The use of treatable traits to address COPD complexity and heterogeneity and to inform the care

Management of Chronic Obstructive Pulmonary Disease in Vietnam during the COVID-19 Period: Current Situation and Challenges

BACKGROUND

To assess the alterations in exacerbation rates, other clinical outcomes, and to identify persistent challenges in the management of chronic obstructive pulmonary disease (COPD) in Vietnamese COPD management units (CMUs).

METHODS

A multi-center, prospective cohort study was conducted on COPD within the CMUs of three study sites. The primary endpoint was exacerbation frequency. Data on demographic and clinical characteristics were collected at the initiation of the study. Participants were followed for 12 to 15 months after enrollment.

RESULTS

Throughout the follow-up period, a decrease was noted in the prevalence of patients requiring hospitalization (from 42.3% to 34.4%) and intensive care unit/emergency department admissions (from 5.7% to 0.6%). The annual rates of exacerbation and hospitalization were 0.75±0.89 and 0.56±0.70, respectively. Factors such as symptom severity, degree of airflow obstruction, and body mass index were associated with increased exacerbation frequency and elevated annual exacerbation rates. Our findings underscore the complexities and obstacles encountered in managing COPD during the coronavirus disease 2019 (COVID-19) pandemic, including the rise in smoking prevalence, inadequate testing rates, and non-compliance with established treatment guidelines.

CONCLUSION

Our study elucidates the challenges and difficulties in managing COPD amidst the COVID-19 pandemic, highlighting issues such as increased smoking rates, insufficient testing, and deviations from established therapeutic guidelines. These insights lay the groundwork for future intervention strategies and policy enhancements.

Characterising airway inflammation in Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander adults with asthma and COPD

OBJECTIVE

To examine airway inflammatory cell profiles in Indigenous Australian adults with asthma and chronic obstructive pulmonary disease (COPD).

DESIGN/SETTING

A retrospective, cross-sectional study on data from a tertiary referral respiratory outpatient clinic.

PARTICIPANTS

Indigenous (n=23) and non-Indigenous (n=71) adults were matched according to diagnosis, gender and age to the ratio of 1:3.

MAIN OUTCOME MEASURES

Participants were defined by self-determined identification as Indigenous (Aboriginal) or non-Indigenous. A relevant history was taken, and lung function was measured by spirometry. In those with a diagnosis of asthma, symptom control was assessed by the Asthma Control Questionnaire, six items (ACQ6). In those with a diagnosis of COPD, symptoms were assessed by the COPD assessment test (CAT). Airway cell counts were obtained in all groups from bronchial lavage (BL) cell count.

RESULTS

Lung function and inhaled corticosteroid dose were similar between groups. Current smoking was three times more common in Indigenous people (35%) compared with non-Indigenous people (12%, p=0.009). In participants with asthma, ACQ6 scores were similar between Indigenous and non-Indigenous participants with asthma. In those with COPD, Indigenous participants had significantly higher total CAT scores as well as scores for cough and sputum with a score indicating a high impact on quality of life (CAT score ≥14, 85%-25%, p=0.017). There was no difference in BL cell differential counts.

CONCLUSIONS

Indigenous people with COPD had higher smoking rates, worsened CAT scores and more symptoms of cough and sputum production. There were no differences between the groups in airway inflammation, but neutrophilic inflammation was associated with poorly-controlled asthma.

Integrating hot topics and implementation of treatable traits in asthma

People with asthma experience many different problems related to their illness. The number and type of problems differ between patients. This results in asthma being a complex and heterogeneous disorder which mandates a personalised approach to management. These features pose very significant challenges for the effective implementation of evidence-based management. "Treatable traits" is a model of care that has been specifically designed to address these issues. Traits are identified in the pulmonary, extrapulmonary (comorbidity) and behavioural/risk factor domains. Traits are clinically relevant, recognisable with validated trait identification markers and treatable using evidence-based therapies. The clinician and patient agree on a personalised management plan that addresses the relevant traits, and trials show superiority of this approach with significant improvements in asthma control and quality of life. A number of tools have now been developed to assist the clinician in the implementation of this approach. The success of the treatable traits model of care is now being realised in other disease areas.

