Revised (2018) COPD Clinical Practice Guideline of the Korean Academy of Tuberculosis and Respiratory Disease: A Summary

Inhaled Corticosteroids and the Risk of Nontuberculous Mycobacterial Infection in Chronic Airway Disease: A Nationwide Population-Based Study

BACKGROUND

Chronic airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD), are increasingly being treated with inhaled corticosteroid (ICS). However, ICSs carry potential infection risks, particularly nontuberculous mycobacteria (NTM). This study investigated the association between ICS use and NTM infection risk using national insurance data, particularly for individuals with chronic airway diseases.

METHODS

We conducted a nationwide population-based study using data from the National Health Insurance Service-National Sample Cohort in South Korea from 2002 to 2019. The cohort included 57,553 patients diagnosed with COPD or asthma. To assess the risk of NTM infection, we used Cox proportional hazards models and propensity score-based inverse probability of treatment weighting (IPTW) to ensure a balanced analysis of covariates.

RESULTS

Of the 57,553 patients (mean age 56.0 years, 43.2% male), 16.5% used ICS and 83.5% did not. We identified 63 NTM infection cases, including nine among ICS users and 54 among non-users. Before and after IPTW, ICS use was associated with a higher risk of NTM infection (adjusted hazard ratio [HR], 4.01; 95% confidence interval [CI], 1.48 to 15.58). Higher risks were significant for patients ≥65 years (adjusted HR, 6.40; 95% CI, 1.28 to 31.94), females (adjusted HR, 10.91; 95% CI, 2.24 to 53.20), never-smokers (adjusted HR, 6.31; 95% CI, 1.49 to 26.64), systemic steroid users (adjusted HR, 50.19; 95% CI, 8.07 to 312.19), and those with higher comorbidity scores (adjusted HR, 6.64; 95% CI, 1.19 to 37.03).

CONCLUSION

ICS use in patients with chronic airway diseases might increase the risk of NTM infection, particularly in older females, never-smokers, and systemic steroid users.

Prescription patterns and effectiveness of medications for chronic obstructive pulmonary disease: A retrospective study of real-world settings

This study aimed to define real-world prescription patterns in Korea and compare the effectiveness of chronic obstructive pulmonary disease (COPD) medications. We used national claims data provided by the Health Insurance Review and Assessment Service in Korea and examined patients who were first diagnosed with COPD and started treatment between May 1, 2017, and April 30, 2018, with no change in drug regimen. Among 30,784 patients with COPD, long-acting β2 agonist (LABA) combined with long-acting muscarinic antagonist (LAMA) (32.7%), inhaled corticosteroid-LABA (ICS-LABA) (25.6%), LAMA (18.3%), ICS (5.8%), or LABA (4.6%) were prescribed as the first-choice inhalers. The use of LABA-LAMA (hazard ratio [HR], 0.248-0.584), LAMA (HR, 0.320-0.641), ICS-LABA (HR, 0.325-0.643), and xanthine (HR, 0.563-0.828) significantly reduced the total and severe exacerbation rates compared with no use of each medication. However, the use of ICS or LABA individually did not yield such effects. The continued use of LABA-LAMA, LAMA, and ICS-LABA showed a significant effect on exacerbation rate, whereas the long-term use of ICS, LABA, and xanthine did not. Moreover, some high doses of ICS-LABA did not show significant effects. This real-world study revealed that LAMA and/or LABA could be the first choice of therapy, as recommended by recent guidelines. However, ICS, xanthine, and high-dose ICS-LABA are still being prescribed frequently as first-line drugs in Korea.

Suboptimal peak inspiratory flow rate in dry-powder inhaler users for chronic obstructive pulmonary disease in Korea

BACKGROUND

A suboptimal peak inspiratory flow rate (PIFR) in dry-powder inhaler (DPI) users can lead to insufficient therapeutic effects in the treatment of chronic obstructive pulmonary disease (COPD). However, few data on the prevalence of and factors associated with suboptimal PIFR in Korean patients with COPD are available.

METHODS

We conducted a cross-sectional study of patients with COPD who had been using DPIs for more than three months. PIFR was measured using an In-Check DIAL G16 device. Suboptimal PIFR was defined as below the resistance-matched threshold. Multivariable logistic regression analysis was used to determine factors associated with suboptimal PIFR.

RESULTS

Of 444 DPI users with COPD, the rate of suboptimal PIFR was 22.0 % (98/444). In a multivariable analysis, significant factors associated with suboptimal PIFR were age (adjusted odds ratio [aOR] = 1.06 by 1-year increase; 95 % confidence interval [CI] = 1.02-1.09), male sex (aOR = 0.28; 95 % CI = 0.11-0.73), body mass index (BMI) (aOR = 0.91 by 1 kg/m2 increase; 95 % CI = 0.85-0.99), post-bronchodilator forced vital capacity (FVC) %pred (aOR = 0.97 by 1%pred increase; 95 % CI = 0.95-0.99), and In-Check DIAL R2-type inhaler [medium-low resistance] use (aOR = 3.70 compared with R1-type inhalers [low resistance]; 95 % CI = 2.03-7.03).

CONCLUSIONS

In Korea, more than one-fifth of DPI users with COPD had a suboptimal PIFR. The factors associated with suboptimal PIFR were age, female gender, low BMI, low FVC, and R2-type inhaler use. Therefore, clinicians should carefully evaluate the possibility of suboptimal PIFR when prescribing DPIs.

