Assessment of pulmonary physiological changes caused by aging, cigarette smoking, and COPD with hyperpolarized 129Xe magnetic resonance

OBJECTIVE

To comprehensively assess the impact of aging, cigarette smoking, and chronic obstructive pulmonary disease (COPD) on pulmonary physiology using 129Xe MR.

METHODS

A total of 90 subjects were categorized into four groups, including healthy young (HY, n = 20), age-matched control (AMC, n = 20), asymptomatic smokers (AS, n = 28), and COPD patients (n = 22). 129Xe MR was utilized to obtain pulmonary physiological parameters, including ventilation defect percent (VDP), alveolar sleeve depth (h), apparent diffusion coefficient (ADC), total septal wall thickness (d), and ratio of xenon signal from red blood cells and interstitial tissue/plasma (RBC/TP).

RESULTS

Significant differences were found in the measured VDP (p = 0.035), h (p = 0.003), and RBC/TP (p = 0.003) between the HY and AMC groups. Compared with the AMC group, higher VDP (p = 0.020) and d (p = 0.048) were found in the AS group; higher VDP (p < 0.001), d (p < 0.001) and ADC (p < 0.001), and lower h (p < 0.001) and RBC/TP (p < 0.001) were found in the COPD group. Moreover, significant differences were also found in the measured VDP (p < 0.001), h (p < 0.001), ADC (p < 0.001), d (p = 0.008), and RBC/TP (p = 0.032) between the AS and COPD groups.

CONCLUSION

Our findings indicate that pulmonary structure and functional changes caused by aging, cigarette smoking, and COPD are various, and show a progressive deterioration with the accumulation of these risk factors, including cigarette smoking and COPD.

CLINICAL RELEVANCE STATEMENT

Pathophysiological changes can be difficult to comprehensively understand due to limitations in common techniques and multifactorial etiologies. 129Xe MRI can demonstrate structural and functional changes caused by several common factors and can be used to better understand patients' underlying pathology.

KEY POINTS

Standard techniques for assessing pathophysiological lung function changes, spirometry, and chest CT come with limitations. 129Xe MR demonstrated progressive deterioration with accumulation of the investigated risk factors, without these limitations. 129Xe MR can assess lung changes related to these risk factors to stage and evaluate the etiology of the disease.

Electrocardiographic alterations in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality, and its incidence has grown within several years, quickly becoming the third leading cause of mortality. The disease is characterized by alveolar destruction, air-trapping, and chronic inflammation due to persistent exposure to a large spectrum of harmful particles. The diagnosis of COPD is made by demonstration of persistent and not fully reversible airflow limitation, and different phenotypes may be recognized based on pathophysiological, clinical, and radiological features. However, COPD is a systemic disease with effects involving several organs. For example, mechanical and functional alterations secondary to COPD involve heart function. Indeed, cardiovascular diseases are highly prevalent in patients affected by COPD and represent the primary cause of mortality in such patients. An electrocardiogram is a simple and cheap test that gives much information about the heart status of COPD patients. Consequently, variations from "normality" can be appreciated in these patients, with the most frequent abnormalities being P-wave, QRS axis, and ventricular repolarization abnormalities, in addition to conduction alterations and a vast number of arrhythmias. As a result, ECG should be routinely performed as a valuable tool to recognize alterations due to COPD (i.e., mechanical and functional) and possible associated heart diseases. This review aims to describe the typical ECG features in most COPD patients and to provide a systematic summary that can be used in clinical practice.

The Challenges of Spirometric Diagnosis of COPD

Chronic obstructive pulmonary disease (COPD) is one of the top causes of morbidity and mortality worldwide. Although for many years its accurate diagnosis has been a focus of intense research, it is still challenging. Due to its simplicity, portability, and low cost, spirometry has been established as the main tool to detect this condition, but its flawed performance makes it an imperfect COPD diagnosis gold standard. This review aims to provide an up-to-date literature overview of recent studies regarding COPD diagnosis; we seek to identify their limitations and establish perspectives for spirometric diagnosis of COPD in the XXI century by combining deep clinical knowledge of the disease with advanced computer analysis techniques.

