Incidence of chronic obstructive pulmonary disease in a cohort of young adults according to the presence of chronic cough and phlegm

[Alveolar epithelial cell injury as an etiopathogenic factor in pulmonary fibrosis]

Idiopathic pulmonary fibrosis (IPF) is characterized by a progressive accumulation of extracellular matrix and an imbalance between profibrotic and antifibrotic mediators. In the last few years, understanding of the mechanisms of the biology of IPF has increased. One of the most significant discoveries is the finding that alveolar epithelial cell injury plays an important role in the pathogenesis of this disease. In this review, we describe some of the mechanisms involved in alveolar cell injury and their contribution to the development of IPF.

LPS-induced lung inflammation in marmoset monkeys - an acute model for anti-inflammatory drug testing

Increasing incidence and substantial morbidity and mortality of respiratory diseases requires the development of new human-specific anti-inflammatory and disease-modifying therapeutics. Therefore, new predictive animal models that closely reflect human lung pathology are needed. In the current study, a tiered acute lipopolysaccharide (LPS)-induced inflammation model was established in marmoset monkeys (Callithrix jacchus) to reflect crucial features of inflammatory lung diseases. Firstly, in an ex vivo approach marmoset and, for the purposes of comparison, human precision-cut lung slices (PCLS) were stimulated with LPS in the presence or absence of the phosphodiesterase-4 (PDE4) inhibitor roflumilast. Pro-inflammatory cytokines including tumor necrosis factor-alpha (TNF-α) and macrophage inflammatory protein-1 beta (MIP-1β) were measured. The corticosteroid dexamethasone was used as treatment control. Secondly, in an in vivo approach marmosets were pre-treated with roflumilast or dexamethasone and unilaterally challenged with LPS. Ipsilateral bronchoalveolar lavage (BAL) was conducted 18 hours after LPS challenge. BAL fluid was processed and analyzed for neutrophils, TNF-α, and MIP-1β. TNF-α release in marmoset PCLS correlated significantly with human PCLS. Roflumilast treatment significantly reduced TNF-α secretion ex vivo in both species, with comparable half maximal inhibitory concentration (IC(50)). LPS instillation into marmoset lungs caused a profound inflammation as shown by neutrophilic influx and increased TNF-α and MIP-1β levels in BAL fluid. This inflammatory response was significantly suppressed by roflumilast and dexamethasone. The close similarity of marmoset and human lungs regarding LPS-induced inflammation and the significant anti-inflammatory effect of approved pharmaceuticals assess the suitability of marmoset monkeys to serve as a promising model for studying anti-inflammatory drugs.

Epidemiology of chronic obstructive pulmonary disease: a literature review

The aim of this study is to quantify the burden of chronic obstructive pulmonary disease (COPD) – incidence, prevalence, and mortality – and identify trends in Australia, Canada, France, Germany, Italy, Japan, The Netherlands, Spain, Sweden, the United Kingdom, and the United States of America. A structured literature search was performed (January 2000 to September 2010) of PubMed and EMBASE, identifying English-language articles reporting COPD prevalence, incidence, or mortality. Of 2838 articles identified, 299 full-text articles were reviewed, and data were extracted from 133 publications. Prevalence data were extracted from 80 articles, incidence data from 15 articles, and mortality data from 58 articles. Prevalence ranged from 0.2%–37%, but varied widely across countries and populations, and by COPD diagnosis and classification methods. Prevalence and incidence were greatest in men and those aged 75 years and older. Mortality ranged from 3–111 deaths per 100,000 population. Mortality increased in the last 30–40 years; more recently, mortality decreased in men in several countries, while increasing or stabilizing in women. Although COPD mortality increased over time, rates declined more recently, likely indicating improvements in COPD management. In many countries, COPD mortality has increased in women but decreased in men. This may be explained by differences in smoking patterns and a greater vulnerability in women to the adverse effects of smoking.

Cost-effectiveness of varenicline versus bupropion, nicotine-replacement therapy, and unaided cessation in Greece

BACKGROUND

Varenicline was designed to relieve symptoms of nicotine withdrawal, including cigarette craving, and to block the reinforcing effects of continued nicotine use. The cost-effectiveness of varenicline in some countries has not been studied.

OBJECTIVE

The aim of this study was to compare the cost-effectiveness of varenicline to that of bupropion, nicotine-replacement therapy (NRT), and unaided cessation in the Greek health care setting. The analysis takes into account a societal security (third-party payer) perspective.

METHODS

To perform the analyses of the benefits of smoking cessation in terms of smoking-related morbidity, mortality, and associated medical costs, a Markov model was used that simulated the progress of a hypothetical cohort of current smokers making a single attempt to quit smoking at the beginning of the timeframe of the analysis. The robustness of the results was assessed using a series of 1-way sensitivity analyses.

RESULTS

Varenicline was associated with the potential prevention of 14.1, 14.2, and 35.1 additional cases of the 4 smoking-related diseases incorporated into the model, per 1000 smokers willing to quit, versus bupropion, NRT, and unaided cessation, respectively. Potentially avoided smoking-related deaths with varenicline were estimated at 3.24, 3.26, and 7.5 per 1000 quitters versus the 3 comparators. Varenicline led to a potential gain of 33.78, 33.91, and 83.97 QALYs per 1000 persons willing to make a quit attempt versus the 3 comparators. Varenicline was associated with cost-savings against both active comparators for the lifetime horizon. Overall, the cost per additional quitter with varenicline, considering only the costs of the smoking-cessation strategy, was €2659 (€1015) for a lifetime horizon compared with bupropion (NRT); however, when all direct costs were incorporated into the analysis, varenicline was cost-saving.

CONCLUSION

The findings from the present study suggest that, compared with the widely used treatment options bupropion and NRT, as well as unaided cessation, varenicline may enhance smoking-cessation treatment outcomes while substantially reducing the overall costs of smoking to the health care system.

