Prognostic Factors of Mortality in Nonchronic Obstructive Pulmonary Disease Chronic Lung Disease: A Scoping Review

Introduction: Patients with chronic lung disease (CLD) experience a heavy symptom burden at the end of life, but their uptake of palliative care is notably low. Having an understanding of a patient's prognosis would facilitate shared decision making on treatment options and care planning between patients, families, and their clinicians, and complement clinicians' assessments of patients' unmet palliative needs. While literature on prognostication in patients with chronic obstructive pulmonary disease (COPD) has been established and summarized, information for other CLDs remains less consolidated. Summarizing the mortality risk factors for non-COPD CLDs would be a novel contribution to literature. Hence, we aimed to identify and summarize the prognostic factors associated with non-COPD CLDs from the literature. Methods: We conducted a scoping review following published guidelines. We searched MEDLINE, Embase, PubMed, CINAHL, Cochrane Library, and Web of Science for studies published between 2000 and 2020 that described non-COPD CLD populations with an all-cause mortality risk period of up to three years. Only primary studies which reported associations with mortality adjusted through multivariable analysis were included. Results: Fifty-five studies were reviewed, with 53 based on interstitial lung disease (ILD) or connective tissue disease-associated ILD populations and two in bronchiectasis populations. Prognostic factors were classified into 10 domains, with pulmonary function and disease being the largest. Older age, lower forced vital capacity, and lower carbon monoxide diffusing capacity were most commonly investigated and associated with statistically significant increases in mortality risks. Conclusions: This comprehensive overview of prognostic factors for patients with non-COPD CLDs would facilitate the identification and prioritization of candidate factors to predict short-term mortality, supporting tool development for decision making and to identify high-risk patients for palliative needs assessments. Literature focused on patients with ILDs, and more studies should be conducted on other CLDs to bridge the knowledge gap.

Risk factors of in-hospital mortality and discriminating capacity of NIVO score in exacerbations of COPD requiring noninvasive ventilation

BACKGROUND

Noninvasive mechanical ventilation (NIV) is recommended as the initial mode of ventilation to treat acute respiratory failure in patients with AECOPD. The Noninvasive Ventilation Outcomes (NIVO) score has been proposed to evaluate the prognosis in patients with AECOPD requiring assisted NIV. However, it is not validated in Chinese patients.

METHODS

We used data from the MAGNET AECOPD Registry study, which is a prospective, noninterventional, multicenter, real-world study conducted between September 2017 and July 2021 in China. Data for the potential risk factors of mortality were collected and the NIVO score was calculated, and the in-hospital mortality was evaluated using the NIVO risk score.

RESULTS

A total of 1164 patients were included in the study, and 57 patients (4.9%) died during their hospital stay. Multiple logistic regression analysis revealed that age ≥75 years, DBP <60 mmHg, Glasgow Coma Scale ≤14, anemia and BUN >7 mmol/L were independent predictors of in-hospital mortality. The in-hospital mortality was associated with an increase in the risk level of NIVO score and the difference was statistically significant (p < .001). The NIVO risk score showed an acceptable accuracy for predicting the in-hospital mortality in AECOPD requiring assisted NIV (AUC: 0.657, 95% CI: 0.584-0.729, p < .001).

CONCLUSION

Our findings identified predictors of mortality in patients with AECOPD receiving NIV, providing useful information to identify severe patients and guide the management of AECOPD. The NIVO score showed an acceptable predictive value for AECOPD receiving NIV in Chinese patients, and additional studies are needed to develop and validate predictive scores based on specific populations.

Mortality in non-exacerbating COPD: a longitudinal analysis of UK primary care data

INTRODUCTION

Non-exacerbating patients with chronic obstructive pulmonary disease (COPD) are a less studied phenotype. We investigated clinical characteristics, mortality rates and causes of death among non-exacerbating compared with exacerbating patients with COPD.

METHODS

We used data from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics between 1 January 2004 and 31 December 2018. Ever smokers with a COPD diagnosis with minimum 3 years of baseline information were included. We compared overall using Cox regression and cause-specific mortality rates using competing risk analysis, adjusted for age, sex, deprivation, smoking status, body mass index, GOLD stage and comorbidities. Causes of death were identified using International Classification of Diseases-10 codes.

RESULTS

Among 67 516 patients, 17.3% did not exacerbate during the 3-year baseline period. Mean follow-up was 4 years. Non-exacerbators were more likely to be male (63.3% vs 52.4%, p<0.001) and less often had a history of asthma (33.9% vs 43.6%, p<0.001) or FEV1<50% predicted (23.7 vs 31.8%) compared with exacerbators. Adjusted HR for overall mortality in non-exacerbators compared with exacerbators was 0.62 (95% CI 0.56 to 0.70) in the first year of follow-up and 0.87 (95% CI 0.83 to 0.91) thereafter. Non-exacerbating patients with COPD died less of respiratory causes than exacerbators (29.2% vs 40.3%) and more of malignancies (29.4% vs 23.4%) and cardiovascular diseases (26.2% vs 22.9%). HRs for malignant and circulatory causes of death were increased after the first year of follow-up.

DISCUSSION

In this primary care cohort, non-exacerbators showed distinct clinical characteristics and lower mortality rates. Non-exacerbators were equally likely to die of respiratory, malignant or cardiovascular diseases.

Long-term effects of air pollution on hospital admissions and mortality for chronic obstructive pulmonary disease in Beijing, China

OBJECTIVE

We aimed to clarify the association between air pollution and hospital admissions for chronic obstructive pulmonary disease (COPD) and mortality in Beijing, China.

METHODS

In this retrospective study, we recruited 510 COPD patients from 1 January 2006 to 31 December 2009. The patient data were obtained from the electronic medical records of Peking University Third Hospital in Beijing. Air pollution and meteorological data were obtained from the Institute of Atmospheric Physics of the Chinese Academy of Sciences. Monthly COPD hospital admissions, mortality and air pollution data were analysed using Poisson regression in generalised additive models adjusted for mean temperature, pressure and relative humidity.

RESULTS

There were positive correlations between sulfur dioxide (SO2 ), particulate matter with an aerodynamic diameter ≤ 10 μm (PM10 ) and COPD hospital admissions in the single-pollutant model. An increase of 10 μg/m3 in SO2 and PM10 were associated with an increase of 4.053% (95% CI: 1.470-5.179%) and 1.401% (95%CI: 0.6656-1.850%) in COPD hospital admissions. In the multiple-pollutant model [SO2 and nitrogen dioxide (NO2 ) combinations], there was only a positive correlation between SO2 and COPD hospital admissions. An increase of 10 μg/m3 in SO2 were associated with an increase of 1.916% (95% CI: 1.118-4.286%) in COPD hospital admissions. There was no correlation between three pollutant combinations and COPD hospital admissions. We did not find correlations between air pollution and COPD mortality in either single- or multiple-pollutant models.

CONCLUSIONS

SO2 and PM10 may be important factors for the increase in COPD hospital admissions in Beijing, China.

COPD Mortality, Goals-of-Care Conversations in Serious Illness, and Advocating for Climate Change Science and Gun Violence Prevention-Highlights From the American Thoracic Society Conference

This Medical News article is an interview with Debra Boyer, MD, MHPE, chair of the 2023 American Thoracic Society Conference.

Airway-Occluding Mucus Plugs and Mortality in Patients With Chronic Obstructive Pulmonary Disease

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.

Low diastolic blood pressure and adverse outcomes in inpatients with acute exacerbation of chronic obstructive pulmonary disease: A multicenter cohort study

BACKGROUND

Although intensively studied in patients with cardiovascular diseases (CVDs), the prognostic value of diastolic blood pressure (DBP) has little been elucidated in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This study aimed to reveal the prognostic value of DBP in AECOPD patients.

METHODS

Inpatients with AECOPD were prospectively enrolled from 10 medical centers in China between September 2017 and July 2021. DBP was measured on admission. The primary outcome was all-cause in-hospital mortality; invasive mechanical ventilation and intensive care unit (ICU) admission were secondary outcomes. Least absolute shrinkage and selection operator (LASSO) and multivariable Cox regressions were used to identify independent prognostic factors and calculate the hazard ratio (HR) and 95% confidence interval (CI) for adverse outcomes.

RESULTS

Among 13,633 included patients with AECOPD, 197 (1.45%) died during their hospital stay. Multivariable Cox regression analysis showed that low DBP on admission (<70 mmHg) was associated with increased risk of in-hospital mortality (HR = 2.16, 95% CI: 1.53-3.05, Z = 4.37, P <0.01), invasive mechanical ventilation (HR = 1.65, 95% CI: 1.32-2.05, Z = 19.67, P <0.01), and ICU admission (HR = 1.45, 95% CI: 1.24-1.69, Z = 22.08, P <0.01) in the overall cohort. Similar findings were observed in subgroups with or without CVDs, except for invasive mechanical ventilation in the subgroup with CVDs. When DBP was further categorized in 5-mmHg increments from <50 mmHg to ≥100 mmHg, and 75 to <80 mmHg was taken as reference, HRs for in-hospital mortality increased almost linearly with decreased DBP in the overall cohort and subgroups of patients with CVDs; higher DBP was not associated with the risk of in-hospital mortality.

CONCLUSION

Low on-admission DBP, particularly <70 mmHg, was associated with an increased risk of adverse outcomes among inpatients with AECOPD, with or without CVDs, which may serve as a convenient predictor of poor prognosis in these patients.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trail Registry, No. ChiCTR2100044625.

