Usefulness of the Chronic Obstructive Pulmonary Disease Assessment Test to evaluate severity of COPD exacerbations

Study protocol for evaluating the efficacy of early pulmonary rehabilitation combined with an internet-based patient management model in patients with COPD: a practical, multicentre, randomised controlled study from China

Background

COPD, a preventable and treatable disease, is characterised by persistent respiratory symptoms and airflow limitations, with high incidence, disability, mortality and disease burden. Currently, drug treatments mainly include bronchodilators and glucocorticoids, which are used to alleviate symptoms and improve lung function. Traditional medical care models and patients' lack of understanding of the disease result in regular and long-term hospitalisations, affect patients' quality of life and cause a need to explore more effective comprehensive intervention plans.

Methods

This study is designed as a multicentre, randomised controlled trial consisting of three parallel groups. Group A will receive early pulmonary rehabilitation in the hospital and remote internet pulmonary rehabilitation after discharge. Group B will receive the same early pulmonary rehabilitation in the hospital but outpatient pulmonary rehabilitation after discharge for 8 weeks and routine follow-up management. Group C will receive outpatient pulmonary rehabilitation during a stable period of 3-4 weeks after discharge and routine follow-up management. 1482 patients will be enrolled from 10 centres in China. The primary outcome measures will be the readmission rate due to acute exacerbation at 90 days and the 12-month readmission rate due to acute exacerbation. The secondary outcomes will mainly include differences in all-cause mortality; the number of acute exacerbations; COPD Assessment Test, modified Medical Research Council scale and St George's Respiratory Questionnaire scores; the pulmonary rehabilitation treatment completion rate; patient compliance; and patient and physician satisfaction scores among the three groups at 3, 6 and 12 months after the different interventions. In addition, the proportion of people with ≥2 acute exacerbations within 12 months and the time of the first acute exacerbation will also be included.

Conclusions

This study aims to further verify the substitutability of remote internet pulmonary rehabilitation for outpatient rehabilitation and its short-term and long-term effects in patients, providing comprehensive interventional evidence for the treatment of COPD.

Identifying COPD patients with poor health status and low exercise tolerance through the five-repetition sit-to-stand test and modified Medical Research Council Dyspnea Score

BACKGROUND

The objective of this study was to determine whether the concomitant presence of poor health status (COPD Assessment Test, CAT ≥ 10 points) and low exercise tolerance (6-Minute Walking Test, 6MWT < 350 m) is associated with worse clinical characteristics in patients with COPD. In addition, we aimed to develop a readily applicable diagnostic model to discriminate COPD patients with these conditions.

METHODS

A cross-sectional multicenter study involving 208 stable COPD patients (FEV1/FVC < 0.7, smoking history of at least 10 pack-years, and chronic respiratory symptoms) was carried out. The outcome measures were the 6MWT, CAT score, 5-repetition sit-to-stand test (5STS) and modified Medical Research Council Dyspnea Scale (mMRC). Patients were categorized into three groups: no condition (6MWT ≥ 350 m and CAT < 10 points), one condition (6MWT < 350 m or CAT ≥ 10 points), and both conditions (6MWT < 350 m and CAT ≥ 10 points).

RESULTS

A total of 26 patients (12,5%) presented both conditions. These patients experienced a higher degree of dyspnea (p = 0.001), smoking pack-years (p = 0.011), severe obstruction (p = 0.006), and time on 5STS (p = 0.001). The probability of having both conditions directly increased with the time spent on the 5STS (β=0.188; p = 0.010) and the degree of dyspnea (β=1.920; p < 0.001) (R2=0.413). The scoring system, using the 5STS and dyspnea as surrogate measures, demonstrated adequate calibration between the predicted and observed risk (linear R2=0.852).

CONCLUSIONS

COPD patients with concurrent conditions have worse clinical status. The diagnostic model developed to discriminate these patients shows good internal validation.

Proposing the potential of utilizing the CAT score for early detection of COPD in asymptomatic patients, shifting towards a patient-centered approach: A review

Chronic obstructive pulmonary disease (COPD) constitutes a significant public health challenge, with delayed diagnosis and underdiagnosis being pervasive issues. The United States Preventive Service Task Force recommends restricting COPD screening to symptomatic smokers, a focus that has exhibited limitations, leading to delayed diagnoses, and imposing a substantial burden on patients, their families, and the healthcare system. This paper explores an alternative approach, highlighting the potential utility of the COPD assessment test (CAT) score as a prescreening tool. A CAT score of 10 or higher could serve as an appropriate threshold for further diagnostic procedures, given its robust correlation with pulmonary function test parameters and is valuable capacity to quantify patients' symptoms. The utilization of CAT as a prescreening tool in primary care signifies a transition towards a more patient-centered and comprehensive approach to COPD diagnosis and care.

Components of the Chronic Obstructive Pulmonary Disease Assessment Test Associated with the Exacerbation of Severe Chronic Obstructive Pulmonary Disease Patients

INTRODUCTION

The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) score is widely used for evaluating the health status of patients diagnosed with COPD. The aim of this study was to identify which components of the CAT are associated with exacerbations in severe COPD patients.

METHODS

Using data from the Korean COPD Subgroup Study (KOCOSS), we identified 3,440 COPD patients, among which 1,027 patients are classified as having severe COPD based on spirometry results. The CAT scores on 8 items were evaluated and classified into respiratory and non-respiratory categories. We analyzed the association between CAT item scores and moderate-to-severe exacerbations during study enrollment and the following years.

RESULTS

Patients with a history of moderate-to-severe exacerbations had higher scores on non-respiratory CAT components. Longitudinal CAT scores on all items after enrollment were higher in the moderate-to-severe exacerbation group. Additionally, the frequency of severe exacerbations was associated with specific CAT components related to limited activities, confidence leaving home, sleeplessness, and energy.

CONCLUSIONS

This study revealed that the non-respiratory CAT component scores were statistically significant factors for predicting the moderate-to-severe exacerbation of severe COPD patients. Non-respiratory symptoms and functional limitations should be considered in patients with severe COPD. Interventions, such as pulmonary rehabilitation, may be needed to improve patients' overall well-being and prevent exacerbations.

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).

Clinical phenotypes of COPD and their impact on quality of life: A cross-sectional study

BACKGROUND

A Chronic Obstructive Pulmonary Disease (COPD) phenotype is a single or group of disease characteristics that describe differences between individuals based on clinically important factors such as symptoms, exacerbations, morbidity, and treatment responses. Many studies estimated the prevalence of various phenotypes, but very few studies looked into their quality of life. We aimed to estimate the prevalence of different COPD phenotypes and their disease-specific Health-Related Quality of Life (HRQoL).

MATERIALS AND METHODS

The prospective study, with a sample size of 136, was conducted between May 2021 and December 2022 in a tertiary teaching institute. Based on their clinical features, COPD patients were classified into 4 different clinical phenotypes, and their disease-specific quality of life was assessed using St. George Respiratory Questionnaire-COPD(SGRQ-c) and COPD Assessment Test (CAT) questionnaires.

RESULTS

Among 136 COPD patients, the frequency of Non-Exacerbator (NE), Exacerbator Emphysema (EEM), Exacerbator Chronic Bronchitis (ECB), and Asthma COPD overlap (ACO) phenotypes was 79(58.1 %), 16(11.8 %), 31(22.8 %), and 10(7.4 %) respectively. Based on the SGRQ-c score, the ECB and EEM phenotypes had a significantly poorer Quality of life (QoL) when compared with NE(P<0.0001), ACO(P=0.011), phenotypes. Similarly, ECB and EEM phenotypes had significantly poorer QoL when compared to NE(P<0.0001), and ACO(P=0.015), based on the CAT score. ECB and EEM patients also had the worst scores in all individual CAT items and SGRQ-c components.

CONCLUSION

NE was the most common followed by ECB phenotype. ECB and EEM phenotypes recorded the poorest quality of life without any significant differences among them. Further research is needed in the future to determine whether phenotype-specific therapies can produce better clinical outcomes.

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

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

Using an electronic diary and wristband accelerometer to detect exacerbations and activity levels in COPD: a feasibility study

Background

Early and accurate identification of acute exacerbations of COPD may lead to earlier treatment and prevent hospital admission. Electronic diaries have been developed for symptom monitoring and accelerometers to monitor activity. However, it is unclear whether this technology is usable in the COPD population. This study aimed to assess the feasibility of an electronic diary (eDiary) for symptom reporting using the MoreCare app and activity monitoring with the Garmin Vivofit 2 in COPD.

Methods

Participants were recruited from the London COPD Cohort. Participants were provided a Garmin Vivofit 2 activity monitor and an android tablet with the MoreCare app for a period of 3 months.

Results

25 COPD patients were recruited (mean±sd age 70.8±7.1 years, forced expiratory volume in 1 s (FEV1) 49.8±14.8% predicted). Age, gender, disease severity and exacerbation frequency had no impact on eDiary compliance. There was a moderate positive correlation between median daily very active minutes and FEV1 % pred (ρ=0.62, p=0.005). Daily step counts decreased during the initial 7 days of exacerbation and recovery compared to a pre-exacerbation baseline. A decision-tree model identified change in sputum colour, change in step count, severity of cold, exacerbation history and use of rescue medication as the most important predictors of acute exacerbations of COPD in this cohort.

Conclusions

Symptom and activity monitoring using digital technology is feasible in COPD. Further large-scale digital health studies are needed to assess whether eDiaries can be used to identify patients at risk of exacerbation and guide early intervention.

Functional capacity and inflammatory biomarkers as predictors for right atrial volume index in COPD patients

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and right-heart complications. So, this study aimed to evaluate the role of right atrial volume index (RAVI), inflammatory biomarkers and functional capacity in predicting poor outcomes for patients with COPD, classified by COPD assessment test (CAT) questionnaire, as early predictors of right heart diseases.

