Upper airway symptoms associate with the eosinophilic phenotype of COPD

BACKGROUND

There is growing evidence that upper airway symptoms coexist with lower airway symptoms in COPD. Still, the prevalence and impact of upper airway disease on the nature and course of COPD remain unclear. We aimed to describe this in a cross-sectional study.

METHODS

We examined a cohort of COPD patients with pulmonary function tests, induced sputum, blood eosinophils, atopy tests and computed tomography (CT) of the paranasal sinuses. Lower airway symptoms were assessed using the COPD Assessment Test (CAT), and upper airway symptoms were assessed using the nasal subdomain of the 22-item Sino Nasal Outcome Test (SNOT22nasal). We recruited patients from five sites in Denmark and Sweden. We excluded patients with a history of asthma.

FINDINGS

In total, 180 patients (female 55%, age 67±8 years, forced expiratory volume in 1 s (FEV1 %) 52.4±16.6, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage: A: 18%, B: 54%, C: 3%, D: 25%) were included in the study. Seventy-four patients (41%) reported high upper airway symptoms (UAS, defined as SNOT22nasal≥6) with a median score of 10 (IQR 8-13). Patients with high UAS reported higher CAT scores (17.4±7.5 versus 14.9±6.6, p<0.05) and displayed higher fractions of eosinophils in blood (median 3.0% (IQR 1.6-4.2%) versus 2.3% (IQR 1.4-3.1%), p<0.05) and in induced sputum (median 1.8% (IQR 0.3-7.1%) versus median 0.5% (IQR 0-1.7%), p<0.05). No differences in atopy, CT findings or exacerbation rates were observed.

CONCLUSION

COPD patients with upper airway disease showed increased evidence of eosinophilic disease and increased lower airway symptom burden.

Asthma-COPD Overlap and Chronic Airflow Obstruction: Definitions, Management, and Unanswered Questions

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a common clinical presentation of chronic airways disease in which patients show some features usually associated with asthma, and some usually associated with COPD. There is ongoing debate over whether ACO is a discrete clinical entity, or if it is part of a continuum of airways disease. Furthermore, there is considerable variation among current definitions of ACO, which makes diagnosis potentially challenging for clinicians. Treating ACO may be equally challenging because ACO is an understudied population, and the evidence base for its management comes largely from asthma and COPD studies, the relevance of which deserves careful consideration. In this review, we synthesize the various approaches to ACO diagnosis and evaluate the role of currently available diagnostic tests. We describe the potential benefits of existing asthma and COPD therapies in treating patients with ACO, and the value of a "treatable traits" approach to ACO management. Throughout the review, we highlight some of the pressing, unanswered questions surrounding ACO that are relevant to the clinical community. Ultimately, addressing these questions is necessary if we are to improve clinical outcomes for this complex and heterogeneous patient population.

Upper respiratory symptoms worsen over time and relate to clinical phenotype in chronic obstructive pulmonary disease

RATIONALE

How nasal symptoms in patients with chronic obstructive pulmonary disease (COPD) change over time and resolve during naturally occurring exacerbations has not been described previously.

OBJECTIVES

To evaluate the evolution and impact of upper airway symptoms in a well-defined COPD cohort when stable and at exacerbation.

METHODS

Patients in the London COPD cohort were asked about the presence of nasal symptoms (nasal discharge, sneezing, postnasal drip, blocked nose, and anosmia) over an 8-year period (2005-2013) every 3 months at routine clinic visits while in a stable state and daily during exacerbations with the use of diary cards. Data were prospectively collected, and, in a subgroup of patients, COPD Assessment Test scores and human rhinovirus identification by polymerase chain reaction were available. Patients were also defined as having infrequent or frequent exacerbations (<2 or ≥2 exacerbations/yr, respectively).