Doctor-patient relationship: a resource to improve respiratory diseases management

BACKGROUND

Many respiratory diseases are chronic conditions that are strongly linked with the patient-physician relationship, disease perception and therapy adherence. The aim of the present study was to evaluate patient's viewpoint about the different aspects involved in their respiratory diseases.

METHODS

This is a prospective observational survey. 46 Italian medical centres were involved and equally distributed. The interviews were carried out and were performed by means of a questionnaire which consisted of 32 questions regarding lung disease, modality of access to medical facilities, therapy and level of medical assistance.

RESULTS

1116 patients were enrolled and the most important respiratory symptoms referred were: dyspnoea (69%), chronic phlegm (28%), cough (13%). During programmed visits 98.3% and 98.8% of interviewed patients knew were aware of asthma and COPD respectively, percentage that dropped, during emergency accesses, to 1.7% and 1.1% knew to have asthma and COPD respectively. Primarily were prescribed 1.67 spirometry/patient/year while only the 2% of patients referred to have performed a blood gas analysis. The 18% of patients spontaneously discontinued the therapy, considering it too complex. The average time that patients identified as being used by the doctor to perform the visit was of 22 minutes, with an high mean medical assistance satisfaction score.

DISCUSSION

There has been little research examining what factors may influence patient acceptance and participation of chronic respiratory diseases. Our national survey demonstrated that a good patient-physician relationship represents one of the first points in the successful management of respiratory diseases.

PPARγ as a Potential Target to Treat Airway Mucus Hypersecretion in Chronic Airway Inflammatory Diseases

Airway mucus hypersecretion (AMH) is a key pathophysiological feature of chronic airway inflammatory diseases such as bronchial asthma, cystic fibrosis, and chronic obstructive pulmonary disease. AMH contributes to the pathogenesis of chronic airway inflammatory diseases, and it is associated with reduced lung function and high rates of hospitalization and mortality. It has been suggested that AMH should be a target in the treatment of chronic airway inflammatory diseases. Recent evidence suggests that a key regulator of airway inflammation, hyperresponsiveness, and remodeling is peroxisome proliferator-activated receptor gamma (PPARγ), a ligand-activated transcription factor that regulates adipocyte differentiation and lipid metabolism. PPARγ is expressed in structural, immune, and inflammatory cells in the lung. PPARγ is involved in mucin production, and PPARγ agonists can inhibit mucin synthesis both in vitro and in vivo. These findings suggest that PPARγ is a novel target in the treatment of AMH and that further work on this transcription factor may lead to new therapies for chronic airway inflammatory diseases.

Antibiotics as immunomodulant agents in COPD

It is widely accepted that some antibiotics have activities beyond their direct antibacterial effects. Macrolide is the antibiotic class with more convincing studies and evidence on its immunomodulatory and anti-inflammatory activities. Different clinical studies have shown that macrolide prophylaxis in patients with moderate-severe chronic obstructive pulmonary disease (COPD) can have a significant impact on the exacerbation rate reducing morbidity and, potentially, mortality of the disease. Other antibiotics, such as fluoroquinolones, demonstrate a variety of immunomodulatory effects but only few clinical data are available in COPD. New macrolide derivatives devoid of antibacterial activity have been synthetized. This review analyses the relevance of immunomodulatory and anti-inflammatory effects of antibiotics in the management of COPD.

Chronic bronchitis in the general population: influence of age, gender and socio-economic conditions

Chronic bronchitis (CB) is an indicator of an increased risk of developing COPD, but its symptoms are often underestimated. Demographic and socio-economic conditions might influence its prevalence, reporting and impact. Data from a large epidemiological survey of the French general population were analyzed to determine the burden of CB, the magnitude of under-diagnosis and the influence of age, gender and socio-economic conditions. Altogether, 9050 participants aged 45 years or more provided complete data. The prevalence of symptoms and diagnosis of CB was 3.5% and 3.4%, respectively. CB was associated with impaired health status and activity and, in women, work loss. Among subjects with symptoms of CB, only 28.6% declared a known diagnosis of respiratory disease. Factors associated with symptoms of CB in multivariate analysis were male gender, active smoking, lower income and occupational category: the highest prevalence was observed in manual workers (5.6%) and self-employed subjects (5.2%). The under-diagnosis of CB was more marked in men and subjects of higher socio-economic categories. These results confirm that CB is markedly under-diagnosed in the general population. Socio-economic conditions influence both its prevalence (higher in low categories) and rate of diagnosis (lower in high categories), which should be considered when elaborating prevention and detection campaigns.

Clinical phenotypes of COPD: identification, definition and implications for guidelines

The term phenotype in the field of COPD is defined as "a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes". Among all phenotypes described, there are three that are associated with prognosis and especially are associated with a different response to currently available therapies. There phenotypes are: the exacerbator, the overlap COPD-asthma and the emphysema-hyperinflation. The exacerbator is characterised by the presence of, at least, two exacerbations the previous year, and on top of long-acting bronchodilators, may require the use of antiinflammatory drugs. The overlap phenotype presents symptoms of increased variability of airflow and incompletely reversible airflow obstruction. Due to the underlying inflammatory profile, it uses to have a good therapeutic response to inhaled corticosteroids in addition to bronchodilators. Lastly, the emphysema phenotype presents a poor therapeutic response to the existing antiinflammatory drugs and long-acting bronchodilators together with rehabilitation are the treatments of choice. Identifying the peculiarities of the different phenotypes of COPD will allow us to implement a more personalised treatment, in which the characteristics of the patients, together with their severity will be key to choose the best treatment option.

Undiagnosed airflow limitation in patients at cardiovascular risk

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and cardiovascular diseases (CVD) share risk factors and impair each other's prognosis.

AIMS

To assess the prevalence of airflow limitation (AL) compatible with COPD in a population at cardiovascular risk and to identify determinants of AL.

