COPD-related bronchiectasis; independent impact on disease course and outcomes

The clinical impacts of lung microbiome in bronchiectasis with fixed airflow obstruction: a prospective cohort study

BACKGROUND

Airflow obstruction is a hallmark of disease severity and prognosis in bronchiectasis. The relationship between lung microbiota, airway inflammation, and outcomes in bronchiectasis with fixed airflow obstruction (FAO) remains unclear. This study explores these interactions in bronchiectasis patients, with and without FAO, and compares them to those diagnosed with chronic obstructive pulmonary disease (COPD).

METHODS

This prospective observational study in Taiwan enrolled patients with either bronchiectasis or COPD. To analyze the lung microbiome and assess inflammatory markers, bronchoalveolar lavage (BAL) samples were collected for 16S rRNA gene sequencing. The study cohort comprised 181 patients: 86 with COPD, 46 with bronchiectasis, and 49 with bronchiectasis and FAO, as confirmed by spirometry.

RESULTS

Patients with bronchiectasis, with or without FAO, had similar microbiome profiles characterized by reduced alpha diversity and a predominance of Proteobacteria, distinctly different from COPD patients who exhibited more Firmicutes, greater diversity, and more commensal taxa. Furthermore, compared to COPD and bronchiectasis without FAO, bronchiectasis with FAO showed more severe disease and a higher risk of exacerbations. A significant correlation was found between the presence of Pseudomonas aeruginosa and increased airway neutrophilic inflammation such as Interleukin [IL]-1β, IL-8, and tumor necrosis factor-alpha [TNF]-α, as well as with higher bronchiectasis severity, which might contribute to an increased risk of exacerbations. Moreover, in bronchiectasis patients with FAO, the ROSE (Radiology, Obstruction, Symptoms, and Exposure) criteria were employed to classify individuals as either ROSE (+) or ROSE (-), based on smoking history. This classification highlighted differences in clinical features, inflammatory profiles, and slight microbiome variations between ROSE (-) and ROSE (+) patients, suggesting diverse endotypes within the bronchiectasis with FAO group.

CONCLUSION

Bronchiectasis patients with FAO may exhibit two distinct endotypes, as defined by ROSE criteria, characterized by greater disease severity and a lung microbiome more similar to bronchiectasis without FAO than to COPD. The significant correlation between Pseudomonas aeruginosa colonization and increased airway neutrophilic inflammation, as well as disease severity, underscores the clinical relevance of microbial patterns. This finding reinforces the potential role of these patterns in the progression and exacerbations of bronchiectasis with FAO.

Clinical Predictors of Nontuberculous Mycobacteria Lung Disease and Coisolates of Potential Pathogenic Microorganisms in Noncystic Fibrosis Bronchiectasis

Background

In bronchiectasis, nontuberculous mycobacteria (NTM) lung disease (NTM-LD) is a well-known coexisting infection. However, microorganism coisolates and clinical NTM-LD predictors are poorly studied.

Methods

Patients with bronchiectasis diagnosed by means of computed tomography between January 2017 and June 2020 were screened, using the date of computed tomography as the index date. Those with a major bronchiectasis diagnosis in ≥2 follow-up visits after the index date were enrolled in the study, and NTM-LD occurrence and its association with pneumonia and hospitalization within 1 year were analyzed.

Results

Of the 2717 participants, 79 (2.9%) had NTM-LD diagnosed. The factors associated with NTM-LD included hemoptysis, postinfectious bronchiectasis, a tree-in-bud score ≥2, a modified Reiff score ≥4, and chronic obstructive pulmonary disease (adjusted odds ratios, 1.80, 2.36, 1.78, 2.95, and 0.51, respectively). Compared with patients in the non-NTM group, those with NTM-LD had higher rates of hospitalization (15.9% vs 32.9%; P < .001) and pneumonia (9.8% vs 20.3%; P = .003). Pseudomonas aeruginosa was the most common microorganism in those with NTM-LD and those in the non-NTM group (10.1% vs 7.8%; P = .40). However, compared with those in the non-NTM group, Acinetobacter baumannii and Escherichia coli were more prevalent in patients with NTM-LD (0.7% vs 3.8% [P = .03%] and 1.0% vs 3.8% [P = .05], respectively).

Conclusions

Postinfectious bronchiectasis with hemoptysis, higher radiological involvement, and a tree-in-bud pattern were associated with NTM-LD risk. The rate of A baumannii and E coli coisolation was higher in bronchiectasis populations with NTM-LD.

A systematic literature review of the clinical and socioeconomic burden of bronchiectasis

BACKGROUND

The overall burden of bronchiectasis on patients and healthcare systems has not been comprehensively described. Here, we present the findings of a systematic literature review that assessed the clinical and socioeconomic burden of bronchiectasis with subanalyses by aetiology (PROSPERO registration: CRD42023404162).

METHODS

Embase, MEDLINE and the Cochrane Library were searched for publications relating to bronchiectasis disease burden (December 2017-December 2022). Journal articles and congress abstracts reporting on observational studies, randomised controlled trials and registry studies were included. Editorials, narrative reviews and systematic literature reviews were included to identify primary studies. PRISMA guidelines were followed.

RESULTS

1585 unique publications were identified, of which 587 full texts were screened and 149 were included. A further 189 citations were included from reference lists of editorials and reviews, resulting in 338 total publications. Commonly reported symptoms and complications included dyspnoea, cough, wheezing, sputum production, haemoptysis and exacerbations. Disease severity across several indices and increased mortality compared with the general population was reported. Bronchiectasis impacted quality of life across several patient-reported outcomes, with patients experiencing fatigue, anxiety and depression. Healthcare resource utilisation was considerable and substantial medical costs related to hospitalisations, treatments and emergency department and outpatient visits were accrued. Indirect costs included sick pay and lost income.

CONCLUSIONS

Bronchiectasis causes significant clinical and socioeconomic burden. Disease-modifying therapies that reduce symptoms, improve quality of life and reduce both healthcare resource utilisation and overall costs are needed. Further systematic analyses of specific aetiologies and paediatric disease may provide more insight into unmet therapeutic needs.

Bronchiectasis is associated with lower lung function in lung cancer screening participants

BACKGROUND AND OBJECTIVE

Bronchiectasis is a frequent incidental finding on chest computed tomography (CT), but its relevance in lung cancer screening is not fully understood. We investigated the association between bronchiectasis and respiratory symptoms, pulmonary function, and emphysema in lung cancer screening participants with and without chronic obstructive pulmonary disease (COPD).

METHODS

We included 3260 (ex-)smokers from the Dutch-Belgian lung cancer screening trial (NELSON). Bronchiectasis was scored by chest radiologists. The relationship with pulmonary function (FEV1%predicted, FEV1/FVC), respiratory complaints (cough, dyspnea, wheezing, mucus hypersecretion), and CT-quantified emphysema (15th percentile) was examined with independent t-tests and multivariate regression.

RESULTS

Bronchiectasis was present in 5.4% (n = 175/3260). There was no difference in prevalence between subjects with and without COPD (68/1121 [5.9%] vs. 109/2139 [5.1%]; p = .368). COPD subjects with bronchiectasis had a lower FEV1%predicted (76.2% vs. 85.0%; p < .001), lower FEV1/FVC (0.58 vs. 0.62; p < .001), and more emphysema (- 938 HU vs. - 930 HU; p = .001) than COPD subjects without bronchiectasis. In COPD subjects, bronchiectasis was independently associated with a lower FEV1%predicted (B =  - 7.7; CI [- 12.3, - 3.3]), lower FEV1/FVC (B =  - 2.5; CI [- 4.3, - 0.8]), more cough (OR 2.4; CI [1.3, 4.3]), more mucus hypersecretion (OR 1.8; CI [1.0, 3.1]) and more dyspnea (OR 2.3; CI [1.3, 3.9]). In those without COPD (n = 2139), bronchiectasis was associated with more cough, mucus hypersecretion, and wheezing, but not with deteriorating lung function.

CONCLUSION

Bronchiectasis was present in 5.4% of our lung cancer screening participants and was associated with more respiratory symptoms and, in those with COPD, with lower lung function and more emphysema.

CLINICAL RELEVANCE STATEMENT

In a lung cancer screening population, bronchiectasis has a prevalence of 5.4% with a mainly mild severity. This finding is of little clinical relevance unless mild COPD is also present. In those subjects, bronchiectasis was associated with a lower lung function, more respiratory symptoms, and more emphysema.

KEY POINTS

• Bronchiectasis was found in 5.4% of lung cancer screening participants, consisting of (ex-)smokers with and without mild COPD. • In those with mild COPD, bronchiectasis was associated with a lower lung function, more respiratory symptoms, and more emphysema. • Incidental findings of mild bronchiectasis are not very relevant in a lung cancer screening population, unless COPD is also present.