Small airway dysfunction measured by impulse oscillometry is associated with exacerbations and poor symptom control in patients with asthma treated in a tertiary hospital subspecialist airways disease clinic

Introduction

Small airways dysfunction contributes to asthma pathophysiology and clinical outcomes including exacerbations and asthma control. Respiratory oscillometry is a simple, non-invasive and effort independent lung function test that provides vital information about small airway function. However, interpretation and clinical utility of respiratory oscillometry has been in part limited by lack of agreed parameters and the respective cutoffs. The aim of this study was to determine the prevalence of small airways dysfunction based on published impulse oscillometry (IOS) definition in patients with asthma referred to a tertiary asthma clinic and the extent to which it correlates with asthma clinical outcomes.

Methods

We retrospectively reviewed the medical records of all patients with asthma managed in the severe asthma clinic between January 2019 and December 2022 who underwent routine lung function tests with oscillometry and spirometry. Small airways dysfunction was determined from various published IOS parameter cutoffs, and the data were analysed to determine correlations between IOS parameters and asthma outcomes.

Results

Amongst the 148 patients, the prevalence of small airways dysfunction ranged from 53% to 78% depending on the defining oscillometry parameter. All oscillometry parameters correlated with the severity of airflow obstruction (FEV1% predicted, p < 0.001). Several oscillometry parameters correlated with asthma symptom burden, the strongest correlation was seen for frequency dependent resistance (R5-R20) with scores of Asthma Control Questionnaire (ACQ6) (Spearman's rank coefficient 0.213, p = 0.028) and Asthma Control Test (ACT) (Spearman's rank coefficient -0.248, p = 0.012). R5-R20 was predictive of poor asthma control defined by ACQ6 >1.5 (OR 2.97, p = 0.022) or ACT <20 (OR 2.44, p = 0.055). Small airways dysfunction defined by R5-R20 and area under the reactance curve (AX) also significantly increases asthma exacerbation risk (OR 2.60, p = 0.02 and OR 2.31, p = 0.03 respectively).

Conclusion

Respiratory oscillometry is a sensitive measure of small airways dysfunction that should complement spirometry in the routine assessment of asthma. Small airways dysfunction is highly prevalent in patients with asthma referred to a tertiary asthma clinic. R5-R20 was the metric most predictive in identifying patients at risk of asthma exacerbations and poor asthma control.

Unravelling the complex interplay of factors behind exercise limitations and physical inactivity in COPD

Exercise limitation and physical inactivity are known treatable traits for people with COPD. Maximising exercise capacity and keeping people physically active improves health status and survival rates among people with COPD. However, managing these two treatable traits can be extremely challenging for clinicians due to the complex intersectionality of factors influencing an individual's capacity, opportunity and motivation to engage in physical activity. This review presents the complex factors influencing exercise capacity ("can do"), levels of physical activity ("do do") and sedentary behaviours amongst people with COPD and provides practical recommendations on how clinicians can address some of these factors in practice. Most importantly, it highlights the importance of referring to pulmonary rehabilitation as a way to improve exercise capacity among people with COPD.

Phenotype to Treatable Traits-Based Management in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD), a heterogeneous respiratory disease driven by various genetic and environmental factors, presents significant challenges in diagnosis and management. Traditional approaches focused on phenotypic classification, but recent paradigms emphasize identifying and addressing treatable traits to personalize treatment strategies. Treatable traits facilitate personalized interventions, optimizing symptom control, and reducing exacerbation risk. Dyspnea and exacerbations, recognized as key traits, guide treatment decisions and follow-up management. Various interventions, including bronchodilators, corticosteroids, and lifestyle modifications, target specific traits like airway inflammation, mucus overproduction, and emphysema. Strategies for assessing and addressing treatable traits during initial encounters and follow-up visits enhance disease monitoring and treatment efficacy. Comprehensive trait assessment demands resources and specialized monitoring, posing barriers to widespread implementation. The lack of standardized protocols and evolving evidence further complicates decision-making and clinical practice. Despite these challenges, the shift toward treatable traits-based management signifies a pivotal advancement in COPD care, emphasizing holistic approaches tailored to individual patient needs. Recognizing and addressing treatable traits offers personalized interventions, enhancing symptom control and disease management. Embracing treatable traits-based approaches holds promise for improving clinical outcomes and enhancing the quality of life for individuals living with COPD.

The treatable traits of asthma in pregnancy: a clinical audit

Rationale

Poor asthma control in pregnancy is associated with adverse perinatal outcomes. Treatable traits improve patient outcomes but the pattern and prevalence of treatable traits in pregnant women with asthma is unknown. Whether treatable traits in pregnant women with asthma can be identified via a virtual care consult is also unknown. The objective of the present study was to assess the prevalence of treatable traits in pregnant women with asthma using a virtual model of care.

