COPD Recent Findings: Impact on Clinical Practice

Exertional Desaturation Has Higher Mortality Than Non-Desaturation in COPD

Background and objectives: Exertional desaturation (ED) is often overlooked in chronic obstructive pulmonary disease (COPD). We aim to investigate the impact of ED on mortality and the predictors of ED in COPD. Materials andmethods: A cohort of COPD patients with clinically stable, widely ranging severities were enrolled. ED is defined as oxyhemoglobin saturation by pulse oximetry (SpO2) < 90% or a drop of ΔSpO2 ≥ 4% during a six-minute walk test (6MWT). Cox regression analysis is used to estimate the hazard ratio (HR) for three-year mortality. Results: A total of 113 patients were studied, including ED (N = 34) and non-ED (N = 79) groups. FVC (% of predicted value), FEV1/FVC (%), FEV1 (% of predicted value), DLCO (%), maximal inspiratory pressure, SpO2 during the 6MWT, GOLD stage, and COPD severity were significantly different between the ED and non-ED groups in univariate analysis. Low minimal SpO2 (p < 0.001) and high maximal heart rate (p = 0.04) during the 6MWT were significantly related to ED in multivariate analysis. After adjusting for age, gender, body mass index, 6MWD, FEV1, mMRC, GOLD staging, exacerbation, hs-CRP, and fibrinogen, the mortality rate of the ED group was higher than that of the non-ED group (p = 0.012; HR = 4.12; 95% CI 1.37–12.39). For deaths, the average survival time of ED was shorter than that of the non-ED group (856.4 days vs. 933.8 days, p = 0.033). Conclusions: ED has higher mortality than non-ED in COPD. COPD should be assessed for ED, especially in patients with low minimal SpO2 and high maximal HR during the 6MWT.

Fibroblast Growth Factor 23 is Associated with a Frequent Exacerbator Phenotype in COPD: A Cross-Sectional Pilot Study

Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory airway disease punctuated by exacerbations (AECOPD). Subjects with frequent AECOPD, defined by having at least two exacerbations per year, experience accelerated loss of lung function, deterioration in quality of life and increase in mortality. Fibroblast growth factor (FGF)23, a hormone associated with systemic inflammation and altered metabolism is elevated in COPD. However, associations between FGF23 and AECOPD are unknown. In this cross-sectional study, individuals with COPD were enrolled between June 2016 and December 2016. Plasma samples were analyzed for intact FGF23 levels. Logistic regression analyses were used to measure associations between clinical variables, FGF23, and the frequent exacerbator phenotype. Our results showed that FGF23 levels were higher in frequent exacerbators as compared to patients without frequent exacerbations. FGF23 was also independently associated with frequent exacerbations (OR 1.02; 95%CI 1.004–1.04; p = 0.017), after adjusting for age, lung function, smoking, and oxygen use. In summary, FGF23 was associated with the frequent exacerbator phenotype and correlated with number of exacerbations recorded retrospectively and prospectively. Further studies are needed to explore the role of FGF 23 as a possible biomarker for AECOPD to better understand the pathobiology of COPD and to help develop therapeutic targets.

Neuromuscular transmission in hypoxemic patients with chronic obstructive pulmonary disease

Many studies have focused on the systemic effects of chronic obstructive pulmonary disease (COPD), but none has examined neuromuscular junction transmission (NMT). We evaluated NMT dysfunction using single-fiber electromyography (SFEMG) in patients with COPD. Twenty patients with COPD and 20 age-matched healthy controls were included in the study. All patients and controls underwent SFEMG. Abnormal NMT was found in seven of 20 patients (35%), but in none of the control subjects. The COPD patients were subgrouped according to the presence of hypoxemia. The patients with normoxemia were classified as Group 1, and the patients with hypoxemia were classified as Group 2. Abnormal NMT was found in six patients in Group 2 and in one in Group 1. While there was significant difference in terms of abnormal NMT between Group 2 and the controls, there was none between Group 1 and the controls. Our results show that NMT abnormalities can be present in hypoxemic patients with COPD.

Exercise and COPD: therapeutic responses, disease-related outcomes, and activity-promotion strategies

Chronic obstructive pulmonary disease (COPD) reduces patients' exercise capacities and their abilities to perform daily physical activities, thereby increasing morbidity and mortality rates. The cycle of dyspnea, deconditioning, and declining physical activity not only accelerates the progression of COPD but also increases the risk for developing or aggravating metabolic and cardiovascular diseases. Cardiovascular and metabolic comorbidities also limit physical function, and their disabling effects in combination with COPD may be greater than the effects of each disease alone. The impact of COPD and its treatment on the ability to exercise, and the degree of physical activity in daily life, can be measured by field-based tests (eg, the 6-minute walk test or incremental and endurance shuttle-walk test), laboratory-based tests (eg, incremental or constant work-rate treadmill and cycle-ergometer tests), and physical activity assessments (eg, questionnaires and accelerometers). Walking tests increase oxygen consumption and desaturation in patients with COPD more than cycling tests with similar work-rate profiles and may more closely resemble patients' normal activities. Despite the questionable relevance of exercise testing to patients' daily functionality, exercise parameters remain important predictors of survival in patients with COPD. Treatment of COPD (pharmacotherapy, pulmonary rehabilitation, or both) can increase exercise capacity and physical activity in daily life, which potentially slows the decline of lung function, reduces the frequencies of exacerbations and hospitalizations, decreases mortality, slows the progression of comorbidities, improves health-related quality of life, and increases the activity reserve for routine function. This article examines the interactions of reduced physical activity and decreased exercise capacity with the progression of COPD, comorbidities, and mortality. The article also describes the available exercise tests for patients with COPD and reviews the evidence indicating that treating COPD improves exercise capacity. Notably, it appears that even mild COPD reduces exercise capacity and daily physical activity, indicating the need for early intervention.