METHODS

151 patients with COPD with ejection fraction (LVEF) > 55% were enrolled and classified according to CAT questionnaire into CAT ≥ 10 (group I) and CAT < 10 (group II). RAVI was calculated using Echocardiography. Assessment of RV systolic function was done by Doppler imaging. Functional capacity parameters were assessed by modified medical research council dyspnea scale (mMRC). IL-1β, adiponectin, hs-CRP and neopterin were evaluated by ELSA kits.

RESULTS

Group I (CAT ≥ 10) had higher RAVI (73.92 ± 21.20 ml/m2 vs 22.73 ± 6.24 ml/m2, p < 0.001), lower S`tri (0.05 ± 0.01 vs 0.13 ± 0.03 m/s, p < 0.001), lower tricuspid annular plane systolic excursion (TAPSE) (1.20 ± 0.17 cm vs 2.17 ± 0.48 cm, p < 0.001), higher RVSP (54.88 ± 7.97 vs 26.79 ± 9.84 mmHg, p < 0.001) compared with group II (CAT < 10). RAVI was good predictor of CAT (r = 0.954, p < 0.001) and strongly correlated with tricuspid S`tri, RVSP, tricuspid E/e' and Mitral E/e' (r = -0.737, r = 0.753, r = 0.817 and r = 0.515, respectively, p < 0.001). RAVI was correlated with TAPSE (r = -0.673, p < 0.001) and with tricuspid E/A ratio & LVEF (r = 0.628, r = -0.407, respectively, p < 0.001). Hs-CRP: 2.50 ± 1.43 vs 2.03 ± 1.19, IL-1β: 37.96 ± 14.35 vs 27.57 ± 8.06, neopterin: 91.37 ± 17.30 vs 76.90 ± 16.75, p < 0.05) were significantly higher besides lower adiponectin levels (3.19 ± 1.98 vs 5.32 ± 1.33 p < 0.05) in group I as compared to group II.

CONCLUSION

Functional capacity might be useful predictor for right heart diseases in COPD patients. Inflammatory biomarkers, low adiponectin and high Hs-CRP, IL-1β and neopterin levels, might not only be useful to monitor treatment response but may also help to discriminate patients with a worsen prognosis.

Prognostic Nutritional Index (PNI) as a Potential Prognostic Tool for Exacerbation of COPD in Elderly Patients

Purpose

In COPD, exacerbation of the disorder causes a deterioration in the quality-of-life and worsens respiratory dysfunction, leading to a poor prognosis. In recent years, nutritional indices have been reported as significant prognostic factors in various chronic diseases. However, the relationship between nutritional indicators and prognosis in elderly subjects with COPD has not been investigated.

Patients and methods

We enrolled 91 subjects who received COPD assessment tests (CAT), spirometry, blood tests, and multidetector computed tomography (MDCT). We divided the subjects into two groups according to age (<75 years (n=57) and ≥ 75 years (n=34)). The prognostic nutritional index (PNI) was used to assess immune-nutritional status and was calculated as 10 x serum albumin + 0.005 x total lymphocyte count. We then examined the relationship between PNI and clinical parameters, including exacerbation events.

Results

There was no significant correlation between the PNI and CAT, the FEV₁%pred, or low attenuation volume percentage (LAV%). In the elderly group, there were significant differences between the groups with or without exacerbation in the CAT and PNI (p=0.008, p=0.004, respectively). FEV₁%pred, neutrophil-to-lymphocyte ratio (NLR) and LAV% did not differ between the two groups. The analytical model combining CAT and PNI improved the prediction of exacerbations in the elderly subjects (p=0.0068).

Conclusion

In elderly subjects with COPD, CAT were associated significantly with the risk of COPD exacerbation, with PNI also a potential predictor. The combined assessment of CAT and PNI may be a useful prognostic tool in subjects with COPD.

Early detection and prediction of acute exacerbation of chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation. Acute exacerbation of COPD (AECOPD) is an acute worsening of respiratory symptoms, which needs additional treatment and can result in worsening health status, increasing risks of hospitalization and mortality. Therefore, it is necessary to early recognize and diagnose exacerbations of COPD. This review introduces the updated definition of COPD exacerbations, the current clinical assessment tools, and the current potential biomarkers. The application of mobile health care in COPD management for early identification and diagnosis is also included in this review.

The prevalence of bronchodilator responsiveness of the small airway (using mid-maximal expiratory flow) in COPD - a retrospective study

BACKGROUND

Bronchodilator responsiveness (BDR) using FEV₁ is often utilised to separate COPD patients from asthmatics, although it can be present in some COPD patients. With the advent of treatments with distal airway deposition, BDR in the small airways (SA) may be of value in the management of COPD. We aimed to identify the prevalence of BDR in the SA, utilizing maximal mid-expiratory flow (MMEF) as a measure of SA. We further evaluated the prevalence of BDR in MMEF with and without BDR in FEV₁ and its association with baseline demographics, including conventional airflow obstruction severity and smoking history.

METHODS

Lung function data of ever-smoking COPD patients were retrospectively analysed. BDR was evaluated 20 min after administering 2.5 mg of salbutamol via jet nebulizer. Increase in percent change of ≥ 12% and absolute change of ≥ 200 ml was used to define a BDR in FEV₁, whereas an increase percent change of MMEF ≥ 30% was used to define a BDR in MMEF. Patients were classified as one of three groups according to BDR levels: group 1 (BDR in MMEF and FEV₁), group 2 (BDR in MMEF alone) and group 3 (no BDR in either measure).

RESULT

BDR in MMEF was present in 59.2% of the patients. Of note, BDR in MMEF was present in all patients with BDR in FEV₁ (group 1) but also in 37.9% of the patients without BDR in FEV₁ (group 2). Patients in group 1 were younger than in groups 2 and 3. BMI was higher in group 1 than in group 3. Baseline FEV₁% predicted and FVC % predicted were also higher in groups 1 and 2 than in group 3.

CONCLUSION

BDR in the SA (evaluated by MMEF) is common in COPD, and it is also feature seen in all patients with BDR in FEV₁. Even in the absence of BDR in FEV₁, BDR in MMEF is detected in some patients with COPD, potentially identifying a subgroup of patients who may benefit from different treatment strategies.

Tiotropium Add-On and Treatable Traits in Asthma-COPD Overlap: A Real-World Pilot Study

Purpose

The 'treatable traits' strategy for patients with chronic inflammatory airway diseases, especially asthma and chronic obstructive pulmonary disease (COPD), is a focus of interest, because it implements precision and personalized medicine. Asthma-COPD overlap (ACO), a phenotype involving both asthma and COPD, is an important disease entity because patients with ACO have significantly worse outcomes, conferring greater economical and social burdens. Some guidelines for ACO recommend add-on therapy of long-acting muscarinic antagonists to inhaled corticosteroids and long-acting β2 agonists. However, this approach is based on extrapolation from patients with asthma or COPD alone. Consequently, a 'treatable traits' approach suitable for ACO remains obscure.

Methods

A 12-week open-label cross-over pilot study was conducted in patients with ACO to investigate the effect of tiotropium bromide (TIO) 5 µg/day add-on therapy to fluticasone propionate/formoterol fumarate (FP/FM) 500/20 µg/day compared with FP/FM 500/20 µg/day alone. A 4-week run-in period and two 4-week treatment periods were included.

Results

A total of 18 male patients with stable ACO participated in this pilot study. All patients were ex-smokers. Mean values ± standard deviation (SD) for forced expiratory volume in 1 second (FEV1) were 1.21 ± 0.49 L after the run-in period, 1.20 ± 0.51 L after the FP/FM combination therapy period, and 1.30 ± 0.48 L after the TIO add-on therapy to FP/FM period. FEV1 values after the TIO add-on therapy FP/FM period were significantly higher than those after the run-in period (p < 0.01).

Conclusion

TIO add-on therapy to FP/FM in patients with ACO, considered difficult to treat because of the presence of both asthma and COPD, resulted in improvements in lung function parameters in this real-world pilot study, indicating the potential value of TIO add-on therapy as a "treatable traits" option for standard treatment for ACO.

Physiological Impairments on Respiratory Oscillometry and Future Exacerbations in Chronic Obstructive Pulmonary Disease Patients without a History of Frequent Exacerbations

Respiratory oscillometry allows measuring respiratory resistance and reactance during tidal breathing and may predict exacerbations in patients with chronic obstructive pulmonary disease (COPD). While the Global Initiative for Chronic Obstructive Lung Disease (GOLD) advocates the ABCD classification tool to determine therapeutic approach based on symptom and exacerbation history, we hypothesized that in addition to spirometry, respiratory oscillometry complemented the ABCD tool to identify patients with a high risk of exacerbations. This study enrolled male outpatients with stable COPD who were prospectively followed-up over 5 years after completing mMRC scale and COPD assessment test (CAT) questionnaires, post-bronchodilator spirometry and respiratory oscillometry to measure resistance, reactance, and resonant frequency (Fres), and emphysema quantitation on computed tomography. Total 134 patients were classified into the GOLD A, B, C, and D groups (n = 48, 71, 5, and 9) based on symptoms on mMRC and CAT and a history of exacerbations in the previous year. In univariable analysis, higher Fres was associated with an increased risk of exacerbation more strongly than other respiratory oscillometry indices. Fres was closely associated with forced expiratory volume in 1 sec (FEV₁). In multivariable Cox-proportional hazard models of the GOLD A and B groups, either lower FEV₁ group or higher Fres group was associated with a shorter time to the first exacerbation independent of the GOLD group (A vs B) and emphysema severity. Adding respiratory oscillometry to the ABCD tool may be useful for risk estimation of future exacerbations in COPD patients without frequent exacerbation history.