Correlation between Hand Grip Strength and Peak Inspiratory Flow Rate in Patients with Stable Chronic Obstructive Pulmonary Disease

Optimal peak inspiratory flow rate (PIFR) is required for effective drug delivery to distal airways when using dry powder inhalers (DPIs). This study aimed to examine the association between PIFR and hand grip strength (HGS) in stable COPD patients. A cross-sectional study was conducted. PIFR was measured using the In-check DIAL to assess for Accuhaler and Turbuhaler DPIs. HGS was measured using a handheld dynamometer. A PIFR of <60 L/min was considered suboptimal PIFR. Demographics, clinical data, and spirometric data were collected and compared. Eighty-one patients (86% men) were included. Mean age was 73.3 ± 8.9 years. FEV1 was 65.3 ± 23.7%. The prevalence of suboptimal PIFR was 38% and 59% for Accuhaler and Turbuhaler, respectively. HGS in the suboptimal PIFR group was lower than in the optimal PIFR group for Accuhaler (22.8 ± 4.7 vs. 33.2 ± 6.9 kg, p < 0.001) and for Turbuhaler (25.3 ± 6.4 vs. 35.1 ± 6.3 kg, p < 0.001). The equation for predicted Accuhaler PIFR (L/min) was −30.340 + (0.274 × hand grip strength) − (0.206 × age) + (0.219 × height) + (1.019 × FVC). The equation for predicted Turbuhaler PIFR (L/min) was 56.196 + (0.321 × hand grip strength) − (0.196 × female) − (0.224 × age) + (0.304 × FVC). The best cutoff values of HGS for predicting optimal PIFR in Accuhaler and Turbuhaler were 26.8 kg (with 82% sensitivity and 84% specificity) and 31.9 kg (with 79% sensitivity and 90% specificity), respectively. In conclusion, HGS correlated with PIFR in patients with clinically stable COPD, especially in the group with pronounced symptoms without frequent exacerbations. HGS threshold values associated with suboptimal PIFR were identified. HGS may be used as an alternative tool to assess an optimal inspiratory force for DPIs.

Outcomes of abdominal aortic aneurysm repairs: Endovascular aneurysm vs open surgical repairs

BACKGROUND

Operative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution.

METHODS

All AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed.

RESULTS

We had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more.

CONCLUSIONS

OSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate.

Spanish clinical practice consensus in internal medicine on chronic obstructive pulmonary disease patients with comorbidities (miEPOC)

Background: Chronic obstructive pulmonary disease (COPD) is one of the diseases that leads to a higher number of hospitalizations in internal medicine departments. These patients are usually older and have greater multimorbidity than COPD patients hospitalized in other departments, which hinders the implementation of clinical guidelines necessarily focused on the management of a single disease.Aims: To ascertain the opinion of Spanish internists on the management of COPD in scenarios in which the available evidence is sparse and to produce a consensus document designed to assist in decision-making in COPD patients with comorbidities treated in internal medicine services.Methods: After identifying the clinical areas of greatest uncertainty by consensus, a survey was designed with 89 questions on the epidemiology and diagnosis of COPD, its management both in stable phase and during decompensation, and the treatment of the associated comorbidities in outpatients and inpatients. The consensus process was carried out using the Delphi method in an anonymized two-round process.Results: The survey was completed by 67 internists experienced in the clinical management of COPD. Of all the questions posed, a consensus was reached for 51 (57.3%) in the first round and for 67 (75.3%) in the second round. The result of the process is a series of 67 suggestions that may assist in the care of these patients.Conclusions: Our study allows us to ascertain the views of a large number of internists experienced in the management of COPD and to learn how the recommendations for guidelines are applied in clinical practice.

Identification of critical genes associated with the development of asthma by co-expression modules construction

INTRODUCTION

Asthma is a worldwide problem that is caused by complex underlying immune dysregulation. The identification of potential prognostic markers of asthma may provide information for treatment. The purpose of this study was to explore the key mechanisms involved in the development of asthma on the basis of microarray analysis.

METHODS

The expression profile data of GSE43696, which contains 20 endobronchial epithelial brushing samples from healthy patients and 88 from asthma patients, were obtained from Gene Expression Omnibus. For the present study, we built co-expression modules by weighted gene co-expression network analysis (WGCNA). This new analysis strategy was applied to the data set to investigate the relationships underlying the modules and the pathogenesis of asthma. Functional enrichment analysis was performed on these co-expression genes from the modules, and a gene network was then constructed. In addition, mouse models of HDM-induced and OVA-induced asthma were established, and the expression of hub genes was measured.

