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Machado A, Barusso M, De Brandt J, Quadflieg K, Haesevoets S, Daenen M, Thomeer M, Ruttens D, Marques A, Burtin C. Impact of acute exacerbations of COPD on patients' health status beyond pulmonary function: A scoping review. Pulmonology 2023; 29:518-534. [PMID: 35715333 DOI: 10.1016/j.pulmoe.2022.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/30/2022] [Accepted: 04/10/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- A Machado
- Respiratory Research and Rehabilitation Laboratory (Lab 3R), School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal; REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, BIOMED Biomedical Research Institute, Hasselt University, Agoralaan Gebouw A, Diepenbeek 3590, Belgium; BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - M Barusso
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, BIOMED Biomedical Research Institute, Hasselt University, Agoralaan Gebouw A, Diepenbeek 3590, Belgium; Laboratory of Spirometry and Respiratory Physiotherapy-LEFiR, Universidade Federal de São Carlos-UFSCar, São Carlos, São Paulo, Brazil
| | - J De Brandt
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, BIOMED Biomedical Research Institute, Hasselt University, Agoralaan Gebouw A, Diepenbeek 3590, Belgium; BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - K Quadflieg
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, BIOMED Biomedical Research Institute, Hasselt University, Agoralaan Gebouw A, Diepenbeek 3590, Belgium; BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - S Haesevoets
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, BIOMED Biomedical Research Institute, Hasselt University, Agoralaan Gebouw A, Diepenbeek 3590, Belgium; BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - M Daenen
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - M Thomeer
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - D Ruttens
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - A Marques
- Respiratory Research and Rehabilitation Laboratory (Lab 3R), School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - C Burtin
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, BIOMED Biomedical Research Institute, Hasselt University, Agoralaan Gebouw A, Diepenbeek 3590, Belgium; BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium.
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2
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Abineza C, Balas VE, Nsengiyumva P. A machine-learning-based prediction method for easy COPD classification based on pulse oximetry clinical use. JOURNAL OF INTELLIGENT & FUZZY SYSTEMS 2022. [DOI: 10.3233/jifs-219270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a progressive, obstructive lung disease that restricts airflow from the lungs. COPD patients are at risk of sudden and acute worsening of symptoms called exacerbations. Early identification and classification of COPD exacerbation can reduce COPD risks and improve patient’s healthcare and management. Pulse oximetry is a non-invasive technique used to assess patients with acutely worsening symptoms. As part of manual diagnosis based on pulse oximetry, clinicians examine three warning signs to classify COPD patients. This may lack high sensitivity and specificity which requires a blood test. However, laboratory tests require time, further delayed treatment and additional costs. This research proposes a prediction method for COPD patients’ classification based on pulse oximetry three manual warning signs and the resulting derived few key features that can be obtained in a short time. The model was developed on a robust physician labeled dataset with clinically diverse patient cases. Five classification algorithms were applied on the mentioned dataset and the results showed that the best algorithm is XGBoost with the accuracy of 91.04%, precision of 99.86%, recall of 82.19%, F1 measure value of 90.05% with an AUC value of 95.8%. Age, current and baseline heart rate, current and baseline pulse ox. (SPO2) were found the top most important predictors. These findings suggest the strength of XGBoost model together with the availability and the simplicity of input variables in classifying COPD daily living using a (wearable) pulse oximeter.
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Affiliation(s)
- Claudia Abineza
- African Center of Excellence in Internet of Things, University of Rwanda, Kigali, Rwanda
| | - Valentina E. Balas
- Department of Automatics and Applied Software, “Aurel Vlaicu” University, Arad, Romania
| | - Philibert Nsengiyumva
- African Center of Excellence in Internet of Things, University of Rwanda, Kigali, Rwanda
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3
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Barber D, Pilsworth S, Wat D. Does availability of point of care C-reactive protein measurement affect provision of antibiotics in a community respiratory service? Br J Community Nurs 2022; 27:218-224. [PMID: 35522449 DOI: 10.12968/bjcn.2022.27.5.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Antibiotic resistance presents a growing threat to health systems and patients at a global scale. Point of care (POC) C-reactive protein (CRP) measurement, as an adjunct to exacerbation assessment, has been studied in primary and secondary care and may represent a useful tool for community teams. A retrospective service review was conducted to determine the effect of CRP measurement on antibiotic provision in a community respiratory setting, with chronic obstructive pulmonary disease (COPD) and bronchiectasis exacerbations. This review compared antibiotic provision for COPD and bronchiectasis patients for those where CRP was measured versus those where it was not. It was found that antibiotic provision dropped by almost 25% points for COPD exacerbations, and almost 59% in bronchiectasis, when a CRP measurement was taken as a component of a respiratory assessment. Antibiotics were also provided at a greater amount based on symptom presentation. Therefore, it is concluded that CRP measurement correlates with a reduction in antibiotic provision, highlighting its use alongside symptom assessment in future work.