Comparison of peak expiratory Flow(PEF) and COPD assessment test (CAT) to assess COPD exacerbation requiring hospitalization: A prospective observational study

Background: Acute exacerbation of chronic obstructive pulmonary disease (COPD) resulting in hospitalization is significantly associated with the increased morbidity and mortality, but there is a lack of an effective method to assess it. This study aimed to compare the ability of peak expiratory flow (PEF) and COPD assessment test (CAT) to assess COPD exacerbations requiring hospitalization. Methods : A cohort of 110 patients with moderate to severe COPD was studied over a period of 12 months, and their daily morning PEFs and CAT scores were recorded throughout the study. Results : After 12 months of follow-up, 72 patients experienced 156 COPD exacerbations, 74 (47%) that resulted in hospitalization and 82 (53%) that did not result in hospitalization. Change in CAT score from baseline to exacerbation was significantly related to change in PEF and Spearman’s rho =0.375 (95% CI, 0.227 to 0.506; p < .001). Change in PEF and CAT score from baseline to hospitalized exacerbation was significantly larger than that from baseline to non-hospitalized exacerbation (p < .05). Multivariable analysis indicated that ΔPEF (OR 1.11, 95% CI 1.06–1.16, p < .001) and ΔCAT (OR 1.64 95% CI 1.18–2.27, p = .003) were independently associated with risk of hospitalized exacerbation. ROC analysis indicated that the optimal cutoff value of ΔPEF for identifying hospitalized exacerbation was 49 L/min (27% from baseline), with a sensitivity and specificity of 82.7% and 76.7% (area under the curve [AUC] = 0.872 (95% CI 0.80–0.944, p < .05). The optimal cutoff value of ΔCAT score for identifying hospitalized exacerbation was 10.5 (63% from baseline), with a sensitivity and specificity of 67.3% and 77.4% [AUC]=0.763 (95% CI 0.67–0.857, p < .05). The AUC of ΔPEF and ΔCAT combined for the identification of hospitalized exacerbation was 0.900 (95% CI 0.841–0.959, p < .05), which was larger than that of ΔCAT or ΔPEF. Conclusions: ΔPEF and ΔCAT were independently associated with risk of hospitalized exacerbation. Compared with CAT, PEF was superior to identify hospitalized exacerbation. Identification via PEF and CAT combined is more effective than using PEF or CAT alone. These results help to assess the severity of COPD exacerbation and provide valuable information for clinical decision-making.

Comparison of clinical characteristics between chronic bronchitis and non-chronic bronchitis in patients with chronic obstructive pulmonary disease

Background

Chronic bronchitis (CB) is associated with poor outcomes in patients with chronic obstructive pulmonary disease. The aim of this study was to identify the characteristics that distinguish chronic bronchitis (CB) from non-CB. In addition, the features of mild CB versus severe CB were compared and a cut-off level was defined according to CAT1 and CAT2 scores.

Methods

This study was based on the Korea COPD Subgroup Study (KOCOSS) database, constructed in a multicenter COPD cohort study that recruited patients from 54 centers. CB was defined as CAT1 and CAT2 scores ≥ 3; severe CB was defined as CAT1 and CAT2 scores ≥ 4, while mild CB was defined as either a CAT1 or a CAT2 score < 4. Baseline characteristics, 1-year exacerbation rate, and 3-year FEV₁ decline were compared in non-CB versus CB patients and in patients with mild CB versus severe CB.

Results

Among the 2162 patients enrolled in this study, 497 (23%) had CB. These patients were more likely than non-CB patients to be current smokers; they also had higher symptom and depression/anxiety scores. Lung function tests showed lower FEV₁, FEV₁/FVC, and DLco values in CB patients. Among CB patients, 67.6% had mild disease. Symptom and depression/anxiety scores were worse in patients with severe CB than in patients with mild CB. There were no significant differences in the lung function tests of the two groups. Analysis of 1-year exacerbation rates in CB patients and non-CB patients revealed that patients with CB more frequently had moderate-to-severe exacerbations (OR = 1.46, p < 0.01). More severe exacerbation was also present in patients with severe CB than in patients with mild CB (OR = 2.52, p = 0.01). The difference in annual FEV₁ decline rate did not significantly differ either between CB patients and non-CB patients or between patients with severe CB and patients with mild CB.

Conclusions

CB patients had worse symptoms and lung function than non-CB patients; CB patients also had more frequent moderate-to-severe exacerbation. Patients with severe CB had higher symptom scores and more frequent severe exacerbation than did patients with mild CB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01854-x.

The Indices of Instantaneous Pulse Rate Variability Are Indicators for Daily Life Quality Assessment in Patients with COPD

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory illness. Questionnaires such as modified Medical Research Council (mMRC) dyspnea scale and COPD assessment test (CAT) are useful for COPD condition and life quality assessment. These questionnaires reflect how respiratory disorder affects daily life. Breathing and autonomic nervous system (ANS) usually regulate each other. Few studies discussed the ANS activity and daily life quality in patients with COPD. Therefore, this study aimed to find the relationship between daily life quality assessed by mMRC or CAT and ANS assessed by a novel method, instantaneous pulse rate variability (iPRV), a method indicating not only the ANS activity but also the peripheral response. The result showed that the change in mMRC and the change in low frequency power to high frequency power ratio, which usually represents the sympathetic activity in conventional heart rate variability analysis, had significant correlation (r = 0.63; p < 0.05). The change in CAT and the change in high frequency power (regulated by vagal nervous and respiratory system) or very high frequency power (new frequency band can be indicated in iPRV spectrum) had significant negative correlation (r = -0.64 and -0.55, respectively; p < 0.05 for both). This study showed the change in iPRV indices when the condition of COPD was improvement or exacerbation. This study presents a possible way to show how cardiovascular activity affects daily life quality in patients with COPD. Increase in LF or decrease in HF and VHF would cause poorer quality of daily life in patients with COPD. The result can also be a reference for patients with COPD to choose the breathing type to adjust rehabilitation and therapy program for ANS regulation to indicate or improve their daily life quality.

Higher COPD Assessment Test Score Associated With Greater Exacerbations Risk: A Post Hoc Analysis of the IMPACT Trial

BACKGROUND

In the InforMing the PAthway of COPD Treatment (IMPACT) trial, single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) reduced moderate/severe exacerbation rates versus FF/VI and UMEC/VI in patients with chronic obstructive pulmonary disease (COPD). This post hoc analysis tested the relationship between baseline health status, risk of future exacerbations, and efficacy outcomes.

METHODS

IMPACT was a Phase 3, double-blind, 52-week trial in patients with symptomatic COPD (COPD Assessment Test [CAT] score ≥10) and ≥1 moderate/severe exacerbation in the prior year randomized 2:2:1 to FF/UMEC/VI 100/62.5/25mcg, FF/VI 100/25mcg, or UMEC/VI 62.5/25mcg. Annual rate of on-treatment moderate/severe exacerbations, lung function, and safety were analyzed by continuous baseline CAT score.

RESULTS

Moderate/severe exacerbation rates increased with increasing baseline CAT scores in FF/UMEC/VI and UMEC/VI arms. There was a very small increase in on-treatment pneumonia rates at higher baseline CAT scores across all treatment arms. FF/UMEC/VI reduced moderate/severe exacerbation rates versus UMEC/VI (i.e., the inhaled corticosteroid effect) consistently across the range of CAT scores. The reduction with FF/UMEC/VI versus FF/VI (i.e., the long-acting muscarinic antagonist effect) was greatest at lower CAT scores and appeared lesser at higher CAT scores. Improvements in lung function were observed with FF/UMEC/VI versus FF/VI and UMEC/VI, regardless of baseline CAT score.

CONCLUSIONS

The CAT score was predictive of exacerbation risk. Worse baseline health status was associated with higher moderate/severe exacerbation and pneumonia rates. Irrespective of baseline CAT score, FF/UMEC/VI improved lung function, and reduced the annual moderate/severe exacerbation rates versus dual therapy. Results indicate an overall favorable benefit-risk profile of triple versus dual therapy, irrespective of CAT score. Clinical Trial Registration:GSK (CTT116855/NCT02164513).

In-hospital pulmonary rehabilitation after completion of primary respiratory disease treatment improves physical activity and ADL performance: A prospective intervention study

INTRODUCTION

Pulmonary rehabilitation improves the physical condition of patients with chronic respiratory disease; however, there are patients who cannot leave the hospital because of their low activities of daily living (ADLs), despite the completion of primary respiratory disease treatment and rehabilitation during treatment. Therefore, this study demonstrated that those patients recovered their ADLs through in-hospital pulmonary rehabilitation after treatment completion.

METHODS

We prospectively studied 24 hospitalized patients who had some remaining symptoms and showed low ADL scores of 9 points or less on the short physical performance battery after undergoing treatment for respiratory disease in Fukujuji Hospital from October 2018 to October 2019, excluding 2 patients who had re-exacerbation and 1 patient who could not be examined using the incremental shuttle walk test (ISWT). After completion of the primary respiratory disease treatment, patients moved to the regional comprehensive care ward, and they received pulmonary rehabilitation for 2 weeks. In the ward, patients who could not yet leave the hospital could undergo pulmonary rehabilitation for up to 60 days. Data were evaluated three times: upon treatment completion (baseline), postrehabilitation, and 3 months after baseline. The main outcome was an improvement in the incremental shuttle walk test (ISWT) postrehabilitation.

RESULTS

The median age of the patients was 80 (interquartile range (IQR): 74.8-84.5), and 14 patients (58.3%) were male. The ISWT distance significantly increased postrehabilitation (median [IQR]: 60 m [18-133] vs 120 m [68-203], P < .001). The Barthel Index (BI) (P < .001), the modified Medical Research Council (P < .001), and other scale scores were also improved. Among patients with acute respiratory diseases such as pneumonia, chronic obstructive pulmonary disease, and interstitial pneumonia, ISWT and other data showed improvement at the postrehabilitation timepoint. Ten patients who could perform examinations at 3 months after baseline were evaluated 3 months after taking baseline data prior to starting rehabilitation. The ISWT showed significant improvement 3 months after baseline compared to baseline (P = .024), and the ISWT distance was maintained after rehabilitation.

