Lung function indices for predicting mortality in COPD

Parenchymal and Functional Lung Changes after Stereotactic Body Radiotherapy for Early-Stage Non-Small Cell Lung Cancer-Experiences from a Single Institution

Introduction

This study aimed to evaluate parenchymal and functional lung changes following stereotactic body radiotherapy (SBRT) for early-stage non-small cell lung cancer (NSCLC) patients and to correlate radiological and functional findings with patient and treatment characteristics as well as survival.

Materials and methods

Seventy patients with early-stage NSCLC treated with SBRT from 2004 to 2015 with more than 1 year of CT follow-up scans were analyzed. Incidence, morphology, severity of acute and late lung abnormalities as well as pulmonary function changes were evaluated and correlated with outcome.

Results

Median follow-up time was 32.2 months with 2-year overall survival (OS) of 83% and local progression-free survival of 88%, respectively. Regarding parenchymal changes, most patients only developed mild to moderate CT abnormalities. Mean ipsilateral lung dose (MLD) in biological effective dose and planning target volume size were significantly associated with maximum severity score of parenchymal changes (p = 0.014, p < 0.001). Furthermore, both maximum severity score and MLD were significantly connected with OS in univariate analysis (p = 0.043, p = 0.025). For functional lung changes, we detected significantly reduced total lung capacity, forced expiratory volume in 1 s, and forced vital capacity (FVC) parameters after SBRT (p ≤ 0.001). Multivariate analyses revealed SBRT with an MLD ≥ 9.72 Gy and FVC reduction ≥0.54 L as independent prognostic factors for inferior OS (p = 0.029, p = 0.004).

Conclusion

SBRT was generally tolerated well with only mild toxicity. For evaluating the possible prognostic impact of MLD and FVC reduction on survival detected in this analysis, larger prospective studies are truly needed.

Chronic obstructive pulmonary disease with mild airflow limitation: current knowledge and proposal for future research - a consensus document from six scientific societies

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity worldwide, with high and growing prevalence. Its underdiagnosis and hence under-treatment is a general feature across all countries. This is particularly true for the mild or early stages of the disease, when symptoms do not yet interfere with daily living activities and both patients and doctors are likely to underestimate the presence of the disease. A diagnosis of COPD requires spirometry in subjects with a history of exposure to known risk factors and symptoms. Postbronchodilator forced expiratory volume in 1 second (FEV₁)/forced vital capacity <0.7 or less than the lower limit of normal confirms the presence of airflow limitation, the severity of which can be measured by FEV₁% predicted: stage 1 defines COPD with mild airflow limitation, which means postbronchodilator FEV₁ ≥80% predicted. In recent years, an elegant series of studies has shown that "exclusive reliance on spirometry, in patients with mild airflow limitation, may result in underestimation of clinically important physiologic impairment". In fact, exercise tolerance, diffusing capacity, and gas exchange can be impaired in subjects at a mild stage of airflow limitation. Furthermore, growing evidence indicates that smokers without overt abnormal spirometry have respiratory symptoms and undergo therapy. This is an essential issue in COPD. In fact, on one hand, airflow limitation, even mild, can unduly limit the patient's physical activity, with deleterious consequences on quality of life and even survival; on the other hand, particularly in younger subjects, mild airflow limitation might coincide with the early stage of the disease. Therefore, we thought that it was worthwhile to analyze further and discuss this stage of "mild COPD". To this end, representatives of scientific societies from five European countries have met and developed this document to stimulate the attention of the scientific community on COPD with "mild" airflow limitation. The aim of this document is to highlight some key features of this important concept and help the practicing physician to understand better what is behind "mild" COPD. Future research should address two major issues: first, whether mild airflow limitation represents an early stage of COPD and what the mechanisms underlying the evolution to more severe stages of the disease are; and second, not far removed from the first, whether regular treatment should be considered for COPD patients with mild airflow limitation, either to prevent progression of the disease or to encourage and improve physical activity or both.

Patient Related Outcomes-BODE (PRO-BODE): A composite index incorporating health utilization resources predicts mortality and economic cost of COPD in real life

Multidimensional scores were proposed for defining COPD outcomes, but without any incorporation of the economic COPD cost to clinical indices.

AIM

using mortality as an outcome, the hypothesis that adding total health care cost to the BODE index would better predict mortality in COPD was investigated.

METHODS

275 COPD patients were surveyed. Anthropometrics, lung function, the BODE and the Charlson Comorbidity Index were determined. History of exacerbations, ER visits, hospitalizations and mortality were also determined over the next three years, being their rates graded and added to the BODE index according to a simple algorithm. The novel PRO-BODE index ranged 0-10 points; its relationship to annual total COPD cost and survival was assessed by linear regression analysis.