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Affiliation(s)
- David Barber
- Advanced Practitioner; Knowsley Community Respiratory Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool
| | - Samantha Pilsworth
- Consultant Physiotherapist; Knowsley Community Respiratory Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool
| | - Dennis Wat
- Consultant Respiratory Physican, Knowsley Community Respiratory Service, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool
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4
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Jenkins CR. Towards precision in defining COPD exacerbations. Breathe (Sheff) 2022; 17:210081. [PMID: 35035551 PMCID: PMC8753624 DOI: 10.1183/20734735.0081-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/28/2021] [Indexed: 11/25/2022] Open
Abstract
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. COPD exacerbations carry high risk for long-term disability and death. As the search for a standardised measure continues, study investigators must ensure definitions are explicit and justified to better understand how to prevent and manage these episodes.https://bit.ly/2UNqScy
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Affiliation(s)
- Christine R Jenkins
- Respiratory Group, The George Institute for Global Health, Sydney, Australia.,UNSW Sydney, Sydney, Australia.,Concord Clinical School, University of Sydney, Sydney, Australia
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5
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Hospital Admission and Readmission Among US Patients Receiving Umeclidinium/Vilanterol or Tiotropium as Initial Maintenance Therapy for Chronic Obstructive Pulmonary Disease. Pulm Ther 2021; 7:203-219. [PMID: 33728597 PMCID: PMC8137777 DOI: 10.1007/s41030-021-00151-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/15/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations are at risk of further readmissions, increased treatment costs, and excess mortality. This study evaluated inpatient admissions and readmissions in patients receiving initial maintenance therapy with umeclidinium/vilanterol (UMEC/VI) versus tiotropium (TIO). Methods This retrospective, matched cohort study identified patients with COPD who initiated maintenance therapy with UMEC/VI or TIO from Optum’s de-identified Clinformatics Data Mart database between January 1, 2013, and December 31, 2018 (index date defined as earliest dispensing). Eligibility criteria included: ≥ 1 medical claim for COPD pre-index or on the index date; ≥ 12 months of continuous eligibility pre-index; age ≥ 40 years at index; no pre- or post-index asthma diagnosis; and no pre-index claims for medications containing inhaled corticosteroids, long-acting β2-agonists, or long-acting muscarinic antagonists. Outcomes included time to first on-treatment COPD-related inpatient admission, rate of on-treatment COPD-related admissions, and rate of all-cause and COPD-related readmissions within 30 and 90 days. Propensity score matching was used to adjust for potential confounders. Results Matched UMEC/VI and TIO cohorts each included 7997 patients and were balanced on baseline characteristics (mean age 70.9 years; female 47.1–47.6%). Over 12 months, patients initiating UMEC/VI had significantly reduced risk (hazard ratio [95% CI]: 0.87 [0.79, 0.96]; p = 0.006) and rates (rate ratio [95% CI]: 0.80 [0.72, 0.92]; p = 0.008) of COPD-related inpatient admissions compared with TIO. While all-cause readmission rates were similar between treatment cohorts, readmission rates among patients with an initial admission length of stay of 1–3 days were numerically lower for UMEC/VI versus TIO (30-day readmissions: 10.5% vs. 12.4%; 90-day readmissions: 15.5% vs. 19.8%). Similar patterns were observed for COPD-related readmissions. Conclusions These findings highlight the real-world benefits of dual therapy with UMEC/VI versus TIO in reducing inpatient admissions and readmissions in patients with COPD, which may translate to lower healthcare costs. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-021-00151-y. Patients with chronic obstructive pulmonary disease (COPD) who are admitted to the hospital are more likely to be readmitted in the future, have higher healthcare costs, and are more likely to die from their illness. Patients who are readmitted to hospital have even higher treatment costs. Identifying which treatments are best at reducing the number of patients with COPD who are admitted to the hospital may help to improve outcomes and reduce the cost of COPD treatment. We used US healthcare claims data to compare two daily treatments for COPD, umeclidinium/vilanterol and tiotropium. We aimed to find out which treatment was more effective at reducing hospital admissions due to COPD. We also compared how many patients on each treatment were readmitted within 30 or 90 days of their original hospital admission for COPD. We found that patients who started treatment with umeclidinium/vilanterol were less likely to be admitted to the hospital for COPD than patients who started treatment with tiotropium. Similar numbers of patients on each treatment were readmitted to the hospital within 30 or 90 days after they were discharged. However, among patients whose initial hospital stay was short (1–3 days), readmissions within 30 or 90 days were less common with umeclidinium/vilanterol than tiotropium. These findings suggest that umeclidinium/vilanterol may be more effective than tiotropium at reducing the number of patients with COPD who need to be admitted or readmitted to hospital. Starting COPD treatment with umeclidinium/vilanterol may lead to better health outcomes and lower costs than tiotropium.
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Cabrera López C, Mascarós E, Azpeitia A, Villarrubia E. A Simplified Algorithm for the Diagnosis, Treatment, and Management of COPD in Routine Primary Care Practice. Int J Chron Obstruct Pulmon Dis 2020; 15:3347-3355. [PMID: 33364753 PMCID: PMC7751579 DOI: 10.2147/copd.s281422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022] Open
Abstract
Background Diagnostic and treatment strategies for chronic obstructive pulmonary disease (COPD) vary greatly. Despite international efforts to standardize the management of COPD, two-thirds of primary care patients are not diagnosed, treated, or managed according to current evidence-based guidelines, probably because of the difficulty of applying these in routine practice. The aim of this study was to develop a simplified algorithm for diagnosing, treating, and managing COPD in primary care whose consistency, scientific relevance, and applicability to routine clinical practice met approval bct 3y family doctors (FDs) and pulmonologists. Methods The algorithm was developed in a series of sequential phases, consisting of a preliminary meeting among group coordinators to design the initial structure, an input meeting with FDs and pulmonologists to refine and validate the proposal, an algorithm design stage, and a Delphi survey in which FDs and pulmonologists evaluated and approved the final version. A target of 75% or more was established for each of the 20 items in the Delphi survey in the FDs group as well as the pulmonologists group. It was estimated that at least two Delphi rounds would be needed to reach consensus. Results In total, 118 physicians (75 FDs and 43 pulmonologists) participated in the Delphi process. Fourteen of the 20 items (70%) were approved in the first round. In the second round (in which 74 FDs and 42 pulmonologists participated), the remaining six items, which had been reformulated based on feedback from the first round, were approved, together with an additional question on the face validity of the algorithm as a whole. Dyspnea was positioned as the main determinant of treatment decisions in the new algorithm. Conclusion According to the experts consulted, this new simplified algorithm for the diagnosis, treatment, and management of COPD in primary care is a clear, functional, and useful tool for routine practice and meets the requirements for the correct management of this condition.
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Affiliation(s)
- Carlos Cabrera López
- Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - Elena Villarrubia
- Health Outcomes Research Department, Advanced Outcomes Research, SL. Barcelona, Spain
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7
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Kerkhof M, Voorham J, Dorinsky P, Cabrera C, Darken P, Kocks JW, Sadatsafavi M, Sin DD, Carter V, Price DB. Association between COPD exacerbations and lung function decline during maintenance therapy. Thorax 2020; 75:744-753. [PMID: 32532852 PMCID: PMC7476283 DOI: 10.1136/thoraxjnl-2019-214457] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/28/2020] [Accepted: 05/07/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Little is known about the impact of exacerbations on COPD progression or whether inhaled corticosteroid (ICS) use and blood eosinophil count (BEC) affect progression. We aimed to assess this in a prospective observational study. METHODS The study population included patients with mild to moderate COPD, aged ≥35 years, with a smoking history, who were followed up for ≥3 years from first to last spirometry recording using two large UK electronic medical record databases: Clinical Practice Research Datalink (CPRD) and Optimum Patient Care Research Database (OPCRD). Multilevel mixed-effects linear regression models were used to determine the relationship between annual exacerbation rate following initiation of therapy (ICS vs non-ICS) and FEV1 decline. Effect modification by blood eosinophils was studied through interaction terms. RESULTS Of 12178 patients included (mean age 66 years; 48% female), 8981 (74%) received ICS. In patients with BEC ≥350 cells/µL not on ICS, each exacerbation was associated with subsequent acceleration of FEV1 decline of 19.4 mL/year (95% CI 12.0 to 26.7, p<0.0001). This excess decline was reduced by 15.1 mL/year (6.6 to 23.6) to 4.3 mL/year (1.9 to 6.7, p<0.0001) in those with BEC ≥350 cells/µL treated with ICS. CONCLUSION Exacerbations are associated with a more rapid loss of lung function among COPD patients with elevated blood eosinophils, defined as ≥350 cells/µL, not treated with ICS. More aggressive prevention of exacerbations using ICS in such patients may prevent excess loss of lung function.