Respiratory pathogen and clinical features of hospitalized patients in acute exacerbation of chronic obstructive pulmonary disease after COVID 19 pandemic

Respiratory infections are common causes of acute exacerbation of chronic obstructive lung disease (AECOPD). We explored whether the pathogens causing AECOPD and clinical features changed from before to after the coronavirus disease 2019 (COVID-19) outbreak. We reviewed the medical records of patients hospitalized with AECOPD at four university hospitals between January 2017 and December 2018 and between January 2021 and December. We evaluated 1180 patients with AECOPD for whom medication histories were available. After the outbreak, the number of patients hospitalized with AECOPD was almost 44% lower compared with before the outbreak. Patients hospitalized with AECOPD after the outbreak were younger (75 vs. 77 years, p = 0.003) and more often stayed at home (96.6% vs. 88.6%, p < 0.001) than patients of AECOPD before the outbreak. Hospital stay was longer after the outbreak than before the outbreak (10 vs. 8 days. p < 0.001). After the COVID-19 outbreak, the identification rates of S. pneumoniae (15.3 vs. 6.2%, p < 0.001) and Hemophilus influenzae (6.4 vs. 2.4%, p = 0.002) decreased, whereas the identification rates of P. aeruginosa (9.4 vs. 13.7%, p = 0.023), Klebsiella pneumoniae (5.3 vs. 9.8%, p = 0.004), and methicillin-resistant Staphylococcus aureus (1.0 vs. 2.8%, p = 0.023) increased. After the outbreak, the identification rate of influenza A decreased (10.4 vs. 1.0%, p = 0.023). After the outbreak, the number of patients hospitalized with AECOPD was lower and the identification rates of community-transmitted pathogens tended to decrease, whereas the rates of pathogens capable of chronic colonization tended to increase. During the period of large-scale viral outbreaks that require quarantine, patients with AECOPD might be given more consideration for treatment against strains that can colonize chronic respiratory disease rather than community acquired pathogens.

Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs).

OBJECTIVES

Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD.

METHODS

PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present.

RESULTS

Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing.

CONCLUSIONS

Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.

Effect of E. cava and C. indicum Complex Extract on Phorbol 12-Myristate 13-Acetate (PMA)-Stimulated Inflammatory Response in Human Pulmonary Epithelial Cells and Particulate Matter (PM)2.5-Induced Pulmonary Inflammation in Mice

This study explores the potential of a natural composite formulation known as ED, consisting of Ecklonia cava (E. cava, family: Lessoniaceae) and Chrysanthemum indicum Linne (C. indicum, family: Asteraceae), in alleviating lung inflammation induced by fine particulate matter (PM2.5). Initial assessments confirmed that neither ED nor one of its components, dieckol, exhibited cytotoxic effects on A549 cells. Subsequently, the impact of ED and dieckol on MUC5AC gene expression in A549 cells stimulated by phorbol 12-myristate 13-acetate (PMA) was investigated, revealing promising results that demonstrated a dose-dependent inhibition of MUC5AC gene expression. The study also delves into the underlying mechanisms, demonstrating that ED and dieckol effectively suppressed the phosphorylation of mitogen-activated protein kinases (MAPKs), including JNK, ERK, and p38, which are known to be involved in the regulation of MUC5AC gene expression. In in vivo experiments using a PM2.5-induced pulmonary inflammation mouse model, the research findings showed that ED mitigated cellular accumulation in the airways, leading to a significant reduction in the total cell count in bronchoalveolar lavage fluid (BALF). Moreover, ED exhibited protective effects against PM2.5-induced pulmonary damage, characterized by reduced inflammatory cell infiltration and decreased mucus secretion in pulmonary tissues. Additionally, ED's anti-inflammatory properties were evident in its ability to decrease the levels of key inflammatory cytokines, TNF-α and IL-6, both in the serum and lung tissue of the PM2.5-induced pulmonary inflammation mouse model. These findings suggest the potential of ED as a therapeutic agent for inflammatory respiratory diseases.

Undiagnosed and 'overdiagnosed' COPD using postbronchodilator spirometry in primary healthcare settings: a systematic review and meta-analysis

BACKGROUND

Despite chronic obstructive pulmonary disease (COPD) being a major global cause of mortality and hospitalisation, it is often undiagnosed or inaccurately diagnosed in clinical settings.

OBJECTIVE

To systematically synthesise all peer-reviewed papers from primary healthcare settings that have reported data on: (1) undiagnosed COPD, that is, patients with respiratory symptoms and postbronchodilator airflow obstruction consistent with COPD, without a formal clinician's diagnosis of COPD either documented in health records or reported by patients and (2) 'overdiagnosed COPD', that is, clinician's diagnosis without postbronchodilator airflow obstruction.

METHODS

Studies investigating these diagnostic metrics in patients from primary healthcare clinics (according to predefined inclusion/exclusion criteria) were sourced from Medline and Embase and assessed for bias (Johanna Briggs Institute tools for prevalence studies and case series). Meta-analyses of studies of adequate sample size used random effect modelling stratified by risk factor categories.

RESULTS

Of 26 eligible articles, 21 cross-sectional studies investigated 3959 cases of spirometry-defined COPD (with or without symptoms), and 5 peer-reviewed COPD case series investigated 7381 patients. The prevalence of spirometry-confirmed COPD without a diagnosis documented in their health records was 14%-26% in studies of symptomatic smokers (N=3). 1 in 4 patients taking inhaled therapies (25% (95% CI 22% to 28%), N=2) and 1 in 6 smokers irrespective of symptoms (16% (95% CI 14% to 18%), N=6) fulfilled diagnostic spirometry criteria but did not report receiving a COPD-related diagnosis. In an adequately powered series of COPD cases documented in primary healthcare records (N=4), only between 50% and 75% of subjects had any airflow obstruction on postbronchodilator spirometry performed by study researchers, therefore, COPD was clinically 'overdiagnosed' in 25%-50% of subjects.

DISCUSSION

Although data were heterogeneous and of modest quality, undiagnosed COPD was common in primary healthcare, especially for symptomatic smokers and patients treated with inhaled therapies. In contrast, frequent COPD 'overdiagnosis' may represent treatment of asthma/reversible component or another medical diagnosis.

PROSPERO REGISTRATION NUMBER

CRD42022295832.