DISCUSSION AND CONCLUSIONS

Physical activity, symptoms, mental health, and ADL status in patients who had not recovered after primary treatment completion for respiratory diseases could improve through in-hospital pulmonary rehabilitation.

Application of oxygen saturation variability analysis for the detection of exacerbation in individuals with COPD: A proof-of-concept study

BACKGROUND

Individuals with chronic obstructive pulmonary disease (COPD) commonly experience exacerbations, which may require hospital admission. Early detection of exacerbations, and therefore early treatment, could be crucial in preventing admission and improving outcomes. Our previous research has demonstrated that the pattern analysis of peripheral oxygen saturation (Sp O2 ) fluctuations provides novel insights into the engagement of the respiratory control system in response to physiological stress (hypoxia). Therefore, this pilot study tested the hypothesis that the pattern of Sp O2 variations in overnight recordings of individuals with COPD would distinguish between stable and exacerbation phases of the disease.

METHODS

Overnight pulse oximetry data from 11 individuals with COPD, who exhibited exacerbation after a period of stable disease, were examined. Stable phase recordings were conducted overnight and one night prior to exacerbation recordings were also analyzed. Pattern analysis of Sp O2 variations was carried examined using sample entropy (for assessment of irregularity), the multiscale entropy (complexity), and detrended fluctuation analysis (self-similarity).

RESULTS

Sp O2 variations displayed a complex pattern in both stable and exacerbation phases of COPD. During an exacerbation, Sp O2 entropy increased (p = 0.029) and long-term fractal-like exponent (α2) decreased (p = 0.002) while the mean and standard deviation of Sp O2 time series remained unchanged. Through ROC analyses, Sp O2 entropy and α2 were both able to classify the COPD phases into either stable or exacerbation phase. With the best positive predictor value (PPV) for sample entropy (PPV = 70%) and a cut-off value of 0.454. While the best negative predictor value (NPV) was α2 (NPV = 78%) with a cut-off value of 1.00.

CONCLUSION

Alterations in Sp O2 entropy and the fractal-like exponent have the potential to detect exacerbations in COPD. Further research is warranted to examine if Sp O2 variability analysis could be used as a novel objective method of detecting exacerbations.

Towards precision in defining COPD exacerbations

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

Virus-induced Volatile Organic Compounds are Detectable in Exhaled Breath During Pulmonary Infection

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a condition punctuated by acute exacerbations commonly triggered by viral and/or bacterial infection. Early identification of exacerbation trigger is important to guide appropriate therapy but currently available tests are slow and imprecise. Volatile organic compounds (VOCs) can be detected in exhaled breath and have the potential to be rapid tissue-specific biomarkers of infection aetiology.

METHODS

We used serial sampling within in vitro and in vivo studies to elucidate the dynamic changes that occur in VOC production during acute respiratory viral infection. Highly sensitive gas-chromatography mass spectrometry (GC-MS) techniques were used to measure VOC production from infected airway epithelial cell cultures and in exhaled breath samples of healthy subjects experimentally challenged with rhinovirus A16 and COPD subjects with naturally-occurring exacerbations.

RESULTS

We identified a novel VOC signature comprising of decane and other related long chain alkane compounds that is induced during rhinovirus infection of cultured airway epithelial cells and is also increased in the exhaled breath of healthy subjects experimentally challenged with rhinovirus and of COPD patients during naturally-occurring viral exacerbations. These compounds correlated with magnitude of anti-viral immune responses, virus burden and exacerbation severity but were not induced by bacterial infection, suggesting they represent a specific virus-inducible signature.

CONCLUSION

Our study highlights the potential for measurement of exhaled breath VOCs as rapid, non-invasive biomarkers of viral infection. Further studies are needed to determine whether measurement of these signatures could be used to guide more targeted therapy with antibiotic/antiviral agents for COPD exacerbations.

Clinical Characteristics of COPD Patients According to COPD Assessment Test (CAT) Score Level: Cross-Sectional Study

PURPOSE

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is widely used to assess the impact of COPD symptoms on health status. Whilst the CAT consists of eight different items, details on the distribution of each item are limited. This study aimed to investigate the distribution and clinical implication of each CAT item, stratified by CAT severity group, in stable COPD patients.

PATIENTS AND METHODS

This was a cross-sectional study at a single referral hospital in South Korea. Spirometry confirmed COPD patients with CAT measured at the first clinical visit were retrospectively identified. Patients were categorized into three groups: low (0 ≤ CAT < 10), medium (10 ≤ CAT < 20), and high (20 ≤ CAT ≤ 40) impact group. For the purpose of this analysis, the first four items (cough, sputum, chest tightness, and dyspnea) and the remaining four items (activities, confidence, sleep and energy) were also grouped as "pulmonary" and "extra-pulmonary", respectively.

RESULTS

A total of 815 patients were included, and mean (SD) forced expiratory volume in 1 s (FEV1) was 62.8 (17.4) % pred. Among them, 300 patients (36.8%) were in the high impact group and had a greater exacerbation history and lower lung function. The proportion of "extra-pulmonary" items score was greater in patients with higher total CAT scores, with the activity and confidence items showing higher scores.

CONCLUSION

In our study, in addition to dyspnea, activity limitation is a particular problem in individual patients with higher CAT total scores, for which physicians need to pay more attention. Our study suggests that whilst CAT total score captures the overall impact of COPD, each item of the CAT contains potentially useful information in understanding the patient's symptom burden.

Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact

In chronic obstructive pulmonary disease (COPD), exacerbations (ECOPD), characterized by an acute deterioration in respiratory symptoms, are fundamental events impacting negatively upon disease progression, comorbidities, wellbeing and mortality. ECOPD also represent the largest component of the socioeconomic burden of COPD. ECOPDs are currently defined as acute worsening of respiratory symptoms that require additional therapy. Definitions that require worsening of dyspnoea and sputum volume/purulence assume that acute infections, especially respiratory viral infections, and/or exposure to pollutants are the main cause of ECOPD. But other factors may contribute to ECOPD, such as the exacerbation of other respiratory diseases and non-respiratory diseases (e.g., heart failure, thromboembolism). The complexity of worsening dyspnoea has suggested a need to improve the definition of ECOPD using objective measurements such as blood counts and C-reactive protein to improve accuracy of diagnosis and a personalized approach to management. There are three time points when we can intervene to improve outcomes: acutely, to attenuate the length and severity of an established exacerbation; in the aftermath, to prevent early recurrence and readmission, which are common, and in the long-term, establishing preventative measures that reduce the risk of future events. Acute management includes interventions such as corticosteroids or antibiotics and measures to support the respiratory system, including non-invasive ventilation (NIV). Current therapies are broad and better understanding of clinical phenotypes and biomarkers may help to establish a more tailored approach, for example in relation to antibiotic prescription. Other unmet needs include effective treatment for viruses, which commonly cause exacerbations. Preventing early recurrence and readmission to hospital is important and the benefits of interventions such as antibiotics or anti-inflammatories in this period are not established. Domiciliary NIV in those patients who are persistently hypercapnic following discharge and pulmonary rehabilitation can have a positive impact. For long-term prevention, inhaled therapy is key. Dual bronchodilators reduce exacerbation frequency but in patients with continuing exacerbations, triple therapy should be considered, especially if blood eosinophils are elevated. Other options include phosphodiesterase inhibitors and macrolide antibiotics. ECOPD are a key component of the assessment of COPD severity and future outcomes (quality of life, hospitalisations, health care resource utilization, mortality) and are a central component in pharmacological management decisions. Targeted therapies directed towards specific pathways of inflammation are being explored in exacerbation prevention, and this is a promising avenue for future research.

Integrating Home-Based Exercise Training with a Hospital at Home Service for Patients Hospitalised with Acute Exacerbations of COPD: Developing the Model Using Accelerated Experience-Based Co-Design

BACKGROUND

Hospital at home (HaH) schemes allow early discharge of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Traditional outpatient pulmonary rehabilitation (PR) following an AECOPD has an established evidence-base, but there are issues with low referral, uptake and completion. One commonly cited barrier to PR post-hospitalisation relates to poor accessibility. To address this, the aim of this project was to enrol service users (patients with COPD and informal carers) and healthcare professionals to co-design a model of care that integrates home-based exercise training within a HaH scheme for patients discharged from hospital following AECOPD.

METHODS

This accelerated experience-based co-design project included three audio-recorded stakeholder feedback events, using key "touchpoints" from previous qualitative interviews and a recent systematic review. Audio-recordings were inductively analysed using directed content analysis. An integrated model of care was then developed and finalised through two co-design groups, with the decision-making process facilitated by the tables of changes approach.

RESULTS

Seven patients with COPD, two informal carers and nine healthcare professionals (from an existing outpatient PR service and HaH scheme) participated in the stakeholder feedback events. Four key themes were identified: 1) individualisation, 2) progression and transition, 3) continuity between services, and 4) communication between stakeholders. Two patients with COPD, one informal carer and three healthcare professionals participated in the first joint co-design group, with five healthcare professionals attending a second co-design group. These achieved a consensus on the integrated model of care. The agreed model comprised face-to-face supervised, individually tailored home-based exercise training one to three times a week, delivered during HaH scheme visits where possible by a healthcare professional competent to provide both home-based exercise training and usual HaH care.

CONCLUSION

An integrated model of care has been co-designed by patients with COPD, informal carers and healthcare professionals to address low uptake and completion of PR following AECOPD. The co-designed model of care has now been integrated within a well-established HaH scheme.

Perioperative changes in respiratory impedance in lobectomy and their clinical impact

Background

Respiratory function declines after lung resection. However, perioperative changes in respiratory impedance and their clinical significance are unclear. The forced oscillation technique can measure respiratory impedance during quiet breathing and possibly early after surgery. We investigated respiratory impedance changes before and after lung lobectomy and examined the correlation of impedance with clinical factors.

