Predictors of Change in Dyspnea Level in Acute Exacerbations of COPD

Treatment of acute exacerbations of chronic obstructive pulmonary disease with acupuncture during hospitalization: a three-arm double-blinded randomized sham-controlled trial

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a healthcare burden. Acupuncture improves dyspnea in patients with chronic obstructive pulmonary disease (COPD) but, to the best of our knowledge, has not been tested in AECOPD. Here, we evaluated the efficacy and safety of true acupuncture added to standard of care (SOC), as compared with both sham procedure plus SOC and SOC only, for the treatment of AECOPD among inpatients.

METHODS

This double-blinded randomized sham-controlled trial was set in a tertiary hospital in Israel. Patients with a clinical diagnosis of AECOPD were assigned to true acupuncture with SOC, sham procedure with SOC or SOC only. The primary outcome was dyspnea improvement as measured daily by the validated modified Borg (mBorg) scale. Secondary outcomes included improvement of other patient-reported outcomes and physiologic features, as well as duration of hospitalization and treatment failure. Acupuncture-related side effects were evaluated by the validated Acup-AE questionnaire.

RESULTS

Seventy-two patients were randomized: 26 to acupuncture treatment, 24 to sham and 22 to SOC only arms. Baseline characteristics were similar in the three groups. A statistically significant difference in dyspnea intensity was found from the first day of evaluation after treatment (p = 0.014) until day 3 after treatment. Similar results were found for sputum production, but no statistical significance was found when comparing physiologic features between the three arms. Acupuncture was not associated with adverse events.

CONCLUSION

Acupuncture seems to be efficacious in the treatment of AECOPD among inpatients hospitalized in internal medicine departments.

TRIAL REGISTRATION NUMBER

NCT03398213 (ClinicalTrials.gov).

Physical and affective components of dyspnoea are improved by pulmonary rehabilitation in COPD

Background

Dyspnoea is a multidimensional experience of breathing discomfort, but its affective dimension is unfrequently assessed in people with chronic obstructive pulmonary disease (COPD). We evaluated the effectiveness of a home-based pulmonary rehabilitation (PR) programme on the physical and affective components of dyspnoea assessed by the Dyspnoea-12 (D-12) questionnaire. We also determined the baseline characteristics that contributed to the change in D-12 scores.

Methods

In this retrospective study, 225 people with COPD (age, 65±11 years; forced expiratory volume in 1 s (FEV₁), 35±15% of predicted value) were enrolled into a person-centric home-based PR, consisting of a weekly supervised 90 min home session during 8 weeks. D-12 questionnaire, health status, anxiety and depressive symptoms, exercise tolerance and general fatigue were assessed at baseline (M0), at the end of PR programme (M2), and 8 (M8) and 14 months (M14) after M0. Multivariable analysis of covariance (ANCOVA) models were performed to identify the baseline characteristics that contributed to the change in D-12 scores.

Results

Both physical and affective components of dyspnoea and all the other outcome measures were improved at M2, M8 and M14 compared with baseline (p<0.05). Baseline body mass index was the only significant independent predictor of the changes in physical dyspnoea score, while the change in the affective dimension of dyspnoea after PR was associated with FEV₁, anxiety symptoms and exercise tolerance (6 min stepper test). However, since these variables had only a small impact on the changes in D-12 questionnaire scores, results from the ANCOVA analysis should be taken cautiously.

Conclusion

Both physical and affective components of dyspnoea were improved, at short term and long term, by 8 weeks of individualised home-based PR. The present results support the importance of assessing dyspnoea as a multidimensional experience during PR, warranting replication by robustly designed randomised and controlled studies.

