerbations.

Results

The median morning symptoms score was 30 in stable COPD patients. Morning symptoms severity was different between COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups (p<0.001). Patients with high morning symptoms (score > 30) had higher scores of mMRC, CAT, and CCQ (p< 0.05). CAT score was an independent risk factor of morning symptoms. During follow-up, 41% of patients experienced ≥1 exacerbation. The frequency of severe exacerbations was higher in patients with high morning symptoms compared to patients with low morning symptoms (p<0.005). The Ch-COPD-MSD score could predict future severe exacerbations; the area under the ROC curve was 0.751 (95% CI: 0.633-0.868, p=0.002).

Conclusion

Worse health status and more dyspnea symptom were associated with increased severity of morning symptoms. Morning symptoms were most strongly related to future severe exacerbations and could predict future exacerbations in patients with COPD.

Burden of Healthcare Utilization among Chronic Obstructive Pulmonary Disease Patients with and without Cancer Receiving Palliative Care: A Population-Based Study in Taiwan

Chronic obstructive pulmonary disease (COPD) is a chronic disease that burdens patients worldwide. This study aims to discover the burdens of health services among COPD patients who received palliative care (PC). Study subjects were identified as COPD patients with ICU and PC records between 2009 and 2013 in Taiwan's National Health Insurance Research Database. The burdens of healthcare utilization were analyzed using logistic regression to estimate the difference between those with and without cancer. Of all 1215 COPD patients receiving PC, patients without cancer were older and had more comorbidities, higher rates of ICU admissions, and longer ICU stays than those with cancer. COPD patients with cancer received significantly more blood transfusions (Odds Ratio, OR: 1.66; 95% C.I.: 1.11-2.49) and computed tomography scans (OR: 1.88; 95% C.I.: 1.10-3.22) compared with those without cancer. Bronchoscopic interventions (OR: 0.26; 95% C.I.: 0.07-0.97) and inpatient physical restraints (OR: 0.24; 95% C.I.: 0.08-0.72) were significantly more utilized in patients without cancer. COPD patients without cancer appeared to receive more invasive healthcare interventions than those without cancer. The unmet needs and preferences of patients in the life-limiting stage should be taken into consideration for the quality of care in the ICU environment.

Long-term effect of hyperoxemia during chronic obstructive pulmonary disease exacerbation managed by emergency medical service and emergency department: a prospective, exploratory study

OBJECTIVE

Long-term effects of hyperoxemia during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) remained unknown. We aimed to explore these effects of hyperoxemia during AECOPD.

METHODS

This was an exploratory follow-up study of a cohort with AECOPD managed by Emergency Medical Service and two emergency departments (EDs). Patients were classified as hyperoxemic (PaO2 > 65 mmHg) or nonhyperoxemic (PaO2 ≤ 65 mmHg). Patients discharged from ED/inpatient care were followed up prospectively for 1 year. The primary outcome was 1-year all-cause mortality in hyperoxemic vs. nonhyperoxemic groups. Secondary outcomes were 3-month all-cause mortality and median number of repeat AECOPD hospitalizations within 1 year. We generated Kaplan-Meier curves and compared them using log-rank test. The primary outcome was also analyzed using Cox proportional-hazards model. We reported crude and adjusted hazard ratios, their 95% confidence intervals (CIs) and P values. We adjusted for two a priori predictors of delayed mortality; age ≥ 70 years and repeat AECOPD hospitalizations.

RESULTS

A total of 231 patients were analyzed. One-year mortality rates in hyperoxemic vs. nonhyperoxemic groups were 26/137 (19.0%) and 12/94 (12.8%), respectively (P = 0.693). Although Kaplan-Meier curves showed divergent courses favoring nonhyperoxemic group, log-rank test was not statistically significant (P = 0.203). The crude and adjusted hazard ratios (reference: nonhyperoxemic group) were 1.55 (95% CIs, 0.78-3.08; P = 0.207) and 1.57 (95% CIs, 0.79-3.13; P = 0.196), respectively. Secondary outcomes did not differ.

CONCLUSIONS

Our study reported no effect on 1-year all-cause mortality associated with hyperoxemia during AECOPD. Further studies are needed to prove/disprove our findings.

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.

