Diagnosis of COPD and clinical course in patients with unrecognized airflow limitation

Synergistic effects of COVID-19 and Pseudomonas aeruginosa in chronic obstructive pulmonary disease: a polymicrobial perspective

This article discusses the connection between the novel coronavirus disease 2019 (COVID-19) caused by the coronavirus-2 (SARS-CoV-2) and chronic obstructive pulmonary disease (COPD). COPD is a multifaceted respiratory illness that is typically observed in individuals with chronic exposure to chemical irritants or severe lung damage caused by various pathogens, including SARS-CoV-2 and Pseudomonas aeruginosa. The pathogenesis of COPD is complex, involving a variety of genotypes and phenotypic characteristics that result in severe co-infections and a poor prognosis if not properly managed. We focus on the role of SARS-CoV-2 infection in severe COPD exacerbations in connection to P.  aeruginosa infection, covering pathogenesis, diagnosis, and therapy. This review also includes a thorough structural overview of COPD and recent developments in understanding its complicated and chronic nature. While COVID-19 is clearly linked to emphysema and chronic bronchitis at different stages of the disease, our understanding of the precise interaction between microbial infections during COPD, particularly with SARS-CoV-2 in the lungs, remains inadequate. Therefore, it is crucial to understand the host-pathogen relationship from the clinician's perspective in order to effectively manage COPD. This article aims to provide a comprehensive overview of the subject matter to assist clinicians in their efforts to improve the treatment and management of COPD, especially in light of the COVID-19 pandemic.

Development and preliminary validation of the chronic obstructive pulmonary disease scale quality of life instruments for chronic diseases-chronic obstructive pulmonary disease based on classical test theory and generalizability theory

Quality of life (QOL) in patients with Chronic obstructive pulmonary disease (COPD) is a major global concern in respiratory care with the specific instruments used rarely being developed using a modular approach. This paper is aimed to develop the COPD scale of the system of QOL Instruments for Chronic Diseases (QLICD-COPD) by the modular approach based on Classical Test Theory and Generalizability Theory (GT). 114 inpatients with COPD were used to provide the data measuring QOL three times before and after treatments. The psychometric properties of the scale were evaluated with respect to validity, reliability and responsiveness employing correlation analysis, factor analyses, multi-trait scaling analysis, and also GT analysis. The Results showed that Multi-trait scaling analysis, correlation and factor analyses confirmed good construct validity and criterion-related validity with almost all correlation coefficients or factor loadings being above 0.40. The internal consistency α and test-retest reliability coefficients (Pearson r and Intra-class correlations ICC) for all domains except for the social domain were larger than 0.70, ranging between 0.70–0.86 with r = 0.85 for the overall. The overall score and scores for physical and the specific domains had statistically significant changes after treatments with moderate effect size SRM (standardized response mean) ranging from 0.32 to 0.44. All G-coefficients and index of dependability were all greater than 0.80 exception of social domain (0.546 and 0.500 respectively), confirming the reliability of the scale further. It concluded that the QLICD-COPD has good validity, reliability, and moderate responsiveness, and can be used as the QOL instrument for patients with COPD.

Protocol Summary of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) Validation in Primary Care Study

Chronic obstructive pulmonary disease (COPD) often remains undiagnosed and untreated. To date, COPD screening/case finding has not been designed to identify clinically significant COPD, disease ready for therapies beyond smoking cessation. Herein, we describe the ongoing prospective, pragmatic cluster-randomized controlled trial to assess specificity and sensitivity of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) tool consisting of 5 questions and peak expiratory flow. The tool is designed to identify clinically significant COPD (forced expiratory volume in 1 second [FEV₁] to forced vital capacity [FVC] ratio <.70 plus FEV₁% predicted <60% or increased risk for exacerbation) and the trial will explore the impact of CAPTURE-based screening on COPD diagnosis and treatment rates in primary care patients. Of a total planned enrollment of 5000 English- or Spanish-speaking patients 45 to 80 years of age without a prior COPD diagnosis from 100 primary care practices, a total of 68 practices and 3064 patients have been enrolled in the study. Practices are centrally randomized to either usual care or clinician receipt of patient-level CAPTURE results. All clinicians receive basic COPD education with those in intervention practices also receiving CAPTURE interpretation education. In a single visit, patient participants complete a CAPTURE screening, pre- and post-bronchodilator spirometry and baseline demographic and health questionnaires to validate CAPTURE sensitivity, specificity, and predictive value of identifying undiagnosed, clinically significant COPD. One-year follow-up chart reviews and participant surveys assess the impact of sharing versus not sharing CAPTURE results with clinicians on clinical outcomes including level of respiratory symptoms and events and clinicians' initiation of recommendation-concordant COPD care. This is one of the first U.S. studies to validate and assess impact of a simple COPD screening tool in primary care.

