Chronic obstructive pulmonary disease: an update on diagnosis and management issues in older adults

Navigating COPD in Aging Populations: Insights Into Pathophysiology and Comprehensive Care

Chronic obstructive pulmonary disease (COPD) poses a significant and growing health burden among aging populations, marked by increasing prevalence and complex management challenges specific to elderly patients. This review explores the multifaceted interplay between COPD and aging, highlighting overlapping pathophysiological processes and comorbidities that complicate diagnosis and treatment. We examine age-specific management strategies, emphasizing the need for tailored approaches that account for the unique physical, cognitive, and health-related quality of life impacts on older adults. Additionally, we discuss preventive treatments and the critical roles of mental health, end-of-life care, and caregiver support in comprehensive disease management. The importance of integrative approaches to enhancing health care delivery is also underscored. Finally, we outline future directions, focusing on novel treatment pathways and the identification of biomarkers for early detection. Addressing these elements is essential for optimizing care in this vulnerable population and alleviating the significant societal and economic impacts of COPD among aging patients.

Open-source software for respiratory rate estimation using single-lead electrocardiograms

Respiratory rate (RR) is a critical vital sign used to assess pulmonary function. Currently, RR estimating instrumentation is specialized and bulky, therefore unsuitable for remote health monitoring. Previously, RR was estimated using proprietary software that extract surface electrocardiogram (ECG) waveform features obtained at several thoracic locations. However, developing a non-proprietary method that uses minimal ECG leads, generally available from mobile cardiac monitors is highly desirable. Here, we introduce an open-source and well-documented Python-based algorithm that estimates RR requiring only single-stream ECG signals. The algorithm was first developed using ECGs from awake, spontaneously breathing adult human subjects. The algorithm-estimated RRs exhibited close linear correlation to the subjects' true RR values demonstrating an R2 of 0.9092 and root mean square error of 2.2 bpm. The algorithm robustness was then tested using ECGs generated by the ischemic hearts of anesthetized, mechanically ventilated sheep. Although the ECG waveforms during ischemia exhibited severe morphologic changes, the algorithm-determined RRs exhibited high fidelity with a resolution of 1 bpm, an absolute error of 0.07 ± 0.07 bpm, and a relative error of 0.67 ± 0.64%. This optimized Python-based RR estimation technique will likely be widely adapted for remote lung function assessment in patients with cardiopulmonary disease.

A meta-analysis of particulate matter and nitrogen dioxide air quality monitoring associated with the burden of disease in sub-Saharan Africa

Exposure to air pollution is a fundamental obstacle that makes it complex to realize the Sustainable Development Goals (SDGs 3) for good health and wellbeing. It is for this reason that air pollution has been characterized as the global environmental health risk facing the current generation. The risks of air pollution on morbidity, and life expectancy are well documented. This feeds directly to the substantial body of the literature that exists regarding the burden of diseases associated with ambient air pollution. However, the bulk of this literature originates from developed countries. Whilst most of the sub-Saharan African studies extrapolate literature from developed countries to contextualize the risks of elevated air pollution exposure levels associated with the burden of disease. However, extrapolation of epidemiological evidence from developed countries is problematic given that it disregards the social vulnerability. Therefore, given this observation, it is ideal to evaluate if the monitoring executions of hazardous particulate matter and nitrogen dioxide do take into consideration the concerted necessary efforts to associate monitored air pollution exposure levels with the burden of disease. Therefore, based on this background, the current meta-analysis evaluated air quality monitoring associated with the burden of disease across sub-Saharan Africa. To this extent, the current meta-analysis strictly included peer-reviewed published journal articles from the sub-Saharan African regions to gain insight on air quality monitoring associated with the burden of disease. The collected meta-analysis data was captured and subsequently analyzed using Microsoft Excel 2019. This program facilitated the presentation of the meta-analysis data in the form of graphs and numerical techniques. Generally, the results indicate that the sub-Saharan Africa is characterized by a substantial gap in the number of regional studies that evaluate the burden of disease in relation with exposure to air quality.Implications: The work presented here is an original contribution and provides a comprehensive yet succinct overview of the monitoring associated with the burden of disease in sub-Saharan Africa. The author explores if the monitoring executions of hazardous particulate matter and nitrogen dioxide do take into considerations the concerted necessary efforts to associate monitored air pollution exposure levels with the burden of disease. The manuscript includes the most relevant and current literature in a field of study that has not received a deserving degree of research attention in recent years. This is especially true in sub-Saharan Africa, characterized by insufficient monitoring of air quality exposure concentrations.