Physical, Psychological, and Social Factors Associated with Exacerbation-Related Hospitalization in Patients with COPD

Background and objective: Exacerbation(s) of chronic obstructive pulmonary disease (eCOPD) entail important events describing an acute deterioration of respiratory symptoms. Changes in medication and/or hospitalization are needed to gain control over the event. However, an exacerbation leading to hospitalization is associated with a worse prognosis for the patient. The objective of this study is to explore factors that could predict the probability of an eCOPD-related hospitalization. Methods: Data from 128 patients with COPD included in a prospective, longitudinal study were used. At baseline, physical, emotional, and social status of the patients were assessed. Moreover, hospital admission during a one year follow-up was captured. Different models were made based on univariate analysis, literature, and practice. These models were combined to come to one final overall prediction model. Results: During follow-up, 31 (24.2%) participants were admitted for eCOPD. The overall model contained six significant variables: currently smoking (OR = 3.93), forced vital capacity (FVC; OR = 0.97), timed-up-and-go time (TUG-time) (OR = 14.16), knowledge (COPD knowledge questionnaire, percentage correctly answered questions (CIROPD_%correct)) (<60% (OR = 1.00); 60%–75%: (OR = 0.30); >75%: (OR = 1.94), eCOPD history (OR = 9.98), and care dependency scale (CDS) total score (OR = 1.12). This model was well calibrated (goodness-of-fit test: p = 0.91) and correctly classified 79.7% of the patients. Conclusion: A combination of TUG-time, eCOPD-related admission(s) prior to baseline, currently smoking, FVC, CDS total score, and CIROPD_%correct allows clinicians to predict the probability of an eCOPD-related hospitalization.

Triple Therapy in COPD

:

Triple inhaled therapy for Chronic Obstructive Pulmonary Disease (COPD) includes an inhaled corticosteroid (ICS), a long-acting b2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) taken in combination. Triple therapy is recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for patients who experience recurrent exacerbations despite treatment with either a dual bronchodilator or LABA/ICS combination. There is consistent evidence that the LABA/LAMA/ICS combination has significantly greater effects on trough FEV1, symptoms, quality of life, and exercise performance compared to comparator treatments.

:

The role of triple therapy in reducing exacerbations in COPD patients is debatable, but recent trials have revealed some intriguing insights.

:

Three pivotal studies, namely TRILOGY, TRINITY and TRIBUTE have been conducted to evaluate the safety and efficacy of extrafine Beclomethasone/Formoterol Fumarate/Glycopyrronium Bromide (BDP/FF/GB) versus different treatment options for COPD. Extrafine BDP/FF/GB has been compared to an ICS/LABA (BDP/FF) combination in the TRILOGY study, to a LAMA monotherapy (Tiotropium-TIO) and an extemporary triple combination of ICS/LABA + LAMA (BDP/FF + TIO) in the TRINITY study, and to one inhalation of LABA/LAMA per day (Indacaterol/ Glycopyrronium - IND/GLY) in the TRIBUTE study.

:

Another triple therapy with Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI) was recently tested in two further studies that included patients with COPD. The FULFIL study compared the efficacy of the triple FF/UMEC/VI therapy to the ICS/LABA association budesonide/formoterol, while the IMPACT study compared the rate of moderate and severe exacerbations between singleinhaler FF/UMEC/VI and single-inhaler FF/VI or UMEC/VI.

Statistical Process Control Improves The Feasibility Of Remote Physiological Monitoring In Patients With Chronic Obstructive Pulmonary Disease

Background

Exacerbations of chronic obstructive pulmonary disease (COPD) occur with increasing frequency as the disease progresses and account for poor health status, worse prognosis, and higher healthcare expenditure.

Methods

We developed a networked system for remote physiological monitoring (RPM) at home and optimized it with statistical process control (SPC) with the goal of earlier detection of COPD exacerbations. We enrolled 17 patients with moderate to severe COPD with a mean (SD) age of 71.1 (7.2) years. We obtained daily symptom scores, treatment adherence and activity levels using a programmable device, and measured daily slow and forced spirometry (FEV₁, FVC, PEF), inspiratory capacity (IC) and oxygenation (SpO₂). To identify exacerbations, we developed rolling prediction intervals for FVC, FEV₁, IC and SpO₂ using SPC.

Results

The time taken to perform daily monitoring was reduced from 12.7 (5.4) minutes to 6.5 (2.6) minutes through software refinements during the study. Adherence to forced and slow spirometry was 62.6% and 62.4%, respectively. The within-subject coefficients of variation for FEV₁, PEF and IC were 12.2%, 16.2%, and 13.1%, respectively. Event rates per patient-year for exacerbations were: self-reported 0.42, 2/3 Anthonisen Criteria (AC) 0.42, modified AC 2.23, systemic corticosteroid use 0.56, and antibiotic use 0.56.

