COPD exacerbations: the importance of a standard definition

Accuracy of the Apple Watch in measuring oxygen saturation: comparison with pulse oximetry and ABG

BACKGROUND

Smartwatches have gained tremendous attention in recent years and have become widely accepted by patients, despite not being intended for medical diagnosis.

OBJECTIVE

This study aimed to determine the accuracy of Apple Watch oxygen saturation measurement in patients with acute exacerbation of COPD by comparing it with medical-grade pulse oximetry and ABG.

METHOD

This single-center, prospective, cross-sectional study involved 167 patients. Patients presenting with cardiac arrest, life-threatening symptoms, severe hypoxia, or obvious jaundice were excluded. Additionally, patients whose SpO2 measurements with the Apple Watch took more than 2 min or required eight attempts were also excluded. Vital signs were measured simultaneously using the IntelliVue MX500 monitor with the Masimo Rainbow Set pulse oximeter and the Apple Watch. Concurrently, arterial blood gas (ABG) samples were drawn.

RESULTS

A strong correlation between the Apple Watch 6 and medical-grade pulse oximetry (r = 0.89, ICC = 0.940) was noted. The Bland-Altman analysis revealed a mean error of 0.458% between the Apple Watch 6 and ABG (SD: 2.78, level of agreement: - 5.912 to 4.996). The mean error between pulse oximetry and ABG (SD: 5.086, level of agreement; - 10.983 to 8.953) was 1.015%. There was a correlation between respiratory rate and the number of attempts to measure SpO2 with the Apple Watch 6 (r = 0.75, p < 0.05).

CONCLUSION

Apple Watch 6 is an accurate and reliable method for measuring SpO2 levels in emergency patients who presented with acute exacerbation of COPD. However, tachypneic patients may encounter challenges due to the potential need for multiple attempts to measure their oxygen saturation.

Association Between Rome Classification Among Hospitalized Patients With COPD Exacerbations and Short-Term and Intermediate-Term Outcomes

BACKGROUND

Recently, the Rome proposal updated the definition of exacerbation of COPD (ECOPD). However, such severity grade has not yet demonstrated intermediate-term clinical relevance.

RESEARCH QUESTION

What is the association between the Rome severity classification and short-term and intermediate-term clinical outcomes?

STUDY DESIGN AND METHODS

We retrospectively grouped hospitalized patients with ECOPD according to the Rome severity classification (ie, mild, moderate, severe). Baseline, clinical, microbiologic, gas analysis, and laboratory variables were collected. In addition, data about the length of hospital stay and mortality (in-hospital and a follow-up time line from 6 months until 3 years) were assessed.

RESULTS

Of the 347 hospitalized patients, 39% were categorized as mild, 31% were categorized as moderate, and 30% were categorized as severe. Overall, patients with severe ECOPD had an extended length of hospital stay. Although in-hospital mortality was similar among groups, patients with severe ECOPD presented a worse prognosis in all follow-up time points. The Kaplan-Meier curves show the role of the severe classification in the cumulative survival at 1 and 3 years (Gehan-Breslow-Wilcoxon test, P = .032 and P = .004, respectively). The multivariable Cox regression analysis showed a higher risk of death at 1 year when patients presented a severe (hazard ratio, 1.99; 95% CI, 1.49-2.65) or moderate grade (hazard ratio, 1.47; 95% CI, 1.10-1.97) compared with a mild grade. Older patients (aged ≥ 80 years), patients requiring long-term oxygen therapy, or patients reporting previous ECOPD episodes had a higher mortality risk. A BMI between 25 and 29 kg/m2 was associated with a lower risk.

INTERPRETATION

The Rome classification makes it possible to discriminate patients with a worse prognosis (severe or moderate) until a 3-year follow-up.

Production and characterization of mono-PEGylated alpha-1 antitrypsin for augmentation therapy

Alpha-1 antitrypsin (AAT) is an endogenous inhibitor of serine proteases which, in physiological conditions, neutralizes the excess of neutrophil elastase and other serine proteases in tissues and especially the lungs. Weekly intravenous infusion of plasma-purified human AAT is used to treat AAT deficiency-associated lung disease. However, only 2 % of the AAT dose reach the lungs after intravenous infusion. Inhalation of AAT might offer an alternative route of administration. Yet, the rapid clearance of AAT from the respiratory tract results in high and frequent dosing by inhalation and limited efficacy. In the present study, we produced and characterized in vitro a PEGylated version of AAT which could offer a prolonged body residence time and thereby be useful for augmentation therapy by the intravenous and inhalation routes. Two PEGylation reactions - N-terminal and thiol PEGylation - and three polyethylene glycol (PEG) chains - linear 30 kDa, linear 40 kDa and 2-armed 40 kDa - were used. The yields of mono-PEGylated AAT following purification by anion exchange chromatography were 40-50 % for N-terminal PEGylation and 60-70% for thiol PEGylation. The PEG-AAT conjugates preserved the ability to form a protease-inhibitor complex with neutrophil elastase and proteinase 3 as well as the full inhibitory capacity to neutralize neutrophil elastase activity. These results open up interesting prospects for PEGylated AAT to achieve a prolonged half-life and an improved therapeutic efficacy in vivo.

The Definition of Paramedicine: An International Delphi Study

Introduction

Although paramedicine is an integral element of healthcare systems, there is a lack of universal consensus on its definition. This study aimed to derive a global consensus definition of paramedicine.

Methods

Key attributes pertaining to paramedicine were identified from existing definitions within the literature. Utilising text analysis, common attribute themes were identified and six initial domains were developed. These domains formed the basis for a four-round Delphi study with a panel of 58 global experts within paramedicine to develop an international consensus definition.

Results

Response rates across the study varied from 96.6% (round 1) to 63.8% (round 4). Participant feedback on appropriate attributes to include in the definition reflected the high level of specialized clinical care inherent within paramedicine, and its status as an essential element of healthcare systems. In addition, the results highlighted the extensive range of paramedicine capabilities and roles, and the diverse environments within which paramedics work.

Conclusion

Delphi methodology was utilized to develop a global consensus definition of paramedicine. This definition is as follows: paramedicine is a domain of practice and health profession that specialises across a range of settings including, but not limited to, emergency and primary care. Paramedics work in a variety of clinical settings such as emergency medical services, ambulance services, hospitals and clinics as well as non-clinical roles, such as education, leadership, public health and research. Paramedics possess complex knowledge and skills, a broad scope of practice and are an essential part of the healthcare system. Depending on location, paramedics may practice under medical direction or independently, often in unscheduled, unpredictable or dynamic settings. We believe that the generation and provision of this consensus definition is essential to enable the further development and maturation of the discipline of paramedicine.

Terms and Definitions Used to Describe Recurrence, Treatment Failure and Recovery of Acute Exacerbations of COPD: A Systematic Review of Observational Studies

Introduction

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are important clinical events, with many patients experiencing multiple AECOPDs annually. The terms used in the literature to define recurring AECOPD events are inconsistent and may impact the ability to describe the true burden of these events. We undertook a systematic review to identify and summarize terms and definitions used in observational studies to describe AECOPD-related events occurring after an initial AECOPD (hereafter “subsequent AECOPD”).

Methods

PubMed was searched (2000–2019) for observational studies on subsequent AECOPD events using broad search strings for “COPD”, “exacerbation”, and “subsequent exacerbation events”. Only English-language studies were included. Small studies (n<50) and studies focusing on hospital re-admission only were excluded. Extracted data were analyzed descriptively to generate a narrative summary, using a thematic approach to group studies utilizing similar terms for subsequent AECOPD.

Results

Forty-seven studies were included. No single, distinct terms or definitions were used to define and identify multiple occurrences of AECOPDs, though most (46) studies used one or more of four clustered terms and definitions: reapse (n = 13), recurrence/re-exacerbation (n = 11), treatment failure (n = 12) and non-recovery/time to recovery (n = 16). Heterogeneity was observed within and between the four clusters with respect to study setting, starting point for observing subsequent AECOPDs, time frame to identify a subsequent AECOPD (except for studies using “time to recovery”), and basis for identifying a subsequent exacerbation.

