Pulmonary arterial enlargement and acute exacerbations of COPD

Structured Cardiac Assessment and Treatment Following Exacerbations of COPD (SCATECOPD): A Pilot Randomised Controlled Trial

Background/Objectives: Heart disease is common in COPD, yet it is underdiagnosed and undertreated. Heart failure (HF) is undiagnosed in up to 20% of hospital inpatients. Hospitalised exacerbations of COPD (ECOPD) confer high mortality and readmission rates, with an elevated temporal cardiac risk. We performed a pilot randomised controlled trial examining the feasibility and effect of inpatient structured cardiac assessment (SCA) to diagnose and prompt guideline-recommended treatment of heart disease. Methods: A total of 115 inpatients with ECOPD were randomised 1:1 to receive usual care (UC) or SCA, comprising transthoracic echocardiography, CT coronary artery calcium scoring, 24 h ECG, blood pressure, and diabetes assessment. Follow-up was for 12 months. The prevalence of underdiagnosis and undertreatment of heart disease were captured, and potential outcome measures for future trials assessed. Results: Among patients undergoing SCA, 42/57 (73.7%) received a new cardiac diagnosis and 32/57 (56.1%) received new cardiac treatment, compared with 11/58 (19.0%; p < 0.001) and 5/58 (8.6%; p < 0.001) in the UC group. More patients in the SCA group were newly diagnosed with HF (36.8% vs. 12.1%; p = 0.002). When heart disease was diagnosed, the proportion receiving optimal treatment at discharge was substantially higher in SCA (35/47 (74%) vs. 4/11 (34%); p = 0.029). The occurrence of a major adverse cardiovascular event (MACE) showed promise as an appropriate clinical outcome for a future definitive trial. MACEs occurred in 17.2% in usual care vs. 10.5% in SCA in one year, with a continued separation of survival curves during follow up, although statistical significance was not shown. Conclusions: A structured cardiac assessment during ECOPD substantially improved diagnosis and treatment of heart disease. HF and coronary artery disease were the most common new diagnoses. Future interventional trials in this population should consider MACEs as the primary outcome.

Pulmonary hypertension associated with COPD: a phenotype analysis

Background

Pulmonary hypertension (PH) associated with COPD (PH-COPD) exhibits diverse phenotypes, challenging therapeutic management. This study aimed to describe the characteristics of COPD patients with distinct phenotypes, namely end-stage COPD with or without PH (group 1), other COPD patients with mild-to-moderate pre-capillary PH-COPD (group 2) and COPD patients with a pulmonary vascular phenotype (PVP) (group 3).

Methods

We performed a retrospective analysis of COPD patients who underwent right heart catheterisation from 2015 to 2022.

Results

81 patients were included in group 1, 37 in group 2 and 35 in group 3. The groups differed in terms of clinical, functional, haemodynamic and imaging characteristics. Group 1 had significantly marked lung hyperinflation with increased total lung capacity and residual volume, a feature not observed in group 3. These results were confirmed by analysis of chest CT scans, which confirmed varying degrees of emphysema, as follows: severe in group 1, moderate in group 2 and mild in group 3, with median total emphysema indices of 55% (48-62), 32% (16-49) and 16% (3.4-31), respectively, p<0.0001.

Conclusions

Our results highlight the broad spectrum of PH in COPD, from PH associated with end-stage COPD (phenotype/group 1), characterised by predominant alveolar wall damage with severe emphysema, to PVP (phenotype/group 3), mainly due to pulmonary vascular changes. Phenotype/group 2 represents an intermediate state combining features of both. In the current debate on how to distinguish PH-COPD phenotypes, it might be of interest to include quantitative thresholds for emphysema in future diagnostic and management algorithms.

The FEV1/DLCO Ratio as an Effective Predictor of Severity and Survival in COPD-Associated Pulmonary Hypertension: A Retrospective Analysis

Background/Objectives: Pulmonary hypertension (PH) is associated with increased morbidity and mortality in chronic obstructive pulmonary disease (COPD). The ratio of the functional vital capacity (FVC) to diffusing capacity of the lung for carbon monoxide (DLCO) has demonstrated predictive and prognostic efficacy in PH due to lung disease, including COPD. However, forced expiratory volume in 1 s (FEV1) is used to grade COPD severity. We aimed to determine whether FEV1/DLCO predicts PH severity in COPD-PH. Methods: This is a retrospective analysis of patients with COPD-PH diagnosed via right heart catheterization and pulmonary function testing. Linear regression assessed the correlation of FEV1/DLCO with RHC parameters. Receiver operating characteristic (ROC) analysis was performed to assess the predictive effectiveness of FEV1/DLCO for severe PH. Results: Among 212 patients with COPD-PH, the FEV1/DLCO ratio positively correlated with mean pulmonary artery pressure (mPAP; r = 0.6, p < 0.001) and pulmonary vascular resistance (PVR; r = 0.56, p < 0.001). In ROC analysis, FEV1/DLCO was effective at predicting severe PH (AUC 0.60, p = 0.02). Those with a FEV1/DLCO ratio > 1.66 had a decreased rate of transplant-free survival as compared to those with a lower ratio (40.8% vs. 59.2%, p = 0.01). Conclusions: Among patients with COPD-PH, FEV1/DLCO correlates well with mPAP and PVR. The FEV1/DLCO ratio may effectively predict severe PH and may predict transplant-free survival in COPD-PH.

ECG-based risk factors for adverse cardiopulmonary events and treatment outcomes in COPD

BACKGROUND

COPD has high mortality, compounded by comorbid cardiovascular disease. We investigated two ECG markers, Cardiac Infarction Injury Score (CIIS) and P pulmonale, as prognostic tools for adverse cardiopulmonary events in COPD.

METHODS

This was a p ost hoc analysis of the IMPACT trial. Outcomes included odds (odds ratio, 95% confidence intervals) of adverse cardiopulmonary events stratified by CIIS threshold (<20 versus ≥20) and P pulmonale (baseline). Events included all-cause death, hospitalisation or death, cardiovascular adverse event of special interest, severe COPD exacerbations, and moderate/severe COPD exacerbations. We also assessed the effects of fluticasone furoate/umeclidinium/vilanterol versus fluticasone furoate/vilanterol or umeclidinium/vilanterol based on CIIS and P pulmonale.

RESULTS

We included 9448 patients. Patients with CIIS ≥20 (versus CIIS <20) had greater odds of all-cause death (OR 1.73, 95% CI 1.27-2.37, p<0.001), hospitalisation or death (OR 1.33, 95% CI 1.17-1.50, p<0.001), cardiovascular adverse event of special interest (OR 1.27, 95% CI 1.08-1.48, p<0.005), severe COPD exacerbations (OR 1.41, 95% CI 1.21-1.64, p<0.001) and moderate/severe COPD exacerbations (OR 1.25, 95% CI 1.13-1.40, p<0.001). Patients with P pulmonale (versus without) had greater odds of all-cause death (OR 2.25, 95% CI 1.54-3.29, p<0.001), hospitalisation or death (OR 1.51, 95% CI 1.28-1.79, p<0.001), severe COPD exacerbations (OR 2.00, 95% CI 1.65-2.41, p<0.001) and moderate/severe COPD exacerbations (OR 1.25, 95% CI 1.08-1.46, p<0.001). A combined model demonstrated that patients with CIIS ≥20 and P pulmonale had increased risk of all-cause death (OR 3.38, 95% CI 1.23-9.30, p=0.019), hospitalisation or death (OR 1.61, 95% CI 1.14-2.22, p=0.004) and rate of severe COPD exacerbations (OR 1.89, 95% CI 1.22-2.91, p=0.004) and moderate/severe COPD exacerbations (OR 1.25, 95% CI 1.00-1.56, p=0.046). The risk of all-cause death and cardiovascular adverse events of special interest was reduced with fluticasone furoate/umeclidinium/vilanterol versus umeclidinium/vilanterol in patients with CIIS ≥20, but not CIIS <20.

CONCLUSIONS

These findings suggest the potential clinical relevance of CIIS and P pulmonale as risk indicators for adverse cardiopulmonary events in COPD.

Early Identification of Exacerbations in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) have a substantial effect on overall disease management, health system costs, and patient outcomes. However, exacerbations are often underdiagnosed or recognized with great delay due to several factors such as patients' inability to differentiate between acute episodes and symptom fluctuations, delays in seeking medical assistance, and disparities in dyspnea perception. Self-management intervention plans, telehealth and smartphone-based programs provide educational material, counseling, virtual hospitals and telerehabilitation, and help COPD patients to identify exacerbations early. Moreover, biomarkers such as blood eosinophil count, fibrinogen, CRP, Serum amyloid A(SAA),together with imaging parameters such as the pulmonary artery-to-aorta diameter ratio, have emerged as potential predictors of exacerbations, yet their clinical utility is limited by variability and lack of specificity. In this review, we provide information regarding the importance of the early identification of exacerbation events in COPD patients and the available methods which can be used for this purpose.