The Lung Microbiome in COPD and Lung Cancer: Exploring the Potential of Metal-Based Drugs

Chronic obstructive pulmonary disease (COPD) and lung cancer 17 are two of the most prevalent and debilitating respiratory diseases worldwide, both associated with high morbidity and mortality rates. As major global health concerns, they impose a substantial burden on patients, healthcare systems, and society at large. Despite their distinct aetiologies, lung cancer and COPD share common risk factors, clinical features, and pathological pathways, which have spurred increasing research interest in their co-occurrence. One area of particular interest is the role of the lung microbiome in the development and progression of these diseases, including the transition from COPD to lung cancer. Exploring novel therapeutic strategies, such as metal-based drugs, offers a potential avenue for targeting the microbiome in these diseases to improve patient outcomes. This review aims to provide an overview of the current understanding of the lung microbiome, with a particular emphasis on COPD and lung cancer, and to discuss the potential of metal-based drugs as a therapeutic strategy for these conditions, specifically concerning targeting the microbiome.

Pharmacotherapies in Older Adults with COPD: Challenges and Opportunities

Older adults have a higher prevalence of chronic obstructive pulmonary disease (COPD), which will likely increase substantially in the coming decades owing to aging populations and increased long-term exposure to risk factors for this disease. COPD in older adults is characterized by low-grade chronic systemic inflammation, known as inflamm-aging. It contributes substantially to age-associated pulmonary changes that are clinically expressed by reduced lung function, poor health status, and limitations in activities of daily living. In addition, inflamm-aging has been associated with the onset of many comorbidities commonly encountered in COPD. Furthermore, physiologic changes that are often seen with aging can influence the optimal treatment of older patients with COPD. Therefore, variables such as pharmacokinetics, pharmacodynamics, polypharmacy, comorbidities, adverse drug responses, drug interactions, method of administration, and social and economic issues that impact nutrition and adherence to therapy must be carefully evaluated when prescribing medication to these patients because each of them alone or together may affect the outcome of treatment. Current COPD medications focus mainly on alleviating COPD-related symptoms, so alternative treatment approaches that target the disease progression are being investigated. Considering the importance of inflamm-aging, new anti-inflammatory molecules are being evaluated, focusing on inhibiting the recruitment and activation of inflammatory cells, blocking mediators of inflammation thought to be important in the recruitment or activation of these inflammatory cells or released by these cells. Potential therapies that may slow the aging processes by acting on cellular senescence, blocking the processes that cause it (senostatics), eliminating senescent cells (senolytics), or targeting the ongoing oxidative stress seen with aging need to be evaluated.

Impact of Oscillating Positive Expiratory Pressure Device Use on Post-Discharge Hospitalizations: A Retrospective Cohort Study Comparing Patients with COPD or Chronic Bronchitis Using the Aerobika® and Acapella® Devices

Purpose

Managing and preventing disease exacerbations are key goals of COPD care. Oscillating positive expiratory pressure (OPEP) devices have been shown to improve clinical outcomes when added to COPD standard of care. This retrospective database study compared real-world resource use and disease exacerbation among patients with COPD or chronic bronchitis prescribed either of two commonly used OPEP devices.

Patients and methods

Patients using the Aerobika^® (Trudell Medical International, London, ON, Canada) or Acapella^® (Smiths Medical, Wampsville, New York, USA) OPEP device for COPD or chronic bronchitis were identified from hospital claims linked to medical and prescription claims between September 2013 and April 2018; the index date was the first hospital visit with an OPEP device. Severe disease exacerbation, defined as an inpatient visit with a COPD or chronic bronchitis diagnosis, and all-cause healthcare resource utilization over 30 days and 12 months post-discharge were compared in propensity score (PS)-matched Aerobika device and Acapella device users.

Results

In total, 619 Aerobika device and 1857 Acapella device users remained after PS matching. After discharge from the index visit, Aerobika device users were less likely to have ≥1 severe exacerbation within 30 days (12.0% vs 17.4%, p=0.01) and/or 12 months (39.6% vs 45.3%, p=0.01) and had fewer 12-month severe exacerbations (mean, 0.7 vs 0.9 per patient per year, p=0.01), with significantly longer time to first severe exacerbation than Acapella users (log-rank p=0.01). Aerobika device users were also less likely to have ≥1 all-cause inpatient visit within 30 days (13.9% vs 20.3%, p<0.001) and 12 months (44.9% vs 51.8%, p=0.003) than Acapella users.

Conclusion

Patients receiving the Aerobika OPEP device, compared to the Acapella device, had lower rates of subsequent severe disease exacerbation and all-cause inpatient admission. This suggests that Aerobika OPEP device may be a beneficial add-on to usual care and that OPEP devices may vary in clinical effectiveness.