Impact of Acute Exacerbation and Its Phenotypes on the Clinical Outcomes of Chronic Obstructive Pulmonary Disease in Hospitalized Patients: A Cross-Sectional Study

Acute exacerbations of COPD (AECOPD) are clinically significant events having therapeutic and prognostic consequences. However, there is a lot of variation in its clinical manifestations described by phenotypes. The phenotypes of AECOPD were categorized in this study based on pathology and exposure. In our cross-sectional study, conducted between 1 January 2016 to 31 December 2020, the patients were categorized into six groups based on pathology: non-bacterial and non-eosinophilic; bacterial; eosinophilic; bacterial infection with eosinophilia; pneumonia; and bronchiectasis. Further, four groups were classified based on exposure to tobacco smoke (TS), biomass smoke (BMS), both, or no exposure. Cox proportional-hazards regression analyses were performed to assess hazard ratios, and Kaplan-Meier analysis was performed to assess survival, which was then compared using the log-rank test. The odds ratio (OR) and independent predictors of ward admission type and length of hospital stay were assessed using binomial logistic regression analyses. Of the 2236 subjects, 2194 were selected. The median age of the cohort was 67.0 (60.0 to 74.0) and 75.2% were males. Mortality rates were higher in females than in males (6.2% vs. 2.3%). AECOPD-B (bacterial infection) subjects [HR 95% CI 6.42 (3.06-13.46)], followed by AECOPD-P (pneumonia) subjects [HR (95% CI: 4.33 (2.01-9.30)], were at higher mortality risk and had a more extended hospital stay (6.0 (4.0 to 9.5) days; 6.0 (4.0 to 10.0). Subjects with TS and BMS-AECOPD [HR 95% CI 7.24 (1.53-34.29)], followed by BMS-AECOPD [HR 95% CI 5.28 (2.46-11.35)], had higher mortality risk. Different phenotypes have different impacts on AECOPD clinical outcomes. A better understanding of AECOPD phenotypes could contribute to developing an algorithm for the precise management of different phenotypes.

Radiographic Phenotypes Affect the Risk of Inhaled Corticosteroid-Associated Pneumonia in Patients with COPD

Purpose

Few studies have reported the association between the radiographic characteristics and the development of pneumonia in patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids (ICSs). Our study aimed to assess the effect of radiographic phenotypes on the risk of pneumonia in patients treated with ICSs.

Patients and Methods

This study retrospectively analysed all patients with COPD treated with ICSs in a subset of the Korea Chronic Obstructive Pulmonary Disorders Subgroup Study registry between January 2017 and December 2019. The association between radiographic phenotypes including the presence and severity of emphysema, airway wall thickening, or bronchiectasis on chest computed tomography were determined visually/qualitatively and the risk of pneumonia was analyzed using the Cox regression model.

Results

Among the 90 patients with COPD treated with ICSs, 41 experienced pneumonia more than once during the median follow-up of 29 (interquartile range, 8–35) months. In univariate Cox regression analysis, older age, longer use of ICSs, use of fluticasone propionate or metered dose inhaler, and severe exacerbation events increased the risk of pneumonia. In multivariate analysis, the presence of emphysema (adjusted hazard ratio [aHR]=3.73, P=0.033), severity measured using the visual sum score (mild-to-moderate, aHR=8.58, P=0.016; severe, aHR=3.58, P=0.042), Goddard sum score (mild-to-moderate, aHR=3.31, P=0.058; severe, aHR=5.38, P=0.014), and the upper lobe distribution of emphysema (aHR=3.76, P=0.032) were associated with a higher risk of pneumonia. Subtypes of centrilobular and panlobular emphysema had a higher risk of pneumonia compared with paraseptal emphysema (aHR=3.98, P=0.033; HR=3.91, P=0.041 vs HR=2.74, P=0.304). The presence of bronchiectasis (aHR=2.41, P=0.02) and emphysema/bronchiectasis overlap phenotype (aHR=2.19, P=0.053) on chest CT was a risk factor for pneumonia in this population. However, severity of bronchiectasis and the presence or severity of bronchial wall thickening according to the visual sum score were not associated with the risk of pneumonia.

Conclusion

Among patients with COPD treated with ICSs, radiographic phenotypes including the presence of emphysema, bronchiectasis or emphysema/bronchiectasis overlap phenotype, severity with emphysema, subtypes of centrilobular or panlobular emphysema, and upper lobe distribution of emphysema may help predict the risk of pneumonia.

Characteristics of Bronchiectasis Associated with Chronic Obstructive Pulmonary Disease

Introduction

An association between chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis has been observed. However, the incidence of this association is variable. The current use of high-resolution Chest Thoracic (CT) scans in patients with COPD has contributed to its demonstration. It is comorbidity or even an overlap syndrome. The aim of this study is to determine the characteristics of bronchiectasis in patients with COPD at the Annaba University Hospital in Algeria.

Subjects and Methods

We prospectively included patients hospitalized at the Annaba University Hospital in Algeria between 1st January, 2013 to 31st December, 2015. All patients were hospitalized for an exacerbation of COPD. One hundred and twelve patients (108 men and 04 women) were enrolled in this study. These patients were classified into two groups: G1 (COPD without bronchiectasis) and G2 (COPD with bronchiectasis). The parameters considered for both the groups were the length of hospitalization, comorbidities as per the Charlson index, number of exacerbations in the previous year, quality of life assessed by the Saint Georges questionnaire, a spirométrie, and C. reactive protein (CRP). The diagnosis of exacerbation, bronchiectasis, and COPD was made. The data collected were statistically analyzed using SPSS/version 16. Parametric data were expressed as mean ± SD, and non-parametric data were expressed as the number and percentage of the total. In all tests, a p-value <0.05 was considered significant. Multivariate logistic regression analysis was performed for statistically significant variables.

Results and Discussion

One hundred and twelve patients (108 men and 04 women) were included in the study. The demographic characteristics of the patients were: age (69.49 years ± 8.15), smoking (53.21 ± 48 p/y), and FEV1(42.55 ± 18.90 l/s). Of the 112 cases included, 21 had COPD associated with bronchiectasis (18.75%). This bronchiectasis was of cylindrical type in the majority of patients, i.e., 17 (80.95%), saccular in 03 cases (14.28%), and mixed in only one case (04.77%). Lesions were bilateral in 16 patients (76.19%) and unilateral in 05 patients (23.81%). FEV1 in the COPD group associated with bronchiectasis was more severe (48.7 ± 6 l/s vs. 40.2 ± 3 l/s) (OR=4.3187; 95% C.I =2.6301 - 6.8740; p <0.017). Furthermore, we noted that the length of hospitalization, the exacerbations during the past year, the CRP rate, the total score of the Saint Georges questionnaire, and the sputum purulence were statistically significant variables with an Odds Ratio significant in the COPD bronchiectasis association.

Conclusion

The diagnosis of bronchiectasis should be more efficient in patients with COPD with a severe respiratory deficit, purulent sputum, accelerated CRP, and deterioration in the quality of life.

Bronchiectasis in Low-Dose CT Screening for Lung Cancer

Background Bronchiectasis is associated with loss of lung function, substantial use of health care resources, and increased morbidity and mortality in people with cardiopulmonary diseases. Purpose To assess the frequency and severity of bronchiectasis and related clinical findings of participants in a low-dose CT (LDCT) screening program. Materials and Methods The Early Lung and Cardiac Action Program (ELCAP) bronchiectasis score (range, 0-42; higher values indicate more severe bronchiectasis) was developed to facilitate bronchiectasis assessment. This quantitative scoring system screened participants based on accumulated knowledge and improved CT imaging capabilities. Secondary review of LDCT studies from smokers aged 40-90 years was performed when they were initially enrolled in the prospective Mount Sinai ELCAP screening study between 2010 and 2019. Medical records were reviewed to identify associated respiratory symptoms and acute respiratory events during the 2 years after LDCT. Logistic regression analysis was performed to examine factors associated with bronchiectasis. Results LDCT studies of 2191 screening participants (mean age, 65 years ± 9; 1140 [52%] women) were obtained, and bronchiectasis was identified in 504 (23%) participants. Median ELCAP bronchiectasis score was 12 (interquartile range, 9-16). Bronchiectasis was most common in the lower lobes for all participants, and lower lobe prevalence was greater with higher ELCAP score (eg, 91% prevalence with an ELCAP score of 16-42). In the fourth quartile, however, midlung involvement was higher compared with lower lung involvement (128 of 131 participants [98%] vs 122 of 131 participants [93%]). Bronchiectasis was more frequent with greater age (odds ratio [OR] = 2.0 per decade; 95% CI: 1.7, 2.4); being a former smoker (OR = 1.33; 95% CI: 1.01, 1.73); and having self-reported chronic obstructive pulmonary disease (OR = 1.38; 95% CI: 1.02, 1.88), an elevated hemidiaphragm (OR = 4; 95% CI: 2, 11), or consolidation (OR = 5; 95% CI: 3, 11). It was less frequent in overweight (OR = 0.7; 95% CI: 0.5, 0.9) or obese (OR = 0.6; 95% CI: 0.4, 0.8) participants. Two years after baseline LDCT, respiratory symptoms, acute respiratory events, and respiratory events that required hospitalization were more frequent with increasing severity of the ELCAP bronchiectasis score (P < .005 for all trends). Conclusion Prevalence of bronchiectasis in smokers undergoing low-dose CT screening was high, and respiratory symptoms and acute events were more frequent with increasing severity of the Early Lung and Cardiac Action Program Bronchiectasis score. © RSNA, 2022 See also the editorial by Verschakelen in this issue.