Electrochemical methods for detection of biomarkers of Chronic Obstructive Pulmonary Disease in serum and saliva

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death nowadays, and its underdiagnosis is still a great challenge. More effective diagnosis method is in urgent need since the traditional spirometry has many limitations in the practical application. The electrochemical (EC) detection methods have their unique advantages of high accuracy, short response time and easy integration of the system. In this review, recent works on the EC methods for COPD biomarkers including interleukin 6 (IL-6), interleukin 8 (IL-8) and C-reactive protein (CRP) are summarized. Five types of EC methods are highlighted in this study, as enzyme-labelled immunosensors, nanoparticle-labelled immunosensors, capacitive or impedimetric immunosensors, magnetoimmunosensors, and field effect transistor (FET) immunosensors. To date, EC immunosensors have been exhibiting high analytical performance with a detection limit that can achieve several pg/mL or even lower. The simplicity of EC immunosensors makes them a perfect solution for a future point-of-care device to use in settings for COPD diagnosis and follow-up. Nevertheless, more efforts need to be paid on the simultaneous detection of multiple biomarkers, a demand for the clinical diagnosis, and processes of assay simplification towards achieving one-step detection.

The Effect of Defining Chronic Obstructive Pulmonary Disease by the Lower Limit of Normal of FEV1/FVC Ratio in Tiotropium Safety and Performance in Respimat Participants

RATIONALE

There is continuing debate about whether to define airflow obstruction by a post-bronchodilator ratio of forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC) below 0.70, or by ratio values falling below the age-dependent lower limit of normal (LLN) derived from general population data.

OBJECTIVES

To determine whether using the LLN criterion affects the classification and outcomes of patients previously defined as having chronic obstructive pulmonary disease by the fixed FEV₁/FVC ratio.

METHODS

We applied the LLN definition to pooled data from the Tiotropium Safety and Performance in Respimat study that used the fixed FEV₁/FVC ratio for the clinical diagnosis of chronic obstructive pulmonary disease.

RESULTS

A total of 17,072 patients were analyzed; of these, 1,807 (10.6%) patients had a ratio greater than or equal to LLN. Patients with a ratio greater than or equal to LLN had similar risks of death from any cause and fatal major adverse cardiovascular (CV) event as those below LLN. Patients with a ratio below LLN had a significantly lower risk of major adverse CV events (hazard ratio = 0.69; 95% confidence interval [CI] = 0.55-0.86; P = 0.001), and had significantly greater risks of moderate to severe exacerbation (rate ratio = 1.48; 95% CI = 1.36-1.61; P < 0.0001) and severe exacerbation (rate ratio = 2.01; 95% CI = 1.68-2.40; P < 0.0001) when compared with patients greater than or equal to LLN. Study outcomes by treatment arm (5 μg tiotropium Respimat vs. 18 μg HandiHaler) were comparable.

CONCLUSIONS

Using the LLN to define airflow obstruction would have excluded patients in the Tiotropium Safety and Performance in Respimat study with a higher risk of nonfatal major adverse CV events and a lower risk of exacerbation; study outcomes by treatment arm (2.5 μg/5 μg tiotropium Respimat vs. 18 μg HandiHaler) remained similar. Clinical trial registered with www.clinicaltrials.gov (NCT01126437).

Implementation of guideline-based therapy for chronic obstructive pulmonary disease: Differences between men and women veterans

Chronic obstructive pulmonary disease (COPD) is common among both men and women, and guidelines recommend the same therapy for both sexes. While previous studies have identified gender differences in other chronic disease management, few studies have examined how implementation of COPD guidelines differs between men and women. We performed a cross-sectional study of veterans admitted to Veterans Affairs (VA) hospitals for COPD during October 1, 2008, to September 30, 2011. We collected information on baseline COPD medications during the 6 months prior to hospitalization and categorized therapies as “appropriate” or “inappropriate” based on current guidelines. We used multivariable logistic regression to examine the differences in COPD medications between men and women, after controlling for baseline patient characteristics. We also examined the differences in hospital outcomes, including length of stay and hospital readmission. We identified 33,558 veterans, including 1149 women and 32,409 men who were admitted to 130 VA hospitals. Women were significantly less likely to have received inhaler therapies prior to admission, with lower rates of short-acting beta agonists, short-acting muscarinic antagonists, long-acting beta agonists, and long-acting muscarinic antagonists compared to men. Women also received fewer appropriate inhaler combinations (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.74–0.93) and more inappropriate combinations (OR = 1.33, 95% CI 1.17–1.51). Women and men were prescribed similar rates of inhaled steroid and oral steroids. Hospital outcomes were also similar between the two groups. These findings highlight a potential gender disparity in appropriate outpatient COPD therapy. Improving the quality of care for patients with COPD should include equitable implementation of guideline-based COPD management.