RESULTS

First, using WGCNA, 20 co-expression modules were constructed with 19,596 genes obtained from 108 human endobronchial epithelial brushing samples. The number of genes within the modules ranged from 41 to 845. According to the colours assigned by the system, the module positively correlated with asthma status was named 'red module', and the module positively correlated with asthma severity was named 'purple module'. The results of a functional enrichment analysis showed that the red module was mainly enriched in intracellular calcium-activated chloride channel activity, intracellular chloride channel activity and endopeptidase inhibitor activity. The purple module was mainly enriched in microtubule motor activity and microtubule-binding and motor activity. Moreover, the mRNA expression levels of the 15 hub genes were confirmed to be significantly upregulated in the HDM mouse model, and 12 hub genes were upregulated in the OVA model.

CONCLUSIONS

The hub genes ANO7, PYCR1 and UBE2C might play potential roles in the pathogenesis of asthma. Our findings provided a framework of co-expression gene modules of asthma and led to the identification of some new markers that might be potential targets for the development of new drugs and diagnostic markers.

The accuracy of a handheld "disposable pneumotachograph device" in the spirometric diagnosis of airway obstruction in a Chinese population

Background and aim

It is desirable to facilitate the use of an affordable, reliable, and portable spirometer, for earlier diagnosis of COPD in China, particularly in rural areas. The aim of this study was to assess the agreement of a handheld "disposable pneumotachograph" (D-PNEU) spirometer with the gold standard spirometer and to evaluate its diagnostic accuracy of spirometric classification of airflow obstruction.

Subjects and methods

A total of 241 adult Chinese subjects ranging from healthy to those with mixed levels of pulmonary disease performed spirometry in a conventional body plethysmograph, and using a D-PNEU device in randomized order. The three best spirometric tests were recorded for comparative analysis. A Bland-Altman graph was created to assess the agreement between devices. Using FEV₁/FVC <70% as the "gold standard" for obstruction, the accuracy of classifying the severity of airway obstruction for all subjects was assessed. For the specific individuals (n=159) able to exhale for at least 6 seconds, the accuracy of classifying airway obstruction was further assessed. For this purpose, a receiver operating characteristic curve was used to determine an optimal cutoff point of FEV₁/FEV₆ ratio obtained by the D-PNEU device, which matched the global definition of FEV₁/FVC <70% by the traditional spirometer.

Results

The Bland-Altman analysis showed that the between-device agreement for key airflow metrics was within clinically acceptable limits. The D-PNEU device had 87.1% accuracy in the classification of severity of obstruction in all 241 subjects, when using FEV₁/FVC<70% as the "gold standard" for both devices. The D-PNEU device had 93.7% accuracy in the 159 individuals able to exhale for at least 6 seconds, when a cutoff point of FEV₁/FEV₆ was 74%.

Conclusion

A disposable handheld spirometry device is capable of accurately identifying and quantifying airway obstruction in patients deemed to be at risk, however, caution should be exercised and all available brands should be tested.

Accuracy of diagnosis of COPD and factors associated with misdiagnosis in primary care setting. E-DIAL (Early DIAgnosis of obstructive lung disease) study group

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and results in both substantial and increasing socioeconomic burden. Guidelines on COPD encourage primary care physicians to detect the disease at an early stage. Our main aim was to evaluate the accuracy of the diagnosis of COPD at the primary health care.

METHODS

6466 patients were randomly selected in 22 Italian primary care practices (46% males, mean age 56 ± 16 years) and were asked about respiratory symptoms and risk for any chronic respiratory disease including COPD. After a prior evaluation, 701 patients (51% males, mean age 59 ± 15 years) were sent by General Practitioners (GPs) to Pulmonary Units (PU) for confirming the diagnosis. The agreement in diagnosing COPD between GPs and pulmonary diseases specialists was assessed by using Cohen's kappa (k) statistic.

RESULTS

Lack of precision in COPD diagnosis resulted in 13% of over-diagnosis and 59% of under-diagnosis. GPs were quite good in correctly excluding the patients who did not have COPD (specificity = 87%), but less good in diagnosing the patients with COPD (sensitivity = 41%). The risk of under-diagnosis was higher in people with age >62 years and in current/ex-smokers, when compared to no COPD, whereas it was higher in subject <62 years old and in those with no previous spirometry when compared to correctly diagnosed COPD.