METHODS

All consecutive patients referred to the cardiovascular prevention unit of a university hospital in 2009 were studied in a cross-sectional analysis. Patients answered questionnaires on socioeconomic status, medical history and lifestyle, and underwent extensive physical examinations, biological measures and spirometry testing. AL was defined as FEV1/FVC<0.70, without any history of asthma. Determinants of AL were assessed using logistic regression.

RESULTS

The sample comprised 493 participants (mean age 57.4±11.1 years); 60% were men, 18% were current smokers, 42% were ex-smokers and 10% of patients had a history of CVD. Ten-year risk of coronary heart disease (CHD) according to the Framingham equation was intermediate (10-20%) for 25% of patients and high (>20%) for 10%. Prevalence of AL was 5.9% (95% confidence interval [CI] 4.0-8.3%) in the whole population and 4.3% (2.6-6.6%) among subjects in primary cardiovascular prevention. AL was independently associated with CVD (adjusted odds ratio 4.18, 95% CI 1.72-10.15; P=0.002) but not with Framingham CHD risk. More than 80% of patients screened with AL had not been diagnosed previously and more than one in two patients was asymptomatic.

CONCLUSION

Patients with CVD are at increased risk of AL and thus should benefit from AL screening as they are frequently asymptomatic.

COPD in the general population: prevalence, incidence and survival

Worldwide, COPD is a leading cause of chronic morbidity and mortality. Although its prevalence is already well documented, very few studies have measured its incidence. We therefore investigated the prevalence, incidence and lifetime risk of COPD in the general population. In a population-based study including subjects ≥ 40, with 12 months of history available in the Dutch IPCI database, we identified COPD cases by a two-step validation algorithm. Among 185,325 participants with 601,283 years of follow-up, 7308 subjects with COPD were identified, and 1713 had incident COPD. The overall IR of physician-diagnosed COPD was 2.92/1000PY (95%CI 2.78-3.06). The incidence of COPD was higher in men (3.54; 95%CI 3.33-3.77) than in women (2.34; 95%CI 2.17-2.52), and the overall baseline prevalence of COPD was 3.02% (95%CI 2.94-3.10). For people who had entered the study free of COPD at the age of 40, the risk of developing COPD within the next 40 years was 12.7% for men and 8.3% for women. In patients with very severe COPD, 26% died after 1 year of follow-up, whereas 2.8% died among the non-COPD subjects. In the general population in the Netherlands, three on 1000 subjects were diagnosed with COPD per year. The incidence increased rapidly with age and was higher in men than in women. One in eight men and one in 12 women, being COPD free at the age of 40, will develop COPD during their further life. Mortality rates differed substantially between COPD patients and non-COPD subjects of the same age, underlining the burden of this disease.

Update on pharmaceutical and minimally invasive management strategies for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a debilitating pulmonary disorder with systemic effects, and it is the fourth leading cause of death in the United States. COPD patients not only develop respiratory limitations, but can also demonstrate systemic wasting, features of depression, and can succumb to social isolation. Smoking cessation is crucial, and pharmacotherapy with bronchodilators is helpful in symptom management. Inhaled corticosteroids may be beneficial in some patients. In addition, pulmonary rehabilitation and palliative care are important components under the right clinical circumstance. This review highlights current guidelines and management strategies for COPD and emphasizes novel pharmacotherapy and minimally invasive (nonsurgical) lung-volume reduction interventions that may prove to be of significant benefit in the future.

Risk factors for chronic obstructive pulmonary disease in a European cohort of young adults

RATIONALE

Few studies have investigated the factors associated with the early inception of chronic obstructive pulmonary disease (COPD).

OBJECTIVES

We investigated COPD risk factors in an international cohort of young adults using different spirometric definitions of the disease.

METHODS

We studied 4,636 subjects without asthma who had prebronchodilator FEV(1)/FVC measured in the European Community Respiratory Health Survey both in 1991 to 1993 (when they were 20-44 yr old) and in 1999 to 2002. COPD was defined according to the Global Initiative for Chronic Obstructive Lung Disease fixed cut-off criterion (FEV(1)/FVC < 0.70), and two criteria based on the Quanjer and LuftiBus reference equations (FEV(1)/FVC less than lower limit of normal). COPD determinants were studied using two-level Poisson regression models.

MEASUREMENTS AND MAIN RESULTS

COPD incidence ranged from 1.85 (lower limit of normal [Quanjer]) to 2.88 (Global Initiative for Chronic Obstructive Lung Disease) cases/1,000/yr. Although about half of the cases had smoked less than 20 pack-years, smoking was the main risk factor for COPD, and it accounted for 29 to 39% of the new cases during the follow-up. Airway hyperresponsiveness was the second strongest risk factor (15-17% of new cases). Other determinants were respiratory infections in childhood and a family history of asthma, whereas the role of sex, age, and of being underweight largely depended on the definition of COPD used.

CONCLUSIONS

COPD may start early in life. Smoking prevention should be given the highest priority to reduce COPD occurrence. Airway hyperresponsiveness, a family history of asthma, and respiratory infections in childhood are other important determinants of COPD. We suggest the need for a definition of COPD that is not exclusively based on spirometry.

Chronic obstructive pulmonary disease and lung cancer: new molecular insights

Both chronic obstructive pulmonary disease (COPD) and lung cancer are major causes of death worldwide. In most cases this reflects cigarette smoke exposure which is able to induce an inflammatory response in the airways of smokers. Indeed, COPD is characterized by lower airway inflammation, and importantly, the presence of COPD is by far the greatest risk factor for lung cancer amongst smokers. Cigarette smoke induces the release of many inflammatory mediators and growth factors including TGF-β, EGFR, IL-1, IL-8 and G-CSF through oxidative stress pathways and this inflammation may persist for decades after smoking cessation. Mucus production is also increased by these inflammatory mediators, further linking airway inflammation to an important mechanism of lung cancer. A greater understanding of the molecular and cellular pathobiology that distinguishes smokers with lung cancer from smokers with and without COPD is needed to unravel the complex molecular interactions between COPD and lung cancer. By understanding the common signalling pathways involved in COPD and lung cancer the hope is that treatments will be developed that not only treat the underlying disease process in COPD, but also reduce the currently high risk of developing lung cancer in these patients.