Conclusion

We successfully implemented a networked system for RPM of symptoms, treatment adherence, and physiology at home in patients with COPD. We demonstrated that SPC improves the feasibility of RPM in COPD patients which may increase the likelihood of detecting COPD exacerbations.

Capturing Exacerbations of Chronic Obstructive Pulmonary Disease with EXACT. A Subanalysis of FLAME

RATIONALE

Chronic obstructive pulmonary disease exacerbations accelerate lung function decline, reduce quality of life, and increase mortality. A subset of patients (n = 457) from the FLAME (Effect of Indacaterol Glycopyrronium vs. Fluticasone Salmeterol on COPD Exacerbations) study used the Exacerbations of COPD Tool (EXACT) to capture symptom-defined exacerbations.

OBJECTIVES

To evaluate the effect of indacaterol/glycopyrronium versus salmeterol/fluticasone on symptom-defined exacerbations measured using EXACT, and to assess differences between these events and exacerbations requiring healthcare resource use (HCRU).

METHODS

All patients in FLAME used an electronic diary to record and detect symptom deteriorations; HCRU-related exacerbations were confirmed by investigators. In patients using the EXACT questionnaire, the onset, recovery, and magnitude of symptom-defined exacerbations were identified by changes in total scores relative to baseline. We analyzed the annualized rate and time to first symptom-defined (EXACT) exacerbation and assessed differences between symptom-defined and HCRU events in terms of number, severity, and concordance.

MEASUREMENTS AND MAIN RESULTS

A nonsignificant 17% reduction in the annualized rate of symptom-defined (EXACT) exacerbations (rate ratio, 0.83; 95% confidence interval [CI], 0.60-1.14; P = 0.242) and a numerically longer time to first symptom-defined exacerbation were observed with indacaterol/glycopyrronium versus salmeterol/fluticasone (hazard ratio, 0.76; 95% CI, 0.56-1.03; P = 0.075). These results were consistent with data from the overall FLAME population. Of the symptom-defined (EXACT) events, 23.5% corresponded to HCRU events, and 22.2% of HRCU events were captured by EXACT (κ index, 0.24; 95% CI, 0.15-0.33).

CONCLUSIONS

Regardless of the exacerbation definition used, our findings support the use of long-acting β₂ agonists/long-acting muscarinic receptor antagonists as the preferred treatment option for patients at risk of future exacerbations. Clinical trial registered with www.clinicaltrials.gov (NCT01782326).

Natural History of Chronic Obstructive Pulmonary Disease Exacerbations in a General Practice-based Population with Chronic Obstructive Pulmonary Disease

RATIONALE

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are important adverse events in the natural history of chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To investigate the natural history of AECOPDs over 10 years of follow-up.

METHODS

We identified 99,574 patients with COPD from January 1, 2004, to March 31, 2015, from the UK Clinical Practice Research Datalink. We defined moderate AECOPDs as those managed outside hospital and severe as those requiring hospitalization. During the baseline period (first year of follow-up), patients were grouped according to the number and severity of AECOPDs and then followed for a maximum of 10 years (mean, 4.9 yr). We investigated the effect of baseline AECOPD number and severity on risk of further events and death.

MEASUREMENTS AND MAIN RESULTS

Around one-quarter of the patients with COPD did not exacerbate during follow-up. Compared with no AECOPDs in the baseline period, AECOPD number predicted the future long-term rate of AECOPDs in a graduated fashion, ranging from hazard ratio (HR) of 1.71 (1.66-1.77) for one event to HR of 3.41 (3.27-3.56) for five or more events. Two or more moderate AECOPDs were also associated with an increased risk of death in a graduated fashion, ranging from HR of 1.10 (1.03-1.18) for two moderate AECOPDs to HR of 1.57 (1.45-1.70) for five or more moderate AECOPDs, compared with those with no AECOPDs at baseline. Severe AECOPDs were associated with an even higher risk of death (HR, 1.79; 1.65-1.94).

CONCLUSIONS

A large proportion of patients with COPD do not exacerbate over a maximum 10 years of follow-up. AECOPD frequency in a single year predicts long-term AECOPD rate. Increasing frequency and severity of AECOPDs is associated with risk of death and highlights the importance of preventing AECOPDs.