Methods

Pregnant women with asthma (n=196) underwent an assessment by an asthma nurse educator and a respiratory physician via telehealth. In this clinical audit, 16 treatable traits were assessed including two traits in the pulmonary domain, five traits in the behavioural/risk factors domain and nine traits in the extrapulmonary domain.

Results

Pregnant women with asthma had a mean±sd of 7.5±2.0 treatable traits per person including 1.0±0.7 treatable traits per person in the pulmonary domain, 3.5±1.56 in the extrapulmonary domain and 2±0.9 in the risk factor/behavioural domain. Treatable traits in the behavioural/risk factor domain were most prevalent and these included limited asthma knowledge (96%), inadequate inhaler technique (84%) and no written asthma action plan (80%). On average 3.8±1.24 interventions per person were delivered for a mean±sd of 7.5±2.0 treatable traits per person.

Conclusion

Virtual antenatal asthma care is a feasible approach for assessing treatable traits in pregnant women with mild asthma. Pregnant women with asthma exhibit multiple management issues. Virtual models of care might increase asthma in pregnancy service uptake and acceptability.

From treatable traits to GETomics in airway disease: moving towards clinical practice

The treatable traits approach represents a strategy for patient management. It is based on the identification of characteristics susceptible to treatments or predictive of treatment response in each individual patient. With the objective of accelerating progress in research and clinical practice relating to such a treatable traits approach, the Portraits event was convened in Barcelona, Spain, in November 2022. Here, while reporting the key concepts that emerged from the discussions during the meeting, we review the current state of the art related to treatable traits and chronic respiratory diseases management, and we describe the possible actions that clinicians can take in clinical practice to implement the treatable traits framework. Furthermore, we explore the new concept of GETomics and the new models of research in the field of COPD.

Treatable traits models of care

Treatable traits is a personalized approach to the management of respiratory disease. The approach involves a multidimensional assessment to understand the traits present in individual patients. Traits are phenotypic and endotypic characteristics that can be identified, are clinically relevant and can be successfully treated by therapy to improve clinical outcomes. Identification of traits is followed by individualized and targeted treatment to those traits. First proposed for the management of asthma and chronic obstructive pulmonary disease (COPD) the approach is recommended in many other areas of respiratory and now immunology medicine. Models of care for treatable traits have been proposed in different diseases and health care setting. In asthma and COPD traits are identified in three domains including pulmonary, extrapulmonary and behavioural/lifestyle/risk-factors. In bronchiectasis and interstitial lung disease, a fourth domain of aetiological traits has been proposed. As the core of treatable traits is personalized and individualized medicine; there are several key aspects to treatable traits models of care that should be considered in the delivery of care. These include person centredness, consideration of patients' values, needs and preferences, health literacy and engagement. We review the models of care that have been proposed and provide guidance on the engagement of patients in this approach to care.

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.

Can Treatable Traits Be the Approach to Addressing the Complexity and Heterogeneity of COPD?

The complexity of COPD implies the need to identify groups of patients with similar clinical characteristics and prognosis or treatment requirements. This is why much attention has been paid to identifying the different clinical phenotypes by investigating the clinical expression of the disease, and endotypes by studying the biological networks that enable and limit reactions. However, this approach is complicated because one endotype gives rise to one or more clinical characteristics, and clinical phenotypes can be derived from several endotypes. To simplify the approach, a new taxonomic classification of COPD based on the different causes (or etiotypes) has been proposed, but these etiotypes have not yet been validated. A simpler method is the so-called tractable traits approach, which is free from any designation of the disorder to be treated and does not present the criticality of using etiotypes. A large randomised controlled trial on using the treatable traits approach in COPD is still lacking. Nevertheless, this approach is already applied by following the GOLD strategy. However, its application is complicated because several potentially treatable traits have been identified within the pulmonary domain, the extrapulmonary domain, and the behavioural/risk factor domain. In addition, the hierarchy of the dominant treatable traits has not yet been established, and they change over time both spontaneously and because of treatment. This means that the patients being treated according to the tractable traits approach must be constantly followed over time so that the therapy is focused on their temporal needs.