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Affiliation(s)
- Marjan Kerkhof
- Observational and Pragmatic Research Institute, Singapore
| | - Jaco Voorham
- Observational and Pragmatic Research Institute, Singapore
| | | | - Claudia Cabrera
- AstraZeneca, Gothenburg, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Patrick Darken
- AstraZeneca, 280 Headquarters Plaza, East Tower, Morristown, NJ 07960, USA
| | - Janwillem Wh Kocks
- Observational and Pragmatic Research Institute, Singapore.,General Practitioners Research Institute, Groningen, The Netherlands
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Don D Sin
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - David B Price
- Observational and Pragmatic Research Institute, Singapore .,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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8
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Mathioudakis AG, Janssens W, Sivapalan P, Singanayagam A, Dransfield MT, Jensen JUS, Vestbo J. Acute exacerbations of chronic obstructive pulmonary disease: in search of diagnostic biomarkers and treatable traits. Thorax 2020; 75:520-527. [PMID: 32217784 PMCID: PMC7279206 DOI: 10.1136/thoraxjnl-2019-214484] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/21/2020] [Accepted: 03/01/2020] [Indexed: 12/12/2022]
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with a significant mortality, health and economic burden. Their diagnosis, assessment and management remain suboptimal and unchanged for decades. Recent clinical and translational studies revealed that the significant heterogeneity in mechanisms and outcomes of exacerbations could be resolved by grouping them etiologically. This is anticipated to lead to a better understanding of the biological processes that underlie each type of exacerbation and to allow the introduction of precision medicine interventions that could improve outcomes. This review summarises novel data on the diagnosis, phenotyping, targeted treatment and prevention of COPD exacerbations.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Wim Janssens
- Respiratory Division, Department of Clinical and Experimental Medicine, University Hospital Leuven & KU Leuven, Leuven, Belgium
| | - Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Aran Singanayagam
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Jens-Ulrik Stæhr Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark.,PERSIMUNE&CHIP: Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK .,North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Mathioudakis AG, Janner J, Moberg M, Alonso-Coello P, Vestbo J. A systematic evaluation of the diagnostic criteria for COPD and exacerbations used in randomised controlled trials on the management of COPD exacerbations. ERJ Open Res 2019; 5:00136-2019. [PMID: 31754621 PMCID: PMC6856493 DOI: 10.1183/23120541.00136-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/29/2019] [Indexed: 01/04/2023] Open
Abstract
Clinical trials evaluating the management of #AECOPD use different diagnostic criteria for COPD and exacerbations, limiting their comparability http://bit.ly/33eIUUX.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,North West Lung Centre, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Julie Janner
- Dept of Respiratory Medicine, Hvidovre University Hospital, Hvidovre, Denmark
| | - Mia Moberg
- Dept of Respiratory Medicine, Hvidovre University Hospital, Hvidovre, Denmark
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,North West Lung Centre, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
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10
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Zhang DD, Lu G, Zhu XF, Zhang LL, Gao J, Shi LC, Gu JH, Liu JN. Neural Respiratory Drive Measured Using Surface Electromyography of Diaphragm as a Physiological Biomarker to Predict Hospitalization of Acute Exacerbation of Chronic Obstructive Pulmonary Disease Patients. Chin Med J (Engl) 2019; 131:2800-2807. [PMID: 30511682 PMCID: PMC6278179 DOI: 10.4103/0366-6999.246057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Neural respiratory drive (NRD) using diaphragm electromyography through an invasive transesophageal multi-electrode catheter can be used as a feasible clinical physiological parameter in patients with chronic obstructive pulmonary disease (COPD) to provide useful information on the treatment response. However, it remains unknown whether the surface diaphragm electromyogram (EMGdi) could be used to identify the deterioration of clinical symptoms and to predict the necessity of hospitalization in acute exacerbation of COPD (AECOPD) patients. Methods: COPD patients visiting the outpatient department due to acute exacerbation were enrolled in this study. All patients who were subjected to EMGdi and classical parameters such as spirometry parameters, arterial blood gas analysis, COPD assessment test (CAT) score, and the modified early warning score (MEWS) in outpatient department, would be treated effectively in the outpatient or inpatient settings according to the Global Initiative for Chronic Obstructive Lung Disease guideline. When the acute exacerbation of the patients was managed, all the examination above would be repeated. Results: We compared the relationships of admission-to-discharge changes (Δ) in the normalized value of the EMGdi, including the change of the percentage of maximal EMGdi (ΔEMGdi%max) and the change of the ratio of minute ventilation to the percentage of maximal EMGdi (ΔVE/EMGdi%max) with the changes of classical parameters. There was a significant positive association between ΔEMGdi%max and ΔCAT, ΔPaCO2, and ΔpH. The change (Δ) of EMGdi%max was negatively correlated with ΔPaO2/FiO2 in the course of the treatment of AECOPD. Compared with the classical parameters including forced expiratory volume in 1 s, MEWS, PaO2/FiO2, the EMGdi%max (odds ratio 1.143, 95% confidence interval 1.004–1.300) has a higher sensitivity when detecting the early exacerbation and enables to predict the admission of hospital in the whole cohort. Conclusions: The changes of surface EMGdi parameters had a direct correlation with classical measures in the whole cohort of AECOPD. The measurement of NRD by surface EMGdi represents a practical physiological biomarker, which may be helpful in detecting patients who should be hospitalized timely.