Ratio of pulmonary artery diameter to ascending aortic diameter and its association with right ventricular failure after left ventricular assist device implantation

BACKGROUND

Several invasive hemodynamic parameters help predict right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation. However, prediction using non-invasive parameters alone has not been established. The ratio of the diameters of the pulmonary artery (PAD) to those of the ascending aorta (AoD) may indicate past hemodynamic load and cardiac dysfunction. We aimed to investigate a predictive model for RVF after LVAD implantation using non-invasive parameters including PAD/AoD ratio.

METHODS

We studied 141 patients who underwent primary LVAD implantation and 117 healthy individuals with computed tomography (CT) data. RVF was defined as the need for a subsequent right ventricular assist device or intravenous inotrope administration for more than 30 days after LVAD implantation. The PAD/AoD ratio was measured at the level of the pulmonary artery bifurcation on the CT transaxial slices.

RESULTS

RVF was observed in 29 patients. The correlation between PAD and AoD differed among healthy individuals, patients with and without RVF. Patients with RVF had higher total bilirubin and log brain natriuretic peptide (BNP) levels, a lower left ventricular end-diastolic diameter (LVDd) index, and a higher PAD/AoD ratio than those without RVF. Decision tree analysis indicated that the subgroup with a high PAD/AoD ratio (≥1.09) and a small LVDd index (<35.4 mm/m2) showed the highest probability of RVF (100 %), while the subgroup with a low PAD/AoD ratio (<1.09) and low log BNP (<2.79) showed the lowest probability of RVF (1 %).

CONCLUSION

Combining non-invasive parameters with the PAD/AoD ratio can predict RVF with high accuracy.

Lobectomy Increases Postoperative Pulmonary Artery Enlargement to a Greater Extent than Segmentectomy

PURPOSE

The underlying mechanism why segmentectomy has demonstrated the non-inferiority to lobectomy in several randomized trials remains unclear. Computed tomography (CT)-measured pulmonary artery (PA) enlargement reflects PA pressure and predicts the prognosis of certain respiratory diseases. We compared the preoperative and postoperative PA diameter to the ascending aorta diameter (PA/A) ratio, investigating its impact on right ventricular function in lung resection.

METHODS

This retrospective study was conducted in patients with lower-lobe lung tumors who underwent anatomical lung resection between 2017 and 2022. The PA diameter at the bifurcation and the ascending aorta diameter at the same CT image slice were measured preoperatively and postoperatively. We calculated the enlargement of PA/A ratio (PA/A change) and compared lobectomy and segmentectomy.

RESULTS

This analysis included 279 patients (235 with lobectomy and 44 with segmentectomy). The PA/A change was significantly greater in patients with lobectomy than segmentectomy (104% vs. 102%, P = 0.02). In the multivariable analysis, airflow obstruction (yes, P = 0.04) and the type of surgery (segmentectomy, P = 0.04) were independent prognostic factors for PA/A change.

CONCLUSIONS

The PA/A change was greater in lobectomy than in segmentectomy. This change could reflect a burden on right ventricular function after lobectomy.

Differential Association of COPD Subtypes With Cardiovascular Events and COPD Exacerbations

BACKGROUND

The coronary artery calcium score (CACS) and ratio of the pulmonary artery to aorta diameters (PA:A ratio) measured from chest CT scans have been established as predictors of cardiovascular events and COPD exacerbations, respectively. However, little is known about the reciprocal relationship between these predictors and outcomes. Furthermore, the prognostic implications of COPD subtypes on clinical outcomes remain insufficiently characterized.

RESEARCH QUESTION

How can these two chest CT scan-derived parameters predict subsequent cardiovascular events and COPD exacerbations in different COPD subtypes?

STUDY DESIGN AND METHODS

Using COPDGene study data, we assessed prospective cardiovascular disease (CVD) and COPD exacerbation risk in participants with COPD (Global Initiative for Chronic Obstructive Lung Disease spirometric grades 2-4), focusing on CACS and PA:A ratio at study enrollment, with logistic regression models. These outcomes were analyzed in three COPD subtypes: 1,042 participants with non-emphysema-predominant COPD (NEPD; low attenuation area at -950 Hounsfield units [LAA-950] < 5%), 1,324 participants with emphysema-predominant COPD (EPD; LAA-950 ≥ 10%), and 465 participants with intermediate emphysema COPD (IE; 5% ≤ LAA-950 < 10%).

RESULTS

Our study indicated significantly higher overall risk for cardiovascular events in participants with higher CACS (≥ median; OR, 1.61; 95% CI, 1.30-2.00) and increased COPD exacerbations in those with higher PA:A ratios (≥ 1; OR, 1.80; 95% CI, 1.46-2.23). Notably, participants with NEPD showed a stronger association between these indicators and clinical events compared to EPD (with CACS/CVD, NEPD vs EPD: OR, 2.02 vs 1.41; with PA:A ratio/COPD exacerbation, NEPD vs EPD: OR, 2.50 vs 1.65); the difference in ORs between COPD subtypes was statistically significant for CACS/CVD.

INTERPRETATION

Two chest CT scan parameters, CACS and PA:A ratio, hold distinct predictive values for cardiovascular events and COPD exacerbations that are influenced by specific COPD subtypes.

TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT00608764; URL: www.

CLINICALTRIALS

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Clinical features, management in the emergency department and mortality of acute heart failure episodes in patients with chronic obstructive pulmonary disease

OBJECTIVES

This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease (COPD) who present to the emergency department with acute heart failure (AHF). Additionally, it examines mortality rates during such episodes.

METHODS

We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD. We compared their baseline characteristics, decompensation episodes, and emergency department management with those of AHF patients without COPD during the same period. We collected data on in-hospital and 30-day all-cause mortality, investigating differences between the two groups using crude and adjusted logistic regression models.

RESULTS

A total of 21,694 AHF patients were analysed (median age = 83 years, 56% female), including 4,942 (23%) with COPD. COPD patients were generally younger and more frequently male, with a higher prevalence of comorbidities (excluding valve disease and dementia, which were more common in non-COPD patients). They exhibited a worse respiratory functional class (NYHA) but a better overall functional capacity (Barthel Index). Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia, hypertensive crisis, or acute coronary syndrome. While there were differences in clinical findings in the emergency department, the severity assessed by the MEESSI-AHF Scale was similar across both groups. In terms of emergency department management, a higher proportion of COPD patients received oxygen therapy, non-invasive ventilation, bronchodilators, corticosteroids, and antibiotics, while fewer received intravenous nitroglycerin, and they were hospitalized more frequently. In-hospital mortality rates were 8.1% for patients with COPD and 7.5% for those without (OR = 1.088, 95% CI = 0.968-1.224), with 30-day mortality rates of 11.0% and 10.0%, respectively (OR = 1.111, 95% CI = 1.002-1.231). After adjusting for clinical characteristics, decompensation episodes, and emergency department management, these odds ratios decreased to 1.040 (95% CI = 0.905-1.195) and 1.080 (95% CI = 0.957-1.219), respectively.

CONCLUSION

Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization. Although they show higher crude 30-day mortality, this is attributable to their differing clinical profiles rather than the presence of COPD itself.

[CT imaging of chronic obstructive pulmonary disease: What aspects and what role?]

Chronic obstructive pulmonary disease (COPD), commonly defined as irreversible airflow limitation, is associated with specific morphological changes involving all three parts of the lung, namely the bronchi, parenchyma and pulmonary vessels. In vivo imaging, with its ability to describe the different types of lung alterations and their regional distribution, helps to elucidate the relationship between lung structure and respiratory function. High-resolution computed tomography (CT) of the lung is the imaging modality best suited to assessing the pathological changes associated with airflow obstruction occurring in COPD. Over the last few decades, numerous studies have demonstrated the role of CT as a morphological and functional method conducive to the phenotyping of COPD patients. This review proposes to examine the data on CT imaging of COPD with a critical approach to recent data, and to determine the extent to which CT could be integrated into care or clinical research on patients with this/these disease(s).