Increased hospitalizations and economic burden in COPD with bronchiectasis: a nationwide representative study

With the increasing use of computed tomography, bronchiectasis has become a common finding in patients with chronic obstructive pulmonary disease (COPD). However, the clinical aspects and medical utilization of COPD with bronchiectasis (BE) remain unclear. We aimed to investigate the BE effect on prognosis and medical utilization in patients with COPD. Among 263,747 COPD patients, we excluded patients lacking chest X-ray, CT, or pulmonary function test codes and classified 2583 GOLD-C/D patients matched according to age, sex, and medical aid as having COPD-BE (447 [17.3%]) and COPD without BE (2136 [82.7%]). Patients with COPD-BE showed a higher rate of acute exacerbation requiring antibiotics than those without BE. Moreover, multivariable analysis showed that BE co-existence was a crucial factor for moderate-to-severe exacerbation (incidence rate ratio [IRR] 1.071; 95% CI 1.012-1.134; p = 0.019). Patients with COPD-BE had a significantly higher rate of exacerbations requiring antibiotics, as well as treatment cost and duration (meant as number of days using hospitalization plus outpatient appointment), than those with COPD without BE (52.64 ± 65.29 vs. 40.19 ± 50.02 days, p < 0.001; 5984.08 ± 8316.96 vs. 4453.40 ± 7291.03 USD, p < 0.001). Compared with patients with COPD without BE, patients with COPD-BE experienced more exacerbations requiring antibiotics, more hospitalizations, and a higher medical cost.

Clinical Impact of the Bronchiectasis with Chronic Bronchitis Symptoms in COPD: Analysis of a Longitudinal Cohort

Purpose

Bronchiectasis (BE) is a poor prognostic factor in COPD. However, it is not clear whether the poor prognosis is a result of BE alone or accompanying chronic bronchitis symptoms. Therefore, we investigated the effect of chronic bronchitis symptoms on clinical outcomes in COPD patients with BE.

Patients and Methods

We analyzed data of COPD patients from the Korean Obstructive Lung Disease (KOLD) cohort. The presence of BE was verified by chest computed tomography. Chronic bronchitis symptoms were determined using items in the symptomatic domain of the SGRQ, which is also used as an alternative definition of chronic bronchitis (CB). Patients were divided into four groups according to the presence of BE and CB symptoms: BE/CB, BE-only, CB-only, and no BE/CB. Demographic features and clinical outcomes were compared among these groups.

Results

In total, 389 COPD patients were included in the analysis. BE was present in 148 (38%) patients and CB symptoms were found in 123 patients (33.2%). The patients were divided according to BE and CB symptoms, and the numbers and percentages of each group were as follows: BE/CB, 52 (13.4%); BE-only, 96 (24.7%); CB-only, 77 (19.8%); no BE/CB, 164 (42.2%). No significant differences were observed in baseline characteristics of lung function, radiological findings, and inflammatory markers among the four groups. The proportion of annual exacerbators was higher in the BE/CB and CB-only groups than the other two groups. After adjusting other parameters, the BE/CB group was significantly associated with acute exacerbation of COPD (AE-COPD) (OR = 2.110, p = 0.045).

Conclusion

BE accompanying CB symptoms is associated with AE-COPD, while BE alone was not significantly associated. This finding suggests that it is more important to examine chronic bronchitis symptoms of BE to predict acute exacerbation than simply to identify BE in COPD patients.

ROSE: radiology, obstruction, symptoms and exposure - a Delphi consensus definition of the association of COPD and bronchiectasis by the EMBARC Airways Working Group

INTRODUCTION

The coexistence of COPD and bronchiectasis seems to be common and associated with a worse prognosis than for either disease individually. However, no definition of this association exists to guide researchers and clinicians.

METHODS

We conducted a Delphi survey involving expert pulmonologists and radiologists from Europe, Turkey and Israel in order to define the "COPD- [bronchiectasis] BE association".A panel of 16 experts from EMBARC selected 35 statements for the survey after reviewing scientific literature. Invited participants, selected on the basis of expertise, geographical and sex distribution, were asked to express agreement on the statements. Consensus was defined as a score of ≥6 points (scale 0 to 9) in ≥70% of answers across two scoring rounds.

RESULTS

102 (72.3%) out of 141 invited experts participated in the first round. Their response rate in the second round was 81%. The final consensus definition of "COPD-BE association" was: "The coexistence of (1) specific radiological findings (abnormal bronchial dilatation, airways visible within 1 cm of pleura and/or lack of tapering sign in ≥1 pulmonary segment and in >1 lobe) with (2) an obstructive pattern on spirometry ([forced expiratory volume in 1 s] FEV1/[forced vital capacity] FVC <0.7), (3) at least two characteristic symptoms (cough, expectoration, dyspnoea, fatigue, frequent infections) and (4) current or past exposure to smoke (≥10 pack-years) or other toxic agents (biomass, etc.)". These criteria form the acronym "ROSE" (Radiology, Obstruction, Symptoms, Exposure).

CONCLUSIONS

The Delphi process formulated a European consensus definition of "COPD-BE association". We hope this definition will have broad applicability across clinical practice and research in the future.

Chronic Obstructive Pulmonary Disease Is Associated With Decreased Quality of Life in Bronchiectasis Patients: Findings From the KMBARC Registry

Most studies have evaluated the impact of non-cystic fibrosis bronchiectasis (hereafter referred to as bronchiectasis) on quality of life (QoL) in patients with chronic obstructive pulmonary disease (COPD) using COPD cohorts. Accordingly, the impact of COPD on QoL in patients with bronchiectasis is not well-elucidated. We used the Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) registry between August 2018 and December 2019, a prospective observational cohort that enrolled patients with bronchiectasis in Korea. We evaluated co-occurrence exposure to COPD in bronchiectasis patients, and the primary outcome was QoL according to the Bronchiectasis Health Questionnaire (BHQ). We also investigated factors associated with decreased QoL, defined as the lowest quartile of the total BHQ score. Of 598 patients with bronchiectasis, 372 (62.2%) had COPD. Bronchiectasis patients with COPD had a significantly lower total BHQ score compared with those without COPD [median = 63.1 (interquartile range: 54.8–68.6) vs. 64.8 (57.4–70.8), p = 0.020]. Multivariable analysis revealed that dyspnea [adjusted odds ratio (aOR) = 3.21, 95% confidence interval (CI) = 1.21–8.60], depression (aOR = 1.28, 95% CI = 1.16–1.44), and fatigue (aOR = 1.05, 95% CI = 1.01–1.09) were significantly associated with decreased QoL in bronchiectasis patients with COPD. In conclusion, bronchiectasis patients with COPD had significantly decreased QoL than patients without COPD. In bronchiectasis patients with COPD, dyspnea, depression, and fatigue were associated with decreased QoL.

Clinical and Radiological Phenotypes and Endotypes

Bronchiectasis is a heterogenous disease with multiple etiologies and associated comorbidities. As bronchiectasis is a complex disease, it is unsound to think of it as a single disease particularly when the differing etiologies are likely to be driving bronchiectasis through initial divergent molecular pathways, known as endotypes, that phenotypically present as the same disease due to protracted airway inflammation, but revealing potential differing underlying mechanisms that may have disparity of drug responses. Improved understanding of the cellular immune, inflammatory, and microbiological milieu associated with clinical and radiological features of bronchiectasis has resulted in the recognition of important endotypes and phenotypes that will allow for personalized treatments to improve quality of life and outcomes of patients with bronchiectasis. Here we discuss clinical and radiological phenotypes, as well as emerging molecular endotypes that are possible treatable traits in bronchiectasis.

The effect of bronchiectasis on the exacerbation and mortality of chronic obstructive pulmonary disease

BACKGROUND

Coexistence of bronchiectasis with chronic obstructive pulmonary disease (COPD) may lead to the worsening of the functional parameters in exacerbations and may negatively affect the outcomes.

METHODS

This study is a retrospective cross-sectional study that aims to investigate the relationships between bronchiectasis with COPD exacerbation and all-cause of mortality. We retrospectively enrolled 122 cases hospitalized for COPD exacerbation from 2010 to 2016. Patients who underwent thoracic tomography in the previous year of the index exacerbation were included in the study. Patients who admitted to the intensive care unit and patients with infected bronchiectasis and with conditions that mimic COPD exacerbation were excluded from the study. Demographic, clinical, and laboratory findings, comorbidities and the number of exacerbations in the previous year and the presence of bronchiectasis were recorded using hospital electronic registry. The radiological evaluation of bronchiectasis was made by the modified Reiff score (MRS).

RESULTS

Bronchiectasis was found in 66 (54%) of 122 patients included in the study. The mean age was 67.5 ± 10.3 in the whole group, 108 (88.5%) of the patients were male, and 14 (11.5%) were female. When patients were stratified according to the presence of bronchiectasis, no statistically significant difference was found in terms of comorbidity scores, respiratory functions, exacerbation parameters, laboratory values and all cause of mortality between the groups (p > 0.05). There was no statistical relation between the presence of bronchiectasis and long-term survival (log-rank test p = 0.83).

CONCLUSIONS

This study shows that patients with bronchiectasis did not cause a poor outcome in patients with COPD exacerbation.