CONCLUSION

Our results confirm that COPD misdiagnosis is common in primary care and that under-diagnosis is a major problem. It is necessary to enhance COPD diagnosis and to reduce misdiagnosis in primary care settings.

Prognostic role of lactate on mortality in younger and older patients with cardio-respiratory failure admitted to an acute intensive care unit

BACKGROUND AND AIM

Acidosis is able to induce negative changes of different organs that increase progressively with aging. At present it is not known whether the levels of lactate may differently influence the prognosis of younger and older patients. Thus, the aim of this study is to evaluate the prognostic value of lactate levels after admission of younger and older patients to an acute intensive care unit.

METHODS

Younger (<65 years, n = 118) and older (≥65 years, n = 165) patients admitted to an acute intensive care unit were prospectively enrolled and classified according to diagnosis of acute heart or/and respiratory failure. For each patient, APACHE II score, time of hospitalization and mortality, blood levels of lactate were collected.

RESULTS

Both in-hospital mortality and lactate >2.5 mmol/L at the admission was higher in the older than in the younger patients (42.4 vs. 20.3 %, p < 0.01 and 57.8 vs. 31.9 %, p < 0.01, respectively). Lactate level was higher in older than in the younger patients both at admission and after 24 h (3.9 ± 3.4 vs. 2.4 ± 2.2 mmol/L and 2.4 ± 2.0 vs. 1.4 ± 1.3 mmol, p < 0.01, respectively). Accordingly, multivariate analysis shows that lactate was predictive of mortality in younger (OR = 2.65, 95 % CI 1.62-5.24, p = 0.03) and even more in the older (OR = 4.74, 95 % CI 2.10-6.70, p < 0.01) patients.

CONCLUSIONS

Lactate concentration increase is associated with increased mortality in younger patients but, even more so, in older patients admitted to an acute intensive care unit. These results confirm the experimental evidence showing acidosis has a greater effect of leading to organ failure and higher mortality with increasing age.

Impact of roflumilast on exacerbations of COPD, health care utilization, and costs in a predominantly elderly Medicare Advantage population

Background

Chronic obstructive pulmonary disease (COPD) exacerbations are associated with declining lung function and health-related quality of life, and increased hospitalization and mortality. Clinical trials often poorly represent the elderly and thus have only partial applicability to their clinical care.

Objective

To compare exacerbations, COPD-related health care utilization (HCU), and costs in a predominantly elderly Medicare COPD population initiated on roflumilast versus those not initiated on roflumilast.

Methods

Deidentified administrative claims data from a large, national payer were utilized. Medicare patients aged 40–89 years with at least one COPD diagnosis from May 1, 2010 to December 31, 2012 were included. Members with at least one roflumilast pharmacy claim (index) were assigned to the roflumilast group and those without were assigned to the non-roflumilast group. Proxy index dates for the non-roflumilast group were randomly assigned for similar distribution of all patients’ time at risk. Subjects with at least one pre-index COPD exacerbation had to be continuously enrolled for ≥365 days pre-index and post-index. Unadjusted and adjusted difference-in-difference (DID) analyses contrasted pre-index with post-index changes in exacerbations, HCU, and costs of roflumilast treatment compared with non-roflumilast treatment.

Results

A total of 500 roflumilast and 60,145 non-roflumilast patients were included (mean age 69.7 and 72.3 years, respectively; P<0.0001). Unadjusted DID favored roflumilast for all exacerbations, with greater pre-index to post-index reductions in mean per 30-day COPD-related hospitalizations (−0.0182 versus −0.0013, P=0.009), outpatient visits (−0.2500 versus −0.0606, P<0.0001), and COPD-related inpatient costs (−US$141 versus −US$11, P=0.0346) and outpatient costs (−US$31 versus −US$4, P<0.0001). Multivariate analyses identified significantly improved pre-index to post-index COPD-related total costs (P=0.0005) and total exacerbations (P<0.0001) for the roflumilast group versus non-roflumilast group.

Conclusion

In a predominantly elderly Medicare COPD population, newly initiated roflumilast patients displayed similar or significantly better unadjusted reductions in all exacerbation-related, COPD-related HCU-related, and COPD-related costs outcomes compared with non-roflumilast patients. These analyses also suggest better adjusted COPD-related costs and total exacerbations for roflumilast-initiated patients.

