Treatment of severe stable COPD: the multidimensional approach of treatable traits

Timing of lung transplant evaluation: considerations, barriers and alternatives

PURPOSE OF REVIEW

Over the past decade, increased knowledge has contributed to improved medical and technical treatments across the spectrum of respiratory diseases. As a result, timing for transplant evaluation might be more challenging. In this review, the focus is on timing of lung transplant evaluation of patients from the main respiratory diseases referred. Disease-specific predictors of survival in relation to timing of transplant evaluation and alternative treatments will be reviewed.

RECENT FINDINGS

Treatment options have evolved for respiratory diseases like chronic obstructive pulmonary disease, pulmonary fibrosis, cystic fibrosis and pulmonary arterial hypertension. These treatments have led to improved quality of life, exercise tolerance, lung function and outcome. However, the effect of these alternative treatments on transplant candidacy and knowledge on timing of lung transplant evaluation are lacking.

SUMMARY

This article reviews the current best evidence to guide clinicians regarding the optimum timing for transplant referral and highlights considerations to optimize transplant candidacy and outcomes.

Patient-centered assessment of treatment for alpha-1 antitrypsin deficiency: literature review to identify concepts and measures for people with alpha1-antitrypsin deficiency

BACKGROUND

Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder that can result in a range of illnesses, with chronic obstructive pulmonary disease (COPD) being one of the most common. Although some people obtain genetic testing that identifies AATD, many people are unaware that they have AATD until they develop COPD, often at a younger age than is typical. Treatment for AATD consists primarily of augmentation with AAT, requiring weekly infusions of blood products for most patients. This treatment can slow disease progression and improve symptoms, but is burdensome; thus, people with AATD could benefit from additional or alternate treatments. However, to guide the development of new treatments, researchers need to identify which outcomes matter to people with AATD.

METHODS

We conducted a scoping literature review to better understand patient experiences with AATD and its treatment and identify patient-reported outcome measures (PROMs) used to assess symptoms and impacts in studies of people with AATD.

RESULTS

The review identified 44 concepts related to symptoms and disease burden, grouped into six domains (symptoms, physical function, cognitive function, emotional function, psychosocial function, and treatment burden) and 24 PROMs that have been used in research on AATD. None of the identified measures were developed specifically for people with AATD. Research on patient-focused outcomes was limited, suggesting a significant gap in knowledge.

CONCLUSIONS

People with AATD experience a variety of disease-related burdens, but this study showed there is a lack of published, in-depth studies to support selection and evaluation of patient-centered outcomes among populations of people with AATD. A limited number of PROMs have been used in research on AATD or in clinical trials of treatment, including COPD-specific measures that assess symptoms and quality of life and measures of mood, sleep, and general physical and psychosocial functioning. The current study documented the available evidence and compiled a list of potential concepts of interest, but further qualitative and quantitative studies will be needed to understand the outcomes that matter to people with AATD and to evaluate the alignment between these outcomes and available measures.

Widening the selection criteria for lung volume reduction surgery

Lung emphysema is a chronic disease that strongly impairs the patient's quality of life and survival. In well-selected patients with severe emphysema, who are breathless despite maximal medical care, lung volume reduction (LVR) can improve lung function and exercise capacity to alleviate symptoms and potentially delay or prevent lung transplantation [1, 2]. The main goal of LVR is to reduce hyperinflation by targeting the excess residual volume (RV), increasing dynamic lung volumes and breathing reserve capacity [2]. Patients should be selected by a specialised multidisciplinary team following thorough functional and morphological assessment [3]. The general accepted selection criteria for lung volume reduction surgery (LVRS) originate from expert recommendations in the NETT trial and include forced expiratory volume in 1 s (FEV1) 20–45% of predicted, total lung capacity >100% pred, RV >150% pred, diffusing capacity for carbon monoxide (D LCO) ≥20% pred, 6-min walking distance (6MWD) 140–450 m, and absence of coronary artery disease or moderate to severe pulmonary hypertension (mean pulmonary arterial pressure <35 mmHg) [4]. Over the past years, expert centres have challenged the lower inclusion limits by reporting successful outcomes in patients with more severe disease (FEV1 <20% pred and D LCO <20% pred) and less favourable morphology in the presence of significant hyperinflation [5–7]. In contrast to these often-challenging cases, to our knowledge, no data is published on LVRS in symptomatic patients exceeding the upper-limit criteria, once deemed “too good” for LVRS. We hypothesise that these patients with a major impact on functional capacity and quality of life due to hyperinflation could benefit from LVRS.

Severely hyperinflated patients with a heterogeneous morphology could be considered for lung volume reduction surgery when surpassing the upper limit criteria for FEV1 and 6MWD, resulting in significant clinical benefits with minimal postoperative risks https://bit.ly/4eWTNy8

The precision medicine strategy to treat COPD pulmonary traits in clinical practice: The role of N-acetylcysteine