Prognosis of COPD depends on severity of exacerbation history: A population-based analysis

BACKGROUND

Differences in previous exacerbation history may influence prognosis of chronic obstructive pulmonary disease (COPD). We hypothesized that prognosis differs between individuals with a history of only medically treated exacerbations (moderate exacerbations) and those with a history of hospitalised exacerbations (severe exacerbations).

METHODS

We included 98 614 adults from the Copenhagen General Population Study and assessed risk of moderate and severe exacerbations, pneumonia hospitalisation, and respiratory and all-cause mortality from 2003 until 2013 according to exacerbation history.

RESULTS

Among 6545 individuals with COPD, 6290 had no exacerbations in the preceding year, 109 had one moderate exacerbation, 108 had two or more moderate exacerbations, and 38 had one or more severe exacerbations. During 9.4 years of follow-up, we observed 926 moderate and 244 severe exacerbations, 477 pneumonias, and 707 deaths, including 69 from respiratory disease. Compared to individuals without previous exacerbations, lung function and symptom adjusted hazard ratios (HRs) for future moderate exacerbation were 4.68 (95% confidence interval:3.31-6.62) for individuals with one previous moderate exacerbation, 21 (13-33) for individuals with two or more previous moderate exacerbations, and 5.30 (3.44-8.15) for individuals with one or more previous severe exacerbations. Corresponding HRs were 1.62(0.78-3.34), 1.29(0.57-2.89), and 5.43 (2.56-12) for severe exacerbation, 1.86(1.06-3.27), 1.74(1.01-2.99), and 4.85 (2.94-8.02) for pneumonia, 0.53(0.10-2.99), 1.65(0.53-5.17), and 2.98 (1.14-7.83) for respiratory mortality, and 1.34(0.79-2.29), 1.57(1.00-2.47), and 1.49 (0.85-2.62) for all-cause mortality, respectively.

CONCLUSION

Individuals with COPD and a history of hospitalised exacerbations carried the poorest prognosis compared to those with a history of only medically treated exacerbations, suggesting difference in risk profile.

Weighing the evidence for pharmacological treatment interventions in mild COPD; a narrative perspective

There is increasing focus on understanding the nature of chronic obstructive pulmonary disease (COPD) during the earlier stages. Mild COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 1 or the now-withdrawn GOLD stage 0) represents an early stage of COPD that may progress to more severe disease. This review summarises the disease burden of patients with mild COPD and discusses the evidence for treatment intervention in this subgroup.

Overall, patients with mild COPD suffer a substantial disease burden that includes persistent or potentially debilitating symptoms, increased risk of exacerbations, increased healthcare utilisation, reduced exercise tolerance and physical activity, and a higher rate of lung function decline versus controls. However, the evidence for treatment efficacy in these patients is limited due to their frequent exclusion from clinical trials. Careful assessment of disease burden and the rate of disease progression in individual patients, rather than a reliance on spirometry data, may identify patients who could benefit from earlier treatment intervention.

Increased risk of major adverse cardiac events following the onset of acute exacerbations of COPD

BACKGROUND AND OBJECTIVE

Acute exacerbations in chronic obstructive pulmonary disease (COPD) may trigger major adverse cardiac events (MACE). We aimed to determine whether the risk of having MACE was transiently increased following the onset of an acute COPD exacerbation.

METHODS

We conducted a nationwide, register-based study from 1997 to 2014 comprising individuals with an acute COPD exacerbation followed by a MACE (acute myocardial infarction (MI), stroke or cardiovascular death). Using the case-crossover design, we estimated odds ratios (OR) for the association between acute exacerbations of COPD and MACE as well as for single outcomes (acute MI, stroke and cardiovascular death), different levels of severity of exacerbations and within patient subgroups.

RESULTS

We identified 118 807 cases with a MACE preceded by an exacerbation. Overall, the risk of MACE increased almost fourfold following the onset of an acute exacerbation compared to periods without exacerbations in the same individuals (OR: 3.70; 95% CI: 3.60-3.80). The associations were consistent for single outcomes (acute MI, OR: 3.57; cardiovascular death, OR: 4.33; and stroke, OR: 2.78) and particularly strong associations were demonstrated for severe exacerbations (OR: 5.92) and the oldest individuals (OR: 4.18).

CONCLUSION

The risk of MACE increased substantially following the onset of an acute exacerbation. This highlights that prevention of cardiac events is an important goal in the management of COPD. Attention should be paid to detecting cardiovascular disease following acute COPD exacerbations.

