Understanding the impact of chronic obstructive pulmonary disease exacerbations on patient health and quality of life

Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review

Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.

Self-management intervention for patients following hospitalization for acute exacerbation of chronic obstructive pulmonary disease (AECOPD): A pilot randomized controlled trial

The purpose of this study was to evaluate the handoff guidance (HG) self-management intervention for multimorbid chronic obstructive pulmonary disease (COPD) patients following hospitalization for acute exacerbation of COPD (AECOPD) using HG self-management intervention compared to a control group on COPD self-management outcomes (self-care, self-efficacy, health engagement) and assess feasibility, acceptability, and healthcare utilization. A randomized pilot study used a 2-group with repeated measures design. Adults with COPD who had been hospitalized for AECOPD were recruited. After discharge, the HG self-management intervention employed health coaching delivered at: 1-3, 10-12, and 20-22 days after hospital discharge. Follow-up data collected was collected at 1-3, 10-12, 20-22, 30, 60, and 90 days after hospital discharge. A total of 29 subjects participated, with a mean age of 66 (+8.7) years old, the majority were females (n = 18). Intervention participants reported the acceptability of the HG self-management intervention. Participants in both groups continued to report COPD symptoms after discharge, which decreased over time, although not significantly different by group. The use of COPD maintenance, monitoring, and management behaviors was higher in the treatment group, although not significantly different.

Exacerbation predictive modelling using real-world data from the myCOPD app

Background

Acute exacerbations of COPD (AECOPD) are episodes of breathlessness, cough and sputum which are associated with the risk of hospitalisation, progressive lung function decline and death. They are often missed or diagnosed late. Accurate timely intervention can improve these poor outcomes. Digital tools can be used to capture symptoms and other clinical data in COPD. This study aims to apply machine learning to the largest available real-world digital dataset to develop AECOPD Prediction tools which could be used to support early intervention and improve clinical outcomes.

Objective

To create and validate a machine learning predictive model that forecasts exacerbations of COPD 1-8 days in advance. The model is based on routine patient-entered data from myCOPD self-management app.

Method

Adaptations of the AdaBoost algorithm were employed as machine learning approaches. The dataset included 506 patients users between 2017 and 2021. 55,066 app records were available for stable COPD event labels and 1263 records of AECOPD event labels. The data used for training the model included COPD assessment test (CAT) scores, symptom scores, smoking history, and previous exacerbation frequency. All exacerbation records used in the model were confined to the 1-8 days preceding a self-reported exacerbation event.

Results

TheEasyEnsemble Classifier resulted in a Sensitivity of 67.0 % and a Specificity of 65 % with a positive predictive value (PPV) of 5.0 % and a negative predictive value (NPV) of 98.9 %. An AdaBoost model with a cost-sensitive decision tree resulted in a a Sensitivity of 35.0 % and a Specificity of 89.0 % with a PPV of 7.08 % and NPV of 98.3 %.

Conclusion

This preliminary analysis demonstrates that machine learning approaches to real-world data from a widely deployed digital therapeutic has the potential to predict AECOPD and can be used to confidently exclude the risk of exacerbations of COPD within the next 8 days.

Inhaled corticosteroid treatment and pneumonia in patients with chronic obstructive pulmonary disease - nationwide development from 1998 to 2018

Background

A decreasing use of inhaled corticosteroids (ICS) in patients with a hospital-registered diagnosis of chronic obstructive pulmonary disease (COPD) has recently been documented in Denmark. ICS treatment is not recommended in patients with high pneumonia risk, and we aimed to assess the development of ICS treatment in relation to pneumonia occurrence.

Methods

Annual nationwide register-based cross-sectional studies from 1998 to 2018 including all patients ≥40 years of age with a hospital-registered ICD-10 diagnosis of COPD on the 31st of December each year. We calculated the annual proportion of patients with at least one outpatient pneumonia (redeemed prescription of relevant antibiotics) or pneumonia hospitalization (hospitalization or ER visit), and stratified by ICS dose (No ICS, low dose, medium dose, or high dose).

Results

The study population increased from 35,656 patients in 1998 to 99,057 patients in 2018. The annual proportion of patients experiencing a pneumonia decreased from 69.4% to 55.2%. The proportion of patients with at least one outpatient pneumonia, but no hospitalization, decreased (59.2% to 46.2%). The overall proportion of patients with at least one pneumonia hospitalization remained unchanged (10.2% to 9.0%), but this proportion increased in patients in high dose ICS (9.9% to 14.6%). The overall proportion of patients in high dose treatment decreased (12.7% to 5.7%), but not in patients with pneumonia hospitalization (16.5% to 15.1).

Conclusions

Our study demonstrates a nationwide decrease from 1998 to 2018 in the proportion of patients who redeemed a prescription for antibiotics used mainly for respiratory tract infections, which may reflect a decrease in the number of outpatient pneumonias. This decrease was largely caused by an increase in the number of patients without pneumonia. No differences over time were seen regarding hospitalization-requiring pneumonia. High dose ICS treatment was unchanged in patients with hospitalization-requiring pneumonia.

Sex based differences in depression, anxiety, and quality of life and predictors of quality of life among South Asian individuals with chronic obstructive pulmonary disease: A Bayesian analysis

BACKGROUND

COPD can affect both men and women leading to deteriorating impact on general well-being, personal, and family life and decreased quality of life. Anxiety, depression, and self-care behaviours can affect the quality of life of individuals with COPD. There is a dearth of sex-based comparative analyses of anxiety, depression, quality of life, and predictors of quality of life among South Asian individuals with COPD.

PURPOSE

To identify the sex-based differences in depression, anxiety, and quality of life and the predictors of quality of life among South Asian individuals with COPD.

METHODS

A cross-sectional survey of 294 men and 114 women with COPD was conducted in Khyber Pakhtunkhwa, Pakistan. Hospital Anxiety and Depression scale, World Health Organization Quality of Life-brief version, Self-Care of Chronic Obstructive Pulmonary Disease Inventory, the Self-Care Self-Efficacy in COPD Scale were used for data collection. Bayesian independent sample t-test was used to compare mean differences in depression, anxiety, and quality of life among men and women. Two regression models were examined to determine if age, years of living with COPD, anxiety, depression, self-care self-efficacy, self-care monitoring, management, and maintenance were predictors of quality of life among men and women.

FINDINGS

Bayesian analysis showed anecdotal evidence that women had higher levels of depression, but lower levels of anxiety compared to men. Anecdotal evidence indicated that the physical quality of life of men was better than women, but strong evidence that their social relationship and environmental quality of life was better than women. Years of living with COPD, anxiety, depression, self-care self-efficacy, self-care management, self-care monitoring, and self-care maintenance were stronger predictors of women's quality of life. Anxiety and depression only predicted men's psychological quality of life, but predicted women's psychological, social relationships, and environmental quality of life.

CONCLUSIONS

The findings contribute to literature highlighting sex-based differences in anxiety, depression, and quality of life among South Asian men and women with COPD. Men generally reported higher levels of quality of life than women across all domains. Women's social relationships and environmental quality of life were greatly impacted by anxiety and depression. Quality of life interventions for women should be targeted at improving their social relationships and environmental satisfaction and addressing anxiety and depression.

Antibiotic treatment for patients with exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

Although respiratory tract infection is a significant factor that triggers exacerbation of chronic obstructive pulmonary disease (COPD), the benefit of antibiotics for patients with COPD exacerbation remains controversial. It is necessary to evaluate the efficacy and safety of antibiotics versus placebo in such patients.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials of antibiotics versus placebo for the treatment of COPD exacerbation, and compared the frequencies of treatment failure, mortality, and adverse events between patients treated with antibiotics and those treated with placebo.

RESULTS

A total of six studies were included in this meta-analysis. The frequency of treatment failure was significantly lower in the antibiotic-treated patients compared to the placebo-treated patients (odds ratios [OR] 0.50, 95% confidence intervals [CI] 0.35-0.71, p = 0.0001). There was no significant difference between the two groups in mortality (OR 0.44, 95% CI 0.05-3.76, p = 0.45) or frequency of adverse events (OR 1.05, 95% CI 0.75-1.48, p = 0.78).

CONCLUSION

In the current systematic review and meta-analysis, we found that antibiotics were superior to placebo in patients with exacerbated COPD, as shown by the lower treatment failure rate.

Targeting respiratory microbiomes in COPD and bronchiectasis

INTRODUCTION

This review summarizes our current understanding of the respiratory microbiome in COPD and Bronchiectasis. We explore the interplay between microbial communities, host immune responses, disease pathology and treatment outcomes.

AREAS COVERED

We detail the dynamics of the airway microbiome, its influence in chronic respiratory diseases, and analytical challenges. Relevant articles from PubMed and Medline searches between Jan 2010 and March 2024 were retrieved and summarized. The review examines clinical correlations of the microbiome in COPD and bronchiectasis, assessing how current therapies impact upon it. The potential of emerging immunotherapies, anti-inflammatories and antimicrobial strategies are discussed, with focus on the pivotal role of commensal taxa in maintaining respiratory health and the promising avenue of microbiome remodeling for disease management.