2004 chronic obstructive pulmonary disease with and without bronchiectasis in Aboriginal Australians: a comparative study

BACKGROUND

Chronic respiratory disorders are highly prevalent in Aboriginal Australian population, including chronic obstructive pulmonary disease (COPD) and bronchiectasis. However, there is paucity of information in the literature among Aboriginal patients with underlying COPD with and without bronchiectasis.

AIMS

In this retrospective study we evaluated the demographic and clinical characteristics of adult Aboriginal Australian patients with a clinical diagnosis of COPD with and without bronchiectasis from the remote communities of the Northern Territory of Australia.

METHODS

Clinical records were reviewed to extract information on demographics, respiratory and medical comorbid conditions, COPD directed treatment, hospital admission frequency and exacerbations. Chest radiology were reviewed to evaluate the presence or absence of bronchiectasis. Spirometry results, sputum culture and cardiac investigations were also recorded.

RESULTS

Of the 767 patients assessed in the remote community respiratory outreach clinics 380 (49%) patients had a clinical diagnosis of COPD. Chest X-ray and computed tomography scan were available to evaluate the presence of bronchiectasis in 258 patients. Of the 258/380 patients, 176/258 (68.2%) were diagnosed to have COPD alone and 82/258 (31.8%) had bronchiectasis along with COPD. The mean age was 56 and 59 years among patients with and without bronchiectasis, respectively, and 57% were males with bronchiectasis. Patients with bronchiectasis had lower body mass index (22 vs 24 kg/m² ), frequent hospital admissions (2.0 vs 1.5/year) and productive cough (32.1% vs 28.9%). Spirometry showed 77% had forced expiratory volume in 1 s (FEV₁ )/forced vital capacity ratio <0.7. In 81% and 75% of patients with and without bronchiectasis the FEV₁ /forced vital capacity ratio was <0.7 and the mean FEV₁ was 39% and 43% respectively.

CONCLUSIONS

About 32% of Aboriginal Australians had co-existent bronchiectasis with COPD. Lower body mass index, productive cough, frequent hospital admission and marginally more severe reduction in lung function were noted among patients with COPD and bronchiectasis compared to those with COPD in isolation.

Favorable Response to Long-Term Azithromycin Therapy in Bronchiectasis Patients with Chronic Airflow Obstruction Compared to Chronic Obstructive Pulmonary Disease Patients without Bronchiectasis

PURPOSE

Long-term macrolide treatment is recommended for patients with chronic obstructive pulmonary disease (COPD) with frequent exacerbations. Bronchiectasis is a common comorbid condition in patients with COPD, for which long-term azithromycin is effective in preventing exacerbation. This study aimed to compare the effect of long-term azithromycin between bronchiectasis patients with chronic airflow obstruction (CAO) and COPD patients without bronchiectasis.

PATIENTS AND METHODS

Patients with CAO who received azithromycin for more than 12 weeks were retrospectively identified at a single referral hospital. CAO was defined as a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.7, and bronchiectasis was determined using computed tomography. The development of exacerbation and symptom improvement were compared between bronchiectasis patients with CAO and COPD patients without bronchiectasis.

RESULTS

A total of 59 patients (43 in bronchiectasis with CAO group vs 16 in COPD without bronchiectasis group) were included in this study. Compared to COPD patients without bronchiectasis, those in bronchiectasis with CAO group were younger, more likely to be female, and never smokers. There was no difference in the previous exacerbation history or FEV1 between the two groups. The median duration of azithromycin treatment was 15 months (interquartile range, 8-25 months). At the 12-month follow-up, the development of ≥2 moderate or ≥1 severe exacerbations was significantly lower in bronchiectasis with CAO group than in COPD without bronchiectasis group (46.5% vs 87.5%, P = 0.005). The proportion of patients with symptom improvement determined by the COPD assessment test score was also significantly higher in bronchiectasis with CAO group than COPD without bronchiectasis group at the 12-month follow-up (68.2% vs 16.7%, P = 0.004).

CONCLUSION

Bronchiectasis patients with CAO could benefit more from long-term azithromycin treatment than COPD patients without bronchiectasis.

Evolution and Comparative Analysis of Hospitalizations in Spain Due to COPD and Bronchiectasis between 2004 and 2015

Chronic obstructive pulmonary disease (COPD) is the leading cause of hospitalization for chronic respiratory illness in Spain. In recent years hospital admissions due to bronchiectasis have been increasing, although it is not known whether this is in proportion to COPD hospitalizations. Our main objective was to analyze the temporal evolution of discharges due to COPD, bronchiectasis, and their combination, and secondly, to assess their impact on in-hospital mortality and healthcare costs. We performed a retrospective study, based on the analysis of the Minimum Basic Data Set (MBDS) of hospital discharges using data from Spanish Ministry of Health with diagnostic codes of COPD or bronchiectasis between 2004 and 2015. We found 3 356 186 discharges with a diagnosis of COPD or bronchiectasis. After exclusions, 1 386 430 episodes were analyzed: 85.2% with COPD, 8.4% bronchiectasis, and 6.4% with both pathologies. Mean age of patients was 74.8 (10.9) years and with a male predominance of 80.1%. The increase in the annual number of discharges was greater in the two groups with bronchiectasis: 48.8% in the bronchiectasis group and 55.4% in the mixed group, compared to 6.6% in the COPD group. The mean length of stay was greater in both groups with bronchiectasis (p < 0.001), while in-hospital mortality was higher in the COPD group (p < 0.001). Similarly, the annual increase of costs was more evident in the two groups with bronchiectasis. Conclusions: Hospitalizations and health costs for bronchiectasis have increased in recent years significantly more than for COPD.Supplemental data for this aricle can be accessed here.

Paired CT Measures of Emphysema and Small Airways Disease and Lung Function and Exercise Capacity in Smokers with Radiographic Bronchiectasis

RATIONALE AND OBJECTIVES

Bronchiectasis (BE) is associated with chronic obstructive pulmonary disease (COPD), but emphysema and small airways disease, main pathologic features of COPD, have been sparsely studied in BE. We aimed to objectively assess those features in smokers with and without radiographic BE and examine its relationships to airflow obstruction and exercise capacity.

MATERIAL AND METHODS

We measured emphysema and small airways disease on paired inspiratory-expiratory computed tomography (CT) scans with the parametric response map (PRM^EMPH and PRM^SAD) method in 1184 smokers with and without radiographic BE. PRM^SAD and PRM^EMPH are expressed as the percentage of lung area. Clinical, spirometry, and exercise capacity data were measured with standardized methods. The differences in PRM^SAD and PRM^EMPH between subjects with and without radiographic BE were assessed using multivariable linear regression analysis, and their associations with FEV₁ and six-minute walk test (6MWT) were assessed with generalized linear models.

RESULTS

Out of 1184 subjects, 383 (32%) had radiographic BE. PRM^EMPH but not PRM^SAD was higher in subjects with radiographic BE than those without radiographic BE in adjusted models. Subjects with radiographic BE and PRM^EMPH (defined as ≥5% on paired CTs) had lower FEV₁ (least square mean, 1479 mL vs. 2350 mL p < 0.0001) and 6MWT (372 m vs. 426 m p = 0.0007) than those with radiographic BE alone in adjusted models.

CONCLUSION

Smokers with radiographic BE have an increased burden of emphysema on paired CTs, and those with radiographic BE and emphysema have lower airflow and exercise capacity.

The clinical phenotype of bronchiectasis and its clinical guiding implications

Bronchiectasis is a chronic airway disease with abnormal and persistent bronchial dilatation caused by a variety of reasons. In recent years, numerous reports have shown that bronchiectasis is heterogeneous, the clinical characteristics of patients with different phenotypes are different, and the efficacy of a treatment regimen may vary greatly in patients with different bronchiectasis phenotypes. This paper summarizes the current clinical phenotypic classification of bronchiectasis from the perspective of etiology, microbiology, and the frequency of acute exacerbation, and cluster analysis was used to determine new clinical phenotypes and their statistical and clinical significance. Different tools for assessing disease severity yield different outcomes. This article summarizes the research progress in the above areas, hoping to provide a more comprehensive understanding of the disease.

Factors associated with bronchiectasis in Korea: a national database study

Background

Many important clinical features of bronchiectasis have been reported. However, the factors were evaluated using a specific disease cohort. Thus, clinical factors associated with bronchiectasis have not been well assessed in comparison to the general population. The aim of this study was to evaluate the factors associated with bronchiectasis using a national representative database.

Methods

We conducted a cross-sectional study using data from the Korean National Health and Nutrition Examination Survey 2007–2009. To evaluate factors associated with bronchiectasis, a multivariable logistic analysis was used with adjustment for demographic and socioeconomic factors.