Chronic obstructive pulmonary disease mortality trends in Spain, 1980-2020

OBJECTIVES

In Spain, there has been a recent increase in the mortality rate for chronic obstructive pulmonary disease (COPD) in younger women. This study aimed to analyze trends in the COPD mortality rate in Spain from 1980 to 2020, evaluating any differences between genders and age groups.

METHODS

Death certificates and mid-year population data were obtained from the Spanish National Institute of Statistics. For both genders, age group-specific and standardized (overall and truncated) rates were calculated by the direct method using the world standard population. The data were analyzed using the joinpoint regression method.

RESULTS

In both men and women, the number of COPD deaths increased from 1980 to 1999 (average annual increase of 7% in men and 4% in women), while from 1999 onwards, deaths decreased by -1.0% per year in both genders. In women, there was a significant final period of increase in the 55-59 to 70-74 age groups and a slowing of the decline in the over 75 age group. Additionally, an increase in mortality for the truncated rates was observed for women between 2006 and 2020. In men under 70 years of age, there was an initial period in which death rates remained stable or significantly increased, followed by a period in which they decreased significantly.

CONCLUSIONS

Our study shows age and gender differences in COPD mortality trends in Spain. Although the data show a downward trend, we have identified a worrying increase in the truncated rates in women for the last few years.

Clinical impact of pulmonary hypertension on the outcomes of acute myocardial infarction patients with or without chronic obstructive pulmonary disease

Acute myocardial infarction (AMI) and chronic obstructive pulmonary disease (COPD) are leading global causes of morbidity and mortality. In patients with both of these conditions, the presence of pulmonary hypertension (PH) can further worsen their prognosis. We examined the outcomes of AMI patients with COPD (AMI+COPD) and without COPD (AMI-COPD), depending on the presence or absence of PH.A total of 318 AMI patients with COPD (AMI+COPD cohort) (n = 109) or without COPD (AMI-COPD cohort) (n = 209) were included in this study and were subdivided into 2 groups according to right ventricular systolic pressure (RVSP) level (PH group [RVSP ≥35 mm Hg] and no PH group [RVSP <35 mm Hg]).We investigated characteristics and clinical outcomes in both the AMI-COPD and AMI+COPD cohorts. When investigating in-hospital clinical outcomes, the PH group had a higher proportion of new-onset heart failure (HF) in both cohorts. In the AMI+COPD cohort, however, the PH group had a higher incidence of cardiogenic shock than the no PH group, which was consistent with the result of the post-inverse probability of treatment weighting (IPTW) analysis. When investigating 1-year clinical outcomes, the PH group had higher incidences of a major adverse cardiac event and all-cause mortality in both cohorts. This finding was mainly driven by cardiac death in the AMI-COPD cohort, whereas it was mainly driven by non-cardiac death in the AMI+COPD cohort. After IPTW adjustment, these differences were statistically attenuated such that all variables were similar between both groups.PH may be associated with the development of new-onset HF (in all patients) and cardiogenic shock (in the AMI+COPD cohort). In addition, PH may be also associated with all-cause mortality, although it was statistically attenuated after IPTW adjustment.

Cardiac biomarkers retain prognostic significance in patients with heart failure and chronic obstructive pulmonary disease

AIMS

Chronic obstructive pulmonary disease (COPD) is a frequent comorbidity in patients with heart failure (HF). We assessed the influence of COPD on circulating levels and prognostic value of three HF biomarkers: N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and soluble suppression of tumorigenesis-2 (sST2).

METHODS

Individual data from patients with chronic HF, known COPD status, NT-proBNP and hs-TnT values (n = 8088) were analysed. A subgroup (n = 3414) had also sST2 values.

RESULTS

Patients had a median age of 66 years (interquartile interval 57-74), 77% were men and 82% had HF with reduced ejection fraction. NT-proBNP, hs-TnT and sST2 were 1207 ng/l (487-2725), 17 ng/l (9-31) and 30 ng/ml (22-44), respectively. Patients with COPD (n = 1249, 15%) had higher NT-proBNP (P = 0.042) and hs-TnT (P < 0.001), but not sST2 (P = 0.165). Over a median 2.0-year follow-up (1.5-2.5), 1717 patients (21%) died, and 1298 (16%) died from cardiovascular causes; 2255 patients (28%) were hospitalized for HF over 1.8 years (0.9-2.1). NT-proBNP, hs-TnT and sST2 predicted the three end points regardless of COPD status. The best cut-offs from receiver-operating characteristics analysis were higher in patients with COPD than in those without. Patients with all three biomarkers higher than or equal to end-point- and COPD-status-specific cut-offs were also those with the worst prognosis.

CONCLUSIONS

Among patients with HF, those with COPD have higher NT-proBNP and hs-TnT, but not sST2. All these biomarkers yield prognostic significance regardless of the COPD status.

Variability of blood eosinophil count and prognosis of COPD exacerbations

BACKGROUND

Eosinophils in peripheral blood are one of the emerging biomarkers in chronic obstructive pulmonary disease (COPD) patients. However, when analysing the relationship between peripheral eosinophilia and COPD prognosis, highly variable results are obtained. The aim of our study is to describe the serum eosinophilia levels in COPD patients and to analyse their relationship to prognosis following hospital admission.

METHODS

A prospective observational study was conducted from 1 October 2016 to 1 October 2018 in the following Spanish centres: Salnés County Hospital in Vilagarcía de Arousa, Arquitecto Marcide Hospital in Ferrol and the University Hospital Complex in Santiago de Compostela. The patients were classified using three cut-off points of blood eosinophil count (BEC): 150 cells/µL, 300 cells/µL, and 400 cells/µL; in addition, the peripheral BEC was analysed on admission.

RESULTS

615 patients were included in the study, 86.2% male, mean age 73.9 years, and mean FEV1 52.7%. The mean stay was 8.4 days, and 6% of all patients were readmitted early. No significant relationship was observed between the BEC, neither in the stable phase nor in the acute phase, and hospital stay, readmissions, deaths during admission, the need for intensive care, or the condition of frequent exacerbator.

CONCLUSION

The results of our study do not seem to support the usefulness of BEC as a COPD biomarker.KEY MESSAGESThere is evidence that BEC participates in pathophysiological mechanisms of the COPD.BEC may be useful as a biomarker in COPD for aspects such as the optimization of treatments.We did not find any relationship between BEC levels and prognosis following hospital admission for AECOPD.

Racial Segregation and Respiratory Outcomes among Urban Black Residents with and at Risk of Chronic Obstructive Pulmonary Disease

Rationale: Racial residential segregation has been associated with worse health outcomes, but the link with chronic obstructive pulmonary disease (COPD) morbidity has not been established.Objectives: To investigate whether racial residential segregation is associated with COPD morbidity among urban Black adults with or at risk of COPD.Methods: Racial residential segregation was assessed using isolation index, based on 2010 decennial census and baseline address, for Black former and current smokers in the multicenter SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study), a study of adults with or at risk for COPD. We tested the association between isolation index and respiratory symptoms, physiologic outcomes, imaging parameters, and exacerbation risk among urban Black residents, adjusting for established COPD risk factors, including smoking. Additional mediation analyses were conducted for factors that could lie on the pathway between segregation and COPD outcomes, including individual and neighborhood socioeconomic status, comorbidity burden, depression/anxiety, and ambient pollution.Measurements and Main Results: Among 515 Black participants, those residing in segregated neighborhoods (i.e., isolation index ⩾0.6) had worse COPD Assessment Test score (β = 2.4; 95% confidence interval [CI], 0.7 to 4.0), dyspnea (modified Medical Research Council scale; β = 0.29; 95% CI, 0.10 to 0.47), quality of life (St. George's Respiratory Questionnaire; β = 6.1; 95% CI, 2.3 to 9.9), and cough and sputum (β = 0.8; 95% CI, 0.1 to 1.5); lower FEV1% predicted (β = -7.3; 95% CI, -10.9 to -3.6); higher rate of any and severe exacerbations; and higher percentage emphysema (β = 2.3; 95% CI, 0.7 to 3.9) and air trapping (β = 3.8; 95% CI, 0.6 to 7.1). Adverse associations attenuated with adjustment for potential mediators but remained robust for several outcomes, including dyspnea, FEV1% predicted, percentage emphysema, and air trapping.Conclusions: Racial residential segregation was adversely associated with COPD morbidity among urban Black participants and supports the hypothesis that racial segregation plays a role in explaining health inequities affecting Black communities.

The MAGENTA model for individual prediction of in-hospital mortality in chronic obstructive pulmonary disease with acute exacerbation in resource-limited countries: A development study

BACKGROUND

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common undesirable event associated with significant morbidity and mortality. Several clinical prediction tools for predicting in-hospital mortality in patients with AECOPD have been developed in the past decades. However, some issues concerning the validity and availability of some predictors in the existing models may undermine their clinical applicability in resource-limited clinical settings.

METHODS

We developed a multivariable model for predicting in-hospitality from a retrospective cohort of patients admitted with AECOPD to one tertiary care center in Thailand from October 2015 to September 2017. Multivariable logistic regression with fractional polynomial algorithms and cluster variance correction was used for model derivation.