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Affiliation(s)
- Dan-Dan Zhang
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Gan Lu
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Xuan-Feng Zhu
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Ling-Ling Zhang
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Jia Gao
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Li-Cheng Shi
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Jian-Hua Gu
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
| | - Jian-Nan Liu
- Chronic Airway Disease Research Office, Department of Respiratory, Geriatric Hospital of Nanjing Medical University, Jiangsu Province Geriatric Hospital, Nanjing, Jiangsu 210024, China
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11
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Calderazzo MA, Trujillo-Torralbo MB, Finney LJ, Singanayagam A, Bakhsoliani E, Padmanaban V, Kebadze T, Aniscenko J, Elkin SL, Johnston SL, Mallia P. Inflammation and infections in unreported chronic obstructive pulmonary disease exacerbations. Int J Chron Obstruct Pulmon Dis 2019; 14:823-832. [PMID: 31114182 PMCID: PMC6497477 DOI: 10.2147/copd.s191946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/22/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose: COPD patients often do not report acute exacerbations to healthcare providers – unreported exacerbations. It is not known whether variances in symptoms, airway obstruction, aetiology and inflammatory responses account for differences in reporting of COPD exacerbations. The aims of the study were to compare symptoms, lung function changes, aetiology and inflammatory markers between exacerbations that were reported to healthcare providers or treated, with those that were unreported and untreated. Patients and methods: We recruited a cohort of COPD patients and collected clinical data and blood and airway samples when stable and during acute exacerbations. Virological and bacterial analyses were carried out and inflammatory markers measured. Results: We found no differences in symptoms, lung function, incidence of infection and inflammatory markers between reported and unreported exacerbations. Subjects who reported all exacerbations had higher BODE scores, lower FEV1 and more exacerbations compared with those who did not. Conclusion: The failure to report exacerbations is not related to the severity, aetiology or inflammatory profile of the exacerbation. Patients with less severe COPD and less frequent exacerbations are less likely to report exacerbations. The decision to report an exacerbation is not an objective marker of exacerbation severity and therefore studies that do not count unreported exacerbations will underestimate the frequency of clinically significant exacerbations. A better understanding of the factors that determine non-reporting of exacerbations is required to improve exacerbation reporting. Trial registration: ClinicalTrials.gov Identifier: NCT01376830. Registered June 17, 2011
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Affiliation(s)
| | - Maria-Belen Trujillo-Torralbo
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | - Vijay Padmanaban
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Tatiana Kebadze
- National Heart and Lung Institute, Imperial College, London, UK
| | - Julia Aniscenko
- National Heart and Lung Institute, Imperial College, London, UK
| | - Sarah L Elkin
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Sebastian L Johnston
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Patrick Mallia
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
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12
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Nishimura K, Nakamura S, Kusunose M, Nakayasu K, Sanda R, Hasegawa Y, Oga T. Comparison of patient-reported outcomes during acute exacerbations of chronic obstructive pulmonary disease. BMJ Open Respir Res 2018; 5:e000305. [PMID: 30397483 PMCID: PMC6203045 DOI: 10.1136/bmjresp-2018-000305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/21/2018] [Indexed: 11/10/2022] Open
Abstract
Introduction The aim of this study was to investigate which patient-reported outcome measure was the best during the recovery phase from severe exacerbation of chronic obstructive pulmonary disease (COPD). Methods The Exacerbations of Chronic Pulmonary Disease Tool (EXACT), the COPD Assessment Test (CAT), the St George’s Respiratory Questionnaire (SGRQ), the Dyspnoea-12 (D-12) and the Hyland Scale (global scale) were recorded every week for the first month and at 2 and 3 months in 33 hospitalised subjects with acute exacerbation of COPD (AECOPD). Results On the day of admission (day 1), the internal consistency of the EXACT total score was high (Cronbach’s alpha coefficient=0.89). The EXACT total, CAT, SGRQ total and Hyland Scale scores obtained on day 1 appeared to be normally distributed. Neither floor nor ceiling effects were observed for the EXACT total and SGRQ total scores. The EXACT total score improved from 50.5±12.4 to 32.5±14.3, and the CAT score also improved from 24.4±8.5 to 13.5±8.4 during the first 2 weeks, and the effect sizes (ES) of the EXACT total and CAT score were −1.40 and −1.36, respectively. The SGRQ, Hyland Scale and D-12 were less responsive, with ES of −0.59, 0.96 and −0.90, respectively. Discussion The EXACT total and CAT scores are shown to be more responsive measures during the recovery phase from severe exacerbation. Considering the conceptual framework, it is recommended that the EXACT total score may be the best measure during the recovery phase from AECOPD. The reasons for the outstanding responsiveness of the CAT are still unknown.
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Affiliation(s)
- Koichi Nishimura
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Saya Nakamura
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Kusunose
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | | | - Ryo Sanda
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Oga
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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13
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'Exacerbation-free time' to assess the impact of exacerbations in patients with chronic obstructive pulmonary disease (COPD): a prospective observational study. NPJ Prim Care Respir Med 2018; 28:12. [PMID: 29615628 PMCID: PMC5882661 DOI: 10.1038/s41533-018-0079-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 02/15/2018] [Accepted: 03/09/2018] [Indexed: 12/19/2022] Open
Abstract
COPD exacerbations are commonly quantified as rate per year. However, the total amount of time a patient suffers from exacerbations may be stronger related to his or her disease burden than just counting exacerbation episodes. In this study, we examined the relationship between exacerbation frequency and exacerbation-free time, and their associations with baseline characteristics and health-related quality of life. A total of 166 COPD patients reported symptom changes during 12 months. Symptom-defined exacerbation episodes were correlated to the number of exacerbation-free weeks per year. Analysis of covariance was used to examine the effects of baseline characteristics on annual exacerbation frequency and exacerbation-free weeks, Spearman’s rank correlations to examine associations between the two methods to express exacerbations and the Chronic Respiratory Questionnaire (CRQ). The correlation between exacerbation frequency and exacerbation-free weeks was −0.71 (p < 0.001). However, among frequent exacerbators (i.e., ≥3 exacerbations/year, n = 113) the correlation was weak (r = −0.25; p < 0.01). Smokers had less exacerbation-free weeks than non-smokers (β = −5.709, p < 0.05). More exacerbation-free weeks were related to better CRQ Total (r = 0.22, p < 0.05), Mastery (r = 0.22, p < 0.05), and Fatigue (r = 0.23, p < 0.05) scores, whereas no significant associations were found between exacerbation frequency and CRQ scores. In COPD patients with frequent exacerbations, there is substantial variation in exacerbation-free time. Exacerbation-free time may better reflect the burden of exacerbations in patients with COPD than exacerbation frequency does. Time spent exacerbation-free may provide a stronger indication of disease burden than exacerbation frequency for patients with chronic lung disease. Exacerbations in chronic obstructive pulmonary disease (COPD) are marked by a sudden decline in lung function, potential hospitalisation and a need to increase medication. Exacerbation frequency is used as a marker in COPD management, but this does not consider the duration of exacerbations or the impact this has on patients’ lives. Lonneke Boer at Radboud University Medical Center, the Netherlands, and co-workers questioned 166 patients every two weeks for a year about their experiences of exacerbation duration and frequency. There was substantial variation in exacerbation-free time between patients, with smokers most likely to suffer longer periods of poorer health. Exacerbation-free time was better correlated with health-related quality of life than exacerbation frequency.