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition and a leading cause of physical decline and death. COPD prevalence is expected to increase steadily in the coming years, and as a result, the healthcare and social burden of this condition will intensify. In this scenario, a patient-centric approach, the treatable trait (TT) strategy, based on the identification of traits that are clinically relevant, identifiable, monitorable and treatable, has emerged. The TT strategy, which considers behavioral/risk factors, as well as pulmonary and extrapulmonary traits, has shown to be a promising strategy in COPD management. This work reviews the TT strategy in COPD, giving special attention to the most relevant pulmonary traits, such as frequent productive cough, chronic bronchitis, type 2 inflammation, neutrophilic inflammation, lung hyperinflation, bronchiectasis, exacerbations and non-reversible airflow limitation. N-acetylcysteine (NAC), a widely used mucolytic agent, might be a major player in this strategy. Indeed, through a thorough review of the literature, it has been possible to highlight that, besides being essential in the treatment of frequent productive cough, NAC could bring benefits in case of airflow limitations, airways inflammation, exacerbations and bronchiectasis. A clinical case in which the TT strategy was able to reduce symptoms and improve lung function and quality of life, minimizing unnecessary medication and side effects, is also presented. The identification of TTs and their proper treatment through personalized medicine remarkably ameliorates COPD management. Of note, the mucolytic, antioxidant, and anti-inflammatory activities of NAC might have beneficial effects on several TTs.

Defining a phenotype of severe COPD patients who develop chronic hypercapnia

INTRODUCTION

Chronic hypercapnia, defined by elevated blood CO2 levels, is a serious complication most prevalent in severe COPD. It negatively impacts quality of life, increases hospitalization rates, and elevates mortality risks. However, not all severe COPD patients develop chronic hypercapnia, and its underlying mechanisms remain unclear. Identifying clinical and pathophysiological predictors of hypercapnia is essential for tailored treatment strategies. This study investigates the relationship between hypercapnia and patient characteristics, lung function, and CT scan features to identify potential therapeutic targets.

METHODS

This cross-sectional study included 1526 COPD patients from three cohorts: a standard care cohort and two research cohorts (NCT04023409; NCT03053973). Data collected included demographic and clinical information, blood gases, lung function (FEV1, FVC, TLC, RV, DLCOc), and high-resolution CT scans (lung volumes, air trapping, emphysema scores, airway wall thickness (Pi10), and diaphragm indices).

RESULTS

Hypercapnia prevalence increased with COPD severity. Hypercapnic patients were older, more likely to smoke, and had more comorbidities. They exhibited lower FEV1 and FVC, and higher RV/TLC ratios, with CT scans showing lower emphysema scores and greater Pi10. Multivariate analysis identified lower PaO2, FEV1% predicted, and emphysema scores, along with higher RV/TLC ratios and NT-proBNP levels, as independent predictors of PaCO2, collectively explaining 46.3 % of the variance.

CONCLUSION

COPD patients with chronic hypercapnia are characterized by higher smoking rates, lower PaO2 levels, poorer lung function, less emphysema, and increased airway pathology. These findings underscore the multifactorial nature of hypercapnia in COPD, highlighting the need for personalized therapeutic strategies targeting these factors to improve outcomes.

Comorbidities reduce survival and quality of life in COPD with severe lung hyperinflation

Rationale and aim

Patients with COPD often present with a significant number of comorbidities, which are thought to be related to a higher mortality risk. Our aim was to investigate the prevalence and impact of comorbidities on survival and quality of life (QoL), specifically in patients with emphysema characterised by severe lung hyperinflation.

Patients and methods

Data were prospectively collected from patients who visited our hospital for evaluating their eligibility for a bronchoscopic lung volume reduction treatment and were included in the Groningen Severe COPD cohort (NCT04023409). Comorbidities were patient-reported by a questionnaire and were validated with patients' medical records. QoL was assessed with the St Georges Respiratory Questionnaire.

Results

We included 830 COPD patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage III and IV. The total number of comorbidities was an independent predictor of survival when adjusting for other factors influencing survival (HR 1.12, 95% CI 1.05-1.20, p<0.001). Of the individual comorbidities, pulmonary arterial hypertension (HR 1.53, 95% CI 1.01-2.32, p=0.045), low body mass index (HR 1.63, 95% CI 1.16-2.27, p=0.004) and anxiety (HR 1.46, 95% CI 1.11-1.92, p=0.007) were independently associated with worse survival. Moreover, patients having 3, 4 or >5 comorbidities had a significantly (all p<0.05) worse QoL, in comparison to patients without comorbidities.

Conclusion

Our results show that comorbidities were associated with lower survival and poor QoL in emphysema patients characterised by severe hyperinflation. Appropriate treatment of treatable traits, including anxiety, low body mass index and pulmonary arterial hypertension, could lead to a survival benefit and improvement in QoL in this specific patient population.

Advancements in automated classification of chronic obstructive pulmonary disease based on computed tomography imaging features through deep learning approaches

Chronic Obstructive Pulmonary Disease (COPD) represents a global public health issue that significantly impairs patients' quality of life and overall health. As one of the primary causes of chronic respiratory diseases and global mortality, effective diagnosis and classification of COPD are crucial for clinical management. Pulmonary function tests (PFTs) are standard for diagnosing COPD, yet their accuracy is influenced by patient compliance and other factors, and they struggle to detect early disease pathologies. Furthermore, the complexity of COPD pathological changes poses additional challenges for clinical diagnosis, increasing the difficulty for physicians in practice. Recently, deep learning (DL) technologies have demonstrated significant potential in medical image analysis, particularly for the diagnosis and classification of COPD. By analyzing key radiological features such as airway alterations, emphysema, and vascular characteristics in Computed Tomography (CT) scan images, DL enhances diagnostic accuracy and efficiency, providing more precise treatment plans for COPD patients. This article reviews the latest research advancements in DL methods based on principal radiological features of COPD for its classification and discusses the advantages, challenges, and future research directions of DL in this field, aiming to provide new perspectives for the personalized management and treatment of COPD.