Practical Recommendations for a Selection of Inhaled Corticosteroids in COPD: A Composite ICO Chart

The use of inhaled corticosteroids (ICS) for the maintenance of bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD) is controversial. While some patients achieve clinical benefits, such as fewer exacerbations and improved symptoms, others do not, and some experience undesired side effects, such as pneumonia. Thus, we reviewed the evidence related to predictors of ICS therapy treatment response in patients with COPD. The first priority clinical markers when considering the efficacy of ICS are type 2 inflammatory biomarkers, followed by a history of suspected asthma and recurrent exacerbations. It is also necessary to consider any potential infection risk associated with ICS, and several risk factors for pneumonia when using ICS have been clarified in recent years. In this article, based on the evidence supporting the selection of ICS for COPD, we propose an ICS composite that can be added to the COPD (ICO) chart for use in clinical practice. The chart divided the type 2 biomarkers into three ranges and provided recommendations (recommend, consider, and against) by combining the history of suspected asthma, history of exacerbations, and risk of infection.

COPD Exacerbation-Related Pathogens and Previous COPD Treatment

We evaluated whether the pathogens identified during acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) are associated with the COPD medications used in the 6 months before AE-COPD. We collected the medical records of patients diagnosed with AE-COPD at 28 hospitals between January 2008 and December 2019 and retrospectively analyzed them. Microorganisms identified at the time of AE-COPD were analyzed according to the use of inhaled corticosteroid (ICS) and systemic steroid after adjusting for COPD severity. We evaluated 1177 patients with AE-COPD and available medication history. The mean age of the patients was 73.9 ± 9.2 years, and 83% were males. The most frequently identified bacteria during AE-COPD were Pseudomonas aeruginosa (10%), followed by Mycoplasma pneumoniae (9.4%), and Streptococcus pneumoniae (5.1%), whereas the most commonly identified viruses were rhinovirus (11%) and influenza A (11%). During AE-COPD, bacteria were more frequently identified in the ICS than non-ICS group (p = 0.009), and in the systemic steroid than non-systemic steroid group (p < 0.001). In patients who used systemic steroids before AE-COPD, the risk of detecting Pseudomonas aeruginosa was significantly higher during AE-COPD (OR 1.619, CI 1.007−2.603, p = 0.047), but ICS use did not increase the risk of Pseudomonas detection. The risk of respiratory syncytial virus (RSV) detection was low when ICS was used (OR 0.492, CI 0.244−0.988, p = 0.045). COPD patients who used ICS had a lower rate of RSV infection and similar rate of P. aeruginosa infection during AE-COPD compared to patients who did not use ICS. However, COPD patients who used systemic steroids within 6 months before AE-COPD had an increased risk of P. aeruginosa infection. Therefore, anti-pseudomonal antibiotics should be considered in patients with AE-COPD who have used systemic steroids.

Analysis of Clinical Characteristics and Risk Factors for Drug Resistance in Newly-Treated Patients with Pulmonary Tuberculosis Complicated with Chronic Obstructive Pulmonary Disease

Objective

To analyze the clinical characteristics and risk factors of drug resistance of newly-treated chronic obstructive pulmonary disease (COPD) complicated pulmonary tuberculosis (PTB).

Methods

A total of 489 newly-treated PTB patients admitted to Beijing Geriatric hospital were retrospectively enrolled in this study. Of these, 138 patients with COPD were allocated to the study group, and the remaining 351 patients without COPD were allocated to the control group. The baseline information, clinical characteristics of PTB and drug resistance of Mycobacterium tuberculosis were compared between the two groups. Logistic regression was used to explore the correlation between drug resistance and COPD complications.

Results

Patients complicated with COPD had a higher proportion of respiratory failure, cough, fever and night sweats, chest short breath, and emaciation between the study group and the control group (P<0.05). In terms of medical history, patients complicated with COPD also had a higher proportion of childhood TB history, cough, tuberculosis exposure rate, dust exposure rate, and malnutrition (P<0.05). There were significantly more patients with pulmonary cavities and a delayed diagnosis of TB in the study group than in the control group (P<0.05). The single drug resistance rates of isoniazid, ethambutol, rifampicin, pyrazinamide, and rifapentine, and drug resistance with any two or more drugs in the study group were significantly higher than those in the control group (P<0.05). Multivariate Logistic regression analysis showed that smoking, extrapulmonary tuberculosis, tuberculosis exposure history, malnutrition, pulmonary cavity, and delayed TB diagnosis were risk factors for drug resistance in newly-treated COPD complicated PTB patients.

Conclusion

The symptoms of COPD complicated PTB were more serious. Smoking history, extrapulmonary tuberculosis, tuberculosis exposure history, malnutrition, pulmonary cavity, and delayed diagnosis of tuberculosis were risk factors for TB resistance in these patients.

[Knowledge Structure of Chronic Obstructive Pulmonary Disease Health Information on Health-Related Websites and Patients' Needs in the Literature Using Text Network Analysis]

PURPOSE

The purpose of this study was to identify the knowledge structure of health information (HI) for chronic obstructive pulmonary disease (COPD).

METHODS

Keywords or meaningful morphemes from HI presented on five health-related websites (HRWs) of one national HI institute and four hospitals, as well as HI needs among patients presented in nine literature, were reviewed, refined, and analyzed using text network analysis and their co-occurrence matrix was generated. Two networks of 61 and 35 keywords, respectively, were analyzed for degree, closeness, and betweenness centrality, as well as betweenness community analysis.

RESULTS

The most common keywords pertaining to HI on HRWs were lung, inhaler, smoking, dyspnea, and infection, focusing COPD treatment. In contrast, HI needs among patients were lung, medication, support, symptom, and smoking cessation, expanding to disease management. Two common sub-topic groups in HI on HRWs were COPD overview and medication administration, whereas three common sub-topic groups in HI needs among patients in the literature were COPD overview, self-management, and emotional management.

CONCLUSION

The knowledge structure of HI on HRWs is medically oriented, while patients need supportive information. Thus, the support system for self-management and emotional management on HRWs must be informed according to the structure of patients' needs for HI. Healthcare providers should consider presenting COPD patient-centered information on HRWs.

