Underreporting exacerbation of chronic obstructive pulmonary disease in a longitudinal cohort

[Use of long-acting triple therapy for chronic obstructive pulmonary disease (COPD) in practice: The ELETHON physicians' survey]

Gaps in optimal COPD management have been identified in clinical practice, with discrepancies between guideline recommendations and routine care. The reasons for such discrepancies are incompletely understood. The ELETHON survey aimed to identify physicians' attitudes towards general concepts of COPD management and, in particular, initiation of inhaled triple therapies.ELETHON was a nationwide cross-sectional survey with general practitioners (GP) and pulmonary specialists (PS) working in the ambulatory outpatient setting in Germany, using a structured 17-item questionnaire (single or multiple choice questions) addressing the topics of secondary prevention, exacerbation detection, strategies for therapy escalation, choice of inhaled triple therapies and evaluation of treatment benefits.Questionnaires filled by n=2028 GPs and n=371 PS were analyzed. In both groups, secondary prevention was deemed important in COPD care (GP/PS 76.4%/90.6%), with inhalation technique, vaccination status, and appropriate inhaled pharmacotherapy as key components. Activity/rehabilitation was rarely mentioned by GPs (48.3% vs. 84.5%). Exacerbations and symptomatic worsening were the main triggers for therapy escalation, but were not recorded in a structured way. "Hospitalization" and "≥2 ambulatory exacerbations" were mentioned most frequently as thresholds. Neither GPs nor PS measured eosinophils in the majority of patients. Fixed triple combinations were preferred, with availability of different treatment steps in the same device as important decision aid. Treatment success was evaluated by exacerbations, quality of life, symptoms, lung function and rescue medication use, while COPD Assessment Test (CAT) score was rarely used by GPs and PS.The ELETHON survey identified gaps in COPD management in Germany. While secondary prevention is deemed important, escalation of inhaled therapy is undertaken rather late, the reported importance of vaccinations does not match current quota in German COPD patients, and non-pharmacological measures are often unused. Exacerbation and symptom documentation is rather subjective, validated questionnaires and blood eosinophils are of minor relevance. These results provide evidence of barriers and hidden potentials towards optimization of routine ambulatory care for COPD patients in Germany.

COPD Exacerbations, Air Pollutant Fluctuations, and Individual-Level Factors in the Pandemic Era

Purpose

Pandemic-era associations between air pollutant exposures and exacerbations of chronic obstructive pulmonary disease (COPD) are under-explored. Given the considerable observed pandemic-era pollutant fluctuations, these associations were investigated along with possible individual-level risk factors.

Patients and Methods

Participants with spirometry-confirmed COPD from Canadian Cohort Obstructive Lung Disease (CanCOLD) were included, with data collected before ("pre-pandemic") and during ("pandemic") the COVID-19 pandemic. Nitrogen dioxide (NO2), fine particulate matter (PM2.5), ground-level ozone (O3), total oxidant (Ox) and weather data were obtained from national databases. Associations between each air pollutant and "symptom-based" exacerbations (increased dyspnea or sputum volume/purulence ≥48hrs) and "event-based" exacerbations ("symptom-based" plus requiring antibiotics, corticosteroids, or unscheduled healthcare use) were estimated in separate models. Generalized estimating equations (GEE) models were reported as rate ratios (RRs) per interquartile range (IQR) increment in pollutant concentration with 95% confidence intervals (95% CIs).

Results

NO2, PM2.5, and Ox (NO2+O3) concentrations (but not O3) fell significantly during the pandemic. In the 673 participants with COPD included, both symptom-based and event-based exacerbation rates were likewise significantly higher during the pre-pandemic period. During the pre-pandemic period, Ox was positively associated with symptom-based exacerbations (RR: 1.21 [1.08,1.36]). During the pandemic period, Ox was positively associated with symptom-based (1.46 [1.13,1.89]) and event-based (1.43 [1.00,2.05]) exacerbations. Fewer self-reported pandemic protective behaviors, and higher viral infectious symptoms, were also associated with exacerbations. In stepwise multivariable risk-factor analyses, female gender (1.23 [1.04,1.45] and 1.41 [1.13,1.76]) and co-morbid asthma (1.65 [1.34,2.03] and 1.54 [1.19,2.00]) were associated with symptom-based and event-based exacerbations, respectively, blood eosinophils (1.42 [1.10,1.84]) were associated with event-based exacerbations, and each IQR increment in Ox was associated with symptom-based exacerbations (1.31 [1.06,1.61]).

Conclusion

Ox exposure was consistently associated with symptom-based COPD exacerbations, and female gender, co-morbid asthma, and blood eosinophilia were found to be relevant risk factors.

A Delphi Consensus Project to Capture Greek Experts' Opinion on the Position of Triple Therapies in COPD: Why, When and to Whom

Background

In recent years, COPD treatment has become more personalized considering specific patient's characteristics.

Aim and Methods

We have performed a DELPHI consensus project to assess the level of consensus among Greek experts on the use of triple therapy in COPD as an initial and follow-up treatment. A three-round Delphi online survey was developed. The questionnaire was developed by a 6-member steering committee, included 54 statements, and divided into 3 domains: (A) triple therapy as initial treatment (divided into subdomains examining the impact of exacerbations based on lung function, bronchodilation reversibility and/or blood eosinophil count, smoking, symptoms, and comorbidities), (B) escalation to triple therapy from dual bronchodilation and (C) de-escalation from triple therapy to dual bronchodilation. The survey was funded by AstraZeneca and was hosted and analysed by an independent external company.

Results

Consensus was reached in 84.8%, 63% and 80% of statements for domains A, B and C, respectively. Experts agreed that initial treatment with triple therapy is a reasonable option for specific patients, while escalation from dual bronchodilation to triple therapy could be considered, besides frequent exacerbators, also in patients with a history of one moderate exacerbation, mainly in the presence of marked bronchodilator reversibility or high blood eosinophil count. Finally, there was a consensus that de-escalation from triple therapy to dual bronchodilation was inappropriate in patients who had experienced one moderate exacerbation in the previous year.

Conclusion

Although consensus was generated in several statements, panelists failed to reach consensus in many aspects of the use of triple therapy, identifying areas for further research.

Early Identification of Exacerbations in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) have a substantial effect on overall disease management, health system costs, and patient outcomes. However, exacerbations are often underdiagnosed or recognized with great delay due to several factors such as patients' inability to differentiate between acute episodes and symptom fluctuations, delays in seeking medical assistance, and disparities in dyspnea perception. Self-management intervention plans, telehealth and smartphone-based programs provide educational material, counseling, virtual hospitals and telerehabilitation, and help COPD patients to identify exacerbations early. Moreover, biomarkers such as blood eosinophil count, fibrinogen, CRP, Serum amyloid A(SAA),together with imaging parameters such as the pulmonary artery-to-aorta diameter ratio, have emerged as potential predictors of exacerbations, yet their clinical utility is limited by variability and lack of specificity. In this review, we provide information regarding the importance of the early identification of exacerbation events in COPD patients and the available methods which can be used for this purpose.

A mixed-methods pilot study of domiciliary nasal high-flow therapy for breathlessness in people with chronic obstructive pulmonary disease who do not qualify for domiciliary long-term oxygen therapy

BACKGROUND

High-flow nasal oxygen (HFNO) therapy delivers humidified, heated air with flow rates of up to 60 L/min with oxygen entrained. HFNO has advantages over conventional oxygen therapy, including precise and reliable fraction of inspired oxygen delivery, therefore is recommended as first-line treatment for people with acute hypoxaemic respiratory failure.

OBJECTIVES

This pilot study aimed to determine the feasibility and acceptability of domiciliary nasal high flow (NHF) without entrained oxygen for people with chronic obstructive pulmonary disease (COPD) and severe breathlessness.

DESIGN

Single-arm, mixed-methods, pilot study of an 8-day, air-only NHF intervention in adults with COPD and severe breathlessness not requiring domiciliary oxygen therapy.

METHODS

Participants were educated and advised to use NHF for ⩾7 h per night for 7 nights with day use as desired. Patient-reported outcome measures were assessed on Days 3, 5 and 8.

PRIMARY OUTCOME

feasibility.

SECONDARY OUTCOMES

breathlessness (dyspnoea), fatigue, quality of life, physical function, sleep, tolerability and safety. Acceptability was also assessed through semi-structured interviews.

RESULTS

Fifteen participants were enrolled (mean age 73.6; 40% women; mean FEV1 41% predicted, mean DLCO 43.0% predicted; mean modified Medical Research Council score 3.7). Thirteen (87%) completed the trial, with 8 (54%) keeping the device at the end of the trial and 3 (20%) continuing use long-term. Adherence varied, with average daily usage higher amongst participants who kept the device compared to those who returned it (6.8 h ± 2.3 h vs 3.4 h ± 3.7 h). No changes in worst breathlessness (mean = 0.7, SD = 1.2, p = 0.109), dyspnoea mastery (mean = 0.3, SD = 0.6, p = 0.176) or fatigue (mean = 0.0, SD = 2.4, p = 1.00) were observed at Day 8 compared to baseline. No significant adverse events were reported. Qualitative interviews demonstrated subjective improvements in breathlessness, dry mouth and sputum production for some participants, whilst others found NHF uncomfortable. Fear of NHF dependence and concerns regarding long-term running costs were reported.