MEASUREMENTS AND MAIN RESULTS

At an aggregate of 4,368 visits, 209 patients with COPD were asked about their nasal symptoms. At 2,033 visits when the patients were stable, the odds ratio (OR) for nasal discharge increased by 1.32% per year (95% confidence interval [CI], 1.19-1.45; P < 0.001); the OR for sneezing increased by 1.16% (95% CI, 1.05-1.29; P = 0.005); the OR for postnasal drip increased by 1.18% (95% CI, 1.03-1.36; P = 0.016); and the OR for anosmia increased by 1.19% (95% CI, 1.03-1.37; P = 0.015). At visits when the patients were having exacerbations, nasal discharge was present for 7 days and blocked nose, sneezing, and postnasal drip increased for just 3 days. Anosmia did not change. Nasal discharge was more likely in patients with frequent exacerbations (OR, 1.96; 95% CI, 1.17-3.28; P = 0.011), and COPD Assessment Test scores were higher by 1.06 units (95% CI, 0.32-1.80; P = 0.005) when patients were stable and higher by 1.30 units (95% CI, 0.05-2.57; P = 0.042) during exacerbations.

CONCLUSIONS

Upper airway symptoms increase over time in patients with COPD and are related to the frequent exacerbation phenotype. These longitudinal changes may be due to increasing airway inflammation or to progression of COPD.

Evaluation of IL-8 nasal lavage levels and the effects of nasal involvement on disease severity in patients with stable chronic obstructive pulmonary disease

Interleukin 8 (IL-8) is used to evaluate the severity of inflammation in the airways. The aim of this study was to evaluate patients with chronic obstructive pulmonary disease (COPD) for the presence of upper respiratory tract involvement by questioning patients regarding nasal symptoms and by measuring levels of IL-8 in nasal lavage material. A total of 47 COPD patients and 23 healthy controls were enrolled in this study. Pulmonary function tests were performed for all participants who were asked to complete a Sinonasal Outcome Test-20 (SNOT-20) questionnaire on the same day, as a measure of quality of life. Median IL-8 level in nasal lavage specimens of COPD patients with stable disease was higher than that of healthy controls. An increase in cigarette pack-years was significantly associated with an increase in nasal IL-8 levels. Similarly, IL-8 levels correlated positively with stage of COPD. A significant link between number of visits to the emergency department and stage of disease was observed. Patients with COPD had a significantly higher mean SNOT-20 severity score compared to healthy controls. Proper management of sinonasal disease may help to decrease the number of COPD attacks and consequently improve quality of life.

Chronic Obstructive Pulmonary Disease Predicts Chronic Rhinosinusitis without Nasal Polyps: A Population-Based Study

Background

Few studies have investigated the relationship between chronic obstructive pulmonary disease (COPD) and chronic rhinosinusitis without nasal polyps (CRSsNP) outcomes. The aim of this study was to investigate the association between COPD and the risk of CRSsNP in a large national sample.

Methods

Patients 15 years or older with a new primary diagnosis of COPD (International Classification of Diseases, Ninth edition [ICD-9], 491, 492, 494, and 496) between 2000 and 2007 were identified from the National Health Insurance Research Database of Taiwan. The patients were compared with sex-, age-, residence-, and insurance premium–matched controls, and both groups were followed up until the end of 2008 for instances of CRSsNP, defined as ICD-9 codes CRS (473, 473.0, 473.1, 473.2, 473.3, 473.8, and 473.9), excluding NP (471, 471.0, 471.1, 471.8, and 471.9). Competing risk-adjusted Cox regression analyses were applied after adjusting for sex, age, residence, insurance premium, steroid use (topical or systemic), hyperlipidemia, diabetes, hypertension, coronary artery disease, hospital admission days, and mortality.

Results

We included 34,029 cases and 34,029 matched controls in this study. Among the 68,058 subjects, 569 developed CRSsNP during a mean (standard deviation [SD]) follow-up period of 5.0 years (SD 2.2 years). COPD was an independent predictor of CRSsNP in the fully adjusted model (hazard ratio = 3.24; 95% CI = 2.65-3.96; p < 0.01).

Conclusion

COPD was associated with an increased risk of CRSsNP in this study population, independent of a number of potential confounding factors.