RESULTS

During the study period, 923 admissions from 600 patients with AECOPD were included. The in-hospital mortality rate was 1.68 per 100 admission-day. Eleven potential predictors from the univariable analysis were included in the multivariable logistic regression. The reduced model, named MAGENTA, incorporated seven final predictors: age, body temperature, mean arterial pressure, the requirement of endotracheal intubation, serum sodium, blood urea nitrogen, and serum albumin. The model discriminative ability based on the area under the receiver operating characteristic curve (AuROC) was excellent at 0.82 (95% confidence interval 0.77, 0.86), and the calibration was good.

CONCLUSION

The MAGENTA model consists of seven routinely available clinical predictors upon patient admissions. The model can be used as an assisting tool to aid clinicians in accurate risk stratification and making appropriate decisions to admit patients for intensive care.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

OBJECTIVES

To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

SEARCH METHODS

We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

MAIN RESULTS

Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

AUTHORS' CONCLUSIONS

Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

The short-term associations of particular matters on non-accidental mortality and causes of death in Chiang Mai, Thailand: a time series analysis study between 2016-2018

Open burnings, agricultural and forest fires, are the major sources of particulate matters (PM) in Chiang Mai during dry season. We aim to determine the association of an increased daily PM (PM₁₀, PM_2.5) and daily non-accidental mortality and causes of death in Chiang Mai. The association between PM and daily non-accidental mortality including causes of death were analyzed using a generalized linear model with Poisson distribution. The results showed that PM₁₀ and PM_2.5 were associated with daily non-accidental mortality on different lag days (adjusted RR range from 1.009-1.018 and 1.016 for each 10 µg/m³ increment of PM₁₀ and PM_2.5, respectively). The causes of death associated with PM₁₀, PM_2.5 found on different lag days were chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and sepsis. We concluded that PM₁₀ and PM_2.5 are associated with daily non-accidental mortality and causes of death were COPD, CAD, and sepsis.

Risk of adverse outcomes in patients with underlying respiratory conditions admitted to hospital with COVID-19: a national, multicentre prospective cohort study using the ISARIC WHO Clinical Characterisation Protocol UK

BACKGROUND

Studies of patients admitted to hospital with COVID-19 have found varying mortality outcomes associated with underlying respiratory conditions and inhaled corticosteroid use. Using data from a national, multicentre, prospective cohort, we aimed to characterise people with COVID-19 admitted to hospital with underlying respiratory disease, assess the level of care received, measure in-hospital mortality, and examine the effect of inhaled corticosteroid use.

METHODS

We analysed data from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study. All patients admitted to hospital with COVID-19 across England, Scotland, and Wales between Jan 17 and Aug 3, 2020, were eligible for inclusion in this analysis. Patients with asthma, chronic pulmonary disease, or both, were identified and stratified by age (<16 years, 16-49 years, and ≥50 years). In-hospital mortality was measured by use of multilevel Cox proportional hazards, adjusting for demographics, comorbidities, and medications (inhaled corticosteroids, short-acting β-agonists [SABAs], and long-acting β-agonists [LABAs]). Patients with asthma who were taking an inhaled corticosteroid plus LABA plus another maintenance asthma medication were considered to have severe asthma.

FINDINGS

75 463 patients from 258 participating health-care facilities were included in this analysis: 860 patients younger than 16 years (74 [8·6%] with asthma), 8950 patients aged 16-49 years (1867 [20·9%] with asthma), and 65 653 patients aged 50 years and older (5918 [9·0%] with asthma, 10 266 [15·6%] with chronic pulmonary disease, and 2071 [3·2%] with both asthma and chronic pulmonary disease). Patients with asthma were significantly more likely than those without asthma to receive critical care (patients aged 16-49 years: adjusted odds ratio [OR] 1·20 [95% CI 1·05-1·37]; p=0·0080; patients aged ≥50 years: adjusted OR 1·17 [1·08-1·27]; p<0·0001), and patients aged 50 years and older with chronic pulmonary disease (with or without asthma) were significantly less likely than those without a respiratory condition to receive critical care (adjusted OR 0·66 [0·60-0·72] for those without asthma and 0·74 [0·62-0·87] for those with asthma; p<0·0001 for both). In patients aged 16-49 years, only those with severe asthma had a significant increase in mortality compared to those with no asthma (adjusted hazard ratio [HR] 1·17 [95% CI 0·73-1·86] for those on no asthma therapy, 0·99 [0·61-1·58] for those on SABAs only, 0·94 [0·62-1·43] for those on inhaled corticosteroids only, 1·02 [0·67-1·54] for those on inhaled corticosteroids plus LABAs, and 1·96 [1·25-3·08] for those with severe asthma). Among patients aged 50 years and older, those with chronic pulmonary disease had a significantly increased mortality risk, regardless of inhaled corticosteroid use, compared to patients without an underlying respiratory condition (adjusted HR 1·16 [95% CI 1·12-1·22] for those not on inhaled corticosteroids, and 1·10 [1·04-1·16] for those on inhaled corticosteroids; p<0·0001). Patients aged 50 years and older with severe asthma also had an increased mortality risk compared to those not on asthma therapy (adjusted HR 1·24 [95% CI 1·04-1·49]). In patients aged 50 years and older, inhaled corticosteroid use within 2 weeks of hospital admission was associated with decreased mortality in those with asthma, compared to those without an underlying respiratory condition (adjusted HR 0·86 [95% CI 0·80-0·92]).

INTERPRETATION

Underlying respiratory conditions are common in patients admitted to hospital with COVID-19. Regardless of the severity of symptoms at admission and comorbidities, patients with asthma were more likely, and those with chronic pulmonary disease less likely, to receive critical care than patients without an underlying respiratory condition. In patients aged 16 years and older, severe asthma was associated with increased mortality compared to non-severe asthma. In patients aged 50 years and older, inhaled corticosteroid use in those with asthma was associated with lower mortality than in patients without an underlying respiratory condition; patients with chronic pulmonary disease had significantly increased mortality compared to those with no underlying respiratory condition, regardless of inhaled corticosteroid use. Our results suggest that the use of inhaled corticosteroids, within 2 weeks of admission, improves survival for patients aged 50 years and older with asthma, but not for those with chronic pulmonary disease.

FUNDING

National Institute for Health Research, Medical Research Council, NIHR Health Protection Research Units in Emerging and Zoonotic Infections at the University of Liverpool and in Respiratory Infections at Imperial College London in partnership with Public Health England.

Large underreporting of COPD as cause of death-results from a population-based cohort study

BACKGROUND

In 2019, WHO estimated COPD to be the third leading cause of death in the world. However, COPD is probably underestimated as cause of death due to the well-known under-diagnosis.

AIM

To evaluate the proportion of and factors associated with COPD recorded as cause of death in a long-term follow-up of a population-based COPD cohort.

METHODS

The study population includes all individuals (n = 551) with COPD defined as chronic airway obstruction (post-bronchodilator FEV₁/FVC<0.70) + respiratory symptoms identified after re-examinations of four population-based cohorts. Mortality and underlying or contributing cause of death following ICD-10 classification were collected from the Swedish National Board of Health and Welfares register from date of examination in 2002-04 until 2016.

RESULTS

The study sample consisted of 32.3% GOLD 1, 55.9% GOLD 2, and 11.8% GOLD 3-4. The mean follow-up time was 10.3 (SD3.77) years and the cumulative mortality 45.0%. COPD (ICD-10 J43-J44) was recorded on 28.2% (n = 70) of the death certificates (11.1%, 25.7% and 57.1% by GOLD stage), whereof n = 35 had COPD recorded as underlying and n = 35 as contributing cause of death. To have COPD recorded as cause of death was independently associated with ex- and current smoking and a self-reported physician diagnosis of COPD, while male sex, overweight/obesity and higher FEV₁% of predicted associated with the absence.

CONCLUSIONS

COPD was largely underreported cause of death. Even among those with severe/very severe disease, COPD was only mentioned on 57.1% of the death certificates.

Impact of COVID-19 lockdown on the incidence and mortality of acute exacerbations of chronic obstructive pulmonary disease: national interrupted time series analyses for Scotland and Wales

BACKGROUND

The COVID-19 pandemic and ensuing national lockdowns have dramatically changed the healthcare landscape. The pandemic's impact on people with chronic obstructive pulmonary disease (COPD) remains poorly understood. We hypothesised that the UK-wide lockdown restrictions were associated with reductions in severe COPD exacerbations. We provide the first national level analyses of the impact of the COVID-19 pandemic and first lockdown on severe COPD exacerbations resulting in emergency hospital admissions and/or leading to death as well as those recorded in primary care or emergency departments.

METHODS

Using data from Public Health Scotland and the Secure Anonymised Information Linkage Databank in Wales, we accessed weekly counts of emergency hospital admissions and deaths due to COPD over the first 30 weeks of 2020 and compared these to the national averages over the preceding 5 years. For both Scotland and Wales, we undertook interrupted time-series analyses to model the impact of instigating lockdown on these outcomes. Using fixed-effect meta-analysis, we derived pooled estimates of the overall changes in trends across the two nations.

RESULTS

Lockdown was associated with 48% pooled reduction in emergency admissions for COPD in both countries (incidence rate ratio, IRR 0.52, 95% CI 0.46 to 0.58), relative to the 5-year averages. There was no statistically significant change in deaths due to COPD (pooled IRR 1.08, 95% CI 0.87 to 1.33). In Wales, lockdown was associated with 39% reduction in primary care consultations for acute exacerbation of COPD (IRR 0.61, 95% CI 0.52 to 0.71) and 46% reduction in COPD-related emergency department attendances (IRR 0.54, 95% CI 0.36 to 0.81).