CONCLUSION

Domiciliary NHF was a feasible intervention, albeit with varied adoption and acceptability. These trial implementation outcomes may have affected preliminary effectiveness outcomes. Further research is required to determine what role domiciliary NHF may have for people with COPD and severe breathlessness.

TRIAL REGISTRATION

ACTRN12621000044820.

Continuous characterisation of exacerbation pathophysiology using wearable technologies in free-living outpatients with COPD: a prospective observational cohort study

BACKGROUND

The most recent exacerbation of COPD (ECOPD) classification criteria relies in part on changes in respiratory rate (RR), heart rate (HR) and oxygen saturation (SpO2). Despite this paradigm shift, a thorough understanding of exacerbation patterns is still lacking, as is the identification of physiological exacerbation biomarkers.

METHODS

Using a convenience sampling approach, this prospective observational cohort study was conducted between February 2023 and January 2024. Continuous measurements of daytime/overnight respiratory (primary outcome), cardiovascular, autonomic, activity and sleep-related parameters were collected by a wearable biometric wristband and ring over 21 consecutive days in free-living outpatients experiencing and receiving treatment (≤3 days) for a current exacerbation from the home environment. The EXACT-PRO questionnaire served as the validated reference for daily symptom burden and to identify 'recovered' versus 'persistent worsening' participants. Unadjusted and adjusted (for age, sex, FEV1) linear mixed-effects models were fitted to estimate associations between each physiological parameter with daily EXACT-PRO score (points, pts), in all, 'recovered', and 'persistent worsening' participants. Results are presented as point estimates with 95% CIs.

FINDINGS

In 21 participants with COPD (43% female, mean age 66.8, BMI 27.7 kg/m2, FEV1 36.3% predicted; 85.7% with GOLD 3-4 disease), significant associations in unadjusted models with daily EXACT-PRO score included RR variability (-1.45 [-2.84, -0.073] pts/breath/min) but not RR, daily step count (-0.56 [-0.82, -0.31] pts/1000 steps), and sleep efficiency (-0.12 [-0.20, -0.037] pts/%asleep). In 'recovered' participants (n = 10), significant associations included nighttime HR, movement intensity and nightly SpO2. In 'persistent worsening' participants (n = 11), significant associations included HR variability, nightly RR variability, nightly SpO2, sleep efficiency, and skin temperature. Similar results were found in adjusted models.

INTERPRETATION

This study provides a prospective continuous characterisation of exacerbations of COPD using remotely collected, ambulatory/free-living data. The physiological patterns presented may contribute to the understanding of exacerbations and may enhance the development of effective remote monitoring solutions.

FUNDING

University hospital (MUHC-CAS) grant.

Machine learning approach to flare-up detection and clustering in chronic obstructive pulmonary disease (COPD) patients

Purpose

Chronic obstructive pulmonary disease (COPD) is a prevalent and preventable condition that typically worsens over time. Acute exacerbations of COPD significantly impact disease progression, underscoring the importance of prevention efforts. This observational study aimed to achieve two main objectives: (1) identify patients at risk of exacerbations using an ensemble of clustering algorithms, and (2) classify patients into distinct clusters based on disease severity.

Methods

Data from portable medical devices were analyzed post-hoc using hyperparameter optimization with Self-Organizing Maps (SOM), Density-Based Spatial Clustering of Applications with Noise (DBSCAN), Isolation Forest, and Support Vector Machine (SVM) algorithms, to detect flare-ups. Principal Component Analysis (PCA) followed by KMeans clustering was applied to categorize patients by severity.

Results

25 patients were included within the study population, data from 17 patients had the required reliability. Five patients were identified in the highest deterioration group, with one clinically confirmed exacerbation accurately detected by our ensemble algorithm. Then, PCA and KMeans clustering grouped patients into three clusters based on severity: Cluster 0 started with the least severe characteristics but experienced decline, Cluster 1 consistently showed the most severe characteristics, and Cluster 2 showed slight improvement.

Conclusion

Our approach effectively identified patients at risk of exacerbations and classified them by disease severity. Although promising, the approach would need to be verified on a larger sample with a larger number of recorded clinically verified exacerbations.

Understanding the Gaps in the Reporting of COPD Exacerbations by Patients: A Review

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with loss of lung function, poor quality of life, loss of exercise capacity, risk of serious cardiovascular events, hospitalization, and death. However, patients underreport exacerbations, and evidence suggests that unreported exacerbations have similar negative health implications for patients as those that are reported. Whilst there is guidance for physicians to identify patients who are at risk of exacerbations, they do not help patients recognise and report them. Newly developed tools, such as the COPD Exacerbation Recognition Tool (CERT) have been designed to achieve this objective. This review focuses on the underreporting of COPD exacerbations by patients, the factors associated with this, the consequences of underreporting, and potential solutions.

Self-report underestimates the frequency of the acute respiratory exacerbations of COPD but is associated with BAL neutrophilia and lymphocytosis: an observational study

RATIONALE

Research studies typically quantify acute respiratory exacerbation episodes (AECOPD) among people with chronic obstructive pulmonary disease (COPD) based on self-report elicited by survey questionnaire. However, AECOPD quantification by self-report could be inaccurate, potentially rendering it an imprecise tool for identification of those with exacerbation tendency.

OBJECTIVE

Determine the agreement between self-reported and health records-documented quantification of AECOPD and their association with airway inflammation.

METHODS

We administered a questionnaire to elicit the incidence and severity of respiratory exacerbations in the three years preceding the survey among current or former heavy smokers with or without diagnosis of COPD. We then examined electronic health records (EHR) of those with COPD and those without (tobacco-exposed persons with preserved spirometry or TEPS) to determine whether the documentation of the three-year incidence of moderate to very severe respiratory exacerbations was consistent with self-report using Kappa Interrater statistic. A subgroup of participants also underwent bronchoalveolar lavage (BAL) to quantify their airway inflammatory cells. We further used multivariable regressions analysis to estimate the association between respiratory exacerbations and BAL inflammatory cell composition with adjustment for covariates including age, sex, height, weight, smoking status (current versus former) and burden (pack-years).

RESULTS

Overall, a total of 511 participants completed the questionnaire, from whom 487 had EHR available for review. Among the 222 participants with COPD (70 ± 7 years-old; 96% male; 70 ± 38 pack-years smoking; 42% current smoking), 57 (26%) reported having any moderate to very severe AECOPD (m/s-AECOPD) while 66 (30%) had EHR documentation of m/s-AECOPD. However, 42% of those with EHR-identified m/s-AECOPD had none by self-report, and 33% of those who reported m/s-AECOPD had none by EHR, suggesting only moderate agreement (Cohen's Kappa = 0.47 ± 0.07; P < 0.001). Nevertheless, self-reported and EHR-identified m/s-AECOPD events were both associated with higher BAL neutrophils (ß ± SEM: 3.0 ± 1.1 and 1.3 ± 0.5 per 10% neutrophil increase; P ≤ 0.018) and lymphocytes (0.9 ± 0.4 and 0.7 ± 0.3 per 10% lymphocyte increase; P ≤ 0.041). Exacerbation by either measure combined was associated with a larger estimated effect (3.7 ± 1.2 and 1.0 ± 0.5 per 10% increase in neutrophils and lymphocytes, respectively) but was not statistically significantly different compared to the self-report only approach. Among the 184 TEPS participants, there were fewer moderate to very severe respiratory exacerbations by self-report (n = 15 or 8%) or EHR-documentation (n = 9 or 5%), but a similar level of agreement as those with COPD was observed (Cohen's Kappa = 0.38 ± 0.07; P < 0.001).

DISCUSSION

While there is modest agreement between self-reported and EHR-identified m/s-AECOPD, events are missed by relying on either method alone. However, m/s-AECOPD quantified by self-report or health records is associated with BAL neutrophilia and lymphocytosis.

New methods to detect bacterial or viral infections in patients with chronic obstructive pulmonary disease

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) are frequently colonized and infected by respiratory pathogens. Identifying these infectious etiologies is critical for understanding the microbial dynamics of COPD and for the appropriate use of antimicrobials during exacerbations.

AREAS COVERED

Traditional methods, such as bacterial and viral cultures, have been standard in diagnosing respiratory infections. However, these methods have significant limitations, including lack of sensitivity and prolonged turnaround time. Modern molecular approaches offer rapid, sensitive, and specific detection, though they also come with their own challenges. This review explores and evaluates the clinical utility of the latest advancements in detecting bacterial and viral respiratory infections in COPD, encompassing molecular techniques, biomarkers, and emerging technologies.

EXPERT OPINION

In the evolving landscape of COPD management, integrating molecular diagnostics and emerging technologies holds great promise. The enhanced sensitivity of molecular techniques has significantly advanced our understanding of the role of microbes in COPD. However, many of these technologies have primarily been developed for pneumonia diagnosis or research applications, and their clinical utility in managing COPD requires further evaluation.