Initiation of Chronic Non-invasive Ventilation

Initiation of home non-invasive ventilation (NIV) requires careful consideration of the patient's condition, motivation, expectations, wishes, and social circumstances. The decision to start NIV depends on a combination of factors including patient symptoms and objective evidence of nocturnal hypoventilation. A solid understanding of the underlying pathophysiology is key to a systematic and well-balanced clinical approach to titrating NIV. The location where NIV is initiated is not the most relevant issue, provided that it is a comfortable, safe environment in which adequate monitoring can be assured. The majority of patients prefer their own home for treatment initiation.

Deventilation Syndrome in Patients with Chronic Obstructive Pulmonary Disease Using Nocturnal Noninvasive Ventilation: What Are the Underlying Mechanisms?

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) commonly experience severe dyspnea after discontinuation of nocturnal noninvasive ventilation (NIV), known as deventilation syndrome (DVS), which negatively affects quality of life. Despite various hypotheses, the precise mechanisms of DVS remain unknown.

METHODS

An observational pilot study was performed monitoring 16 stable COPD patients before, during, and after an afternoon nap on NIV. Seven patients experienced DVS (Borg Dyspnea Scale ≥5), while nine served as controls (Borg Dyspnea Scale ≤2). Hyperinflation was evaluated through inspiratory capacity (IC) measurements and end-expiratory lung impedance (EELI) via electrical impedance tomography. Respiratory muscle activity was assessed by diaphragmatic surface electromyography (sEMG).

RESULTS

Post-NIV dyspnea scores were significantly higher in the DVS group (5 [3-7] vs. 0 [0-1.5], p < 0.001). IC values were lower in the DVS group compared to controls, both pre-NIV (54 [41-63] vs. 88 [72-94] %pred., p = 0.006) and post-NIV (45 [40-59] vs. 76 [65-82] %pred., p = 0.005), while no intergroup difference was seen in IC changes pre- and post-NIV. EELI values after NIV indicated a tendency towards lower values in controls and higher values in DVS patients. sEMG amplitudes were higher in the DVS group within the first 5-min post-NIV (221 [112-294] vs. 100 [58-177]% of baseline, p = 0.030).

CONCLUSION

This study suggests that it is unlikely that DVS originates from the inability to create diaphragmatic muscle activity after NIV. Instead, NIV-induced hyperinflation in individuals with static hyperinflation may play a significant role. Addressing hyperinflation holds promise in preventing DVS symptoms in COPD patients.

Exploring Molecular Mechanisms and Biomarkers in COPD: An Overview of Current Advancements and Perspectives

Chronic obstructive pulmonary disease (COPD) plays a significant role in global morbidity and mortality rates, typified by progressive airflow restriction and lingering respiratory symptoms. Recent explorations in molecular biology have illuminated the complex mechanisms underpinning COPD pathogenesis, providing critical insights into disease progression, exacerbations, and potential therapeutic interventions. This review delivers a thorough examination of the latest progress in molecular research related to COPD, involving fundamental molecular pathways, biomarkers, therapeutic targets, and cutting-edge technologies. Key areas of focus include the roles of inflammation, oxidative stress, and protease-antiprotease imbalances, alongside genetic and epigenetic factors contributing to COPD susceptibility and heterogeneity. Additionally, advancements in omics technologies-such as genomics, transcriptomics, proteomics, and metabolomics-offer new avenues for comprehensive molecular profiling, aiding in the discovery of novel biomarkers and therapeutic targets. Comprehending the molecular foundation of COPD carries substantial potential for the creation of tailored treatment strategies and the enhancement of patient outcomes. By integrating molecular insights into clinical practice, there is a promising pathway towards personalized medicine approaches that can improve the diagnosis, treatment, and overall management of COPD, ultimately reducing its global burden.

Optimizing clinical outcomes for bronchoscopic lung volume reduction with Zephyr® valves

Bronchoscopic lung volume reduction treatment with Zephyr one-way valves is an effective guideline-based treatment option for patients with severe emphysema and hyperinflation. However, in some cases the treatment response is less than anticipated or there might be a loss of initial treatment effect. Reasons for the lack of response can include incorrect assessment of collateral ventilation, improper valve placement, or patient related factors. Loss of initial benefit can be due to granulation tissue formation and subsequent valve dysfunction, or there may be side effects such as excessive coughing or infectious problems. Careful follow-up after treatment with valves is important and evaluation with a CT scan and/or bronchoscopy is helpful if there is no improvement after treatment or loss of initial benefit. This paper aims to describe the most important causes and provide a strategy of how to approach and manage these patients.

Design of the multicentre randomised controlled BENTO trial to demonstrate patient-relevant benefit of bronchoscopic lung volume reduction using thermal vapour ablation in the German healthcare system for patients with upper lobe emphysema: a study protocol

INTRODUCTION

Application of vapour ablation as a novel approach to lung volume reduction has positive effects in patients with severe emphysema. The BENTO study is a randomised, controlled, open, multicentre trial, to assess the effects of bronchoscopic thermal vapour ablation (BTVA) in the German healthcare system.

