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Neder JA, Santyr G, Zanette B, Kirby M, Pourafkari M, James MD, Vincent SG, Ferguson C, Wang CY, Domnik NJ, Phillips DB, Porszasz J, Stringer WW, O'Donnell DE. Beyond Spirometry: Linking Wasted Ventilation to Exertional Dyspnea in the Initial Stages of COPD. COPD 2024; 21:2301549. [PMID: 38348843 DOI: 10.1080/15412555.2023.2301549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/29/2023] [Indexed: 02/15/2024]
Abstract
Exertional dyspnea, a key complaint of patients with chronic obstructive pulmonary disease (COPD), ultimately reflects an increased inspiratory neural drive to breathe. In non-hypoxemic patients with largely preserved lung mechanics - as those in the initial stages of the disease - the heightened inspiratory neural drive is strongly associated with an exaggerated ventilatory response to metabolic demand. Several lines of evidence indicate that the so-called excess ventilation (high ventilation-CO2 output relationship) primarily reflects poor gas exchange efficiency, namely increased physiological dead space. Pulmonary function tests estimating the extension of the wasted ventilation and selected cardiopulmonary exercise testing variables can, therefore, shed unique light on the genesis of patients' out-of-proportion dyspnea. After a succinct overview of the basis of gas exchange efficiency in health and inefficiency in COPD, we discuss how wasted ventilation translates into exertional dyspnea in individual patients. We then outline what is currently known about the structural basis of wasted ventilation in "minor/trivial" COPD vis-à-vis the contribution of emphysema versus a potential impairment in lung perfusion across non-emphysematous lung. After summarizing some unanswered questions on the field, we propose that functional imaging be amalgamated with pulmonary function tests beyond spirometry to improve our understanding of this deeply neglected cause of exertional dyspnea. Advances in the field will depend on our ability to develop robust platforms for deeply phenotyping (structurally and functionally), the dyspneic patients showing unordinary high wasted ventilation despite relatively preserved FEV1.
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Affiliation(s)
- J Alberto Neder
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
| | - Giles Santyr
- Translational Medicine Department, Faculty of Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, Canada
| | - Brandon Zanette
- Translational Medicine Department, Faculty of Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, Canada
| | - Miranda Kirby
- Department of Physics, Faculty of Science, Toronto Metropolitan University, Toronto, Canada
| | - Marina Pourafkari
- Department of Radiology and Diagnostic Imaging, Kingston Health Sciences Centre, Kingston, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
| | - Carrie Ferguson
- The Lundquist Institute for Biomedical Innovation, Harbor U.C.L.A Medical Centre, Torrance, CA, USA
| | - Chu-Yi Wang
- The Lundquist Institute for Biomedical Innovation, Harbor U.C.L.A Medical Centre, Torrance, CA, USA
| | - Nicolle J Domnik
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Devin B Phillips
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Janos Porszasz
- The Lundquist Institute for Biomedical Innovation, Harbor U.C.L.A Medical Centre, Torrance, CA, USA
| | - William W Stringer
- The Lundquist Institute for Biomedical Innovation, Harbor U.C.L.A Medical Centre, Torrance, CA, USA
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
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Richard R, Jensen D, Touron J, Frederic C, Mulliez A, Pereira B, Filaire L, Marciniuk D, Maltais F, Tan W, Bourbeau J, Perrault H. Haemodynamic compensations for exercise tissue oxygenation in early stages of COPD: an integrated cardiorespiratory assessment study. BMJ Open Respir Res 2024; 11:e002241. [PMID: 38548372 PMCID: PMC10982806 DOI: 10.1136/bmjresp-2023-002241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/23/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Cardiovascular comorbidities are increasingly being recognised in early stages of chronic obstructive pulmonary disease (COPD) yet complete cardiorespiratory functional assessments of individuals with mild COPD or presenting with COPD risk factors are lacking. This paper reports on the effectiveness of the cardiocirculatory-limb muscles oxygen delivery and utilisation axis in smokers exhibiting no, or mild to moderate degrees of airflow obstruction using standardised cardiopulmonary exercise testing (CPET). METHODS Post-bronchodilator spirometry was used to classify participants as 'ever smokers without' (n=88), with 'mild' (n=63) or 'mild-moderate' COPD (n=56). All underwent CPET with continuous concurrent