Conclusion

Our review demonstrates that subsequent AECOPDs (including events such as relapse, recurrence/re-exacerbation, treatment failure, non-recovery/time to recovery) are ill-defined in the observational study literature, emphasizing the need to reach consensus on precise and objective definitions (for example, when one AECOPD ends and another begins). Use of standardized terminology and definitions may aid comparability between, and synthesis of, studies, thus improving the understanding of the natural history and burden of exacerbations in COPD patients.

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force

Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.

Development and Validation of a Healthcare Utilization-Based Algorithm to Identify Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Introduction

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are important events that may precipitate other adverse outcomes. Accurate AECOPD event identification in electronic administrative data is essential for improving population health surveillance and practice management.

Objective

Develop codified algorithms to identify moderate and severe AECOPD in two US healthcare systems using administrative data and electronic medical records, and validate their performance by calculating positive predictive value (PPV) and negative predictive value (NPV).

Methods

Data from two large regional integrated health systems were used. Eligible patients were identified using International Classification of Diseases (Ninth Edition) COPD diagnosis codes. Two algorithms were developed: one to identify potential moderate AECOPD by selecting outpatient/emergency visits associated with AECOPD-related codes and antibiotic/systemic steroid prescriptions; the other to identify potential severe AECOPD by selecting inpatient visits associated with corresponding codes. Algorithms were validated via patient chart review, adjudicated by a pulmonologist. To estimate PPV, 300 potential moderate AECOPD and 250 potential severe AECOPD events underwent review. To estimate NPV, 200 patients without any AECOPD identified by the algorithms (100 patients each without moderate or severe AECOPD) during the two years following the index date underwent review to identify AECOPD missed by the algorithm (false negatives).

Results

The PPVs (95% confidence interval [CI]) for both moderate and severe AECOPD were high: 293/298 (98.3% [96.1–99.5]) and 216/225 (96.0% [92.5–98.2]), respectively. NPV was lower for moderate AECOPD (75.0% [65.3–83.1]) than for severe AECOPD (95.0% [88.7–98.4]). Results were consistent across both healthcare systems.

Conclusion

This study developed healthcare utilization-based algorithms to identify moderate and severe AECOPD in two separate healthcare systems. PPV for both algorithms was high; NPV was lower for the moderate algorithm. Replication and consistency of results across two healthcare systems support the external validity of these findings.

Comparison of machine learning algorithms for the identification of acute exacerbations in chronic obstructive pulmonary disease

OBJECTIVES

Identifying acute exacerbations in chronic obstructive pulmonary disease (AECOPDs) is of utmost importance for reducing the associated mortality and financial burden. In this research, the authors aimed to develop identification models for AECOPDs and to compare the relative performance of different modeling paradigms to find the best model for this task.

METHODS

Data were extracted from electronic medical records (EMRs) of patients with chronic obstructive pulmonary disease who admitted to the China-Japan Friendship Hospital between February 2011 and March 2017. Five machine learning algorithms (random forest, support vector machine, logistic regression, K-nearest neighbor and naïve Bayes) were used to develop the AECOPDs identification models. Feature selection was performed to find an optimal feature subset. 10-folds cross-validation was used to find the best hyperparameters for each model. The following metrics:  area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value were used to evaluate the performance of these models.

RESULTS

A total of 303 EMRs (AECOPDs patients:135; None AECOPDs patients: 168) were included in the study. The SVM model obtained the best performance (sensitivity: 0.80, specificity: 0.83, positive predictive value:0.81, negative predictive value:0.85 and area under the receiver operating characteristic curve: 0.90) after performing feature selection.

CONCLUSIONS

Our research confirms that the proposed model based on the support vector machine is a powerful tool to identify AECOPDs patients, and it is promising to provide decision support for clinicians when they are struggling to give a confirmed clinical diagnosis.

Procalcitonin and antibiotics in moderate-severe acute exacerbation of chronic obstructive pulmonary disease: to use or not to use

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Acute exacerbations of COPD (AECOPD) are major driver for healthcare utilization with each exacerbation begetting the next exacerbation. It is, therefore, important to treat each episode effectively to prevent the next. However, this can be challenging as AECOPD result from complex interactions between host, environment and infective agents. The benefits of starting antibiotics in AECOPD, which are not life-threatening (e.g. not requiring mechanical ventilation) or not complicated by pneumonia remain controversial.

RECENT FINDINGS

The use of procalcitonin to guide antibiotic therapy in AECOPD has gained interest in recent years. The main advantage of this approach is a safe reduction in antibiotic use in a large group of patients, which may potentially translate to several other benefits. These include reduced antibiotic-related side-effects, reduced risk of developing antibiotic-resistant organisms and cost savings. This approach is associated with no increase in mortality or morbidity such as treatment failure, re-admission, admission to ICU.

SUMMARY

Procalcitonin-guided antibiotic therapy in AECOPD is a promising and safe approach, which may be ready for the prime time.

Comparison of patient-reported outcomes during acute exacerbations of chronic obstructive pulmonary disease

Introduction

The aim of this study was to investigate which patient-reported outcome measure was the best during the recovery phase from severe exacerbation of chronic obstructive pulmonary disease (COPD).

Methods

The Exacerbations of Chronic Pulmonary Disease Tool (EXACT), the COPD Assessment Test (CAT), the St George’s Respiratory Questionnaire (SGRQ), the Dyspnoea-12 (D-12) and the Hyland Scale (global scale) were recorded every week for the first month and at 2 and 3 months in 33 hospitalised subjects with acute exacerbation of COPD (AECOPD).

Results

On the day of admission (day 1), the internal consistency of the EXACT total score was high (Cronbach’s alpha coefficient=0.89). The EXACT total, CAT, SGRQ total and Hyland Scale scores obtained on day 1 appeared to be normally distributed. Neither floor nor ceiling effects were observed for the EXACT total and SGRQ total scores. The EXACT total score improved from 50.5±12.4 to 32.5±14.3, and the CAT score also improved from 24.4±8.5 to 13.5±8.4 during the first 2 weeks, and the effect sizes (ES) of the EXACT total and CAT score were −1.40 and −1.36, respectively. The SGRQ, Hyland Scale and D-12 were less responsive, with ES of −0.59, 0.96 and −0.90, respectively.

Discussion

The EXACT total and CAT scores are shown to be more responsive measures during the recovery phase from severe exacerbation. Considering the conceptual framework, it is recommended that the EXACT total score may be the best measure during the recovery phase from AECOPD. The reasons for the outstanding responsiveness of the CAT are still unknown.

Management of severe acute exacerbations of COPD: an updated narrative review

Background

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.

Main body

In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.

Conclusion

Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.

Pseudomonas aeruginosa infection increases the readmission rate of COPD patients

Introduction

Acute exacerbation of COPD (AECOPD) leads to rapid deterioration of pulmonary function and quality of life. It is unclear whether the prognosis for AECOPD differs depending on the bacterium or virus identified. The purpose of this study is to determine whether readmission of patients with severe AECOPD varies according to the bacterium or virus identified.

Methods

We performed a retrospective review of medical records of 704 severe AECOPD events at Korea University Guro Hospital from January 2011 to May 2017. We divided events into two groups, one in which patients were readmitted within 30 days after discharge and the other in which there was no readmission.

Results

Of the 704 events, 65 were followed by readmission within 30 days. Before propensity score matching, the readmission group showed a higher rate of bacterial identification with no viral identification and a higher rate of identification with the Pseudomonas aeruginosa (P=0.003 and P=0.007, respectively). Using propensity score matching, the readmission group still showed a higher P. aeruginosa identification rate (P=0.030), but there was no significant difference in the rate of bacterial identification, with no viral identification (P=0.210). In multivariate analysis, the readmission group showed a higher P. aeruginosa identification rate than the no-readmission group (odds ratio, 4.749; 95% confidence interval, 1.296-17.041; P=0.019).