METHODS AND ANALYSIS

Patients with bilateral heterogeneous emphysema of the upper lobes in Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3/4 will be enrolled in this trial and will receive either standard medical management alone (according to GOLD guidelines) or BTVA treatment with the InterVapor system together with standard medical management. Patients will be randomised in a 2:1 ratio (treatment group:control group). A total of 224 patients will be enrolled at 15 study sites. The primary endpoint is the change in patient-reported disease-specific quality of life, as measured by the St George's Respiratory Questionnaire for chronic obstructive pulmonary disease patients between randomisation and the 9-month follow-up visit. Secondary endpoints include adverse events, mortality, vital status, changes in lung function parameters, exercise capacity and other efficacy measures at 3, 9 and 12 months.The BENTO trial was commissioned by the German Federal Joint Committee, to demonstrate that this approach is an efficient and safe treatment option in the German healthcare system.

ETHICS AND DISSEMINATION

The protocol has been approved by the lead ethics committee in Germany (Ethics Committee of the Medical Faculty of Heidelberg) and until present also by the following ethics committees: Ethics Committee of the Medical Faculty of Duisburg-Essen, Ethics Committee of the Medical Faculty of Martin-Luther-University Halle-Wittenberg, Ethics Committee of the State Medical Association of Hessen, Ethics Commission of the State Office for Health and Social Affairs of the State of Berlin, Ethics Committee of the Medical Faculty of Greifswald. The results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05717192.

Lung volume reduction surgery is safe and feasible after initial endobronchial valve treatment for emphysema patients

OBJECTIVES

Bronchoscopic lung volume reduction with endobronchial valves is a guideline treatment leading to improved pulmonary function, exercise tolerance and quality of life, in patients with advanced emphysema, severe hyperinflation and no collateral ventilation. After valve treatment, loss of the initial lung volume reduction effect can occur, as well as local valve-induced complications such as persistent haemoptysis. In these cases, a surgical lobectomy can be considered to achieve similar efficacy outcomes. We evaluated the safety and feasibility of a video-assisted thoracoscopic surgery lobectomy after valve treatment.

METHODS

This single-centre retrospective study included patients who underwent an elective lobectomy after previous valve treatment. Data were evaluated for safety and efficacy for the additional surgical procedure.

RESULTS

Twenty-one patients [73% female, median age 67 (7) years, forced expiratory volume in 1 s 29 (7) %pred, and residual volume 223 (58) %pred] were included. There was no 90-day mortality and there were no postoperative intensive care admissions. Pulmonary infections (14%) and prolonged air leak (14%) were the most common complications. In patients who underwent surgery due to loss or lack of effect of valve treatment, a lobectomy led to a significant improvement in pulmonary function; median forced expiratory volume in 1 s +75 (193) ml (P < 0.013), forced vital capacity +450 (572) ml (P = 0.001), residual volume -665 (715) ml (P = 0.005). In patients who underwent a lobectomy because of complications of valve treatment, all complications were resolved after surgery.

CONCLUSIONS

We demonstrate that an elective lobectomy after an initial valve treatment is safe and feasible and restores the lung volume reduction effect.

Assessment of hyperinflation: comparison of Global Lung Function Initiative and European Community for Steel and Coal lung volume reference equations

Background

Assessment of static hyperinflation severity is crucial to identify COPD patients eligible for lung volume reduction. The current recommendation of residual volume ≥175% predicted may need to be reconsidered owing to potential differences between the Global Lung Function Initiative (GLI) and the European Community for Steel and Coal (ECSC) reference equations for residual volume and concerns about using percentage of predicted.

Methods

We compared the residual volume reference values derived from the GLI and ECSC equations using mathematically simulated data and used a receiver operating characteristic curve to establish a new GLI-derived z-score cut-off for residual volume using body plethysmography data from patients with severe COPD.

Results

The GLI reference equation for residual volume consistently yields a lower predicted residual volume for individuals with an average or below-average height (females ≤163 cm and males ≤177 cm). Our clinical cohort consisted of 1011 patients with COPD (graded using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria as 38% GOLD 3 and 59% GOLD 4). In this cohort, a GLI-derived residual volume z-score of ≥2.9 could accurately replace the ECSC-derived 175% predicted cut-off and a z-score of ≥3.5 was established for the 200% predicted cut-off.

Conclusion

There are substantial differences in predicted residual volume values between the GLI and ECSC equations, with the GLI generally yielding a lower predicted residual volume in the majority of individuals. A GLI-derived residual volume z-score of ≥2.9 could be used to replace the currently used cut-off of ≥175% predicted to identify potential lung volume reduction candidates.

Yiqigubiao pill treatment regulates Sirtuin 5 expression and mitochondrial function in chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of pathophysiological bases of airway inflammation and its anti-inflammatory response. Aberrant mitochondrial signaling and mitochondrial dysfunction underlie the pathomechanisms leading to COPD. This study aims to investigate the effects of the Yiqigubiao (YQGB) pill, a traditional Chinese medicine (TCM), on Sirtuin 5 (SIRT5) and mitochondrial function in patients with COPD.

Methods

Thirty-four patients with COPD were randomized into oral YQGB or placebo groups concurrent with a 24-week routine treatment. The pulmonary function was assessed by examining the levels of forced expiratory volume in one second (FEV1)/forced vital capacity (FVC), FEV1, and FVC. Quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot were used to detect SIRT5 expression in mitochondria isolated from peripheral blood. Flow cytometry was used to detect changes in mitochondrial membrane potential and reactive oxygen species (ROS) in peripheral blood lymphocytes. Human bronchial epithelial (HBE) cells stimulated by cigarette smoke extract (CSE) were treated with YQGB. After SIRT5 was knocked down in cells, the changes in mitochondrial membrane potential, levels of adenosine triphosphate (ATP), and ROS were detected.