The pharmacological approach to the elderly COPD patient

The elderly patient (65 years and older) with chronic obstructive pulmonary disease (COPD) can be a challenge to the clinician. This begins with the correct and early diagnosis, the assessment of disease severity, recognizing complicating comorbidities, determining the burden of symptoms, and monitoring the frequency of acute exacerbations. Comprehensive management of COPD in the elderly patient should improve health-related quality of life, lung function, reduce exacerbations, and promote patient compliance with treatment plans. Only smoking cessation and oxygen therapy in COPD patients with hypoxemia reduce mortality. Bronchodilators, corticosteroids, methylxanthines, phosphodiesterase-4 inhibitors, macrolide antibiotics, mucolytics, and pulmonary rehabilitation improve some outcome measures such as spirometry measures and the frequency of COPD exacerbations without improving mortality. International treatment guidelines to reduce symptoms and reduce the risk of acute exacerbations exist. Relief of dyspnea and control of anxiety are important. The approach to each patient is best individualized. Earlier use of palliative care should be considered when traditional pharmacotherapy fails to achieve outcome measures and before consideration of end-of-life issues.

COPD detected with screening: impact on patient management and prognosis

It is uncertain whether screening of older persons for chronic obstructive pulmonary disease (COPD) is worthwhile because the effects on patient management and prognosis are unknown.

We aimed to assess the short-term consequences of detecting COPD in frail elderly subjects with dyspnoea, considering pulmonary drug use, hospitalisations and all-cause mortality.

Community-dwelling frail elderly subjects, aged 65 years and older, with dyspnoea, participating in a screening study on COPD and heart failure were included. Final diagnoses were assigned by an expert panel based on all data from the screening strategy, including spirometry. Follow-up data were collected from the general practitioners.

Of the 386 patients, 84 (21.8%) were received a new diagnosis of COPD. Overall, changes in pulmonary drug prescription during 6 months of follow-up were infrequent (n = 53, 13.7%; among new cases of COPD, 15 (17.9%) out of 84). Of all participants, 25.9% were hospitalised in the first year of follow-up, with the highest rate in patients with newly detected COPD (32.1%).

Many new cases of COPD could be detected by screening frail elderly subjects with dyspnoea, but the impact on patient management seems limited. Our study underlines the importance of obtaining follow-up data to assess the true impact of a (screen-detected) diagnosis of COPD on patient management and outcome.

Serum cystatin C and indices of lung function in elderly Chinese men with chronic obstructive pulmonary disease

OBJECTIVE

The aim of this cross-sectional case-control study was to determine the relationship between serum cystatin C (sCysC) levels and lung function in elderly male patients with chronic obstructive pulmonary disease (COPD).

METHODS

This study included 251 Chinese men (age ≥ 65 years) who were divided into COPD (n = 129) and non-COPD (n = 122) groups. Participants underwent lung function and laboratory testing, including measurement of sCysC levels. Relationships between sCysC concentration and indices of lung function were assessed by multiple regression analysis.

RESULTS

Participants in the COPD group displayed higher sCysC concentrations (P = 0.041) and lower lung function (P < 0.001) compared to participants in the non-COPD group. Multiple linear regression analyses revealed that the reciprocal of the sCysC concentration (1/sCysC) was positively associated with the predicted forced expiratory volume in 1 s in all subjects (β = 0.156, P = 0.009). The findings indicate that high sCysC levels were directly associated with decreased lung function in elderly Chinese men with COPD.

CONCLUSIONS

High sCysC concentration may be a potential indicator of impaired lung function, and its application may improve the diagnosis and assessment of COPD severity in elderly male patients.

Prevalence of airflow obstruction in nonsmoking older individuals using different spirometric criteria: the AGES Reykjavik Study

BACKGROUND

The prevalence and characteristics of airway obstruction in older individuals varies widely with the definition used. We used a random sample of never smoking older population in Iceland to compare the prevalence and clinical profile of subjects diagnosed with Chronic Obstructive Pulmonary Disease (COPD) based on different spirometric criteria.

MATERIAL AND METHODS

The study uses data from the Age, Gene/Environment Susceptibility-Reykjavik Study, comprising survivors from the Reykjavik Study. Procedures included standardized questionnaires and pre-bronchodilator spirometry for measurement of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC).