Breaking down barriers to COPD management in primary care: applying the updated 2023 Canadian Thoracic Society guideline for pharmacotherapy

Chronic obstructive pulmonary disease (COPD) is a highly prevalent yet under-recognized and sub-optimally managed disease that is associated with substantial morbidity and mortality. Primary care providers (PCPs) are at the frontlines of COPD management, and they play a critical role across the full spectrum of the COPD patient journey from initial recognition and diagnosis to treatment optimization and referral to specialty care. The Canadian Thoracic Society (CTS) recently updated their guideline on pharmacotherapy in patients with stable COPD, and there are several key changes that have a direct impact on COPD management in the primary care setting. Notably, it is the first guideline to formally make recommendations on mortality reduction in COPD, which elevates this disease to the same league as other chronic diseases that are commonly managed in primary care and where optimized pharmacotherapy can reduce all-cause mortality. It also recommends earlier and more aggressive initial maintenance inhaler therapy across all severities of COPD, and preferentially favors the use of single inhaler therapies over multiple inhaler regimens. This review summarizes some of the key guideline changes and offers practical tips on how to implement the new recommendations in primary care. It also addresses other barriers to optimal COPD management in the primary care setting that are not addressed by the guideline update and suggests strategies on how they could be overcome.

Mortality prevention as the centre of COPD management

COPD is a major healthcare problem and cause of mortality worldwide. COPD patients at increased mortality risk are those who are more symptomatic, have lower lung function and lower diffusing capacity of the lung for carbon monoxide, decreased exercise capacity, belong to the emphysematous phenotype and those who have concomitant bronchiectasis. Mortality risk seems to be greater in patients who experience COPD exacerbations and in those who suffer from concomitant cardiovascular and/or metabolic diseases. To predict the risk of death in COPD patients, several composite scores have been created using different parameters. In previous years, large studies (also called mega-trials) have evaluated the efficacy of different therapies on COPD mortality, but until recently only nonpharmaceutical interventions have proven to be effective. However, recent studies on fixed combinations of triple therapy (long-acting β-agonists, long-acting muscarinic antagonists and inhaled corticosteroids) have provided encouraging results, showing for the first time a reduction in mortality compared to dual therapies. The aim of the present review is to summarise available data regarding mortality risk in COPD patients and to describe pharmacological therapies that have shown effectiveness in reducing mortality.

Cognitive and Emotional Responses to Chronic Obstructive Pulmonary Disease Exacerbations and Patterns of Care Seeking

Rationale: Cognitive and emotional responses associated with care seeking for chronic obstructive pulmonary disease (COPD) exacerbations are not well understood.Objectives: We sought to define care-seeking profiles based on whether and when U.S. veterans seek care for COPD exacerbations and compare cognitive and emotional responses with exacerbation symptoms across the profiles.Methods: This study analyzes data from a 1-year prospective observational cohort study of individuals with COPD. Cognitive and emotional responses to worsening symptoms were measured with the Response to Symptoms Questionnaire, adapted for COPD. Seeking care was defined as contacting or visiting a healthcare provider or going to the emergency department. Participants were categorized into four care-seeking profiles based on the greatest delay in care seeking for exacerbations when care was sought: 0-3 days (early), 4-7 days (short delay), >7 days (long delay), or never sought care for any exacerbation. The proportion of exacerbations for which participants reported cognitive and emotional responses was estimated for each care-seeking profile, stratified by the timing of when care was sought.Results: There were 1,052 exacerbations among 350 participants with Response to Symptoms Questionnaire responses. Participants were predominantly male (96%), and the mean age was 69.3 ± 7.2 years. For the 409 (39%) exacerbations for which care was sought, the median delay was 3 days. Those who sought care had significantly more severe COPD (forced expiratory volume in 1 s, modified Medical Research Council dyspnea scale) than those who never sought care. Regardless of the degree of delay until seeking care at one exacerbation, participants consistently reported experiencing serious symptoms if they sought care compared with events for which participants did not seek care (e.g., among early care seekers when care was sought, 36%; when care was not sought, 25%). Similar findings were seen in participants' assessment of the importance of getting care (e.g., among early care seekers when care was sought, 90%; when care was not sought, 52%) and their assessment of anxiety about the symptoms (e.g., among early care seekers when care was sought, 33%; when care was not sought, 17%).Conclusions: Delaying or not seeking care for COPD exacerbations was common. Regardless of care-seeking profile, cognitive and emotional responses to symptoms when care was sought differed from responses when care was not sought. Emotional and cognitive response to COPD exacerbations should be considered when developing individualized strategies to encourage seeking care for exacerbations.Clinical trial registered with www.clinicaltrials.gov (NCT02725294).

Implementation of the Care Bundle for the Management of Chronic Obstructive Pulmonary Disease with/without Heart Failure

Chronic obstructive pulmonary disease (COPD) is often part of a more complex cardiopulmonary disease, especially in older patients. The differential diagnosis of the acute exacerbation of COPD and/or heart failure (HF) in emergency settings is challenging due to their frequent coexistence and symptom overlap. Both conditions have a detrimental impact on each other's prognosis, leading to increased mortality rates. The timely diagnosis and treatment of COPD and coexisting factors like left ventricular overload or HF in inpatient and outpatient care can improve prognosis, quality of life, and long-term outcomes, helping to avoid exacerbations and hospitalization, which increase future exacerbation risk. This work aims to address existing gaps, providing management recommendations for COPD with/without HF, particularly when both conditions coexist. During virtual meetings, a panel of experts (the authors) discussed and reached a consensus on the differential and paired diagnosis of COPD and HF, providing suggestions for risk stratification, accurate diagnosis, and appropriate therapy for inpatients and outpatients. They emphasize that when COPD and HF are concomitant, both conditions should receive adequate treatment and that recommended HF treatments are not contraindicated in COPD and have favorable effects. Accurate diagnosis and therapy is crucial for effective treatment, reducing hospital readmissions and associated costs. The management considerations discussed in this study can potentially be extended to address other cardiopulmonary challenges frequently encountered by COPD patients.

Characteristics of alpha-1 antitrypsin deficiency related lung disease exacerbations using a daily symptom diary and urinary biomarkers

BACKGROUND

Pulmonary exacerbations in alpha-1 antitrypsin deficiency (AATD) related lung disease are a significant contributor to disease burden, as with usual COPD. Separating the early stages of an exacerbation from the day-to-day variation in stable COPD is central to the concerns of both clinicians and patients and has been identified as a research priority by NIHR. Clinical tools that distinguish baseline symptoms from those of an exacerbation could allow early and appropriate treatment of AECOPD to reduce the impact and potentially may slow disease progression thereby improving survival and quality of life. Candidate tools include symptom diaries and biomarkers of infection and acute inflammation. Urinary biomarkers of AECOPD have yet to be explored in AATD related COPD.

METHODS

55 patients with AATD related lung disease with a history of 2 or more AECOPD in the preceding year were prospectively followed for 18 months. Each patient recorded symptom scores daily via an electronic symptom diary (eDiary) based on Bronkotest. Urinary biomarkers for AAT, NE, CRP, TIMP1 and desmosine were measured weekly using a home urinary lateral flow device. During self-reported AECOPD patients were asked to perform urine analysis on the first 7 consecutive days.

RESULTS

Type I Anthonisen exacerbations and episodes occurring in autumn/winter lasted longer than Type II/III exacerbations and spring/summer episodes respectively. Median urinary CRP concentration across all study participants increased during Type I AECOPD. eDiary adherence was 68% over a median of 17.8 months (IQR 15.7 to 18.5).

CONCLUSIONS

Use of an eDiary and urinary biomarkers to detect and characterise AECOPD remotely in AATD related lung disease is feasible over a prolonged period and paves the way for precision detection of exacerbations.

Impact of COPD on mortality: An 8-year observational retrospective healthcare claims database cohort study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality. Here we present a large observational study on the association of COPD and exacerbations with mortality (AvoidEx Mortality).

METHODS

A real-world, observational cohort study with longitudinal analyses of German healthcare claims data in patients ≥40 years of age with a COPD diagnosis from 2011 to 2018 (n = 250,723) was conducted. Patients entered the cohort (index date) upon the first COPD diagnosis. To assess the impact of COPD on all-cause death, a propensity score-matched control group of non-COPD patients was constructed. The number and severity of exacerbations during a 12-month pre-index period were used to form subgroups. For each exacerbation subgroup the exacerbations during 12 months prior to death were analysed.

RESULTS

COPD increases the all-cause mortality risk by almost 60% (HR 1.57 (95% CI 1.55-1.59)) in comparison to matched non-COPD controls, when controlling for other baseline covariates. The cumulative risk of death after 8 years was highest in patients with a history of more than one moderate or severe exacerbation. Among all deceased COPD patients, 17.2% had experienced a severe, and 34.8% a moderate exacerbation, within 3 months preceding death. Despite increasing exacerbation rates towards death, more than the half of patients were not receiving any recommended pharmacological COPD therapy in the year before death.

CONCLUSION

Our study illustrates the impact of COPD on mortality risk and highlights the need for consequent COPD management comprising exacerbation assessment and treatment.