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14
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Oliveira AS, Munhá J, Bugalho A, Guimarães M, Reis G, Marques A. Identification and assessment of COPD exacerbations. Pulmonology 2017; 24:S2173-5115(17)30165-3. [PMID: 29279278 DOI: 10.1016/j.rppnen.2017.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/30/2017] [Indexed: 11/17/2022] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) exacerbations play a central role in the disease natural history of the disease, affecting its overall severity, decreasing pulmonary function, worsening underlying co-morbidities, impairing quality of life (QoL) and leading to severe morbidity and mortality. Therefore, identification and correct assessment of COPD exacerbations is paramount, given it will strongly influence therapy success. For the identification of exacerbations, several questionnaires exist, with varying degrees of complexity. However, most questionnaires remain of limited clinical utility, and symptom scales seem to be more useful in clinical practice. In the assessment of exacerbations, the type and degree of severity should be ascertained in order to define the management setting and optimize treatment options. Still, a consensual and universal classification system to assess the severity and type of an exacerbation is lacking, and there are no established criteria for less severely ill patients not requiring hospital assessment. This might lead to under-reporting of minor to moderate exacerbations, which has an impact on patients' health status. There is a clear unmet need to develop clinically useful questionnaires and a comprehensive system to evaluate the severity of exacerbations that can be used in all settings, from primary health care to general hospitals.
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Affiliation(s)
- A S Oliveira
- Pulmonology Department, Hospital Pulido Valente, CHLN, Lisbon, Portugal
| | - J Munhá
- Pulmonology Department, Centro Hospitalar do Barlavento Algarvio, EPE, Portimão, Portugal
| | - A Bugalho
- Pulmonology Department, Hospital CUF Infante Santo/Hospital CUF Descobertas, Lisbon, Portugal; Chronic Diseases Research Center (CEDOC), Lisbon School of Medical Sciences, Nova University, Lisbon, Portugal
| | - M Guimarães
- Pulmonology Department, Centro Hospitalar Gaia-Espinho, EPE, Portugal
| | - G Reis
- Pulmonology Department, Hospital Distrital de Santarém, Portugal
| | - A Marques
- Pulmonology Department, São João Hospital Center, Porto, Portugal.
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15
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Chabot F. [What are the definitions of acute COPD exacerbations and COPD decompensations?]. Rev Mal Respir 2017; 34:327-330. [PMID: 28476416 DOI: 10.1016/j.rmr.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- F Chabot
- EA INGRES, département de pneumologie, hôpitaux de Brabois, université de Lorraine, CHU de Nancy, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
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16
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DeVries R, Kriebel D, Sama S. Validation of the breathlessness, cough and sputum scale to predict COPD exacerbation. NPJ Prim Care Respir Med 2016; 26:16083. [PMID: 27906157 PMCID: PMC5131613 DOI: 10.1038/npjpcrm.2016.83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022] Open
Abstract
The breathlessness, cough and sputum scale (BCSS) is a three-item questionnaire rating breathlessness, cough and sputum on a 5-point Likert scale from 0 (no symptoms) to 4 (severe symptoms). Researchers have explored the utility of this tool to quantify efficacy of treatment following a chronic obstructive pulmonary disease (COPD) exacerbation; however, little work has been done to investigate the ability of the BCSS to predict COPD exacerbation. As part of a prospective case-crossover study among a cohort of 168 COPD patients residing in central Massachusetts, patients were asked standard BCSS questions during exacerbation and randomly identified non-exacerbation (or healthy) weeks. We found that the BCSS was strongly associated with COPD exacerbation (OR=2.80, 95% CI=2.27-3.45) and that a BCSS sum score of 5.0 identified COPD exacerbation with 83% sensitivity and 68% specificity. These results may be useful in the clinical setting to expedite interventions of exacerbation.
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Affiliation(s)
- Rebecca DeVries
- Department of Work Environment, University of Massachusetts Lowell, Lowell, MA, USA
| | - David Kriebel
- Department of Work Environment, University of Massachusetts Lowell, Lowell, MA, USA
| | - Susan Sama
- Department of Work Environment, University of Massachusetts Lowell, Lowell, MA, USA
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17
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Jonkman NH, Westland H, Trappenburg JC, Groenwold RH, Bischoff EW, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton MJ, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJ, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:2063-74. [PMID: 27621612 PMCID: PMC5012618 DOI: 10.2147/copd.s107884] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most. Methods Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models. Results Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes. Conclusion Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.
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Affiliation(s)
- Nini H Jonkman
- Department of Rehabilitation, Nursing Science and Sports
| | | | | | - Rolf Hh Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | - Erik Wma Bischoff
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada
| | | | - David Coultas
- Veterans Administration Portland Health Care System and Oregon Health & Science University, Portland, OR, USA
| | - Tanja W Effing
- Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, SA, Australia
| | - Michael J Epton
- Canterbury District Health Board, Respiratory Services, Christchurch Hospital, Christchurch, New Zealand
| | - Frode Gallefoss
- Department of Pulmonary Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Judith Garcia-Aymerich
- Centre for Research in Environmental Epidemiology CREAL; Pompeu Fabra University; CIBER Epidemiología y Salud Pública CIBERESP, Barcelona, Spain
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Job van der Palen
- Department of Research Methodology, Measurement and Data Analysis, University of Twente; Department of Clinical Epidemiology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Kathryn L Rice
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis Veterans Affairs Health Care Service and University of Minnesota, Minneapolis, MN, USA
| | - Maria Sedeno
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Stephanie Jc Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Thierry Troosters
- Department of Rehabilitation Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
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18
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Frei A, Siebeling L, Wolters C, Held L, Muggensturm P, Strassmann A, Zoller M, Ter Riet G, Puhan MA. The Inaccuracy of Patient Recall for COPD Exacerbation Rate Estimation and Its Implications: Results from Central Adjudication. Chest 2016; 150:860-868. [PMID: 27400907 DOI: 10.1016/j.chest.2016.06.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 06/01/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND COPD exacerbation incidence rates are often ascertained retrospectively through patient recall and self-reports. We compared exacerbation ascertainment through patient self-reports and single-physician chart review to central adjudication by a committee and explored determinants and consequences of misclassification. METHODS Self-reported exacerbations (event-based definition) in 409 primary care patients with COPD participating in the International Collaborative Effort on Chronic Obstructive Lung Disease: Exacerbation Risk Index Cohorts (ICE COLD ERIC) cohort were ascertained every 6 months over 3 years. Exacerbations were adjudicated by single experienced physicians and an adjudication committee who had information from patient charts. We assessed the accuracy (sensitivities and specificities) of self-reports and single-physician chart review against a central adjudication committee (AC) (reference standard). We used multinomial logistic regression and bootstrap stability analyses to explore determinants of misclassifications. RESULTS The AC identified 648 exacerbations, corresponding to an incidence rate of 0.60 ± 0.83 exacerbations/patient-year and a cumulative incidence proportion of 58.9%. Patients self-reported 841 exacerbations (incidence rate, 0.75 ± 1.01; incidence proportion, 59.7%). The sensitivity and specificity of self-reports were 84% and 76%, respectively, those of single-physician chart review were between 89% and 96% and 87% and 99%, respectively. The multinomial regression model and bootstrap selection showed that having experienced more exacerbations was the only factor consistently associated with underreporting and overreporting of exacerbations (underreporters: relative risk ratio [RRR], 2.16; 95% CI, 1.76-2.65 and overreporters: RRR, 1.67; 95% CI, 1.39-2.00). CONCLUSIONS Patient 6-month recall of exacerbation events are inaccurate. This may lead to inaccurate estimates of incidence measures and underestimation of treatment effects. The use of multiple data sources combined with event adjudication could substantially reduce sample size requirements and possibly cost of studies. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, NCT00706602.