Cough and sputum production as risk factors for poor outcomes in patients with COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in developed countries, and its prevalence is projected to increase over the coming decades. According to the World Health Organization, COPD will become the third leading cause of death worldwide by 2020. COPD has a chronic and progressive course, and is often aggravated by exacerbations, which typically arise as a result of bronchial infection. Exacerbations are characterised by periods of increasing acute symptoms, particularly cough, dyspnoea and production of sputum, which worsen airflow obstruction, further impair quality of life and generally require a change in regular medication. Exacerbations are the most common cause of medical visits, hospital admissions and death in patients with COPD, and frequent exacerbations worsen health status and may cause a permanent decline in lung function. Chronic cough and sputum production are common in the general population, but significantly more prevalent in patients with respiratory disorders; these symptoms have been suggested as a risk factor for exacerbations of COPD. This article will review the consequences of chronic cough and sputum production in patients with COPD and analyse whether these risk factors may be useful for identifying a specific phenotype of patient that requires different management to reduce the occurrence of exacerbations.

An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease

RATIONALE

Although cigarette smoking is the most important cause of chronic obstructive pulmonary disease (COPD), a substantial proportion of COPD cases cannot be explained by smoking alone.

OBJECTIVES

To evaluate the risk factors for COPD besides personal cigarette smoking.

METHODS

We constituted an ad hoc subcommittee of the American Thoracic Society Environmental and Occupational Health Assembly. An international group of members was invited, based on their scientific expertise in a specific risk factor for COPD. For each risk factor area, the committee reviewed the literature, summarized the evidence, and developed conclusions about the likelihood of it causing COPD. All conclusions were based on unanimous consensus.

MEASUREMENTS AND MAIN RESULTS

The population-attributable fraction for smoking as a cause of COPD ranged from 9.7 to 97.9%, but was less than 80% in most studies, indicating a substantial burden of disease attributable to nonsmoking risk factors. On the basis of our review, we concluded that specific genetic syndromes and occupational exposures were causally related to the development of COPD. Traffic and other outdoor pollution, secondhand smoke, biomass smoke, and dietary factors are associated with COPD, but sufficient criteria for causation were not met. Chronic asthma and tuberculosis are associated with irreversible loss of lung function, but there remains uncertainty about whether there are important phenotypic differences compared with COPD as it is typically encountered in clinical settings.

CONCLUSIONS

In public health terms, a substantive burden of COPD is attributable to risk factors other than smoking. To prevent COPD-related disability and mortality, efforts must focus on prevention and cessation of exposure to smoking and these other, less well-recognized risk factors.

High frequency of chronic cough and sputum production with lowered exercise capacity in young smokers

OBJECTIVES

The aim was to evaluate how cigarette smoking is associated with respiratory symptoms, fitness, and anthropometric measures in young smokers.

METHODS

The prevalence of smoking was investigated in a cohort of young military draftees (n = 1130; 98% between 18–21 years of age) in Northern Finland. The associations of smoking with respiratory symptoms, physical fitness (12-min running test), education, and anthropometric measures were analysed using a self-reported questionnaire with high response rate (80%).

RESULTS

Almost half (46.5%) of the young males were daily smokers, 17.4% being occasional smokers. The prevalence of self-reported chronic cough and sputum production was high in daily smokers (40.7%) and occasional smokers (26.9%) compared to non-smokers (12%). These symptoms were significantly associated with the smoking history. Aerobic fitness was worse in regular smokers compared to non-smokers (P < 0.001). Smokers had a higher body mass index than non-smokers (P = 0.035). In the regular smokers, the more active the subjects were in sports, the less they smoked when evaluated by pack year history (P < 0.001). Smokers had a lower educational level than occasional smokers or, especially, non-smokers (P < 0.001).

CONCLUSIONS

The frequency of young smokers with chronic cough and sputum production was very high, posing a serious risk to their future health.

Respiratory symptoms in adults are related to impaired quality of life, regardless of asthma and COPD: results from the European community respiratory health survey

BACKGROUND

Respiratory symptoms are common in the general population, and their presence is related to Health-related quality of life (HRQoL). The objective was to describe the association of respiratory symptoms with HRQoL in subjects with and without asthma or COPD and to investigate the role of atopy, bronchial hyperresponsiveness (BHR), and lung function in HRQoL.

METHODS

The European Community Respiratory Health Survey (ECRHS) I and II provided data on HRQoL, lung function, respiratory symptoms, asthma, atopy, and BHR from 6009 subjects. Generic HRQoL was assessed through the physical component summary (PCS) score and the mental component summary (MCS) score of the SF-36.Factor analyses and linear regressions adjusted for age, gender, smoking, occupation, BMI, comorbidity, and study centre were conducted.

RESULTS

Having breathlessness at rest in ECRHS II was associated with mean score (95% CI) impairment in PCS of -8.05 (-11.18, -4.93). Impairment in MCS score in subjects waking up with chest tightness was -4.02 (-5.51, -2.52). The magnitude of HRQoL impairment associated with respiratory symptoms was similar for subjects with and without asthma/COPD. Adjustments for atopy, BHR, and lung function did not explain the association of respiratory symptoms and HRQoL in subjects without asthma and/or COPD.