Low alanine aminotransferase as a risk factor for chronic obstructive pulmonary disease in males

Alanine aminotransferase (ALT) levels reflect skeletal muscle volume and general performance, which are associated with chronic obstructive pulmonary disease (COPD) development and prognosis. This study aimed to investigate ALT levels as a risk factor for COPD development. This 13-year population-based retrospective observational cohort study included 422,452 participants for analysis. We classified groups according to the baseline ALT levels (groups 1-5: ALT (IU/L) < 10; 10-19; 20-29; 30-39; and ≥ 40, respectively). The incidence of COPD was the highest in group 1, decreasing as the group number increased in males, but not in females. The Cox regression analysis in males revealed that a lower ALT level, as a continuous variable, was a significant risk factor for COPD development [univariable, hazard ratio (HR): 0.992, 95% confidence interval (CI): 0.991-0.994; multivariable, HR: 0.998, 95% CI: 0.996-0.999]. In addition, COPD was more likely to develop in the lower ALT level groups (groups 1-4; < 40 IU/L), than in the highest ALT level group (group 5; ≥ 40 IU/L) (univariable, HR: 1.341, 95% CI: 1.263-1.424; multivariable, HR: 1.097, 95% CI: 1.030-1.168). Our findings suggest that males with low ALT levels should be carefully monitored for COPD development.

COPD Guidelines in the Asia-Pacific Regions: Similarities and Differences

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease that is associated with significant morbidity and mortality, giving rise to an enormous social and economic burden. The Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) report is one of the most frequently used documents for managing COPD patients worldwide. A survey was conducted across country-level members of Asia-Pacific Society of Respiratory (APSR) for collecting an updated version of local COPD guidelines, which were implemented in each country. This is the first report to summarize the similarities and differences among the COPD guidelines across the Asia-Pacific region. The degree of airflow limitation, assessment of COPD severity, management, and pharmacologic therapy of stable COPD will be reviewed in this report.

Effects of azithromycin on treating chronic obstructive pulmonary disease with acute exacerbation of chronic bronchitis in the stable phase

OBJECTIVE

To explore the effects of azithromycinon in treatment of chronic obstructive pulmonary disease (COPD) in patients with acute exacerbation (AE) of chronic bronchitis (CB) in the stable phase.

METHODS

Totally, 60 COPD patients with AE of CB were divided into control group (CG, 30 cases) and experimental group (EG, 30 cases) using the random number residue method. The CG was administered 250 mg salmeterol-fluticasone powder inhalation twice a day combined with 18 µg tiotropium bromide inhalation once a day. The EG was treated with 250 mg azithromycin tablets once a day in addition to the treatment of the CG. We compared the clinical effect, pulmonary function, and fractional exhaled nitric oxide index between two groups after treated for three-months.

RESULTS

Compared with the CG, the EG showed a better clinical effect with a total effective rate at 86.67% after treatment (P<0.05). The EG exhibited better FEV1 and FEV1% than the CG (P<0.05). We also observed the difference between clinically FeNO-invalid patients before and after treatment was significant (P<0.05). After treatment, this difference among groups was statistically significant (P<0.05).

CONCLUSIONS

Azithromycin combined with salmeterol-fluticasone powder inhalation and tiotropium bromide inhalation have good effects for treating COPD patients with AE of CB in the stable stage and can improve the pulmonary function. When COPD with AE of CB was exacerbated, the FeNO index increased significantly, indicating a potential increase in the mucosal inflammatory cells and eosinophils of the airway.

The current status of chronic obstructive pulmonary disease awareness, treatments, and plans for improvement in South Korea: a narrative review

The prevalence of chronic obstructive pulmonary disease (COPD) is high in South Korea which has remained virtually unchanged over the past few years. Other challenges related to COPD in South Korea include a low level of awareness of COPD, underutilization of pulmonary function tests (PFTs) and a low level of inhaler use. Continued efforts have been made to raise awareness of COPD in the general public and promote screening tests for the early detection of COPD patients for high-risk patients, which should be the primary object for better management of the disease. The Korean Academy of Tuberculosis and Respiratory Diseases (KATRD) and the Korea Disease Control and Prevention Agency (KDCA) have been working in tandem on numerous projects to resolve these issues. As the fruit of these efforts, a couple of projects are currently being carried out to add PFTs into the National Health Examination (NHE) of Korea as part of screening tests and improve the quality of COPD treatments in primary care settings. Raising public awareness of a chronic disease such as COPD requires collective efforts of academic societies and government. In addition, personalized education programs that are tailored to individual COPD patients is a necessity to raise adherence of treatment and self-management of COPD. The aim of this manuscript is to report the current status of COPD management in South Korea in hopes that it will help better treat and manage COPD in other nations coping with similar challenges.

Comparative Study of Inhaler Device Handling Technique and Risk Factors for Critical Inhaler Errors in Korean COPD Patients

Objective

Critical inhaler handling errors are associated with an increased risk of adverse outcomes in patients with chronic obstructive pulmonary disease (COPD). However, real-world data on inhaler device handling techniques and the risk factors for critical inhaler errors in the Asian population have been examined in only a few studies. We evaluated the rates and risk factors for critical inhaler errors in the COPD population in Korea.

Methods

COPD patients were prospectively enrolled from January 2018 to November 2019. An advanced practice nurse evaluated their inhaler technique. The 308 inhalers used by the 261 participants in this study included dry powder inhalers (DPIs; Turbuhaler, Breezhaler, Ellipta, Diskus, Genuair), a soft mist inhaler (SMI; Respimat), and pressurized metered dose inhalers (pMDIs).

Results

The percentage critical errors for Turbuhaler, Breezhaler, Ellipta, Diskus, Genuair, Respimat, and pMDI usage were 60.0%, 41.0%, 27.8%, 12.5%, 44.4%, 45.5%, and 55.0%, respectively. In the multivariate analyses, female sex, short COPD duration, dissatisfaction with the inhaler (assessed by FSI-10), and moderate acute exacerbations (AEs) in the prior year were independent risk factors for any critical error in the DPI group. In the SMI group, a low education level and frequent AEs in the prior year were independent risk factors for any critical error, whereas a high COPD assessment test (CAT) score was the only risk factor in the pMDI group.