Undiagnosed chronic obstructive pulmonary disease in patients admitted to an acute assessment unit

Introduction: Chronic obstructive pulmonary disease (COPD) is very prevalent worldwide, yet underdiagnosed. Aim: This study investigates feasibility of performing spirometry in patients in need of acute hospital admission as well as the prevalence of undiagnosed COPD in the same cohort. Methods: During a two-week period, all patients admitted to three large acute assessment units were evaluated. Patients ≥ 18 years, able to perform spirometry, with no surgery to the thorax or abdomen within the last weeks and no known COPD was included. Patients with FEV1/FEV6 ≤ 0.7 or FEV1 < 80% or FEV6 < 80% were offered follow-up visit after 6 weeks. Results: Of the 1145 admitted patients, 46% were eligible: 28% of those had an abnormal spirometry. The offered follow-up visit was attended by 51% and in this group 17% were diagnosed with lung disease. COPD was the most prevalent diagnosis (73%), and 2/3 was in GOLD group A. In total, 75% of the patients with airflow obstruction at the initial examination remained obstructive. Conclusion: Performing spirometry in patients in need of acute hospital admission is feasible, abnormal findings are common, and COPD is the most prevalent diagnosis.

Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study

BACKGROUND AND OBJECTIVE

Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD.

METHODS

Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) < 0.70 and the lower limit of normal of FEV1 /FVC.

RESULTS

A total of 1743 subjects completed the interview; 1540 performed acceptable spirometry. COPD prevalence was 20.1% (n = 309; ranging from 11.0% in Venezuela to 29.6% in Argentina) when defined using post-BD FEV1 /FVC < 0.70, and 14.7% (n = 226; ranging from 8.3% in Venezuela to 21.8% in Colombia) using the lower limit of normal. Logistic regression analysis for both definitions showed that the risk of COPD was significantly higher for persons >50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC < 0.70) of 76% and 79% for the simple and weighted scores, respectively.

CONCLUSION

This simple seven-item score is an accurate screening tool to select subjects for spirometry in primary care.

A retrospective study of two populations to test a simple rule for spirometry

Background

Chronic lung disease is common and often under-diagnosed.

Methods

To test a simple rule for conducting spirometry we reviewed spirograms from two populations, occupational medicine evaluations (OME) conducted by Saint Louis and Wake Forest Universities at 3 sites (n = 3260, mean age 64.14 years, 95 % CI 58.94–69.34, 97 % men) and conducted by Wake Forest University preop clinic (POC) at one site (n = 845, mean age 62.10 years, 95 % CI 50.46–73.74, 57 % men). This retrospective review of database information that the first author collected prospectively identified rates, types, sensitivity, specificity and positive and negative predictive value for lung function abnormalities and associated mortality rate found when conducting spirometry based on the 20/40 rule (≥20 years of smoking in those aged ≥ 40 years) in the OME population. To determine the reproducibility of the 20/40 rule for conducting spirometry, the rule was applied to the POC population.

Results

A lung function abnormality was found in 74 % of the OME population and 67 % of the POC population. Sensitivity of the rule was 85 % for an obstructive pattern and 77 % for any abnormality on spirometry. Positive and negative predictive values of the rule for a spirometric abnormality were 74 and 55 %, respectively. Patients with an obstructive pattern were at greater risk of coronary heart disease (odds ratio (OR) 1.39 [confidence interval (CI) 1.00–1.93] vs. normal) and death (hazard ratio (HR) 1.53, 95 % CI 1.20–1.84) than subjects with normal spirometry. Restricted spirometry patterns were also associated with greater risk of coronary disease (odds ratio (OR) 1.7 [CI 1.23–2.35]) and death (Hazard ratio 1.40, 95 % CI 1.08–1.72).

Conclusions

Smokers (≥ 20 pack years) age ≥ 40 years are at an increased risk for lung function abnormalities and those abnormalities are associated with greater presence of coronary heart disease and increased all-cause mortality. Use of the 20/40 rule could provide a simple method to enhance selection of candidates for spirometry evaluation in the primary care setting.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

8th international conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 1

This paper summarizes the Part 1 of the proceedings of the 8^th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations.