CONCLUSION

Subjects with respiratory symptoms had poorer HRQoL; including subjects without a diagnosis of asthma or COPD. These findings suggest that respiratory symptoms in the absence of a medical diagnosis of asthma or COPD are by no means trivial, and that clarifying the nature and natural history of respiratory symptoms is a relevant challenge. Several community studies have estimated the prevalence of common respiratory symptoms like cough, dyspnoea, and wheeze in adults. Although the prevalence varies to a large degree between studies and geographical areas, respiratory symptoms are quite common. The prevalences of respiratory symptoms in the European Community Respiratory Health Study (ECRHS) varied from one percent to 35%. In fact, two studies have reported that more than half of the adult population suffers from one or more respiratory symptoms. Respiratory symptoms are important markers of the risk of having or developing disease. Respiratory symptoms have been shown to be predictors for lung function decline, asthma, and even all-cause mortality in a general population study . In patients with a known diagnosis of asthma or chronic obstructive pulmonary disease (COPD), respiratory symptoms are important determinants of reduced health related quality of life (HRQoL). The prevalence of respiratory symptoms exceeds the combined prevalences of asthma and COPD, and both asthma and COPD are frequently undiagnosed diseases. Thus, the high prevalence of respiratory symptoms may mirror undiagnosed and untreated disease.The common occurrence of respiratory symptoms calls for attention to how these symptoms affect health also in subjects with no diagnosis of obstructive airways disease. Impaired HRQoL in the presence of respiratory symptoms have been found in two population-based studies 619, but no study of respiratory symptoms and HRQoL have separate analyses for subjects with and without asthma and COPD, and no study provide information about extensive objective measurements of respiratory health. The ECRHS is a randomly sampled, multi-cultural, population based cohort study. The ECRHS included measurements of atopy, bronchial hyperresponsiveness (BHR), and lung function, and offers a unique opportunity to investigate how respiratory symptoms affect HRQoL among subjects both with and without obstructive lung disease.In the present paper we aimed to: 1) Describe the relationship between respiratory symptoms and HRQoL in an international adult general population and: 2) To assess whether this relationship varied with presence of asthma and/or COPD, or presence of objective functional markers like atopy and BHR.

Trends in the epidemiology of chronic obstructive pulmonary disease in England: a national study of 51 804 patients

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) constitute a substantial burden to healthcare services. Analysis of national healthcare datasets offers the possibility to advance understanding about the changing epidemiology of COPD.

AIM

To investigate the epidemiology of physician-diagnosed COPD in general practice.

DESIGN OF STUDY

Cross-sectional study.

SETTINGS

A total of 422 general practices in England contributing to the QRESEARCH database.

METHOD

Data were extracted on 2.8 million patients, including age, sex, socioeconomic status, and geographical area. Trends over time for recorded physician diagnosis of COPD were analysed (2001-2005).

RESULTS

There was little change over time in the incidence rate of COPD (2005: 2.0 per 1000 patient-years, 95% confidence interval [CI] = 2.0 to 2.1), but a significant increase in lifetime prevalence rate (2001: 13.5 per 1000 patients [95% CI = 13.4 to 13.7]; 2005: 16.8 [95% CI = 16.7 to 17.0]; P<0.001). In 2005, 51 804 individuals or one in 59 people in England were recorded with physician-diagnosed COPD. The most deprived people (31.1 per 1000 patients; 95% CI = 30.6 to 31.7) and those living in the north east of England (29.2 per 1000 patients; 95% CI = 28.4 to 30.1) had the highest prevalence. The observed reduction in the rate of smoking by patients with COPD (overall decrease: 2.5%; P<0.001) varied according to socioeconomic group (most affluent: 6.5% decrease, most deprived: 1.3% decrease).

CONCLUSION

Given the peak in the incidence rate of COPD, we may be approaching the summit of COPD incidence and prevalence in England. However, the number of people affected remains high and poses a major challenge for health services, particularly those in the north east of the country and in the most deprived communities in England. The very limited decrease in smoking rates among the more deprived groups of patients with COPD is also a cause for concern.

Lung function in young adults predicts airflow obstruction 20 years later

OBJECTIVE

The burden of obstructive lung disease is increasing, yet there are limited data on its natural history in young adults. To determine in a prospective cohort of generally healthy young adults the influence of early adult lung function on the presence of airflow obstruction in middle age.

METHODS

A longitudinal study was performed of 2496 adults who were 18 to 30 years of age at entry, did not report having asthma, and returned at year 20. Airflow obstruction was defined as an forced expiratory volume in 1 second/forced vital capacity ratio less than the lower limit of normal.

RESULTS

Airflow obstruction was present in 6.9% and 7.8% of participants at years 0 and 20, respectively. Less than 10% of participants with airflow obstruction self-reported chronic obstructive pulmonary disease. In cross-sectional analyses, airflow obstruction was associated with less education, smoking, and self-reported chronic obstructive pulmonary disease. Low forced expiratory volume in 1 second, forced expiratory volume in 1 second/forced vital capacity ratio, and airflow obstruction in young adults were associated with low lung function and airflow obstruction 20 years later. Of those with airflow obstruction at year 0, 52% had airflow obstruction 20 years later. The forced expiratory volume in 1 second/forced vital capacity at year 0 was highly predictive of airflow obstruction 20 years later (c-statistic 0.91; 95% confidence interval, 0.89-0.93). The effect of cigarette smoking on lung function decline with age was most evident in young adults with preexisting airflow obstruction.

CONCLUSION

Airflow obstruction is mostly unrecognized in young and middle-aged adults. Low forced expiratory volume in 1 second, low forced expiratory volume in 1 second/forced vital capacity ratio, airflow obstruction in young adults, and smoking are highly predictive of low lung function and airflow obstruction in middle age.

Global Initiative for Chronic Obstructive Lung Disease stage 0 is associated with excess FEV(1) decline in a representative population sample

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline removed stage 0 (chronic cough and sputum without airflow obstruction, GOLD-0) because of poor prognostic value. Preventative intervention may be relevant for those with chronic symptoms; therefore, we assessed the stability, morbidity, and FEV(1) decline associated with GOLD stage 0 in a representative adult population cohort.