EXPERT OPINION

Given the heterogeneity in microbiome composition and its pivotal role in disease development and progression, a shift toward microbiome-directed therapeutics is appealing. This transition, from traditional 'pathogen-centric' diagnostic and treatment modalities to those acknowledging the microbiome, can be enabled by evolving cross-disciplinary platforms which have the potential to accelerate microbiome-based interventions into routine clinical practice. Bridging the gap between comprehensive microbiome analysis and clinical application, however, remains challenging, necessitating continued innovation in research, diagnostics, trials and therapeutic development pipelines.

Influencing factors of good quality of life among chronic obstructive pulmonary disease patients living in Zhejiang Province, China

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive and debilitating disease that affects quality of life (QOL), especially among patients living in poor environments. This study aimed to determine the influencing factors of good QOL among COPD patients living in Zhejiang, China. A cross-sectional study was conducted to collect data from participants in six tertiary hospitals in Zhejiang Province by a simple random sampling method. A validated questionnaire was used to collect general information, environmental factors, and COPD stage. The standardized St. George's Respiratory Questionnaire (SGRQ) was used to assess QOL. Logistic regression was used to determine influencing factors of good QOL among COPD patients at a significance level of α = 0.05. A total of 420 participants were recruited for analysis. The overall prevalence of patients with good QOL was 25.7%. Six variables were found to be associated with good QOL in the multivariable analysis. Patients who were employed had 2.35 times (95% CI 1.03-5.34) greater odds of having good QOL than those who were unemployed. Those whose family income was higher than 100,000 CNY had 2.49 times (95% CI 1.15-5.39) greater odds of having good QOL than those whose family income was lower than 100,000 CNY. Those who had treatment expenses less than 5,000 CNY had 4.57 (95% CI 1.57-13.30) times greater odds of having good QOL than those who had treatment expenses of 5,000 CNY or higher. Those who had mild or moderate airflow limitation were 5.27 times (95% CI 1.61-17.26) more likely to have good QOL than those who were in a severe or very severe stage of COPD. Those who had a duration of illness less than 60 months had 5.57 times (95% CI 1.40-22.12) greater odds of having good QOL than those who had a duration of illness of 120 months or more. Those who were not hospitalized within the past 3 months had 9.39 times (95% CI 1.62-54.43) greater odds of having good QOL than those who were hospitalized more than twice over the past 3 months. Socioeconomic status, disease stage and accessibility were associated with good QOL among COPD patients in Zhejiang Province, China. Increasing family income and implementing measures to improve the accessibility of medical care, including developing a proper system to decrease the cost of treatment for COPD patients, can improve patients' QOL.

Feasibility of a wearable self-management application for patients with COPD at home: a pilot study

BACKGROUND

Among people with COPD, smartphone and wearable technology may provide an effective method to improve care at home by supporting, encouraging, and sustaining self-management. The current study was conducted to determine if patients with COPD will use a dedicated smartphone and smartwatch app to help manage their COPD and to determine the effects on their self-management.

METHODS

We developed a COPD self-management application for smartphones and smartwatches. Participants were provided with the app on a smartphone and a smartwatch, as well as a cellular data plan and followed for 6 months. We measured usage of the different smartphone app functions. For the primary outcome, we examined the change in self-management from baseline to the end of follow up. Secondary outcomes include changes in self-efficacy, quality of life, and COPD disease control.

RESULTS

Thirty-four patients were enrolled and followed. Mean age was 69.8 years, and half of the participants were women. The most used functions were recording steps through the smartwatch, entering a daily symptom questionnaire, checking oxygen saturation, and performing breathing exercises. There was no significant difference in the primary outcome of change in self-management after use of the app or in overall total scores of health-related quality of life, disease control or self-efficacy.

CONCLUSION

We found older patients with COPD would engage with a COPD smartphone and smartwatch application, but this did not result in improved self-management. More research is needed to determine if a smartphone and smartwatch application can improve self-management in people with COPD.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03857061, First Posted February 27, 2019.

A Randomized Phase I Study of the Anti-Interleukin-33 Antibody Tozorakimab in Healthy Adults and Patients With Chronic Obstructive Pulmonary Disease

Tozorakimab is a human monoclonal antibody that neutralizes interleukin (IL)-33. IL-33 is a broad-acting epithelial "alarmin" cytokine upregulated in lung tissue of patients with chronic obstructive pulmonary disease (COPD). This first-in-human, phase I, randomized, double-blind, placebo-controlled study (NCT03096795) evaluated the safety, tolerability, pharmacokinetics (PKs), immunogenicity, target engagement, and pharmacodynamics (PDs) of tozorakimab. This was a 3-part study. In part 1, 56 healthy participants with a history of mild atopy received single escalating doses of either intravenous or subcutaneous tozorakimab or placebo. In part 2, 24 patients with mild COPD received multiple ascending doses of subcutaneous tozorakimab or placebo. In part 3, 8 healthy Japanese participants received a single intravenous dose of tozorakimab or placebo. The safety data collected included treatment-emergent adverse events (TEAEs), vital signs, and clinical laboratory parameters. Biological samples for PKs, immunogenicity, target engagement, and PD biomarker analyses were collected. No meaningful differences in the frequencies of TEAEs were observed between the tozorakimab and placebo arms. Three tozorakimab-treated participants with COPD experienced treatment-emergent serious adverse events. Subcutaneous or intravenous tozorakimab demonstrated linear, time-independent PKs with a mean half-life of 11.7-17.3 days. Treatment-emergent anti-drug antibody frequency was low. Engagement of tozorakimab with endogenous IL-33 in serum and nasal airways was demonstrated. Tozorakimab significantly reduced serum IL-5 and IL-13 levels in patients with COPD compared with placebo. Overall, tozorakimab was well tolerated, with a linear, time-independent serum PK profile. Additionally, biomarker studies demonstrated proof of mechanism. Overall, these data support the further clinical development of tozorakimab in COPD and other inflammatory diseases.

Validation of the Rome Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbation: A Multicenter Cohort Study

Background

The Rome severity classification is an objective assessment tool for the severity of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) based on readily measurable variables but has not been widely validated. The aim of this study is to evaluate the validity of the Rome classification in distinguishing the severity of AECOPD based on short-term mortality and other adverse outcomes.

Methods

The Rome severity classification was applied to a large multicenter cohort of inpatients with AECOPD. Differences in clinical features, in-hospital and 60-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) and invasive mechanical ventilation (IMV) usage were compared among the mild, moderate and severe AECOPD according to the Rome proposal. Moreover, univariate logistic analysis and Kaplan Meier survival analysis were also performed to find the association between the Rome severity classification and those adverse outcomes.

Results

A total of 7712 patients hospitalized for AECOPD were included and classified into mild (41.88%), moderate (40.33%), or severe (17.79%) group according to the Rome proposal. The rate of ICU admission (6.4% vs 12.0% vs 14.9%, P <0.001), MV (11.7% vs 33.7% vs 45.3%, P <0.001) and IMV (1.4% vs 6.8% vs 8.9%, P <0.001) increased significantly with the increase of severity classification from mild to moderate to severe AECOPD. The 60-day mortality was higher in the moderate or severe group than in the mild group (3.5% vs 1.9%, 4.3% vs 1.9%, respectively, P <0.05) but showed no difference between the moderate and severe groups (2.6% vs 2.5%, P >0.05), results for in-hospital mortality showed the same trends. Similar findings were observed by univariate logistic analysis and survival analysis.

Conclusion

Rome severity classification demonstrated excellent performance in predicting ICU admission and the need for MV or IMV, but how it performs in differentiating short-term mortality still needs to be confirmed.

Associations between the EQ-5D-5L and exacerbations of chronic obstructive pulmonary disease in the ETHOS trial

PURPOSE

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with deteriorating health and health-related quality of life (HRQoL) among people with COPD during and after events. HRQoL data are key to evaluating treatment cost-effectiveness and informing reimbursement decisions in COPD. EuroQoL 5-dimension 5-level (EQ-5D-5L) utility scores, based on various HRQoL measures, are used in economic evaluations of pharmacotherapy. These analyses estimated associations between EQ-5D-5L utility scores and exacerbations (new and previous) in patients with moderate-to-very severe COPD.

METHODS

Longitudinal mixed models for repeated measures (MMRM), adjusted for time and treatment, were conducted using data from the ETHOS study (NCT02465567); models regressed EQ-5D-5L on current and past exacerbations that occurred during the study, adjusting for other patient reported outcomes and clinical factors.