Results

In the present study, the prevalence of bronchiectasis was 0.4%. Compared with subjects without bronchiectasis, subjects with bronchiectasis were older (55.1 vs. 44.4 years, P<0.001) and had lower body mass index (BMI) (23.2 vs. 24.2 kg/m², P<0.001). The proportions of low family income (70.5% vs. 40.2%, P<0.001) and low educational level (less than high school) (85.3% vs. 70.6%, P=0.041) were higher in subjects with bronchiectasis than in subjects without bronchiectasis. Regarding comorbidities, subjects with bronchiectasis were more likely to have asthma (17.8% vs. 2.9%, P<0.001), previous history of pulmonary tuberculosis (TB) (43.5% vs. 5.0%, P<0.001), osteoporosis (19.1% vs. 7.8%, P=0.002), and depression (9.3% vs. 3.0%, P=0.015) compared with subjects without bronchiectasis. In addition, subjects with bronchiectasis had more respiratory symptoms and poorer quality of life measured using the EuroQoL five dimensions questionnaire (EQ-5D) index (0.87 vs. 0.93, P<0.001) than subjects without bronchiectasis. In multivariable logistic regression analysis, low family income (adjusted odds ratio, OR =3.83, 95% confidence interval, CI: 1.46–10.03), asthma (adjusted OR =3.73, 95% CI: 1.29–10.79), pulmonary TB (adjusted OR =7.88, 95% CI: 2.65–23.39), and the presence of airflow limitation (adjusted OR =2.98, 95% CI: 1.01–8.98) were independently associated with bronchiectasis.

Conclusions

Subjects with bronchiectasis suffered from more respiratory symptoms with limited physical activity and poorer quality of life than the general population. Factors independently associated with bronchiectasis were lower family income and comorbid pulmonary conditions, such as previous pulmonary TB, asthma, and airflow limitation.

Consensus Document on the Diagnosis and Treatment of Chronic Bronchial Infection in Chronic Obstructive Pulmonary Disease

Although the chronic presence of microorganisms in the airways of patients with stable chronic obstructive pulmonary disease (COPD) confers a poor outcome, no recommendations have been established in disease management guidelines on how to diagnose and treat these cases. In order to guide professionals, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has prepared a document which aims to answer questions on the clinical management of COPD patients in whom microorganisms are occasionally or habitually isolated. Since the available scientific evidence is too heterogeneous to use in the creation of a clinical practice guideline, we have drawn up a document based on existing scientific literature and clinical experience, addressing the definition of different clinical situations and their diagnosis and management. The text was drawn up by consensus and approved by a large group of respiratory medicine experts with extensive clinical and scientific experience in the field, and has been endorsed by the SEPAR Scientific Committee.

Relationship between clinical and radiological signs of bronchiectasis in COPD patients: Results from COSYCONET

Bronchiectasis (BE) might be frequently present in COPD but masked by COPD symptoms. We studied the relationship of clinical signs of bronchiectasis to the presence and extent of its radiological signs in patients of different COPD severity. Visit 4 data (GOLD grades 1-4) of the COSYCONET cohort was used. Chest CT scans were evaluated for bronchiectasis in 6 lobes using a 3-point scale (0: absence, 1: ≤50%, 2: >50% BE-involvement for each lobe). 1176 patients were included (61%male, age 67.3y), among them 38 (3.2%) with reported physicians' diagnosis of bronchiectasis and 76 (6.5%) with alpha1-antitrypsin deficiency (AA1D). CT scans were obtained in 429 patients. Within this group, any signs of bronchiectasis were found in 46.6% of patients, whereby ≤50% BE occurred in 18.6% in ≤2 lobes, in 10.0% in 3-4 lobes, in 15.9% in 5-6 lobes; >50% bronchiectasis in at least 1 lobe was observed in 2.1%. Scores ≥4 correlated with an elevated ratio FRC/RV. The clinical diagnosis of bronchiectasis correlated with phlegm and cough and with radiological scores of at least 3, optimally ≥5. In COPD patients, clinical diagnosis and radiological signs of BE showed only weak correlations. Correlations became significant with increasing BE-severity implying radiological alterations in several lobes. This indicates the importance of reporting both presence and extent of bronchiectasis on CT. Further research is warranted to refine the criteria for CT scoring of bronchiectasis and to determine the relevance of radiologically but not clinically detectible bronchiectasis and their possible implications for therapy in COPD patients.

Non-Tuberculous Mycobacteria in Respiratory Specimens of Patients with Obstructive Lung Diseases-Colonization or Disease?

Non-tuberculous mycobacteria (NTM) are increasingly a cause of human respiratory tract colonization and mycobacterial lung disease (NTM-LD), especially in patients with chronic lung diseases. The aim of the present study was to find the factors predictive of NTM-LD in patients with obstructive lung diseases and NTM respiratory isolates. A total of 839 isolates of NTM, obtained from 161 patients between 2010 and 2020 in a single pulmonary unit, have been retrospectively reviewed. Of these isolates, 73 concerned 36 patients with obstructive lung diseases (COPD-26, asthma-3, COPD/asthma overlap syndrome-7). NTM-LD was recognized according to the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) criteria in 17 patients, colonization in 19. Lower BMI, elevated body temperature on admission, infiltrative/cavitary lesions on chest CT, and NTM species other than Mycobacterium gordonae were the significant predictors of NTM-LD recognition. Based on the above-mentioned predictive factors, an original scoring system was implemented. The diagnostic utility of the scoring system was higher than that of single parameters. We conclude that NTM-LD prediction in patients with obstructive lung diseases and positive respiratory isolates is difficult. A scoring system based on clinical, radiological and microbiological characteristics was capable of facilitating the differential diagnosis, but it needs further validation in a larger study group.

Diagnosis and quantification of bronchiectasis using computed tomography or magnetic resonance imaging: A systematic review

BACKGROUND

Bronchiectasis is an irreversible dilatation of the airways caused by inflammation and infection. To diagnose bronchiectasis in clinical care and to use bronchiectasis as outcome parameter in clinical trials, a radiological definition with exact cut-off values along with image analysis methods to assess its severity are needed. The aim of this study was to review diagnostic criteria and quantification methods for bronchiectasis.

METHODS

A systematic literature search was performed using Embase, Medline Ovid, Web of Science, Cochrane and Google Scholar. English written, clinical studies that included bronchiectasis as outcome measure and used image quantification methods were selected. Criteria for bronchiectasis, quantification methods, patient demographics, and data on image acquisition were extracted.

RESULTS

We screened 4182 abstracts, selected 972 full texts, and included 122 studies. The most often used criterion for bronchiectasis was an inner airway-artery ratio ≥1.0 (42%), however no validation studies for this cut-off value were found. Importantly, studies showed that airway-artery ratios are influenced by age. To quantify bronchiectasis, 42 different scoring methods were described.

CONCLUSION

Different diagnostic criteria for bronchiectasis are being used, but no validation studies were found to support these criteria. To use bronchiectasis as outcome in future studies, validated and age-specific cut-off values are needed.

Economic Burden of Chronic Obstructive Pulmonary Disease (COPD): A Systematic Literature Review

Background and Objectives

Chronic obstructive pulmonary disease (COPD) affects over 250 million people globally, carrying a notable economic burden. This systematic literature review aimed to highlight the economic burden associated with moderate-to-very severe COPD and to investigate key drivers of healthcare resource utilization (HRU), direct costs and indirect costs for this patient population.

Materials and Methods

Relevant publications published between January 1, 2006 and November 14, 2016 were captured from the Embase, MEDLINE and MEDLINE In-Process databases. Supplemental searches from relevant 2015-2016 conferences were also performed. Titles and abstracts were reviewed by two independent researchers against pre-defined inclusion and exclusion criteria. Studies were grouped by the type of economic outcome presented (HRU or costs). Where possible, data were also grouped according to COPD severity and/or patient exacerbation history.

Results

In total, 73 primary publications were included in this review: 66 reported HRU, 22 reported direct costs and one reported indirect costs. Most of the studies (94%) reported on data from either Europe or North America. Trends were noted across multiple studies for higher direct costs (including mean costs per patient per year and mean costs per exacerbation) being associated with increasingly severe COPD and/or a history of more frequent or severe exacerbations. Similar trends were noted according to COPD severity and/or exacerbation history for rate of hospitalization and primary care visits. Multivariate analyses were reported by 29 studies and demonstrated the statistical significance of these associations. Several other drivers of increased costs and HRU were highlighted for patients with moderate-to-very severe COPD, including comorbidities, and treatment history.

Conclusion

Moderate-to-very severe COPD represents a considerable economic burden for healthcare providers despite the availability of efficacious treatments and comprehensive guidelines on their use. Further research is warranted to ensure cost-efficient COPD management, to improve treatments and ease budgetary pressures.

High Flow Nasal Therapy Use in Patients with Acute Exacerbation of COPD and Bronchiectasis: A Feasibility Study

The efficacy and feasibility of high flow nasal therapy (HFNT) use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and bronchiectasis is unknown. We performed a single-center, single-arm prospective observational study in patients with AECOPD, documented bronchiectasis, pH ≥ 7.35, respiratory rate (RR) ≥ 26 breaths/minute despite receiving maximal medical treatment and oxygen via face mask up to 10 L/m. Patients received HFNT (Airvo 2, Fisher & Paykel) at a gas flow of 50 L/min and FIO₂ adjusted to maintain SpO₂ ≥92%. Dyspnea, rated by Borg scale, RR, arterial blood gases and mucus production (ranging from 1 to 3) were collected before and 1 h after starting HFNT and then every 24 h for 3 days. Tolerance was measured using a visual analogic scale (VAS). Fifteen patients were enrolled. After 24 h, patients showed a significant improvement in dyspnea score [Borg scale from 6.7 ± 1.4 to 4.1 ± 1.3 (p<.001)]; RR decreased from 29.6 ± 2.7 breaths/min to 23.2 ± 2.9 breaths/min (p<.001); pCO2 significantly decreased after 24 h [58.4 ± 13 vs. 51.7 ± 8.2 (p=.003)] while quantity of mucus production increased [(1.1 ± 0,6 vs. 2.4 ± 0.7, p<.001)]. No patient received invasive or noninvasive mechanical ventilation. Overall VAS score for HFNT tolerance was 6.5. HFNT was effective in improving dyspnea score, decreasing RR, improving gas exchange, and increasing mucus production in patients with AECOPD and coexisting bronchiectasis. Moreover, no safety concerns on its use were detected. Nevertheless, due to the single-arm design, the effect of HFNT could not be isolated from standard pharmacological treatment due to the study design.