CONCLUSIONS

The UK-wide lockdown was associated with the most substantial reductions in COPD exacerbations ever seen across Scotland and Wales, with no corresponding increase in COPD deaths. This may have resulted from reduced transmission of respiratory infections, reduced exposure to outdoor air pollution and/or improved COPD self-management.

Strategies to prevent hospital readmission and death in patients with chronic heart failure, chronic obstructive pulmonary disease, and chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

Readmission following hospital discharge is common and is a major financial burden on healthcare systems.

OBJECTIVES

Our objectives were to 1) identify studies describing post-discharge interventions and their efficacy with respect to reducing risk of mortality and rate of hospital readmission; and 2) identify intervention characteristics associated with efficacy.

METHODS

A systematic review of the literature was performed. We searched MEDLINE, PubMed, Cochrane, EMBASE and CINAHL. Our selection criteria included randomized controlled trials comparing post-discharge interventions with usual care on rates of hospital readmission and mortality in high-risk chronic disease patient populations. We used random effects meta-analyses to estimate pooled risk ratios for all-cause and cause-specific mortality as well as all-cause and cause-specific hospitalization.

RESULTS

We included 31 randomized controlled trials encompassing 9654 patients (24 studies in CHF, 4 in COPD, 1 in both CHF and COPD, 1 in CKD and 1 in an undifferentiated population). Meta-analysis showed post-discharge interventions reduced cause-specific (RR = 0.71, 95% CI = 0.63-0.80) and all cause (RR = 0.90, 95% CI = 0.81-0.99) hospitalization, all-cause (RR = 0.73, 95% CI = 0.65-0.83) and cause-specific mortality (RR = 0.68, 95% CI = 0.54-0.84) in CHF studies, and all-cause hospitalization (RR = 0.52, 95% CI = 0.32-0.83) in COPD studies. The inclusion of a cardiac nurse in the multidisciplinary team was associated with greater efficacy in reducing all-cause mortality among patients discharged after heart failure admission (HR = 0.64, 95% CI = 0.54-0.75 vs. HR = 0.87, 95% CI = 0.73-1.03).

CONCLUSIONS

Post-discharge interventions reduced all-cause mortality, cause-specific mortality, and cause-specific hospitalization in CHF patients and all-cause hospitalization in COPD patients. The presence of a cardiac nurse was associated with greater efficacy in included studies. Additional research is needed on the impact of post-discharge intervention strategies in COPD and CKD patients.

Clinical Presentation of Iranian Patients Affected with COVID-19: A Thousand Faces Disease

The coronavirus disease 2019 (COVID-19) pandemic in Iran is part of the worldwide pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The present study aimed to demonstrate the clinical characteristics of patients affected by COVID-19, in our tertiary teaching hospital. Medical records and compiled data of 668 patients with suspected COVID-19 were obtained retrospectively between January to April 2020. The present study outcomes included demographic features of infected patients, underlying diseases and conditions, the relationship between the results of reverse transcription-polymerase chain reaction (RT-PCR) or CT-scan with the manifestations of the disease, mortality rate, and age distribution of fatalities among men and women. The median age of hospitalized patients was 63 years old (from 18 to 94). The patients' chief complaints in the admission time were cough, dyspnea, fever, and gastrointestinal problems, respectively. Hospitalized patients' common comorbidities were hypertension (HTN), and cardiovascular disease (CVD) (24%), diabetes mellitus (DM) (21.5%), asthma, or chronic obstructive pulmonary disease (COPD) (6%), or other underlying diseases (15.5%). One-third of patients had no comorbidity according to the data of medical records. In hospitalized patients, 169 (84.5%) had positive RT-PCR, and 156 (78%) had positive chest CT findings. The mortality rate of males was higher than females (66.3% vs. 33.3%) and in patients with positive RT-PCR compared to patients with positive chest CT-scan findings. The majority of deaths had a history of DM or HTN/CVD in their medical records. The chief complaint of patients was cough. DM and HTN or CVD were the common underlying disease related to death in hospitalized cases. Besides, the hospitalization and mortality rate in males was higher than in females. About 87% of dead hospitalized cases had positive RT-PCR results, and this rate was 82% for chest CT results.

Impact of chronic obstructive pulmonary disease on 10-year mortality after percutaneous coronary intervention and bypass surgery for complex coronary artery disease: insights from the SYNTAX Extended Survival study

Aims

To evaluate the impact of chronic obstructive pulmonary disease (COPD) on 10-year all-cause death and the treatment effect of CABG versus PCI on 10-year all-cause death in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) and COPD.

Methods

Patients were stratified according to COPD status and compared with regard to clinical outcomes. Ten-year all-cause death was examined according to the presence of COPD and the revascularization strategy.

Results

COPD status was available for all randomized 1800 patients, of whom, 154 had COPD (8.6%) at the time of randomization. Regardless of the revascularization strategy, patients with COPD had a higher risk of 10-year all-cause death, compared with those without COPD (43.1% vs. 24.9%; hazard ratio [HR]: 2.03; 95% confidence interval [CI]: 1.56–2.64; p < 0.001). Among patients with COPD, CABG appeared to have a slightly lower risk of 10-year all-cause death compared with PCI (42.3% vs. 43.9%; HR: 0.96; 95% CI: 0.59–1.56, p = 0.858), whereas among those without COPD, CABG had a significantly lower risk of 10-year all-cause death (22.7% vs. 27.1%; HR: 0.81; 95% CI: 0.67–0.99, p = 0.041). There was no significant differential treatment effect of CABG versus PCI on 10-year all-cause death between patients with and without COPD (p_interaction = 0.544).

Conclusions

COPD was associated with a higher risk of 10-year all-cause death after revascularization for complex coronary artery disease. The presence of COPD did not significantly modify the beneficial effect of CABG versus PCI on 10-year all-cause death.

Trial registration: SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050

Graphic abstract

Age is a determinant of short-term mortality in patients hospitalized for an acute exacerbation of COPD

Several factors worsen the prognosis of hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Little is known about the specific contribution of age. Study aim was to evaluate the impact of age on early mortality (90-days).

METHODS

this observational prospective study considered hospitalized AECOPD patients. Three groups were created according to tertiles of age distribution: group 1 (≤ 67 years), group 2 (68-76 years) and group 3 (≥ 77 years). Baseline, clinical, microbiological, gas analysis and laboratory variables were collected at admission. The primary outcome was mortality at 90 days from admission. Multivariate regression models and receiver-operating characteristic (ROC) curves were used to evaluate the predictive power of age versus early mortality and adjusted for gender, comorbidities, staging and disease severity.

RESULTS

we enrolled 449 patients, 33 (7%) of whom died within 90 days from admission. Older patients were predominantly male, with more comorbidities, and higher dyspnoea grade and disease severity. The multivariate logistic regression demonstrated a significant predictive role of age as a continuous variable [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.10; p = 0.046]. The Cox regression analysis found that group 2 [hazard ratio (HR) 6.6; 95% CI 1.5-28.8; p = 0.013], group 3 (HR 7.2; 95% CI 1.6-32.6; p = 0.010) and acute severe hypoxemia at admission (HR 2.7; 95% CI 1.2-6; p = 0.012) were independent significant predictors of mortality. The Kaplan-Meier curves showed a significant role of age in cumulative survival (Gehan-Breslow-Wilcoxon test p = 0.010). ROC curves highlighted 70 years as the best discriminating cut-off.

CONCLUSIONS

age is a determinant of worse prognosis among hospitalized patients with AECOPD.

Pattern of comorbidities and 1-year mortality in elderly patients with COPD hospitalized in internal medicine wards: data from the RePoSI Registry

Currently, chronic obstructive pulmonary disease (COPD) represents the fourth cause of death worldwide with significant economic burden. Comorbidities increase in number and severity with age and are identified as important determinants that influence the prognosis. In this observational study, we retrospectively analyzed data collected from the RePoSI register. We aimed to investigate comorbidities and outcomes in a cohort of hospitalized elderly patients with the clinical diagnosis of COPD. Socio-demographic, clinical characteristics and laboratory findings were considered. The association between variables and in-hospital, 3-month and 1-year follow-up were analyzed. Among 4696 in-patients, 932 (19.8%) had a diagnosis of COPD. Patients with COPD had more hospitalization, a significant overt cognitive impairment, a clinically significant disability and more depression in comparison with non-COPD subjects. COPD patients took more drugs, both at admission, in-hospital stay, discharge and 3-month and 1-year follow-up. 14 comorbidities were more frequent in COPD patients. Cerebrovascular disease was an independent predictor of in-hospital mortality. At 3-month follow-up, male sex and hepatic cirrhosis were independently associated with mortality. ICS-LABA therapy was predictor of mortality at in-hospital, 3-month and 1-year follow-up. This analysis showed the severity of impact of COPD and its comorbidities in the real life of internal medicine and geriatric wards.

Incidence and predictors of COPD mortality in Uganda: A 2-year prospective cohort study

BACKGROUND

Data is lacking on outcomes among COPD patients in sub-Saharan Africa. The objective of the study was to assess the incidence and predictors of mortality among COPD patients enrolled in the Uganda Registry for Asthma and COPD.

RESEARCH QUESTION

What is the Incidence and predictors of mortality among COPD patients in Uganda?

STUDY DESIGN AND METHODS

Individuals with a diagnosis of COPD at six hospitals in Uganda were enrolled into the registry, and followed every six months. Mortality was ascertained through post-mortem reports and verbal autopsies. Mortality rates (MR), mortality rate ratios (MRR), and hazard ratios (HR) were computed to assess associations between socio-demographic, behavioural, and clinical characteristics at enrolment into the registry and mortality up to two years after.

