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Athanazio RA, Bernal Villada L, Avdeev SN, Wang HC, Ramírez-Venegas A, Sivori M, Dreyse J, Pacheco M, Man SK, Noriega-Aguirre L, Farouk H. Rate of severe exacerbations, healthcare resource utilisation and clinical outcomes in patients with COPD in low-income and middle-income countries: results from the EXACOS International Study. BMJ Open Respir Res 2024; 11:e002101. [PMID: 38637115 PMCID: PMC11029392 DOI: 10.1136/bmjresp-2023-002101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/16/2024] [Indexed: 04/20/2024] Open
Abstract
INTRODUCTION The EXAcerbations of Chronic obstructive lung disease (COPD) and their OutcomeS (EXACOS) International Study aimed to quantify the rate of severe exacerbations and examine healthcare resource utilisation (HCRU) and clinical outcomes in patients with COPD from low-income and middle-income countries. METHODS EXACOS International was an observational, cross-sectional study with retrospective data collection from medical records for a period of up to 5 years. Data were collected from 12 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Guatemala, Hong Kong, Mexico, Panama, Russia and Taiwan. The study population comprised patients ≥40 years of age with COPD. Outcomes/variables included the prevalence of severe exacerbations, the annual rate of severe exacerbations and time between severe exacerbations; change in lung function over time (measured by the forced expiratory volume in 1 s (FEV1)); peripheral blood eosinophil counts (BECs) and the prevalence of comorbidities; treatment patterns; and HCRU. RESULTS In total, 1702 patients were included in the study. The study population had a mean age of 69.7 years, with 69.4% males, and a mean body mass index of 26.4 kg/m2. The mean annual prevalence of severe exacerbations was 20.1%, and 48.4% of patients experienced ≥1 severe exacerbation during the 5-year study period. As the number of severe exacerbations increased, the interval between successive exacerbations decreased. A statistically significant decrease in mean (SD) FEV1 from baseline to post-baseline was observed in patients with ≥1 severe exacerbation (1.23 (0.51) to 1.13 (0.52) L; p=0.0000). Mean BEC was 0.198 x109 cells/L, with 64.7% of patients having a BEC ≥0.1 x109 cells/L and 21.3% having a BEC ≥0.3 x109 cells/L. The most common comorbidity was hypertension (58.3%). An increasing number of severe exacerbations per year was associated with greater HCRU. DISCUSSION The findings presented here indicate that effective treatment strategies to prevent severe exacerbations in patients with COPD remain a significant unmet need in low-income and middle-income countries.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- Pulmonology Division, Heart Institute-InCor-Clinical Hospital, Faculty of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | | | - Sergey N Avdeev
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Alejandra Ramírez-Venegas
- Tobacco Smoking and COPD Research Department, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico
| | - Martín Sivori
- Pneumology Unit, Dr J M Ramos Mejía Pulmonology University Center, Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Jorge Dreyse
- Department of Internal Medicine and Critical Care Center, Clínica Las Condes and School of Medicine Universidad Finis Terrae, Santiago, Chile
| | - Manuel Pacheco
- Internal Medicine Research Group, Universidad Tecnológica de Pereira, Pereira, Colombia
- Fundación Universitaria Visión de las Américas y Respiremos Unidad de Neumología, Pereira, Colombia
| | - Sin Kit Man
- Department of Medicine and Geriatrics, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong Special Administrative Region (HKSAR), Tuen Mun, People's Republic of China
| | - Lorena Noriega-Aguirre
- Center for Diagnosis and Treatment of Respiratory Diseases (CEDITER), Panama City, Panama
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Halpin DMG, Mahler DA. Systematic review of the effects of patient errors using inhaled delivery systems on clinical outcomes in COPD. BMJ Open Respir Res 2024; 11:e002211. [PMID: 38626929 PMCID: PMC11029336 DOI: 10.1136/bmjresp-2023-002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/05/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Errors using inhaled delivery systems for COPD are common and it is assumed that these lead to worse clinical outcomes. Previous systematic reviews have included patients with both asthma and COPD and much of the evidence related to asthma. More studies in COPD have now been published. Through systematic review, the relationship between errors using inhalers and clinical outcomes in COPD, including the importance of specific errors, was assessed.MethodsElectronic databases were searched on 27 October 2023 to identify cohort, case-control or randomised controlled studies, which included patients with COPD, an objective assessment of inhaler errors and data on at least one outcome of interest (forced expiratory volume in 1 s, (FEV1), dyspnoea, health status and exacerbations). Study quality was assessed using the Newcastle and Ottawa scales. A narrative synthesis of the results was performed as there was insufficient detail in the publications to allow quantitative synthesis. There was no funding for the review. RESULTS 19 publications were included (7 cohort and 12 case-control) reporting outcomes on 6487 patients. 15 were considered low quality, and most were confounded by the absence of adherence data. There was weak evidence that lower error rates are associated with better FEV1, symptoms and health status and fewer exacerbations. Only one considered the effects of individual errors and found that only some were related to worse outcomes. CONCLUSION Evidence about the importance of specific errors using inhalers and outcomes would optimise the education and training of patients with COPD. Prospective studies, including objective monitoring of inhalation technique and adherence, are needed. PROSPERO REGISTRATION NUMBER CRD42023393120.