Microencapsulation of Fluticasone Propionate and Salmeterol Xinafoate in Modified Chitosan Microparticles for Release Optimization

Chitosan (CS) is a natural polysaccharide, widely studied in the past due to its unique properties such as biocompatibility, biodegradability and non-toxicity. Chemical modification of CS is an effective pathway to prepare new matrices with additional functional groups and improved properties, such as increment of hydrophilicity and swelling rate, for drug delivery purposes. In the present study, four derivatives of CS with trans-aconitic acid (t-Acon), succinic anhydride (Succ), 2-hydroxyethyl acrylate (2-HEA) and acrylic acid (AA) were prepared, and their successful grafting was confirmed by FTIR and ¹H-NMR spectroscopies. Neat chitosan and its grafted derivatives were fabricated for the encapsulation of fluticasone propionate (FLU) and salmeterol xinafoate (SX) drugs, used for chronic obstructive pulmonary disease (COPD), via the ionotropic gelation technique. Scanning electron microscopy (SEM) micrographs demonstrated that round-shaped microparticles (MPs) were effectively prepared with average sizes ranging between 0.4 and 2.2 μm, as were measured by dynamic light scattering (DLS), while zeta potential verified in all cases their positive charged surface. FTIR spectroscopy showed that some interactions take place between the drugs and the polymeric matrices, while X-ray diffraction (XRD) patterns exhibited that both drugs were encapsulated in MPs’ interior with a lower degree of crystallinity than the neat drugs. In vitro release studies of FLU and SX exposed a great amelioration in the drugs’ dissolution profile from all modified CS’s MPs, in comparison to those of neat drugs. The latter fact is attributed to the reduction in crystallinity of the active substances in the MPs’ interior.

The Effects of a Nurse-Led Education and Counseling Program on Dyspnea, Health Status, and Care Dependency in Patients With Chronic Obstructive Pulmonary Disease: A Feasibility Study

The aim of this feasibility study was to determine the effects of a nurse-led education and counseling program for chronic obstructive pulmonary disease (COPD-ECP) on dyspnea, health status, and care dependency in patients. A quasi-experimental, pre-posttest research design without a control group was performed on 30 COPD patients. The patients received an 8-week COPD-ECP via home visits during the first 4 weeks and via phone interviews in the subsequent 4 weeks. After completion of COPD-ECP and a 4-week break, a final follow-up was conducted at the end of 12th week. The Dyspnea-12, COPD Assessment Test (CAT), and Care Dependency Scale (CDS) scores were calculated during the first interview, and on the 4th, 8th, and 12th week of the study. The patients completed all sessions of COPD-ECP without side effects. There was a significant decrease in the total Dyspnea-12 scores at the end of the study period. Compared to the baseline assessment, CAT total scores significantly decreased in the 4th, 8th, and 12th week ( p < 0.05), and CDS scores showed a significant reduction at the 12th week ( p < 0.05). In conclusion, COPD-ECP is feasible in regular clinical practice and well accepted by patients, and it seems to improve health status and decrease dyspnea, and care dependency. Future randomized controlled studies are warranted to explore the effects of COPD-ECP on fatigue, cough and sleep problems, and the best innovative strategies to improve the efficiency of COPD-ECP.

Resting Energy Expenditure in Patients With Familial Dysautonomia: A Preliminary Study

OBJECTIVES

Familial dysautonomia (FD) is a rare hereditary sensory and autonomic neuropathy characterized by chronic lung disease and cyclic vomiting due to hyper-adrenergic crises. Most FD patients are in a depleted nutritional state; however, the phenotype of the disease is quite different between patients, as for the severity of lung disease and the intensity and frequency of these pathognomonic crises. In this study we wanted to investigate whether resting energy expenditure (REE) levels are increased in this population, and if correlations exist between REE levels and phenotype severity.

METHODS

Data was collected from 12 FD patients (6/6 m/f). REE measurements were conducted by indirect calorimeter. Measured REE % predicted were correlated with pulmonary function, severity of the scoliosis, serum C-reactive protein, yearly frequency of hyperadrenergic crisis, hospital admissions and the use of nocturnal noninvasive positive pressure ventilation.

RESULTS

Mean REE was 112 ±13% predicted with 50% being in a hypermetabolic state (REE/HB > 110%). Body mass index (BMI) was below normal range in 75% of patients, and reduced energy intake was also decreased in 75%. No significant correlations to disease severity factors were found. When dividing the subjects to REE levels above or below 125% predicted, Patients with REE above 125% predicted presented with significantly lower inspiratory capacity (42.7% predicted vs 62.8% predicted; P = 0.04).

CONCLUSIONS

Hypermetabolic state was described in 50% of FD patients. The Low BMI is explained by combination of relative anorexia and increased REE. The REE levels are related to the underling respiratory disease.

Prevalence and Predictors of Current and Former Tobacco Use among Older Adults in Indonesia

Purpose:

The study aims to describe sociodemographic and health variable indices related to current and former tobacco use among older adults who participated in the Indonesia Family Life Survey (IFLS-5) in 2014-15.