Preacinar Arterial Dilation Mediates Outcomes of Quantitative Interstitial Abnormalities in the COPDGene Study

Rationale: Quantitative interstitial abnormalities (QIAs) are a computed tomography (CT) measure of early parenchymal lung disease associated with worse clinical outcomes, including exercise capacity and symptoms. The presence of pulmonary vasculopathy in QIAs and its role in the QIA-outcome relationship is unknown. Objectives: To quantify radiographic pulmonary vasculopathy in QIAs and determine whether this vasculopathy mediates the QIA-outcome relationship. Methods: Ever-smokers with QIAs, outcomes, and pulmonary vascular mediator data were identified from the Genetic Epidemiology of COPD (COPDGene) study cohort. CT-based vascular mediators were right ventricle-to-left ventricle ratio, pulmonary artery-to-aorta ratio, and preacinar intraparenchymal arterial dilation (pulmonary artery volume, 5-20 mm2 in cross-sectional area, normalized to total arterial volume). Outcomes were 6-minute walk distance and a modified Medical Council Research Council Dyspnea Scale score of 2 or higher. Adjusted causal mediation analyses were used to determine whether the pulmonary vasculature mediated the QIA effect on outcomes. Associations of preacinar arterial dilation with select plasma biomarkers of pulmonary vascular dysfunction were examined. Measurements and Main Results: Among 8,200 participants, QIA burden correlated positively with vascular damage measures, including preacinar arterial dilation. Preacinar arterial dilation mediated 79.6% of the detrimental impact of QIA on 6-minute walk distance (56.2-100%; P < 0.001). Pulmonary artery-to-aorta ratio was a weak mediator, and right ventricle-to-left ventricle ratio was a suppressor. Similar results were observed in the relationship between QIA and modified Medical Council Research Council dyspnea score. Preacinar arterial dilation correlated with increased pulmonary vascular dysfunction biomarker levels, including angiopoietin-2 and N-terminal brain natriuretic peptide. Conclusions: Parenchymal QIAs deleteriously impact outcomes primarily through pulmonary vasculopathy. Preacinar arterial dilation may be a novel marker of pulmonary vasculopathy in QIAs.

Lung imaging in COPD and asthma

Chronic obstructive pulmonary disease (COPD) and asthma are common lung diseases with heterogeneous clinical presentations. Lung imaging allows evaluations of underlying pathophysiological changes and provides additional personalized approaches for disease management. This narrative review provides an overview of recent advances in chest imaging analysis using various modalities, such as computed tomography (CT), dynamic chest radiography, and magnetic resonance imaging (MRI). Visual CT assessment localizes emphysema subtypes and mucus plugging in the airways. Dedicated software quantifies the severity and spatial distribution of emphysema and the airway tree structure, including the central airway wall thickness, branch count and fractal dimension of the tree, and airway-to-lung size ratio. Nonrigid registration of inspiratory and expiratory CT scans quantifies small airway dysfunction, local volume changes and shape deformations in specific regions. Lung ventilation and diaphragm movement are also evaluated on dynamic chest radiography. Functional MRI detects regional oxygen transfer across the alveolus using inhaled oxygen and ventilation defects and gas diffusion into the alveolar-capillary barrier tissue and red blood cells using inhaled hyperpolarized 129Xe gas. These methods have the potential to determine local functional properties in the lungs that cannot be detected by lung function tests in patients with COPD and asthma. Further studies are needed to apply these technologies in clinical practice, particularly for early disease detection and tailor-made interventions, such as the efficient selection of patients likely to respond to biologics. Moreover, research should focus on the extension of healthy life expectancy in patients at higher risk and with established diseases.

Screening and diagnosis of pulmonary hypertension associated with chronic lung disease (PH-CLD): A consensus statement from the pulmonary vascular research institute's innovative drug development initiative-group 3 pulmonary hypertension

Pulmonary hypertension (PH) is a frequent complication of chronic lung disease (CLD). However, PH is difficult to diagnose early since accompanying symptoms overlap and are similar to those of the underlying CLD. In most cases the PH is mild to moderate and therefore physical signs may be absent or subtle. This consensus paper provides insight into the clues that might suggest the presence of occult PH in patients with CLD. An overview of current diagnostic tools and emerging diagnostic technologies is provided as well as guidance for the work-up and diagnosis of PH in patients with CLD.

Proteomic Risk Score of Increased Respiratory Susceptibility: A Multi-Cohort Study

RATIONALE

Accelerated decline in lung function is associated with incident COPD, hospitalizations and death. However, identifying this trajectory with longitudinal spirometry measurements is challenging in clinical practice.

OBJECTIVE

To determine whether a proteomic risk score trained on accelerated decline in lung function can assess risk of future respiratory disease and mortality.

METHODS

In CARDIA, a population-based cohort starting in young adulthood, longitudinal measurements of FEV1 percent predicted (up to six timepoints over 30 years) were used to identify accelerated and normal decline trajectories. Protein aptamers associated with an accelerated decline trajectory were identified with multivariable logistic regression followed by LASSO regression. The proteomic respiratory susceptibility score was derived based on these circulating proteins and applied to the UK Biobank and COPDGene studies to examine associations with future respiratory morbidity and mortality.

MEASUREMENTS AND RESULTS

Higher susceptibility score was independently associated with all-cause mortality (UKBB: HR 1.56, 95%CI 1.50-1.61; COPDGene: HR 1.75, 95%CI 1.63-1.88), respiratory mortality (UKBB: HR 2.39, 95% CI 2.16-2.64; COPDGene: HR 1.83, 95%CI 1.33-2.51), incident COPD (UKBB: HR 1.84, 95%CI 1.71-1.98), incident respiratory exacerbation (COPDGene: OR 1.11, 95%CI 1.03-1.20), and incident exacerbation requiring hospitalization (COPDGene: OR 1.18, 95%CI 1.08-1.28).

CONCLUSIONS

A proteomic signature of increased respiratory susceptibility identifies people at risk of respiratory death, incident COPD, and respiratory exacerbations. This susceptibility score is comprised of proteins with well-known and novel associations with lung health and holds promise for the early detection of lung disease without requiring years of spirometry measurements.

Significance of Pulmonary Artery Dilatation in Lung Cancer Patients With Chronic Obstructive Pulmonary Disease Who Underwent Pulmonary Resection

Background

The significance of pulmonary artery (PA) diameter in patients with non-small cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD) who undergo pulmonary resection has not been elucidated.

Methods

Data of 357 patients with NSCLC and COPD who underwent pulmonary resection were retrospectively reviewed. The main PA diameter, determined by preoperative computed tomography, relative to the body surface area (PBR), was used as an index of PA dilatation, and patients were divided into 2 groups using median values. The relationship between the PBR and short- and long-term outcomes was also analyzed.

Results

The mean age was 70.8 years, and 82% of the patients were men. The median main PA diameter was 24 mm (range, 17-43 mm), and the median PBR was 14.5 (range, 10.4-28.6). Lobectomy or more was performed in 276 patients (78%) and sublobar resection in 81 patients (22%). The postoperative complication rates did not differ between the low- and high-PBR groups (33% vs 32%, P = .91). The relapse-free survival (RFS) and overall survival (OS) rates of the low-PBR group were significantly better than those of the high-PBR group (5-year RFS: 76% vs 59%, P = .0003; 5-year OS: 88% vs 72%, P = .0010). A multivariable analysis identified high PBR as a poor prognostic factor for both RFS and OS.

Conclusions

PA dilatation was associated with poor long-term outcomes and was an independent poor prognostic factor for both RFS and OS in NSCLC patients with COPD who underwent pulmonary resection.

Revisiting the Clinical Interpretation of CT-Measured Pulmonary Artery-to-Aorta Ratio-The Rotterdam Study

RATIONALE

The pulmonary artery (PA) diameter-to-aorta ratio (PA:A) ratio is a novel marker in cardiovascular imaging for detecting pulmonary hypertension. However, we question the effect of the varying aorta diameter on the ratio, which complicates the interpretation of the PA:A ratio.

OBJECTIVE

Investigate the variability of the PA:A ratio by examining the correlation between PA:A ratio and aorta diameter and by comparing the associations of the PA diameter, aorta diameters, and PA:A ratio.

METHODS

We included 2197 participants from the Rotterdam Study who underwent non-contrast multidetector computed tomography to measure the PA and aorta diameters. Pearson correlation coefficient was calculated between the PA:A ratio and aorta diameter. Multiple linear regression analyses were performed to compare the determinants of the individual diameters and PA:A ratio.

RESULTS

We found a statistically significant correlation between the PA:A ratio and aorta diameter (r = -0.38, p < 0.001). The PA diameter was statistically significantly associated with, height, weight, diastolic blood pressure, blood pressure medication, prevalence of atrial fibrillation, prevalence of heart failure, and prevalence of stroke (p < 0.05). Except for blood pressure medication, the PA:A ratio had similar determinants compared to the PA diameter but was also statistically significantly associated with sex, and systolic blood pressure (p < 0.05), which were statistically significantly associated with the aorta diameter (p < 0.05).

CONCLUSION

The PA:A ratio should not be interpreted without taking into account the variability of the individual components (PA and aorta diameter) according to the anthropomorphic and clinical characteristics.

Severe pulmonary hypertension in chronic obstructive pulmonary disease - From clinical perspective to histological evidence

Severe pulmonary hypertension (PH) in chronic obstructive pulmonary disease (COPD) is currently defined by an elevated mean pulmonary arterial pressure and strongly elevated pulmonary vascular resistance >5 wood units. Clinically, these patients show a male predominance, and usually present with very severe dyspnea, severe hypoxemia, strongly decreased exercise capacity and poor prognosis, even though the clinical picture is frequently associated with less severe airflow obstruction. Explanted lung samples of patients with COPD and severe PH show severe remodeling of small pulmonary arterioles, predominantly in the intima and media of the vessels. In this concise review, we discuss the clinical and histopathological evidence of severe PH in COPD.