monitoring of oxygen uptake (V'O2) and of bioimpedance cardiac output (Qc) enabling computation of arteriovenous differences (a-vO2). Mean values of Qc and a-vO2 were mapped across set ranges of V'O2 and Qc isolines to allow for meaningful group comparisons, at same metabolic and circulatory requirements. RESULTS Peak exercise capacity was significantly reduced in the 'mild-moderate COPD' as compared with the two other groups who showed similar pulmonary function and exercise capacity. Self-reported cardiovascular and skeletal muscle comorbidities were not different between groups, yet disease impact and exercise intolerance scores were three times higher in the 'mild-moderate COPD' compared with the other groups. Mapping of exercise Qc and a-vO2 also showed a leftward shift of values in this group, indicative of a deficit in peripheral O2 extraction even for submaximal exercise demands. Concurrent with lung hyperinflation, a distinctive blunting of exercise stroke volume expansion was also observed in this group. CONCLUSION Contrary to the traditional view that cardiovascular complications were the hallmark of advanced disease, this study of early COPD spectrum showed a reduced exercise O2 delivery and utilisation in individuals meeting spirometry criteria for stage II COPD. These findings reinforce the preventive clinical management approach to preserve peripheral muscle circulatory and oxidative capacities.
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Affiliation(s)
- Ruddy Richard
- Université Clermont Auvergne, Clermont-Ferrand, France
- CRNH, CHU Clermont-Ferrand, Clermont-Ferrand, France
- CHU Clermont Ferrand, Service de médecine du Sport et des Explorations Fonctionnelles, Université Clermont Auvergne, Clermont Ferrand Cedex 1, France
| | - Dennis Jensen
- Kinesiology & Physical Education, McGill University, Montreal, Quebec, Canada
| | | | - Costes Frederic
- Université Clermont Auvergne, Clermont-Ferrand, France
- CHU Clermont Ferrand, Service de médecine du Sport et des Explorations Fonctionnelles, Université Clermont Auvergne, Clermont Ferrand Cedex 1, France
| | | | - Bruno Pereira
- DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Darcy Marciniuk
- Respiratory Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Wan Tan
- The University of British Columbia, Vancouver, Vancouver, Canada
| | | | - Hélène Perrault
- University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
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Kim T, Kim H, Kong S, Shin SH, Cho J, Kang D, Park HY. Association Between Regular Moderate to Vigorous Physical Activity Initiation Following COPD Diagnosis and Mortality: An Emulated Target Trial Using Nationwide Cohort Data. Chest 2024; 165:84-94. [PMID: 37494977 DOI: 10.1016/j.chest.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Moderate to vigorous physical activity (MVPA) in patients with COPD affects their overall health outcomes, including symptom relief and improved quality of life. However, the magnitude of the effect of MVPA initiation on real-world clinical outcomes has not been well investigated. RESEARCH QUESTION How does MVPA initiation affect mortality and severe exacerbation in patients who have not engaged in MVPA prior to COPD diagnosis? STUDY DESIGN AND METHODS This study included patients with COPD aged ≥ 40 years who were not performing MVPA prior to COPD diagnosis and who had at least one health screening visit prior to and following their COPD diagnosis between January 1, 2010, and December 31, 2018. The main exposure was MVPA, defined as vigorous aerobic exercise > 20 min per day on ≥ 3 days per week or moderate aerobic exercise > 30 min per day on ≥ 5 days per week. The primary end point was all-cause mortality, and the secondary end point was initial severe exacerbation as the time to event following COPD diagnosis. RESULTS In total, 110,097 person-trials were included (27,564 MVPA increases and 82,533 control groups). No differences were observed between the covariates following matching. The adjusted hazards ratio of all-cause mortality for the MVPA group compared with the control group was 0.84 (95% CI, 0.79-0.89). In the subgroup analysis, patients aged > 65 years, female patients, those who had never smoked, and patients with a higher Charlson Comorbidity Index score displayed a stronger effect of MVPA on reducing mortality than younger male patients, those who had ever smoked, and patients with a lower Charlson Comorbidity Index score (Pinteraction < .05). The fully adjusted hazards ratio for the risk of severe exacerbation (MVPA group vs control) was 0.90 (95% CI, 0.87-0.94). INTERPRETATION Initiation of MVPA can potentially reduce mortality and severe exacerbations in patients with COPD, although personalized interventions and further clinical trials are necessary.