Conclusion

P. aeruginosa identification is associated with a higher readmission rate in AECOPD patients.

Genetic profile and patient-reported outcomes in chronic obstructive pulmonary disease: A systematic review

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) impacts differently on patients at similar grades, suggesting that factors other than lung function may influence patients' experience of the disease. Recent studies have found associations between genetic variations and patient-reported outcomes (PROs). Identifying these associations might be fundamental to predict the disease progression and develop tailored interventions. This systematic review aimed to identify the genetic variations associated with PROs in COPD.

METHODS AND FINDINGS

Databases were searched until July 2017 (PROSPERO: CRD42016041639) and additional searches were conducted scanning the reference list of the articles. Two independent reviewers assessed the quality of studies using the Q-Genie checklist. This instrument is composed of 11 questions, each subdivided in 7 options from 1 poor-7 excellent. Thirteen studies reporting 5 PROs in association with genes were reviewed. Studies were rated between "good quality" (n = 8) and "moderate" (n = 5). The most reported PRO was frequency of exacerbations (n = 7/13), which was mainly associated with MBL2 gene variants. Other PRO's were health-related quality of life (HRQOL) (n = 4/13), depressive symptoms (n = 1/13), exacerbation severity (n = 1/13) and breathlessness, cough and sputum (n = 1/13), which were commonly associated with other genetic variants.

CONCLUSIONS

Although a limited number of PRO's have been related to genetic variations, findings suggest that there is a significant association between specific gene variants and the number/severity of exacerbations, depressive symptoms and HRQOL. Further research is needed to confirm these findings and assess the genetic influence on other dimensions of patients' lives, since it may enhance our understanding and management of COPD.

Spirometry in Hospitalized Patients with Acute Exacerbation of COPD Accurately Predicts Post Discharge Airflow Obstruction

Purpose: Objective documentation of airflow obstruction is often lacking inhospitalized patients treated for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The utility of spirometry performed in hospitalized patients to identify airflow obstruction, and thus a diagnosis of COPD, is unclear. Our aim was to compare inpatient spirometry, performed during an AECOPD, with outpatient spirometry. Methods: A retrospective analysis of data from patients enrolled in an AECOPD care plan was performed. As part of the plan, patients underwent inpatient spirometry to establish a COPD diagnosis and outpatient clinic spirometry within 4 weeks of hospital discharge to confirm it. Data analyzed included forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), slow vital capacity (SVC) and FEV1/ vital capacity (VC). Obstruction was defined by FEV1/VC<0.70. Results: A total of 159 patients (mean age 63.2 +/- 10.5 years) had corresponding in- and outpatient spirometry. The median days between inpatient and outpatient spirometry was 12 (interquartile range [IQR] 9-16). Inpatient spirometry had a sensitivity of 94%, specificity of 24%, positive predictive value of 83% and negative predictive value of 53% for predicting outpatient obstruction. The area under curve for using inpatient spirometry was 0.82. The mean difference between inpatient and outpatient FEV1 was 0.44 +/- 0.03 liters or 17.3 +/- 1.13 % predicted (p<0.0001) for FEV1. Conclusions: Inpatient spirometry accurately predicts outpatient airflow obstruction, thus providing an opportunity to identify patients admitted with suspected AECOPD who have no prior spirometric documentation.

Comparison of effectiveness of temporary positive expiratory pressure versus oscillatory positive expiratory pressure in severe COPD patients

INTRODUCTION

In chronic obstructive pulmonary disease (COPD) patients few modalities of airway clearance have demonstrated effectiveness in reducing hypersecretion and bronchial obstruction. Positive expiratory pressure (PEP) is one of these.

OBJECTIVE

Our goal was to compare the effectiveness of 2 devices Temporary PEP (T-PEP) and Oscillatory PEP (O-PEP) which use PEP applied at a low expiratory pressure of 1 cm H₂ O which creates oscillations that decrease bronchial obstruction in reducing COPD exacerbations and improving respiratory and health status assessment parameters. Each has different mechanism of action.

METHODS

A 26 week randomized controlled study evaluated their efficacy in reducing exacerbations and improving health status assessment tests as well as respiratory function parameters in severe to very severe COPD patients. One hundred-twenty patients were enrolled: 40 patients received T-PEP therapy; 40 underwent treatment with O-PEP; 40 constituted the control group. The primary outcome was the reduction of exacerbations after 1, 3 and 6 months; secondary outcomes were improvement of lung function and health status assessment tests [Modified Medical Research Council (MMRC) scale, Breathlessness, Cough, and Sputum Scale (BCSS) scale, and COPD Assessment Test (CAT) score].

RESULTS

Only T-PEP statistically reduced the exacerbations after 1 and 3 months compared to the control group. Both the 2 devices improved dyspnea scale (MMRC), lung function parameters, and health status assessment (CAT) tests compared to the control group. Both interventions were well-tolerated by our patients.

CONCLUSIONS

O-PEP and T-PEP are useful for COPD treatment but only T-PEP reduces exacerbations. Adding tools for airway clearance to medical therapy can help the management of COPD.

Long-acting muscarinic antagonists vs. long-acting β 2 agonists in COPD exacerbations: a systematic review and meta-analysis

OBJECTIVE

To determine whether long-acting muscarinic antagonists (LAMAs) provide superior therapeutic effects over long-acting β2 agonists (LABAs) for preventing COPD exacerbations.

METHODS

This was a systematic review and meta-analysis of randomized clinical trials involving patients with stable, moderate to severe COPD according to the Global Initiative for Chronic Obstructive Lung Disease criteria, treated with a LAMA (i.e., tiotropium bromide, aclidinium, or glycopyrronium), followed for at least 12 weeks and compared with controls using a LABA in isolation or in combination with a corticosteroid.

RESULTS

A total of 2,622 studies were analyzed for possible inclusion on the basis of their title and abstract; 9 studies (17,120 participants) were included in the analysis. In comparison with LABAs, LAMAs led to a greater decrease in the exacerbation rate ratio (relative risk [RR] = 0.88; 95% CI: 0.84-0.93]; a lower proportion of patients who experienced at least one exacerbation (RR = 0.90; 95% CI: 0.87-0.94; p < 0.00001); a lower risk of exacerbation-related hospitalizations (RR = 0.78; 95% CI: 0.69-0.87; p < 0.0001); and a lower number of serious adverse events (RR = 0.81; 95% CI: 0.67-0.96; p = 0.0002). The overall quality of evidence was moderate for all outcomes.

CONCLUSIONS

The major findings of this systematic review and meta-analysis were that LAMAs significantly reduced the exacerbation rate (exacerbation episodes/year), as well as the number of exacerbation episodes, of hospitalizations, and of serious adverse events.

Exacerbations in Chronic Obstructive Pulmonary Disease: Identification and Prediction Using a Digital Health System

Background

Chronic obstructive pulmonary disease (COPD) is a progressive, chronic respiratory disease with a significant socioeconomic burden. Exacerbations, the sudden and sustained worsening of symptoms, can lead to hospitalization and reduce quality of life. Major limitations of previous telemonitoring interventions for COPD include low compliance, lack of consensus on what constitutes an exacerbation, limited numbers of patients, and short monitoring periods. We developed a telemonitoring system based on a digital health platform that was used to collect data from the 1-year EDGE (Self Management and Support Programme) COPD clinical trial aiming at daily monitoring in a heterogeneous group of patients with moderate to severe COPD.

Objective

The objectives of the study were as follows: first, to develop a systematic and reproducible approach to exacerbation identification and to track the progression of patient condition during remote monitoring; and second, to develop a robust algorithm able to predict COPD exacerbation, based on vital signs acquired from a pulse oximeter.

Methods

We used data from 110 patients, with a combined monitoring period of more than 35,000 days. We propose a finite-state machine–based approach for modeling COPD exacerbation to gain a deeper insight into COPD patient condition during home monitoring to take account of the time course of symptoms. A robust algorithm based on short-period trend analysis and logistic regression using vital signs derived from a pulse oximeter is also developed to predict exacerbations.