RESULTS

Based on the simplest covariate adjusted model (adjusted for current exacerbations and number of previous exacerbations during the study), a current moderate exacerbation was associated with an EQ-5D-5L disutility of 0.055 (95% confidence interval: 0.048, 0.062) with an additional disutility of 0.035 (0.014, 0.055) if the exacerbation was severe. After resolving, each prior exacerbation was associated with a disutility that persisted for the remainder of the study (moderate exacerbation, 0.014 [0.011, 0.016]; further disutility for severe exacerbation, 0.011 [0.003, 0.018]).

CONCLUSION

An EQ-5D-5L disutility of 0.090 was associated with a current severe exacerbation in ETHOS. Our findings suggest incorporating the effects of current, recently resolved, and cumulative exacerbations into economic models when estimating benefits and costs of COPD pharmacotherapy, as exacerbations have both acute and persistent effects.

Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients

Background

Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design.

Methods

A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement.

Results

Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event.

Conclusions

This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

Systematic Review and Meta-Analysis of Psychological Distress and Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Consequences

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) occasionally develop acute exacerbation of COPD-a potentially fatal condition. Psychological distress was associated with acute exacerbation of COPD. However, the evidence on the effect of psychological distress on acute exacerbation of COPD remains unclear.

OBJECTIVE

The aim of this study was to explore the influence of psychological distress on acute exacerbation of COPD and its consequences.

METHODS

The current review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using three databases (PubMed, CINAHL, and PsyINFO) that were searched to identify relevant articles. Pooled risk ratios and 95% confidential interval were calculated from the included studies' data with random-effect methods to estimate the effect of psychological distress on acute exacerbation of COPD and its consequences.

RESULTS

Nineteen articles were included in the review. Most revealed that psychological distress was significantly associated with increased risk of acute exacerbation of COPD and its consequences. The meta-analyses showed that psychological distress increased risk of acute exacerbation of COPD, COPD-related hospitalization, and death.

CONCLUSION

Psychological distress had negative effects on acute exacerbation of COPD and its consequences. The results of the meta-analyses show that persons with COPD and psychological distress had a greater risk of acute exacerbation of COPD, hospitalization, and death.

Short- and Long-Term Impact of Prior Chronic Obstructive Pulmonary Disease Exacerbations on Healthcare Resource Utilization and Related Costs: An Observational Study (SHERLOCK)

The observational retrospective cohort Study on HEalthcare Resource utiLization (HCRU) related to exacerbatiOns in patients with COPD (SHERLOCK; D5980R00014) evaluated exacerbation-related HCRU and costs using the U.K. National Health Service Greater Glasgow and Clyde Health Board data. Patients (≥40 years) with COPD were stratified by exacerbations one year before the index date: Group A (none), B (1 moderate), C (1 severe) and D (≥2 moderate and/or severe). All-cause and COPD-related HCRU and costs were assessed over 36 months. Adjusted rate ratios (RRs) or relative costs versus Group A were estimated using generalized linear models with appropriate distributions and link functions. The study included 22 462 patients (Group A, n = 7788; B, n = 5151; C, n = 250 and D, n = 9273). At 12 months, RRs (95% CI) versus Group A for all-cause and COPD-related HCRU, respectively, were highest in Groups C (1.28 [1.18, 1.39] and 1.18 [1.09, 1.29]) and D (1.26 [1.23, 1.28] and 1.29 [1.26, 1.31]). General practitioner and outpatient visits, and general ward stays/days accounted for the greatest COPD-related HCRU. All-cause and COPD-related relative costs (95% CI) versus Group A at 12 months, respectively, were 1.03 (0.94, 1.12) and 1.06 (0.99, 1.13) in Group B; 1.47 (1.07, 2.01) and 1.54 (1.20, 1.97) in Group C; 1.47 (1.36, 1.58) and 1.63 (1.54, 1.73) in Group D. Increased HCRU and costs in patients with exacerbation histories persisted at 36 months, demonstrating the sustained impact of exacerbations. The study suggests the importance of management and prevention of exacerbations through intervention optimization and budgeting by payers for exacerbation-related costs.

Bayesian or frequentist: there is no question when comparing single-inhaler triple therapies via network meta-analysis. Focus on fluticasone furoate/umeclidinium/vilanterol fixed-dose combination in chronic obstructive pulmonary disease

OBJECTIVES

Single-inhaler triple therapies (SITTs) have never been directly compared in randomized controlled trials (RCTs) in chronic obstructive pulmonary disease (COPD). Cochrane recommends the Bayesian approach for indirect comparisons but a frequentist network meta-analysis (NMA) reported superiority of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) over other SITT. We assessed the most appropriate inference method for NMA characterized by between-study heterogeneity on SITT in COPD.

METHODS

Bayesian and frequentist NMA were performed on RCTs investigating the effect of SITT on exacerbations and trough forced expiratory volume in the 1st second (FEV1) in COPD.

RESULTS

The included RCTs (ETHOS, FULFIL, IMPACT, KRONOS 200812) reported significant between-study heterogeneity (I2 > 99%, p < 0.001). The Bayesian random-effect NMA provided unbiased evidence that FF/UMEC/VI was not superior to other SITT on exacerbations and trough FEV1. The frequentist fixed-effect NMA indicated that FF/UMEC/VI was significantly (p < 0.05) more effective than other SITT, although results were affected by dispersion, asymmetry, and significant risk of bias. Frequentist random-effect NMA provided effect estimates rather similar but not equal to those of Bayesian approach.

CONCLUSION

Indirect comparison should be performed via Bayesian approach instead of frequentist inference with a fixed-effect model. Claiming the superiority of a specific medication over other therapies should be confirmed by findings originating from well-designed RCTs.

Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review

This scoping review summarized the evidence regarding the impact of acute exacerbations of COPD (AECOPD) on patients' health status beyond pulmonary function. PubMed, Embase, and Web of Science were searched. Prospective cohort studies assessing the health status of patients with COPD in a stable phase of the disease and after a follow-up period (where at least one AECOPD occurred) were included. An integrated assessment framework of health status (i.e., physiological functioning, complaints, functional impairment, quality of life) was used. Twenty-two studies were included. AECOPD acutely affected exercise tolerance, quadriceps muscle strength, physical activity levels, symptoms of dyspnoea and fatigue, and impact of the disease. Long-term effects on quadriceps muscle strength, symptoms of dyspnoea and depression, and quality of life were found. Repeated exacerbations negatively impacted the fat-free mass, levels of dyspnoea, impact of the disease and quality of life. Conflicting evidence was found regarding the impact of repeated exacerbations on exercise tolerance and physical activity levels. AECOPD have well-established acute and long-term adverse effects on health status beyond pulmonary function; nevertheless, the recovery trajectory and the impact of repeated exacerbations are still poorly studied. Further prospective research is recommended to draw firm conclusions on these aspects.

The Impact of Pulmonary Rehabilitation on Mental Health and Quality of Life in Patients With Chronic Obstructive Pulmonary Disease (COPD): A Narrative Review

Chronic obstructive pulmonary disease (COPD) is a complex, prevalent, debilitating, and degenerative disease that affects a large population, and the treatment options for the patients are limited. Although progress has been made in COPD pathogenesis, etiology, and management, there is still an unmet need to develop novel therapies. COPD management has recently seen a focus on a multidisciplinary pulmonary rehabilitation approach to help patients manage the disease better. This review primarily focuses on the role of pulmonary rehabilitation as a novel therapeutic strategy for treating and managing COPD, which is known to decrease patients' quality of life. Disease management and the beneficial effects of pulmonary rehabilitation in COPD are discussed. Subsequently, different methods that are employed in pulmonary rehabilitation are examined, including oxygen therapy, exercise, meditation, and education, emphasizing how they can help patients better manage COPD. Pathophysiology and the effect of pulmonary rehabilitation on the cellular level, such as the release of perforins and Th1 and Th17 cytokines, are also explored. The link between exercise and meditation during pulmonary rehabilitation therapy, which promotes repairing affected organs, is emphasized. Future perspectives on personalized medicine and its use in conjunction with pulmonary rehabilitation are also outlined. In conclusion, pulmonary rehabilitation holds significant promise for the management of COPD by addressing the present limitations of treatment. However, further research is essential to overcome and optimize treatment strategies for COPD patients.

Barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease in Iran: a descriptive qualitative study

OBJECTIVES

Chronic obstructive pulmonary disease is a chronic disease with numerous complications. Therefore, its effective management depends on home-based pulmonary rehabilitation. The effectiveness of home-based pulmonary rehabilitation programmes in turn depends on patient adherence to them. The aim of this study was to explore the barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease.

DESIGN

Qualitative descriptive design.

SETTING

The lung care wards of Al-Zahra and Khorshid teaching hospitals and the comprehensive lung care clinic of Khorshid hospital, Isfahan, Iran.

PARTICIPANTS

Participants patients with chronic obstructive pulmonary disease (n=20), their family caregivers (n=15) and healthcare providers (n=14) recruited via purposive sampling.