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Affiliation(s)
- Taeyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
| | - Hyunsoo Kim
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Sunga Kong
- Patient-Centered Outcomes Research Institute, Samsung Medical Center, Seoul, South Korea; Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea; Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea; Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea; Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea.
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Doña E, Reinoso-Arija R, Carrasco-Hernandez L, Doménech A, Dorado A, Lopez-Campos JL. Exploring Current Concepts and Challenges in the Identification and Management of Early-Stage COPD. J Clin Med 2023; 12:5293. [PMID: 37629335 PMCID: PMC10455125 DOI: 10.3390/jcm12165293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
The need to improve health outcomes, as well as disease prognosis, has led clinicians and researchers to propose new ways of identifying COPD in its earliest forms. This initiative is based on the hypothesis that an earlier intervention would have a greater prognostic impact. However, the operational definition of a patient in the initial stages of the disease is complex, and there is still no unanimously accepted definition. GOLD has recently proposed different concepts to identify COPD in its early stages, such as COPD in young people or COPD with mild functional impairment. In addition, GOLD proposes two other concepts, called pre-COPD (symptomatic non-obstructive patients) and PRISm (preserved ratio with impaired spirometry), which aim to identify the patient at risk of developing this chronic airflow obstruction. However, despite the attractiveness of these concepts, none have been taken up universally by the medical community. A universally accepted identification of how to define COPD in its early stages is necessary as a preliminary step in order to design clinical trials to find out the best way to treat these patients. This review deals with these concepts of COPD at the onset of the disease, highlighting their importance and the problems involved in identifying them as therapeutic targets in real clinical practice.
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Affiliation(s)
- Esperanza Doña
- Unidad Médico-Quirúrgico de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain; (E.D.); (A.D.); (A.D.)
| | - Rocío Reinoso-Arija
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, IBiS, Hospital Universitario Virgen del Rocío, CSIC, Universidad de Sevilla, 41013 Sevilla, Spain; (R.R.-A.); (L.C.-H.)
| | - Laura Carrasco-Hernandez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, IBiS, Hospital Universitario Virgen del Rocío, CSIC, Universidad de Sevilla, 41013 Sevilla, Spain; (R.R.-A.); (L.C.-H.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Adolfo Doménech
- Unidad Médico-Quirúrgico de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain; (E.D.); (A.D.); (A.D.)
| | - Antonio Dorado
- Unidad Médico-Quirúrgico de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain; (E.D.); (A.D.); (A.D.)
| | - José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, IBiS, Hospital Universitario Virgen del Rocío, CSIC, Universidad de Sevilla, 41013 Sevilla, Spain; (R.R.-A.); (L.C.-H.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Duyan M, Saridas A. Relation between partial arterial carbon dioxide pressure and pH value and optic nerve sheath diameter: a prospective self-controlled non-randomized trial study. J Ultrasound 2023; 26:107-116. [PMID: 35511351 PMCID: PMC10063762 DOI: 10.1007/s40477-022-00677-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/14/2022] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE This study aims to determine if there is a correlation between differences in optic nerve sheath diameter (ONSD) and changes in PaCO2 and pH values that were measured in the arterial blood gas (ABG) before and after treatment in COPD patients with acute hypercarbic respiratory failure (AHRF). MATERIALS AND METHODS This study serves as a prospective self-controlled non-randomized trial study conducted in the emergency clinic of a tertiary hospital. Forty-four patients with COPD, who were found to have acidosis and hypercarbia in ABG and had an indication for non-invasive mechanic ventilation (NIMV), were analyzed prospectively. Demographic information, vital findings, initial ABG values, the ONSD measurement (before the NIMV treatment), consciousness state, and the ABG results obtained in the second hour of the monitoring and the ONSD measurement (after the NIMV treatment) were recorded. RESULTS In this study, 13 (29.5%) of the patients were female and 31 (70.5%) were male. The age distribution was evaluated as 68.3 ± 9.2 years; the minimum age was 54 and the maximum was 91. A high level of positively significant correlation was found between the mean ONSD and PaCO2 (p < 0.0001). There is a high fit (0.72) between the mean ONSD and PaCO2. A moderate level of negatively significant correlation was found between the mean ONSD and the pH (p < 0.0001). However, there is an insignificant low fit (0.32) between the mean ONSD and the pH. CONCLUSION The ONSD changed significantly and in a highly correlated manner to acute changes in PaCO2 levels.