RESULTS

total COD cost showed the highest relationship with survival (r = -0.58), even higher than that of age and of BODE index (r = -0.28 and r = -0.21, respectively). The integrated Pro-BODE score proved proportional to the cost of care and inversely proportional to the length of survival.

CONCLUSIONS

Pro-BODE is a novel composite index which helps in predicting in real life the impact of COPD over three years, both in terms of patients' survival and of COPD economic burden.

Long-Term Oxygen Therapy in COPD Patients Who Do Not Meet the Actual Recommendations

Chronic respiratory failure due to chronic obstructive pulmonary disease (COPD) is an increasing problem worldwide. Many patients with severe COPD develop hypoxemic respiratory failure during the natural progression of disease. Long-term oxygen therapy (LTOT) is a well-established supportive treatment for COPD and has been shown to improve survival in patients who develop chronic hypoxemic respiratory failure. The degree of hypoxemia is severe when partial pressure of oxygen in arterial blood (PaO₂) is ≤55 mmHg and moderate if PaO₂ is between 56 and 69 mmHg. Although current guidelines consider LTOT only in patients with severe resting hypoxemia, many COPD patients with moderate to severe disease experience moderate hypoxemia at rest or during special circumstances, such as while sleeping or exercising. The efficacy of LTOT in these patients who do not meet the actual recommendations is still a matter of debate, and extensive research is still ongoing to understand the possible benefits of LTOT for survival and/or functional outcomes such as the sensation of dyspnea, exacerbation frequency, hospitalizations, exercise capacity, and quality of life. Despite its frequent use, the administration of "palliative" oxygen does not seem to improve dyspnea except for delivery with high-flow humidified oxygen. This narrative review will focus on current evidence for the effects of LTOT in the presence of moderate hypoxemia at rest, during sleep, or during exercise in COPD.

ACE and response to pulmonary rehabilitation in COPD: two observational studies

Introduction

Skeletal muscle impairment is an important feature of chronic obstructive pulmonary disease (COPD). Renin–angiotensin system activity influences muscle phenotype, so we wished to investigate whether it affects the response to pulmonary rehabilitation.

Methods

Two studies are described; in the first, the response of 168 COPD patients (mean forced expiratory volume in one second 51.9% predicted) to pulmonary rehabilitation was compared between different ACE insertion/deletion polymorphism genotypes. In a second, independent COPD cohort (n=373), baseline characteristics and response to pulmonary rehabilitation were compared between COPD patients who were or were not taking ACE inhibitors or angiotensin receptor antagonists (ARB).

Results

In study 1, the incremental shuttle walk distance improved to a similar extent in all three genotypes; DD/ID/II (n=48/91/29) 69(67)m, 61 (76)m and 78 (78)m, respectively, (p>0.05). In study 2, fat free mass index was higher in those on ACE-I/ARB (n=130) than those who were not (n=243), 17.8 (16.0, 19.8) kg m⁻² vs 16.5 (14.9, 18.4) kg/m² (p<0.001). However change in fat free mass, walking distance or quality of life in response to pulmonary rehabilitation did not differ between groups.

Conclusions

While these data support a positive association of ACE-I/ARB treatment and body composition in COPD, neither treatment to reduce ACE activity nor ACE (I/D) genotype influence response to pulmonary rehabilitation.

Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease

BACKGROUND

In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique.

SEARCH METHODS

Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software.

MAIN RESULTS

AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV₁) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV₁ (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV₁ (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV₁ (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV₁ (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV₁ and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV₁ (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate.

AUTHORS' CONCLUSIONS

Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.

Endobronchial valves for patients with heterogeneous emphysema and without interlobar collateral ventilation: open label treatment following the BeLieVeR-HIFi study

Outcomes in early trials of bronchoscopic lung volume reduction using endobronchial valves for the treatment of patients with advanced emphysema were inconsistent. However improvements in patient selection with focus on excluding those with interlobar collateral ventilation and homogeneous emphysema resulted in significant benefits in the BeLieVeR-HIFi study compared with sham treated controls. In this manuscript we present data from the control patients in the BeLieVeR-HIFi study who went on to have open label endobronchial valve treatment after completion of the clinical trial (n=12), combined with data from those in the treatment arm who did not have collateral ventilation (n=19). Three months after treatment FEV₁ increased by 27.3 (36.4)%, residual volume reduced by 0.49 (0.76) L, the 6 min walk distance increased by 32.6 (68.7) m and the St George Respiratory Questionnaire for COPD score improved by 8.2 (20.2) points. These data extend the evidence for endobronchial valve placement in appropriately selected patients with COPD.