Geographical Differences and Their Associated Factors in Chronic Obstructive Pulmonary Disease Mortality in Japan: An Ecological Study Using Nationwide Data

Geographical differences in chronic obstructive pulmonary disease (COPD) mortality have not been determined using municipal-specific data in Japan. This study determined the geographical differences in COPD mortality in Japan using municipal-specific data and identified associated factors. Data on COPD mortality from 2013 to 2017 for each municipality were obtained from the Vital Statistics of Japan. We calculated the standardized mortality ratio (SMR) of COPD by an empirical Bayes method for each municipality and located the SMRs on a map of Japan. In addition, an ecological study was conducted to identify factors associated with the SMR using demographic, socioeconomic, and medical characteristics of municipalities by a spatial statistics model. Geographical differences in the SMR were different in men and women, and municipalities with a low SMR tended to be more frequent in women. Spatial regression analysis identified that the total population and taxable income per capita were negatively associated with the SMR in men. In women, population density, the proportion of fatherless households, and the number of clinics per capita were positively associated with the SMR, whereas taxable income per capita was negatively associated with the SMR. There were some differences in regional characteristics associated with COPD mortality by sex.

Changes in symptoms and health-related quality of life in patients with exacerbated chronic obstructive pulmonary disease

AIMS

To describe changes in symptoms and identify distinct subgroups of symptoms, to determine whether the sample's characteristics predicted changes in symptoms, and to examine how changes in symptoms predicted changes in health-related quality of life (HRQOL) over 6 months in patients with exacerbated chronic obstructive pulmonary disease (COPD).

BACKGROUND

Different patterns of changes in symptoms and their relationship to changes in HRQOL in patients with exacerbated COPD over long periods of time have been understudied.

METHODS

In this longitudinal study, participants with COPD (N = 42) had been admitted to a medical ward or had visited a pulmonary medicine clinic for treatment of exacerbation. Descriptive and inferential statistics were used to analyze data from questionnaires that assessed symptoms and HRQOL at baseline, daily symptoms over 6 months, and HRQOL at 6 months after exacerbation.

RESULTS

Not all participants experienced improved symptoms over time. Two sets of subgroups (improving &worsening; constantly better &constantly worse) emerged, based on 6-month changes in symptoms. Sample characteristics of the improving and worsening subgroups were similar, whereas usual dyspnea and HRQOL were significantly different in the constantly better and constantly worse subgroups. Little change in HRQOL was found in the total sample, but HRQOL deteriorated in the worsening subgroup, although deterioration was not meaningful. Changes in symptoms significantly predicted changes in HRQOL over 6 months.

CONCLUSION

Assessing patients' symptoms after exacerbations of COPD may enable health care providers to identify those at risk of future exacerbations and poorer HRQOL.0.

CODEXS: A New Multidimensional Index to Better Predict Frequent COPD Exacerbators with Inclusion of Depression Score

Purpose

Depression is reported in association with chronic obstructive pulmonary disease (COPD). However, to date, no multidimensional indices have taken depression into consideration to predict COPD patients' prognosis. This study aimed to determine whether a new multidimensional index named CODEXS, based on comorbidities, airflow obstruction, dyspnea, previous exacerbation and depression assessed by Self-Rating Depression Scale (SDS), could predict 1-year exacerbations.

Methods

This was a prospective study, patients with stable COPD were used to develop CODEXS at the first visit, and followed up in the 3rd, 6th, and 12th months. After the last visit, patients were divided into frequent and infrequent exacerbators. Another cohort of COPD patients was used for validation. The SDS scoring system in the multidimensional indices ranged from 0 to 4 based on the modified SDS value, representing no depression (25-39 [0], 40-49 [1]), mild depression (50-59), moderate depression (60-69), and severe depression (≥70). Comorbidity, dyspnea, airflow obstruction, and severe exacerbations were calculated according to CODEX thresholds.

Results

Two sets of 105 and 107 patients were recruited in the development and validation cohorts, respectively. Depression was demonstrated as an independent risk factor for frequent exacerbators (odds ratio (OR)= 1.14, 95% confidence interval (CI) = 1.06-1.23, P < 0.001). The prevalence of depression in frequent exacerbators (35.09%) was higher than that in infrequent exacerbators. CODEXS was significantly associated with exacerbation (OR =2.91; 95% CI, 1.89-4.48, p<0.001). Receiver operating characteristic (ROC) curve comparison showed that CODEXS was superior to BODEX(BMI, airflow obstruction, dyspnea, previous exacerbation), BODE (BMI, airflow obstruction, dyspnea, exercise), and updated ADO (age, dyspnea, and airflow obstruction) indices, confirmed by the validation cohort with sensitivity at 85.94% and specificity at 76.74%.