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Affiliation(s)
- Murat Duyan
- Department of Emergency Medicine, Emergency Medicine Specialist, Antalya Training and Research Hospital, Varlik District, Kazim Karabekir Street, 07100 Antalya, Turkey
| | - Ali Saridas
- Department of Emergency Medicine, Emergency Medicine Specialist, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul, Turkey
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Chen KY, Kuo HY, Lee KY, Feng PH, Wu SM, Chuang HC, Chen TT, Sun WL, Tseng CH, Liu WT, Cheng WH, Majumdar A, Stettler M, Tsai CY, Ho SC. Associations of the distance-saturation product and low-attenuation area percentage in pulmonary computed tomography with acute exacerbation in patients with chronic obstructive pulmonary disease. Front Med (Lausanne) 2023; 9:1047420. [PMID: 36687440 PMCID: PMC9846059 DOI: 10.3389/fmed.2022.1047420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) has high global health concerns, and previous research proposed various indicators to predict mortality, such as the distance-saturation product (DSP), derived from the 6-min walk test (6MWT), and the low-attenuation area percentage (LAA%) in pulmonary computed tomographic images. However, the feasibility of using these indicators to evaluate the stability of COPD still remains to be investigated. Associations of the DSP and LAA% with other COPD-related clinical parameters are also unknown. This study, thus, aimed to explore these associations. Methods This retrospective study enrolled 111 patients with COPD from northern Taiwan. Individuals' data we collected included results of a pulmonary function test (PFT), 6MWT, life quality survey [i.e., the modified Medical Research Council (mMRC) scale and COPD assessment test (CAT)], history of acute exacerbation of COPD (AECOPD), and LAA%. Next, the DSP was derived by the distance walked and the lowest oxygen saturation recorded during the 6MWT. In addition, the DSP and clinical phenotype grouping based on clinically significant outcomes by previous study approaches were employed for further investigation (i.e., DSP of 290 m%, LAA% of 20%, and AECOPD frequency of ≥1). Mean comparisons and linear and logistic regression models were utilized to explore associations among the assessed variables. Results The low-DSP group (<290 m%) had significantly higher values for the mMRC, CAT, AECOPD frequency, and LAA% at different lung volume scales (total, right, and left), whereas it had lower values of the PFT and 6MWT parameters compared to the high-DSP group. Significant associations (with high odds ratios) were observed of the mMRC, CAT, AECOPD frequency, and PFT with low- and high-DSP groupings. Next, the risk of having AECOPD was associated with the mMRC, CAT, DSP, and LAA% (for the total, right, and left lungs). Conclusion A lower value of the DSP was related to a greater worsening of symptoms, more-frequent exacerbations, poorer pulmonary function, and more-severe emphysema (higher LAA%). These readily determined parameters, including the DSP and LAA%, can serve as indicators for assessing the COPD clinical course and may can serve as a guide to corresponding treatments.