TRIAL REGISTRATION NUMBER

ISRCTN04761234; Results.

Cost versus utility of aclidinium bromide 400 µg plus formoterol fumarate dihydrate 12 µg compared to aclidinium bromide 400 µg alone in the management of moderate-to-severe COPD

Purpose

Aclidinium–formoterol 400/12 µg is a long-acting muscarinic antagonist (LAMA) and a long-acting β₂-agonist in a fixed-dose combination used in the management of patients with COPD. This study aimed to assess the cost-effectiveness of aclidinium–formoterol 400/12 µg against the long-acting muscarinic antagonist aclidinium bromide 400 µg.

Materials and methods

A five-health-state Markov transition model with monthly cycles was developed using MS Excel to simulate patients with moderate-to-severe COPD and their initial lung-function improvement following treatment with aclidinium–formoterol 400/12 µg or aclidinium 400 µg. Health states were based on severity levels defined by Global Initiative for Chronic Obstructive Lung Disease 2010 criteria. The analysis was a head-to-head comparison without step-up therapy, from the NHS Scotland perspective, over a 5-year time horizon. Clinical data on initial lung-function improvement were provided by a pooled analysis of the ACLIFORM and AUGMENT trials. Management, event costs, and utilities were health state-specific. Costs and effects were discounted at an annual rate of 3.5%. The outcome of the analysis was expressed as cost (UK£) per quality-adjusted life-year (QALY) gained. The analysis included one way and probabilistic sensitivity analyses to investigate the impact of parameter uncertainty on model outputs.

Results

Aclidinium–formoterol 400/12 µg provided marginally higher costs (£41) and more QALYs (0.014), resulting in an incremental cost-effectiveness ratio of £2,976/QALY. Sensitivity analyses indicated that results were robust to key parameter variations, and the main drivers were: mean baseline forced expiratory volume in 1 second (FEV₁), risk of exacerbation, FEV₁ improvement from aclidinium–formoterol 400/12 µg, and lung-function decline. The probability of aclidinium–formoterol 400/12 µg being cost-effective (using a willingness-to-pay threshold of £20,000/QALY) versus aclidinium 400 µg was 79%.

Conclusion

In Scotland, aclidinium–formoterol 400/12 µg can be considered a cost-effective treatment option compared to aclidinium 400 µg alone in patients with moderate-to-severe COPD.

Growth differentiation factor-15 is associated with muscle mass in chronic obstructive pulmonary disease and promotes muscle wasting in vivo

BACKGROUND

Loss of muscle mass is a co-morbidity common to a range of chronic diseases including chronic obstructive pulmonary disease (COPD). Several systemic features of COPD including increased inflammatory signalling, oxidative stress, and hypoxia are known to increase the expression of growth differentiation factor-15 (GDF-15), a protein associated with muscle wasting in other diseases. We therefore hypothesized that GDF-15 may contribute to muscle wasting in COPD.

METHODS

We determined the expression of GDF-15 in the serum and muscle of patients with COPD and analysed the association of GDF-15 expression with muscle mass and exercise performance. To determine whether GDF-15 had a direct effect on muscle, we also determined the effect of increased GDF-15 expression on the tibialis anterior of mice by electroporation.

RESULTS

Growth differentiation factor-15 was increased in the circulation and muscle of COPD patients compared with controls. Circulating GDF-15 was inversely correlated with rectus femoris cross-sectional area (P < 0.001) and exercise capacity (P < 0.001) in two separate cohorts of patients but was not associated with body mass index. GDF-15 levels were associated with 8-oxo-dG in the circulation of patients consistent with a role for oxidative stress in the production of this protein. Local over-expression of GDF-15 in mice caused wasting of the tibialis anterior muscle that expressed it but not in the contralateral muscle suggesting a direct effect of GDF-15 on muscle mass (P < 0.001).

CONCLUSIONS

Together, the data suggest that GDF-15 contributes to the loss of muscle mass in COPD.

COPD patients with severe diffusion defect in carbon monoxide diffusing capacity predict a better outcome for pulmonary rehabilitation

PURPOSE

The aim of this study was to compare the effects of pulmonary rehabilitation (PR) on six-minute walk test (6mWT) between chronic obstructive pulmonary disease (COPD) patients with moderate or severe carbon monoxide diffusion defects. We also evaluated dyspnea sensation, pulmonary functions, blood gases analysis, quality of life parameters and psychological symptoms in both groups before and after pulmonary rehabilitation.