Materials and Methods:

A national population-based cross-sectional study was conducted with a probability sample of 8,001 aged 50 years or older Indonesians.

Results:

The overall prevalence of current tobacco use was 33.3% (62.2% in men and 6.5% in women) and former tobacco use was 9.8% (17.4% among men and 2.8% in women), of which 64.4% quit tobacco use when 50 years and older. In multinomial regression analysis, sociodemographic factors (being male, lower education, lower economic status, living in Java and rural residence) and health variables (cancer or malignant tumour, depression symptoms, functional disability and inadequate fruit and vegetable consumption) were associated with current tobacco use. In addition, being overweight or obese, having had a stroke, and other lung conditions were inversely associated with current tobacco use. Further, in adjusted analysis, sociodemographic factors (being 70 years and older, being male, living in Sumatra) and having chronic conditions (dyslipidemia, heart problems, asthma, stomach or digestive diseases and functional disability) were associated with former tobacco use.

Conclusions:

A high rate of current tobacco use and low rate of former tobacco use was found, particularly among men. The identified risk factors may help to better target this vulnerable population with tobacco cessation programmes.

Testing an optimally weighted combination of common and/or rare variants with multiple traits

Recently, joint analysis of multiple traits has become popular because it can increase statistical power to identify genetic variants associated with complex diseases. In addition, there is increasing evidence indicating that pleiotropy is a widespread phenomenon in complex diseases. Currently, most of existing methods test the association between multiple traits and a single genetic variant. However, these methods by analyzing one variant at a time may not be ideal for rare variant association studies because of the allelic heterogeneity as well as the extreme rarity of rare variants. In this article, we developed a statistical method by testing an optimally weighted combination of variants with multiple traits (TOWmuT) to test the association between multiple traits and a weighted combination of variants (rare and/or common) in a genomic region. TOWmuT is robust to the directions of effects of causal variants and is applicable to different types of traits. Using extensive simulation studies, we compared the performance of TOWmuT with the following five existing methods: gene association with multiple traits (GAMuT), multiple sequence kernel association test (MSKAT), adaptive weighting reverse regression (AWRR), single-TOW, and MANOVA. Our results showed that, in all of the simulation scenarios, TOWmuT has correct type I error rates and is consistently more powerful than the other five tests. We also illustrated the usefulness of TOWmuT by analyzing a whole-genome genotyping data from a lung function study.

Identification of potential key genes associated with severe pneumonia using mRNA-seq

This study aimed to identify the potential key genes associated with severe pneumonia using mRNA-seq. Nine peripheral blood samples from patients with severe pneumonia alone (SP group, n=3) and severe pneumonia accompanied with chronic obstructive pulmonary disease (COPD; CSP group, n=3), as well as volunteers without pneumonia (control group, n=3) underwent mRNA-seq. Based on the sequencing data, differentially expressed genes (DEGs) were identified by Limma package. Following the pathway enrichment analysis of DEGs, the genes that were differentially expressed in the SP and CSP groups were selected for pathway enrichment analysis and coexpression analysis. In addition, potential genes related to pneumonia were identified based on the information in the Comparative Toxicogenomics Database. In total, 645 and 528 DEGs were identified in the SP and CSP groups, respectively, compared with the normal controls. Among these DEGs, 88 upregulated genes and 80 downregulated genes were common between the two groups. The functions of the common DEGs were similar to those of the DEGs in the SP group. In the coexpression network, the commonly downregulated genes (including ND1, ND3, ND4L, and ND6) and the commonly upregulated genes (including TSPY6P and CDY10P) exhibited a higher degree. In addition, 131 DEGs (including ND1, ND3, ND6, MIR449A and TAS2R43) were predicted to be potential pneumonia-related genes. In conclusion, the present study demonstrated that the common DEGs may be associated with the progression of severe pneumonia.

Narrative medicine educational project to improve the care of patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterised by a progressive loss of pulmonary function. Often patients do not adhere to inhaled therapies and this leads clinicians to switch treatments in order to improve control of the symptoms. Narrative medicine is a useful approach that helps healthcare professionals to think over the doctor–patient relationship and how patients live with their disease. The aim of this training project was to teach pulmonologists the basics of narrative medicine: to carefully listen to patients and to practice reflective writing in their relationship with them.

Training on narrative medicine and parallel charts was provided through a webinar and a weekly newsletter.

Across 362 narratives, written by 74 Italian pulmonologists, 92% of patients had activity limitations at their first visit. The main factor influencing the effectiveness and adherence to therapy was a positive doctor–patient relationship; indeed, if such relationship is difficult, only 21% of patients are able to resume all their activities.

After learning the narrative approach, clinicians became aware of the need to spend more time listening to patients, to reflect through writing and to understand more deeply the motivations that lead people towards adherence to new therapies.