Extrafine triple therapy delays COPD clinically important deterioration vs ICS/LABA, LAMA, or LABA/LAMA

Background

Current pharmacological therapies for COPD improve quality of life and symptoms and reduce exacerbations. Given the progressive nature of COPD, it is arguably more important to understand whether the available therapies are able to delay clinical deterioration; the concept of “clinically important deterioration” (CID) has therefore been developed. We evaluated the efficacy of the single-inhaler triple combination beclometasone dipropionate, formoterol fumarate, and glycopyrronium (BDP/FF/G), using data from three large 1-year studies.

Methods

The studies compared BDP/FF/G to BDP/FF (TRILOGY), tiotropium (TRINITY), and indacaterol/glycopyrronium (IND/GLY; TRIBUTE). All studies recruited patients with symptomatic COPD, FEV₁ <50%, and an exacerbation history. We measured the time to first CID and to sustained CID, an endpoint combining FEV₁, St George’s Respiratory Questionnaire (SGRQ), moderate-to-severe exacerbations, and death. The time to first CID was based on the first occurrence of any of the following: a decrease of ≥100 mL from baseline in FEV₁, an increase of ≥4 units from baseline in SGRQ total score, the occurrence of a moderate/severe COPD exacerbation, or death. The time to sustained CID was defined as: a CID in FEV₁ and/or SGRQ total score maintained at all subsequent visits, an exacerbation, or death.

Results

Extrafine BDP/FF/G significantly extended the time to first CID vs BDP/FF (HR 0.61, P<0.001), tiotropium (0.72, P<0.001), and IND/GLY (0.82, P<0.001), and significantly extended the time to sustained CID vs BDP/FF (HR 0.64, P<0.001) and tiotropium (0.80, P<0.001), with a numerical extension vs IND/GLY.

Conclusion

In patients with symptomatic COPD, FEV₁ <50%, and an exacerbation history, extrafine BDP/FF/G delayed disease deterioration compared with BDP/FF, tiotropium, and IND/GLY.

Trial registration

The studies are registered in ClinicalTrials.gov: TRILOGY, NCT01917331; TRINITY, NCT01911364; TRIBUTE, NCT02579850.

Efficacy of a home discharge care bundle after acute exacerbation of COPD

Purpose

Acute exacerbations of COPD (AECOPD) are frequent and associated with a poor prognosis. A home discharge care bundle, the PRADO-BPCO program, has been set up by the French National Health System in order to reduce readmission rate after hospitalization for AECOPD. This program includes early consultations by the general practitioner, a nurse, and a physiotherapist after discharge. The aim of our study was to evaluate the effect of the PRADO-BPCO program on the 28-days readmission rate of COPD patients after hospitalization for AECOPD.

Patients and methods

This was a retrospective cohort study including all patients admitted for AECOPD in our center between November 2015 and January 2017. The readmission or death rate at 28 days after hospitalization for AECOPD was compared between patients included in the PRADO-BPCO program and patients with standard care after discharge. Inclusion in the program was decided by the physician in charge of the patient.

Results

A total of 62 patients were included in the PRADO-BPCO group and 202 in the control group. At baseline, patients in the PRADO group had a more severe COPD disease and more severe exacerbations than the control group and mean inpatient stay was shorter in the PRADO group: 8.6±4.3 vs 10.4±7.4 days (P=0.034). Readmission or death rate at 28 days was similar between groups: 10 (16.1%) in the PRADO group vs 30 (14.9%) in the control group (P=0.81). Ninety-days readmission or death rate and overall survival were similar in the two groups.

Conclusion

In our center, despite more severe COPD and a shorter hospitalization time, the PRADO-BPCO program failed to prove a benefit on the 28 days readmission or death rate when compared with standard care.

Soluble urokinase-type plasminogen activator receptor as a measure of treatment response in acute exacerbation of COPD

Objective:

To evaluate the value of soluble urokinase-type plasminogen activator receptor (suPAR) in the diagnosis of acute exacerbation of COPD (AECOPD) and in monitoring treatment response, analyzing the relationship between suPAR and fibrinogen in AECOPD. AECOPD leads to increased airway inflammation, contributing to an exaggerated release of inflammatory mediators.

Methods:

We recruited 45 patients with AECOPD and 20 healthy control subjects. Medical histories were taken, and all subjects underwent clinical examination, chest X-ray, pulmonary function tests, and blood gas analysis. On day 1 (treatment initiation for the AECOPD patients) and day 14 (end of treatment), blood samples were collected for the determination of serum suPAR and plasma fibrinogen.