METHODS

Patients with COPD underwent a comprehensive 8-week out-patient PR program participated in this study. Patients grouped according to diffusion capacity as moderate or severe. Outcome measures were exercise capacity (6mWT), dyspnea sensation, pulmonary function tests, blood gases analysis, quality of life (QoL) and psychological symptoms.

RESULTS

A total of 68 patients enrolled in the study. Thirty-two (47%) of them had moderate diffusion defect [Tl_CO; 52 (47-61)mmol/kPa] and 36 (53%) of them had severe diffusion defect [Tl_CO; 29 (22-34)mmol/kPa]. At the end of the program, PaO₂ (p=0.001), Modified Medical Research Council dyspnea scale (p=0.001), 6mWT (p<0.001) and quality of life parameters improved significantly in both groups (p<0.05). Also the improvement in Dl_CO (p=0.04) value and FEV₁% (p=0.01) reached a statistically significant level in patients with severe diffusion defect. When comparing changes between groups, dyspnea reduced significantly in patients with severe diffusion defect (p=0.04).

CONCLUSION

Pulmonary rehabilitation improves oxygenation, severity of dyspnea, exercise capacity and quality of life independent of level of carbon monoxide diffusion capacity in patents with COPD. Furthermore pulmonary rehabilitation may improve Dl_CO values in COPD patients with severe diffusion defect.

Is a pulmonary rehabilitation program effective in COPD patients with chronic hypercapnic failure?

OBJECTIVES

Our study aimed to compare the effectiveness of a pulmonary rehabilitation (PR) program between hypercapnic and normocapnic patients with chronic obstructive pulmonary disease (COPD).

METHODS

Hypercapnic (Group 1) and normocapnic (Group 2) patients with COPD who participated in this study underwent a comprehensive 8-week out-patient PR program.

RESULTS

A total of 122 patients were enrolled in the study; (n:86, n:36 groups 1 and 2, respectively.) After PR, both groups had better symptom scores as well as physical, social and emotional functioning. In addition, the groups had reduced dyspnea, anxiety and depression scores. After PR, the hypercapnic group improved significantly more in exercise capacity (∆6 MWT 50 m. vs 40 m.) compared with normocapnic patients (p=0.044). The hypercapnic group demonstrated a significant reduction in the PaCO2 levels after PR within (p<0.05) and between groups (p<0.0001).

CONCLUSIONS

Given the significant reductions in pCO2 levels and significant increases in exercise capacity and QoL parameters after PR, the patients with chronic hypercapnic failure apparently benefited from the PR.

The BODECOST Index (BCI): a composite index for assessing the impact of COPD in real life

Background

Chronic Obstructive Pulmonary Disease (COPD) is a progressive condition which is characterized by a dramatic socio-economic impact.

Several indices were extensively investigated in order to asses the mortality risk in COPD, but the utilization of health care resources was never included in calculations. The aim of this study was to assess the predictive value of annual cost of care on COPD mortality at three years, and to develop a comprehensive index for easy calculation of mortality risk in real life.

Methods

COPD patients were anonymously and automatically selected from the local institutional Data Base. Selection criteria were: COPD diagnosis; both genders; age ≥ 40 years; availability of at least one complete clinical record/year, including history; clinical signs; complete lung function, therapeutic strategy, health BODE index; Charlson Comorbidity Index, and outcomes, collected at the first visit, and over the following 3-years. At the first visit, the health annual cost of care was calculated in each patient for the previous 12 months, and the survival rate was also measured over the following 3 years. The hospitalization and the exacerbation rate were implemented to the BODE index and the novel index thus obtained was called BODECOST index (BCI), ranging from 0 to 10 points. The mean cost for each BCI step was calculated and then compared to the corresponding patients’ survival duration.

Parametrical, non parametrical tests, and linear regression were used; p < 0.05 was accepted as the lower limit of significance.

Results

At the first visit, the selected 275 patients were well matched for all variables by gender. The overall mortality over the 3 year survey was 40.4 % (n = 111/275). When compared to that of BODE index (r = 0.22), the total annual cost of care and the number of exacerbations showed the highest regression value vs the survival time (r = 0.58 and r = 0.44, respectively). BCI score proved strictly proportional to both the cost of care and the survival time in our sample of COPD patients.

Discussion

BCI takes origin from the implementation of the BODE index with the two main components of the annual cost of care, such as the number of hospitalizations and of exacerbations occurring yearly in COPD patients, and their corresponding economic impact. In other words, higher the BCI score, shorter the survival and higher the cost, these trends being strictly linked.

