Exacerbations of chronic obstructive pulmonary disease: time to rename

Exploring patients' and carers' experiences, understandings and expectations of COPD exacerbations:an interview study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) exacerbations are clinically significant events that affect millions of people globally.

AIM

To explore patients' and carers' experiences, understanding, and expectations of, as well as their responses to, exacerbations.

DESIGN & SETTING

Semi-structured interviews conducted with patients who have COPD and their carers from four sites across England.

METHOD

Interviews were conducted with a purposive sample of patients with COPD and their carers recruited from four sites in England: two in Yorkshire, one in Hampshire and one in London. Interviews were theoretically informed by the Breathing Space concept and analysed using reflexive thematic analysis. This research is reported in line with the Standards for Reporting Qualitative Research.

RESULTS

Forty patient participants were recruited: 21 were female, 28 were White, with a mean age 69 years (standard deviation [SD] = 8.1 years), mean COPD duration = 11.3 years (SD = 8.3 years), median exacerbations in past year = 1.5 (range 0-9). Seven carer participants were recruited; of these, six were female and six were White. Three themes were identified: the language that clinicians use in COPD is important; episodes of symptom worsening have profound impacts on patients and carers; and patients' early experiences, including the responses of clinicians to their help-seeking, have a lasting effect on their behaviour. How patients respond to symptom worsening can be considered holistically in the context of the Breathing Space framework. Breathlessness affected all patient participants and was a key symptom that precipitated action.

CONCLUSIONS

Our findings show how early help-seeking experiences shape later behaviour. Early emphasis on symptom management, preparation for exacerbations, and post-exacerbation reviews are practical ways that clinicians can support patients and carers to manage these events better. The Breathing Space concept provides a useful framework to identify needs and tailor COPD management appropriately.

A 7-point evidence-based care discharge protocol for patients hospitalized for exacerbation of COPD: consensus strategy and expert recommendation

Acute exacerbations of COPD (ECOPD) are an important event in the life of a COPD patient as it causes significant deterioration of physical, mental, and social health, hastens disease progression, increases the risk of dying and causes a huge economic loss. Preventing ECOPD is therefore one of the most important goals in the management of COPD. Before the patient is discharged after hospitalization for ECOPD, it is crucial to offer an evidence-based care bundle protocol that will help minimize the future risk of readmissions and death. To develop the content of this quality care bundle, an Expert Working Group was formed, which performed a systematic review of literature, brainstormed, and debated on key clinical issues before arriving at a consensus strategy that could help physicians achieve this goal. A 7-point consensus strategy was prepared, which included: (1) enhancing awareness and seriousness of ECOPD, (2) identifying patients at risk for future exacerbations, (3) optimizing pharmacologic treatment of COPD, (4) identifying and treating comorbidities, (5) preventing bacterial and viral infections, (6) pulmonary rehabilitation, and (7) palliative care. Physicians may find this 7-point care bundle useful to minimize the risk of future exacerbations and reduce morbidity and mortality.

"I know this is on my chest, let's act": a qualitative study exploring self-management of acute COPD exacerbations with a sputum colour chart to reduce unnecessary antibiotic use

Half of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are caused by bacterial infection, but self-management plans (SMPs) generally advocate use of antibiotics and steroids for all events. We report findings from a qualitative study exploring the acceptability of a sputum colour chart and SMP to guide patient use of antibiotics and steroids (commonly termed a 'rescue pack'). Qualitative interviews were conducted with healthcare professionals (HCPs) and patients from the Colour COPD trial - a randomised controlled trial of usual care (SMP alone) versus usual care plus sputum colour chart to manage AECOPD across England and sampled to promote maximum variation. Interviews were audio-recorded, transcribed clean verbatim, then analysed thematically, using an adapted Framework approach. Expert patients contributed to the patient data analysis. Fourteen HCPs and 39 patients were interviewed from primary and secondary care. Three overarching themes were identified. (1) Handling tensions: the tension between stewardship of antimicrobials and need to reduce risk of serious illness. (2) Clinical and embodied legacies: established clinical practices of infection control and patient's own experiences of managing their condition over time have focused on early intervention for AECOPD. (3) Changing self-management practices: opportunities for changing practices through negotiating change between HCP and patient. In conclusion, while, in principle, the assessment of sputum colour using a chart to manage AECOPD was acceptable to both patients and HCPs, in practice, it is unlikely to have significant impact on well-established clinical practices for infection control and patient habits of self-management.

Value of Lung Ultrasound Sonography B-Lines Quantification as a Marker of Heart Failure in COPD Exacerbation

Introduction

Identifying heart failure (HF) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can be challenging. Lung ultrasound sonography (LUS) B-lines quantification has recently gained a large place in the diagnosis of HF, but its diagnostic performance in AECOPD remains poorly studied.