RESULTS

We enrolled 296 COPD patients. Median age was 60 years, and 51·3% were male. The overall mortality rate was 95·90 deaths/1000 person-years. COPD severity by post-bronchodilator FEV1 was the strongest risk factor for mortality. Compared to stage 1, adjusted hazard ratios were as follows for stage 4: 9·86 (95%CI: 1·70-57·14, p = 0·011), stage 3: 6·16 (95%CI: 1·25-30·32, p = 0·025), and stage 2: 1·76 (95%CI: 0·33-9·48, p = 0·51). Underweight patients had a higher incidence of mortality compared to normal weight patients (MRR: 3·47 (95%CI: 1·45-8·31, p = 0·0026).

CONCLUSION

Among COPD patients in Uganda, two-year mortality is high, and disease severity at baseline was the strongest risk factor for mortality. Our findings suggest the need for early, accurate, diagnosis and management of COPD, to potentially improve survival.

The effect of mild hypercapnia on hospital mortality after cardiac arrest may be modified by chronic obstructive pulmonary disease

BACKGROUND

The main objective was to evaluate the effect of carbon dioxide on hospital mortality in chronic obstructive pulmonary disease (COPD) and non-COPD patients with out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a retrospective observational study in OHCA patients from the eICU database (eicu-crd.mit.edu). The main exposure was the partial pressure of arterial carbon dioxide (PaCO₂). The proportion of time spent (PTS) within four predefined PaCO₂ ranges (hypocapnia: <35 mmHg, normocapnia: 35-45 mmHg, mild hypercapnia: 46-55 mmHg, and severe hypercapnia: >55 mmHg) were calculated respectively. The primary outcome was hospital mortality. Multivariable logistic regression models were performed to assess the independent relationship between PTS within PaCO₂ range and hospital mortality, and the interaction between PTS within PaCO₂ range and COPD was explored.

RESULTS

A total of 1721 OHCA patients were included, of which 272 (15.8%) had COPD. After adjusted for the confounders, the PTS within mild hypercapnia was associated with lower odds ratio for hospital mortality in COPD patients (OR 0.923; 95% CI 0.857-0.992; P = 0.036); however, it was associated with higher odds ratio for hospital mortality in non-COPD patients (OR 1.053; 95% CI 1.012-1.097; P = 0.012; P_interaction = 0.008). The PTS within normocapnia was not associated with hospital mortality in COPD patients (OR 0.987; 95% CI 0.914-1.067; P = 0.739); however, it was associated with lower odds ratio for hospital mortality in non-COPD patients (OR 0.944; 95% CI 0.916-0.973; P < 0.001; P_interaction = 0.113).

CONCLUSIONS

The effect of carbon dioxide on hospital mortality differed between COPD and non-COPD patients. Mild hypercapnia was associated with increased hospital mortality for non-COPD patients but reduced hospital mortality for COPD patients. It would be reasonable to adjust PaCO₂ targets in OHCA patients with COPD.

Analysis of prevalence and prognosis of type 2 diabetes mellitus in patients with acute exacerbation of COPD

BACKGROUND

For patients with acute exacerbation of COPD (AECOPD), type 2 diabetes mellitus (T2DM) as comorbidity have poor outcomes. However, data on the impact of previously diagnosed and new- diagnosed T2DM in such a patient population is lacking.

METHODS

Inpatients diagnosed with AECOPD in the department of Pulmonary and Critical Care Medicine of The First Hospital of China Medical University during 2011-2017 were enrolled. Data on demography, prevalence of type 2 DM, other comorbidities, hospital stays and laboratory tests (including arterial partial pressure of oxygen [PaO2]) results were recorded. Results were compared with AECOPD patients having previously diagnosed and new-diagnosed type 2 diabetes. Markers associated with development of type 2 DM and the prognosis of AECOPD patients were identified.

RESULTS

Of the 196 patients enrolled in this study, the overall prevalence of T2DM was 26%. The PaO2 in the newly diagnosed T2DM group was considerably lower versus non-diabetic group. The T2DM group had a longer hospital stay and higher troponin level versus the non-diabetic group. AECOPD patients with T2DM were found to be correlated with hypertension. Age, need for assisted ventilation, increased troponin, and elevated fasting blood glucose on admission were risk factors for death in hospitalized AECOPD patients.

CONCLUSIONS

AECOPD patients had a higher prevalence of T2DM than the general population; T2DM comorbidity caused lower PaO2, longer hospital stays, and increased troponin. Poor blood glucose control may increase the risk of death in AECOPD patients.

Clinical Characteristics and Prognosis of COPD Patients Hospitalized with SARS-CoV-2

Objective

To describe the characteristics and prognosis of patients with COPD admitted to the hospital due to SARS-CoV-2 infection.

Methods

The SEMI-COVID registry is an ongoing retrospective cohort comprising consecutive COVID-19 patients hospitalized in Spain since the beginning of the pandemic in March 2020. Data on demographics, clinical characteristics, comorbidities, laboratory tests, radiology, treatment, and progress are collected. Patients with COPD were selected and compared to patients without COPD. Factors associated with a poor prognosis were analyzed.

Results

Of the 10,420 patients included in the SEMI-COVID registry as of May 21, 2020, 746 (7.16%) had a diagnosis of COPD. Patients with COPD are older than those without COPD (77 years vs 68 years) and more frequently male. They have more comorbidities (hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, heart failure, ischemic heart disease, peripheral vascular disease, kidney failure) and a higher Charlson Comorbidity Index (2 vs 1, p<0.001). The mortality rate in COPD patients was 38.3% compared to 19.2% in patients without COPD (p<0.001). Male sex, a history of hypertension, heart failure, moderate-severe chronic kidney disease, presence of cerebrovascular disease with sequelae, degenerative neurological disease, dementia, functional dependence, and a higher Charlson Comorbidity Index have been associated with increased mortality due to COVID-19 in COPD patients. Survival was higher among patients with COPD who were treated with hydroxychloroquine (87.1% vs 74.9%, p<0.001) and with macrolides (57.9% vs 50%, p<0.037). Neither prone positioning nor non-invasive mechanical ventilation, high-flow nasal cannula, or invasive mechanical ventilation were associated with a better prognosis.

Conclusion

COPD patients admitted to the hospital with SARS-CoV-2 infection have more severe disease and a worse prognosis than non-COPD patients.

Severe COVID-19 among patients with asthma and COPD: a report from the Swedish National Airway Register

BACKGROUND

Patients with obstructive lung diseases may be at risk of hospitalization and/or death due to COVID-19.

AIM

To estimate the frequency of severe COVID-19, and COVID-19-related mortality in a well-defined large population of patients with asthma and chronic inflammatory lung disease (COPD). Further to assess the frequency of asthma and COPD as registered comorbidities at discharge from hospital, and in death certificates.

METHODS

At the start of the pandemic, the Swedish National Airway Register (SNAR) included 271,404 patients with a physician diagnosis of asthma and/or COPD. In September 2020, after the first COVID-19 wave in Sweden, the database was linked with the National Patient Register (NPR), the Swedish Intensive Care Register and the Swedish Cause of Death Register, which all provide data about COVID-19 based on International Classification of Diseases (ICD-10) codes. Severe COVID-19 was defined as hospitalization and/or intensive care or death due to COVID-19.

RESULTS

Among patients in SNAR, 0.5% with asthma, and 1.2% with COPD were identified with severe COVID-19. Among patients  < 18 years with asthma, only 0.02% were severely infected. Of hospitalized adults, 14% with asthma and 29% with COPD died. Further, of patients in SNAR, 56% with asthma and 81% with COPD were also registered in the NPR, while on death certificates the agreement was lower (asthma 24% and COPD 71%).

CONCLUSION

The frequency of severe COVID-19 in asthma and COPD was relative low. Mortality for those hospitalized was double as high in COPD compared to asthma. Comorbid asthma and COPD were not always identified among patients with severe COVID-19.

Comparisons of exacerbations and mortality among LAMA/LABA combinations in stable chronic obstructive pulmonary disease: systematic review and Bayesian network meta-analysis

BACKGROUND

Only few randomized controlled trials (RCTs) for head-to-head comparison have been conducted between various combinations of long-acting muscarinic antagonists (LAMAs) and long-acting beta-agonists (LABAs). Our study was conducted to compare acute exacerbation and all-cause mortality among different LAMA/LABA regimens using Bayesian network meta-analysis (NMA).

METHODS

We searched Medline, EMBASE, and the Cochrane library (search date: July 1, 2019). We included parallel-group RCTs comparing LAMA/LABA combinations with other inhaled drugs in the stable COPD for ≥ 48 weeks. Two different network geometries were used. The geometry of network (A) had nodes of individual drugs or their combination, while that of network (B) combined all other treatments except LAMA/LABA into each drug class. This study was prospectively registered in PROSPERO; CRD42019126753.

RESULTS

We included 16 RCTs involving a total of 39,065 patients with stable COPD. Six combinations of LAMA/LABA were identified: tiotropium/salmeterol, glycopyrrolate/indacaterol, umeclidinium/vilanterol, tiotropium/olodaterol, aclidinium/formoterol, and glycopyrrolate/formoterol. We found that umeclidinium/vilanterol was associated with a lower risk of total exacerbations than other LAMA/LABAs in the NMA using network (A) (level of evidence: low or moderate). However, the significant differences were not present in the NMA of network (B). There were no significant differences among the LAMA/LABA combinations in terms of the number of moderate to severe exacerbations, all-cause mortality, major adverse cardiovascular events, or pneumonia.