Results

YQGB treatment significantly improved lung function in patients with COPD. The expression of SIRT5 and the mitochondrial membrane potential significantly increased and ROS decreased in patients with COPD after YQGB treatment. The CSE decreased cell proliferation and SIRT5 expression, which was alleviated after YQGB treatment. Furthermore, SIRT5 was knocked down in CSE-stimulated HBE cells, and its expression was elevated upon YQGB treatment. The knockdown of SIRT5 significantly altered the CSE-stimulation-induced dysregulation of mitochondrial membrane potential, ATP levels, and ROS. This was also restored after YQGB treatment.

Conclusions

YQGB treatment can elevate SIRT5 expression, restore mitochondrial function in COPD, and exert protective effects.

Home ventilation for patients with end-stage chronic obstructive pulmonary disease

PURPOSE OF THE REVIEW

The number of patients with end-stage chronic obstructive pulmonary disease (COPD) treated with chronic non-invasive ventilation (NIV) has greatly increased. In this review, the authors summarize the evidence for nocturnal NIV and NIV during exercise. The authors discuss the multidisciplinary and advanced care of patients with end-stage COPD treated with NIV.

RECENT FINDINGS

Nocturnal NIV improves gas exchange, health-related quality of life and survival in stable hypercapnic COPD patients. Improvements in care delivery have been achieved by relocating care from the hospital to home based; home initiation of chronic NIV is feasible, non-inferior regarding efficacy and cost-effective compared to in-hospital initiation. However, the effect of NIV on symptoms is variable, and applying optimal NIV for end-stage COPD is complex. While exercise-induced dyspnoea is a prominent complaint in end-stage COPD, nocturnal NIV will not change this. However, NIV applied solely during exercise might improve exercise tolerance and dyspnoea. While chronic NIV is often a long-standing treatment, patient expectations should be discussed early and be managed continuously during the treatment. Further, integration of advance care planning requires a multidisciplinary approach.

SUMMARY

Although chronic NIV is an effective treatment in end-stage COPD with persistent hypercapnia, there are still important questions that need to be answered to improve care of these severely ill patients.

From plugging air leaks to reducing lung volume: a review of the many uses of endobronchial valves

INTRODUCTION

One-way endobronchial valve treatment improves lung function, exercise capacity, and quality of live in patients with severe emphysema and hyperinflation. Other areas of therapeutic application include treatment of persistent air leak (PAL), giant emphysematous bullae, native lung hyperinflation, hemoptysis, and tuberculosis.

AREAS COVERED

In this review, we will assess the clinical evidence and safety of the different applications of one-way endobronchial valves (EBV).

EXPERT OPINION

There is solid clinical evidence for the use of one-way EBV for lung volume reduction in emphysema. Treatment with one-way EBV can be considered for the treatment of PAL. The application of one-way EBV for giant bullae, post lung transplant native lung hyperinflation, hemoptysis, and tuberculosis is under investigation and more research is required to investigate the efficacy and safety of these applications.

The Role of Long-Term Noninvasive Ventilation in Chronic Stable Hypercapnic Chronic Obstructive Pulmonary Disease

Despite the heterogeneity of data on the role of noninvasive ventilation (NIV) in severe stable chronic obstructive pulmonary disease with chronic hypercapnia, the current evidence supports the use of NIV in select populations and phenotypes. The Center for Medicare and Medicaid Services reimbursement criteria are complex, and the practice of navigating the most efficient method to initiate NIV therapy continues to be challenging. These patients optimally require referral to a medical center that has physicians with specific training in pulmonary and sleep medicine, who can navigate the specific needs for the use of NIV.

Application of Acupoint Catgut Embedding Therapy Combined with Liuzijue Breathing Exercise in the Treatment of Patients with Stable Chronic Obstructive Pulmonary Disease

Objective

To evaluate the application value of acupoint catgut embedding therapy combined with Liuzijue breathing exercise in the treatment of patients with stable chronic obstructive pulmonary disease (COPD) and its impact on immune function and quality of life.

Methods

A total of 100 patients with stable COPD admitted to our hospital from February 2020 to February 2021 were included and assigned to the experimental group (n = 50) and the control group (n = 50) according to the order of admission. Both groups of patients received conventional treatment. The control group was given daily inhalation of budesonide and formoterol fumarate powder for inhalation (320 ug/bottle), and the experimental group received additional acupoint catgut embedding therapy combined with Liuzijue breathing exercise. The clinical efficacy, pulmonary function indexes, activities of daily living (ADL) scores, quality of life (QOL) scores, traditional Chinese medicine (TCM) syndrome scores, the number of acute exacerbations, medical expenses, the incidence of adverse reactions, and immune indicators were compared between the two groups of patients.

Results

The experimental group yielded a significantly higher effective rate of treatment than the control group (P < 0.05). After the treatment, the experimental group obtained a superior outcome in terms of lung function indexes, immune function indexes, ADL and QOL scores, and the TCM syndrome scores when compared with the control group (P < 0.05). The number of acute exacerbations in the experimental group was remarkably lower than that in the control group (P < 0.05). No serious adverse reactions were observed in the two groups of patients, and no significant difference in the incidence of adverse reactions was found (P > 0.05).