RESULTS

Total of 495 individuals (150 men and 345 women) met study criteria. Mean age 77 years (range 66-92 years) using fixed ratio (FEV1/FVC < 70%) up to 29% of the population were diagnosed with COPD Stage I. The prevalence of COPD increased with age. Only 7 among 495 (1.4%) were diagnosed with COPD using FEV1/FVC LLN and FEV1 LLN.

CONCLUSION

Application of the GOLD criteria for diagnosis of COPD in older lifelong never smoking subjects identifies a substantial number of non-symptomatic subjects as having COPD. If airway obstruction is defined by FEV1/FVC and FEV1 being below the LLN using appropriate reference equations, only very few non-smoking older individuals fulfill the criteria for COPD.

Relationships between age of puberty onset and height at age 18 years in girls and boys

BACKGROUND

Changes during puberty may influence final adult height. Height is related to multiple health conditions, including lung function. We investigated the association between the age of onset of five puberty events and height at age 18 years, analyzing boys and girls separately.

METHODS

Of 1456 children recruited into the Isle of Wight birth cohort (1989-1990), 1313 were followed up at age 18 years. Height was measured, and age of pubertal onset was collected at age 18 years. Cluster analysis was performed on the five puberty events in boys and girls and linear regression was applied with the clusters predicting height at age 18 years. Individual linear regression analyses assessed the age of onset of each pubertal event as a potential predictor for height at age 18 years.

RESULTS

Of the 1313 children followed up at age 18 years, 653 were males and 660 were females. All puberty variables had high internal consistency. In girls, earlier age of menarche, breast development, and growth spurt were related to shorter height. In boys, earlier age of growth spurt and slower progression through puberty were related to taller height at age 18 years.

CONCLUSIONS

Given that boys and girls may have opposing associations between pubertal timing and adult height and that height is an important predictor of lung function, the effect of pubertal timing on respiratory health should be explored.

On the crest of a wave: Danish prevalence of hospitalisation-required COPD 2002-2009

OBJECTIVE

Symptoms, mortality, and costs of chronic obstructive pulmonary disease (COPD) concentrate among patients who have been hospitalised with the disease. Nevertheless, no solid estimates exist of trends in the prevalence of this condition. This study aimed to investigate age- and sex-specific trends in the prevalence of hospitalisation-required COPD.

METHOD

Using national registers, a cohort trend study was conducted covering the entire Danish population (5.4 million citizens) from 1994 to 2009. Subjects were classified as prevalent in the period between first COPD hospitalisation and either death, migration, or the end of an individual 8-year period with no COPD hospitalisations.

RESULTS

In 2009 in Denmark the prevalence of hospitalisation-required COPD was: For males 45-59 years 0.36%, 60-74 years 1.37%, 75-84 years 4.13%, 85+ years 4.33%, and for females: 45-59 years: 0.49%, 60-74 years: 1.74%, 75-84 years: 3.96%, 85+ years: 2.99%. During the period from 2002 to 2009 the overall prevalence remained constant. However, among subjects aged above and below 75 years, respectively, substantial decreases and increases were found. An increasing female prevalence exceeded male prevalence, which decreased.

CONCLUSION

Some 4% of the Danish population aged above 75 years have been hospitalised with COPD. During the period from 2002 to 2009 the overall prevalence of hospitalisation-required COPD remained constant. However, significant age-specific trends indicate that within a few years, ageing of birth cohorts with low COPD prevalence will lead to a substantial decrease in the prevalence of hospitalisation-required COPD.

Diagnosis of airway obstruction in the elderly: contribution of the SARA study

BACKGROUND

The choice between lower limit of normal or fixed value of forced expiratory volume in one second/forced vital capacity ratio (FEV(1)/FVC) < 0.70 as the criterion for confirming airway obstruction is an open issue. In this study, we compared the criteria of lower limit of normal and fixed FEV(1)/FVC for diagnosis of airway obstruction, with a focus on healthy elderly people.

METHODS

We selected 367 healthy nonsmoking subjects aged 65-93 years from 1971 participants in the population-based SARA (Salute Respiratoria nell'Anziano, Italian for "Respiratory Health in the Elderly") study, analyzed their spirometric data, and tested the relationship between spirometric indices and anthropometric variables. The lower limit of normal for FEV(1)/FVC was calculated as the fifth percentile of the normal distribution for selected subjects.