Conclusions

BCI is a novel composite index which helps in predicting the impact of COPD at 3 years in real life, both in terms of patients’ survival and of COPD economic burden.

Prognostic Value of the Six-Second Spirometry in Patients with Chronic Obstructive Pulmonary Disease: A Cohort Study

BACKGROUND

The six-second spirometry has been proposed as an alternative to diagnose airflow limitation, although its prognostic value in patients with chronic obstructive pulmonary disease (COPD) remains unknown. The purpose of this study was to determine the prognostic value of the postbronchodilator forced expiratory volume in 1 second (FEV1)/forced expiratory volume in 6 seconds (FEV6) ratio and FEV6 in COPD patients.

METHODS AND FINDINGS

The study population consisted of 2,614 consecutive stable patients with COPD. The patients were monitored for an average period of 4.3 years regarding mortality, hospitalizations by COPD exacerbations, diagnosis of lung cancer, and annual lung function decline. The overall rate of death was 10.7 (95%CI: 8.7-12.7) per 1000 person-years. In addition to male gender, age and comorbidity, FEV6 (hazard ratio [HR]: 0.981, 95%CI: 0.968-0.003) and FEV1/FEV6 quartiles (lowest quartile (<74% pred.): HR 3.558, 95%CI: 1.752-7.224; and second quartile (74-84% pred.): HR 2.599, 95%CI: 1.215-5.561; versus best quartile (>0.89% pred.)) were independently associated with mortality, whereas FEV1 was not retained in the model. 809 patients (30.9%) had at least one hospital admission due to COPD exacerbation. In addition to sex, age, smoking and comorbidity, FEV1 and FEV1/FEV6 quartiles were independent risk factors of hospitalization. FEV6 was the only spirometric parameter independently related with lung function annual decline, while the FEV6 and FEV1/FEV6 quartiles were independent risk factors for lung cancer.

CONCLUSIONS

In a general COPD outpatient population, airflow obstruction assessed by the FEV1/FEV6 is an independent risk factor for both death and hospitalization.

Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial

BACKGROUND

Lung volume reduction surgery improves survival in selected patients with emphysema, and has generated interest in bronchoscopic approaches that might achieve the same effect with less morbidity and mortality. Previous trials with endobronchial valves have yielded modest group benefits because when collateral ventilation is present it prevents lobar atelectasis.

METHODS

We did a single-centre, double-blind sham-controlled trial in patients with both heterogeneous emphysema and a target lobe with intact interlobar fissures on CT of the thorax. We enrolled stable outpatients with chronic obstructive pulmonary disease who had a forced expiratory volume in 1 s (FEV1) of less than 50% predicted, significant hyperinflation (total lung capacity >100% and residual volume >150%), a restricted exercise capacity (6 min walking distance <450 m), and substantial breathlessness (MRC dyspnoea score ≥3). Participants were randomised (1:1) by computer-generated sequence to receive either valves placed to achieve unilateral lobar occlusion (bronchoscopic lung volume reduction) or a bronchoscopy with sham valve placement (control). Patients and researchers were masked to treatment allocation. The study was powered to detect a 15% improvement in the primary endpoint, the FEV1 3 months after the procedure. Analysis was on an intention-to-treat basis. The trial is registered at controlled-trials.com, ISRCTN04761234.

FINDINGS

50 patients (62% male, FEV1 [% predicted] mean 31·7% [SD 10·2]) were enrolled to receive valves (n=25) or sham valve placement (control, n=25) between March 1, 2012, and Sept 30, 2013. In the bronchoscopic lung volume reduction group, FEV1 increased by a median 8·77% (IQR 2·27-35·85) versus 2·88% (0-8·51) in the control group (Mann-Whitney p=0·0326). There were two deaths in the bronchoscopic lung volume reduction group and one control patient was unable to attend for follow-up assessment because of a prolonged pneumothorax.

INTERPRETATION

Unilateral lobar occlusion with endobronchial valves in patients with heterogeneous emphysema and intact interlobar fissures produces significant improvements in lung function. There is a risk of significant complications and further trials are needed that compare valve placement with lung volume reduction surgery.

FUNDING

Efficacy and Mechanism Evaluation Programme, funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.

Relationship between linear and nonlinear dynamics of heart rate and impairment of lung function in COPD patients

BACKGROUND

In chronic obstructive pulmonary disease (COPD), functional and structural impairment of lung function can negatively impact heart rate variability (HRV); however, it is unknown if static lung volumes and lung diffusion capacity negatively impacts HRV responses. We investigated whether impairment of static lung volumes and lung diffusion capacity could be related to HRV indices in patients with moderate to severe COPD.