The effect of the presence and severity of bronchiectasis on the respiratory functions, exercise capacity, dyspnea perception, and quality of life in patients with chronic obstructive pulmonary disease

BACKGROUND:

Bronchiectasis is common in patients with advanced chronic obstructive pulmonary disease (COPD) and adversely affects the patients' clinical condition. This study aimed to investigate the effects of bronchiectasis on exercise capacity, dyspnea perception, disease-specific quality of life, and psychological status in patients with COPD and determine the extent of these adverse effects by the severity of bronchiectasis.

METHODS:

A total of 387 COPD patients (245 patients with only COPD [Group 1] and 142 COPD patients with accompanying bronchiectasis [Group 2]) were included in the study. The patients in Group 2 were divided into three subgroups as mild, moderate, and severe using the Bronchiectasis Severity Index. Six-minute walk distance, dyspnea perception, St. George's Respiratory Questionnaire (SGRQ), and hospital anxiety and depression scores were compared between the groups.

RESULTS:

In Group 2, dyspnea perception, SGRQ total scores, depression score were higher, and walking distance was lower (P = 0.001, P = 0.007, P = 0.001, and P = 0.011, respectively). Group 2 had significantly worse arterial blood gas values. Dyspnea perception increased with the increasing severity in Group 2 (P < 0.001). Walking distance was lower in patients with severe bronchiectasis (P < 0.001). SGRQ total score, anxiety, and depression scores were significantly higher in the severe subgroup (P < 0.001, P = 0.003, and P = 0.002, respectively).

CONCLUSIONS:

In patients with Stage 3 and 4 COPD, the presence of bronchiectasis adversely affects the clinical status of the patients, decreases their exercise capacity, deteriorates their quality of life, and disrupts their psychological status. Investigating the presence of bronchiectasis in COPD patients is crucial for early diagnosis and proper treatment.

Characteristics and related factors of bronchiectasis in chronic obstructive pulmonary disease

The purpose of this study was to understand the incidence, clinical characteristics and related factors of bronchiectasis in chronic obstructive pulmonary disease (COPD) patients.From January 2015 to January 2017, 133 patients with moderate to severe COPD admitted to our hospital were enrolled in the study. Bronchiectasis analysis was performed by high resolution CT of the chest, the clinical data of all patients were collected including increasing state of COPD, peripheral blood samples, pulmonary function, blood gas. And sputum samples were collected for detection of microorganisms.the patients were aged 70.18 ± 8.31 years, and 62.4% of the patients were male. FEV1 accounted for an estimated value of 37.91 ± 10.68%, and 104 (78.2%) were severe COPD, and 43 (32.3%) had bronchiectasis. Bronchiectasis is mainly bilateral, multiple and columnar bronchiectasis. The most easily involved sites are the left lower lobe, left lingual lobe and right middle lobe. Bronchiectasis is associated with history of disease (P = .027), at least one hospitalization exacerbated by COPD in the past year (P = .025), and the separation of potential pathogenic microorganisms from sputum (P = .022). The most commonly isolated pathogen was Pseudomonas aeruginosa (P < .001).Bronchiectasis should be noted in patients with COPD who often suffer from exacerbation or repeated respiratory infections, especially in those who isolate P aeruginosa from respiratory specimens.

Clinical Features of Patients with Bronchiectasis with Comorbid Chronic Obstructive Pulmonary Disease in China

Background

The prevalence of bronchiectasis with comorbid chronic obstructive pulmonary disease (COPD) is rising, which causes extremely high risk of exacerbation and mortality. We aimed to evaluate the differences in clinicopathological manifestations, immune function, and inflammation in bronchiectasis patients with comorbid COPD vs. patients who only have COPD.

Material/Methods

Clinicopathological characteristics, including common potentially pathogenic microorganisms, lung function, immune function, and inflammation were assessed in bronchiectasis patients with comorbid COPD and in patients who only had COPD.

Results

Compared to patients who only had COPD, patients with bronchiectasis with comorbid COPD had a higher positive rate of sputum bacteria (45.27% vs. 28.03%, P<0.01). Among them, Pseudomonas aeruginosa (P. aeruginosa) accounted for 25.19% in COPD (4.37%) (P<0.01). Likewise, patients with bronchiectasis with comorbid COPD had worse lung function, worse COPD assessment test scores, and worse Modified Medical Research Council scores. Moreover, compared with COPD only cases, patients with bronchiectasis with comorbid COPD had higher levels of white blood cells (WBC), neutrophils, C-reactive protein (CRP), and procalcitonin (PCT) (all P<0.05). Interestingly, the expression levels of Treg in patients with bronchiectasis with comorbid COPD were lower than in patients with COPD only (P<0.05). Th17 and Th17/Treg levels were higher (P<0.05). Furthermore, remarkable increased level of IL17 and IL-6 and decreased level of IL-10 and TGF-β were observed in the bronchiectasis combined COPD than in pure COPD (All P<0.05).

Conclusions

Our findings suggest that P. aeruginosa is the main pathogen of bacterial infection in bronchiectasis patients with comorbid COPD. These patients have more serious clinical manifestations and immune imbalance, which should be considered when providing clinical treatment.

Bronchiectasis in patients hospitalized with acute exacerbation of COPD in Spain: Influence on mortality, hospital stay, and hospital costs (2006-2014) according to gender

PURPOSE

The objectives of this study were to analyze the characteristics of male and female patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) during 2006-2014 according to the presence or absence of bronchiectasis and to study the factors associated with in-hospital mortality (IHM) in patients hospitalized with AE-COPD and concomitant bronchiectasis.

METHODS

We used the Spanish National Hospital Database to analyze patients admitted with AE-COPD as their primary diagnosis. Patients included in the study were stratified according to the presence or absence of bronchiectasis as their secondary diagnosis.

RESULTS

We identified 386,646 admissions for AE-COPD, of which 19,679 (5.09%) involved patients with concomitant bronchiectasis. When patients with and without bronchiectasis were compared, we observed that the incidence of infection by Pseudomonas aeruginosa was substantially higher in the former, as were the mean stay, cost, and percentage of readmissions, although IHM and comorbidity were lower. The course of patients with AE-COPD and bronchiectasis was characterized by a gradual increase in prevalence and mean age among men and no differences in prevalence or lower mean age in women. Mortality was 4.24% and 5.02% in patients with and without bronchiectasis, respectively, although significance was lost after a multivariate adjustment (OR 0.94; 95% CI, 0.88-1.01). The factors associated with IHM were older age, higher comorbidity, isolation of P. aeruginosa, mechanical ventilation and readmission.

CONCLUSIONS

The prevalence of admission with AE-COPD and bronchiectasis increased in men but not in women during the study period. In patients hospitalized with AE-COPD, we did not find differences in mortality when comparing the presence and absence of bronchiectasis. The analysis of temporal trends revealed a significant reduction in mortality from 2006 to 2014 in male patients with COPD and concomitant bronchiectasis, but not among women. It is important to consider the factors associated with IHM such as age, comorbidity, isolation of P. aeruginosa, mechanical ventilation and readmission to better identify those patients who are at greater risk of dying during hospitalization.

Mucolytic Agents and Statins Use is Associated with a Lower Risk of Acute Exacerbations in Patients with Bronchiectasis-Chronic Obstructive Pulmonary Disease Overlap

BACKGROUND

Bronchiectasis-chronic obstructive pulmonary disease (COPD) overlap (BCO) is a neglected area of trials, and it is not covered by guidelines for clinical practice.

METHODS

Using the National Health Insurance Research Database of Taiwan, COPD patients with or without bronchiectasis from 2000 to 2009 were enrolled as the BCO and COPD alone cohorts, respectively. Patients followed for <28 days, diagnosed with COPD who were not prescribed with COPD medications, and those diagnosed with bronchiectasis who did not receive a chest X-ray or computed tomography were excluded. The primary endpoints were acute exacerbations and mortality.