Purpose

This study aimed to assess the contribution of LUS B-lines score (LUS score) in the diagnosis of HF in AECOPD patients.

Patients and methods

This is a prospective cross-sectional multicenter cohort study including patients admitted to the emergency department for AECOPD. All included patients underwent LUS. A lung ultrasound score (LUS score) based on B-lines calculation was assessed. A cardiac origin of dyspnea was retained for a LUS score greater than 15. HF diagnosis was based on clinical examination, pro-brain natriuretic peptide levels, and echocardiographic findings. The LUS score diagnostic performance was assessed by receiver operating characteristic (ROC) curve, sensitivity, specificity, and likelihood ratio at the best cutoffs.

Results

We included 380 patients, mean age was 68±11.6 years, sex ratio (M/F) 1.96. Patients were divided into two groups: the HF group [n=157 (41.4%)] and the non-HF group [n=223 (58.6%)]. Mean LUS score was higher in the HF group (26.8±8.4 vs 15.3±7.1; p<0.001). The mean LUS score in the HF patients with reduced LVEF was 29.2±8.7, and was 24.5±7.6 in the HF patients with preserved LVEF. LUS score area under ROC curve for the diagnosis of HF was 0.71 [0.65-0.76]. The best sensitivity (89% [85.9-92,1]) was observed at the threshold of 5; the best specificity (85% [81.4-88.6]) was observed at the threshold of 30. Correlation between LUS score and E/E' ratio was good (R=0.46, p=0.0001).

Conclusion

Our results suggest that LUS score could be helpful and should be considered in the diagnostic approach of HF in AECOPD patients, at least as a ruling in test.

Review of the British Thoracic Society Winter Meeting 23 November 2022 23-25 November 2022

The British Thoracic Society Winter Meeting at the QEII Centre in London provided the first opportunity for the respiratory community to meet and disseminate research findings face to face since the start of the COVID-19 pandemic. World-leading researchers from the UK and abroad presented their latest findings across a range of respiratory diseases. This article aims to represent the range of the conference and as such is written from the perspective of a basic scientist, a physiotherapist and two doctors. The authors reviewed showcase sessions plus a selection of symposia based on their personal highlights. Content ranged from exciting new developments in basic science to new and unpublished results from clinical trials, delivered by leading scientists from their fields including former deputy chief medical officer Professor Sir Jonathan Van-Tam and former WHO chief scientist Dr Soumya Swaminathan.

Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission

Despite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Additionally, despite the heterogeneity of COPD, diagnostic approaches have not changed in decades and rely almost exclusively on post-bronchodilator spirometry, which is insensitive for early pathological changes, underused, often misinterpreted, and not predictive of symptoms. Furthermore, guidelines recommend only simplistic disease classification strategies, resulting in the same therapeutic approach for patients with widely differing conditions that are almost certainly driven by variable pathophysiological mechanisms. And, compared with other diseases with similar or less morbidity and mortality, the investment of financial and intellectual resources from both the public and private sector to advance understanding of COPD, reduce exposure to known risks, and develop new therapeutics has been woefully inadequate.

Advances in microfluidics devices and its applications in personalized medicines

Microfluidics is an exponentially growing area and is being used for numerous applications from basic science to advanced biotechnology and medicines. Microfluidics provides a platform to the research community for studying and building new strategies for the diagnosis and therapeutics applications. In the last decade, microfluidic have enriched the field of diagnostics by providing new solutions which was not possible with conventional detection and treatment methods. Microfluidics has the ability to precisely control and perform high-throughput functions. It has been proven as an efficient and rapid method for biological sample preparation, analysis and controlled drug delivery system. Microfluidics plays significant role in personalized medicine. These personalized medicines are used for medical decisions, practices and other interventions as well as for individual patients based on their predicted response or risk of disease. This chapter highlights microfluidics in developing personalized medical applications for its applications in diseases such as cancer, cardiovascular disease, diabetes, pulmonary disease and several others.

Blood eosinophils in COPD: friend or foe?

INTRODUCTION

The pathogenesis of chronic obstructive pulmonary disease (COPD) is highly complex and the underlying cellular and molecular mechanisms remain poorly understood.

AREAS COVERED

COPD has been traditionally associated with neutrophilic inflammation of the bronchi, but in the last decade, studies have demonstrated that eosinophils may also migrate into the lower airways of patients with COPD and their increased numbers can be noticed during exacerbations as well as stable disease. In this review, we present clinical characteristics of eosinophilic COPD, as well as the role of eosinophils as a biomarker-guided therapy in COPD. A systematic research using the database of Pubmed up to February 2021 was performed. The terms we searched were eosinophilic inflammation, COPD, COPD phenotypes, COPD exacerbations, corticosteroids in COPD, and monoclonal antibodies in COPD.