The experience of 79 Italian pulmonologists using the narrative medicine approach in COPDhttp://ow.ly/NfnY30jdEpS

A hierarchical clustering method for dimension reduction in joint analysis of multiple phenotypes

Genome-wide association studies (GWAS) have become a very effective research tool to identify genetic variants of underlying various complex diseases. In spite of the success of GWAS in identifying thousands of reproducible associations between genetic variants and complex disease, in general, the association between genetic variants and a single phenotype is usually weak. It is increasingly recognized that joint analysis of multiple phenotypes can be potentially more powerful than the univariate analysis, and can shed new light on underlying biological mechanisms of complex diseases. In this paper, we develop a novel variable reduction method using hierarchical clustering method (HCM) for joint analysis of multiple phenotypes in association studies. The proposed method involves two steps. The first step applies a dimension reduction technique by using a representative phenotype for each cluster of phenotypes. Then, existing methods are used in the second step to test the association between genetic variants and the representative phenotypes rather than the individual phenotypes. We perform extensive simulation studies to compare the powers of multivariate analysis of variance (MANOVA), joint model of multiple phenotypes (MultiPhen), and trait-based association test that uses extended simes procedure (TATES) using HCM with those of without using HCM. Our simulation studies show that using HCM is more powerful than without using HCM in most scenarios. We also illustrate the usefulness of using HCM by analyzing a whole-genome genotyping data from a lung function study.

Narrative medicine to improve the management and quality of life of patients with COPD: the first experience applying parallel chart in Italy

Purpose

Poor adherence to therapy and the failure of current smoking cessation programs demonstrate that the current management of COPD can be improved, and it is necessary to educate physicians about new approaches for taking care of patients. Parallel chart is a narrative medicine tool that improves the doctor–patient relationship by asking physicians to write about their patients’ lives, thereby encouraging reflective thoughts on care.

Patients and methods

Between October 2015 and March 2016, 50 Italian pulmonologists were involved in the collection of parallel charts of anonymous patients with COPD. The narratives were analyzed according to the Grounded Theory methodology.

Results

In the 243 parallel charts collected, the patients (mean age 69 years, 68% men) are described as still active and as a resource for their families (71%). The doctor–patient relationship started as difficult in 50% of cases, and younger age and smoking were the main risk factors. The conversations turned positive in 78% of narratives, displaying deeper mutual knowledge, trust for the clinicians’ ability to establish effective therapy (92%), support efforts to quit smoking (63%), or restore patients’ activities (78%).

Conclusion

All the physicians concurred that the adoption of innovative parallel charts was useful for improving clinical care and worthy of official inclusion in protocols for the management of COPD.

Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec's Family Medicine Groups, 2002-2010

BACKGROUND

We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance.

METHODS

We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000-2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models.

RESULTS

Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=-2.83% [-4.08%, -1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=-0.24% [-2.24%; 1.75%]).

CONCLUSIONS

We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.

An Adaptive Fisher's Combination Method for Joint Analysis of Multiple Phenotypes in Association Studies

Currently, the analyses of most genome-wide association studies (GWAS) have been performed on a single phenotype. There is increasing evidence showing that pleiotropy is a widespread phenomenon in complex diseases. Therefore, using only one single phenotype may lose statistical power to identify the underlying genetic mechanism. There is an increasing need to develop and apply powerful statistical tests to detect association between multiple phenotypes and a genetic variant. In this paper, we develop an Adaptive Fisher’s Combination (AFC) method for joint analysis of multiple phenotypes in association studies. The AFC method combines p-values obtained in standard univariate GWAS by using the optimal number of p-values which is determined by the data. We perform extensive simulations to evaluate the performance of the AFC method and compare the power of our method with the powers of TATES, Tippett’s method, Fisher’s combination test, MANOVA, MultiPhen, and SUMSCORE. Our simulation studies show that the proposed method has correct type I error rates and is either the most powerful test or comparable with the most powerful test. Finally, we illustrate our proposed methodology by analyzing whole-genome genotyping data from a lung function study.

Impact of GOLD groups of chronic pulmonary obstructive disease on surgical complications

Purpose

Chronic obstructive pulmonary disease (COPD) is associated with increased postoperative complications. Recently, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classified COPD patients into four groups based on spirometry results and the severity of symptoms. The objective of this study was to evaluate the impact of GOLD groups on postoperative complications.

Patients and methods

We reviewed the medical records of COPD patients who underwent preoperative spirometry between April and August 2013 at a tertiary hospital in Korea. We divided the patients into GOLD groups according to the results of spirometry and self-administered questionnaires that assessed the symptom severity and exacerbation history. GOLD groups, demographic characteristics, and operative conditions were analyzed.