RESULTS

There were 831 patients in the BCO cohort and 3321 patients in the COPD alone cohort, covering 3763.08 and 17,348.95 person-years, respectively, from 2000 to 2011. The BCO cohort had higher risk for exacerbations (adjusted hazard ratio (HR) 2.26, 95% confidence interval (CI) 1.94⁻2.63) and mortality (HR 1.46, 95% CI 1.24⁻1.73) than the COPD alone cohort. In the patients overall, the use of statins, macrolides, and mucolytic agents was associated with significantly lower risks of acute exacerbations (statins, HR 0.37, 95% CI 0.29⁻0.46; macrolides, HR 0.65, 95% CI 0.45⁻0.93; mucolytic agents, HR 0.68, 95% CI 0.59⁻0.78). Statins were associated with a significantly lower risk of mortality (HR 0.32, 95% CI 0.25⁻0.41). In the BCO group, statins and mucolytic agents use was associated with significantly lower risks of acute exacerbations (statins, HR 0.44, 95% CI 0.29⁻0.65; mucolytic agents, HR 0.58, 95% CI 0.45⁻0.75).

CONCLUSION

Statins and mucolytic agents use may lower risk of acute exacerbation in patients with BCO.

Difference in systemic inflammation and predictors of acute exacerbation between smoking-associated COPD and tuberculosis-associated COPD

Purpose

Tuberculosis-associated COPD (T-COPD) has clinical characteristics similar to those of smoking-associated COPD (S-COPD), such as dyspnea, sputum production, and acute exacerbation (AE). However, the degree of systemic inflammation and prognosis might be different because of difference in the pathophysiology. The aim of this study was to compare the lung function, systemic inflammatory markers, and their impacts on AE in patients with S-COPD and T-COPD.

Patients and methods

We performed a multicenter cross-sectional cohort study. We evaluated clinical characteristics, pulmonary function tests, levels of inflammatory markers, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and IL-6, and the association of these markers with AE in patients with S-COPD and T-COPD.

Results

Patients with T-COPD included more women and had lesser smoking history and higher St George Respiratory Questionnaire score than did patients with S-COPD. Although the FEV₁ of both groups was similar, FVC, vital capacity, total lung capacity, and functional residual capacity were lower in patients with T-COPD than in those with S-COPD. CRP, ESR, and IL-6 levels were significantly higher in patients with T-COPD compared to patients with S-COPD. According to a multivariate logistic regression analysis, FEV₁ was a significant factor predicting AE in S-COPD, and IL-6 was a significant factor predicting AE in T-COPD. IL-6 level greater than 2.04 pg/mL was a cutoff for predicting exacerbation of T-COPD (sensitivity 84.8%, specificity 59.3%, P<0.001).

Conclusion

Patients with T-COPD have higher levels of inflammatory markers, and IL-6 has a predictive value for AE in T-COPD.

The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions

Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.

Elevated interleukin-6 and bronchiectasis as risk factors for acute exacerbation in patients with tuberculosis-destroyed lung with airflow limitation

Background

Patients with tuberculosis-destroyed lungs (TDLs), with airflow limitation, have clinical characteristics similar to those of patients with chronic obstructive pulmonary disease (COPD). Acute exacerbation is an important factor in the management of TDL. Therefore, the aim of this study was to investigate the factors associated with acute exacerbations in patients with stable TDL with airflow limitation.

Methods

We evaluated the clinical characteristics, such as lung function, image findings, and serum laboratory findings, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and interleukin (IL)-6, in patients with TDL with chronic airflow limitation (n=94). We evaluated the correlation of these parameters with acute exacerbation.

Results

We found that patients with exacerbation were more likely to have bronchiectasis than those without exacerbation (patients with exacerbation, 66.7%; patients without exacerbation, 30.5%; P=0.001). CRP and IL-6 levels were significantly higher in patients with exacerbation than in those without exacerbation (P=0.001 and P<0.001, respectively). Bronchiectasis [OR, 3.248; 95% confidence interval (CI), 1.063-9.928; P=0.039] and elevated IL-6 levels (OR, 1.128; 95% CI, 1.013-1.257; P=0.028) were the most important parameters associated with acute exacerbation in patients with TDL with airflow limitation.

Conclusions

Patients with bronchiectasis and high IL-6 levels may require more intensive treatment to prevent acute exacerbation.

Risk of Bacterial Transmission in Bronchiectasis Outpatient Clinics

Purpose of Review

The purpose of this review is to discuss the risk of bacterial cross-infection for bronchiectasis patients in the outpatient setting. Cross-infection has primarily been a matter of concern in cystic fibrosis (CF). There is considerable evidence of transmission of pathogens between CF patients, and this has led to guideline recommendations advocating strict segregation policies. Guidelines in bronchiectasis do not specifically address the issue of cross-infection. If cross-infection is prevalent, it may have significant implications for patients and the practical running of specialist care.

Recent Findings

Multiple UK-based studies have now published evidence of cross-infection with Pseudomonas aeruginosa within cohorts of bronchiectasis patients; however, the risk does not appear to be high. There is also evidence suggesting cross-infection from CF patients to bronchiectasis patients.

Summary

The current evidence for cross-infection in bronchiectasis is limited, but suggests a small risk with Pseudomonas aeruginosa. Longitudinal studies looking at Pseudomonas aeruginosa and other pathogens are now required.

High prevalence of bronchiectasis in emphysema-predominant COPD patients

Background

COPD has been identified as an etiology or related disease of bronchiectasis, and bronchiectasis has been classified as a comorbidity of COPD. In this study, we investigated the prevalence of bronchiectasis in different phenotypes of COPD subjects and the correlation between bronchiectasis and different phenotypes, especially emphysema.

Methods

COPD patients were recruited from April 2012 to December 2015. The presence of bronchiectasis and related information were statistically analyzed. COPD subjects were separated into subgroups in two ways: COPD with and without bronchiectasis groups and emphysema-predominant (emphysema index, EI≥9.9%) and non-emphysema-predominant (EI<9.9%) groups.

Results

In total, 1,739 COPD patients were incorporated into the study, among which 140 cases (8.1%) were accompanied with radiological bronchiectasis. COPD patients with concomitant bronchiectasis presented worse pulmonary function (FEV1% predicted, P<0.001), higher EI (15.0% vs 13.4%, P<0.001), and higher proportion of pulmonary hypertension and cor pulmonale (6.4% vs 2.4%, P=0.005 and 23.6% vs 16.1%, P=0.022) than patients without bronchiectasis. Of all the COPD patients, 787 with EI data were divided into emphysema-predominant (n=369) and non-emphysema-predominant groups (n=418). The proportion of bronchiectasis was 16.5% and 10.3% (P=0.01), respectively. Severity of bronchiectasis increased as the degree of airflow limitation (r=-0.371, P<0.001) and emphysema increased (r=0.226, P=0.021). After adjusting confounding factors, FEV1% predicted (OR, 1.636; 95% CI, 1.219-2.197; P=0.001) and EI (OR, 1.993; 95% CI, 1.199-3.313; P=0.008) were significantly related with the presence of bronchiectasis in COPD patients.

Conclusion

The proportion of bronchiectasis is higher in emphysema-predominant COPD subjects. Emphysema measured by EI and FEV1% predicted are independent predictors for bronchiectasis in COPD subjects, while the underlying mechanism deserves further investigation.

Impact of bronchiectasis on outcomes of hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease: A propensity matched analysis

The coexistence of both Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis (BE) define an emerging phenotype with a worse prognosis; however, data about these patients do not consider baseline characteristics as confounders. We evaluate the impact of BE on outcomes of hospitalized patients with acute exacerbation of COPD (AECOPD). We prospectively considered AECOPD patients, analysed using a propensity score matching (PSM) method. The outcomes included length of hospital stay, use of non-invasive and invasive mechanical ventilation, intensive care unit admission, and mortality up to 3-years. Out of the 449 patients enrolled, 160 had associated BE. AECOPD with BE were older, had lower body mass index and greater functional impairment and severity of symptoms than AECOPD without BE. After PSM, 91 patients were considered for each group and no significant differences were found for all baseline characteristics. In full cohort, the cumulative mortality rate, the survival time, the Kaplan-Meier survival curves and the risk of death were worse in AECOPD with BE in the follow-up of 6-months, 1-year and 3-years. After PSM, data on mortality were similar between AECOPD with and without BE. In conclusion, in AECOPD patients the presence of BE does not influence mortality in a long-term follow-up.

The impact of acute air pollution fluctuations on bronchiectasis pulmonary exacerbation: a case-crossover analysis

In bronchiectasis, exacerbations are believed to be triggered by infectious agents, but often no pathogen can be identified. We hypothesised that acute air pollution exposure may be associated with bronchiectasis exacerbations.

We combined a case-crossover design with distributed lag models in an observational record linkage study. Patients were recruited from a specialist bronchiectasis clinic at Ninewells Hospital, Dundee, UK.

We recruited 432 patients with clinically confirmed bronchiectasis, as diagnosed by high-resolution computed tomography. After excluding days with missing air pollution data, the final model for particles with a 50% cut-off aerodynamic diameter of 10 µm (PM10) was based on 6741 exacerbations from 430 patients and for nitrogen dioxide (NO2) it included 6248 exacerbations from 426 patients. For each 10 µg·m−³ increase in PM10 and NO2, the risk of having an exacerbation that same day increased significantly by 4.5% (95% CI 0.9–8.3) and 3.2% (95% CI 0.7–5.8) respectively. The overall (lag zero to four) increase in risk of exacerbation for a 10 μg·m−3 increase in air pollutant concentration was 11.2% (95% CI 6.0–16.8) for PM10 and 4.7% (95% CI 0.1–9.5) for NO2. Subanalysis showed higher relative risks during spring (PM10 1.198 (95% CI 1.102–1.303), NO2 1.146 (95% CI 1.035–1.268)) and summer (PM10 2.142 (95% CI 1.785–2.570), NO2 1.352 (95% CI 1.140–1.602)) when outdoor air pollution exposure would be expected to be highest.