Exploring the impact of comorbid dementia on exacerbation occurrence in general practice patients with chronic obstructive pulmonary disease

OBJECTIVE

Previous studies have shown an increased risk of dementia in patient with COPD, but whether comorbid dementia modifies the risk of exacerbations in patients with COPD is unknown. We explored exacerbation occurrence in patients with COPD with comorbid dementia and compared this to patients with COPD without comorbid dementia.

METHODS

We performed a retrospective cohort study based on medical record data from 88 Dutch general practices. Patients diagnosed with COPD and comorbid dementia (n = 244, index group) were matched 1:1 to patients with COPD without comorbid dementia (n = 244, controls). Exacerbations were assessed 1 year before and 1 year after the dementia diagnosis (or corresponding date in controls) and compared between index and control groups by calculating Rate Ratios (RRs).

RESULTS

Average number of COPD exacerbations after dementia diagnosis increased from 5 to 14 per 100 patient years in the index group (RR = 2.70, 95%CI 1.42-5.09; p = 0.02) and from 17 to 30 per 100 patient years in the control group (RR = 1.74, 1.19-2.54; p = 0.04). These RRs did not significantly differ between the index and control groups (RR ratio = 1.55, 0.74-3.25; p = 0.25).

DISCUSSION

We conclude that although the risk of exacerbation increased after patients with COPD were diagnosed with dementia, their change in exacerbation risk did not seem to differ from the change observed in patients with COPD without comorbid dementia. However, as our study was hypothesis-generating in nature, further investigations on the subject matter are needed.

Development of a Communication Tool between Patients and Physicians for Recognizing COPD Exacerbations in Japan

In Japan, exacerbations are underreported compared with other countries, possibly due in part to a failure to recognize them. This study aimed to create a simple chronic obstructive pulmonary disease (COPD) Exacerbation Recognition Tool (CERT-J) specifically for Japanese patients. Patients ≥40 years with confirmed COPD or asthma-COPD overlap were included. Focus groups were held to identify words and phrases used by patients to describe symptoms associated with an exacerbation, resulting in candidate items being identified. Following cognitive debriefing, the items were refined based on item frequency, level of endorsement and effect of demographic factors. Exploratory factor analysis (EFA) was then performed to inform an expert panel's choice of items to form the new tool. A total of 41 patients were included in the focus groups and nine patients performed the cognitive debrief. Following this, the expert panel identified 26 items for testing in a further 100 patients (mean age 72 years, forced expiratory volume in 1 s 54.8% predicted and 1.8 exacerbations in the preceding 12 months). Eleven items were associated with breathlessness or activity limitation and seven of these were the most frequently endorsed. EFA identified four factors, with one (breathlessness) being dominant. The expert panel recommended that the CERT-J should include six items: breathlessness and activity limitation (3 items), cough (1 item) and phlegm (2 items). The final CERT-J should benefit patients with COPD by providing them with an increased understanding and recognition of exacerbations.Clinical Trial Registration: GSK K.K (jRCT1080224526).

Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is a major health problem with a high prevalence, a rising incidence, and substantial morbidity and mortality. Its course is punctuated by acute episodes of increased respiratory symptoms, termed exacerbations of chronic obstructive pulmonary disease (ECOPD). ECOPD are important events in the natural history of the disease, as they are associated with lung function decline and prolonged negative effects on quality of life. The present-day therapy for ECOPD with short courses of antibiotics and steroids and escalation of bronchodilators has resulted in only modest improvements in outcomes. Recent data indicate that ECOPD are heterogeneous, raising the need to identify distinct etioendophenotypes, incorporating traits of the acute event and of patients who experience recurrent events, to develop novel and targeted therapies. These characterizations can provide a complete clinical picture, the severity of which will dictate acute pharmacological treatment, and may also indicate whether a change in maintenance therapy is needed to reduce the risk of future exacerbations. In this review we discuss the latest knowledge of ECOPD types on the basis of clinical presentation, etiology, natural history, frequency, severity, and biomarkers in an attempt to characterize these events.

Effects of Adherence to an mHealth Tool for Self-Management of COPD Exacerbations

Purpose

Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth adherence on exacerbation-free weeks and self-management behavior. We also explored differences in self-efficacy and stages of grief between adherent and non-adherent COPD patients.

Patients and Methods

We conducted secondary analyses using data from a recent randomized controlled trial (RCT) that compared the effects of mHealth (intervention) with a paper action plan (comparator) for COPD exacerbation self-management. We used data from the intervention group only to assess differences in exacerbation-free weeks (primary outcome) between patients who were adherent and non-adherent to the mHealth tool. We also assessed differences in the type and timing of self-management actions and scores on self-efficacy and stages of grief (secondary outcomes). We used generalized negative binomial regression analyses with correction for follow-up length to analyze exacerbation-free weeks and multilevel logistic regression analyses with correction for clustering for secondary outcomes.

Results

We included data of 38 patients of whom 13 (34.2%) (mean (SD) age 69.2 (11.2) years) were adherent and 25 (65.8%) (mean (SD) age 68.7 (7.8) years) were non-adherent. Adherent patients did not differ from non-adherent patients in exacerbation-free weeks (mean (SD) 31.5 (14.5) versus 33.5 (10.2); p=0.63). Although statistically not significant, adherent patients increased their bronchodilator use more often and more timely, contacted a healthcare professional and/or initiated prednisolone and/or antibiotics more often, and showed at baseline higher scores of self-efficacy and disease acceptance and lower scores of denial, resistance, and sorrow, compared with non-adherent patients.

Conclusion

Adherence to mHealth may be positively associated with COPD exacerbation self-management behavior, self-efficacy and disease acceptance, but its association with exacerbation-free weeks remains unclear. Our results should be interpreted with caution by this pilot study's explorative nature and small sample size.

Short-term air pollution exposure and exacerbation events in mild to moderate COPD: a case-crossover study within the CanCOLD cohort

BACKGROUND

Infections are considered as leading causes of acute exacerbations of chronic obstructive pulmonary disease (COPD). Non-infectious risk factors such as short-term air pollution exposure may play a clinically important role. We sought to estimate the relationship between short-term air pollutant exposure and exacerbations in Canadian adults living with mild to moderate COPD.

METHODS

In this case-crossover study, exacerbations ('symptom based': ≥48 hours of dyspnoea/sputum volume/purulence; 'event based': 'symptom based' plus requiring antibiotics/corticosteroids or healthcare use) were collected prospectively from 449 participants with spirometry-confirmed COPD within the Canadian Cohort Obstructive Lung Disease. Daily nitrogen dioxide (NO2), fine particulate matter (PM2.5), ground-level ozone (O3), composite of NO2 and O3 (Ox), mean temperature and relative humidity estimates were obtained from national databases. Time-stratified sampling of hazard and control periods on day '0' (day-of-event) and Lags ('-1' to '-6') were compared by fitting generalised estimating equation models. All data were dichotomised into 'warm' (May-October) and 'cool' (November-April) seasons. ORs and 95% CIs were estimated per IQR increase in pollutant concentrations.

RESULTS

Increased warm season ambient concentration of NO2 was associated with symptom-based exacerbations on Lag-3 (1.14 (1.01 to 1.29), per IQR), and increased cool season ambient PM2.5 was associated with symptom-based exacerbations on Lag-1 (1.11 (1.03 to 1.20), per IQR). There was a negative association between warm season ambient O3 and symptom-based events on Lag-3 (0.73 (0.52 to 1.00), per IQR).

CONCLUSIONS

Short-term ambient NO2 and PM2.5 exposure were associated with increased odds of exacerbations in Canadians with mild to moderate COPD, further heightening the awareness of non-infectious triggers of COPD exacerbations.

Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations

Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.

Clinical Concepts for Triple Therapy Use in Patients with COPD: A Delphi Consensus

Purpose

Role of triple therapy in chronic obstructive pulmonary disease (COPD) management is supported by growing evidence, but consensus is lacking on various aspects. We conducted a Delphi survey in respiratory experts on the effects of triple therapy on exacerbation reduction, early optimization, pneumonia risk, and mortality benefits in COPD management.

Methods

The study comprised 2-round online surveys and a participant meeting with 21 respiratory experts from 10 countries. The 31-statement questionnaire was prepared using Decipher software after literature review. Responses were recorded using Likert scale ranging from 1 (disagreement) to 9 (agreement) with a consensus threshold of 75%.

Results

All experts participated in both surveys and 14/21 attended participant meeting. Consensus was reached on 13/31 questions in first survey and 4/14 in second survey on: mortality benefits of triple therapy; comparable pneumonia risk between single inhaler triple therapy (SITT) and multiple inhaler triple therapy (81%); preference of SITT for patients with high eosinophil count (95%); exacerbation risk reduction and healthcare cost benefits with early initiation of SITT post exacerbation-related hospitalization (<30 days) (86%). No consensus was reached on first line SITT use after first exacerbation resulting in COPD diagnosis (62%).

Conclusion

This study demonstrated that there is consensus among experts regarding many of the key concepts about appropriate clinical use and benefits of triple therapy in COPD. More evidence is required for evaluating the benefits of early optimisation of triple therapy.