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Affiliation(s)
- David M G Halpin
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Valley Regional Hospital, Claremont, New Hampshire, USA
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Vogelmeier CF, Rhodes K, Garbe E, Abram M, Halbach M, Müllerová H, Kossack N, Timpel P, Kolb N, Nordon C. Elucidating the risk of cardiopulmonary consequences of an exacerbation of COPD: results of the EXACOS-CV study in Germany. BMJ Open Respir Res 2024; 11:e002153. [PMID: 38555102 PMCID: PMC10982767 DOI: 10.1136/bmjresp-2023-002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/29/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Exacerbations of chronic obstructive pulmonary disease (COPD) represent a period of vulnerability. This study explored the association between time periods following an exacerbation and the risk of severe cardiovascular (CV) events or death in Germany. METHODS A longitudinal cohort study was conducted using routinely collected healthcare data. Individuals with COPD were identified between 2014 and 2018. Exposure was moderate or severe exacerbation of COPD. Periods at risk were the 1-7, 8-14, 15-30, 31-180 and 181-365 days following each exacerbation onset occurring after cohort entry. The main outcome of interest was the first hospitalisation for a CV event or all-cause death. Time-dependent Cox proportional hazards models estimated the HR for the association between subperiods versus periods outside exacerbations, and the risk of outcome. RESULTS Among 126 795 patients, 58 720 (46.3%) exacerbated at least once and 48 982 (38.6%) experienced at least one CV event or died during a median follow-up of 36 months. The rate of outcome was increased during 1-7 days following a severe exacerbation onset (HR 15.84, 95% CI 15.26 to 16.45), and remained elevated for up to a year (181-365 days HR 1.17, 95% CI 1.11 to 1.23). In the 1-7 days following a moderate exacerbation onset, the increased rate was HR 1.17, 95% CI 1.05 to 1.31). CONCLUSION The risk of a CV event or death increased in time periods following both moderate and severe exacerbations of COPD, emphasising the need to promptly manage the risk of CV events following the onset of an exacerbation, to prevent exacerbations of any severity, and more generally, to address the cardiopulmonary risk in patients with COPD.