In conclusion, acute air pollution fluctuations are associated with increased exacerbation risk in bronchiectasis.

Patient information, education and self-management in bronchiectasis: facilitating improvements to optimise health outcomes

BACKGROUND

Bronchiectasis is an incurable lung disease characterised by irreversible airway dilatation. It causes symptoms including chronic productive cough, dyspnoea, and recurrent respiratory infections often requiring hospital admission. Fatigue and reductions in quality of life are also reported in bronchiectasis. Patients often require multi-modal treatments that can be burdensome, leading to issues with adherence. In this article we review the provision of, and requirement for, education and information in bronchiectasis.

DISCUSSION

To date, little research has been undertaken to improve self-management in bronchiectasis in comparison to other chronic conditions, such as COPD, for which there has been a wealth of recent developments. Qualitative work has begun to establish that information deficit is one of the potential barriers to self-management, and that patients feel having credible information is fundamental when learning to live with and manage bronchiectasis. Emerging research offers some insights into ways of improving treatment adherence and approaches to self-management education; highlighting ways of addressing the specific unmet information needs of patients and their families who are living with bronchiectasis.

CONCLUSIONS

We propose non-pharmacological recommendations to optimise patient self-management and symptom recognition; with the aim of facilitating measurable improvements in health outcomes for patients with bronchiectasis.

Acute respiratory events in patients with bronchiectasis-COPD overlap syndrome: A population-based cohort study

BACKGROUND

The clinical phenotypes of chronic obstructive pulmonary disease (COPD) are related to various outcomes. We investigated the risk of acute respiratory events in patients with bronchiectasis-COPD overlap syndrome (BCOS) in Taiwan.

METHODS

We included 3955 patients who received diagnoses of COPD and bronchiectasis from 2000 to 2007 from the Taiwan Longitudinal Health Insurance Database in the BCOS cohort. In the comparison cohort, we included patients with COPD but without bronchiectasis at a ratio of 4:1, frequency matched by age, sex, and index year with each patient with BCOS. We followed both cohorts for 5 years to investigate the incidence and risk of acute respiratory events in the BCOS cohort relative to the comparison cohort, the incidence rate ratios (IRRs) and corresponding 95% confidence intervals (CIs) were determined using Poisson regression models.

RESULTS

The BCOS cohort experienced more episodes of acute respiratory events than did the comparison cohort (16.4 vs 5.52 per 100 person-y). After adjustment for potential covariates, the BCOS cohort had a 2.20-fold higher risk of pneumonia (adjusted IRR = 2.20, 95% CI = 2.06-2.34), a 3.88-fold higher risk of acute exacerbation (adjusted IRR = 3.88,95% CI = 3.64-4.13), a 1.74-fold higher risk of acute respiratory failure (adjusted IRR = 1.74,95% CI = 1.47-2.06), and a 1.99-fold higher risk of cardiopulmonary arrest (adjusted IRR = 1.99,95% CI = 1.81-2.20) than did the comparison cohort.

CONCLUSION

The patients with BCOS had a higher risk of acute respiratory events than did COPD patients without bronchiectasis.

Quantitative computed tomography features and clinical manifestations associated with the extent of bronchiectasis in patients with moderate-to-severe COPD

Background

Few studies have investigated the quantitative computed tomography (CT) features associated with the severity of bronchiectasis in COPD patients. The purpose of this study was to identify the quantitative CT features and clinical values to determine the extent of bronchiectasis in moderate-to-severe COPD patients.

Methods

A total of 127 moderate-to-severe COPD patients were selected from the cohort of COPD in Dusty Areas (CODA). The study subjects were classified into three groups according to the extent of bronchiectasis on CT: no bronchiectasis, mild bronchiectasis, and moderate-to-severe bronchiectasis. The three groups were compared with respect to demographic data, symptoms, medical history, serum inflammatory markers, pulmonary function, and quantitative CT values.

Results

Among 127 moderate-to-severe COPD subjects, 73 patients (57.5%) were detected to have bronchiectasis, 51 patients (40.2%) to have mild bronchiectasis, and 22 patients (17.3%) to have moderate-to-severe bronchiectasis. Compared with COPD patients without bronchiectasis, those with bronchiectasis were older and had higher frequency of prior tuberculosis, lower prevalence of bronchodilator reversibility (BDR), and more severe air trapping (P < 0.05). Moderate-to-severe bronchiectasis patients had lower body mass index (BMI), higher frequency of prior tuberculosis, lower prevalence of BDR, worse pulmonary function, and more severe air trapping (P < 0.05) than those in the mild bronchiectasis group.

Conclusion

Moderate-to-severe bronchiectasis was associated with a history of pulmonary tuberculosis, lower BMI, severe airflow obstruction, and lower BDR in moderate-to-severe COPD patients. Quantitative analysis of CT showed that severe air trapping was associated with the extent of bronchiectasis in these patients.

Co-existence of COPD and bronchiectasis: a risk factor for a high ratio of main pulmonary artery to aorta diameter (PA:A) from computed tomography in COPD patients

Background

Pulmonary vascular disease, especially pulmonary hypertension, is an important complication of COPD. Bronchiectasis is considered not only a comorbidity of COPD, but also a risk factor for vascular diseases. The main pulmonary artery to aorta diameter ratio (PA:A ratio) has been found to be a reliable indicator of pulmonary vascular disease. It is hypothesized that the co-existence of COPD and bronchiectasis may be associated with relative pulmonary artery enlargement (PA:A ratio >1).

Methods

This retrospective study enrolled COPD patients from 2012 through 2016. Demographic and clinical data were collected. Bhalla score was used to determine the severity of bronchiectasis. Patient characteristics were analyzed in two ways: the high (PA:A >1) and low (PA:A ≤1) ratio groups; and COPD with and without bronchiectasis groups. Logistic regression analysis was used to assess risk factors for high PA:A ratios.

Results

In this study, 480 COPD patients were included, of whom 168 had radiographic bronchiectasis. Patients with pulmonary artery enlargement presented with poorer nutrition (albumin, 35.6±5.1 vs 38.3±4.9, P<0.001), lower oxygen partial pressure (74.4±34.5 vs 81.3±25.4, P<0.001), more severe airflow obstruction (FEV1.0, 0.9±0.5 vs 1.1±0.6, P=0.004), and a higher frequency of bronchiectasis (60% vs 28.8%, P<0.001) than patients in the low ratio group. Patients with both COPD and bronchiectasis had higher levels of systemic inflammation (erythrocyte sedimentation rate, P<0.001 and fibrinogen, P=0.006) and PA:A ratios (P<0.001). A higher PA:A ratio was significantly closely correlated with a higher Bhalla score (r=0.412, P<0.001). Patients with both COPD and bronchiectasis with high ratios presented higher levels of NT-proBNP (P<0.001) and systolic pulmonary artery pressure (P<0.001). Multiple logistic analyses have indicated that bronchiectasis is an independent risk factor for high PA:A ratios in COPD patients (OR =3.707; 95% CI =1.888-7.278; P<0.001).

Conclusion

Bronchiectasis in COPD has been demonstrated to be independently associated with relative pulmonary artery enlargement.

Sensitization to Aspergillus fumigatus as a risk factor for bronchiectasis in COPD

BACKGROUND

Bronchiectasis-chronic obstructive pulmonary disease (COPD) overlap presents a possible clinical phenotype of COPD, but it is unclear why it develops in a subset of patients. We hypothesized that sensitization to Aspergillus fumigatus (A fum) is associated with bronchiectasis in COPD and occurs more frequently in vitamin D-deficient patients.

METHODS

This observational study investigated sensitization to A fum in an outpatient clinical cohort of 300 COPD patients and 50 (ex-) smoking controls. Total IgE, A fum-specific IgE against the crude extract and against the recombinant antigens and A fum IgG were measured using ImmunoCAP fluoroenzyme immunoassay. Vitamin D was measured by radioimmunoassay, and computed tomography images of the lungs were scored using the modified Reiff score.

RESULTS

Sensitization to A fum occurred in 18% of COPD patients compared to 4% of controls (P=0.0110). In all, 31 COPD patients (10%) were sensitized to the crude extract and 24 patients (8%) had only IgE against recombinant antigens. A fum IgG levels were significantly higher in the COPD group (P=0.0473). Within COPD, A fum-sensitized patients were more often male (P=0.0293) and more often had bronchiectasis (P=0.0297). Pseudomonas aeruginosa and Serratia marcescens were more prevalent in historical sputum samples of A fum-sensitized COPD patients compared to A fum-non-sensitized COPD patients (P=0.0436). Vitamin D levels were comparable (P=0.2057). Multivariate analysis demonstrated that sensitization to recombinant f1 or f3 had a 2.8-fold increased risk for bronchiectasis (P=0.0030).

CONCLUSION

These results highlight a potential role for sensitization to A fum in COPD-related bronchiectasis.