RESULTS

While FEV(1) and FVC decreased significantly with aging, the relationship between FEV(1)/FVC and age was not statistically significant in men or women. The lower limit of normal for FEV(1)/FVC was 0.65 in men and 0.67 in women. Fifty-five participants (15%) had FEV(1)/FVC < 0.70 and would have been inappropriately classified as obstructed according to the Global Initiative for Obstructive Lung Disease, American Thoracic Society/European Respiratory Society, and Canadian guidelines on chronic obstructive pulmonary disease. By applying different FEV(1)/FVC thresholds for the different age groups, as previously proposed in the literature, (0.70 for <70 years, 0.65 for 70-80 years, and 0.60 for >80 years) the percentage of patients classified as obstructed decreased to 6%. No subjects older than 80 years had an FEV(1)/FVC < 0.60.

CONCLUSION

The present results confirm the inadequacy of FEV(1)/FVC < 0.70 as a diagnostic criterion for airway obstruction after the age of 65 years. FEV(1)/FVC < 0.65 and <0.67 (for men and women, respectively) could identify subjects with airway obstruction in such a population. Further reduction of the threshold after 80 years is not justified.

Handgrip strength measurement as a predictor for successful dry powder inhaler treatment: application in older individuals with COPD

BACKGROUND

More than 10% of elderly people suffer from chronic obstructive pulmonary disease (COPD). Drug treatment for COPD involves inhalants. Dry powder inhalers (DPIs) have proven easiest for the elderly to use. Their effectiveness is dependent, however, on the inspiratory flow which can be generated, and it is unclear which geriatric assessment parameter permits inspiratory flow to be assessed.

METHODS

In a randomly generated group of geriatric hospital patients, manual strength was measured as a complement to basic geriatric assessment and inspiratory flow assessed using a Turbohaler trainer.

RESULTS

A total of 87 (27%) men (mean age 81 ± 7 years) and 231 (73%) women (mean age 82 ± 8 years) were included in the study. The threshold value of 40 l/min for minimum inspiratory flow was achieved by 194 (61%) of the patients. Manual strength was the only assessment parameter to correlate with the minimum inspiratory flow achieved. ROC analysis produced a threshold value for manual strength of 10 kg. The sensitivity and specificity for this threshold value were 70% each, while the positive and negative predictive values were 79% and 84%, respectively.

CONCLUSION

A threshold value of 10 kg for manual strength enables the inspiratory flow achievable by elderly patients to be predicted satisfactorily. This is the only parameter which correlates sufficiently with inspiratory flow. Manual strength should be measured in all geriatric patients with COPD and should be taken into account when deciding whether or not to initiate differential treatment.

Do symptoms predict COPD in smokers?

BACKGROUND

The US Preventive Services Task Force recommends against spirometry in the absence of symptoms. However, as much as 50% of COPD cases in the United States remain undiagnosed.

METHODS

Report of symptoms, smoking history, and spirometric data were collected from subjects screened for a work-related medical evaluation (N = 3,955). Prevalence of airflow obstruction and respiratory symptoms were assessed. Sensitivity, specificity, positive and negative predictive values, and relative risks of predicting symptoms and smoking history for COPD were calculated.

RESULTS

Forty-four percent of smokers in our sample had airways obstruction (AO). Of these, 36% reported a diagnosis of or treatment for COPD. Odds ratio (95% CI) for AO with smoking (> or = 20 pack-years) was 3.73 (3.12- 4.45), 1.98 (1.73-2.27) for cough, 1.79 (1.55-2.08) for dyspnea, 1.95 (1.70-2.34) for sputum, and 2.59 (2.26-2.97) for wheeze. Respiratory symptoms were reported by 92% of smokers with AO, 86% smokers with restriction, 76% smokers with normal spirometry, and 73% of nonsmokers. Sensitivity (92% vs 90%), specificity (19% vs 22%), positive (47% vs 40%) and negative (75% vs 80%) predictive values for the presence of one or more symptoms were similar between smokers and all subjects.

CONCLUSIONS

COPD is underdiagnosed in the United States. Symptoms are frequent in subjects with AO and increase their risk for COPD, but add little beyond age and smoking history to the predictive value of spirometry. In view of the high prevalence of symptoms and their poor predictive value, a simpler and more effective approach would be to screen older smokers.