Exacerbations in COPD Patients with Bronchiectasis

Early Identification of Exacerbations in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) have a substantial effect on overall disease management, health system costs, and patient outcomes. However, exacerbations are often underdiagnosed or recognized with great delay due to several factors such as patients' inability to differentiate between acute episodes and symptom fluctuations, delays in seeking medical assistance, and disparities in dyspnea perception. Self-management intervention plans, telehealth and smartphone-based programs provide educational material, counseling, virtual hospitals and telerehabilitation, and help COPD patients to identify exacerbations early. Moreover, biomarkers such as blood eosinophil count, fibrinogen, CRP, Serum amyloid A(SAA),together with imaging parameters such as the pulmonary artery-to-aorta diameter ratio, have emerged as potential predictors of exacerbations, yet their clinical utility is limited by variability and lack of specificity. In this review, we provide information regarding the importance of the early identification of exacerbation events in COPD patients and the available methods which can be used for this purpose.

[Bronchial dilatations in patients with chronic obstructive pulmonary disease in a Tunisian center: effect on disease progression and prognosis]

INTRODUCTION

bronchial dilations (BDs) seem to have a major role in the natural history of chronic obstructive pulmonary disease (COPD). The purpose of our study was to evaluate the impact of BDs on the severity and progression of COPD as well as on patients' prognosis.

METHODS

we conducted a retrospective, single-center, analytical study over the period 1995- 2017. The study was based on data from the medical records of patients with COPD who had undergone chest CT scan during the follow-up period. We compared two groups (G) of patients: G1: COPD with BDs; G2: COPD without BDs.

RESULTS

our study included 466 patients with COPD. Among them 101 (21.6%) had BDs associated with COPD. G1 patients had lower maximum expiratory volume in the first second (FEV1) (G1: 1.21 L, G2: 1.37 L, p = 0.015), lower forced vital capacity (FVC) (p = 0.014), a lower PaO2 at steady state (p = 0.049), a higher rate of acute exacerbations (AE) per year (G1: 3.31, G2: 2.44, p = 0.001) and a higher rate of hospitalizations in the Intensive Care Unit per year (p = 0.02). G1 patients with AE receiving treatment in hospital had lower PaO2 3) on admission (G1: 60 mmHg, G2: 63.7 mmHg, p = 0.02 G2: 63.7 mmHg, p = 0.023), more elevated carbon dioxide (CO2) levels (p = 0.001) and were characterized by a higher use of non-invasive ventilation (NIV) (p = 0.044) and invasive mechanical ventilation (p = 0.011). G2 patients had better overall survival (p = 0.002).

CONCLUSION

bronchial dilatations are an indicator of poor prognosis in patients with chronic obstructive pulmonary disease, expecially because of the higher rate and severity of exacerbations, airway obstructions and mortality.

Effects of a Long-Term Use of Carbocysteine on Frequency and Duration of Exacerbations in Patients with Bronchiectasis

BACKGROUND

The failure of mucus clearance in bronchiectasis can be improved by chest physiotherapy or/and mucoactive agents.

AIM

To assess the effects of long-term use of carbocysteine on frequency and duration of exacerbations in patients with bronchiectasis.

METHODS

We performed an observational, non-randomized, open study (a real-life study) including 64 patients with bronchiectasis divided into two groups, examined group (EG) and control group (CG). All participants were treated with appropriate treatment for the stable disease, but in the study, subjects of EG two capsules 375 mg carbocysteine three times a day was added over three months. Daily diary cards realised collection of data regarding the occurrence and duration of exacerbation in all study subjects.

RESULTS

Over the study period 43 exacerbations were documented, 17 in the EG and 26 in the CG, 10 (23.4%) of which required hospital treatment (four in the EG [23.5%] and six in the CG [23.1%]). A mean number of exacerbations over the study period was significantly lower in the EG (0.5 ± 0.1) as compared to their mean number in the CG (0.8 ± 0.2) (P = 0.0000). Mean duration of exacerbations expressed in days needed for complete resolution of symptoms or return of the symptoms to their baseline severity in the EG was significantly shorter than the mean duration of exacerbations in the CG (10.1 ± 2.6 vs 12.8 ± 2.1; P = 0.0000). The frequency of adverse effects, i.e. mild gastrointestinal manifestations and headache which did not require discontinuation of the treatment, in the EG during the study period was 15.6%.

CONCLUSION

Our findings indicated positive effects of carbocysteine regarding the frequency and duration of exacerbations, as well as its good tolerability in the patients with bronchiectasis.

A clinical prediction model for hospitalized COPD exacerbations based on "treatable traits"

Background

Assessing risk of future exacerbations is an important component in COPD management. History of exacerbation is a strong and independent predictor of future exacerbations, and the criterion of ≥2 nonhospitalized or ≥1 hospitalized exacerbation is often used to identify high-risk patients in whom therapy should be intensified. However, other factors or "treatable traits" also contribute to risk of exacerbation.

Objective

The objective of the study was to develop and externally validate a novel clinical prediction model for risk of hospitalized COPD exacerbations based on both exacerbation history and treatable traits.

Patients and methods

A total of 237 patients from the COPD Registry of Changi General Hospital, Singapore, aged 75±9 years and with mean post-bronchodilator FEV1 60%±20% predicted, formed the derivation cohort. Hospitalized exacerbation rate was modeled using zero-inflated negative binomial regression. Calibration was assessed by graphically comparing the agreement between predicted and observed annual hospitalized exacerbation rates. Predictive (discriminative) accuracy of the model for identifying high-risk patients (defined as experiencing ≥1 hospitalized exacerbations) was assessed with area under the curve (AUC) and receiver operating characteristics analyses, and compared to other existing risk indices. We externally validated the prediction model using a multicenter dataset comprising 419 COPD patients.

Results

The final model included hospitalized exacerbation rate in the previous year, history of acute invasive/noninvasive ventilation, coronary artery disease, bronchiectasis, and sputum nontuberculous mycobacteria isolation. There was excellent agreement between predicted and observed annual hospitalized exacerbation rates. AUC was 0.789 indicating good discriminative accuracy, and was significantly higher than the AUC of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) risk assessment criterion (history of ≥1 hospitalized exacerbation in the previous year) and the age, dyspnea, and obstruction index. When applied to the independent multicenter validation cohort, the model was well-calibrated and discrimination was good.

Conclusion

We have derived and externally validated a novel risk prediction model for COPD hospitalizations which outperforms several other risk indices. Our model incorporates several treatable traits which can be targeted for intervention to reduce risk of future hospitalized exacerbations.

[Integral approach to the acute exacerbation of chronic obstructive pulmonary disease]

Chronic obstructive pulmonary disease is a set of clinical processes that have in common a chronic and progressive obstruction to airflow, with episodes of exacerbation. These exacerbations are more frequent and severe over time, deteriorating the lung function. The main cause of exacerbations is bacterial infection. There are multiple guidelines and documents that statement the management of this pathology. However, they focus primarily on the treatment during the stable phase. This document addresses the problem of acute exacerbation due to an infection from a multidisciplinary perspective, focusing on the integral approach to the process, and including etiology, microbiological studies, resistance to antimicrobials, risk stratification and initial empirical therapeutic management (antibiotic and concomitant). In addition, it includes an approach to more complex aspects such as the management of special populations (elderly and immunosuppressed) or therapeutic failure. Finally, more controversial topics such as prophylaxis of infection or palliative treatment are specifically discussed.