The clinical characteristics associated with the ratio between the main pulmonary artery and ascending aorta diameter in patients with acute exacerbation of chronic obstructive pulmonary disease

Background

A pulmonary artery-to-aorta (PA/A) ratio of ≥1 is a reliable indicator of pulmonary hypertension and is associated with an increased risk of acute exacerbation of chronic obstructive pulmonary disease (COPD) and long-term mortality in patients with stable COPD. However, it is unclear whether a PA/A ratio of ≥1 is associated with mortality in patients hospitalized with acute exacerbation of COPD. The purpose of this study was to evaluate the clinical course and mortality of patients with PA/A ratios of ≥1 who were hospitalized with acute exacerbation of COPD.

Methods

We retrospectively reviewed the medical charts of patients admitted to a tertiary referral hospital and a secondary hospital with acute exacerbation of COPD between 2016 and 2021. Chest computed tomography was used to measure the pulmonary artery (PA), aorta (A) diameter, and the PA/A ratio. The study involved 324 and 111 patients with PA/A ratios <1 and ≥1, respectively.

Results

The average age in the two groups was 74.1 and 74.5 years, which was not significantly different. When compared with the group with PA/A ratios of <1, the group with PA/A ratios of ≥1 had a lower proportion of males (71.2% vs. 89.5%, P<0.001), more patients with type 2 respiratory failure (35.1% vs. 18.8%), higher high-flow nasal cannula use (10.8% vs. 4.6%), higher use of non-invasive ventilation (NIV) (21.6% vs. 7.7%), and longer hospital stay (10.9 vs. 9.5 days). In-hospital mortality was not significantly different between the two groups. A PA/A ratio of ≥1 was identified as an independent predictor of the need for high-flow nasal cannula, NIV, and intubation in COPD patients.

Conclusions

Patients with PA/A ratios of ≥1 had a high incidence of type 2 acute respiratory failure and required advanced treatment, including high-flow nasal cannula, NIV, and intubation. Therefore, hospitalized patients with acute exacerbation of COPD and PA/A ratios of ≥1 require more aggressive treatment.

Non-invasive surrogate markers of pulmonary hypertension are associated with poor survival in patients with cancer

BACKGROUND

Cancer is one of the leading causes of death worldwide, and cardiopulmonary comorbidities may further adversely affect cancer prognosis. We recently described lung cancer-associated pulmonary hypertension (PH) as a new form of PH and comorbidity of lung cancer. While patients with lung cancer with PH had significantly reduced overall survival compared with patients without PH, the prevalence and impact of PH in other cancers remain unclear.

METHODS

In this retrospective, observational cohort study, we analysed the prevalence and impact of PH on clinical outcomes in 1184 patients with solid tumours other than lung cancer, that is, colorectal, head and neck, urological, breast or central nervous system tumours, using surrogate markers for PH determined by CT.

RESULTS

PH prevalence in this cohort was 10.98%. A Cox proportional hazard model revealed a significant reduction in the median survival time of patients with cancer with PH (837 vs 2074 days; p<0.001). However, there was no correlation between pulmonary metastases and PH. A subgroup analysis showed that PH was linked to decreased lung and cardiac function. Additionally, PH was associated with systemic arterial hypertension (p<0.001) and coronary artery disease (p=0.014), but not emphysema.

CONCLUSIONS

In this study, fewer patients with cancer had surrogate parameters for PH compared with previously published results among patients with lung cancer. Consequently, the prevalence of PH in other cancers might be lower compared with lung cancer; however, PH still has a negative impact on prognosis. Furthermore, our data does not provide evidence that lung metastases cause PH. Thus, our results support the idea that lung cancer-associated PH represents a new category of PH. Our results also highlight the importance of further studies in the field of cardio-oncology.

Increased adiposity-to-muscle ratio and severity of sinusitis affect quality of life in asthma: Computed tomographic analysis

Background

Deteriorated sinusitis and increased adiposity relative to muscle mass may affect quality of life in patients with asthma. However, whether these effects are observed regardless of intrapulmonary pathology is unknown.

Objectives

We evaluated the correlation of the cross-sectional ratio of abdominal visceral fat (VF) to erector spinae muscle (ESM) and sinus findings based on Lund-Mackey scoring system (LMS) on computed tomography (CT) with the impaired score of the Asthma Quality of Life Questionnaire (AQLQ), regardless of airway and parenchymal disease, in patients with asthma.

Methods

We recruited participants from the Hokkaido-based severe asthma cohort who had completed AQLQ and CT examination at the entry. The participants were divided into high (highest) and low (other quartiles) groups on the bases of the extrapulmonary indices. Multivariate analysis examined the association of VF/ESM for the adiposity-to-muscle ratio and LMS with AQLQ after adjusting for the airway fractal dimension for airway index and percentage of low attenuation volume to lung volume for parenchymal index.

Results

No significant differences were observed in VF/ESM and LMS in terms of sex. The AQLQ score in the high VF/ESM group and high LMS group was lower than those in low VF/ESM group and low LMS group (63 male and 100 female subjects). High VF/ESM (estimate [95% confidence interval] (-0.43 [-0.61, -0.25]) and high LMS scores (-0.22 [-0.41, -0.03]) were associated with low AQLQ scores when adjusted for age, body mass index, smoking status, blood eosinophil count, and intrapulmonary CT indices.

Conclusions

Increased VF relative to ESM mass and high LMS may deteriorate asthma-related quality of life, regardless of presence of intrapulmonary disease.

A Multicenter Study of COPD and Cognitive Impairment: Unraveling the Interplay of Quantitative CT, Lung Function, HIF-1α, and Clinical Variables

Purpose

The exact link between cognitive impairment (CI) and chronic obstructive pulmonary disease (COPD) is still limited. Thus, we aim to find the relationship and interaction of quantitative CT (QCT), lung function, HIF-1α, and clinical factors with the development of CI among COPD patients.

Patients and Methods

A cross-sectional multicentre study was conducted from January 2022 to December 2023. We collected clinical data, spirometry, CT images, and venous blood samples from 114 COPD participants. Cognitive impairment assessment using the Montreal Cognitive Assessment Indonesian version (MoCA-Ina) with a cutoff value 26. The QCT analysis consists of lung density, airway wall thickness, pulmonary artery-to-aorta ratio (PA:A), and pectoralis muscles using 3D Slicer software. Serum HIF-1α analysis was performed using ELISA.

Results

We found significant differences between %LAA-950, age, COPD duration, BMI, FEV1 pp, and FEV1/FVC among GOLD grades I-IV. Only education duration was found to correlate with CI (r = 0.40; p < 0.001). We found no significant difference in HIF-1α among GOLD grades (p = 0.149) and no correlation between HIF-1α and CI (p = 0.105). From multiple linear regression, we observed that the MoCA-Ina score was influenced mainly by %LAA-950 (p = 0.02) and education duration (p = 0.01). The path analysis model showed both %LAA and education duration directly and indirectly through FEV1 pp contributing to CI.

Conclusion

We conclude that the utilization of QCT parameters is beneficial as it can identify abnormalities and contribute to the development of CI, indicating its potential utility in clinical decision-making. The MoCA-Ina score in COPD is mainly affected by %LAA-950 and education duration. Contrary to expectations, this study concludes that HIF-1α does not affect CI among COPD patients.

Vessel and Airway Characteristics in One-Year Computed Tomography-defined Rapid Emphysema Progression: SPIROMICS

Rationale: Rates of emphysema progression vary in chronic obstructive pulmonary disease (COPD), and the relationships with vascular and airway pathophysiology remain unclear. Objectives: We sought to determine if indices of peripheral (segmental and beyond) pulmonary arterial dilation measured on computed tomography (CT) are associated with a 1-year index of emphysema (EI; percentage of voxels <-950 Hounsfield units) progression. Methods: Five hundred ninety-nine former and never-smokers (Global Initiative for Chronic Obstructive Lung Disease stages 0-3) were evaluated from the SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study) cohort: rapid emphysema progressors (RPs; n = 188, 1-year ΔEI > 1%), nonprogressors (n = 301, 1-year ΔEI ± 0.5%), and never-smokers (n = 110). Segmental pulmonary arterial cross-sectional areas were standardized to associated airway luminal areas (segmental pulmonary artery-to-airway ratio [PAARseg]). Full-inspiratory CT scan-derived total (arteries and veins) pulmonary vascular volume (TPVV) was compared with small vessel volume (radius smaller than 0.75 mm). Ratios of airway to lung volume (an index of dysanapsis and COPD risk) were compared with ratios of TPVV to lung volume. Results: Compared with nonprogressors, RPs exhibited significantly larger PAARseg (0.73 ± 0.29 vs. 0.67 ± 0.23; P = 0.001), lower ratios of TPVV to lung volume (3.21 ± 0.42% vs. 3.48 ± 0.38%; P = 5.0 × 10-12), lower ratios of airway to lung volume (0.031 ± 0.003 vs. 0.034 ± 0.004; P = 6.1 × 10-13), and larger ratios of small vessel volume to TPVV (37.91 ± 4.26% vs. 35.53 ± 4.89%; P = 1.9 × 10-7). In adjusted analyses, an increment of 1 standard deviation in PAARseg was associated with a 98.4% higher rate of severe exacerbations (95% confidence interval, 29-206%; P = 0.002) and 79.3% higher odds of being in the RP group (95% confidence interval, 24-157%; P = 0.001). At 2-year follow-up, the CT-defined RP group demonstrated a significant decline in postbronchodilator percentage predicted forced expiratory volume in 1 second. Conclusions: Rapid one-year progression of emphysema was associated with indices indicative of higher peripheral pulmonary vascular resistance and a possible role played by pulmonary vascular-airway dysanapsis.