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Affiliation(s)
- Claus F Vogelmeier
- Pulmonary and Critical Care Medicine, German Center for Lung Research (DZL), Marburg, Germany
| | - Kirsty Rhodes
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Edeltraut Garbe
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | | | | | | | - Nils Kossack
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Leipzig, Germany
| | - Patrick Timpel
- WIG2 GmbH Scientific Institute for Health Economics and Health System Research, Leipzig, Germany
| | - Nikolaus Kolb
- ZEG - Berlin Center for Epidemiology and Health Research GmbH, Berlin, Germany
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Tsai SH, Hung JY, Su PF, Hsu CH, Yu CH, Liao XM, Wang JD, Hsiue TR, Chen CZ. Chronic obstructive pulmonary disease trajectory: severe exacerbations and dynamic change in health-related quality of life. BMJ Open Respir Res 2024; 11:e002037. [PMID: 38387996 PMCID: PMC10882291 DOI: 10.1136/bmjresp-2023-002037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND The life trajectory of chronic obstructive pulmonary disease (COPD) remains unknown. PATIENTS AND METHODS We collected data from two populations. In the first cohort, we recruited 375 patients with COPD from our hospital, and 1440 repeated assessments of quality of life (QoL) using the European Quality of Life-5 Dimensions questionnaire from 2006 to 2020. We analysed their dynamic changes using the kernel-smoothing method. The second cohort comprised 27 437 patients from the National Health Insurance (NHI) dataset with their first severe acute exacerbations (AEs) requiring hospitalisation from 2008 to 2017 were analysed for their long-term course of AEs. We employed a Cox hazard model to analyse the predictors for mortality or AEs. RESULTS Cohorts from our hospital and NHI were male predominant (93.6 and 83.5%, respectively). After the first severe AE, the course generally comprised three phases. The first was a 1-year period of elevated QoL, followed by a 2-year prolonged stable phase with a slowly declining QoL. After the second AE, the final phase was characterised by a rapid decline in QoL. For NHI cohort, 2712 died during the 11-year follow-up, the frequency of the first AE was approximately 5 per 10 000 per day. The median time from the first to the second AE was 3 years, which decreased to less than 6 and 3 months from 4th to 5th and 8th to 9th AE, respectively. The frequency of AE was increased 10-fold and 15-fold and risk of subsequent AE was increased 12-fold and 20-fold after the 6th and the 10th AE, relative to the first. Male gender, heart failure comorbidities were associated with the risk of subsequent AE and death. CONCLUSIONS The life trajectory of COPD includes the accelerated frailty phase, as well as elevated health and prolonged stable phase after the first AE.
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Affiliation(s)
- Sheng-Han Tsai
- Division of General Medicine, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Jo-Ying Hung
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Fang Su
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hui Hsu
- Clinical Medicine Research Center, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chun-Hsiang Yu
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Xin-Min Liao
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Der Wang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzuen-Ren Hsiue
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiung-Zuei Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Patel K, Pye A, Edgar RG, Beadle H, Ellis PR, Sitch A, Dickens AP, Turner AM. Cluster randomised controlled trial of specialist-led integrated COPD care (INTEGR COPD). Thorax 2024; 79:209-218. [PMID: 38286619 DOI: 10.1136/thorax-2023-220435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/24/2023] [Indexed: 01/31/2024]
Abstract
OBJECTIVE Studies in hospital settings demonstrate that there is greater guideline adherence when care is delivered by a respiratory specialist, however, this has not been explored in primary care. The aim of this study is to determine the impact integrating respiratory specialists into primary care has on the delivery of guideline adherent chronic obstructive pulmonary disease (COPD) care. METHODS 18 general practitioner (GP) practices were randomised to provide either usual or specialist-led COPD care. Patients at participating practices were included if they had an existing diagnosis of COPD. Outcomes were measured at the individual patient level. The primary outcome was guideline adherence, assessed as achieving four or more items of the COPD care bundle. Secondary outcome measures included quality of life, number of exacerbations, number of COPD-related hospitalisations and respiratory outpatient attendances. RESULTS 586 patients from 10 practices randomised to the intervention and 656 patients from 8 practices randomised to the control arm of the study were included. The integration of respiratory specialists into GP practices led to a statistically significant (p<0.001) improvement in the provision of guideline adherent care when compared with usual care in this cohort (92.7% vs 70.1%) (OR 4.14, 95% CI 2.14 to 8.03). CONCLUSION This is the first study to demonstrate that guideline adherence is improved through the integration of respiratory specialists into GP practices to deliver annual COPD reviews. To facilitate changes in current healthcare practice and policy, the findings of this paper need to be viewed in combination with qualitative research exploring the acceptability of specialist integration. TRIAL REGISTRATION NUMBER NCT03482700.