CONCLUSIONS

The present NMA including all available RCTs provided that there is no strong evidence suggesting different benefits among LAMA/LABAs in patients with stable COPD who have been followed up for 48 weeks or more.

TRIAL REGISTRATION

This study was prospectively registered in PROSPERO; CRD42019126753.

Assessment of the Modified CHA2DS2VASc Risk Score in Predicting Mortality in Patients Hospitalized With COVID-19

Since the modified CHA2DS2VASC (M-CHA2DS2VASc) risk score includes the prognostic risk factors for COVID-19; we assumed that it might predict in-hospital mortality and identify high-risk patients at an earlier stage compared with troponin increase and neutrophil-lymphocyte ratio (NLR). We aimed to investigate whether M-CHA2DS2VASC RS is an independent predictor of mortality in patients hospitalized with COVID-19 and to compare its discriminative ability with troponin increase and NLR in terms of predicting mortality. A total of 694 patients were retrospectively analyzed and divided into 3 groups according to M-CHA2DS2VASC RS which was simply created by changing gender criteria of the CHA2DS2VASC RS from female to male (Group 1, score 0-1 (n = 289); group 2, score 2-3 (n = 231) and group 3, score ≥4 (n = 174)). Adverse clinical events were defined as in-hospital mortality, admission to intensive care unit, need for high-flow oxygen and/or intubation. As the M-CHA2DS2VASC RS increased, adverse clinical outcomes were also significantly increased (Group 1, 3.8%; group 2, 12.6%; group 3, 20.8%; p <0.001 for in-hospital mortality). The multivariate logistic regression analysis showed that M-CHA2DS2VASC RS, troponin increase and neutrophil-lymphocyte ratio were independent predictors of in-hospital mortality (p = 0.005, odds ratio 1.29 per scale for M-CHA2DS2VASC RS). In receiver operating characteristic analysis, comparative discriminative ability of M-CHA2DS2VASC RS was superior to CHA2DS2VASC RS score. Area under the curve (AUC) values for in-hospital mortality was 0.70 and 0.64, respectively. (AUC_{M-CHA2DS2-VASc} vs. AUC_CHA2DS2-VASc z test = 3.56, p 0.0004) In conclusion, admission M-CHA2DS2VASc RS may be a useful tool to predict in-hospital mortality in patients with COVID-19.

[Bronchial dilatations in patients with chronic obstructive pulmonary disease in a Tunisian center: effect on disease progression and prognosis]

INTRODUCTION

bronchial dilations (BDs) seem to have a major role in the natural history of chronic obstructive pulmonary disease (COPD). The purpose of our study was to evaluate the impact of BDs on the severity and progression of COPD as well as on patients' prognosis.

METHODS

we conducted a retrospective, single-center, analytical study over the period 1995- 2017. The study was based on data from the medical records of patients with COPD who had undergone chest CT scan during the follow-up period. We compared two groups (G) of patients: G1: COPD with BDs; G2: COPD without BDs.

RESULTS

our study included 466 patients with COPD. Among them 101 (21.6%) had BDs associated with COPD. G1 patients had lower maximum expiratory volume in the first second (FEV1) (G1: 1.21 L, G2: 1.37 L, p = 0.015), lower forced vital capacity (FVC) (p = 0.014), a lower PaO2 at steady state (p = 0.049), a higher rate of acute exacerbations (AE) per year (G1: 3.31, G2: 2.44, p = 0.001) and a higher rate of hospitalizations in the Intensive Care Unit per year (p = 0.02). G1 patients with AE receiving treatment in hospital had lower PaO2 3) on admission (G1: 60 mmHg, G2: 63.7 mmHg, p = 0.02 G2: 63.7 mmHg, p = 0.023), more elevated carbon dioxide (CO2) levels (p = 0.001) and were characterized by a higher use of non-invasive ventilation (NIV) (p = 0.044) and invasive mechanical ventilation (p = 0.011). G2 patients had better overall survival (p = 0.002).

CONCLUSION

bronchial dilatations are an indicator of poor prognosis in patients with chronic obstructive pulmonary disease, expecially because of the higher rate and severity of exacerbations, airway obstructions and mortality.

Prevalence of co-morbidities and their association with mortality in patients with COVID-19: A systematic review and meta-analysis

AIM

To estimate the prevalence of both cardiometabolic and other co-morbidities in patients with COVID-19, and to estimate the increased risk of severity of disease and mortality in people with co-morbidities.

MATERIALS AND METHODS

Medline, Scopus and the World Health Organization website were searched for global research on COVID-19 conducted from January 2019 up to 23 April 2020. Study inclusion was restricted to English language publications, original articles that reported the prevalence of co-morbidities in individuals with COVID-19, and case series including more than 10 patients. Eighteen studies were selected for inclusion. Data were analysed using random effects meta-analysis models.

RESULTS

Eighteen studies with a total of 14 558 individuals were identified. The pooled prevalence for co-morbidities in patients with COVID-19 disease was 22.9% (95% CI: 15.8 to 29.9) for hypertension, 11.5% (9.7 to 13.4) for diabetes, and 9.7% (6.8 to 12.6) for cardiovascular disease (CVD). For chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), cerebrovascular disease and cancer, the pooled prevalences were all less than 4%. With the exception of cerebrovascular disease, all the other co-morbidities presented a significantly increased risk for having severe COVID-19. In addition, the risk of mortality was significantly increased in individuals with CVD, COPD, CKD, cerebrovascular disease and cancer.

CONCLUSIONS

In individuals with COVID-19, the presence of co-morbidities (both cardiometabolic and other) is associated with a higher risk of severe COVID-19 and mortality. These findings have important implications for public health with regard to risk stratification and future planning.

Mortality and its predictors among patients treated for acute exacerbations of chronic obstructive respiratory diseases in Jimma Medical Center; Jimma, Ethiopia: Prospective observational study

Background

Chronic obstructive pulmonary disease (COPD) and asthma exacerbations are associated with ill health, increased mortality, and health care costs. However, there is limited evidence regarding mortality and its predictors among patients treated for COPD and asthma exacerbations in low-income nations, particularly in Ethiopia.

Methods

A-6 month prospective observational study was conducted from April 20-September 20, 2019. Data were collected on socio-demographic, baseline clinical characteristics and outcomes of asthma and COPD exacerbations. Data were entered into Epi-Data version 4.02.01 for cleaning and exported to STATA 14.0 for analysis. Kaplan-Meier (Log-rank test) was used to compare the baseline survival experience of the study participants and Cox proportional hazard regression analysis was conducted to determine the predictors of mortality. Adjusted hazard ratios (AHRs) with two-sided p-value <0.05 were considered statistically significant.

Results

A total of 130 patients (60% males) were included. The median (interquartile range (IQR)) age of the study participants was 59(50–70) years. The median (IQR) survival time to death was 17.5 (10–26) days. The total proportion of in-hospital mortality was 10.78% (14/130), and the incidence rate of mortality was 2.56 per 1000 person-years. The duration of oxygen therapy ≥16hours/day (AHR = 6.330, 95% CI [1.092–36.679], and old age (AHR = 1.066, 95% CI [1.0001–1.136] were the independent predictors of in-hospital mortality.

Conclusion

In this study, the in-hospital mortality rate was very high. Moreover, prolonged oxygen therapy (≥16hours/day) and old age were independently associated with in-hospital mortality. Therefore, special attention should be given to recipients of prolonged oxygen therapy and the elderly during hospital stay.

Randomized Trial of Nocturnal Oxygen in Chronic Obstructive Pulmonary Disease

BACKGROUND

Long-term oxygen therapy improves survival in patients with chronic obstructive pulmonary disease (COPD) and chronic severe daytime hypoxemia. However, the efficacy of oxygen therapy for the management of isolated nocturnal hypoxemia is uncertain.

METHODS

We designed this double-blind, placebo-controlled, randomized trial to determine, in patients with COPD who have nocturnal arterial oxygen desaturation without qualifying for long-term oxygen therapy, whether nocturnal oxygen provided for a period of 3 to 4 years would decrease mortality or the worsening of disease such that patients meet current specifications for long-term oxygen therapy. Patients with an oxygen saturation of less than 90% for at least 30% of the recording time on nocturnal oximetry were assigned, in a 1:1 ratio, to receive either nocturnal oxygen or ambient air from a sham concentrator (placebo). The primary outcome was a composite of death from any cause or a requirement for long-term oxygen therapy as defined by the Nocturnal Oxygen Therapy Trial (NOTT) criteria in the intention-to-treat population.

RESULTS

Recruitment was stopped prematurely because of recruitment and retention difficulties after 243 patients, of a projected 600, had undergone randomization at 28 centers. At 3 years of follow-up, 39.0% of the patients assigned to nocturnal oxygen (48 of 123) and 42.0% of those assigned to placebo (50 of 119) met the NOTT-defined criteria for long-term oxygen therapy or had died (difference, -3.0 percentage points; 95% confidence interval, -15.1 to 9.1).

CONCLUSIONS

Our underpowered trial provides no indication that nocturnal oxygen has a positive or negative effect on survival or progression to long-term oxygen therapy in patients with COPD. (Funded by the Canadian Institutes of Health Research; INOX ClinicalTrials.gov number, NCT01044628.).