RESULTS

The five main categories of the barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease were patient-related barriers, caregivers' caregiving burden, limited support for patients, healthcare providers' limited professional competence and ineffective home-based pulmonary rehabilitation planning.

CONCLUSION

Different and complex factors related to patients, families and healthcare providers can affect adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease. Healthcare authorities can use the findings of this study to develop strategies to support patients with chronic obstructive pulmonary disease and their family caregivers and thereby reduce the physical and mental complications of Chronic obstructive pulmonary disease.

DElaying Disease Progression In COPD with Early Initiation of Dual Bronchodilator or Triple Inhaled PharmacoTherapy (DEPICT): A Predictive Modelling Approach

INTRODUCTION

Clinical studies demonstrate an accelerated decline in lung function in patients with moderate chronic obstructive pulmonary disease (COPD) (Global Initiative for Chronic Obstructive Lung Disease [GOLD] grade 2) versus severe and very severe COPD (GOLD grades 3 and 4). This predictive modelling study assessed the impact of initiating pharmacotherapy earlier versus later on long-term disease progression in COPD.

METHODS

The modelling approach used data on decline in forced expiratory volume in 1 s (FEV1) extracted from published studies to develop a longitudinal non-parametric superposition model of lung function decline with progressive impact of exacerbations from 0 per year to 3 per year and no ongoing pharmacotherapy. The model simulated decline in FEV1 and annual exacerbation rates from age 40 to 75 years in COPD with initiation of long-acting anti-muscarinic antagonist (LAMA)/long-acting beta2-agonist (LABA) (umeclidinium (UMEC)/vilanterol (VI)) or triple (inhaled corticosteroid (ICS)/LAMA/LABA; fluticasone furoate (FF)/UMEC/VI) therapy at 40, 55 or 65 years of age.

RESULTS

Model-predicted decline in FEV1 showed that, compared with 'no ongoing' therapy, initiation of triple or LAMA/LABA therapy at age 40, 55 or 65 years preserved an additional 469.7 mL or 236.0 mL, 327.5 mL or 203.3 mL, or 213.5 mL or 137.5 mL of lung function, respectively, by the age of 75. The corresponding average annual exacerbation rates were reduced from 1.57 to 0.91, 1.06 or 1.23 with triple therapy or to 1.2, 1.26 and 1.4 with LAMA/LABA therapy when initiated at 40, 55 or 65 years of age, respectively.

CONCLUSIONS

This modelling study suggests that earlier initiation of LAMA/LABA or triple therapy may have positive benefits in slowing disease progression in patients with COPD. Greater benefits were demonstrated with early initiation therapy with triple versus LAMA/LABA.

Performance-based outcome measures to assess functionality in hospitalised patients with COPD exacerbations: a systematic review of the measurement properties

INTRODUCTION

Hospitalised patients with exacerbations of COPD (ECOPD) may have physical and functional impairments that impact morbidity and readmission. Therefore, it is crucial to properly identify reduced functionality in these patients to support a personalised rehabilitation. The objective of this study is to summarise and compare the measurement properties of functionality performance-based outcome measures for hospitalised patients with ECOPD.

METHODS

A systematic review based on the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) was performed. The PubMed, Embase, PEDro and Cochrane databases were searched using terms related to functionality, hospitalised patients with ECOPD and measurement properties. Studies were selected and extracted by two researchers. The COSMIN Risk of Bias checklist was applied to assess the methodological quality of the studies and measurement property results were compared with the criteria for good measurement properties. Quality of evidence was graded using a modified Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

13 studies were included with nine outcome measures, namely the 6-min pegboard ring test, the de Morton mobility index, the incremental shuttle walk test (ISWT), the 6-min walk test (6MWT), maximum inspiratory pressure (MIP), the Berg balance scale, 4-m gait speed, handgrip strength and the 6-min stepper test. Construct validity was rated as sufficient, except for the ISWT. Responsiveness, assessed only for MIP, was considered insufficient and measurement errors for the ISWT and 6MWT were insufficient, with a very low quality of evidence for all measurement properties.

CONCLUSION

Measurement properties of performance-based outcome measures to assess functionality in patients hospitalised with ECOPD are still scarce, with very low evidence supporting validity and a lack of evidence of responsiveness and reliability. Further studies are needed to address this topic and guide assertive and personalised management.

Management of acute COPD exacerbations in the internal medicine departments in Israel-a national survey

Background

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Acute exacerbations of COPD (AECOPD) drastically affect the clinical course of the disease. We aimed to evaluate the treatment of AECOPD in the internal medicine departments in Israel, nationwide.

Methods

The COPD Israeli survey (COPDIS) is the first national survey of patients admitted with AECOPD to internal medicine departments between 2017 and 2019. The survey includes prospective (n = 344) and retrospective (n = 1,166) data from 13 medical centers. We analyzed the pre-hospital, in-hospital, and pre-discharge care. Hospital evaluation, outcomes and discharge recommendations were assessed as well.

Results

The mean (±SD) age was 74 (±8) years, and 54% were males. 74% had comorbidities, and 88% had a diagnosis of COPD in their history. 70% of the patients received systemic steroids and antibiotics during their hospitalization, yet upon discharge, a lower rate of antibiotics prescription (10%) was found. Treatment with most long-acting bronchodilators dramatically dropped during admission, compared with their pre-hospital use. Overall, a long-acting bronchodilator (LABD) was used by 47% before admission, 28% in-hospital, and was prescribed to 54% at discharge. The discharge plan included a referral to pulmonary rehabilitation in only 11% and a smoking cessation recommendation in 43% of active smokers. The in-hospital mortality was 3% and the 1-year mortality rate was 25%. In multivariate analysis, performing a chest X-ray (adjusted OR 0.64, 95% CI 0.46-0.90) and prescribing LABD at discharge (AOR 0.73, 95% CI 0.57-0.95) were independent predictors for lower 1-year mortality.

Conclusion

Our results demonstrate AECOPD characteristics in Israel, and highlight several important gaps in AECOPD healthcare, which must be addressed to improve patient care.

Clinicians' Perspectives of Wearable Technology to Detect and Monitor Exacerbations of Chronic Obstructive Pulmonary Disease: Mixed-Method Survey

Objective

To investigate clinicians' perspectives on the current use of wearable technology for detecting COPD exacerbations, and to identify potential facilitators and barriers to its adoption in clinical settings.

Methods

A mixed-method survey was conducted through an online survey platform involving clinicians working with COPD patients. The questionnaires were developed by an expert panel specialising in respiratory medicine at UCL. The questionnaire evaluated clinicians' perspectives on several aspects: the current extent of wearable technology utilisation, the perceived feasibility, and utility of these devices, as well as the potential facilitators and barriers that hinder its wider implementation.

Results

Data from 118 clinicians were included in the analysis. Approximately 80% of clinicians did not currently use information from wearable devices in routine clinical care. A majority of clinicians did not have confidence in the effectiveness of wearables and their consequent impact on health outcomes. However, clinicians highlighted the potential value of wearables in helping deliver personalised care and more rapid assistance. Ease of use, technical support and accessibility of data were considered facilitating factors for wearable utilisation. Costs and lack of technical knowledge were the most frequently reported barriers to wearable utilisation.

Conclusion

Clinicians' perspectives of the use of wearable technology to detect and monitor COPD exacerbations are variable. While accessibility and technical support facilitate wearable implementation, cost, technical issues, and knowledge act as barriers. Our findings highlight the facilitators and barriers to using wearables in patients with COPD and emphasise the need to assess patients' perspectives on wearable acceptability.

Experimental drugs in clinical trials for COPD: Artificial Intelligence via Machine Learning approach to predict the successful advance from early-stage development to approval

INTRODUCTION

Therapeutic advances in drug therapy of chronic obstructive pulmonary disease (COPD) really effective in suppressing the pathological processes underlying the disease deterioration are still needed. Artificial Intelligence (AI) via Machine Learning (ML) may represent an effective tool to predict clinical development of investigational agents.

AREAL COVERED

Experimental drugs in Phase I and II development for COPD from early 2014 to late 2022 were identified in the ClinicalTrials.gov database. Different ML models, trained from prior knowledge on clinical trial success, were used to predict the probability that experimental drugs will successfully advance toward approval in COPD, according to Bayesian inference as follows: ≤25% low probability, >25% and ≤ 50% moderate probability, >50% and ≤ 75% high probability, and > 75% very high probability.

EXPERT OPINION

The Artificial Neural Network and Random Forest ML models indicated that, among the current experimental drugs in clinical trials for COPD, only the bifunctional muscarinic antagonist - β₂-adrenoceptor agonists (MABA) navafenterol and batefenterol, the inhaled corticosteroid (ICS)/MABA fluticasone furoate/batefenterol, and the bifunctional phosphodiesterase (PDE) 3/4 inhibitor ensifentrine resulted to have a moderate to very high probability of being approved in the next future, however not before 2025.