Results

On the basis of 27,260 sessions recorded during the clinical trial (average usage of 5.3 times per week for 12 months), there were 361 exacerbation events. There was considerable variation in the length of exacerbation events, with a mean length of 8.8 days. The mean value of oxygen saturation was lower, and both the pulse rate and respiratory rate were higher before an impending exacerbation episode, compared with stable periods. On the basis of the classifier developed in this work, prediction of COPD exacerbation episodes with 60%-80% sensitivity will result in 68%-36% specificity.

Conclusions

All 3 vital signs acquired from a pulse oximeter (pulse rate, oxygen saturation, and respiratory rate) are predictive of COPD exacerbation events, with oxygen saturation being the most predictive, followed by respiratory rate and pulse rate. Combination of these vital signs with a robust algorithm based on machine learning leads to further improvement in positive predictive accuracy.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 40367841; http://www.isrctn.com/ISRCTN40367841 (Archived by WebCite at http://www.webcitation.org/6olpMWNpc)

Validation of the breathlessness, cough and sputum scale to predict COPD exacerbation

The breathlessness, cough and sputum scale (BCSS) is a three-item questionnaire rating breathlessness, cough and sputum on a 5-point Likert scale from 0 (no symptoms) to 4 (severe symptoms). Researchers have explored the utility of this tool to quantify efficacy of treatment following a chronic obstructive pulmonary disease (COPD) exacerbation; however, little work has been done to investigate the ability of the BCSS to predict COPD exacerbation. As part of a prospective case-crossover study among a cohort of 168 COPD patients residing in central Massachusetts, patients were asked standard BCSS questions during exacerbation and randomly identified non-exacerbation (or healthy) weeks. We found that the BCSS was strongly associated with COPD exacerbation (OR=2.80, 95% CI=2.27-3.45) and that a BCSS sum score of 5.0 identified COPD exacerbation with 83% sensitivity and 68% specificity. These results may be useful in the clinical setting to expedite interventions of exacerbation.

Biomarker Development in COPD: Moving From P Values to Products to Impact Patient Care

There is a great interest in developing biomarkers to enable precision medicine and improve health outcomes of patients with COPD. However, biomarker development is extremely challenging and expensive, and translation of research endeavors to date has been largely unsuccessful. In most cases, biomarkers fail because of poor replication of initial promising results in independent cohorts and/or inability to transfer the biomarker from a discovery platform to a clinical assay. Ultimately, new biomarker assays must address 5 questions for optimal clinical translation. They include the following: is the biomarker likely to be (1) superior (will the test outperform current standards?); (2) actionable (will the test change patient management?); (3) valuable (will the test improve patient outcomes?); (4) economical (will the implementation of the biomarker in the target population be cost-saving or cost-effective?); and (5) clinically deployable (is there a pathway for the biomarker and analytical technology to be implemented in a clinical laboratory?)? In this article we review some of the major barriers to biomarker development in COPD and provide possible solutions to overcome these limitations, enabling translation of promising biomarkers from discovery experiments to clinical implementation.

Costs of Treatment of Chronic Obstructive Pulmonary Disease

The aim of this study was to analyze direct costs of COPD therapy in relation with clinical course and stage of the disease. Sixty patients with moderate to severe COPD were included into the study. The average cost was taken from institutional data file and was also assessed from a social perspective. Results were presented as average costs per patient per year. Forty two percent of patients was classified as GOLD D category, while categories A, B, and C accounted for 8 %, 27 %, and 23 %, respectively. Approximately 65 % of patients had 2-3 degrees of dyspnea according to the Modified Medical Research Council Dyspnea Scale. About 60 % of patients underwent two or three exacerbations per year and those patients had one or two co-morbidities diagnosed. Treatment costs almost doubled with disease progression, mainly due to exacerbations. In patients in Group C and Group D with exacerbations the direct costs were several times higher than in group A or B and the difference increased with progression of the disease. In Groups A and B, the costs of treatment of stable disease or with exacerbation were comparable. We conclude that costs of treatment of COPD patients were highest in advanced disease and were strongly related to COPD exacerbations.

A Systematic Review of Diagnostic Biomarkers of COPD Exacerbation

The aims of this systematic review were to determine which blood-based molecules have been evaluated as possible biomarkers to diagnose chronic obstructive pulmonary disease (COPD) exacerbations (AECOPD) and to ascertain the quality of these biomarker publications. Patients of interest were those that have been diagnosed with COPD. MEDLINE, EMBASE, and CINAHL databases were searched systematically through February 2015 for publications relating to AECOPD diagnostic biomarkers. We used a modified guideline for the REporting of tumor MARKer Studies (mREMARK) to assess study quality. Additional components of quality included the reporting of findings in a replication cohort and the use of receiver-operating characteristics area-under-the curve statistics in evaluating performance. 59 studies were included, in which the most studied biomarkers were C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). CRP showed consistent elevations in AECOPD compared to control subjects, while IL-6 and TNF-α had variable statistical significance and results. mREMARK scores ranged from 6 to 18 (median score of 13). 12 articles reported ROC analyses and only one study employed a replication cohort to confirm biomarker performance. Studies of AECOPD diagnostic biomarkers remain inconsistent in their reporting, with few studies employing ROC analyses and even fewer demonstrating replication in independent cohorts.

Self-administered prescriptions of oral steroids and antibiotics in chronic obstructive pulmonary disease: are we doing more harm than good?

Patients with chronic obstructive pulmonary disease (COPD) are often given a prescription for a short course of oral steroids and antibiotics for self-administration during an acute exacerbation. The main objective of this study was to determine the impact of such prescriptions on medical care utilization, and steroids and antibiotics intake. This retrospective cohort study included patients with moderate to severe COPD participating in a self-management programme. We compared the number of unplanned medical visits (including hospitalizations) and the utilization of systemic steroids (number of short courses, number of days on treatment) and antibiotics (number of treatments) over a period of six months following registration to the programme in patients who received such a prescription and those who did not. Data were collected from hospital and community pharmacy files. A total of 89 patients were included; 46 received a self-administered prescription. During the study period, we found no difference between the two groups in the number of unplanned medical visits. However, we observed small but significant differences in the number of short courses of Prednisone ( P = 0.018) and antibiotics ( P = 0.006). This translated in an important difference in the number of days on steroids over the same period (`Prescription' group: 26; controls: 8; P = 0.005). Self-administered prescriptions may increase steroids and antibiotics utilization in patients with moderate to severe COPD, without reducing the number of unplanned medical visits. Chronic Respiratory Disease 2007; 4: 143—147

Study on risk factors and phenotypes of acute exacerbations of chronic obstructive pulmonary disease in Guangzhou, China-design and baseline characteristics

BACKGROUND

To describe a study design that focuses on risk factors and patterns of chronic obstructive pulmonary disease (COPD) exacerbations.

METHODS

A 2-year, single centre, observational study was conducted in Guangzhou in China. The study enrolled 318 subjects with COPD aged 40-79 years, stratified into different but equally sized groups according to global initiative for chronic obstructive lung disease (GOLD) stage (including Stage 0) and 86 lung healthy controls. An assessment each year was scheduled including questionnaires, lung function testing, Chest X-ray and blood collection. A sub-group, called sub-group X, consisting of 203 subjects with COPD and 51 lung healthy controls, was selected to answer a symptom questionnaire daily (EXACT-PRO) via a BlackBerry Personal Digital Assistant (PDA) device. Upon an alert that indicated a change in daily symptom pattern, the patients were contacted by the clinic to decide whether they had experienced an exacerbation and should have an extra visit within 24-48 hours. At an extra visit, nasal and throat swabs, induced sputum and blood were collected. Air pollution, temperature and humidity were also monitored daily. A subset of sub-group X, called sub-group M that consisted of 52 COPD patients and 15 healthy controls was dedicated to measure muscle strength and a dexa scan.