METHODS

Baseline (n = 4,060) and follow-up (n = 3,206, mean 3.5 years) clinic assessment of the North West Adelaide Health Study included postbronchodilator spirometry, anthropometry, and measures of doctor-diagnosed asthma, respiratory symptoms, smoking status, quality of life, and depression.

RESULTS

Baseline GOLD-0 prevalence was 17.0% (n = 584). At follow-up (n = 420), 39.8% remained stable, 1.4% progressed to GOLD stages 1 to 2, and 58.8% resolved to no symptoms. Persistent GOLD-0 at follow-up was associated with persistent smoking (men: odds ratio [OR] = 11.9, 95% CI, 6.4-22.1; women: OR = 4.0, 95% CI, 2.1-7.4), and depressive symptoms (men: OR = 3.8, 95% CI, 1.9-7.6; women: OR = 3.2, 95% CI, 1.7-5.9), with highest quartile of FEV(1) decline (mL) per year (OR = 2.1, 95% CI, 1.2-3.7) and the metabolic syndrome (OR = 1.7, 95% CI, 1.01-3.0) in men, and with older age in women. These associations generally held in smokers and never-smokers. Resolving GOLD-0 was associated with smoking cessation (OR = 13.7; 95% CI, 4.6-40.1), FEV(1) decline (mL) per year below the median (OR = 2.0; 95% CI, 1.1-3.5), normal BMI, and younger age groups. Sensitivity analyses based on the presence of sputum did not change the observed associations.

CONCLUSION

Persistent GOLD-0 identified people with physical and psychologic morbidity in both smokers and nonsmokers. Identification of those with persistent respiratory symptoms is therefore important. Excess FEV(1) decline in men suggests GOLD-0 may identify a group at risk to progress to COPD over time.

Early detection of COPD combined with individualized counselling for smoking cessation: a two-year prospective study

OBJECTIVE

Though the prevalence of COPD is related to the definition, even with this proviso COPD remains under-diagnosed. Screening can detect many new COPD cases, but its effects on smoking cessation remain unknown.

DESIGN

To evaluate symptoms in "healthy" cigarette smokers, to screen new COPD cases using international and national guidelines, and to assess the success of a smoking cessation.

SUBJECTS

Healthy asymptomatic smokers with a >20 pack-years smoking history were recruited. The first visit included a standardized personal interview, Fagerstom nicotine dependence test (FNDT) and individualized smoking counselling by Motivational Interviewing. At the follow-up visit two years later, the same analyses were repeated and smoking status assessed. To avoid bias in the counselling attributable to spirometry, the test was evaluated at the two-year follow-up assessment.

RESULTS

Almost all, 93.2%, of 584 participants attended the second visit. Spirometry revealed COPD by GOLD criteria in 11.0% and by national guidelines in 15.3%, mid-expiratory flow (MEF50) had significantly declined in 19.5%, chronic cough or sputum production was detected in 62% of the subjects. After two years, 23.3% had succeeded in giving up smoking. There were four predictors of successful quitting, i.e. positive attitude to the intervention, pharmacotherapy, older age, and higher BMI, whereas other factors such as cough, obstruction, gender, pack-years, or nicotine dependence showed no association with ability to achieve successful cessation.

CONCLUSION

Significant numbers of "healthy" smokers experience symptoms, according to detailed questionnaires, and have COPD. Motivation is the most significant factor in determining the chance of stopping smoking.

Long-term outcomes in mild/moderate chronic obstructive pulmonary disease in the European community respiratory health survey

RATIONALE

Little is known about the long-term outcomes of individuals with mild/moderate chronic obstructive pulmonary disease (COPD) according to spirometric criteria.

OBJECTIVES

To test whether nonsmokers and asymptomatic subjects with a spirometric diagnosis of COPD have a steeper decrease in lung function and higher hospitalization rates than subjects without airway obstruction.

METHODS

A total of 5,205 subjects without asthma (20-44 years of age) from the general population, with FEV(1) >or= 50% predicted at baseline, were followed for 9 years in the frame of an international cohort study. Percent decrease in FEV(1) (DeltaFEV(1)%) and the annual hospitalization rate for respiratory causes during the follow-up were assessed for each subject.

MEASUREMENTS AND MAIN RESULTS

At baseline, 324 (6.2%) subjects had the prebronchodilator FEV(1)/FVC ratio less than the lower limit of normal (LLN-COPD), and 105 (2.0%) subjects had the same ratio less than 0.70 (modified GOLD-COPD). At follow-up, smokers with LLN-COPD (n = 205) had a greater mean DeltaFEV(1)% (1.7%; 95% confidence interval [CI], 0.8-2.7) and a higher hospitalization rate (rate ratio [RR], 2.52; 95% CI, 1.65-3.86) than normal subjects. Similarly, symptomatic subjects with LLN-COPD (n = 104) had DeltaFEV(1)% (2.0%; 95% CI, 0.8-3.3) and the hospitalization rate (RR, 4.18; 95% CI, 2.43-7.21) higher than the reference group. By contrast, nonsmokers and asymptomatic subjects with LLN-COPD had outcomes that were similar or even better than normal subjects. Among subjects with LLN-COPD, the association of symptoms with DeltaFEV(1)% varied according to smoking habits (P = 0.007); it was particularly strong in symptomatic smokers and disappeared in symptomatic nonsmokers. Similar results were found with the modified GOLD classification.

CONCLUSIONS

In relatively young populations, COPD is associated with poor long-term outcomes in smokers and in symptomatic subjects only.

Chronic bronchitis before age 50 years predicts incident airflow limitation and mortality risk

BACKGROUND

Previous studies on the relationship of chronic bronchitis to incident airflow limitation and all-cause mortality have provided conflicting results, with positive findings reported mainly by studies that included populations of young adults. This study sought to determine whether having chronic cough and sputum production in the absence of airflow limitation is associated with onset of airflow limitation, all-cause mortality and serum levels of C-reactive protein (CRP) and interleukin-8 (IL-8), and whether subjects' age influences these relationships.