Conclusion

Critical inhaler errors are common among patients with COPD, regardless of their preferred inhaler device. The rates and risk factors for critical inhaler errors differed among patients using different devices. Optimal device selection considering the risk factors of inhaler misusage will improve disease control in COPD patients.

Reliability of Portable Spirometry Performed in the Korea National Health and Nutrition Examination Survey Compared to Conventional Spirometry

Background

The Korea National Health and Nutrition Examination Survey (KNHANES) is a well-designed survey to collect national data, which many researchers have used for their studies. In KNHANES, although portable spirometry was used, its reliability has not been verified.

Methods

We prospectively enrolled 58 participants from four Korean institutions. The participants were classified into normal pattern, obstructive pattern, and restrictive pattern groups according to their previous spirometry results. Lung function was estimated by conventional spirometry and portable spirometry, and the results were compared.

Results

The intraclass correlation coefficients of forced vital capacity (FVC) (coefficient, 9.993; 95% confidence interval [CI], 0.988–0.996), forced expiratory volume in 1 second (FEV₁) (coefficient, 0.997; 95% CI, 0.995–0.998), FEV₁/FVC ratio (coefficient, 0.995; 95% CI, 0.992–0.997), and forced expiratory flow at 25–75% (FEF25–75%; coefficient, 0.991; 95% CI, 0.984–0.994) were excellent (all p<0.001). In the subgroup analysis, the results of the three parameters were similar in all groups. In the overall and subgroup analyses, Pearson’s correlation of all the parameters was also excellent in the total (coefficient, 0.986–0.994; p<0.001) and subgroup analyses (coefficient, 0.915–0.995; p<0.001). In the paired t-test, FVC, FEV₁/FVC, and FEF25–75% estimated by the two instruments were statistically different. However, FEV₁ was not significantly different.

Conclusion

Lung function estimated by portable spirometry was well-correlated with that estimated by conventional spirometry. Although the values had minimal differences between them, we suggest that the spirometry results from the KNHANES are reliable.

Updated view on the treatment of chronic obstructive pulmonary disease in Korea

Chronic obstructive pulmonary disease (COPD) is prevalent (13.4% in the population above the age of 40) but less recognized by patients and physicians in Korea. The definition and treatment strategies of COPD have changed with the accumulation of evidence, and the Korean COPD guidelines recommended by the Korean Academy of Tuberculosis and Respiratory Disease have also been updated. This review will cover some important points, that should be considered in the management of stable COPD in clinical practice. COPD is a treatable disease and earlier detection should be emphasized to achieve better clinical benefits in the mild stages. In addition, etiologies other than smoking are critical in the development of COPD. Medical treatment strategies have been updated focusing on the role of long-acting bronchodilators and the updated Korean COPD guidelines include specific Korean situations in the management of COPD.

A genome wide association study for lung function in the Korean population using an exome array

BACKGROUND/AIMS

Lung function is an objective indicator of diagnosis and prognosis of respiratory diseases. Many common genetic variants have been associated with lung function in multiple ethnic populations. We looked for coding variants associated with forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC) in the Korean general population.

METHODS

We carried out exome array analysis and lung function measurements of the FEV1 and FEV1/FVC in 7,524 individuals of the Korean population. We evaluated single variants with minor allele frequency greater than 0.5%. We performed look-ups for candidate coding variants associations in the UK Biobank, SpiroMeta, and CHARGE consortia.

RESULTS

We identified coding variants in the SMIM29 (C6orf1) (p = 1.2 × 10-5) and HMGA1 locus on chromosome 6p21, the GIT2 (p = 6.5 × 10-5) locus on chromosome 12q24, and the ARHGEF40 (p = 9.9 × 10-5) locus on chromosome 14q11 as having a significant association with lung function (FEV1). We also confirmed a previously reported association with lung function and chronic obstructive pulmonary disease in the FAM13A (p = 4.54 × 10-6) locus on chromosome 4q22, in TNXB (p = 1.30 × 10-6) and in AGER (p = 1.09 × 10-8) locus on chromosome 6p21.

CONCLUSION

Our exome array analysis identified that several protein coding variants were associated with lung function in the Korean population. Common coding variants in SMIM29 (C6orf1), HMGA1, GIT2, FAM13A, TNXB, AGER and low-frequency variant in ARHGEF40 potentially affect lung function, which warrant further study.

Direct Switch from Tiotropium to Indacaterol/Glycopyrronium in Chronic Obstructive Pulmonary Disease Patients in Korea

Background

Many chronic obstructive pulmonary disease (COPD) patients receiving monotherapy continue to experience symptoms, exacerbations and poor quality of life. This study aimed to assess the efficacy and safety of direct switch from once-daily tiotropium (TIO) 18 μg to indacaterol/glycopyrronium (IND/GLY) 110/50 μg once daily in COPD patients in Korea.

Methods

This was a randomized, open-label, parallel group, 12-week trial in mild-to-moderate COPD patients who received TIO 18 μg once daily for ≥12 weeks prior to study initiation. Patients aged ≥40 years, with predicted post-bronchodilator forced expiratory volume in 1 second (FEV₁) ≥50%, post-bronchodilator FEV₁/forced vital capacity <0.7 and smoking history of ≥10 pack-years were included. Eligible patients were randomized in a 1:1 ratio to either IND/GLY or TIO. The primary objective was to demonstrate superiority of IND/GLY over TIO in pre-dose trough FEV₁ at week 12. Secondary endpoints included transition dyspnea index (TDI) focal score, COPD assessment test (CAT) total score, and rescue medication use following the 12-week treatment, and safety assessment.