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Affiliation(s)
- Anja Frei
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland.
| | - Lara Siebeling
- Department of General Practice, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Callista Wolters
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Leonhard Held
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Patrick Muggensturm
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland; Department of Internal Medicine, Zollikerberg Hospital, Zollikon, Switzerland
| | - Alexandra Strassmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Marco Zoller
- Institute of General Practice and Health Services Research, University of Zurich, Switzerland
| | - Gerben Ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
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19
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Jones PW. Long-acting muscarinic antagonists for the prevention of exacerbations of chronic obstructive pulmonary disease. Ther Adv Respir Dis 2015; 9:84-96. [DOI: 10.1177/1753465815576471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) have important consequences for lung function, health status and mortality. Furthermore, they are associated with high economic costs, predominantly related to hospitalization. They are managed acutely with short-acting bronchodilators, systemic corticosteroids or antibiotics; however, a large proportion of COPD exacerbations are unreported and therefore untreated or self-managed. There is evidence to suggest that these unreported exacerbations also have important consequences for health status; therefore, reducing exacerbation risk is an important goal in the management of COPD. Current guidelines recommend long-acting muscarinic antagonists (LAMAs) as first-line bronchodilator therapy in patients with stable COPD who have a high risk of exacerbation or increased symptoms. To date, three LAMAs, tiotropium bromide, aclidinium bromide and glycopyrronium bromide, have been approved as maintenance bronchodilator treatments for stable COPD. These all provide clinically significant improvements in lung function, reduce symptoms and improve health status compared with placebo in patients with COPD. This paper reviews evidence from randomized, controlled clinical trials demonstrating that tiotropium, aclidinium and glycopyrronium reduce exacerbation risk in patients with COPD. Reductions were seen irrespective of the exacerbation measure used, whether time to first event or annualized exacerbation rate. Furthermore, studies with aclidinium suggest LAMAs can reduce exacerbation risk irrespective of whether exacerbation events are assessed, using an event-based approach or a symptom-based method which includes unreported events. Together these results demonstrate that LAMAs have the potential to provide clinical benefit in the management of exacerbations in patients with stable COPD.
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Affiliation(s)
- Paul W. Jones
- St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK
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20
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Andrews L, Barlow R, Easton I. Differences in patient outcomes between a 6, 7 and 8 week pulmonary rehabilitation programme: A service evaluation. Physiotherapy 2015; 101:62-8. [DOI: 10.1016/j.physio.2014.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 04/11/2014] [Indexed: 11/30/2022]
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21
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Corradi M, Goldoni M, Mutti A. A review on airway biomarkers: exposure, effect and susceptibility. Expert Rev Respir Med 2015; 9:205-20. [PMID: 25561087 DOI: 10.1586/17476348.2015.1001373] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Current research in pulmonology requires the use of biomarkers to investigate airway exposure and diseases, for both diagnostic and prognostic purposes. The traditional approach based on invasive approaches (lung lavages and biopsies) can now be replaced, at least in part, through the use of non invasively collected specimens (sputum and breath), in which biomarkers of exposure, effect and susceptibility can be searched. The discovery of specific lung-related proteins, which can spill over in blood or excreted in urine, further enhanced the spectrum of airway specific biomarkers to be studied. The recent introduction of high-performance 'omic' technologies - genomics, proteomics and metabolomics, and the rate at which biomarker candidates are being discovered, will permit the use of a combination of biomarkers for a more precise selection of patient with different outcomes and responses to therapies. The aim of this review is to critically evaluate the use of airway biomarkers in the context of research and clinical practice.
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Affiliation(s)
- Massimo Corradi
- Department of Clinical and Experimental Medicine, University of Parma, Via Gramsci 14, 43123 Parma, Italy
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22
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Zwerink M, Brusse‐Keizer M, van der Valk PDLPM, Zielhuis GA, Monninkhof EM, van der Palen J, Frith PA, Effing T. Self management for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014; 2014:CD002990. [PMID: 24665053 PMCID: PMC7004246 DOI: 10.1002/14651858.cd002990.pub3] [Citation(s) in RCA: 266] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Self management interventions help patients with chronic obstructive pulmonary disease (COPD) acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable patients to control their disease. Since the first update of this review in 2007, several studies have been published. The results of the second update are reported here. OBJECTIVES 1. To evaluate whether self management interventions in COPD lead to improved health outcomes.2. To evaluate whether self management interventions in COPD lead to reduced healthcare utilisation. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials (current to August 2011). SELECTION CRITERIA Controlled trials (randomised and non-randomised) published after 1994, assessing the efficacy of self management interventions for individuals with COPD, were included. Interventions with fewer than two contact moments between study participants and healthcare providers were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. Investigators were contacted to ask for additional information. When appropriate, study results were pooled using a random-effects model. The primary outcomes of the review were health-related quality of life (HRQoL) and number of hospital admissions. MAIN RESULTS Twenty-nine studies were included. Twenty-three studies on 3189 participants compared self management versus usual care; six studies on 499 participants compared different components of self management on a head-to-head basis. Although we included non-randomised controlled clinical trials as well as RCTs in this review, we restricted the primary analysis to RCTs only and reported these trials in the abstract.In the 23 studies with a usual care control group, follow-up time ranged from two to 24 months. The content of the interventions was diverse. A statistically relevant effect of self management on HRQoL was found (St George's Respiratory Questionnaire (SGRQ) total score, mean difference (MD) -3.51, 95% confidence interval (CI) -5.37 to -1.65, 10 studies, 1413 participants, moderate-quality evidence). Self management also led to a lower probability of respiratory-related hospitalisation (odds ratio (OR) 0.57, 95% CI 0.43 to 0.75, nine studies, 1749 participants, moderate-quality evidence). Over one year of follow-up, eight (95% CI 5 to 14) participants with a high baseline risk of respiratory-related hospital admission needed to be treated to prevent one participant with at least one hospital admission, and 20 (95% CI 15 to 35) participants with a low baseline risk of hospitalisation needed to be treated to prevent one participant with at least one respiratory-related hospital admission.No statistically significant effect of self management on all-cause hospitalisation (OR 0.77, 95% CI 0.45 to 1.30, 6 studies, 1365 participants, low-quality evidence) or mortality (OR 0.79, 95% CI 0.58 to 1.07, 8 studies, 2134 participants, very low-quality evidence) was detected. Also, dyspnoea measured by the (modified) Medical Research Council Scale ((m)MRC) was reduced in individuals who participated in self management (MD -0.83, 95% CI -1.36 to -0.30, 3 studies, 119 participants, low-quality evidence). The difference in exercise capacity as measured by the six-minute walking test was not statistically significant (MD 33.69 m, 95% CI -9.12 to 76.50, 6 studies, 570 participants, very low-quality evidence). Subgroup analyses depending on the use of an exercise programme as part of the intervention revealed no statistically significant differences between studies with and without exercise programmes in our primary outcomes of HRQoL and respiratory-related hospital admissions.We were unable to pool head-to-head trials because of heterogeneity among interventions and controls; thus results are presented narratively within the review. AUTHORS' CONCLUSIONS Self management interventions in patients with COPD are associated with improved health-related quality of life as measured by the SGRQ, a reduction in respiratory-related hospital admissions, and improvement in dyspnoea as measured by the (m)MRC. No statistically significant differences were found in other outcome parameters. However, heterogeneity among interventions, study populations, follow-up time and outcome measures makes it difficult to formulate clear recommendations regarding the most effective form and content of self management in COPD.
