Prediction and prevention of exacerbations and mortality in patients with COPD

Relationship between Antithrombin III Activity and Mortality in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

We aimed to explore the role of antithrombin III (AT-III) activity in diagnosing patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and chronic bronchitis, and its relationship with all-cause mortality of AECOPD patients. We performed univariate and multivariate Cox regression analyses of the factors determining all-cause mortality. We recruited 279 patients with AECOPD and 91 with chronic bronchitis. On admission, patients with AECOPD had lower AT-III activity (80.7 vs. 86.35%, p = 0.002) and higher neutrophil percentages (70.12 vs. 66.40%, p = 0.02) than those with chronic bronchitis. The patients who died were older (78 vs. 73 years, p < 0.001); had higher CRP (39.05 vs. 5.65 mg/L, p < 0.001), D-dimer (1.72 vs. 0.46 mg/L, p < 0.001), FIB (3.56 vs. 3.05 g/L, p = 0.01) levels; and exhibited lower AT-III activity (71.29 vs. 82.94%, p < 0.001) than the survivors. The AT-III area under the receiver operating characteristic curve for predicting COPD all-cause mortality was 0.75 (p < 0.001), optimal cutoff point 79.75%, sensitivity 86.8%, and specificity 57.1%. Multivariate Cox regression analyses showed that increased levels of CRP (HR = 1.005, p = 0.02), D-dimer (HR = 1.17, p = 0.01), WBC count (HR = 1.11, p = 0.002), and reduced AT-III activity (HR = 0.97, p = 0.02) were independent prognostic factors for all-cause mortality. Patients with AT-III ≤ 79.75% were 4.52 times (p = 0.001) more likely to die than those with AT-III > 79.75%. AT-III activity was lower in patients with AECOPD than in those with chronic bronchitis and is potentially useful as an independent predictor of all-cause mortality in patients with AECOPD: reduced AT-III activity and increased CRP and D-dimer levels indicate a higher risk of all-cause mortality.

Effectiveness of Proton-Pump Inhibitors in Chronic Obstructive Pulmonary Disease: A Meta-Analysis of Randomized Controlled Trials

Background

Although several randomized controlled trials (RCTs) have been published in recent years, the role of proton-pump inhibitors (PPI) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. This preliminary meta-analysis was conducted to evaluate the clinical efficacy of PPI in patients with COPD.

Methods

RCTs related to PPI in the treatment of patients with a definite diagnosis of COPD were enrolled in this meta-analysis. PubMed, Embase, Cochrane Library, CNKI, Wanfang and VIP databases were retrieved to identify eligible studies from database establishment to September 22, 2021. Two researchers independently screened the articles, extracted the data and evaluated the risk of bias in the included studies independently. The study complied with PRISMA 2020 guideline for this study. The meta-analysis was performed using RevMan 5.3. Heterogeneity among studies was tested using the I² test. The results were presented as risk ratios (RRs) with 95% confidence intervals (CIs).

Results

A total of 15 RCTs, including 1,684 patients, were enrolled. The meta-analysis revealed that PPI plus conventional treatment was superior to conventional treatment with respect to the case fatality rate (RR = 0.30; 95% CI, 0.18–0.52; P < 0.001), the incidence of gastrointestinal bleeding (RR = 0.23; 95% CI, 0.14–0.38; P < 0.001), the incidence of other adverse reactions (RR = 0.33; 95% CI, 0.28–0.39; P < 0.001) and the number of acute exacerbations [mean difference (MD) = −1.17; 95% CI, 1.75 to −0.60: P < 0.001] in patients with COPD. No significant differences were found in clinical efficacy (RR = 1.08; 95% CI, 0.95–1.22; P = 0.25), FEV1/FVC (MD = 3.94; 95% CI, −8.70 to 16.58; P = 0.54) and nosocomial infection rate (RR = 1.31; 95% CI, 0.57–3.00; P = 0.52) between the two groups.

Discussion

This comprehensive meta-analysis suggested that PPI treatment for COPD may reduce the case fatality rate, incidence of gastrointestinal bleeding and other adverse reactions and number of acute exacerbations. However, the present meta-analysis also has some limitations of the evidence, such as the high risk of bias of the included studies, and predominance of included studies from China, which may result in publication bias. Therefore, further large-scale RCTs are needed to confirm our findings.

Systematic Trial Registration

Identifier: CRD42022301304.

Lung Deposition and Inspiratory Flow Rate in Patients with Chronic Obstructive Pulmonary Disease Using Different Inhalation Devices: A Systematic Literature Review and Expert Opinion

BACKGROUND

Our aim was to describe: 1) lung deposition and inspiratory flow rate; 2) main characteristics of inhaler devices in chronic obstructive pulmonary disease (COPD).