Results

Among a total of 405 COPD patients, 70 (17.3%) patients experienced various postoperative complications, including infection, wound, or pulmonary complications. Thoracic surgery, upper abdominal surgery, general anesthesia, large estimated blood loss during surgery, and longer anesthesia time were significant risk factors for postoperative complications. Patients in high-risk group (GOLD groups C or D) had an increased risk of postoperative complications compared to those in low-risk group (GOLD groups A or B).

Conclusion

COPD patients in GOLD groups representing a high exacerbation risk have an increased risk of postoperative complications compared to those with low risk.

Chronic obstructive pulmonary disease, hospital visits, and comorbidities: National Survey of Residential Care Facilities, 2010

OBJECTIVE

To characterize the prevalence of chronic obstructive pulmonary disease (COPD) among residential care facility (RCF) residents in the United States, and to compare patterns of hospital visits and comorbidities with residents without COPD.

METHOD

Resident data from the 2010 National Survey of Residential Care Facilities were analyzed. Medical history and information on past-year hospital visits for 8,089 adult residents were obtained from interviews with RCF staff.

RESULTS

COPD prevalence was 12.4%. Compared with residents without COPD, emergency department visits or overnight hospital stays in the previous year were more prevalent (p < .05) among residents with COPD. Less than 3% of residents with COPD had no comorbidities. Arthritis, depression, congestive heart failure (CHF), diabetes, coronary heart disease, and asthma were more common (p < .05) among residents with COPD than those without COPD, but Alzheimer's disease was less common.

DISCUSSION

COPD is associated with more emergency department visits, hospital stays, and comorbidities among RCF residents.

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.

An optimized method for estimating the tidal volume from intracardiac or body surface electrocardiographic signals: implications for estimating minute ventilation

The ability to accurately monitor tidal volume (TV) from electrocardiographic (ECG) signals holds significant promise for improving diagnosis treatment across a variety of clinical settings. The objective of this study was to develop a novel method for estimating the TV from ECG signals. In 10 mechanically ventilated swine, we collected intracardiac electrograms from catheters in the coronary sinus (CS), left ventricle (LV), and right ventricle (RV), as well as body surface electrograms, while TV was varied between 0 and 750 ml at respiratory rates of 7-14 breaths/min. We devised an algorithm to determine the optimized respirophasic modulation of the amplitude of the ECG-derived respiratory signal. Instantaneous measurement of respiratory modulation showed an absolute error of 72.55, 147.46, 85.68, 116.62, and 50.89 ml for body surface, CS, LV, RV, and RV-CS leads, respectively. Minute TV estimation demonstrated a more accurate estimation with an absolute error of 69.56, 153.39, 79.33, 122.16, and 48.41 ml for body surface, CS, LV, RV, and RV-CS leads, respectively. The RV-CS and body surface leads provided the most accurate estimations that were within 7 and 10% of the true TV, respectively. Finally, the absolute error of the bipolar RV-CS lead was significantly lower than any other lead configuration (P < 0.0001). In conclusion, we have demonstrated that ECG-derived respiratory modulation provides an accurate estimation of the TV using intracardiac or body surface signals, without the need for additional hardware.

Effect of Different Positions on FVC and FEV1 Measurements of Asthmatic Patients

[Purpose] The purpose of our study was to investigate the effect of different positions on pulmonary function test (PFT) values such as forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) of asthmatic patients .[Subjects and Methods] Thirty subjects with severe asthma aged between 20-39 years were enrolled after they had signed a written consent. Subjects were selected using the inclusion criteria, and PFT were randomly administered. Spirometer measurements (FVC, FEV1) were taken in the supine, side lying on right, side lying on left, sitting and standing positions. Each measurement was taken three times, and the average values were analyzed. [Results] One- way analysis of variance (ANOVA) and Tukey's Test (post hoc) for pair- wise comparison indicated that there was a significant difference in the FEV1 values of the asthmatic patients however a significant difference was obtained between standing and supine positions. There was also a significant difference in the FVC values between the standing and supine lying position in the pair -wise comparison. [Conclusion] This study showed standing is the best position for measuring FEV1 and FVC of asthmatic subjects. The more upright the position, the higher the FEV1 and FVC will be.

Protein-protein interaction network analysis in chronic obstructive pulmonary disease

BACKGROUND

The aim of this study was to investigate the gene expression profile of chronic obstructive pulmonary disease (COPD) patients and non-COPD patients.

METHODS

Microarray raw data (GSE29133) was downloaded from Gene Expression Omnibus, including three COPD samples and three normal controls. Gene expression profiling was performed using Affymetrix human genome u133 plus 2.0 GeneChip. Differentially expressed genes were identified by Student's t test and genes with p < 0.05 were considered significantly changed. Up- and downregulated genes were submitted to the molecular signatures database (MSigDB) to search for a possible association with other previously published gene expression signatures. Furthermore, we constructed a COPD protein-protein interaction (PPI) network and used the connectivity map (cMap) to query for potential drugs for COPD.