EXPERT OPINION

Blood eosinophil levels show strong potential as a prognostic and theragnostic biomarker in the clinical management of COPD being at the moment the most reliable biomarker. The lack of a certain cutoff value of blood eosinophils as guidance for treatment with ICS and biologic therapies and the uncertainty regarding the stability of eosinophilia and eosinophilic phenotype through the course of COPD remain as unmet dilemmas and problems.

Renaming COPD exacerbations: the UK respiratory nursing perspective

BACKGROUND

Patients with COPD experience acute worsenings, termed 'exacerbations'. While other terms to describe these events have been proposed there is no consensus on terminology which has led to multiple terms being used across the UK. Respiratory nurses are part of a multi-disciplinary team managing COPD patients, however, the nursing perspective on the term 'exacerbation' is unknown.

METHODS

An anonymised survey of 17 questions was sent to respiratory nurses through an email invitation link. The survey link was open for one month. The aim was to understand the nurse perspective on 'exacerbation'. Alternative terms used in the UK were compared versus the term 'exacerbation'.

RESULTS

Responses were received from 113 nurses. The majority (88%) were female. There was no consensus on preference or meaning for the term 'exacerbation' between nurses. Less than 5% of nurses thought that patients with COPD would understand the term 'exacerbation'. In ranked order, the nurses preferred the following terms: 'flare-up', 'lung attack', 'crisis', 'exacerbation' and 'chest infection'. The term 'crisis', although new, was considered to be the term that most resonated with clinical practice.

CONCLUSION

Respiratory nurses in the UK report that the term 'exacerbation' is not fit for purpose for patients, and alternatives should be sought.

Personalising exacerbation prediction strategies in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity worldwide. One of the most important features of this disease is exacerbations where a patient’s respiratory symptoms episodically worsen. Exacerbations accounted for over 140000 hospital admissions in 2012 in the United Kingdom with considerably more exacerbations being treated in primary care. Despite significant research in this area in recent years, treatment of acute exacerbations in the community remains limited to oral glucocorticoids, antibiotics and bronchodilators. One of the issues with unpicking the complexity of exacerbations is trying to find out the exact underlying cause and mechanism that leads to symptoms and lung destruction. Currently symptoms are initially guided by symptoms alone though multiple causes of exacerbations have common presentations. This includes viral and bacterial infections and episodes relating to environmental triggers such as pollen and pollution. There is also evidence that cardiovascular factors can contribute to symptoms of breathlessness that can mimic COPD exacerbations. In this editorial we discuss recent advances in the use of precision medicine to more accurately treat exacerbations of COPD. This includes identification of phenotypes that could help rationalise treatment and more importantly identify novel drug targets. We also consider the future role of precision medicine in preventing exacerbations and identifying COPD patients that are at increased risk of developing them.

Heart Failure is Highly Prevalent and Difficult to Diagnose in Severe Exacerbations of COPD Presenting to the Emergency Department

BACKGROUND

Some 20% of patients with stable Chronic Obstructive Pulmonary Disease (COPD) might have heart failure (HF). HF contribution to acute exacerbations of COPD (AECOPD) presenting to the emergency department (ED) is not well established.

AIMS

To assess (1) the HF incidence in patients presenting to the ED with AECOPD; (2) the concordance between ED and respiratory ward (RW) diagnosis; (3) the factors associated with risk of death after hospital discharge.

METHODS

Retrospective chart review of 119 COPD patients presenting to ED for acute exacerbation of respiratory symptoms and then admitted to RW where a final diagnosis of AECOPD, AECOPD and HF and AECOPD and OD (other diagnosis), was obtained. ED and RW diagnosis were then compared. Factors affecting survival at follow-up were investigated.

RESULTS

At RW, 40.3% of cases were diagnosed of AECOPD, 40.3% of AECOPD and HF and 19.4% of AECOPD and OD, with ED diagnosis coinciding with RW's in 67%, 23%, and 57% of cases respectively. At RW, 60% of patients in GOLD1 had HF, of which 43% were diagnosed at ED, while 40% in GOLD4 had HF that was never diagnosed at ED. Lack of inclusion in a COPD care program, HF, and early readmission for AECOPD were associated with mortality.

CONCLUSIONS

HF is highly prevalent and difficult to diagnose in patients in all GOLD stages presenting to the ED with severe AECOPD, and along with lack of inclusion in a COPD care program, confers a high risk for mortality.

Urgent need of a management plan for survivors of COVID-19

Acute exacerbations of COPD (AECOPD) or “COPD crises” [1], are crucial events in the natural course of COPD. Although they can occur at any severity stage, their impact increases as patients develop more severe airflow limitation.