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Affiliation(s)
- Kuan-Yuan Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Hsiao-Yun Kuo
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Kang-Yun Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Po-Hao Feng
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Sheng-Ming Wu
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Hsiao-Chi Chuang
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,School of Respiratory Therapy, College of Medicine, Taipei Medical University, New Taipei City, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Tzu-Tao Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Wei-Lun Sun
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chien-Hua Tseng
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City, Taiwan,Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Wen-Te Liu
- Sleep Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Research Center of Artificial Intelligence in Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Wun-Hao Cheng
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, New Taipei City, Taiwan
| | - Arnab Majumdar
- Department of Civil and Environmental Engineering, Imperial College London, London, United Kingdom
| | - Marc Stettler
- Department of Civil and Environmental Engineering, Imperial College London, London, United Kingdom
| | - Cheng-Yu Tsai
- Sleep Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,Department of Civil and Environmental Engineering, Imperial College London, London, United Kingdom,Cheng-Yu Tsai,
| | - Shu-Chuan Ho
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan,School of Respiratory Therapy, College of Medicine, Taipei Medical University, New Taipei City, Taiwan,*Correspondence: Shu-Chuan Ho,
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Danzo F, Radovanovic D, Gatti M, Saad M, Perotto L, Franceschi E, Santus P. A reappraisal of inspiratory capacity in chronic obstructive pulmonary disease: clinical correlates and role of long-acting muscarinic antagonists and long-acting β2 agonists. Expert Rev Respir Med 2022; 16:623-635. [PMID: 35722753 DOI: 10.1080/17476348.2022.2090343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION In patients with chronic obstructive pulmonary disease (COPD), static and dynamic hyperinflation, together with expiratory flow limitation and gas exchange abnormalities, is one of the major causes of dyspnea, decreased exercise performance and ventilatory failure. An increase in functional residual capacity (FRC) is accompanied by a decrease in inspiratory capacity (IC), which is a volume readily available, repeatable, and simple to measure with any spirometer. Changes in IC and FRC after bronchodilation, contrary to changes in FEV1, have been closely associated with improvements in dyspnea and exercise performance. We systematically searched PubMed and Embase databases for clinical trials that assessed the effects of dual bronchodilation on inspiratory capacity in patients with COPD. AREAS COVERED Despite their pivotal role in COPD, IC and static volumes have rarely been considered as primary outcomes in randomized clinical trials assessing the efficacy of bronchodilators. Available studies on dual bronchodilation have shown a significant and persistent positive impact on IC focusing mainly on patients with moderate-to-severe COPD, whereas dynamic hyperinflation is also present at milder disease stages. EXPERT OPINION This narrative review discusses the pathophysiological and clinical importance of measuring IC in patients with COPD and how IC can be modified by maximizing bronchodilation combining long-acting muscarinic antagonists and long-acting β2 agonists.
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Affiliation(s)
- Fiammetta Danzo
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Marina Gatti
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Luca Perotto
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Elisa Franceschi
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
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Radovanovic D, Contoli M, Braido F, Maniscalco M, Micheletto C, Solidoro P, Santus P, Carone M. Future Perspectives of Revaluating Mild COPD. Respiration 2022; 101:688-696. [PMID: 35468602 DOI: 10.1159/000524102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
In 2020, COPD was the third leading cause of death worldwide. Lung function is central for the diagnosis of this disease, and COPD severity is still partially classified based on airflow obstruction, which can range from "mild" (GOLD 1 group, FEV1 ≥80% predicted) to "very severe" (GOLD 4, FEV1 <30% predicted). However, the term "mild COPD" needs to be carefully analyzed. Several studies have shown that even in the presence of a mild obstruction, patients can have significant symptoms, physiological deterioration, evidence of emphysema, and suffer from recurrent exacerbations. Small airways pathology significantly correlates with the presence of symptoms, and it has been demonstrated that the onset of bronchiolitis occurs earlier than that of emphysema. These damages have long been known to not be detectable with conventional tests, and exclusive reliance on spirometry is not enough to adequately study and stage a patient with "mild COPD." Therefore, early identification of COPD is of utmost importance in the light of modifying the natural course of the disease. However, patients with early lung damage are yet to be included and studied in interventional clinical trials.