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Affiliation(s)
- Marlies Zwerink
- Medisch Spectrum TwenteDepartment of Pulmonary MedicineHaaksbergerstraat 55EnschedeNetherlands7513 ER
| | - Marjolein Brusse‐Keizer
- Medisch Spectrum TwenteDepartment of Pulmonary MedicineHaaksbergerstraat 55EnschedeNetherlands7513 ER
| | - Paul DLPM van der Valk
- Medisch Spectrum TwenteDepartment of Pulmonary MedicineHaaksbergerstraat 55EnschedeNetherlands7513 ER
| | - Gerhard A Zielhuis
- Radboud University Medical CenterDepartment for Health EvidencePO Box 9101NijmegenNetherlands6500 HB
| | - Evelyn M Monninkhof
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 GA
| | - Job van der Palen
- Medisch Spectrum TwenteDepartment of Pulmonary MedicineHaaksbergerstraat 55EnschedeNetherlands7513 ER
- University of TwenteDepartment of Research Methodology, Measurement and Data AnalysisEnschedeNetherlands
| | - Peter A Frith
- Repatriation General HospitalRespiratory Clinical Research UnitDaw ParkSouth AustraliaAustralia
- Flinders UniversitySchool of MedicineAdelaideSouth AustraliaAustralia
| | - Tanja Effing
- Repatriation General HospitalRespiratory Clinical Research UnitDaw ParkSouth AustraliaAustralia
- Flinders UniversitySchool of MedicineAdelaideSouth AustraliaAustralia
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White P, Thornton H, Pinnock H, Georgopoulou S, Booth HP. Overtreatment of COPD with inhaled corticosteroids--implications for safety and costs: cross-sectional observational study. PLoS One 2013; 8:e75221. [PMID: 24194824 PMCID: PMC3806778 DOI: 10.1371/journal.pone.0075221] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 08/14/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Combined inhaled long-acting beta-agonists and corticosteroids (LABA+ICS) are costly. They are recommended in severe or very severe chronic obstructive pulmonary disease (COPD). They should not be prescribed in mild or moderate disease. In COPD ICS are associated with side-effects including risk of pneumonia. We quantified appropriateness of prescribing and examined the risks and costs associated with overuse. METHODS Data were extracted from the electronic and paper records of 41 London general practices (population 310,775) including spirometry, medications and exacerbations. We classified severity, assessed appropriateness of prescribing using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for 2009, and performed a sensitivity analysis using the broader recommendations of the 2011 revision. RESULTS 3537 patients had a diagnosis of COPD. Spirometry was recorded for 2458(69%). 709(29%) did not meet GOLD criteria. 1749(49%) with confirmed COPD were analysed: 8.6% under-treated, 38% over-treated. Over-prescription of ICS in GOLD stage I or II (n=403, 38%) and in GOLD III or IV without exacerbations (n=231, 33.6%) was common. An estimated 12 cases (95%CI 7-19) annually of serious pneumonia were likely among 897 inappropriately treated. 535 cases of overtreatment involved LABA+ICS with a mean per patient cost of £553.56/year (€650.03). Using the broader indications for ICS in the 2011 revised GOLD guideline 25% were still classified as over-treated. The estimated risk of 15 cases of pneumonia (95%CI 8-22) in 1074 patients currently receiving ICS would rise by 20% to 18 (95%CI 9.8-26.7) in 1305 patients prescribed ICS if all with GOLD grade 3 and 4 received LABA+ICS. CONCLUSION Over-prescription of ICS in confirmed COPD was widespread with considerable potential for harm. In COPD where treatment is often escalated in the hope of easing the burden of disease clinicians should consider both the risks and benefits of treatment and the costs where the benefits are unproven.