A risk nomogram for predicting prolonged intensive care unit stays in patients with chronic obstructive pulmonary disease

BACKGROUND

Providing intensive care is increasingly expensive, and the aim of this study was to construct a risk column line graph (nomograms)for prolonged length of stay (LOS) in the intensive care unit (ICU) for patients with chronic obstructive pulmonary disease (COPD).

METHODS

This study included 4,940 patients, and the data set was randomly divided into training (n = 3,458) and validation (n = 1,482) sets at a 7:3 ratio. First, least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection by running a tenfold k-cyclic coordinate descent. Second, a prediction model was constructed using multifactorial logistic regression analysis. Third, the model was validated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow tests, calibration plots, and decision-curve analysis (DCA), and was further internally validated.

RESULTS

This study selected 11 predictors: sepsis, renal replacement therapy, cerebrovascular disease, respiratory failure, ventilator associated pneumonia, norepinephrine, bronchodilators, invasive mechanical ventilation, electrolytes disorders, Glasgow Coma Scale score and body temperature. The models constructed using these 11 predictors indicated good predictive power, with the areas under the ROC curves being 0.826 (95%CI, 0.809-0.842) and 0.827 (95%CI, 0.802-0.853) in the training and validation sets, respectively. The Hosmer-Lemeshow test indicated a strong agreement between the predicted and observed probabilities in the training (χ2 = 8.21, p = 0.413) and validation (χ2 = 0.64, p = 0.999) sets. In addition, decision-curve analysis suggested that the model had good clinical validity.

CONCLUSION

This study has constructed and validated original and dynamic nomograms for prolonged ICU stay in patients with COPD using 11 easily collected parameters. These nomograms can provide useful guidance to medical and nursing practitioners in ICUs and help reduce the disease and economic burdens on patients.

High use of short-acting β2-agonists in COPD is associated with an increased risk of exacerbations and mortality

Background

Short-acting β₂-agonist (SABA) overuse has been associated with an increased risk of exacerbations in asthma; however, less is known about SABA use in COPD. Our aim was to describe SABA use and investigate potential associations between high SABA use and the risk of future exacerbations and mortality in COPD.

Methods

This observational study identified COPD patients in primary care medical records in Sweden. Data were linked to the National Patient Registry, the Prescribed Drug Registry and the Cause of Death Registry. The index date was 12 months after the date of COPD diagnosis. During a 12-month prior to index baseline period, information on SABA use was collected. Patients were followed with respect to exacerbations and mortality for 12 months post index.

Results

Of the 19 794 COPD patients included (mean age 69.1 years, 53.3% females), 15.5% and 7.0% had collected ≥3 or ≥6 SABA canisters during the baseline period, respectively. A higher level of SABA use (≥6 canisters) was independently associated with a higher risk of both moderate and severe exacerbations (hazard ratio (HR) 1.28 (95% CI 1.17‒1.40) and 1.76 (95% CI 1.50‒2.06), respectively) during follow-up. In total, 673 (3.4%) patients died during the 12-month follow-up period. An independent association was found between high SABA use and overall mortality (HR 1.60, 95% CI 1.07‒2.39). This association, however, was not found in patients using inhaled corticosteroids as maintenance treatment.

Conclusion

In COPD patients in Sweden, high SABA use is relatively common and associated with a higher risk of exacerbations and all-cause mortality.

Patient and physician factors associated with symptomatic undiagnosed asthma or COPD

BACKGROUND

It remains unclear why some symptomatic individuals with asthma or COPD remain undiagnosed. Here, we compare patient and physician characteristics between symptomatic individuals with obstructive lung disease (OLD) who are undiagnosed and individuals with physician-diagnosed OLD.

METHODS

Using random-digit dialling and population-based case finding, we recruited 451 participants with symptomatic undiagnosed OLD and 205 symptomatic control participants with physician-diagnosed OLD. Data on symptoms, quality of life and healthcare utilisation were analysed. We surveyed family physicians of participants in both groups to elucidate differences in physician practices that could contribute to undiagnosed OLD.

RESULTS

Participants with undiagnosed OLD had lower mean pre-bronchodilator forced expiratory volume in 1 s percentage predicted compared with those who were diagnosed (75.2% versus 80.8%; OR 0.975, 95% CI 0.963-0.987). They reported greater psychosocial impacts due to symptoms and worse energy and fatigue than those with diagnosed OLD. Undiagnosed OLD was more common in participants whose family physicians were practising for >15 years and in those whose physicians reported that they were likely to prescribe respiratory medications without doing spirometry. Undiagnosed OLD was more common among participants who had never undergone spirometry (OR 10.83, 95% CI 6.18-18.98) or who were never referred to a specialist (OR 5.92, 95% CI 3.58-9.77). Undiagnosed OLD was less common among participants who had required emergency department care (OR 0.44, 95% CI 0.20-0.97).

CONCLUSIONS

Individuals with symptomatic undiagnosed OLD have worse pre-bronchodilator lung function and present with greater psychosocial impacts on quality of life compared with their diagnosed counterparts. They were less likely to have received appropriate investigations and specialist referral for their respiratory symptoms.

A smartphone-based algorithm comprising cough analysis and patient-reported symptoms identifies acute exacerbations of asthma: a prospective, double blind, diagnostic accuracy study

Objective: Early and accurate recognition of asthma exacerbations reduces the duration and risk of hospitalization. Current diagnostic methods depend upon patient recognition of symptoms, expert clinical examination, or measures of lung function. Here, we aimed to develop and test the accuracy of a smartphone-based diagnostic algorithm that analyses five cough events and five patient-reported features (age, fever, acute or productive cough and wheeze) to detect asthma exacerbations.Methods: We conducted a double-blind, prospective, diagnostic accuracy study comparing the algorithm with expert clinical opinion and formal lung function testing. Results: One hundred nineteen participants >12 years with a physician-diagnosed history of asthma were recruited from a hospital in Perth, Western Australia: 46 with clinically confirmed asthma exacerbations, 73 with controlled asthma. The groups were similar in median age (54yr versus 60yr, p=0.72) and sex (female 76% versus 70%, p=0.5). The algorithm's positive percent agreement (PPA) with the expert clinical diagnosis of asthma exacerbations was 89% [95% CI: 76%, 96%]. The negative percent agreement (NPA) was 84% [95% CI: 73%, 91%]. The algorithm's performance for asthma exacerbations diagnosis exceeded its performance as a detector of patient-reported wheeze (sensitivity, 63.7%). Patient-reported wheeze in isolation was an insensitive marker of asthma exacerbations (PPA=53.8%, NPA=49%). Conclusions: Our diagnostic algorithm accurately detected the presence of an asthma exacerbation as a point-of-care test without requiring clinical examination or lung function testing. This method could improve the accuracy of telehealth consultations and might be helpful in Asthma Action Plans and patient-initiated therapy.

REALizing and improving management of stable COPD in China: results of a multicentre, prospective, observational study (REAL)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) management in China is far from adequate; underdiagnosis and undertreatment are major barriers to optimal care and improved patient outcomes.

OBJECTIVE

To generate reliable information on COPD management, outcomes, treatment patterns and adherence, and disease knowledge in China in a real-world setting.

DESIGN

A 52-week multicentre, prospective, observational study.

METHODS

Outpatients (⩾40 years old) diagnosed with COPD were enrolled from 50 secondary and tertiary hospitals across six geographical regions. Data were collected in routine clinical practice.

RESULTS

Between June 2017 and January 2019, 5013 patients were enrolled and 4978 included in the analysis. Mean [standard deviation (SD)] age was 66.2 (8.9) years, 79.5% were male and 90% had moderate-to-very-severe airflow limitation. Annual rates of overall and severe exacerbation were 0.56 and 0.31, respectively. During 1 year, 1536 (30.8%) patients experienced ⩾1 exacerbation and 960 (19.3%) patients had ⩾1 exacerbation requiring hospitalization/emergency visit. Mean (SD) COPD assessment test score was 14.6 (7.6) at baseline and 10.6 (6.8) at follow-up; however, 42-55% of patients had persistent dyspnoea, chest tightness and wheezing at 1 year. The most prescribed treatments were inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) (36.0%), ICS/LABA + long-acting muscarinic antagonist (LAMA) (17.7%) and LAMA monotherapy (15.3%). Among patients with high exacerbation risk (GOLD Groups C and D), 10.1% and 13.1%, respectively, did not receive any long-acting inhalers; only 53.8% and 63.6% of Group C and D patients with ⩾1 exacerbation during follow-up were prescribed ICS-containing therapy, respectively. Mean (SD) adherence for long-acting inhalers was 59.0% (34.3%). Mean (SD) score for the COPD questionnaire was 6.7 (2.4).

CONCLUSION

These results indicate a high burden of severe exacerbations and symptoms in Chinese outpatients with COPD, and low adherence with treatment guidelines, highlighting the need for more effective management nationwide.

REGISTRATION

The trial was registered on 20 March 2017 (ClinicalTrials.gov identifier: NCT03131362).