RESULTS

More than 78% of the enrolled patients completed the study successfully. There appeared a difference between the patient groups and the controls in gender, age, body mass index (BMI), forced expiratory volume in 1 second (FEV1), FEV1/FVC and smoking at baseline. In sub-group X 90 out of 203 (44.4%) selected COPD patients developed one or more exacerbations in the 2-year observation period. They were more severe COPD patients according to GOLD stage at study start. On average most exacerbations occurred in the month March and the least number of exacerbations occurred in October.

CONCLUSIONS

This study with the obtained patient dataset will allow a better insight in many aspects of exacerbations in COPD (e.g., the identification, the risk factors, phenotypes and the biomarkers).

Patients' experience of identifying and managing exacerbations in COPD: a qualitative study

Background:

Effective self-management in chronic obstructive pulmonary disease (COPD) is crucial to reduce hospital admissions and improve outcomes for patients. This includes early detection and treatment of exacerbations by patients themselves.

Aims:

To explore patients’ current understanding and experience of managing and identifying COPD exacerbations at home.

Methods:

A qualitative, interview-based study was carried out in patients’ homes. Interviews were audio-recorded, transcribed and analysed using a grounded theory approach. Forty-four patients (17 women, 27 men; age range 55–85 years), with moderate-to-very-severe COPD, were recruited to the interview study from primary and secondary care settings in Oxford, UK, during 2012–2013.

Results:

Patients identified exacerbations on the basis of measurable, ‘visible’ symptoms, such as cough and sputum and ‘invisible’ symptoms, such as chest sensations and bodily knowledge. Most patients seemed to use a combination of these approaches when identifying exacerbations, according to the symptoms that had the most impact on their well-being. Patients used additional self-management strategies during an exacerbation, such as self-medication (antibiotics and steroids) and monitored their recovery. Contact with health-care professionals usually occurred when patients felt no longer able to manage themselves.

Conclusions:

Patients use both assessment of objective biomarkers, which are aligned with medical knowledge, and subjective symptoms based on their experience, to identify and manage exacerbations of COPD. Health-care professionals and clinicians should acknowledge this ‘expert patient’ knowledge and integrate this into patients’ care plans to facilitate early recognition and treatment of exacerbations.

Pulmonary rehabilitation at the time of the COPD exacerbation

Pulmonary rehabilitation (PR) is associated with improvements in exercise capacity, health related quality of life, psychological symptoms and response to utilization. Acute exacerbations threaten these improvements. An awareness of the clinical sequelae of acute exacerbation of chronic obstructive pulmonary disease enables approaches, such as early post exacerbation rehabilitation to mitigate its negative effects.

Evolution of the COPD Assessment Test score during chronic obstructive pulmonary disease exacerbations: determinants and prognostic value

BACKGROUND

An adequate evaluation of exacerbations is a primary objective in managing patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To define the profile of health status recovery during severe exacerbations of COPD using the COPD Assessment Test (CAT) questionnaire and to evaluate its prognostic value.

METHODS

Forty-five patients with previous COPD diagnoses who were hospitalized due to severe exacerbation(s) were included in the study. These patients were treated by their respective physicians following current recommendations; health status was assessed daily using the CAT questionnaire. The CAT score, spirometry and recurrent hospitalizations were recorded one and three months after hospital discharge.

RESULTS

Global initiative for chronic Obstructive Lung Disease (GOLD) stage was an independent determinant for increased CAT score during the first days of exacerbation with respect to postexacerbation values. From hospitalization day 5, the CAT score was similar to that obtained in the stable phase. Body mass index, GOLD stage and education level were related to health status recovery pattern. CAT score increase and the area under the curve of CAT recovery were inversely related to the forced expiratory volume in 1 s achieved three months after discharge (r=-0.606; P<0.001 and r=-0.532; P<0.001, respectively). Patients with recurrent hospitalizations showed higher CAT score increases and slower recovery.

CONCLUSIONS

The CAT detects early health status improvement during severe COPD exacerbations. Its initial worsening and recovery pattern are related to lung function and recurrent hospitalizations.

Real-life use of fluticasone propionate/salmeterol in patients with chronic obstructive pulmonary disease: a French observational study

BACKGROUND

In Europe, administration of an inhaled corticosteroid (ICS) combined with a long-acting β2 agonist is approved in chronic obstructive pulmonary disease (COPD) patients with a pre-bronchodilator FEV1 < 60% predicted normal, a history of repeated exacerbations, and who have significant symptoms despite regular bronchodilator therapy. Minimal data are available on the use of the fluticasone propionate/salmeterol xinafoate combination (FSC) in the real-life COPD setting and prescription compliance with the licensed specifications.

METHODS

A French observational study was performed to describe the COPD population prescribed with FSC, prescription modalities, and the coherence of prescription practices with the market authorized population. Data were collected for patients initiating FSC treatment (500 μg fluticasone propionate, 50 μg salmeterol, dry powder inhaler) prescribed by a general practitioner (GP) or a pulmonologist, using physician and patient questionnaires.

RESULTS

A total of 710 patients were included, 352 by GPs and 358 by pulmonologists. Mean age was over 60 years, and 70% of patients were male. More than half were retired, and overweight or obese. Approximately half were current smokers and one-third had cardiovascular comorbidities. According to both physician evaluation and GOLD 2006 classification, the majority of patients (>75%) had moderate to very severe COPD. Strict compliance by prescribing physicians with the market-approved population for dry powder inhaler SFC in COPD was low, notably in ICS-naïve patients; all three conditions were fulfilled in less than a quarter of patients with prior ICS and less than 7% of ICS-naïve patients.

CONCLUSIONS

Prescription of dry powder inhaler SFC by GPs and pulmonologists has very low conformity with the three conditions defining the licensed COPD population. Prescription practices need to be improved and systematic FEV1 evaluation for COPD diagnosis and treatment management should be emphasized.

Self management for patients with chronic obstructive pulmonary disease

BACKGROUND

Self management interventions help patients with chronic obstructive pulmonary disease (COPD) acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable patients to control their disease. Since the first update of this review in 2007, several studies have been published. The results of the second update are reported here.

OBJECTIVES

1. To evaluate whether self management interventions in COPD lead to improved health outcomes.2. To evaluate whether self management interventions in COPD lead to reduced healthcare utilisation.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (current to August 2011).

SELECTION CRITERIA

Controlled trials (randomised and non-randomised) published after 1994, assessing the efficacy of self management interventions for individuals with COPD, were included. Interventions with fewer than two contact moments between study participants and healthcare providers were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Investigators were contacted to ask for additional information. When appropriate, study results were pooled using a random-effects model. The primary outcomes of the review were health-related quality of life (HRQoL) and number of hospital admissions.

MAIN RESULTS

Twenty-nine studies were included. Twenty-three studies on 3189 participants compared self management versus usual care; six studies on 499 participants compared different components of self management on a head-to-head basis. Although we included non-randomised controlled clinical trials as well as RCTs in this review, we restricted the primary analysis to RCTs only and reported these trials in the abstract.In the 23 studies with a usual care control group, follow-up time ranged from two to 24 months. The content of the interventions was diverse. A statistically relevant effect of self management on HRQoL was found (St George's Respiratory Questionnaire (SGRQ) total score, mean difference (MD) -3.51, 95% confidence interval (CI) -5.37 to -1.65, 10 studies, 1413 participants, moderate-quality evidence). Self management also led to a lower probability of respiratory-related hospitalisation (odds ratio (OR) 0.57, 95% CI 0.43 to 0.75, nine studies, 1749 participants, moderate-quality evidence). Over one year of follow-up, eight (95% CI 5 to 14) participants with a high baseline risk of respiratory-related hospital admission needed to be treated to prevent one participant with at least one hospital admission, and 20 (95% CI 15 to 35) participants with a low baseline risk of hospitalisation needed to be treated to prevent one participant with at least one respiratory-related hospital admission.No statistically significant effect of self management on all-cause hospitalisation (OR 0.77, 95% CI 0.45 to 1.30, 6 studies, 1365 participants, low-quality evidence) or mortality (OR 0.79, 95% CI 0.58 to 1.07, 8 studies, 2134 participants, very low-quality evidence) was detected. Also, dyspnoea measured by the (modified) Medical Research Council Scale ((m)MRC) was reduced in individuals who participated in self management (MD -0.83, 95% CI -1.36 to -0.30, 3 studies, 119 participants, low-quality evidence). The difference in exercise capacity as measured by the six-minute walking test was not statistically significant (MD 33.69 m, 95% CI -9.12 to 76.50, 6 studies, 570 participants, very low-quality evidence). Subgroup analyses depending on the use of an exercise programme as part of the intervention revealed no statistically significant differences between studies with and without exercise programmes in our primary outcomes of HRQoL and respiratory-related hospital admissions.We were unable to pool head-to-head trials because of heterogeneity among interventions and controls; thus results are presented narratively within the review.