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Affiliation(s)
- Ketan Patel
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anita Pye
- University of Birmingham Institute of Applied Health Research, Birmingham, UK
| | - Ross G Edgar
- Lung Function and Sleep Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Helen Beadle
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul R Ellis
- University of Birmingham Institute of Applied Health Research, Birmingham, UK
| | - Alice Sitch
- NIHR Birmingham Biomedical Research Centre, Birmingham, UK
| | - Andrew P Dickens
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Alice M Turner
- University of Birmingham Institute of Applied Health Research, Birmingham, UK
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Sciurba FC, Dransfield MT, Kim V, Marchetti N, Comellas A, Hogarth DK, Majid A. Bronchial rheoplasty for chronic bronchitis: 2-year results from a US feasibility study with RheOx. BMJ Open Respir Res 2023; 10:e001710. [PMID: 38151258 PMCID: PMC10753755 DOI: 10.1136/bmjresp-2023-001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/30/2023] [Indexed: 12/29/2023] Open
Abstract
INTRODUCTION Chronic bronchitis (CB), a phenotype of chronic obstructive pulmonary disease (COPD) characterised by persistent cough and mucus hypersecretion, is associated with poor outcomes despite guideline-based treatment. Bronchial rheoplasty (BR) with the RheOx system delivers non-thermal pulsed electric fields to the lower airway epithelium and submucosa to reduce mucus producing cells. Early phase clinical trials including 1-year follow-up have demonstrated reduction in airway goblet cell hyperplasia and improvement in CB symptoms. METHODS The current multicentre observational BR study enrolled 21 patients with CB at six centres in the USA, with bilateral treatment and 2-year follow-up. Entry criteria included elevated cough and sputum scores from COPD Assessment Test (CAT) and forced expiratory volume in one second<80% predicted. Safety was assessed by serious adverse event (SAE) incidence through 24 months. Clinical utility was evaluated using changes in the CAT, the St. George's Respiratory Questionnaire (SGRQ) and by comparing exacerbation rates before and following intervention. RESULTS No procedure-related or device-related SAEs occurred. Mean (SD) changes from baseline in CAT at 12 and 24 months were -9.0 (6.7) (p<0.0001) and -5.6 (7.1) (p<0.0047) and in SGRQ were -16.6 (13.2) (p<0.0001) and -11.8 (19.2) (p<0.0227), respectively. There was a 34% reduction in moderate and a 64% reduction in severe COPD exacerbation events compared with the year prior to treatment. CONCLUSIONS This study extends the findings from previous feasibility studies, demonstrating that BR can be performed safely and may significantly improve symptoms and health-related quality of life for patients with CB through 24 months. TRAIL REGISTRATION NUMBER NCT03631472.
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Affiliation(s)
- Frank C Sciurba
- Emphysema Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark T Dransfield
- Pulmonary, Allergy, and Critical Care Medicine, School of Medicine, Lung Health Center, University of Alabama, Birmingham, Alabama, USA
| | - Victor Kim
- Division of Pulmonary and Critical Care Medicine, Thoracic Medicine and Surgery, School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Nathaniel Marchetti
- Pulmonary and Critical Care Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | | | - Douglas Kyle Hogarth
- Pulmonary/Critical Care, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Trifirò G, Crisafulli S. Is antidepressant use a concern for patients with COPD? Thorax 2023; 79:3-4. [PMID: 37714536 DOI: 10.1136/thorax-2023-220517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Siraj RA, Bolton CE, McKeever TM. Association between antidepressants with pneumonia and exacerbation in patients with COPD: a self-controlled case series (SCCS). Thorax 2023; 79:50-57. [PMID: 37336642 DOI: 10.1136/thorax-2022-219736] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/26/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To assess whether antidepressant prescriptions are associated with an increased risk of pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. METHODS A self-controlled case series was performed to investigate the rates of pneumonia and COPD exacerbation during periods of being exposed to antidepressants compared with non-exposed periods. Patients with COPD with pneumonia or COPD exacerbation and at least one prescription of antidepressant were ascertained from The Health Improvement Network in the UK. Incidence rate ratios (IRR) and 95% CI were calculated for both outcomes. RESULTS Of 31 253 patients with COPD with at least one antidepressant prescription, 1969 patients had pneumonia and 18 483 had a COPD exacerbation. The 90-day risk period following antidepressant prescription was associated with a 79% increased risk of pneumonia (age-adjusted IRR 1.79, 95% CI 1.54 to 2.07). These associations then disappeared once antidepressants were discontinued. There was a 16% (age-adjusted IRR 1.16, 95% CI 1.13 to 1.20) increased risk of COPD exacerbation within the 90 days following antidepressant prescription. This risk persisted and slightly increased in the remainder period ((age-adjusted IRR 1.38, 95% CI 1.34 to 1.41), but diminished after patients discounted the treatment. CONCLUSION Antidepressants were associated with an increased risk of both pneumonia and exacerbation in patients with COPD, with the risks diminished on stopping the treatment. These findings suggest a close monitoring of antidepressant prescription side effects and consideration of non-pharmacological interventions.