Impact of COPD Exacerbations and Burden of Disease in Spain: AVOIDEX Study

Purpose

Chronic obstructive pulmonary disease (COPD) is characterized by high morbidity and mortality, with a considerable consumption of healthcare resources (HRU). This study aims to obtain real world evidence regarding the consequences of COPD exacerbations and to provide updated data on the burden of this disease and its treatment.

Patients and Methods

A retrospective study in seven Spanish regions was conducted among COPD patients diagnosed between 1/01/2010 and 31/12/2017. The index date was the diagnosis of COPD and patients were followed until lost to follow-up, death or end of the study, whichever occurred first. Patients were classified by patient pattern (incident or prevalent), type and severity of exacerbations, and treatments prescribed. Demographic and clinical characteristics were evaluated, together with the incidence of exacerbations, comorbidities, and the use of HRU, during the baseline (12 months before the index date) and the follow-up periods by incident/prevalent and treatment prescribed. Mortality rate was also measured.

Results

The study included 34,557 patients with a mean age of 70 years (standard deviation: 12). The most frequent comorbidities were diabetes, osteoporosis, and anxiety. Most patients received inhaled corticosteroids (ICS) with long-acting beta agonists (LABA), or long-acting muscarinic agonists (LAMA), followed by LABA with LAMA. Incident patients (N=8229; 23.8%) had fewer exacerbations than prevalent patients (N=26328; 76.2%), 0.3 vs 1.2 exacerbations per 100 patient-years. All treatment patterns present a substantial disease burden, which seems to increase with the evolution of the disease (ie moving from initial treatments to combination therapies). The overall mortality rate was 40.2 deaths/1000 patient-years. General practitioner visits and tests were the HRU most frequently required. The frequency and severity of exacerbations positively correlated with the use of HRU.

Conclusion

Despite receiving treatment, patients with COPD suffer a considerable burden mainly due to exacerbations and comorbidities, which require a substantial use of HRU.

Global knowledge, attitude, and practice towards COVID-19 among pregnant women: a systematic review and meta-analysis

BACKGROUND

Pregnant women form a specially vulnerable group due to unique changes in pregnancy, leading to a higher risk of getting a severe infection. As severe COVID-19 increases the risk of preeclampsia, preterm delivery, gestational diabetes, and low birth weight in pregnancy, there is a need to enhance pregnant women's knowledge, attitudes, and practices to prevent these complications. This systematic review and meta-analysis aimed to determine their levels of knowledge, attitudes, and practice (KAP) regarding COVID-19 at the global level.

METHODS

The systematic literature search was conducted in the English language, including Google Scholar, Scopus, PubMed/MEDLINE, Science Direct, Web of Science, EMBASE, Springer, and ProQuest, from the occurrence of the pandemic until September 2022. We used The Newcastle Ottawa scale for cross-sectional studies checklist to evaluate the risk of bias in the studies. Data were extracted by a Microsoft Excel spreadsheet and analyzed by STATA software version 14. We also employed Cochran Q statistics to assess the heterogeneity of studies and utilized Inverse variance random-effects models to estimate the pooled level of pregnant women's KAP towards COVID-19 infection prevention.

RESULTS

Based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and inclusion criteria, 53 qualified studies were acquired from several countries. In total, 51 articles (17,319 participants) for knowledge, 15 articles (6,509 participants) for attitudes, and 24 articles (11,032 participants) for practice were included in this meta-analysis. The pooled good knowledge, positive attitude, and appropriate practice in pregnant women were estimated at 59%(95%CI: 52-66%), 57%(95%CI: 42-72%), and 53%(95%CI: 41-65%), respectively. According to subgroup analysis, the level of knowledge, attitude, and practice were 61%(95%CI: 49-72), 52%(95%CI: 30-74), and 50%(95%CI: 39-60), respectively, in Africa, and 58.8%(95%CI: 49.2-68.4), 60%(95%CI: 41-80) and 60% (95%CI: 41-78), respectively, in Asia.

CONCLUSION

The Knowledge, attitude, and practice towards COVID-19 infection prevention in pregnant women were low. It is suggested that health education programs and empowerment of communities, especially pregnant women, about COVID-19 continue with better planning. For future studies, we propose to investigate the KAP of COVID-19 in pregnant women in countries of other continents and geographical regions.

Exacerbations Predict Severe Cardiovascular Events in Patients with COPD and Stable Cardiovascular Disease–A Nationwide, Population-Based Cohort Study

Objective

Patients with chronic obstructive pulmonary disease (COPD) commonly present with cardiovascular disease (CVD). We investigated the association between COPD exacerbations and major cardiovascular (CV) events in a COPD population with a history of CVD.

Methods

This population-based and register-based cohort study identified all Danish COPD patients aged ≥40 years who visited a hospital-based, pulmonary outpatient clinic for COPD between 1st January, 2010, and 31st December, 2016, from a nationwide COPD registry. Patients with a history of a major CV event 36‒6 months prior to their COPD measurement date and no CV event 6 months before this date were included. During a 6-month assessment period, the risks of a new CV event (hospitalization with fatal/non-fatal stroke, myocardial infarction, or heart failure) and moderate and severe COPD exacerbations were evaluated. Odds ratios with 95% confidence intervals for CV events and death were estimated using adjusted logistic regression models.

Results

Of the 1501 COPD patients included, 55% experienced a COPD exacerbation and 13% experienced both an exacerbation and a CV event during follow-up (6 months). The odds of a CV event were 1.5 times higher in patients with a moderate exacerbation and more than 6-times higher in those with a severe exacerbation vs patients with no exacerbation(s). The majority of CV events occurred within 30 days post exacerbation in patients who experienced both an exacerbation and a CV event. In total, 113 patients died during the study period: 28% of deaths were caused by CVD and 72% by reasons other than CVD, mostly COPD.

Conclusion

In patients with known CVD, severe COPD exacerbations are associated with increased odds of major CV events that occur within 30 days post exacerbation, highlighting the need to prevent exacerbations in COPD patients with concomitant CVD to potentially improve both respiratory and CV health.

Insomnia in chronic obstructive pulmonary disease and associations with healthcare utilization and costs

Insomnia has been linked to adverse chronic obstructive pulmonary disease (COPD) outcomes including exacerbations, yet its impact on COPD-related healthcare utilization and costs is unknown. In this study, we investigated the associations between insomnia and healthcare utilization and costs in patients with COPD. A retrospective cohort of veterans with COPD were identified from national Veterans Affairs administration data for fiscal years 2012-2017. Insomnia was operationalized as having an insomnia diagnosis based on International Classification of Disease codes or having a prescription of > 30 doses of a sedative-hypnotic medication in a given fiscal year. The index date for insomnia was the first date when dual criteria for COPD and insomnia was met. The index date for those without insomnia was set as the COPD index date. Our primary outcomes were 1-year healthcare utilization and costs related to outpatient visits and hospitalizations after index date. COPD-related healthcare utilization variables included number of prescription fills of corticosteroids and/or antibiotics and outpatient visits and hospitalizations with a primary diagnosis of COPD. Out of 1,011,646 patients (96% men, mean age 68.4 years) diagnosed with COPD, 407,363 (38.8%) had insomnia. After adjustment for confounders, insomnia was associated with higher rates of outpatient visits, hospitalizations, and fills for corticosteroids and/or antibiotics, longer hospital length of stay, and $10,344 higher hospitalization costs in the 12 months after index date. These findings highlight the importance of insomnia as a potentially modifiable target for reducing the burden of COPD on patients and healthcare systems.

Cigarette smoke-induced pulmonary impairment is associated with social recognition memory impairments and alterations in microglial profiles within the suprachiasmatic nucleus of the hypothalamus

Chronic obstructive pulmonary disease (COPD) is a major, incurable respiratory condition that is primarily caused by cigarette smoking (CS). Neurocognitive disorders including cognitive dysfunction, anxiety and depression are highly prevalent in people with COPD. It is understood that increased lung inflammation and oxidative stress from CS exposure may 'spill over' into the systemic circulation to promote the onset of these extra-pulmonary comorbidities, and thus impacts the quality of life of people with COPD. The precise role of the 'spill-over' of inflammation and oxidative stress in the onset of COPD-related neurocognitive disorders are unclear. The present study investigated the impact of chronic CS exposure on anxiety-like behaviors and social recognition memory, with a particular focus on the role of the 'spill-over' of inflammation and oxidative stress from the lungs. Adult male BALB/c mice were exposed to either room air (sham) or CS (9 cigarettes per day, 5 days a week) for 24 weeks and were either daily co-administered with the NOX2 inhibitor, apocynin (5 mg/kg, in 0.01 % DMSO diluted in saline, i.p.) or vehicle (0.01 % DMSO in saline) one hour before the initial CS exposure of the day. After 23 weeks, mice underwent behavioral testing and physiological diurnal rhythms were assessed by monitoring diurnal regulation profiles. Lungs were collected and assessed for hallmark features of COPD. Consistent with its anti-inflammatory and oxidative stress properties, apocynin treatment partially lessened lung inflammation and lung function decline in CS mice. CS-exposed mice displayed marked anxiety-like behavior and impairments in social recognition memory compared to sham mice, which was prevented by apocynin treatment. Apocynin was unable to restore the decreased Bmal1-positive cells, key in cells in diurnal regulation, in the suprachiasmatic nucleus of the hypothalamus to that of sham levels. CS-exposed mice treated with apocynin was associated with a restoration of microglial area per cell and basal serum corticosterone. This data suggests that we were able to model the CS-induced social recognition memory impairments seen in humans with COPD. The preventative effects of apocynin on memory impairments may be via a microglial dependent mechanism.

Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia

Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.

PROMETHEUS: Long-Term Exacerbation and Mortality Benefits of Implementing Single-Inhaler Triple Therapy in the US COPD Population

Background: The US population includes 24 million to 29 million people with diagnosed and undiagnosed chronic obstructive pulmonary disease (COPD). Studies have demonstrated the safety and efficacy of single-inhaler triple therapy (SITT) in reducing COPD exacerbations. Long-term population implications of SITT use have not been quantified. Objectives: This simulation-based projection aimed to estimate the potential impact of widespread SITT use on the US COPD population. Methods: Exacerbation and all-cause mortality reductions reported in the Efficacy and Safety of Triple Therapy in Obstructive Lung Disease trial (ETHOS; NCT02465567) were used to project clinical outcomes in US patients meeting ETHOS trial eligibility criteria (ETHOS-Eligible) and patients meeting a practical definition of SITT eligibility (Expanded ETHOS-Eligible). The US COPD population was modeled with 1000 simulations of patient progression over 10 years. Agent characteristics were based on literature and claims analysis of the 2016-2018 Medicare 100% fee-for-service and IBM MarketScan® databases. Agent annual characteristics reflected incident cases, changes in COPD severity, treatment, mortality, and exacerbations under status quo treatment patterns and scenarios for the adoption of SITT. The scenarios assumed the reduced exacerbation and mortality rates associated with SITT according to ETHOS trial outcomes mean values. Results: Higher than current SITT adoption over 10 years would be expected to substantially reduce COPD exacerbation-associated hospitalizations by 2 million. Applying mean improvements reported in ETHOS for SITT would extend average patient life expectancy 2.2 years for ETHOS-Eligible patients and 1.7 years for Expanded ETHOS-Eligible patients. The number needed to treat to extend the average patient life by 1 year was 8 for the ETHOS-Eligible population and 10 for the Expanded ETHOS-Eligible population. Discussion: Widespread SITT adoption may be impeded by competitive pressures from generic treatments and nonadherence, and efficacy observed in clinical trials may not occur in real-world populations. Conclusions: Assuming ETHOS treatment effects and adherence translate to clinical practice, higher than current use of SITT can substantially reduce COPD exacerbations and hospitalizations and extend survival. These results should be viewed cautiously, because the improved outcomes for SITT in the ETHOS final retrieved vital statistics data were not statistically significant for all comparator therapy groups.

All-cause admissions following a first ever exacerbation-related hospitalisation in COPD

Background

Hospital admissions are important contributors to the overall burden of chronic obstructive pulmonary disease (COPD). Understanding the patterns and causes of hospital admissions will help to identify targets for preventive interventions. This study aimed to determine the 5-year all-cause hospital admission trajectories of patients with COPD following their first ever exacerbation-related hospitalisation.

Methods

Patients with COPD were identified from the Danish national registries. Patients experiencing their first ever exacerbation-related hospitalisation, defined as the index event, between 2000 and 2014 were included. All-cause hospital admissions were examined during a subsequent 5-year follow-up period, and categorised using the International Classification of Diseases, 10th revision.

Results

In total, 82 964 patients with COPD were included. The mean±sd age was 72±10 years and 48% were male. Comorbidities were present in 58%, and 65% of the patients collected inhalation medication ≤6 months prior to the index event. In total, 337 066 all-cause hospital admissions were identified, resulting in a 5-year admission rate of 82%. Most admissions were due to nonrespiratory causes (59%), amongst which cardiac events were most common (19%).

Conclusion

Hospital admissions following a first exacerbation-related hospitalisation are common; nonrespiratory events constitute the majority of admissions. Besides the respiratory causes, treatment targeting the nonrespiratory causes of hospital admission should be considered to effectively decrease the burden of hospitalisation in COPD.

[What Is an Acute COPD Exacerbation? Results of a Survey among Primary Care Physicians in the German-Speaking Part of Switzerland]

What Is an Acute COPD Exacerbation? Results of a Survey among Primary Care Physicians in the German-Speaking Part of Switzerland Abstract. Acute exacerbations have a relevant impact on morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD), which is why prophylactic and early treatment have become indispensable. However, COPD exacerbations are significantly under-diagnosed, possibly due to linguistic discrepancies between physician and patient. The aim of this study was to disclose how exacerbations are perceived by the GPs (general practitioners) and their patients and what linguistic conventions they use. This survey showed that GPs and their patients quite often have a divergent notion a common of COPD exacerbations.

Changes in Serum Immunoglobulin G Subclasses during the Treatment of Patients with Chronic Obstructive Pulmonary Disease with Infectious Exacerbations

Introduction: Despite the theoretical importance of serum immunoglobulin (Ig) in the outcome of COPD exacerbations, the existing evidence for this has not been enough. This study was performed to evaluate changes in serum Ig levels and their relationship with outcomes of acute infectious exacerbations in patients with COPD. Methods: The prospective study was conducted at Military Hospital 103 from August 2017 to April 2019. Group D patients with COPD with infectious exacerbation were selected for participation in the study. The control group consisted of 30 healthy people. The patients were provided clinical examination and laboratory service; simultaneously, we measured their serum Ig levels (total IgG, IgG1, IgG2, IgG3, IgG4) at two time points: at admission (T1) and the final health outcome (T2). Results: The median levels of total IgG in patients at times T1 and T2 were significantly lower compared with those in the healthy group (1119.3 mg/dL and 1150.6 mg/dL compared with 2032.2 mg/dL) (p < 0.001). Regarding changes among IgG subclasses, the IgG1, IgG3, and IgG4 levels measured at T1 and T2 were reduced significantly compared with the control group (p < 0.05); the IgG3 levels at T1 were significantly higher than those at T2. IgG3 levels in patients with life-threatening exacerbations were significantly lower than the remaining ones (24.6 (26.8−155.5) mg/dL and 25.6 (29.5−161.2) mg/dL, respectively, p = 0.023). Conclusions: In group D patients with COPD with infectious exacerbations, there was a decrease in the serum IgG, IgG1, IgG3, and IgG4 levels. IgG3 levels were associated with the severity of COPD exacerbation.

Prognostic risk factors for moderate-to-severe exacerbations in patients with chronic obstructive pulmonary disease: a systematic literature review

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD exacerbations are associated with a worsening of lung function, increased disease burden, and mortality, and, therefore, preventing their occurrence is an important goal of COPD management. This review was conducted to identify the evidence base regarding risk factors and predictors of moderate-to-severe exacerbations in patients with COPD.

Methods

A literature review was performed in Embase, MEDLINE, MEDLINE In-Process, and the Cochrane Central Register of Controlled Trials (CENTRAL). Searches were conducted from January 2015 to July 2019. Eligible publications were peer-reviewed journal articles, published in English, that reported risk factors or predictors for the occurrence of moderate-to-severe exacerbations in adults age ≥ 40 years with a diagnosis of COPD.

Results

The literature review identified 5112 references, of which 113 publications (reporting results for 76 studies) met the eligibility criteria and were included in the review. Among the 76 studies included, 61 were observational and 15 were randomized controlled clinical trials. Exacerbation history was the strongest predictor of future exacerbations, with 34 studies reporting a significant association between history of exacerbations and risk of future moderate or severe exacerbations. Other significant risk factors identified in multiple studies included disease severity or bronchodilator reversibility (39 studies), comorbidities (34 studies), higher symptom burden (17 studies), and higher blood eosinophil count (16 studies).

Conclusions

This systematic literature review identified several demographic and clinical characteristics that predict the future risk of COPD exacerbations. Prior exacerbation history was confirmed as the most important predictor of future exacerbations. These prognostic factors may help clinicians identify patients at high risk of exacerbations, which are a major driver of the global burden of COPD, including morbidity and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02123-5.

Qualitative Validation of COPD Evidenced Care Pathways in Japan, Canada, England, and Germany: Common Barriers to Optimal COPD Care

Background

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. A comprehensive and detailed understanding of COPD care pathways from pre-diagnosis to acute care is required to understand the common barriers to optimal COPD care across diverse health systems.