Coronavirus disease (COVID-19): A systematic review and meta-analysis to evaluate the impact of various comorbidities on serious events

BACKGROUND AND AIMS

Currently there is limited knowledge on medical comorbidities and COVID-19; we conducted a systematic review and meta-analysis to evaluate the impact of various morbidities on serious events in COVID 19.

METHODS

PubMed, Cochrane Central Register of Clinical Trials were searched on April 28, 2020, to extract published articles that reported the outcomes of COVID-19 patients. The search terms were "coronavirus" and "clinical characteristics". ICU admission, mechanical ventilation, ARDS, Pneumonia, death was considered serious events. The comorbidities assessed in the study were Hypertension (HTN), Diabetes mellitus (DM), Cardiovascular diseases (CVD), Chronic obstructive pulmonary disease (COPD) and Chronic Kidney disease (CKD). Subsequently, comparisons between comorbidity patient group and the non-comorbidity patient groups, in terms of serious events were made using the pooled estimates of odd's ratio (OR) RESULTS: We identified 688 published results and 16 studies with 3994 patients were included in the systematic review. Serious events were seen in 526(13.16%) patients. Presence of hypertension with OR 2.95, diabetes mellitus with OR 3.07, Cardio vascular disease with OR 4.58, COPD with OR 6.66 and Chronic kidney disease with OR 5.32 had significant association in patients with COVID 19 on having serious events. Presence of diabetes mellitus (OR 2.78)) had a significant impact on death in COVID 19 patients with a p-value 0.004.

CONCLUSIONS

Presence of medical comorbidities in COVID-19 leads to higher risk of developing serious events i.e. ICU admission, mechanical intubation and mortality. The presence of Diabetes mellitus has a significant impact on mortality rate in COVID-19 patients.

Machine Learning and Prediction of All-Cause Mortality in COPD

BACKGROUND

COPD is a leading cause of mortality.

RESEARCH QUESTION

We hypothesized that applying machine learning to clinical and quantitative CT imaging features would improve mortality prediction in COPD.

STUDY DESIGN AND METHODS

We selected 30 clinical, spirometric, and imaging features as inputs for a random survival forest. We used top features in a Cox regression to create a machine learning mortality prediction (MLMP) in COPD model and also assessed the performance of other statistical and machine learning models. We trained the models in subjects with moderate to severe COPD from a subset of subjects in Genetic Epidemiology of COPD (COPDGene) and tested prediction performance in the remainder of individuals with moderate to severe COPD in COPDGene and Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE). We compared our model with the BMI, airflow obstruction, dyspnea, exercise capacity (BODE) index; BODE modifications; and the age, dyspnea, and airflow obstruction index.

RESULTS

We included 2,632 participants from COPDGene and 1,268 participants from ECLIPSE. The top predictors of mortality were 6-min walk distance, FEV1 % predicted, and age. The top imaging predictor was pulmonary artery-to-aorta ratio. The MLMP-COPD model resulted in a C index ≥ 0.7 in both COPDGene and ECLIPSE (6.4- and 7.2-year median follow-ups, respectively), significantly better than all tested mortality indexes (P < .05). The MLMP-COPD model had fewer predictors but similar performance to that of other models. The group with the highest BODE scores (7-10) had 64% mortality, whereas the highest mortality group defined by the MLMP-COPD model had 77% mortality (P = .012).

INTERPRETATION

An MLMP-COPD model outperformed four existing models for predicting all-cause mortality across two COPD cohorts. Performance of machine learning was similar to that of traditional statistical methods. The model is available online at: https://cdnm.shinyapps.io/cgmortalityapp/.

Understanding resource utilization and mortality in COPD to support policy making: A microsimulation study

Chronic obstructive pulmonary disease (COPD) poses a significant but heterogeneous burden to individuals and healthcare systems. Policymakers develop targeted policies to minimize this burden but need personalized tools to evaluate novel interventions and target them to subpopulations most likely to benefit. We developed a platform to identify subgroups that are at increased risk of emergency department visits, hospitalizations and mortality and to provide stratified patient input in economic evaluations of COPD interventions. We relied on administrative and survey data from Ontario, Canada and applied a combination of microsimulation and multi-state modeling methods. We illustrated the functionality of the platform by quantifying outcomes across smoking status (current, former, never smokers) and by estimating the effect of smoking cessation on resource use and survival, by comparing outcomes of hypothetical cohorts of smokers who quit at diagnosis and smokers that continued to smoke post diagnosis. The cumulative incidence of all-cause mortality was 37.9% (95% CI: 34.9, 41.4) for never smokers, 34.7% (95% CI: 32.1, 36.9) for current smokers, and 46.4% (95% CI: 43.6, 49.0) for former smokers, at 14 years. Over 14 years, smokers who did not quit at diagnosis had 16.3% (95% CI: 9.6, 38.4%) more COPD-related emergency department visits than smokers who quit at diagnosis. In summary, we combined methods from clinical and economic modeling to create a novel tool that policymakers and health economists can use to inform future COPD policy decisions and quantify the effect of modifying COPD risk factors on resource utilization and morality.

GBD Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Previous attempts to characterise the burden of chronic respiratory diseases have focused only on specific disease conditions, such as chronic obstructive pulmonary disease (COPD) or asthma. In this study, we aimed to characterise the burden of chronic respiratory diseases globally, providing a comprehensive and up-to-date analysis on geographical and time trends from 1990 to 2017.

METHODS

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, we estimated the prevalence, morbidity, and mortality attributable to chronic respiratory diseases through an analysis of deaths, disability-adjusted life-years (DALYs), and years of life lost (YLL) by GBD super-region, from 1990 to 2017, stratified by age and sex. Specific diseases analysed included asthma, COPD, interstitial lung disease and pulmonary sarcoidosis, pneumoconiosis, and other chronic respiratory diseases. We also assessed the contribution of risk factors (smoking, second-hand smoke, ambient particulate matter and ozone pollution, household air pollution from solid fuels, and occupational risks) to chronic respiratory disease-attributable DALYs.

FINDINGS

In 2017, 544·9 million people (95% uncertainty interval [UI] 506·9-584·8) worldwide had a chronic respiratory disease, representing an increase of 39·8% compared with 1990. Chronic respiratory disease prevalence showed wide variability across GBD super-regions, with the highest prevalence among both males and females in high-income regions, and the lowest prevalence in sub-Saharan Africa and south Asia. The age-sex-specific prevalence of each chronic respiratory disease in 2017 was also highly variable geographically. Chronic respiratory diseases were the third leading cause of death in 2017 (7·0% [95% UI 6·8-7·2] of all deaths), behind cardiovascular diseases and neoplasms. Deaths due to chronic respiratory diseases numbered 3 914 196 (95% UI 3 790 578-4 044 819) in 2017, an increase of 18·0% since 1990, while total DALYs increased by 13·3%. However, when accounting for ageing and population growth, declines were observed in age-standardised prevalence (14·3% decrease), age-standardised death rates (42·6%), and age-standardised DALY rates (38·2%). In males and females, most chronic respiratory disease-attributable deaths and DALYs were due to COPD. In regional analyses, mortality rates from chronic respiratory diseases were greatest in south Asia and lowest in sub-Saharan Africa, also across both sexes. Notably, although absolute prevalence was lower in south Asia than in most other super-regions, YLLs due to chronic respiratory diseases across the subcontinent were the highest in the world. Death rates due to interstitial lung disease and pulmonary sarcoidosis were greater than those due to pneumoconiosis in all super-regions. Smoking was the leading risk factor for chronic respiratory disease-related disability across all regions for men. Among women, household air pollution from solid fuels was the predominant risk factor for chronic respiratory diseases in south Asia and sub-Saharan Africa, while ambient particulate matter represented the leading risk factor in southeast Asia, east Asia, and Oceania, and in the Middle East and north Africa super-region.

INTERPRETATION

Our study shows that chronic respiratory diseases remain a leading cause of death and disability worldwide, with growth in absolute numbers but sharp declines in several age-standardised estimators since 1990. Premature mortality from chronic respiratory diseases seems to be highest in regions with less-resourced health systems on a per-capita basis.

FUNDING

Bill & Melinda Gates Foundation.

Time-weighted average of fine particulate matter exposure and cause-specific mortality in China: a nationwide analysis

BACKGROUND

Most previous assessments of the hazardous effects attributable to fine particulate matter (PM_2·5) exposure have used ambient PM_2·5 as an exposure metric, resulting in substantial bias in effect estimates. We did a study to examine the association between cause-specific mortality and the time-weighted average of PM_2·5 exposure after accounting for indoor exposure in 267 cities in China.

METHODS

We did a nationwide study, using Laser Egg air quality monitors in 36 cities to obtain data for indoor PM_2·5 concentrations from 18 484 anonymised households between Nov 1, 2015 and July 2, 2018. We developed and validated a nationwide indoor PM_2·5 prediction model for a further 302 cities by retrieving raw records of hourly concentrations from residents' air sensors; the model was used to predict indoor PM_2·5 during 2013 to 2018. Daily ambient PM_2·5 concentration data were estimated by averaging hourly ambient PM_2·5 concentrations obtained from China's National Urban Air Quality Real-time Publishing Platform. Daily numbers of deaths from all non-accidental causes were obtained from 324 cities from the Disease Surveillance Point System of China between Jan 1, 2013, to Dec 31, 2017, and calculated for 267 cities that had an average daily mortality above three, and data for PM_2·5 concentrations and meteorological information for at least 1 year between 2013 and 2017. We used distributed lag non-linear models to estimate city-specific associations between cause-specific mortality and reconstructed PM_2·5 exposure by considering indoor PM_2·5 exposure. We combined the city-specific effect estimates at the national level using a random effects meta-analysis.