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Affiliation(s)
- Rayan A Siraj
- Department of Respiratory Care, King Faisal University, Al-Ahasa, Saudi Arabia
- Respiratory Medicine, NIHR Nottingham Biomedical Research Centre Respiratory Theme, University of Nottingham, Nottingham, UK
| | - Charlotte E Bolton
- Respiratory Medicine, NIHR Nottingham Biomedical Research Centre Respiratory Theme, University of Nottingham, Nottingham, UK
| | - Tricia M McKeever
- NIHR Nottingham Biomedical Research Centre Respiratory Theme, School of Medince, University of Nottingham, Nottingham, UK
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Echevarria C, Steer J, Prasad A, Quint JK, Bourke SC. Admission blood eosinophil count, inpatient death and death at 1 year in exacerbating patients with COPD. Thorax 2023; 78:1090-1096. [PMID: 37487711 DOI: 10.1136/thorax-2022-219463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 06/16/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Blood eosinophil counts have been studied in patients with stable chronic obstructive pulmonary disease (COPD) and are a useful biomarker to guide inhaled corticosteroid use. Less is known about eosinophil counts during severe exacerbation. METHODS In this retrospective study, 2645 patients admitted consecutively with COPD exacerbation across six UK hospitals were included in the study, and the clinical diagnosis was confirmed by a respiratory specialist. The relationship between admission eosinophil count, inpatient death and 1-year death was assessed. In a backward elimination, Poisson regression analysis using the log-link function with robust estimates, patients' markers of acute illness and stable-state characteristics were assessed in terms of their association with eosinopenia. RESULTS 1369 of 2645 (52%) patients had eosinopenia at admission. Those with eosinopenia had a 2.5-fold increased risk of inpatient death compared with those without eosinopenia (12.1% vs 4.9%, RR=2.50, 95% CI 1.88 to 3.31, p<0.001). The same mortality risk with eosinopenia was seen among the subgroup with pneumonic exacerbation (n=788, 21.3% vs 8.5%, RR=2.5, 95% CI 1.67 to 2.24, p<0.001). In a regression analysis, eosinopenia was significantly associated with: older age and male sex; a higher pulse rate, temperature, neutrophil count, urea and C reactive protein level; a higher proportion of patients with chest X-ray consolidation and a reduced Glasgow Coma Score; and lower systolic and diastolic blood pressure measurements and lower oxygen saturation, albumin, platelet and previous admission counts. DISCUSSION During severe COPD exacerbation, eosinopenia is common and associated with inpatient death and several markers of acute illness. Clinicians should be cautious about using eosinophil results obtained during severe exacerbation to guide treatment decisions regarding inhaled corticosteroid use.
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Affiliation(s)
- Carlos Echevarria
- Respiratory department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - John Steer
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
- Respiratory department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Arun Prasad
- Respiratory department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Jennifer K Quint
- Department of Respiratory Epidemiology Occupational Medicine and Public Health, Imperial College London, London, UK
| | - Stephen C Bourke
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
- Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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Sharma VK, Singh PK, Govindagoudar MB, Thulasi A, Chaudhry D, Shriram CP, Lalwani LK, Ahuja A. Efficacy of different respiratory supports to prevent hypoxia during flexible bronchoscopy in patients of COPD: a triple-arm, randomised controlled trial. BMJ Open Respir Res 2023; 10:e001524. [PMID: 37931978 PMCID: PMC10632894 DOI: 10.1136/bmjresp-2022-001524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 07/31/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Patients with chronic-obstructive-pulmonary-disease (COPD) undergo bronchoscopy for various reasons, and are at relatively higher risk of complications. This study evaluated the efficacy of non-invasive ventilation (NIV) and high-flow-oxygen-therapy (HFOT) compared with