METHODS

1412 participants in the long-term Tucson Epidemiological Study of Airway Obstructive Disease who at enrolment (1972-1973) were 21-80 years old and had FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) > or = 70% and no asthma were identified. Chronic bronchitis was defined as cough and phlegm production on most days for > or = 3 months in two or more consecutive years. Incidence of airflow limitation was defined as the first follow-up survey with FEV(1)/FVC <70%. Serum IL-8 and CRP levels were measured in cryopreserved samples from the enrolment survey.

RESULTS

After adjusting for covariates, chronic bronchitis at enrolment significantly increased the risk for incident airflow limitation and all-cause mortality among subjects <50 years old (HR 2.2, 95% CI 1.3 to 3.8; and HR 2.2, 95% CI 1.3 to 3.8; respectively), but not among subjects > or = 50 years old (HR 0.9, 95% CI 0.6 to 1.4; and HR 1.0, 95% CI 0.7 to 1.3). Chronic bronchitis was associated with increased IL-8 and CRP serum levels only among subjects <50 years old.

CONCLUSIONS

Among adults <50 years old, chronic bronchitis unaccompanied by airflow limitation may represent an early marker of susceptibility to the effects of cigarette smoking on systemic inflammation and long-term risk for chronic obstructive pulmonary disease and all-cause mortality.

The natural history of chronic airflow obstruction revisited: an analysis of the Framingham offspring cohort

RATIONALE

Understanding normal lung development and aging in health and disease, both in men and in women, is essential to interpreting any therapeutic intervention.

OBJECTIVES

We aimed to describe lung function changes in healthy never-smoking males and females, from adolescence to old age, and to determine the effects of smoking and those derived from quitting.

METHODS

Prospective cohort study within all participants of the Framingham Offspring cohort who had two or more valid spirometry measurements during follow-up (n = 4,391; age range at baseline 13 to 71 yr), with a median follow-up time of 23 years.

MEASUREMENTS AND MAIN RESULTS

To best fit the curves describing FEV(1) changes with age to raw data, we used a generalized additive model with smooth terms and incorporating the subject-specific (longitudinal) random effects. We found that: (1) healthy never-smoker females achieve full lung growth earlier than males, and their rate of decline with age was slightly, but not significantly, lower; (2) smoking increases the rate of lung function decline, both in males and in females; (3) there is a range of susceptibility to the effects of smoking. The presence of respiratory symptoms at baseline and/or a respiratory diagnosis during follow-up appears to identify a group of susceptible smokers; and (4) quitting smoking has a beneficial effect at any age, but it is more pronounced in earlier quitters.

CONCLUSIONS

Lung function changes from adolescence to old age differ in males and females, smoking has similar deleterious effects in both sexes, and quitting earlier is better.

Cough and sputum production are associated with frequent exacerbations and hospitalizations in COPD subjects

BACKGROUND

Epidemiologic studies indicate that chronic cough and sputum production are associated with increased mortality and disease progression in COPD subjects. Our objective was to identify features associated with chronic cough and sputum production in COPD subjects.

METHODS

Cross-sectional analysis of data were obtained in a multicenter (17 university hospitals in France) cohort of COPD patients. The cohort comprised 433 COPD subjects (65 +/- 11 years; FEV(1), 50 +/- 20% predicted). Subjects with (n = 321) and without (n = 112) chronic cough and sputum production were compared.

RESULTS

No significant difference was observed between groups for age, FEV(1), body mass index, and comorbidities. Subjects with chronic cough and sputum production had increased total mean numbers of exacerbations per patient per year (2.20 +/- 2.20 vs 0.97 +/- 1.19, respectively; p < 0.0001), moderate exacerbations (1.80 +/- 2.07 vs 0.66 +/- 0.85, respectively; p < 0.0001), and severe exacerbations requiring hospitalizations (0.43 +/- 0.95 vs 0.22 +/- 0.56, respectively; p < 0.02). The total number of exacerbations per patient per year was the only variable independently associated with chronic cough and sputum production. Frequent exacerbations (two or more per patient per year) occurred in 55% vs 22% of subjects, respectively, with and without chronic cough and sputum production (p < 0.0001). Chronic cough and sputum production and decreased FEV(1) were independently associated with an increased risk of frequent exacerbations and frequent hospitalizations.

CONCLUSIONS

Chronic cough and sputum production are associated with frequent COPD exacerbations, including severe exacerbations requiring hospitalizations.

Natural history of emphysema

Chronic obstructive pulmonary disease (COPD) is a progressive disease with studies of disease progression generally focusing on measures of airflow and mortality. In nonsmokers, maximal lung function is attained around age 15 to 25 years, and after a variable plateau phase, subsequently declines at approximately 20 to 25 ml/year. Smoking may reduce the maximal FEV(1) achieved, shorten or eliminate the plateau phase, and may accelerate the rate of decline in lung function in a dose-dependent manner. Some smokers are predisposed to more rapid declines in lung function than others, and recent reports suggest that females may be at higher risk of lung damage related to smoke exposure than males. Progressive deterioration in dyspnea, functional status, and health-related quality of life (HRQL) in patients with COPD is well known, but the magnitude and rate of decline and its association with severity of airflow obstruction remains poorly defined. Many studies have identified pulmonary function, in particular the FEV(1), as the single best predictor of survival. An impaired diffusing capacity and overall impairment in functional status have also been associated with impaired survival in COPD. The National Emphysema Treatment Trial has provided additional insight into these features in a large, well-characterized group of patients with severe airflow obstruction and structural emphysema.

Nutrition and children's respiratory health in Guangzhou, China

OBJECTIVE

To investigate the role of nutrition in children's respiratory health in subjects participating in a study on air pollution and respiratory health.