RESULTS

A total of 680 upregulated genes and 530 downregulated genes in COPD were identified. The MSigDB investigation found that upregulated genes were highly similar to gene signatures that respond to interferon and downregulated genes were similar to erythroid progenitor cells from fetal livers of E13.5 embryos with KLF1 knocked out. A PPI network consisting of 814 gene/proteins and 2,613 interactions was identified by Search Tool for the Retrieval of Interacting Genes. The cMap predicted helveticoside, disulfiram, and lanatoside C as the top three possible drugs that could perhaps treat COPD.

CONCLUSION

Comprehensive analysis of the gene expression profile for COPD versus control reveals helveticoside, disulfiram, and lanatoside C as potential molecular targets in COPD. This evidence provides a new breakthrough in the medical treatment of patients with COPD.

The role of social support in anxiety for persons with COPD

OBJECTIVE

This study examined the contribution of perceived social support to the presence of anxiety in persons with chronic obstructive pulmonary disease (COPD).

METHODS

A cross-sectional survey sample of 452 persons with COPD (61.3% female; 53.5% older than 65; 70.8% without a college degree or higher educational achievement, and 54.8% with household income of $40,000 or less) completed a telephone survey. Measures included the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), 5 social support subscales from the Positive and Negative Social Exchanges (PANSE) Scale, a COPD Severity Score (CSS; a weighted algorithmic combination of symptoms and the need for various COPD medical interventions), and the Geriatric Depression Scale, Short Form (GDS-SF). Zero order correlations and a series of multiple regression analyses were calculated.

RESULTS

Multiple regression analysis revealed that the receipt of instrumental support, feeling let down by the failure of others to provide needed help, and unsympathetic or insensitive behavior from others each positively predicted a higher level of patient anxiety in COPD patients, after controlling for demographic variables, smoking status, comorbid depression (GDS) and severity of illness (CSS). Additionally, the control variable of depression was the strongest predictor of anxiety, suggesting a high degree of co-morbidity in this sample.

CONCLUSION

Anxiety and depression are serious co-morbid mental health concerns for persons with COPD. It is important to examine both positive and negative aspects of perceived social support for COPD patients and how they may impact or interact with these mental health concerns.

Modulation of bacterial pathogenesis by oppressive aging factors: insights into host-pneumococcal interaction strategies

Streptococcus pneumonia, (Spn, the pneumococcus), is the leading cause of community-acquired pneumonia (CAP) and is responsible for 15–40% deaths in the elderly worldwide. A primed inflammatory status is a significant risk factor for the increased severity of infectious diseases among the elderly (≥65 years of age). Studies have shown that expression of host receptors that the pneumococci bind to invade the tissues are increased thereby increasing the susceptibility to pneumococcal challenge in aged mice. Cellular senescence, an age-related phenomenon that leads to cell cycle arrest may also contribute to increased inflammation in aged mice. Evidence of cellular senescence in aged lungs of humans and mice adds credits to the concept of inflammaging and enhanced bacterial ligands expression during aging. Furthermore, cell senescence has been shown to occur in age-associated lung pathologies such as idiopathic pulmonary fibrosis (IPF) and chronic obstructive pulmonary disease (COPD) that may predispose the elderly to pathogenic assaults, including S. pneumoniae. This review highlights the aspects of: chronic inflammation in the aged population; contribution of cellular senescence to age-associated inflammation and their impact on host receptor expression; and, increased susceptibility of fibrosis and emphysematous lesions-bearing lungs to microbial infections.

The Syndrome of Sleep Apnea in the Elderly Suffering from COPD and Live in the County of Attica, Greece

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) and obstructive sleep apnea syndrome are two diseases, which often coexist in one person. The sleep apnea is often caused by an interruption to breath when sleeping, due to an obstruction of the upper airway during inhalation, causing chronic snoring, morning headaches, increased body weight, blood pressure and sleepiness during the day.

AIM

The purpose of this study is to investigate the extend of this problem among a large group of elderly people living in the Attica Basin.

MATERIAL AND METHODS

Material of the study was 500 people aged 70 and above years old, including 274 men and 226 women. Data collection was facilitated with the use of an anonymous questionnaire with the purpose to identify patients with apnea, after a personal interview with the researcher. Data analysis was performed with the use of the statistical package SPSS 17.

RESULTS

Based on their responses to the questionnaires, it was found that 98.0% of the participants have abnormal sleepiness during the day. The 35.4% of them show no apnea, while 36.0% of the sample suffer from mild sleep apnea. It is important though, the fact that about one out of three seniors, 28.6%, shows sleep apnea in a high risk level.