conventional-oxygen-therapy (COT) in patients with COPD undergoing bronchoscopy, to prevent hypoxia. METHODS It was a triple-arm, open-label, randomised controlled trial. Ninety patients with COPD were randomly assigned into three intervention arms in 1:1:1 ratio. The incidence of hypoxia, lowest recorded oxygen saturation measured by plethysmography (SpO2), ECG, patient vitals and comfort levels were assessed. RESULTS Mean age of the study population was 61.71±7.5 years. Out of 90 cases enrolled, 51, 34 and 5 were moderate, severe and very-severe COPD, respectively, as per GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification. Rest of the baseline characteristics were similar. SpO2 during flexible bronchoscopy (FB) was lowest in COT group (COT: 87.03±5.7% vs HFOT: 95.57±5.0% vs NIV: 97.40±1.6%, p<0.001). Secondary objectives were similar except respiratory-rate (breaths-per-minute) which was highest in COT group (COT: 20.23±3.1 vs HFOT: 18.57±4.1 vs NIV: 16.80±1.9, p<0.001). Whereas post FB partial of oxygen in arterial blood was highest in NIV group (NIV: 84.27±21.6 mm Hg vs HFOT: 69.03±13.6 mm Hg vs COT: 69.30±11.9 mm Hg, p<0.001). Post FB partial pressure of carbon dioxide in arterial blood was similar in the three arms. Operator's ease-of-performing-procedure was least in the NIV group as assessed with Visual Analogue Scale (p<0.01). A higher number of NIV group participants reported nasal pain as compared with the other two arms (p<0.01). CONCLUSION NIV and HFOT are superior to COT in preventing hypoxia during bronchoscopy, but NIV is associated with poor patient-tolerance and inferior operator's ease of doing procedure. TRIAL REGISTRATION NUMBER CTRI/2021/03/032190.
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Affiliation(s)
- Vinod Kumar Sharma
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Pawan Kumar Singh
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Manjunath B Govindagoudar
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Athul Thulasi
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Dhruva Chaudhry
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Chaudhari Pramod Shriram
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Lokesh Kumar Lalwani
- Respiratory Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Aman Ahuja
- Pulmonary & Critical Care Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Lin SJ, Liao XM, Chen NY, Chang YC, Cheng CL. Beta-blockers reduce severe exacerbation in patients with mild chronic obstructive pulmonary disease with atrial fibrillation: a population-based cohort study. BMJ Open Respir Res 2023; 10:e001854. [PMID: 37989489 PMCID: PMC10660430 DOI: 10.1136/bmjresp-2023-001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Beta-blockers (BBs) decrease mortality and acute exacerbation (AE) rates in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular disease; however, information on their effects in patients with COPD and atrial fibrillation (AF) is limited. We aimed to assess the AE risk in patients with different severities of COPD and AF receiving BBs compared with that in patients receiving calcium channel blockers (CCBs). METHODS This retrospective cohort study used data from the Taiwan National Health Insurance Database from 2009 to 2018. Outcomes included AE-related emergency room visits and hospitalisation. HRs and 95% CIs were estimated using the Cox proportional hazards model. COPD severity was classified as mild or severe based on exacerbation history. Sensitivity analyses included treatment and subgroup analyses, and competing risk adjustment. RESULTS After propensity score matching, 4486 pairs of BB and CCB users from 13 462 eligible patients were included. The exacerbation risk for BB users was lower (HR 0.80; 95% CI 0.72 to 0.89) than that of CCB users. After stratification, BB benefits persisted in the mild COPD group (HR 0.75; 95% CI 0.66 to 0.85), unlike the severe COPD group (HR 0.95; 95% CI 0.75 to 1.20). The results of the subgroup analysis showed consistent protective effects even in patients without heart failure or myocardial infarction (adjusted HR 0.82; 95% CI 0.71 to 0.94). CONCLUSION We found that BB use in patients with mild COPD and AF was associated with a lower exacerbation risk than CCB use, and that close monitoring of BB use in patients with severe COPD and AF is warranted.