METHODS

Sixteen sedentary males with COPD were enrolled in this study. Resting blood gases, static lung volumes, and lung diffusion capacity for carbon monoxide (DLCO) were measured. The RR interval (RRi) was registered in the supine, standing, and seated positions (10 minutes each) and during 4 minutes of a respiratory sinus arrhythmia maneuver (M-RSA). Delta changes (Δsupine-standing and Δsupine-M-RSA) of the standard deviation of normal RRi, low frequency (LF, normalized units [nu]) and high frequency (HF [nu]), SD1, SD2, alpha1, alpha2, and approximate entropy (ApEn) indices were calculated.

RESULTS

HF, LF, SD1, SD2, and alpha1 deltas significantly correlated with forced expiratory volume in 1 second, DLCO, airway resistance, residual volume, inspiratory capacity/total lung capacity ratio, and residual volume/total lung capacity ratio. Significant and moderate associations were also observed between LF/HF ratio versus total gas volume (%), r=0.53; LF/HF ratio versus residual volume, %, r=0.52; and HF versus total gas volume (%), r=-0.53 (P<0.05). Linear regression analysis revealed that ΔRRi supine-M-RSA was independently related to DLCO (r=-0.77, r (2)=0.43, P<0.05).

CONCLUSION

Responses of HRV indices were more prominent during M-RSA in moderate to severe COPD. Moreover, greater lung function impairment was related to poorer heart rate dynamics. Finally, impaired lung diffusion capacity was related to an altered parasympathetic response in these patients.

Breathlessness, physical activity and sustainability of healthcare

We welcome the important paper by Grønsethet al. [1], which used data from the Burden of Obstructive Lung Disease (BOLD) project to highlight the prevalence of breathlessness across the world. As well as being significant because it is a source of suffering that should be ameliorated, we believe that attention to breathlessness, particularly in midlife, has important implications for sustainable healthcare because it allows timely diagnosis, would drive the promotion of physical activity, forms part of a strategy to reduce the burden of comorbidities and would have beneficial environmental effects.

Targeting breathlessness is important for delivering sustainable future healthcarehttp://ow.ly/AgKoA

A combined pulmonary function and emphysema score prognostic index for staging in Chronic Obstructive Pulmonary Disease

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is characterized by high morbidity and mortality. Lung computed tomography parameters, individually or as part of a composite index, may provide more prognostic information than pulmonary function tests alone.

Aim

To investigate the prognostic value of emphysema score and pulmonary artery measurements compared with lung function parameters in COPD and construct a prognostic index using a contingent staging approach.

Material-Methods

Predictors of mortality were assessed in COPD outpatients whose lung computed tomography, spirometry, lung volumes and gas transfer data were collected prospectively in a clinical database. Univariate and multivariate Cox proportional hazard analysis models with bootstrap techniques were used.

Results

169 patients were included (59.8% male, 61.1 years old; Forced Expiratory Volume in 1 second % predicted: 40.5±19.2). 20.1% died; mean survival was 115.4 months. Age (HR = 1.098, 95% Cl = 1.04–1.252) and emphysema score (HR = 1.034, 95% CI = 1.007–1.07) were the only independent predictors of mortality. Pulmonary artery dimensions were not associated with survival. An emphysema score of 55% was chosen as the optimal threshold and 30% and 65% as suboptimals. Where emphysema score was between 30% and 65% (intermediate risk) the optimal lung volume threshold, a functional residual capacity of 210% predicted, was applied. This contingent staging approach separated patients with an intermediate risk based on emphysema score alone into high risk (Functional Residual Capacity ≥210% predicted) or low risk (Functional Residual Capacity <210% predicted). This approach was more discriminatory for survival (HR = 3.123; 95% CI = 1.094–10.412) than either individual component alone.

Conclusion

Although to an extent limited by the small sample size, this preliminary study indicates that the composite Emphysema score-Functional Residual Capacity index might provide a better separation of high and low risk patients with COPD, than other individual predictors alone.