An Update on Outcomes for COPD Pharmacological Trials: A COPD Investigators Report - Reassessment of the 2008 American Thoracic Society/European Respiratory Society Statement on Outcomes for COPD Pharmacological Trials

Background: In 2008, a dedicated American Thoracic Society/European Respiratory Society task force published a paper on the possible use and limitations of clinical outcomes and biomarkers to evaluate the impact of pharmacological therapy in patients with chronic obstructive pulmonary disease. Since then, our scientific understanding of chronic obstructive pulmonary disease has increased considerably; there has been a progressive shift from a one-size-fits-all diagnostic and therapeutic approach to a personalized approach; and many new treatments currently in development will require new endpoints to evaluate their efficacy adequately. Objectives: The emergence of several new relevant outcome measures motivated the authors to review advances in the field and highlight the need to update the content of the original report. Methods: The authors separately created search strategies for the literature, primarily based on their opinions and assessments supported by carefully chosen references. No centralized examination of the literature or uniform criteria for including or excluding evidence were used. Measurements and Main Results: Endpoints, outcomes, and biomarkers have been revisited. The limitations of some of those reported in the American Thoracic Society/European Respiratory Society task force document have been highlighted. In addition, new tools that may be useful, especially in evaluating personalized therapy, have been described. Conclusions: Because the "label-free" treatable traits approach is becoming an important step toward precision medicine, future clinical trials should focus on highly prevalent treatable traits, and this will influence the choice of outcomes and markers to be considered. The use of the new tools, particularly combination endpoints, could help better identify the right patients to be treated with the new drugs.

Inhibition of oxidative stress by apocynin attenuated chronic obstructive pulmonary disease progression and vascular injury by cigarette smoke exposure

BACKGROUND AND PURPOSE

Cardiovascular disease affects up to half of the patients with chronic obstructive pulmonary disease (COPD), exerting deleterious impact on health outcomes and survivability. Vascular endothelial dysfunction marks the onset of cardiovascular disease. The present study examined the effect of a potent NADPH Oxidase (NOX) inhibitor and free-radical scavenger, apocynin, on COPD-related cardiovascular disease.

EXPERIMENTAL APPROACH

Male BALB/c mice were exposed to either room air (Sham) or cigarette smoke (CS) generated from 9 cigarettes·day-1 , 5 days a week for up to 24 weeks with or without apocynin treatment (5 mg·kg-1 ·day-1 , intraperitoneal injection).

KEY RESULTS

Eight-weeks of apocynin treatment reduced airway neutrophil infiltration (by 42%) and completely preserved endothelial function and endothelial nitric oxide synthase (eNOS) availability against the oxidative insults of cigarette smoke exposure. These preservative effects were maintained up until the 24-week time point. 24-week of apocynin treatment markedly reduced airway inflammation (reduced infiltration of macrophage, neutrophil and lymphocyte), lung function decline (hyperinflation) and prevented airway collagen deposition by cigarette smoke exposure.

CONCLUSION AND IMPLICATIONS

Limiting NOX activity may slow COPD progression and lower cardiovascular disease risk, particularly when signs of oxidative stress become evident.

Rational use of inhaled corticosteroids for the treatment of COPD

Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.

Multidisciplinary care in chronic airway diseases: the Newcastle model

Chronic airway diseases including, asthma and chronic obstructive pulmonary disease (COPD) are prevalent and high burden conditions with the majority of patients successfully managed in the primary care setting. However, some patients with more complex disease such as difficult-to-treat or severe asthma, or complex COPD, tertiary care is required. This review provides an overview of the successful tertiary care multidisciplinary respiratory service that operates in Newcastle, New South Wales, Australia, which has been integrated into the tertiary care outpatient clinics for almost three decades. The service is multifaceted in terms of the clinical care it provides, and includes an “Inpatient service”, “Asthma Management Service”, “Difficult Airway Clinic”, “Drug Administration Clinic”, “Rapid Access Clinic”, “Pulmonary Rehabilitation” and has an integrated research programme. The core of the multidisciplinary approach to airway diseases is a person-centred model of care, the “Treatable Traits” approach. The staffing of this service comprises of consultant physicians, respiratory advanced trainees, respiratory scientists, physiotherapists, speech pathologists, nurse specialists and a nurse consultant. Patients that present to this service undergo an initial assessment and clinical review by team members, synthesis of relevant data, and development of a diagnosis and management plan. Based on this review specific interventions are determined according to the traits identified. Overtime the service has evolved to accommodate the increasing numbers of patients requiring access to the “Difficult Airways Clinic” assessment and therapies. This has been facilitated by partnered with the Centres of Excellence in Severe Asthma and Treatable Traits to develop educational and practice management tools.

Targeted therapy in respiratory disease

Advances in understanding of respiratory diseases have allowed the development of targeted therapies tailored to the individual patienthttps://bit.ly/3CEhokk