STUDY DESIGN

Cross-sectional survey.

METHODS

The relationships between consumption of fresh fruit, vegetables and milk and pulmonary function (forced expiratory volume in 1 s, FEV(1)) and respiratory symptoms (phlegm with cold, phlegm without cold, cough with cold, and cough without cold) were examined in 2228 children (age 10.07+/-0.86 years) in Guangzhou, China.

RESULTS

A positive association was found between consumption of leafy vegetables and lung function in children. Subjects with the highest consumption of leafy vegetables had significant higher FEV(1) values than subjects who ate leafy vegetables less than once per week (1.68 l vs 1.56 l; P=0.047). Children with high consumption of fresh fruit and milk had higher lung function values than children with low consumption, although the differences were not statistically significant. Milk consumption was a protective factor for phlegm with cold, cough with cold, and cough without cold [odds ratio (OR) 0.62, 95% confidence interval (CI) 0.39-0.97; OR 0.53, 95% CI 0.36-0.79; OR 0.43, 95% CI 0.21-0.92, respectively, in the highest intake group]. Consumption of vegetables was a protective factor for cough with cold (P for trend=0.003) and cough without cold (P for trend=0.028). Consumption of fresh fruit was marginally associated with reduced prevalence of respiratory symptoms.

CONCLUSIONS

This study suggests that dietary nutrients are important protective factors for children's respiratory health. Following-up these children may provide more evidence to confirm these associations.

Development and validation of a cough and sputum assessment questionnaire

Although cough and sputum production may impact patients' well being and functioning in COPD and chronic bronchitis, there is no validated instrument for cough and sputum symptoms and their impact on patients' daily activities. To fill that gap, we developed and validated a specific, multilingual Cough and Sputum Assessment Questionnaire (CASA-Q) that evaluates clinical symptoms and their impact on patients with COPD or chronic bronchitis. In a three-country validation study (n=671), there was adequate internal consistency (Cronbach's alphas, 0.80-0.91) and test-retest reliability (correlation coefficients>0.70) for the CASA-Q. The cough impact and sputum impact domains correlated with the SGRQ impact domain and SGRQ total score, as did the cough impact domain with the SF-36 social functioning domain. The cough symptom and sputum symptom domains correlated with sputum wet weight (p<0.05; r=-0.56), but not with cough recordings. The mean CASA-Q cough symptom and sputum symptom domain scores indicated responsiveness towards both worse and improved symptoms, whereas the impact domains scored already in the upper third of the scale range, indicating the need for further improvement of its properties. Differences in the CASA-Q domain scores by smoking status (current vs. former smokers) were highest for cough symptoms and lowest for sputum impact. These data indicate that the CASA-Q may be a useful measure of cough and sputum production, and their impact in patients with COPD and/or chronic bronchitis. Further validation will need to assess the responsiveness of the CASA-Q to changes in symptoms.

FEV1/FVC and FEV1 for the assessment of chronic airflow obstruction in prevalence studies: do prediction equations need revision?

Little is known on the long-term validity of reference equations used in the calculation of FEV(1) and FEV(1)/FVC predicted values. This survey assessed the prevalence of chronic airflow obstruction in a population-based sample and how it is influenced by: (i) the definition of airflow obstruction; and (ii) equations used to calculate predicted values. Subjects aged 45 or more were recruited in health prevention centers, performed spirometry and fulfilled a standardized ECRHS-derived questionnaire. Previously diagnosed cases and risk factors were identified. Prevalence of airflow obstruction was calculated using: (i) ATS-GOLD definition (FEV(1)/FVC<0.70); and (ii) ERS definition (FEV(1)/FVC<lower limit of normal) with European Community for Coal and Steel (ECCS) reference equations and with predicted values derived from the presumably normal fraction of the studied population. A total of 5008 subjects (4764 adequate datasets) were studied. Prevalence of airflow obstruction was 8.71% with ATS-GOLD definition and 6.40% with ERS definition and ECCS predicted values. The ERS definition with predicted values derived from the studied population provided a 7.96% prevalence. Severity distribution of airflow obstruction was also influenced by the equation used to calculate predicted values of FEV(1). Prevalence and severity of chronic airflow obstruction are influenced not only by the definition used but also by equations used to calculate predicted FEV(1)/FVC and FEV(1) values. These equations likely need to be periodically revised.

Smoking: relationship to chronic bronchitis, chronic obstructive pulmonary disease and mortality

PURPOSE OF REVIEW

To describe the recent findings concerning the relationship between smoking, chronic bronchitis, chronic obstructive pulmonary disease and mortality.

RECENT FINDINGS

During their lifetime, over 40% of smokers develop chronic bronchitis. Chronic bronchitis is associated with an accelerated decline in lung function - a risk of developing chronic obstructive pulmonary disease and mortality. Approximately one-quarter of smokers can be affected by clinically significant chronic obstructive pulmonary disease. The incidence of chronic obstructive pulmonary disease is also substantial in young adults. Smokers may reduce their risk of developing chronic obstructive pulmonary disease by physical activity and increase their survival by smoking reduction. In adults and the elderly population, severe chronic obstructive pulmonary disease is associated with the most rapid decline in lung function, which is, in turn, associated with chronic obstructive pulmonary disease-related hospitalization and mortality. Using a fixed forced expiratory volume in 1 s/force vital capacity ratio (0.7) to define obstruction in chronic obstructive pulmonary disease at old age is acceptable. In chronic obstructive pulmonary disease patients, the disease is still underreported on death certificates. Chronic mucus production and being a female are associated with chronic obstructive pulmonary disease mentioned on death certificates.

SUMMARY

Chronic bronchitis is a marker identifying high-risk individuals. With respect to chronic obstructive pulmonary disease and mortality, interventions to promote smoking cessation are important to reduce these risks.