Expiratory Venous Volume and Arterial Tortuosity are Associated with Disease Severity and Mortality Risk in Patients with COPD: Results from COSYCONET

Purpose

The aim of this study was to evaluate the association between computed tomography (CT) quantitative pulmonary vessel morphology and lung function, disease severity, and mortality risk in patients with chronic obstructive pulmonary disease (COPD).

Patients and Methods

Participants of the prospective nationwide COSYCONET cohort study with paired inspiratory-expiratory CT were included. Fully automatic software, developed in-house, segmented arterial and venous pulmonary vessels and quantified volume and tortuosity on inspiratory and expiratory scans. The association between vessel volume normalised to lung volume and tortuosity versus lung function (forced expiratory volume in 1 sec [FEV1]), air trapping (residual volume to total lung capacity ratio [RV/TLC]), transfer factor for carbon monoxide (TLCO), disease severity in terms of Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D, and mortality were analysed by linear, logistic or Cox proportional hazard regression.

Results

Complete data were available from 138 patients (39% female, mean age 65 years). FEV1, RV/TLC and TLCO, all as % predicted, were significantly (p < 0.05 each) associated with expiratory vessel characteristics, predominantly venous volume and arterial tortuosity. Associations with inspiratory vessel characteristics were absent or negligible. The patterns were similar for relationships between GOLD D and mortality with vessel characteristics. Expiratory venous volume was an independent predictor of mortality, in addition to FEV1.

Conclusion

By using automated software in patients with COPD, clinically relevant information on pulmonary vasculature can be extracted from expiratory CT scans (although not inspiratory scans); in particular, expiratory pulmonary venous volume predicted mortality.

Trial Registration

NCT01245933.

Obstructive Sleep Apnea Effects on Chronic Airway Disease Exacerbations-Missed Opportunities for Improving Outcomes in Chronic Obstructive Pulmonary Disease and Asthma

In patients with chronic obstructive pulmonary disease (COPD) and asthma, exacerbations determine the natural history of both diseases. Patients with both respiratory diseases who suffer from obstructive sleep apnea (OSA) as a comorbidity (overlap syndromes) have a higher risk of exacerbations and hospitalization. In cases of OSA/COPD and OSA/asthma, continuous positive airway pressure treatment is indicated. Adequate adherence to therapy appears to reduce exacerbations and their severity, especially in OSA/COPD overlap. However, there is a lack of randomized trials that definitively demonstrate this evidence.

Advances in COPD imaging using CT and MRI: linkage with lung physiology and clinical outcomes

Recent years have witnessed major advances in lung imaging in patients with COPD. These include significant refinements in images obtained by computed tomography (CT) scans together with the introduction of new techniques and software that aim for obtaining the best image whilst using the lowest possible radiation dose. Magnetic resonance imaging (MRI) has also emerged as a useful radiation-free tool in assessing structural and more importantly functional derangements in patients with well-established COPD and smokers without COPD, even before the existence of overt changes in resting physiological lung function tests. Together, CT and MRI now allow objective quantification and assessment of structural changes within the airways, lung parenchyma and pulmonary vessels. Furthermore, CT and MRI can now provide objective assessments of regional lung ventilation and perfusion, and multinuclear MRI provides further insight into gas exchange; this can help in structured decisions regarding treatment plans. These advances in chest imaging techniques have brought new insights into our understanding of disease pathophysiology and characterising different disease phenotypes. The present review discusses, in detail, the advances in lung imaging in patients with COPD and how structural and functional imaging are linked with common resting physiological tests and important clinical outcomes.

Survival and response to pulmonary vasodilator therapies in patients with chronic obstructive pulmonary disease and pulmonary vascular phenotype

BACKGROUND

The aim of the study was to describe and investigate the effect of pulmonary arterial hypertension (PAH) therapies in a cohort of patients with severe precapillary pulmonary hypertension (PH) associated with chronic obstructive pulmonary disease (COPD; PH-COPD), and to assess factors predictive of treatment response and mortality.

MATERIAL AND METHODS

We retrospectively included patients with severe incident PH-COPD who received PAH therapy and underwent RHC at diagnosis and on treatment.

RESULTS

From 2015 to 2022, 35 severe PH-COPD patients, with clinical features of pulmonary vascular phenotype, were included. Seventeen (48.5%) patients were treated with combined PAH therapy. PAH therapy led to a significant improvement in hemodynamics (PVR -3.5 Wood Units (-39.3%); p < 0.0001), and in the simplified four-strata risk-assessment score, which improved by at least one category in 21 (60%) patients. This effect was more pronounced in patients on dual therapy. Kaplan-Meier estimated survival rates at 1, 3 and 5 years were 94%, 65% and 42% respectively. Univariate analysis showed a significant reduction in survival in patients with a higher simplified risk score at follow-up (Hazard ratio (HR) 2.88 [1.16-7.15]; p = 0.02). Hypoxemia <50 mmHg was correlated to mortality in multivariate analysis (HR 4.33 [1.08-17.42]; p = 0.04).

CONCLUSIONS

Our study confirms the poor prognosis of patients with COPD and a pulmonary vascular phenotype and the potential interest of combined PAH therapy in this population, with good tolerability and greater clinical and hemodynamic improvement than monotherapy. Using the simplified risk score during follow-up could be of interest in this population.

Cardiovascular disease and risk in COPD: a state of the art review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases (CVD) commonly co-exist. Outcomes of people living with both conditions are poor in terms of symptom burden, receiving evidence-based treatment and mortality. Increased understanding of the underlying mechanisms may help to identify treatments to relieve this disease burden. This narrative review covers the overlap of COPD and CVD with a focus on clinical presentation, mechanisms, and interventions. Literature up to December 2023 are cited.

AREAS COVERED

1. What is COPD 2. The co-existence of COPD and cardiovascular disease 3. Mechanisms of cardiovascular disease in COPD. 4. Populations with COPD are at risk of CVD 5. Complexity in the co-diagnosis of COPD in those with cardiovascular disease. 6. Therapy for COPD and implications for cardiovascular events and risk. 7. Cardiovascular risk and exacerbations of COPD. 8. Pro-active identification and management of CV risk in COPD.

EXPERT OPINION

The prospective identification of co-morbid COPD in CVD patients and of CVD and CV risk in people with COPD is crucial for optimizing clinical outcomes. This includes the identification of novel treatment targets and the design of clinical trials specifically designed to reduce the cardiovascular burden and mortality associated with COPD. Databases searched: Pubmed, 2006-2023.

Prevalence of pulmonary artery dilation in non-cystic fibrosis bronchiectasis: a computed tomography analysis from a cohort of the US Bronchiectasis and Nontuberculous Mycobacteria Research Registry

Although pulmonary artery (PA) dilation is independently associated with significant morbidity and mortality in patients with pulmonary diseases irrespective of diagnosed pulmonary hypertension, its relationship with nontuberculous mycobacteria (NTM) is unknown. The Bronchiectasis and NTM Research Registry is a multicenter registry created to foster research in non-cystic fibrosis (CF) bronchiectasis and NTM lung disease. The majority of patients with non-CF bronchiectasis at Oregon Health & Science University have NTM infections. To determine the prevalence of PA dilation in these patients and its association with supplemental oxygen use, severity of bronchiectasis, tobacco use, and NTM in the sputum culture, we evaluated the chest computed tomography (CT) scans from 321 patients in a cross-sectional analysis. We measured the severity of bronchiectasis by applying modified Reiff criteria and measured the diameters of the PA and aorta (Ao), with PA dilation defined as a PA:Ao ratio >0.9. In our cohort, the mean age was 67.3 years and 83.2% were female. The mean modified Reiff score was 7.1, indicating moderate disease severity. Forty-two patients (13.1%) were found to have PA dilation. PA dilation was positively associated with the use of supplemental oxygen (P<0.001), but there was no association between PA dilation and NTM infection.