Methods

We prospectively included patients who underwent lobectomy between February 2018 and March 2020 and measured respiratory impedance by forced oscillation preoperatively and postoperative days 1 and 7. We statistically analyzed changes in perioperative forced oscillation measurements and their correlation with clinical factors, including subjective symptoms. The modified British Medical Research Council scale and the chronic obstructive pulmonary disease (COPD) assessment test were used for scoring subjective symptoms.

Results

Forty-four subjects were included, in whom respiratory impedance could be measured from postoperative day 1. The respective mean values for forced oscillation measurements preoperatively and at postoperative days 1 and 7 were as follows: respiratory resistance, 5 Hz: 2.28, 2.77, and 2.75; respiratory resistance, 20 Hz: 2.00, 2.36, and 2.32; difference in respiratory resistance at 5 and 20 Hz: 0.28, 0.40, and 0.43; respiratory reactance, 5 Hz: -0.31, -0.65, and -0.56; resonant frequency: 7.45, 10.41, and 9.81; and low-frequency reactance area: 1.33, 3.27, and 2.84. These changes were statistically significant (P<0.01). Besides the difference in respiratory resistance at 5 and 20 Hz, all other measurements on postoperative day 7 were relatively weakly correlated with the modified Medical Research Council scale score at this time point (all P<0.05). Respiratory complications correlated with the respiratory resistance difference, respiratory reactance, and resonant frequency on day 7 (R =0.415, -0.421, and 0.441), while the latter also correlated with postoperative hypoxemia on day 1 (R =0.433).

Conclusions

Respiratory impedance was measurable even early after surgery and significantly changed postoperatively. As the sample size was small and appeared to be biased, assessing respiratory impedance and clinical factors in detail was difficult. Since respiratory impedance is suggested to be associated with clinical factors that affect the postoperative course, it is necessary to accumulate cases and observe them over longer periods.

Long-Term Auscultation in Chronic Obstructive Pulmonary Disease: Renaissance of an Ideograph of Medical Care

BACKGROUND

Electronic auscultation technology has advanced dramatically in the last few years. Therefore, long-term pulmonary auscultation could provide additional information about respiratory system by monitoring acute chronic obstructive pulmonary disease (AECOPD) exacerbations or by identifying wheezing phenotypes amongst stable COPD patients.

OBJECTIVES

Comparison of respiratory sounds in stable versus AECOPD patients recorded with a portable respiratory sound monitor over a period of 24 h.

METHODS

This prospective trial evaluated cough and wheezing events using an auscultation monitor specially developed for this purpose with 4 integrated highly sensitive microphones, in stable and severely AECOPD patients for a period of 24 h in an inpatient setting.

RESULTS

Twenty stable COPD patients (12 male, 60%) and 20 severely exacerbated COPD patients (14 male, 70%) were analyzed. In AECOPD patients, long-term auscultation revealed a significantly higher number of wheezing epochs than stable COPD patients (591 [IQR: 145-1,645] vs. 152 [IQR: 90-400]; p = 0.021). Conversely, cough epochs did not differ between AECOPD and stable COPD patients (213 [IQR: 140-327] vs. 162 [IQR: 123-243]; p = 0.256). The Borg-dyspnea scale, CAT score, and total CCQ score each showed no correlation with wheezing frequency, while CAT and CCQ scores did correlate with coughing frequency.

CONCLUSION

Wheezing, but not coughing, occurs more frequently in AECOPD patients than in stable COPD patients, indicating that severe wheezing is an important clinical sign of exacerbation, while coughing is not. Therefore, the patterns of wheezing and coughing, as assessed by long-term auscultation, differ in stable versus exacerbated COPD patients.

Investigating Patient and Family Satisfaction with the Respiratory Status in Patients with Chronic Obstructive Pulmonary Disease

The current chronic obstructive pulmonary disease (COPD) management aims to improve the patients' quality of life and healthy life expectancy; however, few studies have evaluated the level of satisfaction with the patients' current respiratory status in COPD patients and their families. This study aimed to examine the level of patient and family satisfaction with the patients' current respiratory status and to identify the clinical factors closely linked to dissatisfaction.This multicenter, cross-sectional study included 454 outpatients with COPD and 296 family members. Patients and families were allocated to the satisfied and dissatisfied groups based on their satisfaction with the patients' current respiratory status. Patients' health status, dyspnoea, appetite, respiratory function, and mood disorders were assessed.Among the participants of this study, 67% of patients and 60% of their families were dissatisfied with the patients' current respiratory status. The COPD assessment test (CAT) was the most sensitive marker of dissatisfaction compared to other clinical factors (p < 0.01). The statistical cut-off value of CAT for predicting patient dissatisfaction was 11. CAT reflected patient dissatisfaction independent of age, sex, dyspnoea, appetite, mood disorders, body mass index, and respiratory function (odds ratio: CAT; 1.12 (1.07-1.19): p < 0.01).Many patients and families are dissatisfied with the patients' respiratory status, and the patients' CAT score is useful to predict dissatisfaction. Our findings are consistent with the Global Initiative for Chronic Obstructive Lung Disease indicating that treatment should be enhanced in patients with a CAT score ≥10. Furthermore, treatment strategies targeting CAT may contribute to an improved patient satisfaction.

Correlation of Luminal Mucus Score in Large Airways with Lung Function and Quality of Life in Severe Acute Exacerbation of COPD: A Cross-Sectional Study

BACKGROUND AND OBJECTIVE

Luminal mucus plugging in small airways is associated with lung function decline and death of patients with chronic obstructive pulmonary disease (COPD). However, little attention has been paid to the possible role of mucus in large airways in acute exacerbation of COPD (AECOPD). Therefore, this study aimed to explore the relationship between the luminal mucus score of large airways and other physiological parameters of severe AECOPD.

SUBJECTS AND METHODS

A total of 74 AECOPD inpatients were enrolled in this cross-sectional study. All patients underwent lung function tests and bronchoscopy, and their luminal mucus was observed and scored through bronchoscopy. Four questionnaires, including the St. George Respiratory Questionnaire (SGRQ), modified Medical Research Council dyspnea scale (mMRC), COPD Assessment Test (CAT) and Exacerbation of Chronic pulmonary disease Tool (EXACT), were used to assess health-related quality of life (HRQoL).

RESULTS

The luminal mucus score of large airways was significantly correlated with spirometry parameters and HRQoL score. Both mMRC grade and SGRQ score were significantly positively correlated with luminal mucus score (ρ=0.527, P<0.001; ρ=0.441, P<0.001, respectively). Forced expiratory flow at 25% to 75% of the FVC (FEF_25%-75%) and FEV₁% predicted, as functional measures reflecting small airway disease, were significantly negatively correlated with luminal mucus score (ρ=-0.518, P<0.001; ρ=-0.498, P<0.001, respectively). The stepwise multiple linear regression model suggested that mMRC grade and FEV₁% predicted could predict luminal mucus score (R ²=0.348, F=18.960, P<0.001).

CONCLUSION

For severe acute exacerbation of COPD, bronchoscopy-identified luminal mucus in large airways is associated with reduced lung function and worse health-related quality of life.

Once Daily Versus Overnight and Symptom Versus Physiological Monitoring to Detect Exacerbations of Chronic Obstructive Pulmonary Disease: Pilot Randomized Controlled Trial

BACKGROUND

Earlier detection of chronic obstructive pulmonary disease (COPD) exacerbations may facilitate more rapid treatment with reduced risk of hospitalization. Changes in pulse oximetry may permit early detection of exacerbations. We hypothesized that overnight pulse oximetry would be superior to once-daily monitoring for the early detection of exacerbations.

OBJECTIVE

This study aims to evaluate whether measuring changes in heart rate and oxygen saturation overnight is superior to once-daily monitoring of both parameters and to assess symptom changes in facilitating earlier detection of COPD exacerbations.

METHODS

A total of 83 patients with COPD were randomized to once-daily or overnight pulse oximetry. Both groups completed the COPD assessment test questionnaire daily. The baseline mean and SD for each pulse oximetry variable were calculated from 14 days of stable monitoring. Changes in exacerbation were expressed as Z scores from this baseline.

RESULTS

The mean age of the patients was 70.6 (SD 8.1) years, 52% (43/83) were female, and the mean FEV1 was 53.0% (SD 18.5%) predicted. Of the 83 patients, 27 experienced an exacerbation. Symptoms were significantly elevated above baseline from 5 days before to 12 days after treatment initiation. Day-to-day variation in pulse oximetry during the stable state was significantly less in the overnight group than in the once-daily group. There were greater relative changes at exacerbation in heart rate than oxygen saturation. An overnight composite score of change in heart rate and oxygen saturation changed significantly from 7 days before initiation of treatment for exacerbation and had a positive predictive value for exacerbation of 91.2%. However, this was not statistically better than examining changes in symptoms alone.

CONCLUSIONS

Overnight pulse oximetry permits earlier detection of COPD exacerbations compared with once-daily monitoring. Monitoring physiological variables was not superior to monitoring symptoms, and the latter would be a simpler approach, except where there is a need for objective verification of exacerbations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03003702; https://clinicaltrials.gov/ct2/show/NCT03003702.