COPD and associated comorbidities: a review of current diagnosis and treatment

Health care utilization and costs associated with chronic obstructive pulmonary disease (COPD) continue to increase, notwithstanding evidence-based management strategies described by major respiratory societies. Cardiovascular diseases, asthma, diabetes and its precursors (obesity and metabolic syndrome), depression, cognitive impairment, and osteoporosis are examples of common comorbidities that can affect or be affected by COPD. Appropriate diagnosis and management (from a pharmacologic and nonpharmacologic perspective) of COPD and its associated comorbidities are important to ensure optimal patient care. An evolving understanding of COPD as a multimorbid disease that affects an aging population, rather than just a lung-specific disease, necessitates an integrated, tailored disease-management approach to improve prognoses and reduce costs.

Fibroblast Growth Factor-23 and Hypophosphatemia in Chronic Obstructive Pulmonary Disease Patients

Impaired serum phosphate levels may contribute to respiratory muscle weakness that further negatively impacts Chronic Obstructive Pulmonary Disease (COPD) patients. Recently, Fibroblast Growth Factor 23 (FGF-23) has been shown to play an important role in the regulation of body phosphate. The current study includes 2 groups: 70 COPD patients and 34 control subjects. Blood samples were taken for a panel of routine lab tests. FGF-23 was measured using a commercially available ELISA kit. Plasma FGF-23 levels were significantly higher in the patient group compared to the control group (P=0.000). Tubular maximum absorption of phosphate was significantly reduced in COPD patients compared to the control group (P=0.04). Plasma FGF-23 negatively correlated with FEV1 and serum albumin. Elevated plasma FGF-23 levels found in COPD patients correlated with disease severity and may represent an additional factor causing low serum phosphate.

Chronic obstructive pulmonary disease: a complex comorbidity of lung cancer

Chronic obstructive pulmonary disease (COPD) is a major burden throughout the world. It is associated with a significantly increased incidence of lung cancer and may influence treatment options and outcome. Impaired lung function confirming COPD is an independent risk factor for lung cancer. Oxidative stress and inflammation may be a key link between COPD and lung cancer, with numerous molecular markers being analysed to attempt to understand the pathway of lung cancer development. COPD negatively influences the ability to deliver radical treatment options, so attempts must be made to look for alternative methods of treating lung cancer, while aiming to manage the underlying COPD. Detailed assessment and management plans utilising the multidisciplinary team must be made for all lung cancer patients with COPD to provide the best care possible.

Journal of Comorbidity 2011;1:45–50

Functional polymorphism of cyclooxygenase-2 gene (G-765C) in chronic obstructive pulmonary disease patients

Cyclooxygenase two (COX-2) is an important enzyme metabolizing arachidonic acid. In contrast to constitutive cyclooxygenase one (COX-1), COX-2 is induced by proinflammatory factors. Polymorphism -765 G/C in COX-2-encoding gene promoter is associated with development of Alzheimer's disease, depression, carcinoma of the pancreas in smokers, breast cancer and rheumatoid arthritis. It is interesting whether the -765 G/C polymorphism in COX-2-encoding gene promoter can be associated with COPD, a disease which is inflammatory in character. It is highly probable as the breast and pancreas cancers, whose associations with the analyzed polymorphism have been studied, are smoking-dependent tumors. Additionally, tobacco smoke has been demonstrated to induce COX-2 in the lungs. The study group consisted of 122 COPD patients (48 females, 74 males). The control group consisted of 149 healthy nonsmoking subjects (83 females, 66 males). Polymerase chain reaction/restriction fragment length polymorphism was used for genotyping. A statistically significant difference in genotype distribution was observed as a result of the comparison between healthy subjects and patients with COPD. The distribution of alleles in both groups conformed with Hardy-Weinberg equilibrium. In the group of COPD patients, GG allele was found in 79 subjects, GC in 36, and CC in 7 subjects (F = 0.094, P = 0.296927); in the control group, 73 subjects had GG allele, 68--GC and 8--CC (F = 0.12728, P = 0.120265). The allele frequency revealed differences between those groups, attaining the level of statistical significance (χ(2) = 29.043, df = 2, P = 0.0000. The carriers of -765 G allele are at 1.53-fold higher risk of developing COPD. The presence of GG genotype does not increase significantly the risk of the disease. It is also noteworthy that the carriers of CC or GC genotypes are at significantly lower risk of developing COPD than the group of subjects with GG genotype.