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Affiliation(s)
- Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Marco Contoli
- Respiratory Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Fulvio Braido
- Respiratory Unit for Continuity of Care, IRCCS, Ospedale Policlinico San Martino, Department of Internal Medicine (DiMI), University of Genova, Genova, Italy
| | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri, Pavia. IRCCS di Telese, Telese Terme, Italy
| | - Claudio Micheletto
- UOC di Pneumologia, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Paolo Solidoro
- Medical Sciences Department, University of Torino, Turin, Italy.,Division of Respiratory Diseases, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy.,Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri, Pavia. IRCCS di Bari, Bari, Italy
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9
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Association of Baseline Patient-reported Health-related Quality of Life Metrics with Outcome in Localised Prostate Cancer. Clin Oncol (R Coll Radiol) 2021; 34:e61-e68. [PMID: 34728131 DOI: 10.1016/j.clon.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 11/22/2022]
Abstract
AIMS Although health-related quality of life (HR-QoL) outcomes are pivotal in oncology, the prognostic significance of patient-reported HR-QoL metrics is largely undefined in localised prostate cancer. We report the association of baseline HR-QoL metrics with overall survival and toxicity in localised prostate cancer. MATERIALS AND METHODS This was a secondary analysis of a phase III randomised controlled study conducted in a single-payer health system. Patients with Gleason score ≤7, clinical stage T1b-T3a and prostate-specific antigen <30 ng/ml were randomised to neoadjuvant and concurrent androgen deprivation therapy (ADT) for 6 months starting 4 months before prostate radiotherapy or concurrent and adjuvant ADT for 6 months starting simultaneously with prostate radiotherapy. HR-QoL scores were estimated using the European Organisation for Research and Treatment of Cancer QoL questionnaire. A multistate Markov model was used to determine the association of baseline HR-QoL metrics with overall survival and a multilevel multivariable Cox regression was used to determine the association with the incidence of delayed-onset grade ≥3 radiotherapy-related toxicities. To adjust for multiple analyses, P < 0.025 was considered as statistically significant. RESULTS Overall, 393 patients with baseline HR-QoL data were included in this analysis: 194 in the neoadjuvant arm and 199 in the adjuvant arm. Baseline financial difficulty (hazard ratio 1.020, 95% confidence interval 1.010-1.030, P = 0.02) and dyspnoea (hazard ratio 1.020, 95% confidence interval 1.003-1.030, P = 0.01) were associated with inferior overall survival. Baseline dyspnoea was associated with a higher incidence of grade ≥3 toxicity (hazard ratio 1.020, 95% confidence interval 1.010-1.030, P = 0.023). CONCLUSION In a cohort of localised prostate cancer patients treated with radiotherapy and short-term ADT, a 10-point higher baseline financial difficulty or dyspnoea was associated with a 20% increased risk of death. With each 10-point increase in baseline dyspnoea, we noted a 20% increase in the associated risk of grade ≥3 delayed-onset radiotherapy-related toxicity.
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10
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Neder JA, Berton DC, O'Donnell DE. Out-of-proportion dyspnea and exercise intolerance in mild COPD. ACTA ACUST UNITED AC 2021; 47:e20210205. [PMID: 34231782 PMCID: PMC8332727 DOI: 10.36416/1806-3756/e20210205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- José Alberto Neder
- . Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Kingston Health Science Center & Queen's University, Kingston, ON, Canada
| | - Danilo Cortozi Berton
- . Unidade de Fisiologia Pulmonar, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | - Denis E O'Donnell
- . Pulmonary Function Laboratory and Respiratory Investigation Unit, Division of Respirology, Kingston Health Science Center & Queen's University, Kingston, ON, Canada
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11
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Iglesias D, Masson W, Barbagelata L, Rossi E, Mora M, Cornejo G, Lagoria J, Belziti C, Vulcano N, Marenchino R, Pizarro R, Ventura H. Prognostic value of cardiopulmonary exercise test after heart transplantation. Clin Transplant 2021; 35:e14387. [PMID: 34153128 DOI: 10.1111/ctr.14387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/18/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The clinical utility of cardiopulmonary exercise testing (CPET) has not been extensively studied yet in heart transplantation (HTX) patients. OBJECTIVE To analyze the predictive value of the CPET on hospitalizations and mortality in HTX recipients. METHODS A retrospective cohort was performed from a secondary database. Patients > 18 years with HTX who underwent a CPET between 3 and 12 months after transplantation were included. Time to the first primary endpoint (HTX-related hospitalization) was analyzed and adjusted using Cox proportional hazards regression model. RESULTS A total of 122 patients (mean age 50.1 years, 77.0% men) were included. Fifty-seven patients (46.7%) had the primary endpoint. Peak VO2 (HR .95; CI 95% .90-.99, P = .03), oxygen pulse (HR .57; CI 95% .34-.96, P = .03) and predicted VO2 (HR .97; CI 95% .96-.99, P = .002) were associated with the endpoint. We did not find a significant association between the other variables and the outcome. CONCLUSION In HTX recipients, peak VO2 , oxygen pulse, and predicted VO2 were independently associated with hospitalizations at follow up.