Targeted Retreatment of Incompletely Recovered Chronic Obstructive Pulmonary Disease Exacerbations with Ciprofloxacin. A Double-Blind, Randomized, Placebo-controlled, Multicenter, Phase III Clinical Trial

Rationale: Chronic obstructive pulmonary disease (COPD) exacerbations are prone to nonrecovery, but there are no data about the effectiveness of retreatment for these prolonged events. We examined whether further therapy with ciprofloxacin for incompletely resolved COPD exacerbations prolonged the time until the next event.Objectives: To assess whether incompletely recovered COPD exacerbations benefit from additional treatment with ciprofloxacin, at Day 14.Methods: In a multicenter, randomized double-blind placebo-controlled trial, we studied retreatment with oral ciprofloxacin 500 mg or matched placebo twice daily for 7 days in patients with Global Initiative for Chronic Obstructive Lung Disease stage II-IV COPD and persistent symptoms and/or serum C-reactive protein ≥8 mg/L initiated 14 (±3) days after an index COPD exacerbation. The primary outcome was the time to the next exacerbation within a 90-day period.Measurements and Main Results: Among 826 patients screened at four centers, 144 eligible participants with incomplete recovery were randomized to receive ciprofloxacin (n = 72) or placebo (n = 72). Within 90 days of randomization, 57% of the patients in the ciprofloxacin group and 53% in the placebo group experienced one or more exacerbations. The median time to the next exacerbation was 32.5 days (interquartile range 13-50) in the placebo arm and 34 days (interquartile range 17-62) in the ciprofloxacin arm, which was not significantly different (adjusted hazard ratio, 1.07; 95% confidence interval, 0.68-1.68; P = 0.76). No significant differences were seen in quality-of-life scores or lung function between the treatment groups.Conclusions: In patients with persistent symptoms and/or raised C-reactive protein 14 days after a COPD exacerbation, an additional course of ciprofloxacin resulted in no additional benefit compared with placebo. This suggests that nonrecovered exacerbations are not driven by ongoing bacterial infection and may potentially be targeted with antiinflammatory therapy.Clinical trial registered with www.clinicaltrials.gov (NCT02300220).

Assessing Symptom Burden

Evaluating symptoms is a central part of the chronic obstructive pulmonary disease (COPD) assessment system as suggested by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Considering the pros and cons of all currently available tests, GOLD suggests using primarily the modified Medical Research Council dyspnea scale or the COPD Assessment Test. Based on the test results, patients are categorized as having a low or high level of symptoms. This level then becomes one of the 2 dimensions of the ABCD grading system, which was designed to match the best initial treatment option to the individual patient's needs.

Clinical phenotypes and heath-related quality of life of COPD patients in a rural setting in Malaysia - a cross-sectional study

BACKGROUND

The Spanish chronic obstructive pulmonary disease (COPD) guideline phenotypes patients according to the exacerbation frequency and COPD subtypes. In this study, we compared the patients' health-related quality of life (HRQoL) according to their COPD phenotypes.

METHODS

This was a cross-sectional study of COPD patients who attended the outpatient clinic of the Serian Divisional Hospital and Bau District Hospital from 23th January 2018 to 22th January 2019. The HRQoL was assessed using modified Medical Research Council (mMRC), COPD Assessment Test (CAT), and St George's Respiratory Questionnaire for COPD (SGRQ-c).

RESULTS

Of 185 patients, 108 (58.4%) were non-exacerbators (NON-AE), 51 (27.6%) were frequent exacerbators (AE), and the remaining 26 (14.1%) had asthma-COPD overlap (ACO). Of AE patients, 42 (82.4%) had chronic bronchitis and only 9 (17.6%) had emphysema. Of the 185 COPD patients, 65.9% had exposure to biomass fuel and 69.1% were ex- or current smokers. The scores of mMRC, CAT, and SGRQ-c were significantly different between COPD phenotypes (p <  0.001). There were significantly more patients with mMRC 2-4 among AE (68.6%) (p <  0.001), compared to those with ACO (38.5%) and NON-AE (16.7%). AE patients had significantly higher total CAT (p = 0.003; p <  0.001) and SGRQ-c (both p <  0.001) scores than those with ACO and NON-AE. Patients with ACO had significantly higher total CAT and SGRQ-c (both p <  0.001) scores than those with NON-AE. AE patients had significantly higher score in each item of CAT and component of SGRQ-c compared to those with NON-AE (all p <  0.001), and ACO [(p = 0.003-0.016; p = < 0.001-0.005) except CAT 1, 2 and 7. ACO patients had significantly higher score in each item of CAT and component of SGRQ-c (p = < 0.001-0.040; p <  0.001) except CAT 2 and activity components of SGRQ-c.

CONCLUSIONS

The HRQoL of COPD patients was significantly different across different COPD phenotypes. HRQoL was worst in AE, followed by ACO and NON-AE. This study supports phenotyping COPD patients based on their exacerbation frequency and COPD subtypes. The treatment of COPD should be personalised according to these two factors.

Day-to-day variability of forced oscillatory mechanics for early detection of acute exacerbations in COPD

BACKGROUND

Telemonitoring trials for early detection of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have provided mixed results. Day-to-day variations in lung function measured by the forced oscillation technique (FOT) may yield greater insight. We evaluated the clinical utility of home telemonitoring of variability in FOT measures in terms of 1) the relationship with symptoms and quality of life (QoL); and 2) the timing of variability of FOT measures and symptom changes prior to AECOPD.

METHODS

Daily FOT parameters at 5 Hz (resistance (R) and reactance (X); Resmon Pro Diary, Restech Srl, Milan, Italy), daily symptoms (COPD Assessment Test (CAT)) and 4-weekly QoL data (St George's Respiratory Questionnaire (SGRQ)) were recorded over 8-9 months from chronic obstructive pulmonary disease (COPD) patients. Variability of R and X was calculated as the standard deviation (sd) over 7-day running windows and we also examined the effect of varying window size. The relationship of FOT versus CAT and SGRQ was assessed using linear mixed modelling, daily changes in FOT variability and CAT prior to AECOPD using one-way repeated measures ANOVA.

RESULTS

Fifteen participants with a mean±sd age of 69±10 years and a % predicted forced expiratory volume in 1 s (FEV₁) of 39±10% had a median (interquartile range (IQR)) adherence of 95.4% (79.0-98.8%). Variability of the inspiratory component of X (indicated by the standard deviation of inspiratory reactance (SDX_insp)) related to CAT and weakly to SGRQ (fixed effect estimates 1.57, 95% CI 0.65-2.49 (p=0.001) and 4.41, 95% CI -0.06 to 8.89 (p=0.05), respectively). SDX_insp changed significantly on the same day as CAT (1 day before AECOPD, both p=0.02) and earlier when using shorter running windows (3 days before AECOPD, p=0.01; accuracy=0.72 for 5-day windows).

CONCLUSIONS

SDX_insp from FOT telemonitoring reflects COPD symptoms and may be a sensitive biomarker for early detection of AECOPD.

Moderate-to-Severe Obstructive Sleep Apnea and Cognitive Function Impairment in Patients with COPD

Purpose

Prior studies have indicated that patients with chronic obstructive pulmonary disease (COPD) exhibit significant cognitive defects on neuropsychological testing. Obstructive sleep apnea (OSA) is common in patients with COPD and is associated with reduced cognitive function; however, the combined impact of these two conditions on cognitive function is unknown. The aim of the study was to investigate the impact of OSA on cognitive impairment in patients with COPD.

Methods

Sixty-five stable COPD patients aged over 60 years underwent overnight polysomnography (PSG). Global cognitive functions were evaluated using the Mini-Mental State Examination (MMSE).

Results

Compared to patients with COPD alone, patients with both COPD and OSA performed worse on the MMSE (25.5±2.9 vs 23.5±3.2; p=0.01) and were more likely to be at risk for developing dementia based on the MMSE score (MMSE≤24) (31% vs 66%; p<0.01), independent of key demographic, educational and medical variables known to affect cognitive function in COPD. COPD patients with an apnea hypopnea index (AHI) of ≥30 events/h had lower MMSE scores than those with an AHI of <15 events/h. In addition to age and education level, the severity of nocturnal intermittent hypoxia is an independent predictor of the risk of dementia in patients with COPD (OR=1.24, 95% CI 1.04-1.48, p = 0.02).

Conclusion

The current findings indicate that patients with COPD with comorbid OSA may be at greater risk for global cognitive impairment relative to patients with COPD alone. The mechanisms underlying the exaggerated cognitive dysfunction seem to be related to intermittent hypoxia. Further work is needed to understand the impact of OSA on the specific domains of cognitive impairment and the therapeutic implications of OSA in COPD.

An overview of exacerbations of chronic obstructive pulmonary disease: Can tests of small airways' function guide diagnosis and management?

Chronic obstructive pulmonary disease (COPD) is common and debilitating. Most patients with COPD experience intermittent, acute deterioration in symptoms which require additional therapy, termed exacerbations. Exacerbations are prevalent in COPD and are associated with poor clinical outcomes including death, a faster decline in lung health, and a reduced quality of life. Current guidelines highlight the need to treat exacerbations promptly and then mitigate future risk. However, exacerbations are self-reported, difficult to diagnose and are treated with pharmacological therapies which have largely been unchanged over 30 years. Recent research has highlighted how exacerbations vary in their underlying cause, with specific bacteria, viruses, and cell types implicated. This variation offers the opportunity for new targeted therapies, but to develop these new therapies requires sensitive tools to reliably identify the cause, the start, and end of an exacerbation and assess the response to treatment. Currently, COPD is diagnosed and monitored using spirometric measures, principally the forced expiratory volume in 1 s and forced vital capacity, but these tests alone cannot reliably diagnose an exacerbation. Measures of small airways' function appear to be an early marker of COPD, and some studies have suggested that these tests might also provide physiological biomarkers for exacerbations. In this review, we will discuss how exacerbations of COPD are currently defined, stratified, monitored, and treated and review the current literature to determine if tests of small airways' function might improve diagnostic accuracy or the assessment of response to treatment.

COPD Assessment Test Changes from Baseline Correlate with COPD Exacerbations: A Longitudinal Analysis of the DACCORD Observational Study

PURPOSE

A number of analyses have shown the immediate impact of COPD exacerbations on health status. However, none evaluated the long-term correlation between health status and the occurrence of exacerbations.