Conclusion

Depression is an independent risk factor for COPD exacerbation. CODEXS is a useful predictor for predicting frequent exacerbators within 1 year and is superior to other previously published indices.

Responsiveness of PROMIS® to change in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease characterized by airflow obstruction that leads to shortness of breath and substantial negative impacts on health-related quality of life (HRQL). The course of COPD includes periodic acute exacerbations that require changes in treatment and/or hospitalizations. This study was designed to examine the responsiveness of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures to changes associated with COPD exacerbation recovery.

METHODS

A longitudinal analysis using mixed-effects models was conducted of people who were enrolled while stable (n = 100) and those who experienced an acute exacerbation (n = 85). PROMIS (physical function, pain interference, pain behavior, fatigue, anxiety, depression, anger, social roles, discretionary social activities, Global Health, dyspnea severity and dyspnea functional limitations) and COPD-targeted HRQL measures were completed at baseline and at 12 weeks.

RESULTS

We administered PROMIS measures using computer adaptive testing (CAT), followed by administration of any remaining short form (SF) items that had not yet been administered by CAT. Examination of the difference between group differences from baseline to 12 weeks in the stable and exacerbation groups revealed that the exacerbation group changed (improved) significantly more than the stable group in anxiety (p < .001 to p < .01; f2 effect size [ES] = 0.023/0.021), fatigue (p < .0001; ES = 0.036/0.047) and social roles (p < .001 to p < .05; ES = 0.035/0.024). All effect sizes were small in magnitude and smaller than hypothesized. Depression was also statistically significant (p < .05, SF only) but the ES was trivial. For all other PROMIS domains, the differences were not significant and ES were trivial.

CONCLUSIONS

This longitudinal study provides some support for the validity of the PROMIS fatigue, anxiety, and social roles domains in COPD, but further evaluation of responsiveness is warranted.

Incidence and predictors of dyspnea on exertion in a prospective cohort of patients with rheumatoid arthritis

OBJECTIVE

To investigate the incidence and predictors of dyspnea on exertion among subjects with rheumatoid arthritis (RA).

METHODS

We investigated dyspnea on exertion using a prospective cohort, the Brigham RA Sequential Study (BRASS). Clinically significant dyspnea on exertion was defined as a score of ≥3 (unable to ambulate without breathlessness or worse) on the validated Medical Research Council (MRC) scale (range 0-5). We analyzed subjects with MRC score <3 at BRASS baseline and ≥1 year of follow-up. The MRC scale was administered annually. We determined the incidence rate (IR) of dyspnea on exertion. We used Cox regression to estimate the HR for dyspnea on exertion occurring one year after potential predictors were assessed.

RESULTS

We analyzed 829 subjects with RA and no clinically significant dyspnea on exertion during mean follow-up of 3.0 years (SD 1.9). At baseline, mean age was 55.7 years (SD 13.6), 82.4% were female, and median RA duration was 8 years. During follow-up, 112 subjects (13.5%) developed incident dyspnea on exertion during 2,476 person-years of follow-up (IR 45.2 per 1000 person-years). Independent predictors of incident dyspnea on exertion were: older age (HR 1.03 per year, 95%CI 1.01-1.04), female sex (HR 2.22, 95%CI 1.14-4.29), mild dyspnea (HR 2.62, 95%CI 1.60-4.28), and worsened MDHAQ (HR 2.36 per unit, 95%CI 1.54-3.60). Methotrexate use, RA disease activity, and seropositivity were not associated with incident dyspnea on exertion.

CONCLUSION

Dyspnea on exertion occurred commonly in patients with RA. Older women with impaired physical function were especially vulnerable to developing dyspnea on exertion.