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Affiliation(s)
- Diego Iglesias
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Walter Masson
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Leandro Barbagelata
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Emiliano Rossi
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mishel Mora
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Cornejo
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Lagoria
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Cesar Belziti
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Norberto Vulcano
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ricardo Marenchino
- Cardiovascular Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rodolfo Pizarro
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Hector Ventura
- Section Cardiomyopathy and Heart Transplantation, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
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12
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Neder JA, de Torres JP, O'Donnell DE. Recent Advances in the Physiological Assessment of Dyspneic Patients with Mild COPD. COPD 2021; 18:374-384. [PMID: 33902376 DOI: 10.1080/15412555.2021.1913110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is growing recognition that a sizable fraction of COPD patients with forced expiratory volume in one second (FEV1)/forced vital capacity ratio below the lower limit of normal but preserved FEV1 reports out-of-proportion dyspnea relative to the severity of airflow limitation. Most physicians, however, assume that patients' breathlessness is unlikely to reflect the negative physiological consequences of COPD vis-à-vis FEV1 normalcy. This concise review integrates the findings of recent studies which uncovered the key pathophysiological features shared by these patients: poor pulmonary gas exchange efficiency (increased "wasted" ventilation) and gas trapping. These abnormalities are associated with two well-known causes of exertional dyspnea: heightened ventilation relative to metabolic demand and critically low inspiratory reserves, respectively. From a clinical standpoint, a low diffusion capacity associated with increased residual volume (RV) and/or RV/total lung capacity ratio might uncover these disturbances, identifying the subset of patients in whom exertional dyspnea is causally related to "mild" COPD.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, ON, Canada
| | - Juan P de Torres
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, ON, Canada
| | - Denis E O'Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respirology, Department of Medicine, Queen's University & Kingston General Hospital, Kingston, ON, Canada
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13
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Domnik NJ, Walsted ES, Langer D. Clinical Utility of Measuring Inspiratory Neural Drive During Cardiopulmonary Exercise Testing (CPET). Front Med (Lausanne) 2020; 7:483. [PMID: 33043023 PMCID: PMC7530180 DOI: 10.3389/fmed.2020.00483] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/16/2020] [Indexed: 12/18/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) has traditionally included ventilatory and metabolic measurements alongside electrocardiographic characterization; however, research increasingly acknowledges the utility of also measuring inspiratory neural drive (IND) through its surrogate measure of diaphragmatic electromyography (EMGdi). While true IND also encompasses the activation of non-diaphragmatic respiratory muscles, the current review focuses on diaphragmatic measurements, providing information about additional inspiratory muscle groups for context where appropriate. Evaluation of IND provides mechanistic insight into the origins of dyspnea and exercise limitation across pathologies; yields valuable information reflecting the integration of diverse mechanical, chemical, locomotor, and metabolic afferent signals; and can help assess the efficacy of therapeutic interventions. Further, IND measurement during the physiologic stress of exercise is uniquely poised to reveal the underpinnings of physiologic limitations masked during resting and unloaded breathing, with important information provided not only at peak exercise, but throughout exercise protocols. As our understanding of IND presentation across varying conditions continues to grow and methods for its measurement become more accessible, the translation of these principles into clinical settings is a logical next step in facilitating appropriate and nuanced management tailored to each individual's unique physiology. This review provides an overview of the current state of understanding of IND measurement during CPET: its origins, known patterns of behavior and links with dyspnea in health and major respiratory diseases, and the possibility of expanding this approach to applications beyond exercise.
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Affiliation(s)
- Nicolle J Domnik
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Emil S Walsted
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Daniel Langer
- Research Group for Rehabilitation in Internal Disorders, Respiratory Rehabilitation and Respiratory Division, Department of Rehabilitation Sciences, University Hospital Leuven, KU Leuven, Leuven, Belgium
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