METHODS

DACCORD is an observational study in patients with COPD recruited across Germany following initiation or change in COPD maintenance medication. Data collected include COPD Assessment Test (CAT) total score on entry and after 1 and 2 years, and the occurrence of exacerbations. We analysed the correlation between change from baseline in CAT total score and exacerbations, after excluding patients who exacerbated during the quarter immediately prior to the CAT assessment of interest.

RESULTS

The initial correlation analysis was performed in 6075 patients, 28% with ≥ 1 exacerbation over the 2-year follow-up, and 58% with a clinically relevant CAT improvement. There was a significant correlation between exacerbations over 2 years and CAT change from baseline at Year 2 (p = 0.0041). The Spearman's correlation coefficient was 0.03711, indicating very weak correlation-potentially driven by the high proportion of non-exacerbating patients. In a subsequent logistic regression, the probability of experiencing frequent (≥ 2 per year) or severe exacerbations was higher in patients with worsening in CAT total score (p < 0.001). However, the probability of a patient exacerbating in Year 1 or Year 2 did not correlate with CAT change.

CONCLUSIONS

In this population (initiating or changing maintenance COPD medication), patients with frequent or severe exacerbations had a long-term worsening in health status (beyond the acute effect of an exacerbation) compared with patients who do not exacerbate.

Impact of baseline symptoms and health status on COPD exacerbations in the FLAME study

BACKGROUND

COPD is a heterogeneous disease and patients may respond differently to therapies depending on baseline symptom burden.

METHODS

This post-hoc analysis from the 52-week FLAME study investigated the impact of baseline symptom burden in terms of health status, dyspnoea, bronchitis status, eosinophil levels and smoking status on the subsequent risk of moderate or severe exacerbations. Health status was measured by St. George's Respiratory Questionnaire (SGRQ) score (higher ≥46.6 and lower < 46.6) and COPD Assessment Test (CAT) score (higher ≥17 and lower < 17); dyspnoea and bronchitis were assessed via an electronic diary (eDiary). Differential response to once-daily indacaterol/glycopyrronium (IND/GLY) 110/50 μg versus twice-daily salmeterol/fluticasone (SFC) 50/500 μg was assessed.

RESULTS

Data from 3354 patients was analysed. The risk of exacerbations was lower in patients who had less severe health impairment (rate ratio [RR] [95% CI]): SGRQ-C, (0.88 [0.78, 0.99]); CAT, 0.85 [0.75, 0.96]) and lower dyspnoea (0.79 [0.69, 0.90]) at baseline versus those with more severe health impairment and higher dyspnoea, respectively. Compared with SFC, IND/GLY led to better prevention of moderate-to-severe exacerbations in the majority of groups studied.

CONCLUSION

Patients with more severe health status impairment and greater symptom burden at baseline subsequently experienced more exacerbations in the FLAME study. IND/GLY was overall more effective in preventing exacerbations versus SFC, regardless of baseline symptom burden. Our results suggest that future studies on novel exacerbation therapies should consider targeting patients with higher symptom burden at baseline.

CLINICAL TRIAL IDENTIFIER

NCT01782326.

Effect of high-flow nasal therapy during early pulmonary rehabilitation in patients with severe AECOPD: a randomized controlled study

Background

Chronic obstructive pulmonary disease (COPD) is airway inflammation characterized and low daily physical activity. Most pulmonary rehabilitation (PR) programs are often provided to stable patients, but fewer training programs are specific for hospitalized patients with acute exacerbation (AE). Patients with AECOPD experience increased dyspnea sensations and systemic inflammation during exercise training. High-flow nasal therapy (HFNT) reduces the minute volume, lowers the respiratory rate, and decreases the work of breathing. However, it is not clear whether HFNT is efficient during exercise training. In this study, we investigated the effects of HFNT during exercise training in an early PR program among hospitalized patients with severe AECOPD.

Methods

We enrolled COPD patients hospitalized due to AE. They were randomized into two groups according to their status into HFNT PR and non-HFNT PR groups. This study collected basic data, and also assessed a pulmonary function test, 6-min walking test, blood inflammatory biomarkers, and arterial gas analysis at the baseline, and at 4 and 12 weeks of the intervention. Data were analyzed using SPSS statistical software.

Result

We recruited 44 AECOPD patients who completed the 12-week PR program. The HFNT PR program produced significant improvements in exercise tolerance as assessed by the 6-min walking distance (6MWD), reduced dyspnea sensations in the modified Medical Research Council (mMRC), and decreased systemic inflammation as evidenced by the a lower C-reactive protein (CRP) level. A reduction in the length of hospitalization was achieved with PR in the 1-year follow-up in the two groups. The HFNT PR group showed better trends of reduced air trapping in the delta inspiration capacity (IC) and an increased quality of life according to the COPD assessment test (CAT) than did the non-HFNT PR group.

Conclusions

HFNT during exercise training in early PR increases exercise tolerance and reduces systemic inflammation in hospitalized patients with severe AECOPD.

Triple Therapy with Budesonide/Glycopyrrolate/Formoterol Fumarate Improves Inspiratory Capacity in Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap

Purpose

Asthma-chronic obstructive pulmonary disease overlap (ACO), characterized by airway limitation, is an important condition with high incidence and mortality. Although some guidelines recommend triple therapy with inhaled corticosteroids/long-acting muscarinic antagonists/long-acting β2 agonists, this treatment approach is based on the extrapolation of data from studies of asthma or chronic obstructive pulmonary disease (COPD) alone.

Methods

A 12-week, randomized, open-label cross-over pilot study was conducted in 19 patients with ACO to investigate the effect of triple therapy with glycopyrrolate (GLY) 50 µg/day on budesonide/formoterol fumarate (BUD/FORM) 640/18 µg/day. The study period included a 4-week wash-out, 4-week run-in, and 4-week treatment period. Respiratory function tests, fractional exhaled nitric oxide (FeNO), a COPD assessment test (CAT) and an asthma control questionnaire (ACQ) were carried out 0, 4, and 8 weeks after randomization.

Results

A total of 19 patients with stable ACO (19 males and no females) with a mean age of 70.7 ± 7.6 years (± standard deviation, SD; range 55-83 years) participated in this study. All patients were ex-smokers with a smoking history of 63.1 ± 41.1 pack-years (± SD). Mean values for inspiratory capacity (IC), an index of hyperinflation of the lung that causes exertional dyspnea and reduced exercise, were 1.93 L (± 0.47 L) after the run-in, 1.85 L (± 0.51 L) after the BUD/FORM dual therapy period and 2.11 L (± 0.58 L) after the BUD/GLY/FORM triple therapy period. IC values after the BUD/GLY/FORM triple therapy were significantly higher than those after the run-in (p < 0.02). FeNO values, ACQ, and CAT scores were not significantly different among the run-in, wash-out, and triple-therapy periods.

Conclusion

The present pilot study showed that triple therapy with BUD/GLY/FORM results in an improvement in lung function parameters including IC, indicating the potential value of triple therapy as standard treatment for ACO.

Assessment of the COPD Assessment Test Within U.S. Primary Care

Rationale

Uptake of the COPD Assessment Test (CAT^TM) is not yet widespread in patients with chronic obstructive pulmonary disease (COPD) within U.S. primary care and its alignment with other assessments has not been evaluated in U.S. clinical practice.

Objectives

To assess the alignment of the CAT with other standard measures of COPD severity and its usability in a U.S. primary care population.

Methods

This was a multicenter, prospective, observational, longitudinal study of patients with COPD and their primary care physicians. Patients with spirometry-confirmed airflow restriction completed a daily electronic diary (eDiary) over 12 weeks; surveys were also administered at baseline and at 6- and 12-week follow-up.

Measurements and Main Results

In the study population (n=178), statistically significant differences (P<0.05) were found across 4 CAT impact score groups where at all time points patients in the Low Impact CAT score group had superior lung function and physical/mental health status than patients in the Medium, High, and Very High Impact groups. Numerical, though lesser, differences were also found across these latter 3 groups. Furthermore, the average total EXAcerbations of COPD Tool (EXACT®) score was significantly worse in patients in the highest CAT score group over the first 7 days.

Conclusions

COPD severity; respiratory symptoms; frequency, severity, and duration of pulmonary exacerbations; and overall physical and mental health status are linked concurrently and prospectively to CAT impact score categories. The stratification of patients according to CAT impact scores, and application of clinical and functional health status information to these categories, enhances the usability of the CAT in practice settings for COPD management.

Clinical Role of the Chronic Obstructive Pulmonary Disease Assessment Test in Prediction of the Response to Treatment for Exacerbations

BACKGROUND

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is a validated, eight-item questionnaire used to quantify the health status of patients. The aim of this study was to evaluate the usefulness of the CAT questionnaire as a tool to assess the response to treatment in acute exacerbations of COPD in an outpatient setting.

METHODS

A multicenter, phase 3 randomized controlled trial was conducted previously to examine the efficacy and safety of oral zabofloxacin for the treatment of COPD exacerbations. In the present post hoc analysis of the original study, patients with COPD exacerbation were categorized as responders or non-responders according to the respiratory symptoms persisting on day 10 (visit 3) of treatment. The CAT questionnaire was completed daily by patients at home from the initial visit to the second visit on day 5. Subsequently, the questionnaire was completed in the presence of a physician on days 10 (visit 3) and 36 (visit 4). Multivariate regression analysis was performed to determine the association between CAT scores and the therapeutic response.

RESULTS

The CAT scores decreased more rapidly in responders compared to non-responders during the first 5 days (23.3-20.4 vs. 23.5-22). Among responders, patients with higher severity of illness also revealed higher CAT scores on the first day of an exacerbation (mild, 19.8; moderate, 21.4; severe, 23.8; very severe, 28.6). Multivariate analysis revealed that a change in the CAT score during the first 3 days influenced the therapeutic response. A significant decrease in scores in the domains of sputum production, chest tightness, and activities of daily living was seen among responders.