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Affiliation(s)
- Patrick White
- Department of Primary Care and Public Health Sciences, King’s College London, King’s Health Partners, London, United Kingdom
| | - Hannah Thornton
- Department of Primary Care and Public Health Sciences, King’s College London, King’s Health Partners, London, United Kingdom
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Sofia Georgopoulou
- Department of Primary Care and Public Health Sciences, King’s College London, King’s Health Partners, London, United Kingdom
| | - Helen P. Booth
- Department of Primary Care and Public Health Sciences, King’s College London, King’s Health Partners, London, United Kingdom
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Kocks J, de Jong C, Berger MY, Kerstjens HAM, van der Molen T. Putting health status guided COPD management to the test: protocol of the MARCH study. BMC Pulm Med 2013; 13:41. [PMID: 23826685 PMCID: PMC3704975 DOI: 10.1186/1471-2466-13-41] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 06/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible and usually progressive. Current guidelines, among which the Dutch, have so far based their management strategy mainly on lung function impairment as measured by FEV1, while it is well known that FEV1 has a poor correlation with almost all features of COPD that matter to patients. Based on this discrepancy the GOLD 2011 update included symptoms and impact in their treatment algorithm proposal. Health status measures capture both symptoms and impact and could therefore be used as a standardized way to capture the information a doctor could otherwise only collect by careful history taking and recording. We hypothesize that a treatment algorithm that is based on a simple validated 10 item health status questionnaire, the Clinical COPD Questionnaire (CCQ), improves health status (as measured by SGRQ) and classical COPD outcomes like exacerbation frequency, patient satisfaction and health care utilization compared to usual care based on guidelines. METHODS/DESIGN This hypothesis will be tested in a randomized controlled trial (RCT) following 330 patients for two years. During this period general practitioners will receive treatment advices every four months that are based on the patient's health status (in half of the patients, intervention group) or on lung function (the remaining half of the patients, usual care group). DISCUSSION During the design process, the selection of outcomes and the development of the treatment algorithm were challenging. This is discussed in detail in the manuscript to facilitate researchers in designing future studies in this changing field of implementation research. TRIAL REGISTRATION Netherlands Trial Register, NTR2643.
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Affiliation(s)
- Janwillem Kocks
- Department of General Practice, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 97136 AV, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, The Netherlands
| | - Corina de Jong
- Department of General Practice, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 97136 AV, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 97136 AV, Groningen, the Netherlands
| | - Huib AM Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 97136 AV, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, The Netherlands
| | - Thys van der Molen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 97136 AV, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, The Netherlands
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Matkovic Z, Miravitlles M. Chronic bronchial infection in COPD. Is there an infective phenotype? Respir Med 2012; 107:10-22. [PMID: 23218452 PMCID: PMC7126218 DOI: 10.1016/j.rmed.2012.10.024] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Revised: 09/13/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023]
Abstract
Microorganisms, particularly bacteria, are frequently found in the lower airways of COPD patients, both in stable state and during exacerbations. The host–pathogen relationship in COPD is a complex, dynamic process characterised by frequent changes in pathogens, their strains and loads, and subsequent host immune responses. Exacerbations are detrimental events in the course of COPD and evidence suggests that 70% may be caused by microorganisms. When considering bacterial exacerbations, recent findings based on molecular typing have demonstrated that the acquisition of new strains of bacteria or antigenic changes in pre-existing strains are the most important triggers for exacerbation onset. Even in clinically stable COPD patients the presence of microorganisms in their lower airways may cause harmful effects and induce chronic low-grade airway inflammation leading to increased exacerbation frequency, an accelerated decline in lung function and impaired health-related quality of life. Besides intraluminal localisation in the distal airways, bacteria can be found in the bronchial walls and parenchymal lung tissue of COPD patients. Therefore, the isolation of pathogenic bacteria in stable COPD should be considered as a form of chronic infection rather than colonisation. This new approach may have important implications for the management of patients with COPD.
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Affiliation(s)
- Zinka Matkovic
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Ciber de Enfermedades Respiratorias (CIBERES), Hospital Clínic, Barcelona, Spain
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Roche N, Aguilaniu B, Burgel PR, Durand-Zaleski I, Dusser D, Escamilla R, Perez T, Raherison C, Similowski T. [Prevention of COPD exacerbation: a fundamental challenge]. Rev Mal Respir 2012; 29:756-74. [PMID: 22742463 DOI: 10.1016/j.rmr.2012.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/25/2011] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a cause of suffering for patients and a burden for healthcare systems and society. Their prevention represents individual and collective challenge. The present article is based on the work of a group of experts who met on 5th and 6th May 2011 and seeks to highlight the importance of AECOPD. STATE OF THE ART In the absence of easily quantifiable criteria, the definition of AECOPD varies in the literature, making identification difficult and affecting interpretation of study results. Exacerbations increase mortality and risk of cardiovascular disease. They also increase the risk of developing further exacerbations, accelerate the decline in lung function and contribute to reduction in muscle mass. By limiting physical activity and affecting mental state (anxiety, depression), AECOPD are disabling and impair quality of life. They increase work absenteeism and are responsible for about 60% of the global cost of COPD. PERSPECTIVES Earlier identification with simple criteria, possibly associated to patient phenotyping, could be helpful in preventing hospitalization. CONCLUSIONS Given their immediate and delayed impact, AECOPD should not be trivialized or neglected. Their prevention is a fundamental issue.
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Affiliation(s)
- N Roche
- Service de pneumologie et réanimation, pôle Arcole, Hôtel-Dieu, 1, place du Parvis-Notre-Dame, Assistance publique-Hôpitaux de Paris, université Paris Descartes, 75181 Paris cedex 04, France.
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Aisanov Z, Bai C, Bauerle O, Colodenco FD, Feldman C, Hashimoto S, Jardim J, Lai CKW, Laniado-Laborin R, Nadeau G, Sayiner A, Shim JJ, Tsai YH, Walters RD, Waterer G. Primary care physician perceptions on the diagnosis and management of chronic obstructive pulmonary disease in diverse regions of the world. Int J Chron Obstruct Pulmon Dis 2012; 7:271-82. [PMID: 22563246 PMCID: PMC3340113 DOI: 10.2147/copd.s28059] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a multicomponent disorder that leads to substantial disability, impaired quality of life, and increased mortality. Although the majority of COPD patients are first diagnosed and treated in primary care practices, there is comparatively little information on the management of COPD patients in primary care. A web-based pilot survey was conducted to evaluate the primary care physician’s, or general practitioner’s (GP’s), knowledge, understanding, and management of COPD in twelve territories across the Asia-Pacific region, Africa, eastern Europe, and Latin America, using a 10-minute questionnaire comprising 20 questions and translated into the native language of each participating territory. The questionnaire was administered to a total of 600 GPs (50 from each territory) involved in the management of COPD patients and all data were collated and analyzed by an independent health care research consultant. This survey demonstrated that the GPs’ understanding of COPD was variable across the territories, with large numbers of GPs having very limited knowledge of COPD and its management. A consistent finding across all territories was the underutilization of spirometry (median 26%; range 10%–48%) and reliance on X-rays (median 14%; range 5%–22%) for COPD diagnosis, whereas overuse of blood tests (unspecified) was particularly high in Russia and South Africa. Similarly, there was considerable underrecognition of the importance of exacerbation history as an important factor of COPD and its initial management in most territories (median 4%; range 0%–22%). Management of COPD was well below guideline-recommended levels in most of the regions investigated. The findings of this survey suggest there is a need for more ongoing education and information, specifically directed towards GPs outside of Europe and North America, and that global COPD guidelines appear to have limited reach and application in most of the areas studied.
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