The impact of pulmonary artery to ascending aorta diameter ratio progression on the prognosis of NSCLC patients treated with immune checkpoint inhibitors

Background

Immunotherapy, represented by immune checkpoint inhibitors (ICIs), is a major breakthrough in cancer treatment. Studies have reported that the use of ICIs is associated with an increase in the pulmonary artery to ascending aorta diameter (PAD/AoD) ratio. However, the impact of PAD/AoD ratio progression on the prognosis of patients is unclear.

Methods

This retrospective cohort study included patients with stage III or IV non-small cell lung cancer (NSCLC) treated with ICIs at the Wuhan Union Hospital between March 1, 2020, and September 1, 2022. The baseline and post-treatment PAD/AoD ratios of patients were evaluated through chest CT scans. The primary outcome of this study was overall survival (OS), while the secondary outcomes included progression-free survival (PFS), objective response rate (ORR) and disease control rate (DCR).

Results

The PAD/AoD ratio increased after the initiation of ICIs (from 0.75 to 0.78; P < 0.001). A total of 441 patients were divided into severe group (n=221) and non-severe group (n=220) according to the median increase of PAD/AoD ratio (1.06). Compared with the non-severe group, the severe group had a lower DCR (87.8% vs. 96.0%, P = 0.005) and ORR (87.5% vs. 96.0%, P = 0.063). Over the entire duration of follow-up (median 22.0 months), 85 (38.5%) patients in the severe group and 30 (7.3%) patients in the non-severe group died. An increased PAD/AoD ratio was associated with shorter PFS (Hazard ratio (HR): 1.48 [95% CI, 1.14 to 1.93]; P = 0.003) and OS (HR: 3.50 [95% CI, 2.30 to 5.30]; P < 0.001). Similar results were obtained across subgroups.

Conclusions

ICI treatment exacerbates an increase in the PAD/AoD ratio in patients with cancer, and greater increase in the PAD/AoD ratio was associated with a worse prognosis. PAD/AoD ratio could be a biomarker to stratify prognosis of NSCLC patients treated with ICIs.

Diagnosis of COVID-19 with simultaneous accurate prediction of cardiac abnormalities from chest computed tomographic images

COVID-19 has potential consequences on the pulmonary and cardiovascular health of millions of infected people worldwide. Chest computed tomographic (CT) imaging has remained the first line of diagnosis for individuals infected with SARS-CoV-2. However, differentiating COVID-19 from other types of pneumonia and predicting associated cardiovascular complications from the same chest-CT images have remained challenging. In this study, we have first used transfer learning method to distinguish COVID-19 from other pneumonia and healthy cases with 99.2% accuracy. Next, we have developed another CNN-based deep learning approach to automatically predict the risk of cardiovascular disease (CVD) in COVID-19 patients compared to the normal subjects with 97.97% accuracy. Our model was further validated against cardiac CT-based markers including cardiac thoracic ratio (CTR), pulmonary artery to aorta ratio (PA/A), and presence of calcified plaque. Thus, we successfully demonstrate that CT-based deep learning algorithms can be employed as a dual screening diagnostic tool to diagnose COVID-19 and differentiate it from other pneumonia, and also predicts CVD risk associated with COVID-19 infection.

Analyses of Factors Associated with Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Review

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is the exacerbation of a range of respiratory symptoms during the stable phase of chronic obstructive pulmonary disease (COPD). AECOPD is thus a dangerous stage and key event in the course of COPD, as its deterioration and frequency seriously affects the quality of life of patients and shortens their survival. Acute exacerbations occur and develop due to many factors such as infection, tobacco smoke inhalation, air pollution, comorbidities, airflow limitation, various biomarkers, history of previous deterioration, natural killer cell abnormalities, immunoglobulin G deficiency, genetics, abnormal muscle and nutritional status, negative psychology, and seasonal temperature changes. There is relatively limited research on the impact of the role of standardized management on the alleviation of AECOPD. However, with the establishment of relevant prevention and management systems and the promotion of artificial intelligence technology and Internet medical approaches, long-term effective and standardized management of COPD patients may help to achieve the quality of life and disease prognosis in COPD patients and reduce the risk of AE.

Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is a major health problem with a high prevalence, a rising incidence, and substantial morbidity and mortality. Its course is punctuated by acute episodes of increased respiratory symptoms, termed exacerbations of chronic obstructive pulmonary disease (ECOPD). ECOPD are important events in the natural history of the disease, as they are associated with lung function decline and prolonged negative effects on quality of life. The present-day therapy for ECOPD with short courses of antibiotics and steroids and escalation of bronchodilators has resulted in only modest improvements in outcomes. Recent data indicate that ECOPD are heterogeneous, raising the need to identify distinct etioendophenotypes, incorporating traits of the acute event and of patients who experience recurrent events, to develop novel and targeted therapies. These characterizations can provide a complete clinical picture, the severity of which will dictate acute pharmacological treatment, and may also indicate whether a change in maintenance therapy is needed to reduce the risk of future exacerbations. In this review we discuss the latest knowledge of ECOPD types on the basis of clinical presentation, etiology, natural history, frequency, severity, and biomarkers in an attempt to characterize these events.

The utility of quantitative computed tomography in cohort studies of chronic obstructive pulmonary disease: a narrative review

Background and Objective

Chronic obstructive pulmonary disease (COPD) is a significant contributor to global morbidity and mortality. Quantitative computed tomography (QCT), a non-invasive imaging modality, offers the potential to assess lung structure and function in COPD patients. Amidst the coronavirus disease 2019 (COVID-19) pandemic, chest computed tomography (CT) scans have emerged as a viable alternative for assessing pulmonary function (e.g., spirometry), minimizing the risk of aerosolized virus transmission. However, the clinical application of QCT measurements is not yet widespread enough, necessitating broader validation to determine its usefulness in COPD management.

Methods

We conducted a search in the PubMed database in English from January 1, 2013 to April 20, 2023, using keywords and controlled vocabulary related to QCT, COPD, and cohort studies.

Key Content and Findings

Existing studies have demonstrated the potential of QCT in providing valuable information on lung volume, airway geometry, airway wall thickness, emphysema, and lung tissue density in COPD patients. Moreover, QCT values have shown robust correlations with pulmonary function tests, and can predict exacerbation risk and mortality in patients with COPD. QCT can even discern COPD subtypes based on phenotypic characteristics such as emphysema predominance, supporting targeted management and interventions.

Conclusions

QCT has shown promise in cohort studies related to COPD, since it can provide critical insights into the pathogenesis and progression of the disease. Further research is necessary to determine the clinical significance of QCT measurements for COPD management.

Association Between Pulmonary Vascular Volume and Cardiac Structure and Function in Patients With Atrial Fibrillation

Pulmonary vascular abnormalities, quantified from computed tomography scans, have frequently been observed in patients with pulmonary diseases. However, little is known about pulmonary vascular changes in patients with cardiac disease. Thus, we aimed to examine the cardiopulmonary relation in patients with atrial fibrillation (AF) by comparing pulmonary vascular volume (PVV) to echocardiographic measures and AF severity. A total of 742 patients (median age 63 years, 70% men) who underwent ablation for AF were included. Preprocedural cardiac computed tomography was used to measure the total and small-vessel PVV, along with the pulmonary artery to aorta ratio and the degree of emphysema. The association between PVV and echocardiographic parameters was evaluated using a multivariable linear regression analysis. Lower total and small-vessel PVV were associated with more impaired measures of cardiac structure and function, including but not limited to left ventricular ejection fraction and peak atrial longitudinal strain. Patients with reduced total and small-vessel PVV had higher odds of having persistent AF than paroxysmal AF in the unadjusted logistic regression analyses. However, after clinical and echocardiographic adjustments, only reduced small-vessel PVV remained independently associated with persistent AF (odds ratio 1.90, 95% confidence interval 1.26 to 2.87, p = 0.002). In conclusion, pulmonary vascular remodeling is associated with persistent AF and with more impaired measures of cardiac structure and function, providing further insights into heart-lung interactions in this patient group.