Conclusion

Acupoint catgut embedding therapy combined with Liuzijue breathing exercise, with high safety, can improve the treatment effect and the quality of life of patients with stable COPD, which merits clinical promotion.

Aqueous dispersions of oxygen nanobubbles for potential application in inhalation therapy

Inhalation is a non-invasive method of local drug delivery to the respiratory system. This study analyzed the potential use of aqueous dispersion of oxygen nanobubbles (ADON) as a drug carrier with the additional function of oxygen supplementation to diseased lungs. The suitability of the membrane-based method of ADON preparation and, next, the stability of ADON properties during storage and after aerosolization in nebulizers of various designs (jet, ultrasonic, and two vibrating mesh devices) was investigated. The increased oxygen content in the aerosol generated in two mesh nebulizers suggests that the proposed concept may be helpful in the oxygen supplementation during drug delivery by aerosol inhalation without using an additional oxygen source. This application can increase the overall effectiveness of lung disease treatment and pulmonary rehabilitation.

Treatable Traits in Chronic Respiratory Disease: A Comprehensive Review

Chronic respiratory diseases are major contributors to the global burden of disease. While understanding of these diseases has improved, treatment guidelines have continued to rely on severity and exacerbation-based approaches. A new personalised approach, termed the "treatable traits" approach, has been suggested to address the limitations of the existing treatment strategies. We aim to systematically review the current evidence regarding treatable traits in chronic respiratory diseases and to identify gaps in the current literature. We searched the PubMed and Embase databases and included studies on treatable traits and chronic respiratory diseases. We then extracted information on prevalence, prognostic implications, treatment options and benefits from these studies. A total of 58 papers was included for review. The traits identified were grouped into five broad themes: physiological, biochemical, psychosocial, microbiological, and comorbidity traits. Studies have shown advantages of the treatable traits paradigm in the clinical setting. However, few randomised controlled trials have been conducted. Findings from our review suggest that multidisciplinary management with therapies targeted at treatable traits has the potential to be efficacious when added to the best practices currently implemented. This paradigm has the potential to improve the holistic care of chronic respiratory diseases.

Treatable Traits in COPD - A Proposed Approach

The well-recognized individual heterogeneity within COPD patients has led to a growing interest in greater personalization in the approach of these patients. Thus, the treatable traits strategy has been proposed as a further step towards precision medicine in the management of chronic airway disease, both in stable phase and acute exacerbations. The aim of this paper is to perform a critical review on the treatable traits strategy and propose a guide to approach COPD patients in the light of this new concept. An innovative stepwise approach is proposed - a multidisciplinary model based on two distinct phases, with the potential to be implemented in both primary care and hospital settings. The first phase is the initial and focused assessment of a selected subset of treatable traits, which should be addressed in all COPD patients in both settings (primary care and hospital). As some patients may present with advanced disease at diagnosis or may progress despite this initial treatment requiring a more specialized assessment, they should progress to a second phase, in which a broader approach is recommended. Beyond stable COPD, we explore how the treatable traits strategy may be applied to reduce the risk of future exacerbations and improve the management of COPD exacerbations. Since many treatable traits have already been related to exacerbation risk, the strategy proposed here represents an opportunity to be proactive. Although it still lacks prospective validation, we believe this is the way forward for the future of the COPD approach.

The Role of Palliative Care in COPD

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is a serious respiratory illness characterized by years of progressively debilitating breathlessness, high prevalence of associated depression and anxiety, frequent hospitalizations, and diminished wellbeing. Despite the potential to confer significant quality of life benefits for patients and their care partners and to improve end-of-life care, specialist palliative care is rarely implemented in COPD and when initiated it often occurs only at the very end of life. Primary palliative care delivered by frontline clinicians is a feasible model, but is not routinely integrated in COPD. In this review, we discuss the following: 1) the role of specialist and primary palliative care for patients with COPD and the case for earlier integration into routine practice; 2) the domains of the National Consensus Project Guidelines for Quality Palliative Care applied to people living with COPD and their care partners; and, 3) triggers for initiating palliative care and practical ways to implement palliative care using case-based examples. In the end, this review solidifies that palliative care is much more than hospice and end-of-life care and demonstrates that early palliative care is appropriate at any point during the COPD trajectory. We emphasize that palliative care should be integrated long before the end of life to provide comprehensive support for patients and their care partners and to better prepare them for the end of life.

Palliative Care For Patients with Advanced COPD in Primary Care

Patients with advanced COPD have a high symptom burden that is often multidimensional. Identification of patients who might benefit from palliative care through validated identification tools, multidimensional symptom management, and timely discussion of advance planning are elements of a palliative care approach for these patients and their families. Coordination among stakeholders providing care and support to these patients is central to ensuring high-quality care and meeting all of their needs.