Methods

Country-specific COPD care pathways were created for four high-income countries using international recommendations and country-specific guidelines, then populated with published epidemiological, clinical, and economic data. To refine and validate the pathways, semi-structured interviews using pre-prepared discussion guides and country-specific pathway maps were held with twenty-four primary and secondary care respiratory healthcare professionals. Thematic analysis was then performed on the interview transcripts.

Results

The COPD care pathway showed broad consistency across the countries. Three key themes relating to barriers in optimal COPD management were identified across the countries: journey to diagnosis, treatment, and the impact of COVID-19. Common barriers included presentation to healthcare with advanced COPD, low COPD consideration, and sub-optimal acute and chronic disease management. COVID-19 has negatively impacted disease management across the pathway but presents opportunities to retain virtual consultations. Structural factors such as insurance and short duration of appointments also impacted the diagnosis and management of COPD.

Conclusion

COPD is an important public health issue that needs urgent prioritization. The use of Evidenced Care Pathways with decision-makers can facilitate evidence-based decision making on interventions and policies to improve care and outcomes for patients and reduce unnecessary resource use and associated costs for the healthcare provider/payer.

Relationship between risk, cumulative burden of exacerbations and mortality in patients with COPD: modelling analysis using data from the ETHOS study

BACKGROUND

The major drivers of cost-effectiveness for chronic obstructive pulmonary disease (COPD) therapies are the occurrence of exacerbations and deaths. Exacerbations, including acute and long-term events, can cause worsening of COPD and lead to an increased risk of further exacerbations, and ultimately may elevate the risk of death. In contrast to this, health economic models are based on COPD severity progression. In this post hoc analysis of the ETHOS study, we focus on the progression of COPD due to exacerbations and deaths.

METHODS

We fitted semi-parametric and fully parametric multi-state Markov models with the following five progressive states: State 1, no exacerbation; State 2, 1 moderate exacerbation; State 3, ≥ 2 moderate exacerbations; State 4, ≥ 1 severe exacerbations; State 5, death. The models only allowed a patient to transition to a worsened health state, and transitions did not necessarily have to be to the next adjacent state. We used the multi-state models to analyse data from ETHOS, a phase III, 52-week study assessing the efficacy and safety of triple therapy with budesonide/glycopyrronium/formoterol fumarate dihydrate in moderate-to-very severe COPD.

RESULTS

The Weibull multi-state Markov model showed good fit of the data. In line with clinical evidence, we found a higher mortality risk after a severe exacerbation (11.4-fold relative ratio increase [95% CI, 7.7-17.0], 6.4-fold increase [95% CI, 3.8-10.8] and 5.4-fold increase [95% CI, 2.9-10.3] relative to no exacerbations, 1 moderate exacerbation or ≥ 2 moderate exacerbations, respectively). One moderate exacerbation increased mortality risk 1.8-fold (95% CI, 1.1-2.9) vs no exacerbations. We also found a higher risk of severe exacerbation and mortality following ≥ 2 moderate exacerbations.

CONCLUSION

Multi-state modelling of patients with COPD in ETHOS found an acute and chronic effect of severe exacerbations on mortality risk. Risk was also increased after a moderate exacerbation. Clinical management with effective pharmacotherapies should be optimised to avoid even moderate exacerbations. Modelling with exacerbations could be an alternative to current COPD models focused on disease progression.

TRIAL REGISTRATION

NCT02465567.

Clinical features predicting COVID-19 mortality risk

Currently, the world is involved by a pandemic of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), which has been responsible for the deaths of hundreds of thousands of people so far. The consequences of infection with SARS-CoV-2 vary widely from asymptomatic to severe. Considering the increasing prevalence of different types of virus and acute infection with this disease, strategies to prevent mortality from COVID-19 should be seriously analyzed. In this study, the epidemiological, clinical and laboratory characteristics of patients with COVID-19 were investigated in order to identify risk factors for mortality. Chronic diseases such as chronic kidney disease (CKD), COPD, diabetes, hypertension, cardiovascular disease (CVD), cancer, increased D-dimer, male gender, old age, smoking and obesity are among the deadly risk factors associated COVID-19. Furthermore, lymphopenia and neutrophilia are often present in patients with SARS-CoV-2, and the ratio of absolute neutrophils to lymphocytes (NLR) was significantly increased in patients without bacterial infection. These findings could be used in the future to control and prevent disease, because timely identification of patients with risk of COVID-19 is important to provide better treatment strategies for reduction of mortality.

Use of single-inhaler triple therapy in the management of obstructive airway disease: Indian medical experts' review

Obstructive airway disease (OAD), which includes COPD and asthma, is the leading cause of morbidity and mortality in India. Long-acting bronchodilators (long-acting β2 agonists (LABAs) and/or long-acting muscarinic antagonists (LAMAs)) and inhaled corticosteroids (ICS) have a vital role in the management of patients with OAD. While symptom burden and exacerbations are common amongst treated patients, poor adherence to inhaler therapy is a frequent challenge. Better treatment options that optimise symptom control, improve quality of life, reduce exacerbation risk and improve adherence are desired. Triple therapy (ICS/LABA/LAMA) is recommended in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 guidelines for symptomatic COPD patients on ICS/LABA or LABA/LAMA, and who are at increased risk for frequent or severe exacerbations. Similarly, add-on LAMA is recommended in uncontrolled asthma patients on medium- to high-dose ICS/LABA by the Global Initiative for Asthma (GINA) 2021 guideline. In the real world, high-risk and overlapping phenotypes exist, which necessitate early initiation of triple therapy. We aim to provide an expert review on the use of single-inhaler triple therapy (SITT) for OAD management in global and Indian settings, knowledge from which can be extrapolated for appropriate treatment of Indian patients. The OAD population in India may benefit from early optimisation to SITT characterised by a high burden of exacerbating OAD, nonsmoker COPD and asthma-COPD overlap.

Remote Monitoring for Prediction and Management of Acute Exacerbations in Chronic Obstructive Pulmonary Disease (AECOPD)

The progression of chronic obstructive pulmonary disease (COPD) is characterized by episodes of acute exacerbation (AECOPD) of symptoms, decline in respiratory function, and reduction in quality-of-life increasing morbi-mortality and often requiring hospitalization. Exacerbations can be triggered by environmental exposures, changes in lifestyle, and/or physiological and psychological factors to greater or lesser extents depending on the individual’s COPD phenotype. The prediction and early detection of an exacerbation might allow patients and physicians to better manage the acute phase. We summarize the recent scientific data on remote telemonitoring (TM) for the prediction and management of acute exacerbations in COPD patients. We discuss the components of remote monitoring platforms, including the integration of environmental monitoring data; patient reported outcomes collected via interactive Smartphone apps, with data from wearable devices that monitor physical activity, heart rate, etc.; and data from medical devices such as connected non-invasive ventilators. We consider how telemonitoring and the deluge of data it potentially generates could be combined with electronic health records to provide personalized care and multi-disease management for COPD patients.

Nature-Based Interventions for Psychological Wellbeing in Long-Term Conditions: A Systematic Review

Background: With the global burden of disease increasing, particularly in relation to often preventable chronic diseases, researchers and clinicians are keen to identify interventions that can mitigate ill health and enhance the psychological wellbeing of people living with long-term conditions (LTCs). It is long established that engagement with nature can support human health and wellbeing, and in recent years, nature-based interventions (NBIs) have been advanced as of potential benefit. This review thus sought to systematically appraise published evidence of the application of NBIs to address psychological wellbeing for those living with LTCs. Methods: A systematic search of three databases, PsycINFO, MEDLINE and SCOPUS, was undertaken, and the BestBETs quality assessment checklist was used to appraise methodological quality of elicited studies. Results: Of 913 studies identified, 13 studies (12 using quantitative methods, one qualitative) were used. Included papers reported use of a variety of psychological outcomes alongside more circumscribed physiological outcomes. Quality appraisal showed modest robustness, some methodological weaknesses and a dominance of application in developed countries, yet synthesis of studies suggested that reported psychological and physiological outcomes present a strong argument for NBIs having a promising and positive impact on psychological wellbeing. Conclusions: NBIs have positive psychological and physiological impacts on people with LTCs, suggesting they may be a suitable addition to current maintenance treatment. Future research should focus on minimising study bias and increasing the potential for cross-cultural applications.

Physical activity endpoints in trials of chronic respiratory diseases: summary of evidence

Background

Physical activity contributes to improving respiratory symptoms. However, validated end-points are few, and there is limited consensus about what is a clinically meaningful improvement for patients. This review summarises the evidence to date on the range of physical activity end-points used in COPD, asthma and idiopathic pulmonary fibrosis (IPF) whilst evaluating their appropriateness as end-points in trials and their relation to patients’ everyday life.