Results:

Serum levels of suPAR were significantly higher in the AECOPD group than in the control group. In the AECOPD patients, there was a significant post-treatment decrease in the mean serum suPAR level. The sensitivity, specificity, and accuracy of suPAR were 95.6%, 80.0%, and 93.0%, respectively. The Global Initiative for Chronic Obstructive Lung Disease stage (i.e., COPD severity) correlated positively and significantly with serum levels of suPAR and plasma levels of fibrinogen.

Conclusions:

Monitoring the serum suPAR level can be helpful in the evaluation of the COPD treatment response and might be a valuable biomarker for determining the prognosis of AECOPD. Because serum suPAR correlated with plasma fibrinogen, both markers could be predictive of AECOPD.

Guideline adherence in hospital recruited and population based COPD patients

BACKGROUND

Evidence from several studies show poor guideline adherence to COPD treatment, but no such study has been undertaken in Norway. The objectives of this study, was to estimate and compare the guideline adherence to COPD treatment in general population-based and hospital-recruited COPD patients, and find possible predictors of guideline adherence.

METHODS

From the prospective, observational EconCOPD-study, we analysed guideline adherence for 90 population-based COPD cases compared to 245 hospital-recruited COPD patients. Overall guideline adherence was defined as correct pharmacological treatment, and influenza vaccination the preceding year, and having received smoking cessation advice. Multivariate logistic regression analysis was performed with the dichotomous outcome overall guideline adherence adjusting for relevant variables.

RESULTS

The overall guideline adherence for population-based COPD cases was 6.7%, significantly lower than the 29.8% overall guideline-adherence amongst hospital-recruited COPD patients. Adherence to pharmacological treatment guidelines was 10.0 and 35.5%, for the two recruitment sources, respectively. GOLD-stage 3 to 4 was associated with significantly better guideline adherence compared to GOLD-stage 2 (OR (95% CI) 18.9 (8.37,42.7)). The unadjusted difference between the two recruitment sources was completely explained by degree of airflow obstruction.

CONCLUSION

Overall guideline adherence was very low for both recruitment sources. We call for increased attention from authorities and healthcare personnel to improve the quality of care given to this patient group.

Spirometric changes during exacerbations of COPD: a post hoc analysis of the WISDOM trial

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with loss of lung function and poor outcomes for patients. However, there are limited data on the time course of changes in forced expiratory volume in 1 s (FEV₁) preceding the first reported symptom and after the start of an exacerbation.

METHODS

WISDOM was a multinational, randomized, double-blind, active-controlled, 52-week study in patients with severe-to-very severe COPD. Patients received triple therapy (long-acting muscarinic antagonist and long-acting β₂-agonist/inhaled corticosteroid [ICS]) for 6 weeks, and were randomized to continue triple therapy or stepwise withdrawal of the ICS (dual bronchodilator group). After suitable training, patients performed daily spirometry at home using a portable, battery-operated spirometer. In the present post hoc analysis, patients who continued to perform daily home spirometry and completed at least one measurement per week for a 56-day period before and after the start of a moderate or severe exacerbation were included. Missing values were imputed by linear interpolation (intermittent), backfilling (beginning) or carry forward (end). Exacerbation onset was the first day of a reported symptom of exacerbation.

RESULTS

Eight hundred and eighty-eight patients in the WISDOM study had a moderate/severe exacerbation after the complete ICS withdrawal visit; 360 of them contributed at least one FEV₁ measure per week for the 8 weeks before and after the event and are included in this analysis. Mean daily FEV₁ began to decline from approximately 2 weeks before the onset of symptoms of an exacerbation, dropping from 0.907 L (mean Days - 56 to - 36 before the exacerbation) to 0.860 L on the first day of the exacerbation. After the exacerbation, mean FEV₁ improved but did not return to pre-exacerbation levels (mean Days 36-56 after the exacerbation, 0.875 L). The pattern of FEV₁ changes around exacerbations was similar in the triple therapy and dual bronchodilator groups, and a similar pattern was seen in moderate and severe exacerbations when analysed separately.

CONCLUSIONS

Mean lung function starts to decline prior to the first reported symptoms of an exacerbation, and does not recover to pre-exacerbation levels 8 weeks after the event.

TRIAL REGISTRATION

WISDOM (ClinicalTrials.gov number, NCT00975195 ).