COPD Exacerbation Syndrome: The Spanish Perspective on an Old Dilemma

The definition of exacerbation of COPD as a syndrome, as proposed by the Spanish COPD guidelines (GesEPOC) 2021 update, and the consequences that this implies, have direct implications on patient care. This review analyzes this novel vision of the COPD exacerbation syndrome, its rationale, and its clinical implications, as opposed to the traditional symptoms-based or event-based definitions. An exacerbation conceived as a syndrome provides us with an umbrella term to include a set of diverse alterations, which, either in isolation or more frequently in combination, are clinically expressed in a similar way in patients with COPD. In patients with COPD, this occurs as a consequence of worsening expiratory airflow limitation or the underlying inflammatory process, producing a worsening in symptoms with respect to the baseline situation. This definition therefore assumes a worsening in at least one of the two key physiopathological markers, lung function and inflammation. The main features of this new physiopathological proposal include a syndromic approach with narrower differential diagnosis, the use of several biomarkers, treatable traits to better guide treatment, and a new severity classification. Further research is needed to examine the role of eosinophils in this context, but currently, the early results are promising. The evaluation of severity is key in the multidimensional characterization of exacerbation and the GesEPOC 2021 proposes new approaches and also recommends the use of multidisciplinary scores for severity categorization in patients. Finally, another innovation in the GesEPOC 2021 refers to the recurrence of exacerbations, which has implications for disease prognosis or long-term clinical impact which need to be elucidated in further studies.

Accuracy and economic evaluation of screening tests for undiagnosed COPD among hypertensive individuals in Brazil

In Brazil, prevalence of diagnosed COPD among adults aged 40 years and over is 16% although over 70% of cases remain undiagnosed. Hypertension is common and well-recorded in primary care, and frequently co-exists with COPD because of common causes such as tobacco smoking, therefore we conducted a cross-sectional screening test accuracy study in nine Basic Health Units in Brazil, among hypertensive patients aged ≥40 years to identify the optimum screening test/combinations to detect undiagnosed COPD. We compared six index tests (four screening questionnaires, microspirometer and peak flow) against the reference test defined as those below the lower limit of normal (LLN-GLI) on quality diagnostic spirometry, with confirmed COPD at clinical review. Of 1162 participants, 6.8% (n = 79) had clinically confirmed COPD. Peak flow had a higher specificity but lower sensitivity than microspirometry (sensitivity 44.3% [95% CI 33.1, 55.9], specificity 95.5% [95% CI 94.1, 96.6]). SBQ performed well compared to the other questionnaires (sensitivity 75.9% [95% CI 65.0, 84.9], specificity 59.2% [95% CI 56.2, 62.1]). A strategy requiring both SBQ and peak flow to be positive yielded sensitivity of 39.2% (95% CI 28.4, 50.9) and specificity of 97.0% (95% CI 95.7, 97.9). The use of simple screening tests was feasible within the Brazilian primary care setting. The combination of SBQ and peak flow appeared most efficient, when considering performance of the test, cost and ease of use (costing £1690 (5554 R$) with 26.7 cases detected per 1,000 patients). However, the choice of screening tests depends on the clinical setting and availability of resources.ISRCTN registration number: 11377960.

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

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

Monitoring daily symptoms and (self-reported) exacerbations in patients with bronchiectasis: a prospective study

Background

Exacerbations are pivotal events in the natural history of patients with non-cystic fibrosis bronchiectasis (NCFB), since they have a negative impact on the functional evolution of these individuals. The daily symptoms of patients with NCFB show great variability, which negatively affects their self-perception of symptoms and exacerbations. The aim of this study was to identify daily symptoms in patients with NCFB, and to investigate whether there is a correlation between the frequency of self-reported exacerbations and events defined according to the criteria established in the literature to define exacerbation in bronchiectasis.

Methods

This observational and prospective study was carried out in outpatient clinics of a Brazilian public university hospital. Over 24 weeks, patients completed a diary in which daily symptoms, self-reported exacerbations, and demands for medical care for respiratory symptoms were recorded. The instrument used (diary and symptom scores ranging from 0 to 12) were developed by the researchers. The participants also answered questionnaires mMRC, Leicester's, and St. George's Respiratory (SGRQ).

Results

Twenty-eight patients returned the diary, their mean age was 54 years, and 50% out of them were classified as mild by the FACED score. Cough (64%) and expectoration (62%) were the most frequent symptoms. Correlations were found between the stability score and the mMRC (r=0.4727, p=0.011) and SGRQ (r=0.6748, p<0.0001) questionnaires. The number of self-perceived exacerbations (24) was significantly lower than exacerbations using the exacerbation consensus (63) (p<0.01). Additionally, no correlation was found between these two criteria.

Conclusions

There was great variability of symptoms among the individuals sampled, and even for the same individual, over time. Patients had low self-perception of exacerbations, which suggests that strategies aimed at improving this self-perception may contribute to the early detection of exacerbations.

MRI-assessed diaphragmatic function can predict frequent acute exacerbation of COPD: a prospective observational study based on telehealth-based monitoring system

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have considerably high mortality and re-hospitalisation rate. Diaphragmatic dysfunction (DD) is common in COPD patients. However, whether diaphragmatic dysfunction is related to acute exacerbation is yet to be elucidated. This study aimed to evaluate the diaphragm function by magnetic resonance imaging (MRI) in COPD patients and assess whether the impact of DD may help predict AECOPD.

METHODS

20 healthy adult volunteers and 80 COPD patients were enrolled. The diaphragms function parameters were accessed by MRI. Patients were guided to start self-management by the Telehealth-based monitoring system following the enrolment. Events of acute exacerbation of COPD were recorded by the system and confirmed by healthcare providers. Binary univariate and multivariate logistic regression analyses were performed to investigate the factors associated with the frequency of AECOPD. Receiver operating characteristic (ROC) curves were further used to assess the value of prediction indexes.

RESULTS

Fifty-nine COPD patients completed a one-year follow-up based on the Telehealth-based monitoring system. The clinical outcomes showed that the diaphragm function parameters at the end of maximal breathing were lower in the COPD group than in the healthy control group (P < 0.05). ANOVA showed significant differences among Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages for diaphragm function parameters, including chest wall motion, lung area, upper-lower diameter, and the diaphragm thickening fraction at the end of maximal breathing (P < 0.05). Moreover, significant differences in diaphragm function parameters were observed between patients with infrequent AECOPD (n = 28) and frequent AECOPD (n = 31) based on the frequency of AECOPD (P < 0.05). The diaphragm thickening fraction and the chest wall motion were associated with AECOPD after adjusting for age, sex, BMI, and lung functions, and the combination of predictions showed better accuracy in predicting the frequency of AECOPD.

CONCLUSIONS

In COPD patients, diaphragm function parameters correlate with the severity of airflow limitation. The diaphragm thickening fraction and the chest wall motion were associated with the frequency of AECOPD and can predict it.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

A proof of concept for continuous, non-invasive, free-living vital signs monitoring to predict readmission following an acute exacerbation of COPD: a prospective cohort study

Background

The use of vital signs monitoring in the early recognition of an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) post-hospital discharge is limited. This study investigated whether continuous vital signs monitoring could predict an AECOPD and readmission.

Methods

35 people were recruited at discharge following hospitalisation for an AECOPD. Participants were asked to wear an Equivital LifeMonitor during waking hours for 6 weeks and to complete the Exacerbations of Chronic Pulmonary Disease Tool (EXACT), a 14-item symptom diary, daily. The Equivital LifeMonitor recorded respiratory rate (RR), heart rate (HR), skin temperature (ST) and physical activity (PA) every 15-s. An AECOPD was classified as mild (by EXACT score), moderate (prescribed oral steroids/antibiotics) or severe (hospitalisation).

Results

Over the 6-week period, 31 participants provided vital signs and symptom data and 14 participants experienced an exacerbation, of which, 11 had sufficient data to predict an AECOPD. HR and PA were associated with EXACT score (p < 0.001). Three days prior to an exacerbation, RR increased by mean ± SD 2.0 ± 0.2 breaths/min for seven out of 11 exacerbations and HR increased by 8.1 ± 0.7 bpm for nine of these 11 exacerbations.

Conclusions

Increased heart rate and reduced physical activity were associated with worsening symptoms. Even with high-resolution data, the variation in vital signs data remains a challenge for predicting AECOPDs. Respiratory rate and heart rate should be further explored as potential predictors of an impending AECOPD.

Trial registration: ISRCTN registry; ISRCTN12855961. Registered 07 November 2018—Retrospectively registered, https://www.isrctn.com/ISRCTN12855961

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02018-5.

Clinical implementation of an algorithm for predicting exacerbations in patients with COPD in telemonitoring: a study protocol for a single-blinded randomized controlled trial

BACKGROUND

Acute exacerbations have a significant impact on patients with COPD by accelerating the decline in lung function leading to decreased health-related quality of life and survival time. In telehealth, health care professionals exercise clinical judgment over a physical distance. Telehealth has been implemented as a way to monitor patients more closely in daily life with an intention to intervene earlier when physical measurements indicate that health deteriorates. Several studies call for research investigating the ability of telehealth to automatically flag risk of exacerbations by applying the physical measurements that are collected as part of the monitoring routines to support health care professionals. However, more research is needed to further develop, test, and validate prediction algorithms to ensure that these algorithms improve outcomes before they are widely implemented in practice.