Methods

Trials reporting physical activity end-points were collected using Citeline's database Trialtrove; this was supplemented by searches in PubMed.

Results

The daily-patient-reported outcome (PRO)active and clinical visit-PROactive physical activity composite end-points appeared superior at capturing the full experience of physical activity in patients with COPD and were responsive to bronchodilator intervention. Time spent in moderate-to-vigorous physical activity is a recently validated end-point for IPF that correlates with exercise capacity and quality of life. Step count appears the best available physical activity measure for asthma, which consistently declines with worse disease status. However, evidence suggests a time lag before significant improvement in step count is seen which may reflect the impact of human behaviour on physical activity.

Conclusions

Physical activity represents a challenging domain to accurately measure. This is the first review evaluating physical activity measures used specifically within the respiratory field. Whilst physical activity can be effectively captured using PROactive in patients with COPD, this review highlights the unmet need for novel patient-focused end-points in asthma and IPF which would offer opportunities to develop efficacious medicines with impact on patients’ therapeutic care and quality of life.

Physical activity (PA) is a challenging domain to measure accurately. Patient-centric measures have been developed for the COPD population; however, the appropriateness of PA measures used in asthma and IPF populations remains sporadic and controversial.https://bit.ly/3HmmaGp

Can COPD Exacerbations Be Picked Up Early via a Weekly Medication Question Through a Smartphone Application?

BACKGROUND

Exacerbations affect the disease trajectory of patients with COPD and result in an acute drop of functional status and physical activity. Timely detection of exacerbations by non-medical healthcare professionals is needed to counteract this decline. The use of digital health applications in patient interaction allows embedded detection of exacerbations. However, it is unknown if this is an effective way to pick up exacerbations.

METHOD

We investigated the detection of exacerbations in patients with COPD enrolled in a physical activity coaching program, by prompting a weekly question on changes in medication via the smartphone application. Data on response rate and occurrence of exacerbations were collected.

RESULTS

Response rate to the medication question, evaluated in 42 patients, was 72% (n = 497). A change in medication was reported through the smartphone application in 38 (7.6%) of the answered questions. The response rate was significantly lower at 6 months follow-up compared to the first month (p =0.03). When evaluating the occurrence of adverse events in a subset of patients who completed 6 months of follow-up (n = 27), 18 exacerbations were registered in eight patients, of which 10 of these exacerbations (56%) were picked up by the medication question in the coaching application.

CONCLUSION

Electronic interaction through a weekly medication question, embedded in a smartphone application, is feasible to support the detection of the occurrence of COPD exacerbations and can be used complementary to regular forms of detecting exacerbations. Compliance and smartphone literacy should be optimized when further using this method to report on COPD exacerbations.

Towards precision in defining COPD exacerbations

COPD is the most prevalent chronic respiratory disease worldwide and a major cause of disability and death. Acute exacerbations of COPD remain a key feature of the disease in many patients and research assessing interventions to prevent and treat them requires a robust definition with high sensitivity and specificity. To date, no such definition exists, and multiple different definitions are used in clinical studies depending on the research question. The strengths and weaknesses of current definitions are discussed in the context of evolving knowledge and different settings in which studies are undertaken. Whether identification and recording of exacerbations remains essentially clinical, or can be identified with a dependable biomarker, it should be sensitive and adaptable to context while retaining clarity and facilitating data collection. This is essential to progress a better understanding of the pathophysiology and phenotypic expression of exacerbations to reduce their impact and personal burden for patients.

COPD exacerbations carry high risk for long-term disability and death. As the search for a standardised measure continues, study investigators must ensure definitions are explicit and justified to better understand how to prevent and manage these episodes.https://bit.ly/2UNqScy

Impact of influenza infection on the short- and long-term health of patients with chronic obstructive pulmonary disease

BACKGROUND

Influenza is a common cause of acute respiratory infection that leads to exacerbation of underlying chronic obstructive pulmonary disease (COPD). To elucidate the short- and long-term effects of influenza in patients with COPD, we examined health care resource utilization (HRU) and costs up to 13 months following influenza infection.

METHODS

We conducted a retrospective cohort study using U.S. insurance claims data from MarketScan. Patients with an influenza diagnosis during the 2012-2014 influenza seasons and continuous enrollment in a health plan from 12 months before to 13 months after the index influenza diagnosis were identified and propensity score-matched 1:5 to controls without evidence of influenza. COPD- and pneumonia-related outcomes were assessed over 13 months following influenza diagnosis.

RESULTS

COPD-associated outcomes after diagnosis were significantly worse in patients with influenza (n = 7,087) vs. controls (n = 35,435) during the first month (exacerbation: 16.1 vs. 3.4%; outpatient visits: 57.1 vs. 35.2%; emergency department (ED) visits: 10.5 vs. 1.8%; and inpatient visits: 5.6 vs. 0.7%) and months 2-13 (exacerbation: 25.1 vs. 21.1%; outpatient visits: 86.1 vs. 85.8%; ED visits: 20.0 vs. 15.7%; and inpatient visits: 6.5 vs. 5.3%). COPD- and pneumonia-associated costs for months 1 and 2-13 were higher in patients with influenza.

LIMITATIONS

The study was subject to a residual imbalance between cohorts despite propensity score matching. The use of diagnostic codes to select patients and identify complications could introduce inaccuracies in estimating events.

CONCLUSIONS

HRU and costs were higher in COPD patients with influenza during the first month and over the entire year following infection. This suggests influenza has an impact on respiratory health in patients with COPD that lasts beyond the acute infection.

AND-ASPEN and ESPEN consensus, and GLIM criteria for malnutrition identification in AECOPD patients: a longitudinal study comparing concurrent and predictive validity

BACKGROUND/OBJECTIVES

Malnutrition in chronic obstructive pulmonary disease (COPD) patients is prevalent and usually assessed by body mass index (BMI), which can lead to misdiagnosis. The subjective global assessment (SGA) is the reference method for this diagnose in hospitalized patients. In the last decade, new tools have emerged Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition [AND-ASPEN], European Society for Clinical Nutrition and Metabolism [ESPEN], and Global Leadership Initiative on Malnutrition [GLIM]). Therefore, this study aimed to assess the concurrent and predictive validity of these tools in acute exacerbated COPD (AECOPD) patients.

SUBJECTS/METHODS

Prospective cohort study with hospitalized AECOPD patients. Malnutrition was diagnosed by SGA (reference method), AND-ASPEN, ESPEN, and GLIM consensus. Hospital length of stay (LOS) and mortality were the outcomes evaluated.

RESULTS

In 241 patients (46.5% males; 68.3 ± 10.2 years), malnutrition was found in 50.0% by SGA, 54.4% by AND-ASPEN, 20.2% by ESPEN, and 47.8% by GLIM. AND-ASPEN had the best accuracy (AUC = 0.837; 95% CI 0.783-0.841) and concordance (kappa = 0.674) with SGA and it was an independent predictor of prolonged LOS (OR = 1.73; 95% CI 1.01-3.37). ESPEN consensus did not agree with SGA, but was associated with prolonged LOS (OR = 2.57 95% CI, 1.27-5.20). The GLIM had good concordance (kappa = 0.533) and accuracy with SGA (AUC = 0.768; 95% CI 0.701-0.835), but was not associated with outcomes.

CONCLUSIONS

The AND-ASPEN was the most accurate tool for diagnosing malnutrition in AECOPD patients and was an independent predictor of prolonged LOS.

Genetics plays a limited role in predicting chronic obstructive pulmonary disease treatment response and exacerbation

BACKGROUND

Combination treatments, targeting multiple disease processes, benefit subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, predicting treatment response and exacerbation risk remain challenging.

OBJECTIVE

To identify genetic associations with AECOPD risk and response to combination therapy (fluticasone furoate, umeclidinium bromide and vilanterol).

METHODS

The genetic basis of AECOPD disease was investigated in 19,841 subjects from 23 clinical studies and 2 disease cohorts to identify exacerbation disease targets. AECOPD pharmacogenetic effects were examined in 8439 moderate to severe COPD patients with exacerbation rate, lung function and quality of life endpoints; results were followed up in an additional 2201 subjects.

RESULTS

We did not identify significant associations in the AECOPD disease analysis. In the AECOPD pharmacogenetics analysis, rs56195836 (MAPK8) was significantly associated with moderate to severe exacerbation rate in subjects on fluticasone furoate with baseline blood eosinophils ≥150 cells/μl (P = 1.8 × 10^-8). Post-hoc, one variant was associated with on-treatment moderate to severe exacerbation rate stratifying by exacerbation history. AZU1 rs1962343 was significantly associated in subjects with frequent moderate exacerbation history when treated with fluticasone furoate/vilanterol (P = 1.1 × 10^-8). Neither of these signals was supported in independent follow-up.

CONCLUSION

Common genetic variants do not play major roles in AECOPD disease nor predict response to triple therapy or its components in moderate to very severe COPD.