CONCLUSIONS

COPD is a complex disease that occurs in a large proportion of the elderly. Emphasis should be given on early diagnosis and treatment of sleep apnea syndrome, in order to improve the quality of the elderly life.

Lung Disease in Older Patients with HIV

Successful treatment of HIV with combination antiretroviral therapy (ART) has resulted in an aging HIV-infected population. As HIV-infected patients are living longer, noninfectious pulmonary diseases are becoming increasingly prevalent with a proportional decline in the incidence of opportunistic infections (OIs). Pulmonary OIs such as Pneumocystis jirovecii pneumonia (PCP) and tuberculosis are still responsible for a significant proportion of pulmonary diseases in HIV-infected patients. However, bacterial pneumonia (BP) and noninfectious pulmonary diseases such as chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary arterial hypertension (PAH), and interstitial lung disease (ILD) account for a growing number of pulmonary diseases in aging HIV-infected patients. The purpose of this chapter is to discuss the spectrum and management of pulmonary diseases in aging HIV-infected patients, although limited data exists to guide management of many noninfectious pulmonary diseases in HIV-infected patients. In the absence of such data, treatment of lung diseases in HIV-infected patients should generally follow guidelines for management established in HIV-uninfected patients.

Teaching inhaler use in chronic obstructive pulmonary disease patients

PURPOSE

To review barriers to the successful use of inhalers in patients with chronic obstructive pulmonary disease (COPD), and the role of the nurse practitioner (NP) in facilitating optimum inhaler use.

DATA SOURCES

Review of the national and international scientific literature.

CONCLUSIONS

Pharmacologic treatment of COPD patients comprises mainly inhaled medications. Incorrect use of inhalers is very common in these individuals. Some of the consequences of poor inhaler technique include reduced therapeutic dosing, medication adherence, and disease stability, which can lead to increased morbidity, decreased quality of life, and a high burden on the healthcare system. Knowledgeable evaluation and frequent reassessment of inhaler use coupled with education of patients, caregivers, and healthcare professionals can significantly improve the benefits COPD patients derive from inhaled therapy.

IMPLICATIONS FOR PRACTICE

Patient education is vital for correct use of inhalers and to ensure the effectiveness of inhaled medications. The NP has a critical role in assessing potential barriers to successful learning by the patient and improving inhaler technique and medication management. The NP can also facilitate success with inhaled medications by providing up-to-date inhaler education for other healthcare team members, who may then act as patient educators.

Factors associated with mortality in patients with exacerbation of chronic obstructive pulmonary disease hospitalized in General Medicine departments

We aim to improve knowledge on risk factors that relate to mortality in subjects with exacerbation of chronic obstructive pulmonary disease (COPD) who are hospitalized in General Medicine departments. In a cross-sectional multicenter study, by means of a logistic regression analysis, we assessed the possible association of death during hospitalization with the following groups of variables of participating patients: sociodemographic features, treatment received prior to admission and during hospitalization, COPD-related clinical features recorded prior to admission, comorbidity diagnosed prior to admission, clinical data recorded during hospitalization, laboratory results recorded during hospitalization, and electrocardiographic findings recorded during hospitalization. A total of 398 patients was included; 353 (88.7%) were male, and the median age of the patients was 75 years. Of these patients, 21 (5.3%) died during hospitalization. Only 270 (67.8%) received inhaled β(2) agonists during hospitalization, while 162 (40.7%) received angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. The median of predicted FEV(1) prior to admission was 42%. A total of 350 patients (87.9%) had been diagnosed with two or more comorbid conditions prior to admission. An association was found between increased risk of death during hospitalization and the previous diagnoses of pneumonia, coronary heart disease, and stroke. In conclusion, comorbidity is an important contributor to mortality among patients hospitalized in General Medicine departments because of COPD exacerbation.

Pulmonary rehabilitation: an underutilized resource in primary COPD care

Pulmonary rehabilitation (PR) is an important component of chronic obstructive pulmonary disease (COPD) management. Physician use of PR for patients with COPD lags behind national and international guideline recommendations. In this article, we discuss the important components of PR, including exercise training, self-management education, and psychosocial and nutritional interventions, as based on the American Thoracic Society/European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We also discuss the potential benefits of PR, including reduction of respiratory symptoms, decreased disability, and increased participation in physical and social activities. Increased activity promotes independence, improves quality of life, and reduces the number of COPD exacerbations and hospitalizations. In all stages of COPD, PR has been shown to result in improved exercise tolerance, with reduced dyspnea and fatigue, although the greatest improvement has been seen in patients with GOLD stages II to IV. Pulmonary rehabilitation is now a well-recognized therapy that should be available to all patients with symptomatic COPD. To facilitate inclusion of PR in COPD management, primary care physicians need to recognize and diagnose COPD, and regularly decide when PR best fits in an individual's COPD treatment program.