FINDINGS

13 972 records of daily indoor PM_2·5 concentrations for 36 cities, extracted from 47 459 183 raw records from the sensors were included for modelling indoor PM_2·5 levels. The nationwide indoor PM_2·5 concentration was 40 μg/m³ (SD 21) between 2013 and 2017, which was approximately 20% lower than the ambient PM_2·5 concentration of 50 μg/m³ (42). An increase of 10 μg/m³ in time-averaged PM_2·5 exposure concentrations was associated with increased daily mortality estimates of 0·44% (95% CI 0·33-0·54) for total non-accidental causes, 0·50% (0·37-0·63) for cardiovascular diseases, 0·46% (0·28-0·63) for coronary heart disease, 0·49% (0·32-0·66) for stroke, 0·59% (0·39-0·79) for respiratory diseases, and 0·69% (0·45-0·92) for chronic obstructive pulmonary disease, respectively. Compared with previous estimations based on ambient PM_2·5, our estimates approximately doubled the size of the effects related to PM_2·5.

INTERPRETATION

This nationwide study revealed a higher mortality risk attributed to time-averaged indoor and ambient PM_2·5 exposure compared with the risk associated with ambient PM_2·5 exposure alone, which indicates that caution should be exercised when using ambient PM_2·5 as a surrogate for PM_2·5 exposure.

FUNDING

National Natural Science Foundation of China (Youth Program) and the Fundamental Research Project of Beihang University.

Predicting Mortality Due to SARS-CoV-2: A Mechanistic Score Relating Obesity and Diabetes to COVID-19 Outcomes in Mexico

BACKGROUND

The SARS-CoV-2 outbreak poses a challenge to health care systems due to its high complication rates in patients with cardiometabolic diseases. Here, we identify risk factors and propose a clinical score to predict COVID-19 lethality, including specific factors for diabetes and obesity, and its role in improving risk prediction.

METHODS

We obtained data of confirmed and negative COVID-19 cases and their demographic and health characteristics from the General Directorate of Epidemiology of the Mexican Ministry of Health. We investigated specific risk factors associated to COVID-19 positivity and mortality and explored the impact of diabetes and obesity on modifying COVID-19-related lethality. Finally, we built a clinical score to predict COVID-19 lethality.

RESULTS

Among the 177 133 subjects at the time of writing this report (May 18, 2020), we observed 51 633 subjects with SARS-CoV-2 and 5,332 deaths. Risk factors for lethality in COVID-19 include early-onset diabetes, obesity, chronic obstructive pulmonary disease, advanced age, hypertension, immunosuppression, and chronic kidney disease (CKD); we observed that obesity mediates 49.5% of the effect of diabetes on COVID-19 lethality. Early-onset diabetes conferred an increased risk of hospitalization and obesity conferred an increased risk for intensive care unit admission and intubation. Our predictive score for COVID-19 lethality included age ≥ 65 years, diabetes, early-onset diabetes, obesity, age < 40 years, CKD, hypertension, and immunosuppression and significantly discriminates lethal from non-lethal COVID-19 cases (C-statistic = 0.823).

CONCLUSIONS

Here, we propose a mechanistic approach to evaluate the risk for complications and lethality attributable to COVID-19, considering the effect of obesity and diabetes in Mexico. Our score offers a clinical tool for quick determination of high-risk susceptibility patients in a first-contact scenario.

Prediction of five-year mortality after COPD diagnosis using primary care records

Accurate prognosis information after a diagnosis of chronic obstructive pulmonary disease (COPD) would facilitate earlier and better informed decisions about the use of prevention strategies and advanced care plans. We therefore aimed to develop and validate an accurate prognosis model for incident COPD cases using only information present in general practitioner (GP) records at the point of diagnosis. Incident COPD patients between 2004-2012 over the age of 35 were studied using records from 396 general practices in England. We developed a model to predict all-cause five-year mortality at the point of COPD diagnosis, using 47,964 English patients. Our model uses age, gender, smoking status, body mass index, forced expiratory volume in 1-second (FEV1) % predicted and 16 co-morbidities (the same number as the Charlson Co-morbidity Index). The performance of our chosen model was validated in all countries of the UK (N = 48,304). Our model performed well, and performed consistently in validation data. The validation area under the curves in each country varied between 0.783-0.809 and the calibration slopes between 0.911-1.04. Our model performed better in this context than models based on the Charlson Co-morbidity Index or Cambridge Multimorbidity Score. We have developed and validated a model that outperforms general multimorbidity scores at predicting five-year mortality after COPD diagnosis. Our model includes only data routinely collected before COPD diagnosis, allowing it to be readily translated into clinical practice, and has been made available through an online risk calculator (https://skiddle.shinyapps.io/incidentcopdsurvival/).

Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD

BACKGROUND

Triple fixed-dose regimens of an inhaled glucocorticoid, a long-acting muscarinic antagonist (LAMA), and a long-acting β₂-agonist (LABA) for chronic obstructive pulmonary disease (COPD) have been studied at single dose levels of inhaled glucocorticoid, but studies at two dose levels are lacking.

METHODS

In a 52-week, phase 3, randomized trial to evaluate the efficacy and safety of triple therapy at two dose levels of inhaled glucocorticoid in patients with moderate-to-very-severe COPD and at least one exacerbation in the past year, we assigned patients in a 1:1:1:1 ratio to receive twice-daily inhaled doses of triple therapy (inhaled glucocorticoid [320 μg or 160 μg of budesonide], a LAMA [18 μg of glycopyrrolate], and a LABA [9.6 μg of formoterol]) or one of two dual therapies (18 μg of glycopyrrolate plus 9.6 μg of formoterol or 320 μg of budesonide plus 9.6 μg of formoterol). The primary end point was the annual rate (the estimated mean number per patient per year) of moderate or severe COPD exacerbations, as analyzed in the modified intention-to-treat population with the use of on-treatment data only.

RESULTS

The modified intention-to-treat population comprised 8509 patients. The annual rates of moderate or severe exacerbations were 1.08 in the 320-μg-budesonide triple-therapy group (2137 patients), 1.07 in the 160-μg-budesonide triple-therapy group (2121 patients), 1.42 in the glycopyrrolate-formoterol group (2120 patients), and 1.24 in the budesonide-formoterol group (2131 patients). The rate was significantly lower with 320-μg-budesonide triple therapy than with glycopyrrolate-formoterol (24% lower: rate ratio, 0.76; 95% confidence interval [CI], 0.69 to 0.83; P<0.001) or budesonide-formoterol (13% lower: rate ratio, 0.87; 95% CI, 0.79 to 0.95; P = 0.003). Similarly, the rate was significantly lower with 160-μg-budesonide triple therapy than with glycopyrrolate-formoterol (25% lower: rate ratio, 0.75; 95% CI, 0.69 to 0.83; P<0.001) or budesonide-formoterol (14% lower: rate ratio, 0.86; 95% CI, 0.79 to 0.95; P = 0.002). The incidence of any adverse event was similar across the treatment groups (range, 61.7 to 64.5%); the incidence of confirmed pneumonia ranged from 3.5 to 4.5% in the groups that included inhaled glucocorticoid use and was 2.3% in the glycopyrrolate-formoterol group.

CONCLUSIONS

Triple therapy with twice-daily budesonide (at either the 160-μg or 320-μg dose), glycopyrrolate, and formoterol resulted in a lower rate of moderate or severe COPD exacerbations than glycopyrrolate-formoterol or budesonide-formoterol. (Funded by AstraZeneca, ETHOS ClinicalTrials.gov number, NCT02465567.).

Blood neutrophil counts are associated with exacerbation frequency and mortality in COPD

BACKGROUND

Identifying patients with COPD at increased risk of poor outcomes is challenging due to disease heterogeneity. Potential biomarkers need to be readily available in real-life clinical practice. Blood eosinophil counts are widely studied but few studies have examined the prognostic value of blood neutrophil counts (BNC).

METHODS

In a large population-based COPD registry in the East of Scotland (TARDIS: Tayside Allergic and Respiratory Disease Information System), BNC were compared to measures of disease severity and mortality for up to 15 years follow-up. Potential mechanisms of disease modification by BNC were explored in a nested microbiome substudy.

RESULTS

178,120 neutrophil counts were obtained from 7220 people (mean follow up 9 years) during stable disease periods. Median BNC was 5200cells/μL (IQR 4000-7000cells/μL). Mortality rates among the 34% of patients with elevated BNCs (defined as 6000-15000cells/μL) at the study start were 80% higher (14.0/100 person years v 7.8/100py, P < 0.001) than those with BNC in the normal range (2000-6000cells/μL). People with elevated BNC were more likely to be classified as GOLD D (46% v 33% P < 0.001), have more exacerbations (mean 2.3 v 1.3/year, P < 0.001), and were more likely to have severe exacerbations (13% vs. 5%, P < 0.001) in the following year. Eosinophil counts were much less predictive of these outcomes. In a sub-cohort (N = 276), patients with elevated BNC had increased relative abundance of Proteobacteria and reduced microbiome diversity.

CONCLUSION

High BNC may provide a useful indicator of risk of exacerbations and mortality in COPD patients.