Results

Of the 442 patients screened, 379 were randomized and 347 completed the study. IND/GLY demonstrated superiority in pre-dose trough FEV₁ versus TIO at week 12 (least squares mean treatment difference [Δ], 50 mL; p=0.013). Also, numerical improvements were observed with IND/GLY in the TDI focal score (Δ, 0.31), CAT total score (Δ, −0.81), and rescue medication use (Δ, −0.09 puffs/day). Both treatments were well tolerated by patients.

Conclusion

A direct switch from TIO to IND/GLY provided improvements in lung function and other patient-reported outcomes with an acceptable safety profile in patients with mild-to-moderate airflow limitation.

Effects of Particulate Matter 10 Inhalation on Lung Tissue RNA expression in a Murine Model

Background

Particulate matter 10 (PM₁₀; airborne particles <10 μm) inhalation has been demonstrated to induce airway and lung diseases. In this study, we investigate the effects of PM₁₀ inhalation on RNA expression in lung tissues using a murine model.

Methods

Female BALB/c mice were affected with PM₁₀, ovalbumin (OVA), or both OVA and PM₁₀. PM₁₀ was administered intranasally while OVA was both intraperitoneally injected and intranasally administered. Treatments occurred 4 times over a 2-week period. Two days after the final challenges, mice were sacrificed. Full RNA sequencing using lung homogenates was conducted.

Results

While PM₁₀ did not induce cell proliferation in bronchoalveolar fluid or lead to airway hyper-responsiveness, it did cause airway inflammation and lung fibrosis. Levels of interleukin 1β, tumor necrosis factor-α, and transforming growth factor-β in lung homogenates were significantly elevated in the PM₁₀-treated group, compared to the control group. The PM₁₀ group also showed increased RNA expression of Rn45a, Snord22, Atp6v0c-ps2, Snora28, Snord15b, Snora70, and Mmp12. Generally, genes associated with RNA splicing, DNA repair, the inflammatory response, the immune response, cell death, and apoptotic processes were highly expressed in the PM₁₀-treated group. The OVA/PM₁₀ treatment did not produce greater effects than OVA alone. However, the OVA/PM₁₀-treated group did show increased RNA expression of Clca1, Snord22, Retnla, Prg2, Tff2, Atp6v0c-ps2, and Fcgbp when compared to the control groups. These genes are associated with RNA splicing, DNA repair, the inflammatory response, and the immune response.

Conclusion

Inhalation of PM₁₀ extensively altered RNA expression while also inducing cellular inflammation, fibrosis, and increased inflammatory cytokines in this murine mouse model.

FEF25-75% Values in Patients with Normal Lung Function Can Predict the Development of Chronic Obstructive Pulmonary Disease

Purpose

The forced mid-expiratory flow (FEF_25-75%) value is a potentially sensitive marker of obstructive peripheral airflow. We aimed to assess whether FEF_25-75% can be an early predictor of chronic obstructive pulmonary disease (COPD).

Patients and Methods

Between July 1, 2007 and June 31, 2009, we identified 3624 patients who underwent a pulmonary function test (PFT) in Gangnam Severance Hospital. We selected 307 patients aged over 40 years without COPD who had normal PFT results at baseline and who had follow-up PFT records more than 1 year later. A FEF_25-75% z-score less than −0.8435 was considered low. We defined COPD as a forced expiratory volume in one second/forced vital capacity value of less than 0.7 before July 31, 2019.

Results

Among 307 patients, 91 (29.6%) had low FEF_25-75% at baseline. After 10 years, the incidence rate of COPD in the low FEF_25-75% group was significantly higher than that in the normal FEF_25-75% group (41.8% vs 7.4%; P-value<0.001). The Cox proportional hazard model showed that age (hazard ratio [HR] 1.09; P-value<0.001), smoking status (occasional smoker HR, 4.59; P-value<0.001 and long-term smoker HR, 2.18; P-value=0.023), and low FEF_25-75% (HR, 3.31; P-value<0.001) were predictive factors for the development of COPD.

Conclusion

The FEF_25-75% value in patients with normal lung function is a useful predictor for the development of COPD. We should carefully monitor patients who present with low FEF_25-75% values, even if they have normal lung function.

Implications of Managing Chronic Obstructive Pulmonary Disease in Cardiovascular Diseases

Globally, cardiovascular diseases and chronic obstructive pulmonary disease (COPD) are the leading causes of the noncommunicable disease burden. Overlapping symptoms such as breathing difficulty and fatigue, with a lack of awareness about COPD among physicians, are key reasons for under-diagnosis and resulting sub-optimal care relative to COPD. Much has been published in the past on the pathogenesis and implications of cardiovascular comorbidities in COPD. However, a comprehensive review of the prevalence and impact of COPD management in commonly encountered cardiac diseases is lacking. The purpose of this study was to summarize the current knowledge regarding the prevalence of COPD in heart failure, ischemic heart disease, and atrial fibrillation. We also discuss the real-life clinical presentation and practical implications of managing COPD in cardiac diseases. We searched PubMed, Scopus, EMBASE, and Google Scholar for studies published 1981-May 2020 reporting the prevalence of COPD in the three specified cardiac diseases. COPD has high prevalence in heart failure, atrial fibrillation, and ischemic heart disease. Despite this, COPD remains under-diagnosed and under-managed in the majority of patients with cardiac diseases. The clinical implications of the diagnosis of COPD in cardiac disease includes the recognition of hyperinflation (a treatable trait), implementation of acute exacerbations of COPD (AECOPD) prevention strategies, and reducing the risk of overuse of diuretics. The pharmacological agents for the management of COPD have shown a beneficial effect on cardiac functions and mortality. The appropriate management of COPD improves the cardiovascular outcomes by reducing hyperinflation and preventing AECOPD, thus reducing the risk of mortality, improving exercise tolerance, and quality of life.

Comparing Inhaler Use Technique Based on Inhaler Type in Elderly Patients with Respiratory Disease

Background

The aim of this study was to investigate inhaler device handling in elderly patients. Inhaler devices with respect to misuse and error correction were also compared.