AUTHORS' CONCLUSIONS

Self management interventions in patients with COPD are associated with improved health-related quality of life as measured by the SGRQ, a reduction in respiratory-related hospital admissions, and improvement in dyspnoea as measured by the (m)MRC. No statistically significant differences were found in other outcome parameters. However, heterogeneity among interventions, study populations, follow-up time and outcome measures makes it difficult to formulate clear recommendations regarding the most effective form and content of self management in COPD.

Non-invasive biomarkers in exacerbations of obstructive lung disease

BACKGROUND AND OBJECTIVE

Current methods of diagnosing exacerbations of asthma and chronic obstructive pulmonary disease (COPD) shed little light on their aetiology or pathophysiology. This study aimed to define the inflammatory biomarker profile of subjects with obstructive lung disease and to compare these with control subjects also with respiratory infections, using exhaled breath condensate (EBC) and induced sputum biomarker analysis.

METHODS

EBC, induced sputum and C-reactive protein were collected from subjects with exacerbations of asthma (n = 28), exacerbations of COPD (n = 29) and otherwise healthy controls with symptoms of respiratory tract infection (n = 28). Subjects were tested again after recovery. EBC and induced sputum were analysed for protein, hydrogen peroxide, interferon gamma inducible protein-10 (IP-10), neopterin, interleukin (IL)-6, IL-8, leukotriene B4 and tumour necrosis factor (TNF)-α. Sputum cell counts and EBC pH were also analysed.

RESULTS

EBC pH was significantly lower in exacerbation compared with recovery (5.54 0.07 vs 6.04 ± 0.08; P < 0.001). The novel markers IP-10 and neopterin were significantly increased in induced sputum supernatant (pooled groups pre and post exacerbation: IP-10: 188.6 ± 102.1 vs 5.40 ± 1.28 pg/mL, P = 0.006; neopterin: 15.81 ± 2.50 vs 5.38 ± 0.45 nmol/L, P < 0.0001), as was TNF-α (137.8 ± 49.64 vs 71.56 ± 45.03 pg/mL, P = 0.018). Few other biomarkers proved significantly different in exacerbation, although C-reactive protein was raised.

CONCLUSIONS

Non-invasive biomarker assessment may provide useful information in exacerbation of obstructive lung diseases, particularly sputum IP-10 and neopterin and EBC pH.

Managing older patients with coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges

Asthma and chronic obstructive pulmonary disease (COPD) are common obstructive airway diseases, especially among older people. These conditions are associated with a significant and increasing disease burden. The diagnosis and management of asthma and COPD in older populations are complex, and consequently clinicians are faced with many therapeutic and diagnostic challenges. Both aging and obstructive airway diseases are associated with complex co-morbidities and these coexisting illnesses confound management. Moreover, the age-related physiological changes that occur in the lungs may lead to airflow limitation, and this may be difficult to distinguish from an active disease state. In practice, management of asthma and COPD is informed by disease-specific clinical practice guidelines; however, most older people with these conditions are excluded from clinical trials that are designed to inform practice, creating major evidence gaps. Furthermore, seldom do clinical practice guidelines consider the complexities of management in older populations. The problems experienced by older people are complex and multifactorial and our approach to management must reflect these challenges. Opportunities exist to improve the management and outcomes for older people with obstructive airway disease and there is an urgent need for clinical trials to test management approaches in this population; current research must consider the challenges and evidence gaps that exist.

Exacerbations among chronic bronchitis patients treated with maintenance medications from a US managed care population: an administrative claims data analysis

PURPOSE

Chronic obstructive pulmonary disease (COPD) exacerbations are the leading cause of hospital admission and death among chronic bronchitis (CB) patients. This study estimated annual COPD exacerbation rates, related costs, and their predictors among patients treated for CB.

METHODS

This was a retrospective study using claims data from the HealthCore Integrated Research Database (HIRD(SM)). The study sample included CB patients aged ≥ 40 years with at least one inpatient hospitalization or emergency department visit or at least two office visits with CB diagnosis from January 1, 2004 to May 31, 2011, at least two pharmacy fills for COPD medications during the follow-up year, and ≥2 years of continuous enrollment. COPD exacerbations were categorized as severe or moderate. Annual rates, costs, and predictors of exacerbations during follow-up were assessed.

RESULTS

A total of 17,382 individuals treated for CB met the selection criteria (50.6% female; mean ± standard deviation age 66.7 ± 11.4 years). During the follow-up year, the mean ± standard deviation number of COPD maintenance medication fills was 7.6 ± 6.3; 42.6% had at least one exacerbation and 69.5% of patients with two or more exacerbations during the 1 year prior to the index date (baseline period) had any exacerbation during the follow-up year. The mean ± standard deviation cost per any exacerbation was $269 ± $748 for moderate and $18,120 ± $31,592 for severe exacerbation. The number of baseline exacerbations was a significant predictor of the number of exacerbations and exacerbation costs during follow-up.

CONCLUSION

Exacerbation rates remained high among CB patients despite treatment with COPD maintenance medications. New treatment strategies, designed to reduce COPD exacerbations and associated costs, should focus on patients with high prior-year exacerbations.

Lower health literacy is associated with poorer health status and outcomes in chronic obstructive pulmonary disease

BACKGROUND

Limited health literacy is associated with poor outcomes in many chronic diseases, but little is known about health literacy in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To examine the associations between health literacy and both outcomes and health status in COPD. PARTICIPANTS, DESIGN AND MAIN MEASURES: Structured interviews were administered to 277 subjects with self-report of physician-diagnosed COPD, recruited through US random-digit telephone dialing. Health literacy was measured with a validated three-item battery. Multivariable linear regression, controlling for sociodemographics including income and education, determined the cross-sectional associations between health literacy and COPD-related health status: COPD Severity Score, COPD Helplessness Index, and Airways Questionnaire-20R [measuring respiratory-specific health-related quality of life (HRQoL)]. Multivariable logistic regression estimated associations between health literacy and COPD-related hospitalizations and emergency department (ED) visits.

KEY RESULTS

Taking socioeconomic status into account, poorer health literacy (lowest tertile compared to highest tertile) was associated with: worse COPD severity (+2.3 points; 95 % CI 0.3-4.4); greater COPD helplessness (+3.7 points; 95 % CI 1.6-5.8); and worse respiratory-specific HRQoL (+3.5 points; 95 % CI 1.8-4.9). Poorer health literacy, also controlling for the same covariates, was associated with higher likelihood of COPD-related hospitalizations (OR = 6.6; 95 % CI 1.3-33) and COPD-related ED visits (OR = 4.7; 95 % CI 1.5-15). Analyses for trend across health literacy tertiles were statistically significant (p < 0.05) for all above outcomes.

CONCLUSIONS

Independent of socioeconomic status, poor health literacy is associated with greater COPD severity, greater COPD helplessness, worse respiratory-specific HRQoL, and higher odds of COPD-related emergency health-care utilization. These results underscore that COPD patients with poor health literacy may be at particular risk for poor health-related outcomes.