This paper (Part 1) includes sections regarding: Advances in Asthma and COPD Therapy (Novel Therapeutic Targets for Asthma: Proteinases, Blood Biomarker Changes in COPD Patients); The problem of Hospital Re-Admission following Discharge after the COPD Exacerbation (Characteristics of the Hospitalized COPD Patient, Reducing Hospital Readmissions Following COPD Exacerbation).

ALAT-2014 Chronic Obstructive Pulmonary Disease (COPD) Clinical Practice Guidelines: questions and answers

ALAT-2014 COPD Clinical Practice Guidelines used clinical questions in PICO format to compile evidence related to risk factors, COPD screening, disease prognosis, treatment and exacerbations. Evidence reveals the existence of risk factors for COPD other than tobacco, as well as gender differences in disease presentation. It shows the benefit of screening in an at-risk population, and the predictive value use of multidimensional prognostic indexes. In stable COPD, similar benefits in dyspnea, pulmonary function and quality of life are achieved with LAMA or LABA long-acting bronchodilators, whereas LAMA is more effective in preventing exacerbations. Dual bronchodilator therapy has more benefits than monotherapy. LAMA and combination LABA/IC are similarly effective, but there is an increased risk of pneumonia with LABA/IC. Data on the efficacy and safety of triple therapy are scarce. Evidence supports influenza vaccination in all patients and anti-pneumococcal vaccination in patients <65years of age and/or with severe airflow limitation. Antibiotic prophylaxis may decrease exacerbation frequency in patients at risk. The use of systemic corticosteroids and antibiotics are justified in exacerbations requiring hospitalization and in some patients managed in an outpatient setting.

The diagnosis of chronic obstructive pulmonary disease

BACKGROUND

Estimates of the prevalence of chronic obstructive pulmonary disease (COPD) in Germany range from 1.9% to 13.2%, depending on the population studied and the investigative methods used. About 30% of all patients already have severe airway obstruction by the time the condition is diagnosed.

METHODS

Review of pertinent literature retrieved by a selective search, including current guidelines and textbooks.

RESULTS

Smoking is the main risk factor for COPD. The diagnosis is based on characteristic symptoms that patients at risk should be actively asked about-cough, dyspnea, diminished physical reserve, and frequent airway infections-together with abnormal pulmonary function tests. Spirometry usually suffices to document impaired air flow. The clinical evaluation and the treatment strategy are based on the severity of airway obstruction and dyspnea, and the frequency of exacerbations. According to a European study, dyspnea is present in 73% of persons with severe COPD, expectoration in 64%, cough in 59%, and wheezing in 42%. Asthma, congestive heart failure, and interstitial lung disease are the main differential diagnoses.

CONCLUSION

COPD may begin with symptoms that are only mild at first even in a longstanding smoker. The available diagnostic techniques need better prospective validation with respect to relevant endpoints, including mortality, symptom progression, quality of life, and frequency of exacerbations.

Therapeutic paralysis in veterans with COPD

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a common disorder of Veterans that causes significant morbidity and mortality. To measure Veterans' perceptions about COPD, the effect of COPD on their lives and health, and their needs for improved health, we performed a postal survey.

METHODS

3263 Veterans with a diagnosis of COPD who received care at the Cincinnati Veterans Affairs Medical Center in 2008 were stratified into quintiles by Veterans Health Administration-associated COPD healthcare cost and uniformly sampled.

RESULTS

493 of 1000 surveys (49%) were completed and returned. COPD had different effects on respondents in top and bottom quintiles (highest and lowest COPD-related cost) for: knowledge of COPD diagnosis (89% vs. 73%, p = 0.03); activities affected by breathing, including work (69% vs. 45%), recreation (85% vs. 62%), change in living arrangements (36% vs 16%), and increased need for help (54% vs. 25%) (p < 0.05 for all comparisons); emotional effect of respiratory symptoms, including depression (53% vs. 30%), fear (41% vs. 15%), and helplessness (49% vs. 24%) (p < 0.05 for all comparisons). 91% of Veterans were prescribed inhalers and one-quarter had difficulties using them. 25% of Veterans did nothing when they had symptoms of an exacerbation.

CONCLUSIONS

COPD has profound effects on Veterans' breathing related activities and generates many negative emotions. Primary care providers are critical in conveying the diagnosis of COPD and providing information about the disease and its management. Veterans with COPD adhere poorly to their medications, and report little instruction about COPD or its management.