CONCLUSION

Early improvement in CAT scores may be associated with a more favorable response to the treatment of COPD exacerbations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01658020.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0000532.

Effects of Chinese medicine on patients with acute exacerbations of COPD: study protocol for a randomized controlled trial

BACKGROUND

The incidence, mortality, and prevalence of chronic obstructive pulmonary disease (COPD) are high in China. Acute exacerbations of COPD (AECOPD) are important events in the management of COPD because they negatively impact health status, rates of hospitalization and readmission, and disease progression. AECOPD have been effectively treated with Chinese medicine for a long time. The aim of this proposed trial is to assess the therapeutic effect of Chinese medicine (CM) on AECOPD.

METHODS/DESIGN

This proposed study is a multicenter, double-blind, parallel-group randomized controlled trial (RCT). We will randomly assign 378 participants with AECOPD into two groups in a 1:1 ratio. On the basis of health education and conventional treatment, the intervention group will be treated with CM, and the control group is given CM placebo according to CM syndrome. Patients are randomized to either receive CM or placebo, 10 g/packet, twice daily. The double-blind treatment lasts for 2 weeks and is followed up for 4 weeks. The main outcome is the COPD Assessment Test; secondary outcomes are treatment failure rate, treatment success rate, length of hospital stay, AECOPD readmission rate, intubation rate, mortality, dyspnea, the 36-item Short Form Health Survey, and the COPD patient-reported outcome scale. We will document these outcomes faithfully at the beginning of the study, 2 weeks after treatment, and at the 4 weeks follow-up.

DISCUSSION

This high-quality RCT with strict methodology and few design deficits will help to prove the effectiveness of CM for AECOPD. We hope this trial will provide useful evidence for developing a therapeutic schedule with CM for patients with AECOPD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03428412. Registered on 4 February 2018.

Obstructive Sleep Apnea in Patients With Fibrotic Interstitial Lung Disease and COPD

STUDY OBJECTIVES

Despite the clinical and prognostic significance of obstructive sleep apnea (OSA) in chronic respiratory diseases (CRDs), there have been few studies about the possible predictors of OSA and the effect of OSA on quality of life in patients with CRDs. The objectives were to identify physiological and clinical parameters that predict the occurrence and severity of OSA and to investigate the effect of OSA on quality of life in patients with CRDs.

METHODS

Seventy-three patients with chronic obstructive pulmonary disease (COPD) and 77 patients with fibrotic interstitial lung disease (ILD) underwent overnight polysomnography (PSG) and pulmonary function testing and completed clinical questionnaires. The oximetry tracing was interpreted blindly with respect to the PSG results.

RESULTS

The prevalence of OSA was 44% and 62% in COPD and ILD, respectively. The COPD assessment test item scores related to sleep quality and daily vitality were worse among patients with OSA than among patients without OSA. The STOP-BANG questionnaire (cutoff point ≥ 3) and oxygen desaturation index from the oximetry recording (oxygen desaturation index (ODI) were associated with OSA in CRDs. The STOP-BANG questionnaire with a cutoff point ≥ 3 or 6 had the highest sensitivity and specificity, respectively, in detecting OSA in CRDs. ODI had the best accuracy in identifying OSA and was independently associated with the apnea-hypopnea index in CRDs.

CONCLUSIONS

We found OSA to be common and associated with worse sleep quality and less daily vitality in patients with advanced CRDs. The STOP-BANG questionnaire with different cutoff points may help rule in or rule out OSA. Overnight oximetry can be used as a screening tool for OSA and can assist the clinical evaluation of OSA in patients with CRDs.

Efficacy of umeclidinium/vilanterol versus umeclidinium and salmeterol monotherapies in symptomatic patients with COPD not receiving inhaled corticosteroids: the EMAX randomised trial

BACKGROUND

Prospective evidence is lacking regarding incremental benefits of long-acting dual- versus mono-bronchodilation in improving symptoms and preventing short-term disease worsening/treatment failure in low exacerbation risk patients with chronic obstructive pulmonary disease (COPD) not receiving inhaled corticosteroids.

METHODS

The 24-week, double-blind, double-dummy, parallel-group Early MAXimisation of bronchodilation for improving COPD stability (EMAX) trial randomised patients at low exacerbation risk not receiving inhaled corticosteroids, to umeclidinium/vilanterol 62.5/25 μg once-daily, umeclidinium 62.5 μg once-daily or salmeterol 50 μg twice-daily. The primary endpoint was trough forced expiratory volume in 1 s (FEV1) at Week 24. The study was also powered for the secondary endpoint of Transition Dyspnoea Index at Week 24. Other efficacy assessments included spirometry, symptoms, heath status and short-term disease worsening measured by the composite endpoint of clinically important deterioration using three definitions.

RESULTS

Change from baseline in trough FEV1 at Week 24 was 66 mL (95% confidence interval [CI]: 43, 89) and 141 mL (95% CI: 118, 164) greater with umeclidinium/vilanterol versus umeclidinium and salmeterol, respectively (both p < 0.001). Umeclidinium/vilanterol demonstrated consistent improvements in Transition Dyspnoea Index versus both monotherapies at Week 24 (vs umeclidinium: 0.37 [95% CI: 0.06, 0.68], p = 0.018; vs salmeterol: 0.45 [95% CI: 0.15, 0.76], p = 0.004) and all other symptom measures at all time points. Regardless of the clinically important deterioration definition considered, umeclidinium/vilanterol significantly reduced the risk of a first clinically important deterioration compared with umeclidinium (by 16-25% [p < 0.01]) and salmeterol (by 26-41% [p < 0.001]). Safety profiles were similar between treatments.

CONCLUSIONS

Umeclidinium/vilanterol consistently provides early and sustained improvements in lung function and symptoms and reduces the risk of deterioration/treatment failure versus umeclidinium or salmeterol in symptomatic patients with low exacerbation risk not receiving inhaled corticosteroids. These findings suggest a potential for early use of dual bronchodilators to help optimise therapy in this patient group.

Increased levels of inflammatory biomarker CX3CL1 in patients with chronic obstructive pulmonary disease

OBJECTIVE

To investigate the concentration of CX3CL1 in serum of patients with chronic obstructive pulmonary disease (COPD), and to evaluate the associations between the CX3CL1 level and systemic inflammation, small airway obstruction, and COPD assessment test (CAT) scores in COPD patients.

METHODS

Enzyme-linked immunosorbent assay were utilized to detect the CX3CL1 protein in serum separately from 64 patients with COPD and 53 healthy controls.

RESULTS

Compared with healthy non-smokers, healthy smokers and COPD non-smokers, serum CX3CL1 protein levels were significantly elevated in COPD smokers (258.33 ± 56.27 pg/mL versus 177.32 ± 43.21 pg/mL, 185.64 ± 47.03 pg/mL, and 226.55 ± 51.79 pg/mL, P < 0.05). Correlation analysis indicated that serum CX3CL1 in COPD smokers was negatively correlated with FEV₁/FVC (justified r = -0.319, P < 0.001), FEV₁/Pre (justified r = -0.476, P < 0.001), FEV₃/FVC (justified r = -0.354, P < 0.001), MMEF25-75/Pre (justified r = -0.428, P < 0.001), but positively correlated with CRP (justified r = 0.331, P < 0.001) and MMP-12 (justified r = 0.352, P < 0.001). However, our results showed no significant correlation between serum CX3CL1 of COPD smokers and the diffusing capacity of the lung for carbon monoxide (DLCO) (justified r = 0.0397, P = 0.6025), but a positive correlation with COPD assessment test (CAT) scores (justified r = 0.367, P < 0.001). Finally, through multivariate linear analysis, statistical results demonstrated age (β = -0.2694, P = 0.005), FEV₁/Pred (β = -0.2653, P = 0.003), CRP (β = 0.1427, P = 0.0478) and MMP-12 (β = 0.430, P < 0.001) are independent parameters associated with CX3CL1.

CONCLUSION

The results demonstrated that elevated circulating CX3CL1 level is associated with the systemic inflammation, small airway obstruction, and CAT scores in COPD patients, suggesting that CX3CL1 may play crucial roles in the pathogenesis of COPD. Blocking CX3CL1 might prevent the progression of chronic obstructive pulmonary disease.

COPD Assessment Test in Bronchiectasis: Minimum Clinically Important Difference and Psychometric Validation: A Prospective Study

BACKGROUND

Health-related quality of life (QoL) is one of the most important end points in bronchiectasis (BE). However, the majority of health-related QoL questionnaires are time-consuming or not validated in BE. The COPD Assessment Test (CAT) is an easy-to-use questionnaire. The objective of this study was to perform a complete validation of the CAT in BE.

METHODS

This was an observational, multicenter, prospective study in patients with BE. Psychometric properties of the CAT were measured: internal consistency (Cronbach α), repeatability (test-retest; intraclass correlation coefficient), discriminant validity (correlation with severity scores), convergent validity (correlation with some validated QoL questionnaire and other clinical variables of interest), longitudinal validity (measuring before and after each exacerbation during follow-up to determine the sensitivity to change and responsiveness), predictive validity to future exacerbations, and finally minimum clinically important difference.

RESULTS

Ninety-six patients were included and followed up for 1 year. Their mean age was 62.2 (15.6) years (79.2% women). The CAT showed excellent internal consistency (α, 0.95) and repeatability (intraclass correlation coefficient, 0.95). The validity of the CAT was excellent in all the measures (almost all with a Pearson coefficient > 0.40) except for the correlations with severity scores (Pearson coefficient between 0.22 and 0.26). Sensitivity to change before and after exacerbations was set at between 5.4 and 5.8 points. A CAT value ≥ 10 points showed prognostic value for patients with more than one exacerbation, and finally the minimum clinically important difference was set at 3 points.

CONCLUSIONS

The CAT presented excellent psychometric properties and is a questionnaire that is easy to use and interpret in patients with BE.