[Characteristics of stable chronic obstructive pulmonary disease related to systemic inflammation]

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is characterized by a systemic inflammation. The aim of this study was to evaluate the association between systemic inflammation, measured with C reactive protein (CRP), and clinical and functional outcomes of the disease.

PATIENTS AND METHODS

A randomized sample of 413 COPD patients from 31 primary health care centers of Barcelona was evaluated. Medical history, anthropometric measurements, toxic habits, treatments, Chronic Respiratory Questionnaire (CRQ) and dyspnea were registered. Spirometry, exhaled CO concentration and CRP in capillary blood were performed.

RESULTS

Median (standard deviation) of the age was 72 (8.4) years and forced expiratory volume in one second (FEV(1)) postbronchodilatador 1.65 (0.65) l. The correlation was negative between CRP and FEV(1) postbronchodilatador(r=-0.25, P<0.001) and between CRP and CRQ scores (r=-0.098, P=0.048) and positive between CRP and CO (r=0.1, P=0.039). The ratio of patients with elevated CRP was higher in advanced GOLD stage (P<0.001), worst dyspnea (P=0.042), patients treated with inhaled corticosteroids (P=0.018) and if they had been hospitalized during the last year (P=0.026). The multivariant analysis showed, as independent factors of elevated CRP, FEV(1) postbronchodilator and CO concentration.

CONCLUSION

In COPD patients, active smoking habit and the airway's obstruction degree are associated with a greater intensity of the inflammatory systemic response measured by the CRP.

Usefulness of a patient symptom diary card in the monitoring of exacerbations of chronic bronchitis and chronic obstructive pulmonary disease

OBJECTIVE

To assess the usefulness of a patient diary card of symptoms for monitoring the evolution of an exacerbation of chronic bronchitis (CB) and chronic obstructive pulmonary disease (COPD) in primary care.

METHOD

Multicentre, observational study. Patients with an exacerbation filled out a diary every day before bedtime during 10 days. The diary score ranged from 0 (best) to 28 (worst). A visit was performed at day 15 to collect the patient diaries.

RESULTS

Of the 1101 patients studied 921 returned the diaries (83.7%). Clinical failure was found in 236 patients (25.6%). The mean global score on day 1 was 21.5 ± 3.8. Patients considered as cured at day 10 presented a lower score at day 1 (21.1 ± 3.9) vs. those who failed (22.6 ± 4.2; p < 0.001). When no reduction was observed in the score from days 1 to 3, the percentage of failures was 36.1%, being only 11.6% with a reduction of 5 points or more (p < 0.001). The strongest correlation with failure was observed with general status, breathing, symptom scale and the need for extra inhaler doses.

CONCLUSION

A symptom diary card seems to be a valuable tool to monitor the evolution of an acute exacerbation of CB/COPD in primary care.

Oral hygiene, periodontal health and chronic obstructive pulmonary disease exacerbations

AIM

To assess the associations of oral hygiene and periodontal health with chronic obstructive pulmonary disease (COPD) exacerbations.

MATERIAL AND METHODS

In total, 392 COPD patients were divided into frequent and infrequent exacerbation (≥2 times and <2 times in last 12 months) groups. Their lung function and periodontal status were examined. Information on oral hygiene behaviours was obtained by interview.

RESULTS

In the univariate analysis, fewer remaining teeth, high plaque index (PLI) scores, low tooth brushing times, and low regular supra-gingival scaling were significantly associated with COPD exacerbations (all p-values <0.05). After adjustment for age, gender, body mass index, COPD severity and dyspnoea severity, the associations with fewer remaining teeth (p = 0.02), high PLI scores (p = 0.02) and low tooth brushing times (p = 0.008) remained statistically significant. When stratified by smoking, fewer remaining teeth (OR = 2.05, 95% CI: 1.04-4.02) and low tooth brushing times (OR = 4.90, 95% CI: 1.26-19.1) among past smokers and high PLI scores (OR = 3.43, 95% CI: 1.19-9.94) among never smokers were significantly associated with COPD exacerbations.

CONCLUSIONS

Fewer remaining teeth, high PLI scores, and low tooth brushing times are significant correlates of COPD exacerbations, indicating that improving periodontal health and oral hygiene may be a potentially preventive strategy against COPD exacerbations.

Outpatient treatment of Pseudomonas aeruginosa bronchial colonization with long-term inhaled colistin, tobramycin, or both in adults without cystic fibrosis

STUDY OBJECTIVE

To compare clinical and microbiologic outcomes in adults without cystic fibrosis who had Pseudomonas aeruginosa bronchial colonization and were receiving inhaled colistin or colistin plus tobramycin with those who were receiving inhaled tobramycin as outpatient treatment.

DESIGN

Prospective, observational cohort study.

SETTING

Referral pneumology service at a tertiary university care hospital.

PATIENTS

Eighty-one Caucasian adults without cystic fibrosis who received 97 courses of inhaled colistin alone, colistin plus tobramycin, or inhaled tobramycin alone as outpatient treatment of P. aeruginosa bronchial colonization between January 2004 and December 2008.

MEASUREMENTS AND MAIN RESULTS

The frequency and duration of hospitalizations for respiratory exacerbations were the primary outcomes compared among treatment groups. Secondary outcomes were emergence of bacterial resistance, antibiotic use during admission, emergence of other opportunistic microorganisms, achievement of sustained P. aeruginosa eradication in the airways, and mortality, as well as safety and changes in respiratory function. No significant differences between colistin and tobramycin were found in the mean number of hospital admissions, duration of hospitalizations, duration of antibiotic treatment, adverse events, mortality, or emergence of other opportunistic microorganisms. Emergence of resistance to colistin was lower than resistance to tobramycin (hazard ratio 0.09, 95% confidence interval [CI] 0.03-0.32). Patients treated with both inhaled antibiotics had fewer days of hospitalization and fewer days of antibiotic use than those treated with tobramycin alone (relative risk [RR] 0.33, 95% CI 0.10-1.12, and RR 0.27, 95% CI 0.08-0.93, respectively).

CONCLUSION

Results with colistin were similar to those with tobramycin for inhaled treatment of P. aeruginosa colonization in this population; however, combined use of colistin and tobramycin appeared to be associated with fewer days of hospitalization and shorter duration of antibiotic treatment. Prospective, double-blind, placebo-controlled trials of outpatient nebulized antibiotics, especially colistin plus tobramycin, should be performed to ascertain the efficacy of this therapy for treatment of P. aeruginosa colonization in patients without cystic fibrosis.

Bronchus-associated lymphoid tissue (BALT) structure and function

Bronchus-associated lymphoid tissue (BALT) is a constitutive mucosal lymphoid tissue adjacent to major airways in some mammalian species, including rats and rabbits, but not humans or mice. A related tissue, inducible BALT (iBALT), is an ectopic lymphoid tissue that is formed upon inflammation or infection in both mice and humans and can be found throughout the lung. Both BALT and iBALT acquire antigens from the airways and initiate local immune responses and maintain memory cells in the lungs. Here, we discuss the development and function of BALT and iBALT in the context of pulmonary immunity to infectious agents, tumors, and allergens as well as autoimmunity and inflammatory diseases of the lung.

Association between lung function and exacerbation frequency in patients with COPD

PURPOSE

To quantify the relationship between severity of chronic obstructive pulmonary disease (COPD) as expressed by Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage and the annual exacerbation frequency in patients with COPD.

METHODS

We performed a systematic literature review to identify randomized controlled trials and cohort studies reporting the exacerbation frequency in COPD patients receiving usual care or placebo. Annual frequencies were determined for total exacerbations defined by an increased use of health care (event-based), total exacerbations defined by an increase of symptoms, and severe exacerbations defined by a hospitalization. The association between the mean forced expiratory volume in one second (FEV(1))% predicted of study populations and the exacerbation frequencies was estimated using weighted log linear regression with random effects. The regression equations were applied to the mean FEV(1)% predicted for each GOLD stage to estimate the frequency per stage.