Investigation of the Clinical, Radiological and Biological Factors Associated with Disease Progression, Phenotypes and Endotypes of COPD in China (COMPASS): study design, protocol and rationale

COPD is heterogeneous, and its presentation varies between countries. The major COPD cohort studies have only been performed in Western populations; the disease is not well characterised in other regions. The COMPASS (Investigation of the Clinical, Radiological and Biological Factors, Humanistic and Healthcare Utilisation Burden Associated with Disease Progression, Phenotypes and Endotypes of COPD in China; NCT04853225) is a prospective, 2.5-year-long, multi-centre, longitudinal, observational study with three aims: 1) to characterise stable and exacerbation phenotypes/endotypes in terms of clinical characteristics, blood and sputum biomarkers, lung microbiome and lung imaging; 2) to understand the relevance of markers of COPD disease progression identified in Western cohorts to Chinese patients; and 3) to characterise treatment pathways and healthcare resource utilisation. COMPASS will recruit 2000 participants, of which 1700 will be in Global Initiative for Chronic Obstructive Lung Disease (GOLD) Grades I–IV (n=700, 700, 200 and 100, respectively), 180 participants with chronic bronchitis without airflow limitation and 120 never-smoker healthy controls. Study visits will be at baseline, 6, 18 and 30 months and at exacerbation. Assessments include lung function, exacerbation frequency, health status, blood biomarkers and, in a sub-cohort of 400 patients, chest high-resolution computed tomography, additional blood and sputum biomarkers, airway micro-, viral- and myco-biome, and physical activity. COMPASS will establish a unique clinical and biological dataset in a well-characterised cohort of individuals with COPD in China, with a particular focus on milder patients. As the first study of its kind attempting to understand the disease in an Asian setting, it will provide valuable insights into regional and ethnic differences in COPD.

COMPASS, a prospective, multicentre, observational study of Chinese patients with COPD, will characterise stable and exacerbation phenotypes/endotypes, treatment pathways and HRU, and investigate COPD progression biomarkers' relevance to these patientshttps://bit.ly/3dyIpf1

Opioids in patients with COPD and refractory dyspnea: literature review and design of a multicenter double blind study of low dosed morphine and fentanyl (MoreFoRCOPD)

Background

Refractory dyspnea or breathlessness is a common symptom in patients with advanced chronic obstructive pulmonary disease (COPD), with a high negative impact on quality of life (QoL). Low dosed opioids have been investigated for refractory dyspnea in COPD and other life-limiting conditions, and some positive effects were demonstrated. However, upon first assessment of the literature, the quality of evidence in COPD seemed low or inconclusive, and focused mainly on morphine which may have more side effects than other opioids such as fentanyl. For the current publication we performed a systematic literature search. We searched for placebo-controlled randomized clinical trials investigating opioids for refractory dyspnea caused by COPD. We included trials reporting on dyspnea, health status and/or QoL. Three of fifteen trials demonstrated a significant positive effect of opioids on dyspnea. Only one of four trials reporting on QoL or health status, demonstrated a significant positive effect. Two-thirds of included trials investigated morphine. We found no placebo-controlled RCT on transdermal fentanyl. Subsequently, we hypothesized that both fentanyl and morphine provide a greater reduction of dyspnea than placebo, and that fentanyl has less side effects than morphine.

Methods

We describe the design of a robust, multi-center, double blind, double-dummy, cross-over, randomized, placebo-controlled clinical trial with three study arms investigating transdermal fentanyl 12 mcg/h and morphine sustained-release 10 mg b.i.d. The primary endpoint is change in daily mean dyspnea sensation measured on a numeric rating scale. Secondary endpoints are change in daily worst dyspnea, QoL, anxiety, sleep quality, hypercapnia, side effects, patient preference, and continued opioid use. Sixty patients with severe stable COPD and refractory dyspnea (FEV₁ < 50%, mMRC ≥ 3, on optimal standard therapy) will be included.

Discussion

Evidence for opioids for refractory dyspnea in COPD is not as robust as usually appreciated. We designed a study comparing both the more commonly used opioid morphine, and transdermal fentanyl to placebo. The cross-over design will help to get a better impression of patient preferences. We believe our study design to investigate both sustained-release morphine and transdermal fentanyl for refractory dyspnea will provide valuable information for better treatment of refractory dyspnea in COPD.

Trial registration NCT03834363 (ClinicalTrials.gov), registred at 7 Feb 2019, https://clinicaltrials.gov/ct2/show/NCT03834363.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01647-8.

Chronic non-invasive ventilation for chronic obstructive pulmonary disease

BACKGROUND

Chronic non-invasive ventilation (NIV) is increasingly being used to treat people with COPD who have respiratory failure, but the evidence supporting this treatment has been conflicting.

OBJECTIVES

To assess the effects of chronic non-invasive ventilation at home via a facial mask in people with COPD, using a pooled analysis of IPD and meta-analysis.

SEARCH METHODS

We searched the Cochrane Airways Register of Trials, MEDLINE, Embase, PsycINFO, CINAHL, AMED, proceedings of respiratory conferences, clinical trial registries and bibliographies of relevant studies. We conducted the latest search on 21 December 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing chronic NIV for at least five hours per night for three consecutive weeks or more (in addition to standard care) versus standard care alone, in people with COPD. Studies investigating people initiated on NIV in a stable phase and studies investigating NIV commenced after a severe COPD exacerbation were eligible, but we reported and analysed them separately. The primary outcomes were arterial blood gases, health-related quality of life (HRQL), exercise capacity (stable COPD) and admission-free survival (post-exacerbation COPD). Secondary outcomes for both populations were: lung function, COPD exacerbations and admissions, and all-cause mortality. For stable COPD, we also reported respiratory muscle strength, dyspnoea and sleep efficiency.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. After inclusion of a study, we requested the IPD. We analysed continuous and time-to-event data using linear- and cox-regression mixed-effect models with a random effect on study level. We analysed dichotomous IPD using generalised estimating equations. We adjusted all models for age and sex. We assessed changes in outcomes after three and 12 months.  We also conducted a meta-analysis on aggregated trial data.