Methods

Inhaler use technique was assessed using standardized checklists at the first visit and 3-month follow-up visit after retraining. The primary outcome was difference in the acceptable use ratio among inhaler devices. Secondary outcomes included differences in error correction, the most common step of misuse, and factors affecting the accuracy of inhaler use.

Results

A total of 251 patients (mean age, 76.4 years) were included. The handling of 320 devices was assessed in the study. All patients had been trained before. However, only 24.7% of them used inhalers correctly. Proportions of acceptable use for Evohaler, Respimat, Turbuhaler, Ellipta, and Breezhaler/Handihaler were 38.7%, 50.0%, 61.4%, 60.8%, and 43.2%, respectively (p=0.026). At the second visit, the acceptable use ratio had increased. There were no significant differences among inhaler types (Evohaler, 63.9%; Respimat, 86.1%; Turbuhaler, 74.3%; Ellipta, 64.6%; and Breezhaler/Handihaler, 65.3% [p=0.129]). In multivariate analysis, body mass index, Turbuhaler, and Ellipta showed positive correlations with acceptable use of inhalers, whereas Chronic Obstructive Pulmonary Disease Assessment Test score showed a negative correlation.

Conclusion

Although new inhalers have been developed, the accuracy of inhaler use remains low. Elderly patients showed more errors when using pressurized metered-dose inhalers than using dry powder inhalers and soft-mist inhalers. However, there were no significant differences in misuse among inhaler devices after individual training. Results of this study suggests that repeat training is more important than inhaler type.

Efficacy and safety of Jia Wei Bushen Yiqi formulas as an adjunct therapy to systemic glucocorticoids on acute exacerbation of COPD: study protocol for a randomized, double-blinded, multi-center, placebo-controlled clinical trial

Background

Systemic glucocorticoids are effective for the management of chronic obstructive pulmonary disease (COPD) exacerbation but have serious adverse effects. Traditional Chinese medicine (TCM) can bring additional benefits to these patients but has few adverse effects. The present study aims to evaluate the efficacy and safety of Jia Wei Bushen Yiqi (JWBY) formulas in patients who suffer from COPD exacerbations and to investigate whether the short-term (5-days) systemic glucocorticoid therapy is non-inferior to the long-term (9-day) regime.

Methods

In this multi-center, randomized, double-blinded trial, eligible inpatients with COPD exacerbation are randomly assigned to four groups (A, B, C, and D). Group A will receive placebo plus 5-day prednisone, group B will receive placebo plus 9-day prednisone, group C will receive JWBY formulas plus 5-day prednisone, and group D will receive JWBY formulas plus 9-day prednisone. The primary outcomes are the time interval to the patient’s next exacerbation during a 180-day following up and the COPD assessment test (CAT) during treatment. Secondary outcomes include lung function, TCM syndrome assessment, laboratory tests, and safety. The changes of the hypothalamic pituitary adrenaline axis (HPA axis) and inflammatory cytokine will be measured as well.

Discussion

By demonstrating the advantages of utilizing TCM and an appropriate duration of systemic glucocorticoids, this effectiveness comparison trial will provide new references to physicians on how to improve the management of COPD exacerbation. The results of HPA axis and inflammation cytokine measurements will shed light on the molecular mechanisms and entail further mechanism studies.

Trial registration

www.chictr.org.cn ChiCTR1900023364. Registered on 24 May 2019.

Relationship Between Changes in Inhalation Treatment Level and Exacerbation of Chronic Obstructive Pulmonary Disease: Nationwide the Health Insurance and Assessment Service Database

Background and Objective

Maintaining adequacy in chronic obstructive pulmonary disease (COPD) care is essential to sustain an adequate level of care. We aimed to assess the current status of COPD quality control and the influence of inhaler changes on disease-related health care utilization.

Methods

The Health Insurance Review and Assessment Service (HIRA) nationwide database for reimbursed insurance claims from all medical institutions in South Korea from May 2014 to April 2017 was investigated. COPD care quality was assessed by the performance rate of spirometry, the percentage of persistent visit patients and patients prescribed a bronchodilator. The number of severe exacerbations was evaluated.

Results

A total of 68,942 COPD patients were included for 3 years of longitudinal analyses. The overall spirometry enforcement rate was just over 50%, the percentage of regular follow-up patients was over 85%, and bronchodilators were prescribed to over 80% of the patients. COPD-related hospitalization or ER visit rates were 16.6%, 15.3%, and 17.8% for three consequent assessments, respectively. Inhaler changes were analyzed between the first and second assessments: 57.1% were maintained, 0.4% were changed to another class, 9% were escalated, and 5.2% were de-escalated. Only in the escalated group, especially those who changed from the mono to dual inhaler and dual to triple inhaler, had fewer hospitalizations or ER visits.

Conclusion

Adequacy of COPD care status was not that high considering the low-enforcement rate of spirometry, but most patients were prescribed a bronchodilator and regularly followed up. Those who escalated inhaler treatment experienced less health care utilization.

Frequent Outpatient Visits Prevent Exacerbation of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory airway disease requiring frequent outpatient visits and lifelong management. We aimed to evaluate the roles of frequent outpatient visits in prognosis of COPD. We used claims data in the national medical insurance review system provided by the Health Insurance Review and Assessment Service of Korea from May 1, 2014 to April 30, 2015. A definition of COPD was used based on the diagnosis code and medication. Frequent visitors were defined as subjects who visited the outpatient clinic for COPD three or more times per year. Among 159,025 subjects, 117,483 (73.9%) were classified as frequent visitors. Frequent visitors underwent pulmonary function tests and used various inhalers more often than did infrequent visitors. The rates of COPD exacerbation requiring admission to a general ward, emergency room, or intensive care unit were significantly lower in frequent visitors than in infrequent visitors. In multivariable analysis, frequent visits were identified as an independent factor preventing COPD exacerbation that required admission to a ward (odds ratio [OR], 0.387), emergency room, (OR, 0.558), or intensive care unit (OR, 0.39) (all P < 0.001). In conclusion, we showed frequent outpatient visits reduce the risk of COPD exacerbation by 45-60%.