Quantitative CT measures of pulmonary vascular volume distribution in pulmonary hypertension associated with COPD: Association with clinical characteristics and outcomes

To determine whether quantitative computed tomography (qCT)-derived metrics of pulmonary vascular volume distribution could distinguish chronic obstructive pulmonary disease (COPD) subjects with associated pulmonary hypertension (PH) from those without and to characterize associations of these measurements with clinical and physiological characteristics and outcomes. We collected retrospective CT, pulmonary hemodynamic, clinical, and outcomes data from subjects with COPD and right-heart catheterization-confirmed PH (PH-COPD) and control subjects with COPD but without PH. We measured the volumes of pulmonary vessels < 5 and >10 mm2 in cross-sectional area as a percentage of total pulmonary vascular volume (qCT-derived volume of pulmonary vessels < 5 mm2 in cross-sectional area as a volume fraction of total pulmonary blood volume [BV5%] and qCT-derived volume of pulmonary vessels > 10 mm2 in cross-sectional area [BV10] as a volume fraction of total pulmonary blood volume [BV10%], respectively) using Functional Respiratory Imaging (FRI), an automated qCT platform, and compared them between PH and control arms and between subjects with mild-moderate PH and those with severe disease. Correlations of hemodynamics with pulmonary function and associations with survival were tested. Forty-five PH-COPD and 42 control subjects were studied. BV5% was lower in PH subjects (32.2% vs. 37.7%, p = 0.003), and BV10% was higher (50.2% vs. 43.5, p = 0.001). Subjects with severe PH did not differ from those with mild-moderate PH in qCT. Pulmonary vascular volumes were not associated with pulmonary function. BV10 was associated with mean pulmonary artery pressure (r = 0.3, p = 0.05). Associations with survival were observed for BV5% (hazard ratio 0.63, p = 0.02) and BV10% (hazard ratio 1.43, p = 0.03) in the PH-COPD arm, but not for controls. qCT-derived measures of pulmonary vascular volume may have diagnostic and prognostic significance in PH-COPD and should be investigated further as screening and risk stratification tools.

Stronger Associations of Centrilobular Than Paraseptal Emphysema With Longitudinal Changes in Diffusing Capacity and Mortality in COPD

BACKGROUND

The factors associated with longitudinal changes in diffusing capacity remain unclear among patients with COPD. Centrilobular emphysema (CLE) and paraseptal emphysema (PSE) are major emphysema subtypes that may have distinct clinical-physiological impacts in these patients.

RESEARCH QUESTION

Are CLE and PSE differently associated with longitudinal changes in diffusing capacity and mortality in patients with COPD?

STUDY DESIGN AND METHODS

This pooled analysis included 399 patients with COPD from two prospective observational COPD cohorts. CLE and PSE were visually assessed on CT scan according to the Fleischner Society statement. The diffusing capacity and transfer coefficient of the lung for carbon monoxide (Dlco and KCO) and FEV1 were evaluated at least annually over a 5-year period. Mortality was recorded over 10 years. Longitudinal changes in FEV1, Dlco, and KCO and mortality were compared between mild or less severe and moderate or more severe CLE and between present and absent PSE in each Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage.

RESULTS

The Dlco and KCO decline was weakly associated with FEV1 and greater in GOLD stage 3 or higher than in GOLD stages 1 and 2. Furthermore, moderate or more severe CLE, but not present PSE, was associated with steeper declines in Dlco for GOLD stages 1 and 3 or higher and KCO for all GOLD stages independent of age, sex, height, and smoking history. The moderate or more severe CLE, but not present PSE, was associated with additional FEV1 decline and higher 10-year mortality among patients with GOLD stage 3 or higher.

INTERPRETATION

A CT scan finding of moderate or more severe CLE, but not PSE, was associated with a subsequent accelerated impairment in diffusing capacity and higher long-term mortality in severe GOLD stage among patients with COPD.

Lung Imaging in COPD Part 2: Emerging Concepts

The diagnosis, prognostication, and differentiation of phenotypes of COPD can be facilitated by CT scan imaging of the chest. CT scan imaging of the chest is a prerequisite for lung volume reduction surgery and lung transplantation. Quantitative analysis can be used to evaluate extent of disease progression. Evolving imaging techniques include micro-CT scan, ultra-high-resolution and photon-counting CT scan imaging, and MRI. Potential advantages of these newer techniques include improved resolution, prediction of reversibility, and obviation of radiation exposure. This article discusses important emerging techniques in imaging patients with COPD. The clinical usefulness of these emerging techniques as they stand today are tabulated for the benefit of the practicing pulmonologist.

Exacerbations of COPD

COPD exacerbations are associated with significant morbidity, mortality, and increased health care expenditures. The recently published Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations have further refined the definition of an exacerbation. A better understanding of the risk factors associated with the development of an exacerbation exists, and improvements are being made in earlier detection approaches. Pharmacologic treatment strategies have been the cornerstone of effective therapy. In addition, both pharmacologic and non-pharmacologic strategies have been proven successful in the prevention of future exacerbations. Newer technologies, including the use of artificial intelligence and wearable monitoring devices, are now being used to help in the earlier detection of exacerbations. Such preventive and earlier detection strategies can help to develop a more personalized care model and improve outcomes for patients with COPD.

The PH-ILD Detection tool: External validation and use in patients with ILD

Pulmonary hypertension (PH) results in increased morbidity and mortality in patients with interstitial lung disease (ILD). Early recognition of PH in this population is essential for planning diagnostic testing, initiating therapy, and evaluating for lung transplantation. The previously developed PH-ILD Detection tool has significant potential in the evaluation and treatment of ILD patients; the aim of this study was to validate the tool in an independent, multicenter cohort of patients. We conducted a retrospective review of prospectively collected data from 161 ILD patients. Patients were stratified into low- (n = 78, 48.4%), intermediate- (n = 54, 33.5%), and high-risk (n = 29, 18.0%) groups based on the score obtained with the tool. Intermediate- and high-risk patients underwent follow-up echocardiogram (TTE); 49.4% (n = 41) had an abnormal TTE suggestive of underlying PH. These patients underwent right heart catheterization; PH-ILD was diagnosed in 73.2% (n = 30) of these cases. The PH-ILD Detection tool has a sensitivity of 93.3%, specificity of 90.9%, and area-under-the-curve of 0.921 for diagnosing PH in ILD patients, validating the findings from the original study and establishing the tool as a fundamental resource for early recognition of PH in ILD patients.

Pulmonary artery diameter and NT-proBNP in patients with Covid-19: Predicting prognosis and mortality

Background

The diverse and complex presentations of COVID-19 continue to impact the world. Factors related to prognosis and mortality are still not fully illuminated.

Objectives

We aimed to asses the relationship of N-terminal pro B-type natriuretic peptide (NT-proBNP) and main pulmonary artery diameter (MPAD) with COVID-19 prognosis and mortality.

Methods

152 COVID-19 patients over the age of 18, were included in the study. Thoracic CT, NT-proBNP values, laboratory and demographic data of these patients were obtained by retrospectively examining the patient files and scanning the results through the patient registry.

Results

According to multivariate logistic regression (LR) analysis, high NT-proBNP level (OR=3.542; 95% CI=1.745-9.463; p=0.021) and MPAD/ascending aortic diameter (AAD) ratio>0.75 (OR=2.692; 95% CI=1.264-9.312; p=0.036) were determined as independent risk factors predicting mortality in COVID-19 patients. A significant positive correlation was observed between NT-proBNP level and MPA diameter (r=0.296, p<0.001). The cut-off value was measured as 27.5 mm for MPA diameter and 742 pg/ml for NT-proBNP.

Conclusions

Accurate and effective interpretation of available radiological and laboratory data is essential to reveal the factors predicting prognosis and mortality in COVID-19. In this study,we evaluated that the thorax CTs and determined that the MPAD/AAD and NT-proBNP level were independent risk factors in predicting mortality.

Prevalence of pulmonary artery dilation in non-cystic fibrosis bronchiectasis: A CT analysis from a cohort of the US Bronchiectasis and Nontuberculous Mycobacteria Research Registry

Although pulmonary artery (PA) dilation is independently associated with significant morbidity and mortality in patients with pulmonary diseases irrespective of diagnosed pulmonary hypertension, its relationship to nontuberculous mycobacteria (NTM) is unknown. To determine the prevalence of PA dilation in patients with NTM-predominant non-CF bronchiectasis, we evaluated the chest computed tomography (CT) scans from 321 patient in the United States based Bronchiectasis and NTM Research Registry. The majority of our cohort had NTM infection. We measured the severity of bronchiectasis using modified Reiff criteria and measured the diameters of the PA and aorta (Ao), with PA dilation defined as a PA:Ao ratio > 0.9. Forty-two patients (13%) were found to have PA dilation. PA dilation was positively associated with the use of supplemental oxygen (p < 0.001), but there was no association between PA dilation and NTM infection.

Preoperative Pulmonary Artery-to-Aorta Diameter Ratio as a Predictor of Postoperative Severe Right Ventricular Failure and 1-Year Mortality After Left Ventricular Assist Device Implantation

OBJECTIVES

To evaluate the association of pulmonary artery diameter and pulmonary artery- to-aorta diameter ratio (PA/Ao) with right ventricular failure and mortality within 1 year after left ventricular assist device implantation.

DESIGN

This was a retrospective observational study between March 2013 and July 2019.

SETTING

The study was conducted at a single, quaternary-care academic center.

PARTICIPANTS

Adults (≥18 years old) receiving a durable left ventricular assist device (LVAD). Inclusion if (1) a chest computed tomography scan was performed within 30 days before the LVAD and (2) a right and left heart catheterization was completed within 30 days before the LVAD.