METHOD

This trial tests a COPD prediction algorithm that is integrated into an existing telehealth system, which has been developed from the previous Danish large-scale trial, TeleCare North (NCT: 01984840). The COPD prediction algorithm aims to support clinical decisions by predicting the risk of exacerbations for patients with COPD based on selected physiological parameters. A prospective, parallel two-armed randomized controlled trial with approximately 200 participants with COPD will be conducted. The participants live in Aalborg municipality, which is located in the North Denmark Region. All participants are familiar with the telehealth system in advance. In addition to the participants' usual weekly monitored measurements, they are asked to measure their oxygen saturation two more times a week during the trial period. The primary outcome is the number of exacerbations defined as an acute hospitalization from baseline to follow-up. Secondary outcomes include changes in health-related quality of life measured by both the 12-Item Short Form Survey version 2 and EuroQol-5 Dimension Questionnaire as well as the incremental cost-effectiveness ratio.

DISCUSSION

This trial seeks to explore whether the COPD prediction algorithm has the potential to support early detection of exacerbations in a telehealth setting. The COPD prediction algorithm may initiate timely treatment, which may decrease the number of hospitalizations.

TRIAL REGISTRATION

NCT05218525 (pending at clinicaltrials.gov ) (date, month, year).

The Development of a COPD Exacerbation Recognition Tool (CERT) to Help Patients Recognize When to Seek Medical Advice

INTRODUCTION

Many patients with chronic obstructive pulmonary disease (COPD) do not report exacerbations and may benefit from simple guidance about when to seek medical attention, so we developed a COPD Exacerbation Recognition Tool (CERT).

METHODS

The study was run across three sites in China in patients who had an exacerbation within the previous year. Step 1: focus group qualitative study (total 48 patients) captured symptoms associated with an exacerbation. Step 2: cognitive debriefing to ensure items were appropriately worded. Step 3: 150 patients (69 years, 21% female, FEV1 63% predicted, CAT 15, 2 exacerbations in previous year) completed a questionnaire composed of the items from Steps 1 and 2 using two response options - severity during an exacerbation and magnitude of change from usual state. Responses were analysed in terms of frequency and tested for influence of demographic factors. Exploratory factor analysis (EFA) identified key domains. Using these results, an expert panel guided choice of items that formed the CERT.

RESULTS

Following Steps 1 and 2, 29 candidate items were selected for Step 3. Response rates with the two response options were very similar. There was minimal influence of demographic factors on response to the items. EFA using the 11 items with the highest response rates identified two principal factors, Factor 1: breathlessness and activity limitation (79.1% of variance), Factor 2: cough and sputum (20.9% of variance). Five items were selected for the CERT based on response rate and EFA factor loading: worsening cough, increased sputum volume, shortness of breath, laborious breathing, and limitation of motion. Sensitivity analysis suggested that worsening of two or more symptoms had good sensitivity and specificity for the presence of an exacerbation.

DISCUSSION

The CERT is an evidence-based tool to provide patients with simple-to-follow guidance about when to seek medical attention when their COPD symptoms worsen.

Predictors and outcomes of obstructive sleep apnea in patients with chronic obstructive pulmonary disease in China

BACKGROUND

"Overlap syndrome" refers to obstructive sleep apnea (OSA) combined with chronic obstructive pulmonary disease (COPD), and has poorer outcomes than either condition alone. We aimed to evaluate the prevalence and possible predictors of overlap syndrome and its association with clinical outcomes in patients with COPD.

METHODS

We assessed the modified Medical Research Council dyspnea scale (mMRC), Epworth sleepiness scale (ESS), COPD assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), Charlson Comorbidity Index (CCI), and STOP-Bang questionnaire (SBQ) and performed spirometry and full overnight polysomnography in all patients. An apnea-hypopnea index (AHI) ≥ 5 events per hour was considered to indicate OSA. Risk factors for OSA in COPD patients were identified by univariate and multivariate logistic regression analyses.

RESULTS

A total of 556 patients (66%) had an AHI ≥ 5 events per hour. There were no significant differences in age, sex ratio, mMRC score, smoking index, number of acute exacerbations and hospitalizations in the last year, and prevalence of cor pulmonale between the two groups (all p > 0.05). Body mass index (BMI), neck circumference, CAT score, CCI, ESS, HADS, and SBQ scores, forced expiratory volume (FEV)1, FEV1% pred, FEV1/forced vital capacity ratio, and prevalence of hypertension, coronary heart disease, and diabetes were all significantly higher and the prevalence of severe COPD was significantly lower in the COPD-OSA group compared with the COPD group (p < 0.05). BMI, neck circumference, ESS, CAT, CCI, HADS, hypertension, and diabetes were independent risk factors for OSA in COPD patients (p < 0.05). SBQ could be used for OSA screening in patients with COPD. Patients with severe COPD had a lower risk of OSA compared with patients with mild or moderate COPD (β =  - 0.459, odds ratio = 0.632, 95% confidence interval 0.401-0.997, p = 0.048).

CONCLUSION

Patients with overlap syndrome had a poorer quality of life, more daytime sleepiness, and a higher prevalence of hypertension and diabetes than patients with COPD alone. BMI, neck circumference, ESS, CAT, CCI, HADS, hypertension, and diabetes were independent risk factors for OSA in patients with COPD. The risk of OSA was lower in patients with severe, compared with mild or moderate COPD.

COPD - do the right thing

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

Clinical characteristics of patients with chronic obstructive pulmonary disease assessed using GOLD 2016 and GOLD 2018 classifications: a cross-sectional study in China

Background

In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) removed spirometry as a criterion for classifying GOLD risk groups (A–D, low–high risk).

Methods

In this cross-sectional observational study in China, we used the GOLD 2016 (spirometry included) and 2018 (spirometry eliminated) criteria for classifying GOLD risk groups to describe: the proportion of patients with chronic obstructive pulmonary disease (COPD) in each GOLD risk group; disease severity; demographics and comorbidities. Patients aged ≥40 years with a clinical COPD diagnosis for ≥1 year were included. During a single study visit, patients completed the COPD assessment test, modified Medical Research Council (mMRC) dyspnea scale assessment, and spirometry tests. Demographics, medical history, and treatment data were recorded.

Results

In total, 838 patients were included. Most patients were male (86.4%), ≥65 years old (58.6%), and current or former smokers (78.5%). By GOLD 2016, the highest proportion of patients were Group D (42.8%), followed by B (28.2%). By GOLD 2018, the highest proportion of patients were Group B (57.3%), followed by A (25.5%). A total of 296 patients (35.3%) were reclassified, either from Group C to Group A or from Group D to Group B. Overall, 36.2% of patients were receiving treatment concordant with GOLD 2016 recommendations; 34.1% were not receiving any inhaled medication.

Conclusions

The distribution of COPD severity shifted from a high-risk category (by GOLD 2016) to a low-risk category (by GOLD 2018). The high proportion of patients not receiving maintenance medication reflects a high level of under-treatment of the disease.

Overcoming Therapeutic Inertia to Reduce the Risk of COPD Exacerbations: Four Action Points for Healthcare Professionals

Background

Therapeutic inertia, defined as failure to escalate or initiate adequate therapy when treatment goals are not met, contributes to poor management of COPD exacerbations.

Methods

A multidisciplinary panel of five expert clinicians actively managing COPD and representative of UK practice developed action points to reduce exacerbation risk, based on evidence, clinical expertise, and experience. The action points are applicable despite changing circumstances (eg, virtual clinics). The panel agreed areas where further evidence is needed.

Results

The four action points were (1) an experienced HCP, such as a GP or member of the multi-professional COPD team should review patients within one month of every exacerbation that requires oral steroids, antibiotics, or hospitalization to address modifiable risk factors, optimize non-pharmacological measures, and evaluate pharmacological therapy. (2) Presenting to hospital with an exacerbation defines an important window of opportunity to reduce the risk of further exacerbations. Follow-up by a GP, or member of the multi-professional specialist COPD team within one month of discharge with a full management review and appropriate escalation of pharmacological treatment is essential. (3) Healthcare professionals (HCPs) in all healthcare settings should be able to recognize COPD exacerbations, refer as appropriate and document the episode accurately in medical records across service boundaries. HCPs should support patients to recognize and report exacerbations. (4) HCPs should intervene proactively based on risk assessments, disease activity and any treatable traits at or as soon as possible after diagnosis and annually thereafter. Delivering these action points needs coordinated action with policymakers, funders, and service providers.

Conclusion

These action points should be a fundamental part of clinical practice to determine if a change in management is necessary to reduce the risk of exacerbations. Policymakers should use these action points to develop systems and initiatives that reduce the risk of further exacerbations.

Effectiveness of Telemonitoring for Respiratory and Systemic Symptoms of Asthma and COPD: A Narrative Review

Asthma and chronic obstructive pulmonary diseases (COPD) are highly prevalent chronic lung diseases that require ongoing self-management, which itself is often suboptimal. Therefore, telemonitoring has been used to help patients measure their symptoms, share data with healthcare providers and receive education and feedback to improve disease management. In this study, we conducted a narrative review of recent evidence on the effectiveness of telemonitoring for asthma and COPD in adults. Of the thirteen identified studies, eleven focused on COPD and two focused on asthma. All studies were reviewed, and effects were compared between intervention and care as usual groups. Of the study interventions, seven showed a positive outcome on at least one outcome measure, and six had no significant results on any of the outcome measures. All of the interventions with a positive outcome included an educational component, while only one of the six interventions without positive outcomes included an educational component. We conclude that telemonitoring interventions for asthma and COPD seem more effective if they included an educational component regarding different aspects of self-management.