Hyperuricemia Is Not Predictive of Long-Term Outcome in Patients with Stable Chronic Obstructive Pulmonary Disease

BACKGROUND

Although the association of hyperuricemia with an increased risk of mortality has been demonstrated in the context of acute exacerbation of chronic obstructive pulmonary disease (COPD), the long-term outcomes of hyperuricemia have not been studied in the case of stable COPD.

METHODS

We retrospectively analyzed baseline data of 240 men with stable COPD enrolled in the Korea Obstructive Lung Disease cohort. We evaluated associations between serum uric acid levels and clinical parameters, risk factors for all-cause mortality, and acute exacerbation of COPD.

RESULTS

The mean age of subjects was 66.4 ± 7.7 years, and the median follow-up time was 5.9 years. We identified no significant difference in terms of lung function or laboratory findings between patients with hyperuricemia and those without. Serum uric acid level was negatively associated with systemic inflammation indicated by neutrophil-lymphocyte ratio (r = -0.211, P = 0.001). Univariate Cox regression analysis revealed hyperuricemia to not be associated with an increased risk of all-cause mortality in men with stable COPD (hazard ratio [HR], 0.580; 95% confidence interval [CI], 0.250-1.370; P = 0.213). In the multivariate Cox regression model, hyperuricemia was not an independent predictor of acute exacerbation (HR, 1.383; 95% CI, 0.977-1.959; P = 0.068).

CONCLUSION

Among men with stable COPD, hyperuricemia is not an independent predictor of all-cause mortality or future acute exacerbation of COPD. These results differ from those of previous studies on patients with acute exacerbation of COPD.

Adherence to the GOLD Guideline in COPD Management of South Korea: Findings from KOCOSS Study 2011-2018

The guidelines for chronic obstructive pulmonary disease (COPD) treatment are important for the management of the disease. However, studies regarding the treatment adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been scarce in Korea. Therefore, to examine the adherence to the GOLD guidelines, we examined the patterns of prescribed medication in COPD patients from 2011 to 2018. Patients were classified as having been appropriately and inappropriately treated (overtreatment or undertreatment) for the GOLD group. Appropriate medical therapy was defined as using the first choice or alternative choice drug recommended in the GOLD guidelines. Inappropriate therapy was classified as overtreatment or undertreatment in accordance with the categorization in the GOLD guidelines. According to treatment of 2011 GOLD guidelines, there was inappropriate treatment in 52.3% in group A, 47.3% in group B, 56.3% in group C, and 17.8% in group D. According to treatment of 2017 GOLD guidelines, there was inappropriate treatment in 66.7% in group A, 45.3% in group B, 14.3% in group C, and 24.0% in group D. The common type of inappropriate COPD treatment is overtreatment, with inhaled corticosteroid (ICS) containing regimens. In conclusions, adherence to the GOLD guideline by the pulmonologist in clinical practice is still low in Korea. Therefore, we need better strategies to both optimize the use of the guidelines and adhere to the guidelines as well.

Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain?

Chronic pain is highly prevalent and more common in people with chronic obstructive pulmonary disease (COPD) than people of similar age/sex in the general population. This systematic review aimed to describe how frequently and in which contexts pain is considered in the clinical practice guidelines (CPGs) for the broad management of COPD. Databases (Medline, Scopus, CiNAHL, EMbase, and clinical guideline) and websites were searched to identify current versions of COPD CPGs published in any language since 2006. Data on the frequency, context, and specific recommendations or strategies for the assessment or management of pain were extracted, collated, and reported descriptively. Of the 41 CPGs (English n = 20) reviewed, 16 (39%) did not mention pain. Within the remaining 25 CPGs, pain was mentioned 67 times (ranging from 1 to 10 mentions in a single CPG). The most frequent contexts for mentioning pain were as a potential side effect of specific pharmacotherapies (22 mentions in 13 CPGs), as part of differential diagnosis (14 mentions in 10 CPGs), and end of life or palliative care management (7 mentions in 6 CPGs). In people with COPD, chronic pain is common; adversely impacts quality of life, mood, breathlessness, and participation in activities of daily living; and warrants consideration within CPGs for COPD.

Prescription Status and Clinical Outcomes of Methylxanthines and Leukotriene Receptor Antagonists in Mild-to-Moderate Chronic Obstructive Pulmonary Disease

BACKGROUND

Methylxanthines and leukotriene receptor antagonists (LTRA) are not a first-line medical treatment for chronic obstructive pulmonary disease (COPD) but are frequently prescribed despite limited evidence. We aimed to elucidate the real prescribing status and clinical impacts of these agents in early COPD patients.

METHODS

Patients with mild-to-moderate COPD (FEV₁>50%) were selected from the Korean National Health and Nutrition Examination Survey data between 2007 and 2012. Besides analyzing the prescription status of methylxanthines and LTRA and the contributing factors to the prescription, we evaluated the clinical impacts of these drugs on the exacerbation, hospitalization, and medical costs.

RESULTS

Of 2269 patients with mild-to-moderate COPD, 378 patients (16.7%) were under medical treatments, and the users of methylxanthines and/or LTRA were 279 patients (12.3%); however, only 139 patients (6.1%) were inhaler users. The contributing factors for the prescription of methylxanthines were a comorbidity of asthma or allergic disease, poor lung function, low quality of life, prescribing doctor from the specialty of internal medicine, and an institution type of private hospital. The prescription of LTRA was associated with the comorbidity of allergic disease. The methylxanthine and/or LTRA users had more hospital utilization but did not have significant differences in acute exacerbations and medical cost for hospital utilization, compared with the non-users.

CONCLUSION

Methylxanthines and LTRA were used in a significant proportion of patients with mild-to-moderate COPD in real fields without favorable impacts on the exacerbations, hospitalizations, or medical costs. The use of more effective inhaled medications should be encouraged.