Significance of Patent Foramen Ovale in Patients with GOLD Stage II Chronic Obstructive Pulmonary Disease (COPD)

Background: Patent foramen ovale (PFO) is a common finding in adults. A PFO is associated with right to left shunting but its importance in the aetiology of hypoxia in early COPD remains uncertain, although it has not proved possible to demonstrate a role for PFOs in the aetiology of hypoxia in patients with Global Initiative for chronic Obstructive Lung Disease (GOLD) stage III/IV disease. We compared the characteristics of GOLD stage II patients with or without a PFO and assessed its impact on exercise performance. Methods: In 22 GOLD stage II COPD patients we measured exercise performance, arterial oxygen tension and lung function and used contrast transcranial Doppler ultrasonography (TCD) to assess the presence of a PFO. Patients (n=20) underwent TCD measurements during incremental cycle ergometry with respiratory pressures measured using an esophageal balloon catheter (n=13). Results:Twelve individuals (54%) had a PFO. Patients with a PFO were more hypoxic; mean(SD) partial pressure of oxygen in arterial blood (PaO₂)10.2(1.1) kilopascals (kPa) vs. 11.7(0.9)kPa (p<0.01), but the presence of a PFO was not associated with reduced exercise performance either on cycle ergometry or a 6 Minute Walk Test (6MWT). A strong relationship was noted between the esophageal pressure swing (P_SwingEs) and the degree of shunting observed during exercise (r=0.7; p<0.001). Conclusions:The presence of a PFO in GOLD stage II COPD patients does not appear to influence exercise performance despite increased right-to-left shunting.

Survival in COPD: impact of lung dysfunction and comorbidities

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in industrialized countries. Recent studies investigated the impact of comorbidities on the survival in COPD, but most of them lacked a referent group of comorbidity-matched, nonobstructed individuals.We examined the 10-year mortality in a sample of 200 COPD patients and 201 nonobstructed controls. They were part of a larger cohort enrolled in a European case-control study aimed at assessing genetic susceptibility to COPD. By design, the COPD group included patients with a forced expiratory volume in 1 second (FEV1) ≤70% predicted. Cases and controls were matched on age, sex, and cumulative smoking history, and shared a nearly identical prevalence of cardiovascular and metabolic disorders. We estimated the hazard of death with Cox regression and percentiles of survival with Laplace regression. COPD was the main exposure variable of interest. Five comorbidities (hypertension, coronary artery disease, prior myocardial infarction, chronic heart failure, and diabetes) were included as covariates in multiple regression models.The all-cause mortality rate was significantly higher in cases than in controls (43% vs 16%, P < 0.001). The unadjusted hazard of death for COPD was 3-fold higher than the referent category (P < 0.001), and remained nearly unchanged after introducing the 5 comorbidities in multiple regression. Patients with COPD had significantly shorter survival percentiles than comorbidity-matched controls (P < 0.001). Notably, 15% of the nonobstructed controls died by 10.3 years into the study; the same proportion of COPD patients had died some 6 years earlier, at 4.6 years.In a separate analysis, we split the whole sample into 2 groups based on the lower tertile of FEV1 and carbon monoxide lung diffusing capacity (DLCO). The hazard of death for COPD patients with low FEV1 and DLCO was nearly 3.5-fold higher than in all the others (P < 0.001), and decreased only slightly after introducing age and chronic heart failure as relevant covariates.COPD is a strong predictor of reduced survival independently of coexisting cardiovascular and metabolic disorders. Efforts should be made to identify patients at risk and to ensure adherence to prescribed therapeutic regimens.

Fatigue Affects Health Status and Predicts Mortality Among Subjects with COPD: Report from the Population-Based OLIN COPD Study

BACKGROUND

COPD is associated to increased fatigue, decreased health status and mortality. However, these relationships are rarely evaluated in population-based studies.

AIMS

To describe the relationship between health status, respiratory symptoms and fatigue among subjects with and without COPD. Further, to evaluate whether fatigue and/or health status predicts mortality in these groups.

METHODS

Data were collected in 2007 from the population-based OLIN COPD study. Subjects participated in lung function tests and structured interviews, and 434 subjects with and 655 subjects without COPD were identified. Fatigue was assessed by FACIT-Fatigue and health status by the generic SF-36 questionnaire including physical (PCS) and mental (MCS) components. Mortality data until February 2012 were collected.

RESULTS

Fatigue greatly impacts the physical and mental dimensions of health status, both among subjects with and without COPD. Among subjects with clinically significant fatigue, COPD subjects had significantly lower PCS-scores compared to non-COPD subjects. Fairly strong correlations were found between FACIT-F, SF-36 PCS and MCS, respectively. In multivariate models adjusting for covariates, increased fatigue, decreased physical and mental dimensions of health status were all associated to mortality in subjects with COPD (OR 1.06, CI 1.02-1.10, OR 1.04, CI 1.01-1.08 and OR 1.06, CI 1.02-1.10), but not in non-COPD.