MAIN RESULTS

We included 14 new RCTs in this review update, in addition to the seven previously included. Seventeen studies investigated chronic NIV in stable COPD and four studies investigated chronic NIV commenced after a severe COPD exacerbation. Three studies compared NIV to sham continuous positive airway pressure (2 to 4 cmH2O). Seven studies used a nasal mask, one study used an oronasal mask and eight studies used both interfaces. Five studies did not report the interface. The majority of trials (20/21) were at high risk of performance bias due to an unblinded design. We considered 11 studies to have a low risk of selection bias and 13 to have a low risk of attrition bias. We collected and analysed the IPD from 13 stable COPD studies (n = 778, 68% of the participants included) and from three post-exacerbation studies (n = 364, 96% of the participants included). In the stable COPD group, NIV probably results in a minor benefit on the arterial partial pressure of oxygen (PaO2) after three months (adjusted mean difference (AMD) 0.27 kPa, 95% CI 0.04 to 0.49; 9 studies, 271 participants; moderate-certainty evidence), but there was little to no benefit at 12 months (AMD 0.09 kPa, 95% CI -0.23 to 0.42; 3 studies, 171 participants; low-certainty evidence). The arterial partial pressure of carbon dioxide (PaCO2) was reduced in participants allocated to NIV after three months (AMD -0.61 kPa, 95% CI -0.77 to -0.45; 11 studies, 475 participants; high-certainty evidence) and persisted up to 12 months (AMD -0.42 kPa, 95% CI -0.68 to -0.16; 4 studies, 232 participants; high-certainty evidence).  Exercise capacity was measured with the 6-minute walking distance (minimal clinical important difference: 26 m). There was no clinically relevant effect of NIV on exercise capacity (3 months: AMD 15.5 m, 95% CI -0.8 to 31.7; 8 studies, 330 participants; low-certainty evidence; 12 months: AMD 26.4 m, 95% CI -7.6 to 60.5; 3 studies, 134 participants; very low-certainty evidence). HRQL was measured with the Severe Respiratory Insufficiency and the St. Georges's Respiratory Questionnaire and may be improved by NIV, but only after three months (3 months: standardised mean difference (SMD) 0.39, 95% CI 0.15 to 0.62; 5 studies, 259 participants; very low-certainty evidence; 12 months: SMD 0.15, 95% CI -0.13 to 0.43; 4 studies, 200 participants; very low-certainty evidence). Lastly, the risk for all-cause mortality is likely reduced by NIV (adjusted hazard ratio (AHR) 0.75, 95% CI 0.58 to 0.97; 3 studies, 405 participants; moderate-certainty evidence). In the post-exacerbation COPD group, there was little to no benefit on the PaO2 after three months, but there may be a slight decrease after 12 months (3 months: AMD -0.10 kPa, 95% CI -0.65 to 0.45; 3 studies, 234 participants; low-certainty evidence; 12 months: -0.27 kPa, 95% CI -0.86 to 0.32, 3 studies; 170 participants; low-certainty evidence). The PaCO2 was reduced by NIV at both three months (AMD -0.40 kPa, 95% CI -0.70 to -0.09; 3 studies, 241 participants; moderate-certainty evidence) and 12 months (AMD -0.52 kPa, 95% CI -0.87 to -0.18; 3 studies, 175 participants; high-certainty evidence). NIV may have little to no benefit on HRQL (3 months: SMD 0.25, 95% CI -0.01 to 0.51; 2 studies, 219 participants; very low-certainty evidence; 12 months: SMD 0.25, 95% -0.06 to 0.55; 2 studies, 164 participants; very low-certainty evidence). Admission-free survival seems improved with NIV (AHR 0.71, 95% CI 0.54 to 0.94; 2 studies, 317 participants; low-certainty evidence), but the risk for all-cause mortality does not seem to improve (AHR 0.97, 95% CI 0.74 to 1.28; 2 studies, 317 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Regardless of the timing of initiation, chronic NIV improves daytime hypercapnia. In addition, in stable COPD, survival seems to be improved and there might be a short term HRQL benefit. In people with persistent hypercapnia after a COPD exacerbation, chronic NIV might prolong admission-free survival without a beneficial effect on HRQL. In stable COPD, future RCTs comparing NIV to a control group receiving standard care might no longer be warranted, but research should focus on identifying participant characteristics that would define treatment success. Furthermore, the optimal timing for initiation of NIV after a severe COPD exacerbation is still unknown.

Lung volume reduction in real clinical practice

Pragmatic studies and capturing routine care clinical data in registration databases are important to further guide and optimise treatments in the future https://bit.ly/3el1lh7.

Endobronchial Valves for the Treatment of Advanced Emphysema

Bronchoscopic lung volume reduction with one-way endobronchial valves is a guideline treatment option for patients with advanced emphysema that is supported by extensive scientific data. Patients limited by severe hyperinflation, with a suitable emphysema treatment target lobe and with absence of collateral ventilation, are the responders to this treatment. Detailed patient selection, a professional treatment performance, and dedicated follow up of the valve treatment, including management of complications, are key ingredients to success. This treatment does not stand alone; it especially requires extensive knowledge of COPD for which the most appropriate treatment is discussed in a multidisciplinary approach. We discuss the endobronchial valve treatment for emphysema and provide a guideline for patient selection, treatment guidance, and practice tools, based on our own experience and literature.