Revealing the Nature of Chronic Obstructive Pulmonary Disease Using Self-tracking and Analysis of Contact Patterns: Longitudinal Study

Background

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and is characterized by a progressive loss of pulmonary function over time with intermittent episodes of exacerbations. Rapid and proactive interventions may reduce the burden of the condition for the patients. Telehealth solutions involving self-tracking of vital parameters such as pulmonary function, oxygen saturation, heart rate, and temperature with synchronous communication of health data may become a powerful solution as they enable health care professionals to react with a proactive and adequate response. We have taken this idea to the next level in the Epital Care Model and organized a person-centered technology-assisted ecosystem to provide health services to COPD patients.

Objective

The objective is to reveal the nature of COPD by combining technology with a person-centered design aimed to benefit from interactions based on patient-reported outcome data and to assess the needed kind of contacts to best treat exacerbations. We wanted to know the following: (1) What are the incidences of mild, moderate, and severe exacerbations in a mixed population of COPD patients? (2) What are the courses of mild, moderate, and severe exacerbations? And (3) How is the activity and pattern of contacts with health professionals related to the participant conditions?

Methods

Participants were recruited by convenience sampling from November 2013 to December 2015. The participants’ sex, age, forced expiratory volume during the first second, pulse rate, and oxygen saturation were registered at entry. During the study, we registered number of days, number of exacerbations, and number of contact notes coded into care and treatment notes. Each participant was classified according to GOLD I-IV and risk factor group A-D. Participants reported their clinical status using a tablet by answering 4 questions and sending 3 semiautomated measurements.

Results

Of the 87 participants, 11 were in risk factor group A, 24 in B, 13 in C, and 39 in D. The number of observed days was 31,801 days with 12,470 measurements, 1397 care notes, and 1704 treatment notes. A total of 254 exacerbations were treated and only 18 caused hospitalization. Those in risk factor group D had the highest number of hospitalizations (16), exacerbations (151), and contacts (1910). The initial contacts during the first month declined within 3 months to one-third for care contacts and one-half for treatment contacts and reached a plateau after 4 months.

Conclusions

The majority of COPD patients in risk factor group D can be managed virtually, and only 13% of those with severe exacerbations required hospitalization. Contact to the health care professionals decreases markedly within the first months after enrollment. These results provide a new and detailed insight into the course of COPD. We propose a resilience index for virtual clinical management making it easier to compare results across settings.

Examining the Trends in Online Health Information-Seeking Behavior About Chronic Obstructive Pulmonary Disease in Singapore: Analysis of Data From Google Trends and the Global Burden of Disease Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally, and timely health care seeking is imperative for its prevention, early detection, and management. While online health information-seeking behavior (OHISB) is increasingly popular due to widespread internet connectivity, little is known about how OHISB for COPD has changed in comparison with the COPD disease burden, particularly at a country-specific level.

OBJECTIVE

This study aimed to examine the trends in OHISB for COPD and how that compared with the estimates of COPD disease burden in Singapore, a highly wired country with a steadily increasing COPD disease burden.

METHODS

To examine the trends in OHISB for COPD, we performed Prais-Winsten regression analyses on monthly search volume data for COPD from January 2004 to June 2020 downloaded from Google Trends. We then conducted cross-correlational analyses to examine the relationship between annualized search volume on COPD topics and estimates of COPD morbidity and mortality reported in the Global Burden of Disease study from 2004 to 2017.

RESULTS

From 2004 to 2020, the trend in COPD search volume was curvilinear (β=1.69, t₁₉₄=6.64, P<.001), with a slope change around the end of 2006. There was a negative linear trend (β=-0.53, t₃₃=-3.57, P=.001) from 2004 to 2006 and a positive linear trend (β=0.51, t₁₅₉=7.43, P<.001) from 2007 to 2020. Cross-correlation analyses revealed positive associations between COPD search volume and COPD disease burden indicators: positive correlations between search volume and prevalence, incidence, years living with disability (YLD) at lag 0, and positive correlations between search volume and prevalence, YLD at lag 1.

CONCLUSIONS

Google search volume on COPD increased from 2007 to 2020; this trend correlated with the upward trajectory of several COPD morbidity estimates, suggesting increasing engagement in OHISB for COPD in Singapore. These findings underscore the importance of making high-quality, web-based information accessible to the public, particularly COPD patients and their carers.

Unmet need in the management of chronic obstructive pulmonary disease in the Middle East and Africa region: An expert panel consensus

Chronic obstructive pulmonary disease (COPD) has a significant impact on healthcare systems and health-related quality of life. Increased prevalence of smoking is an important factor contributing to high burden of COPD in the Middle East and Africa (MEA). Several other factors including sedentary lifestyle, urbanization, second-hand smoke, air pollution, and occupational exposure are also responsible for the upsurge of COPD in the MEA. Frequent COPD exacerbations accelerate disease progression, progressively deteriorate the lung function, and negatively affect quality of life. This consensus is based on review of the published evidence, international and regional guidelines, and insights provided by the expert committee members from the MEA region. Spirometry, though the gold standard for diagnosis, is often unavailable and/or underutilized leading to underdiagnosis of COPD in primary care settings. Low adherence to the treatment guidelines and delayed use of appropriate combination therapy including triple therapy are additional barriers in management of COPD in MEA. It is necessary to recognize COPD as a screenable condition and develop easy and simple screening tools to facilitate early diagnosis. Knowledge of the disease symptomatology at patient and physician level and adherence to the international or regional guidelines are important to create awareness about harmful effects of smoking and develop national guidelines to focus on prevention on COPD. Implementation of vaccination program and pulmonary rehabilitation are equally valuable to manage patients with COPD at local and regional level. We present recommendations made by the expert panel for improved screening, diagnosis, and management of COPD in MEA.

Towards precision in defining COPD exacerbations

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

A qualitative study of clinician perceptions regarding the potential role for digital health interventions for the management of COPD

Effective self-management of chronic obstructive pulmonary disease (COPD) can lead to increased patient control and reduced health care costs. However, both patients and healthcare professionals encounter significant challenges. Digital health interventions, such as smart oximeters and COPD self-management applications, promise to enhance the management of COPD, yet, there is little evidence to support their use and user-experience issues are still common. Understanding the needs of healthcare professionals is central for increasing adoption and engagement with digital health interventions but little is known about their perceptions of digital health interventions in COPD. This paper explored the perceptions of healthcare professionals regarding the potential role for DHI in the management of COPD. Snowball sampling was used to recruit the participants (n = 32). Each participant underwent a semi-structured interview. Using NVivo 12 software, thematic analysis was completed. Healthcare professionals perceive digital health interventions providing several potential benefits to the management of COPD including the capture of patient status indicators during the interappointment period, providing new patient data to support the consultation process and perceived digital health interventions as a potential means to improve patient engagement. The findings offer new insights regarding potential future use-cases for digital health interventions in COPD, which can help ease user-experience issues as they align with the needs of healthcare professionals.

Early identification and treatment of COPD exacerbation using remote respiratory monitoring

Remote patient monitoring (RPM) is increasingly more accessible and accurate. The optimal utilization of RPM requires medical conditions which have predictive physiologic changes and effective outpatient therapies. Respiratory rate elevation has been shown to be predictive of impending chronic obstructive pulmonary disease (COPD) exacerbation and treatment often focuses on home-based medical therapies. In this case, we report the successful treatment of a patient with an exacerbation of COPD based on pre-identification via respiratory RPM.

Daily Activities: The Impact of COPD and Cognitive Dysfunction

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation; however, pulmonary function does not fully account for patients' functional difficulties. The primary aim of the study was to determine the association between several domains of cognition and daily activity among those with COPD.

METHOD

Eighty-nine former smokers completed a neuropsychological battery including measures across multiple domains of cognition, pulmonary function measures, and daily activity questionnaires. Using a cross-sectional design, we compared daily activity between former smokers with and without COPD using two measures (St. George's Respiratory Questionnaire [SGRQ] Activity Subscale and Lawton Instrumental Activities of Daily Living [IADL] Scale) and examined the association between cognition and daily activity among those with COPD.

RESULTS

As expected, former smokers with COPD reported more difficulty than those without COPD on both activity measures (SGRQ Activity Subscale p < .001; Lawton IADL Scale p = .040). Among former smokers with COPD, poorer delayed recall was associated with more difficulty with daily activities (SGRQ Activity Subscale) (p = .038) while adjusting for severity of airflow limitation, exercise tolerance, oxygen use, dyspnea, and symptoms of anxiety and depression.

CONCLUSION

The findings suggest that cognition is associated with daily activity in patients with COPD. Future research should examine whether cognitive interventions may help to maximize patients' engagement in daily activities.