CONCLUSIONS

Fatigue and decreased health status were closely related among subjects with and without COPD. Not only physical health status, but also fatigue and mental health predicted mortality among subjects with COPD. Fatigue assessed by FACIT-F, can be a useful instrument of prognostic value in the care of subjects with COPD.

Phenotypic characteristics associated with reduced short physical performance battery score in COPD

BACKGROUND

The Short Physical Performance Battery (SPPB) is commonly used in gerontology, but its determinants have not been previously evaluated in COPD. In particular, it is unknown whether pulmonary aspects of COPD would limit the value of SPPB as an assessment tool of lower limb function.

METHODS

In 109 patients with COPD, we measured SPPB score, spirometry, 6-min walk distance, quadriceps strength, rectus femoris cross-sectional area, fat-free mass, physical activity, health status, and Medical Research Council dyspnea score. In a subset of 31 patients with COPD, a vastus lateralis biopsy was performed, and the biopsy specimen was examined to evaluate the structural muscle characteristics associated with SPPB score. The phenotypic characteristics of patients stratified according to SPPB were determined.

RESULTS

Quadriceps strength and 6-min walk distance were the only independent predictors of SPPB score in a multivariate regression model. Furthermore, while age, dyspnea, and health status were also univariate predictors of SPPB score, FEV 1 was not. Stratification by reduced SPPB score identified patients with locomotor muscle atrophy and increasing impairment in strength, exercise capacity, and daily physical activity. Patients with mild or major impairment defined as an SPPB score < 10 had a higher proportion of type 2 fibers (71% [14] vs 58% [15], P = .04).

CONCLUSIONS

The SPPB is a valid and simple assessment tool that may detect a phenotype with functional impairment, loss of muscle mass, and structural muscle abnormality in stable patients with COPD.

Patent foramen ovale is not associated with hypoxemia in severe chronic obstructive pulmonary disease and does not impair exercise performance

RATIONALE

Patent foramen ovale (PFO) may be disadvantageous in chronic obstructive pulmonary disease (COPD). It is unknown whether right-to-left shunting through PFO increases during exercise impairing exercise performance.

OBJECTIVES

To determine whether (1) PFO prevalence is greater in hypoxemic versus less hypoxemic patients with COPD, (2) PFO is associated with clinically relevant impairment, and (3) right-to-left shunting increases during exercise and impairs exercise performance.

METHODS

Patients with COPD and age-matched control subjects underwent contrast transthoracic echocardiography and transcranial Doppler to identify PFO. Patients with COPD with no shunt and patients with large PFO underwent cardiopulmonary exercise tests with contrast transcranial Doppler, esophageal, and gastric balloon catheters.

MEASUREMENTS AND MAIN RESULTS

PFO prevalence was similar in 50 patients with COPD and 50 healthy control subjects (46% vs. 30%; P = 0.15). Large shunts were more common in patients with COPD (26% vs. 6%; P = 0.01). In an expanded COPD cohort, PFO prevalence was similar in 31 hypoxemic (Pao2 ≤ 7.3 kPa) and 63 less hypoxemic (Pao2 > 8.0 kPa) patients with COPD (39% vs. 52%; P = 0.27). Patients with intrapulmonary shunting had lower Pao2 than both patients with PFO and those with no right-to-left shunt (7.7 vs. 8.6 vs. 9.3 kPa, respectively; P = 0.002). Shunting significantly increased during exercise in patients with COPD with PFO. Endurance time at 60% Vo2max was 574 (178) seconds for patients with PFO and 534 (279) seconds for those without (P = ns).

CONCLUSIONS

Hypoxemic patients with COPD do not have a higher prevalence of PFO. Patients with COPD with PFO do not perform less well either on a 6-minute walk or submaximal exercise testing despite increased right-to-left shunting during exercise.

Surgical approaches for lung volume reduction in emphysema

Lung volume reduction surgery (LVRS) for chronic obstructive pulmonary disease (COPD) is recommended in both British and international guidelines because trials have shown improvement in survival in selected patients with poor baseline exercise capacity and upper lobe-predominant emphysema. Despite this, few procedures are carried out, possibly because of historical concerns about high levels of morbidity and mortality associated with the operation. The authors reviewed data on lung volume reduction procedures at their institution between January 2000 and September 2012. There were no deaths within 90 days of unilateral LVRS (n = 81), bullectomy (n = 20) or intracavity drainage procedures (n = 14). These data suggest that concerns about surgical mortality should not discourage LVRS in selected patients with COPD, provided that it is undertaken within a multidisciplinary team environment involving appropriate patient selection.