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Mettler SK, Nath HP, Grumley S, Orejas JL, Dolliver WR, Nardelli P, Yen AC, Kligerman SJ, Jacobs K, Manapragada PP, Abozeed M, Aziz MU, Zahid M, Ahmed AN, Terry NL, Elalami R, Estépar RSJ, Sonavane S, Billatos E, Wang W, Estépar RSJ, Richards JB, Cho MH, Diaz AA. Silent Airway Mucus Plugs in COPD and Clinical Implications. Chest 2023:S0012-3692(23)05825-7. [PMID: 38013161 DOI: 10.1016/j.chest.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Airway mucus plugs are frequently identified on CT scans of patients with COPD with a smoking history without mucus-related symptoms (ie, cough, phlegm [silent mucus plugs]). RESEARCH QUESTION In patients with COPD, what are the risk and protective factors associated with silent airway mucus plugs? Are silent mucus plugs associated with functional, structural, and clinical measures of disease? STUDY DESIGN AND METHODS We identified mucus plugs on chest CT scans of participants with COPD from the COPDGene study. The mucus plug score was defined as the number of pulmonary segments with mucus plugs, ranging from 0 to 18, and categorized into three groups (0, 1-2, and ≥ 3). We determined risk and protective factors for silent mucus plugs and the associations of silent mucus plugs with measures of disease severity using multivariable linear and logistic regression models. RESULTS Of 4,363 participants with COPD, 1,739 had no cough or phlegm. Among the 1,739 participants, 627 (36%) had airway mucus plugs identified on CT scan. Risk factors of silent mucus plugs (compared with symptomatic mucus plugs) were older age (OR, 1.02), female sex (OR, 1.40), and Black race (OR, 1.93) (all P values < .01). Among those without cough or phlegm, silent mucus plugs (vs absence of mucus plugs) were associated with worse 6-min walk distance, worse resting arterial oxygen saturation, worse FEV1 % predicted, greater emphysema, thicker airway walls, and higher odds of severe exacerbation in the past year in adjusted models. INTERPRETATION Mucus plugs are common in patients with COPD without mucus-related symptoms. Silent mucus plugs are associated with worse functional, structural, and clinical measures of disease. CT scan-identified mucus plugs can complement the evaluation of patients with COPD.
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Affiliation(s)
- Sofia K Mettler
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Hrudaya P Nath
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Scott Grumley
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - José L Orejas
- Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Wojciech R Dolliver
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Pietro Nardelli
- Harvard Medical School, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Andrew C Yen
- Department of Radiology, University of California San Diego, San Diego, CA
| | | | - Kathleen Jacobs
- Department of Radiology, University of California San Diego, San Diego, CA
| | - Padma P Manapragada
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Mostafa Abozeed
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Muhammad Usman Aziz
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Mohd Zahid
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Asmaa N Ahmed
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Nina L Terry
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Rim Elalami
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ruben San José Estépar
- Harvard Medical School, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | | | - Ehab Billatos
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Wei Wang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, MA
| | - Raúl San José Estépar
- Harvard Medical School, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Jeremy B Richards
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA; Harvard Medical School, Boston, MA
| | - Michael H Cho
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alejandro A Diaz
- Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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Diaz AA, Orejas JL, Grumley S, Nath HP, Wang W, Dolliver WR, Yen A, Kligerman SJ, Jacobs K, Manapragada PP, Abozeed M, Aziz MU, Zahid M, Ahmed AN, Terry NL, San José Estépar R, Kim V, Make BJ, Han MK, Sonavane S, Washko GR, Cho M, San José Estépar R. Airway-Occluding Mucus Plugs and Mortality in Patients With Chronic Obstructive Pulmonary Disease. JAMA 2023; 329:1832-1839. [PMID: 37210745 PMCID: PMC10201404 DOI: 10.1001/jama.2023.2065] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/07/2023] [Indexed: 05/23/2023]
Abstract
Importance Airway mucus plugs are common in patients with chronic obstructive pulmonary disease (COPD); however, the association of airway mucus plugging and mortality in patients with COPD is unknown. Objective To determine whether airway mucus plugs identified on chest computed tomography (CT) were associated with increased all-cause mortality. Design, Setting, and Participants Observational retrospective analysis of prospectively collected data of patients with a diagnosis of COPD in the Genetic Epidemiology of COPD cohort. Participants were non-Hispanic Black or White individuals, aged 45 to 80 years, who smoked at least 10 pack-years. Participants were enrolled at 21 centers across the US between November 2007 and April 2011 and were followed up through August 31, 2022. Exposures Mucus plugs that completely occluded airways on chest CT scans, identified in medium- to large-sized airways (ie, approximately 2- to 10-mm lumen diameter) and categorized as affecting 0, 1 to 2, or 3 or more lung segments. Main Outcomes and Measures The primary outcome was all-cause mortality, assessed with proportional hazard regression analysis. Models were adjusted for age, sex, race and ethnicity, body mass index, pack-years smoked, current smoking status, forced expiratory volume in the first second of expiration, and CT measures of emphysema and airway disease. Results Among the 4483 participants with COPD, 4363 were included in the primary analysis (median age, 63 years [IQR, 57-70 years]; 44% were women). A total of 2585 (59.3%), 953 (21.8%), and 825 (18.9%) participants had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. During a median 9.5-year follow-up, 1769 participants (40.6%) died. The mortality rates were 34.0% (95% CI, 32.2%-35.8%), 46.7% (95% CI, 43.5%-49.9%), and 54.1% (95% CI, 50.7%-57.4%) in participants who had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. The presence of mucus plugs in 1 to 2 vs 0 and 3 or more vs 0 lung segments was associated with an adjusted hazard ratio of death of 1.15 (95% CI, 1.02-1.29) and 1.24 (95% CI, 1.10-1.41), respectively. Conclusions and Relevance In participants with COPD, the presence of mucus plugs that obstructed medium- to large-sized airways was associated with higher all-cause mortality compared with patients without mucus plugging on chest CT scans.
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Affiliation(s)
- Alejandro A. Diaz
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - José L. Orejas
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Scott Grumley
- Department of Radiology, University of Alabama at Birmingham
| | - Hrudaya P. Nath
- Department of Radiology, University of Alabama at Birmingham
| | - Wei Wang
- Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Wojciech R. Dolliver
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew Yen
- Department of Radiology, University of California, San Diego
| | - Seth J. Kligerman
- Department of Radiology, University of California, San Diego
- now with Department of Radiology, National Jewish Health, Denver, Colorado
| | - Kathleen Jacobs
- Department of Radiology, University of California, San Diego
| | | | - Mostafa Abozeed
- Department of Radiology, University of Alabama at Birmingham
| | | | - Mohd Zahid
- Department of Radiology, University of Alabama at Birmingham
| | - Asmaa N. Ahmed
- Department of Radiology, University of Alabama at Birmingham
| | - Nina L. Terry
- Department of Radiology, University of Alabama at Birmingham
| | - Ruben San José Estépar
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Victor Kim
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Barry J. Make
- Division of Pulmonary, Critical Care and Sleep Medicine at National Jewish Health, Denver, Colorado
| | - MeiLan K. Han
- Division of Pulmonary and Critical Care at the University of Michigan, Ann Arbor
| | | | - George R. Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael Cho
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Raúl San José Estépar
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
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