METHODS

A systematic literature review (SLR) was conducted to analyze the features and results of inhaler devices in COPD patients. These devices included pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), and a soft mist inhaler (SMI). Inclusion and exclusion criteria were established, as well as search strategies (Medline, Embase, and the Cochrane Library up to April 2019). In vitro and in vivo studies were included. Two reviewers selected articles, collected and analyzed data independently. Narrative searches complemented the SLR. We discussed the results of the reviews in a nominal group meeting and agreed on various general principles and recommendations.

RESULTS

The SLR included 71 articles, some were of low-moderate quality, and there was great variability regarding populations and outcomes. Lung deposition rates varied across devices: 8%-53% for pMDIs, 7%-69% for DPIs, and 39%-67% for the SMI. The aerosol exit velocity was high with pMDIs (more than 3 m/s), while it is much slower (0.84-0.72 m/s) with the SMI. In general, pMDIs produce large-sized particles (1.22-8 μm), DPIs produce medium-sized particles (1.8-4.8 µm), and 60% of the particles reach an aerodynamic diameter <5 μm with the SMI. All inhalation devices reach central and peripheral lung regions, but the SMI distribution pattern might be better compared with pMDIs. DPIs' intrinsic resistance is higher than that of pMDIs and SMI, which are relatively similar and low. Depending on the DPI, the minimum flow inspiratory rate required was 30 L/min. pMDIs and SMI did not require a high inspiratory flow rate.

CONCLUSION

Lung deposition and inspiratory flow rate are key factors when selecting an inhalation device in COPD patients.

Susceptibility to frequent exacerbation in COPD patients: Impact of the exacerbations history, vaccinations and comorbidities?

INTRODUCTION

Exacerbations are key events in the natural history of COPD, but our understanding of their longitudinal determinants remains unclear. We used data from a large observational study to test the hypothesis that vaccination status and comorbidities could be associated with the occurrence of exacerbations profile.

METHODS

Diagnosed COPD patients have been included by their pulmonologists, with up to 3 years of follow-up. Data were analyzed using the KmL method designed to cluster longitudinal data and receiver operating characteristic curve analysis to determine the best threshold to allocate patients to identified clusters.

RESULTS

932 COPD patients were included since January 2014, 446 patients (65.68% males, 35.59% current smokers) were followed over a period of 3 years with complete data. 239(28.15%) patients reported two or more exacerbations in the year before enrolment (frequent exacerbations). Among them 142(16.68%) also had frequent exacerbations in the first year of the study, and 69(8.10%) who remained frequent exacerbators in the second year. Based on our hypothesis, we were able to determine four phenotypes: A (infrequent), B (frequent in underweight patients), C (transient), and D (frequent in obese patients). Frequent exacerbators had more airflow limitation and symptoms. Irrespective of cut-offs set to define the optimal number of clusters, a history of exacerbations OR: 3.72[2.53-5.49], presence of anxiety OR: 2.03[1.24-3.31] and absence of the annual influenza vaccination OR: 1.97[1.20-3.24] remained associated with the frequent exacerbator phenotypes.

CONCLUSIONS

The most important determinants of frequent exacerbations are a history of exacerbations, anxiety and unvaccinated against influenza.

Comparative safety and effectiveness of inhaled bronchodilators and corticosteroids for treating asthma-COPD overlap: a systematic review and meta-analysis

OBJECTIVE

To determine the safety and effectiveness of current pharmacotherapies consisting of long-acting beta₂-agonist (LABA) and/or inhaled corticosteroids (ICS) in patients with asthma-COPD overlap.

DATA SOURCES

A systematic search was conducted using the PubMed, EMBASE, and Web of Science databases up to June 2018.

STUDY SELECTIONS

Only studies comparing the safety and effectiveness of LABA and/or ICS in patients with asthma-COPD overlap were included. A meta-analysis was performed to calculate risk ratio (RR) and 95% confidence interval (CI) using Inverse Variance Random-effects model.

RESULTS

From a total of 3382 articles retrieved, three randomized controlled trials (RCTs), six cohort studies (CS), one nested case control study fulfilled the inclusion criteria for three independent meta-analyses representing 181,603 participants. Three CS results show LABA was associated with decreased risk of myocardial infarction (combined RR: 0.80, 95% CI 0.74-0.87) versus non-LABA use; ICS/LABA was associated with a lower risk of death or hospitalization (combined RR: 0.82, 95% CI 0.75-0.90) compared to no use. Results from RCTs, no clear difference in lung function decline in FEV₁ was found (combined mean difference: 0.08, 95% CI 0.15-0.32) in patients receiving ICS and/or LABA compared to placebo. However, due to lack of data, exacerbations, fractures and nontuberculous mycobacterial pulmonary disease outcomes were not meta-analyzed.