RESULTS

Thirty-seven relevant studies were found, with 43 reports of total exacerbation frequency (event-based, n = 19; symptom-based, n = 24) and 14 reports of frequency of severe exacerbations. Annual event-based exacerbation frequencies per GOLD stage were estimated at 0.82 (95% confidence interval 0.46-1.49) for mild, 1.17 (0.93-1.50) for moderate, 1.61 (1.51-1.74) for severe, and 2.10 (1.51-2.94) for very severe COPD. Annual symptom-based frequencies were 1.15 (95% confidence interval 0.67-2.07), 1.44 (1.14-1.87), 1.76 (1.70-1.88), and 2.09 (1.57-2.82), respectively. For severe exacerbations, annual frequencies were 0.11 (95% confidence interval 0.02-0.56), 0.16 (0.07-0.33), 0.22 (0.20-0.23), and 0.28 (0.14-0.63), respectively. Study duration or type of study (cohort versus trial) did not significantly affect the outcomes.

CONCLUSION

This study provides an estimate of the exacerbation frequency per GOLD stage, which can be used for health economic and modeling purposes.

The impact of psychological distress on exacerbation rates in COPD

BACKGROUND

exacerbations are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to COPD morbidity and mortality. COPD is also associated with high levels of psychological distress, which has been shown to be associated with higher exacerbation rates. However, the existing literature on the association between psychological distress and exacerbation risk remains largely misunderstood.

OBJECTIVES

to critically review the current literature on the association between psychological distress (defined as anxiety and depressive symptoms or anxiety and depressive disorders) and COPD exacerbations in COPD patients, to highlight the limitations of the existing literature, and to provide recommendations for future research.

METHODS

a critical review of English-language peer-reviewed longitudinal and retrospective studies was conducted. The Ovid portal to Medline, EMBASE, and PsycINFO databases were accessed.

RESULTS

some acceptable evidence suggested that psychological distress confers greater risk for exacerbations, more specifically symptom-based exacerbations or those treated in the patient's own environment. However, most studies showed an absence of a positive association, especially with exacerbations leading to hospitalization.

CONCLUSIONS

methodological weaknesses and the use of a wide range of psychological tools mean that there is an inconsistent association between psychological distress and exacerbations in the current literature. However, psychological distress may confer greater risk for symptom-based rather than event-based defined exacerbations. Further studies are needed to more comprehensively assess the question, particularly in light of the high levels of both anxiety and depression in COPD patients.

Long-acting beta-agonists in the management of chronic obstructive pulmonary disease: current and future agents

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation and debilitating symptoms. For patients with moderate-to-severe COPD, long-acting bronchodilators are the mainstay of therapy; as symptoms progress, guidelines recommend combining bronchodilators from different classes to improve efficacy. Inhaled long-acting β2-agonists (LABAs) have been licensed for the treatment of COPD since the late 1990s and include formoterol and salmeterol. They improve lung function, symptoms of breathlessness and exercise limitation, health-related quality of life, and may reduce the rate of exacerbations, although not all patients achieve clinically meaningful improvements in symptoms or health related quality of life. In addition, LABAs have an acceptable safety profile, and are not associated with an increased risk of respiratory mortality, although adverse effects such as palpitations and tremor may limit the dose that can be tolerated. Formoterol and salmeterol have 12-hour durations of action; however, sustained bronchodilation is desirable in COPD. A LABA with a 24-hour duration of action could provide improvements in efficacy, compared with twice-daily LABAs, and the once-daily dosing regimen could help improve compliance. It is also desirable that a new LABA should demonstrate fast onset of action, and a safety profile at least comparable to existing LABAs.A number of novel LABAs with once-daily profiles are in development which may be judged against these criteria. Indacaterol, a LABA with a 24-hour duration of bronchodilation and fast onset of action, is the most advanced of these. Preliminary results from large clinical trials suggest indacaterol improves lung function compared with placebo and other long-acting bronchodilators. Other LABAs with a 24-hour duration of bronchodilation include carmoterol, vilanterol trifenatate and oldaterol, with early results indicating potential for once-daily dosing in humans.The introduction of once-daily LABAs also provides the opportunity to develop combination inhalers of two or more classes of once-daily long-acting bronchodilators, which may be advantageous for COPD patients through simplification of treatment regimens as well as improvements in efficacy. Once-daily LABAs used both alone and in combination with long-acting muscarinic antagonists represent a promising advance in the treatment of COPD, and are likely to further improve outcomes for patients.

[Budesonide/formoterol in the treatment of COPD]

Two large, 12-month clinical trials have been performed with budesonide-formoterol in patients with stable COPD and have shown clear data on the efficacy of this combination in improving pulmonary function, symptoms and health-related quality of life and in reducing the number of exacerbations. Before these trials, information was already available on the efficacy of both monocomponents in this disease, although the main clinical data obtained with formoterol and budesonide separately in the treatment of COPD come from the respective branches of these drugs in the two large clinical trials described in the present article. Improvement in pulmonary function variables [forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF)] was always greater with the combination of budesonide-formoterol. The scores obtained in quality of life questionnaires were also more favorable in the combination treatment branches as early as the first week of treatment and persisted at 12 months of follow-up. Improvement in symptoms and in the use of reliever medication was also greater in the combination branch. The frequency of mild and severe exacerbations, as well as the use of oral corticosteroids, was lower in the budesonide-formoterol branch. The time to first exacerbation was also more prolonged in this group. The present review discusses the main findings on the efficacy of the combination of budesonide-formoterol in stable COPD.

Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations

Current methods for assessing clinical outcomes in COPD mainly rely on physiological tests combined with the use of questionnaires. The present review considers commonly used outcome measures such as lung function, health status, exercise capacity and physical activity, dyspnoea, exacerbations, the multi-dimensional BODE score, and mortality. Based on current published data, we provide a concise overview of the principles, strengths and weaknesses, and discuss open questions related to each methodology. Reviewed is the current set of markers for measuring clinically relevant outcomes with particular emphasis on their limitations and opportunities that should be recognized when assessing and interpreting their use in clinical trials of COPD.

The diagnosis and treatment of elderly patients with acute exacerbation of chronic obstructive pulmonary disease and chronic bronchitis

The syndrome of chronic obstructive pulmonary disease (COPD) consists of chronic bronchitis (CB), bronchiectasis, emphysema, and reversible airway disease that combine uniquely in an individual patient. Older patients are at risk for COPD and its components—emphysema, CB, and bronchiectasis. Bacterial and viral infections play a role in acute exacerbations of COPD (AECOPD) and in acute exacerbations of CB (AECB) without features of COPD. Older patients are at risk for resistant bacterial organisms during their episodes of AECOPD and AECB. Organisms include the more‐common bacteria implicated in AECOPD/AECB such as Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Less‐common nonenteric, gram‐negative organisms including Pseudomonas aeruginosa, gram‐positive organisms including Staphylococcus aureus, and strains of nontuberculosis Mycobacteria are more often seen in AECOPD/AECB episodes involving elderly patients with frequent episodes of CB or those with bronchiectasis. Risk‐stratified antibiotic treatment guidelines appear useful for purulent episodes of AECOPD and episodes of AECB. These guidelines have not been prospectively validated for the general population and especially not for the elderly population. Using a risk‐stratification approach for elderly patients, first‐line antibiotics (e.g., amoxicillin, ampicillin, pivampicillin, trimethoprim/sulfamethoxazole, and doxycycline), with a more‐limited spectrum of antibacterial coverage, are used in patients who are likely to have a low probability of resistant organisms during AECOPD/AECB. Second‐line antibiotics (e.g., amoxicillin/clavulanic acid, second‐ or third‐generation cephalosporins, and respiratory fluoroquinolones) with a broader spectrum of coverage are reserved for patients with significant risk factors for resistant organisms and those who have failed initial antibiotic treatment.