INTERVENTIONS

A left ventricular assist device was used for intervention.

MEASUREMENTS AND MAIN RESULTS

A total of 176 patients were included in this study. Median PA diameter and PA/Ao ratio were significantly greater in the severe right ventricular failure (RVF) group (p = 0.001, p < 0.001, respectively). Receiver operating characteristic analysis revealed PA/Ao and RVF as predictors for mortality (area under the curve = 0.725 and 0.933, respectively). Logistic regression analysis-predicted probability gave a PA/Ao ratio cutoff point of 1.04 (p < 0.001). Survival probability was significantly worse in patients with a PA/Ao ratio ≥1.04 (p = 0.005).

CONCLUSIONS

The PA/Ao ratio is an easily measurable noninvasive indicator that can predict RVF and 1-year mortality after LVAD implantation.

COPD: Providing the right treatment for the right patient at the right time

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Predicting severe chronic obstructive pulmonary disease exacerbations using quantitative CT: a retrospective model development and external validation study

BACKGROUND

Quantitative CT is becoming increasingly common for the characterisation of lung disease; however, its added potential as a clinical tool for predicting severe exacerbations remains understudied. We aimed to develop and validate quantitative CT-based models for predicting severe chronic obstructive pulmonary disease (COPD) exacerbations.

METHODS

We analysed the Subpopulations and Intermediate Outcome Measures In COPD Study (SPIROMICS) cohort, a multicentre study done at 12 clinical sites across the USA, of individuals aged 40-80 years from four strata: individuals who never smoked, individuals who smoked but had normal spirometry, individuals who smoked and had mild to moderate COPD, and individuals who smoked and had severe COPD. We used 3-year follow-up data to develop logistic regression classifiers for predicting severe exacerbations. Predictors included age, sex, race, BMI, pulmonary function, exacerbation history, smoking status, respiratory quality of life, and CT-based measures of density gradient texture and airway structure. We externally validated our models in a subset from the Genetic Epidemiology of COPD (COPDGene) cohort. Discriminative model performance was assessed using the area under the receiver operating characteristic curve (AUC), which was also compared with other predictors, including exacerbation history and the BMI, airflow obstruction, dyspnoea, and exercise capacity (BODE) index. We evaluated model calibration using calibration plots and Brier scores.

FINDINGS

Participants in SPIROMICS were enrolled between Nov 12, 2010, and July 31, 2015. Participants in COPDGene were enrolled between Jan 10, 2008, and April 15, 2011. We included 1956 participants from the SPIROMICS cohort who had complete 3-year follow-up data: the mean age of the cohort was 63·1 years (SD 9·2) and 1017 (52%) were men and 939 (48%) were women. Among the 1956 participants, 434 (22%) had a history of at least one severe exacerbation. For the CT-based models, the AUC was 0·854 (95% CI 0·852-0·855) for at least one severe exacerbation within 3 years and 0·931 (0·930-0·933) for consistent exacerbations (defined as ≥1 acute episode in each of the 3 years). Models were well calibrated with low Brier scores (0·121 for at least one severe exacerbation; 0·039 for consistent exacerbations). For the prediction of at least one severe event during 3-year follow-up, AUCs were significantly higher with CT biomarkers (0·854 [0·852-0·855]) than exacerbation history (0·823 [0·822-0·825]) and BODE index 0·812 [0·811-0·814]). 6965 participants were included in the external validation cohort, with a mean age of 60·5 years (SD 8·9). In this cohort, AUC for at least one severe exacerbation was 0·768 (0·767-0·769; Brier score 0·088).

INTERPRETATION

CT-based prediction models can be used for identification of patients with COPD who are at high risk of severe exacerbations. The newly identified CT biomarkers could potentially enable investigation into underlying disease mechanisms responsible for exacerbations.

FUNDING

National Institutes of Health and the National Heart, Lung, and Blood Institute.

Investigation of Pulmonary Artery and Ascending Aorta Morphology in the Coronavirus Disease 2019: A Radioanatomical Study

OBJECTIVE

This study aimed to determine the maximum diameters of the pulmonary artery and ascending aorta and their ratio to each other to enable early diagnosis and treatment of possible pulmonary hypertension and to prevent possible complications in patients infected with severe acute respiratory syndrome coronavirus 2.

MATERIAL AND METHODS

A total of 120 patients aged 40 years and older, 60 patients (30 females and 30 males) with severe acute respiratory syndrome coronavirus 2 infection and 60 individuals (30 females and 30 males), were included in this retrospective study. Maximum pulmonary artery and maximum ascending aorta diameters were measured at the level of bifurcatio trunci pulmonalis in the transverse axial plane by computed tomography, and their ratios to each other were determined.

RESULTS

Our study revealed a statistically significant increase in maximum pulmonary artery and maximum ascending aorta diameters in both genders in patients with coronavirus disease 2019 compared to the control group and a statistically significant increase was found in the maximum pulmonary artery-maximum ascending aorta ratio in women with coronavirus disease 2019 compared to the control group (P < .05).

CONCLUSIONS

Knowing the diameters of maximum pulmonary artery and maximum ascending aorta and the maximum pulmonary artery-maximum ascending aorta ratio in hospitalized severe acute respiratory syndrome coronavirus 2-infected patients is a valuable predictive marker of pulmonary hypertension and a guide in determining the appropriate treatment. These data, which are easy to calculate from thorax computed tomography, may be beneficial in the prognosis of the disease.

Clinical and Radiological Features Between Patients with Stable COPD from Plateau and Flatlands: A Comparative Study

Background

COPD patients living in Tibet are exposed to specific environments and different risk factors and probably have different characteristics of COPD from those living in flatlands. We aimed to describe the distinction between stable COPD patients permanently residing at the Tibet plateau and those in flatlands.

Methods

We conducted an observational cross-sectional study that enrolled stable COPD patients from Tibet Autonomous Region People's Hospital (Plateau Group) and Peking University Third Hospital (Flatland Group), respectively. Their demographic information, clinical features, spirometry test, blood routine and high-resolution chest CT were collected and evaluated.

Results

A total of 182 stable COPD patients (82 from plateau and 100 from flatland) were consecutively enrolled. Compared to those in flatlands, patients in plateau had a higher proportion of females, more biomass fuel use and less tobacco exposure. CAT score and frequency of exacerbation in the past year were higher in plateau patients. The blood eosinophil count was lower in plateau patients, with fewer patients having an eosinophil count ≥300/μL. On CT examination, the proportions of previous pulmonary tuberculosis and bronchiectasis were higher in plateau patients, but emphysema was less common and milder. The ratio of diameters of pulmonary artery to aorta ≥1 was more often in plateau patients.

Conclusion

Patients with COPD living at Tibet Plateau had a heavier respiratory burden, lower blood eosinophil count, less emphysema but more bronchiectasis and pulmonary hypertension. Biomass exposure and previous tuberculosis were more common in these patients.

Asymmetric Dimethylarginine in COPD Exacerbation

Objectives

Chronic obstructive pulmonary disease (COPD) is a disease with progressive airway limitation. The asymmetric dimethylarginine (ADMA) molecule is known to be effective in airway inflammation and remodeling. We investigated the relationship between ADMA and COPD, and its role in the course of the disease in cases with exacerbation.

Methods

This single-center study performed in our patient clinic included 56 patients (57.1% of males) with median age 67 (41-88) presented with COPD exacerbation and 26 sex-matched healthy controls. ADMA, white blood cell count, eosinophil, neutrophil, lymphocyte, C-reactive protein, fibrinogen, oxygen saturation%, and pulmonary function test values were compared.

Results

ADMA values were significantly higher (516.93 vs. 320.05 median, p<0.05) in the COPD group compared to the control group. No significant difference was demonstrated in ADMA concentrations according to Global Initiative for Chronic Obstructive Lung Disease Stages (p>0.05). In the receiver operating characteristic analysis to estimate the predictive power of COPD, the cutoff ADMA concentration >301 ng/ml was found to be able to distinguish COPD patients in all cases.

Conclusion

ADMA levels increase with complex mechanisms in COPD. It can be a significant indicator of the disease. However, more extensive research is needed for its use as a biomarker in severity and progression of COPD.

Chronic Obstructive Pulmonary Disease and Small Airways Diseases

The small airways are a common target of injury within the lungs and may be affected by a wide variety of inhaled, systemic, and other disorders. Imaging is critical in the detection and diagnosis of small airways disease since significant injury may occur prior to pulmonary function tests showing abnormalities. The goal of this article is to describe the typical imaging findings and patterns of small airways diseases. An approach which divides the imaging appearances into four categories (tree-in-bud opacities, poorly defined centrilobular nodules, mosaic attenuation, and emphysema) will provide a framework in which to formulate appropriate and focused differential diagnoses.