CONCLUSIONS

Among patients with asthma-COPD overlap, LABA is associated with decreased risk of myocardial infarction; and the combination therapy of ICS/LABA appears to reduce the risk of death or hospitalization. More studies of quality data and larger number of patients are needed.

REGISTRATION

PROSPERO (CRD42018090863).

Slowing Progression of Airway Diseases by Smoking Cessation and Reducing Infections

The prevalence of respiratory diseases, including asthma and chronic obstructive pulmonary disease, has increased in recent decades, placing a significant burden on healthcare systems and economies around the world. As these diseases are largely incurable, the aim of treatment is to control symptoms and improve quality of life. Aside from stopping smoking and reducing biomass fuel exposure, arguably the most effective strategy in the long-term management of chronic respiratory diseases is the prevention or control of respiratory infections via vaccines and antimicrobial agents. By preventing these infections or reducing exposure to some of the major risk factors, we can reduce further lung damage in these patients, thereby slowing disease progression. This review looks at maintaining long-term respiratory health in patients with asthma and chronic obstructive pulmonary disease, primarily through smoking cessation, reducing exposure to allergens and air pollutants, and infection control.

Obstructive sleep apnea, COPD, the overlap syndrome, and mortality: results from the 2005-2008 National Health and Nutrition Examination Survey

Objective

The aim of this study was to investigate the role of obstructive sleep apnea (OSA) on all-cause mortality in patients with COPD.

Methods

Data for this cross-sectional study were obtained from the National Health and Nutrition Examination Survey (NHANES) data (year 2005–2008). Eligible subjects were ≥20 years who had no COPD or OSA (n=9,237), had only OSA (n=366), had only COPD (n=695), and had OSA/COPD overlap syndrome (n=90). Univariate and multivariate analyses were used to evaluate factors associated with overall mortality.

Results

Multivariate analysis found that the COPD and OSA/COPD overlap syndrome groups had significantly higher chance of all-cause mortality than the group of subjects who did not have OSA or COPD (adjusted hazard ratio [HR] =1.5 for the COPD group and 2.4 for the overlap syndrome group) (P≤0.007). Although not significant, having OSA/COPD overlap syndrome was associated with higher likelihood of death than COPD alone (HR =1.5; P=0.160). Other factors associated with higher overall mortality were aging, poorer family status, current smoker, serum vitamin D deficiency, cardiovascular disease, history of cancer, diabetes, and impaired renal function.

Conclusion

The present study found that COPD and OSA/COPD overlap syndrome were associated with higher all-cause mortality compared with patients without either disease and that OSA did not significantly increase mortality in patients with COPD.

Seasonal influenza vaccination in patients with COPD: a systematic literature review

BACKGROUND

Influenza is a frequent cause of exacerbations of chronic obstructive pulmonary disease (COPD). Exacerbations are associated with worsening of the airflow obstruction, hospitalisation, reduced quality of life, disease progression, death, and ultimately, substantial healthcare-related costs. Despite longstanding recommendations to vaccinate vulnerable high-risk groups against seasonal influenza, including patients with COPD, vaccination rates remain sub-optimal in this population.

METHODS

We conducted a systematic review to summarise current evidence from randomised controlled trials (RCTs) and observational studies on the immunogenicity, safety, efficacy, and effectiveness of seasonal influenza vaccination in patients with COPD. The selection of relevant articles was based on a three-step selection procedure according to predefined inclusion and exclusion criteria. The search yielded 650 unique hits of which 48 eligible articles were screened in full-text.

RESULTS

Seventeen articles describing 13 different studies were found to be pertinent to this review. Results of four RCTs and one observational study demonstrate that seasonal influenza vaccination is immunogenic in patients with COPD. Two studies assessed the occurrence of COPD exacerbations 14 days after influenza vaccination and found no evidence of an increased risk of exacerbation. Three RCTs showed no significant difference in the occurrence of systemic effects between groups receiving influenza vaccine or placebo. Six out of seven studies on vaccine efficacy or effectiveness indicated long-term benefits of seasonal influenza vaccination, such as reduced number of exacerbations, reduced hospitalisations and outpatient visits, and decreased all-cause and respiratory mortality.

CONCLUSIONS

Additional large and well-designed observational studies would contribute to understanding the impact of disease severity and patient characteristics on the response to influenza vaccination. Overall, the evidence supports a positive benefit-risk ratio for seasonal influenza vaccination in patients with COPD, and supports current vaccination recommendations in this population.