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Affiliation(s)
- Shan-Ju Lin
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Xin-Min Liao
- Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of clinical medicine, National Cheng Kung University, Tainan, Taiwan
| | - Nai-Yu Chen
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Ching Chang
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Lan Cheng
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University, Tainan, Taiwan
- Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Verstraete K, Gyselinck I, Huts H, Das N, Topalovic M, De Vos M, Janssens W. Estimating individual treatment effects on COPD exacerbations by causal machine learning on randomised controlled trials. Thorax 2023; 78:983-989. [PMID: 37012070 PMCID: PMC10511983 DOI: 10.1136/thorax-2022-219382] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/13/2023] [Indexed: 04/05/2023]
Abstract
RATIONALE Estimating the causal effect of an intervention at individual level, also called individual treatment effect (ITE), may help in identifying response prior to the intervention. OBJECTIVES We aimed to develop machine learning (ML) models which estimate ITE of an intervention using data from randomised controlled trials and illustrate this approach with prediction of ITE on annual chronic obstructive pulmonary disease (COPD) exacerbation rates. METHODS We used data from 8151 patients with COPD of the Study to Understand Mortality and MorbidITy in COPD (SUMMIT) trial (NCT01313676) to address the ITE of fluticasone furoate/vilanterol (FF/VI) versus control (placebo) on exacerbation rate and developed a novel metric, Q-score, for assessing the power of causal inference models. We then validated the methodology on 5990 subjects from the InforMing the PAthway of COPD Treatment (IMPACT) trial (NCT02164513) to estimate the ITE of FF/umeclidinium/VI (FF/UMEC/VI) versus UMEC/VI on exacerbation rate. We used Causal Forest as causal inference model. RESULTS In SUMMIT, Causal Forest was optimised on the training set (n=5705) and tested on 2446 subjects (Q-score 0.61). In IMPACT, Causal Forest was optimised on 4193 subjects in the training set and tested on 1797 individuals (Q-score 0.21). In both trials, the quantiles of patients with the strongest ITE consistently demonstrated the largest reductions in observed exacerbations rates (0.54 and 0.53, p<0.001). Poor lung function and blood eosinophils, respectively, were the strongest predictors of ITE. CONCLUSIONS This study shows that ML models for causal inference can be used to identify individual response to different COPD treatments and highlight treatment traits. Such models could become clinically useful tools for individual treatment decisions in COPD.
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Affiliation(s)
- Kenneth Verstraete
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Iwein Gyselinck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Helene Huts
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Nilakash Das
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | | | - Maarten De Vos
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Wim Janssens
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
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Bemand TJ, Chatoor R, Natale P, Strippoli G, Delaney A. Acetazolamide for metabolic alkalosis complicating respiratory failure with chronic obstructive pulmonary disease or obesity hypoventilation syndrome: a systematic review. Thorax 2023; 78:1004-1010. [PMID: 37217290 DOI: 10.1136/thorax-2023-219988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/03/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Metabolic alkalosis may lead to respiratory inhibition and increased need for ventilatory support or prolongation of weaning from ventilation for patients with chronic respiratory disease. Acetazolamide can reduce alkalaemia and may reduce respiratory depression. METHODS We searched Medline, EMBASE and CENTRAL from inception to March 2022 for randomised controlled trials comparing acetazolamide to placebo in patients with chronic obstructive pulmonary disease, obesity hypoventilation syndrome or obstructive sleep apnoea, hospitalised with acute respiratory deterioration complicated by metabolic alkalosis. The primary outcome was mortality and we pooled data using random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 (Risk of Bias 2) tool, heterogeneity was assessed using the I2 value and χ2 test for heterogeneity. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. RESULTS Four studies with 504 patients were included. 99% of included patients had chronic obstructive pulmonary disease. No trials recruited patients with obstructive sleep apnoea. 50% of trials recruited patients requiring mechanical ventilation. Risk of bias was overall low to some risk. There was no statistically significant difference with acetazolamide in mortality (relative risk 0.98 (95% CI 0.28 to 3.46); p=0.95; 490 participants; three studies; GRADE low certainty) or duration of ventilatory support (mean difference -0.8 days (95% CI -7.2 to 5.6); p=0.36; 427 participants; two studies; GRADE: low certainty). CONCLUSION Acetazolamide may have little impact on respiratory failure with metabolic alkalosis in patients with chronic respiratory diseases. However, clinically significant benefits or harms are unable to be excluded, and larger trials are required. PROSPERO REGISTRATION NUMBER CRD42021278757.
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Affiliation(s)
- Timothy John Bemand
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
- Rural Clinical School Wagga Wagga Campus, University of New South Wales, Wagga Wagga, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard Chatoor
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
- Rural Clinical School Wagga Wagga Campus, University of New South Wales, Wagga Wagga, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giovanni Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Division of Critical Care, The George Institute for Global Health, Newtown, New South Wales, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, ANZIC-RC, Melbourne, Victoria, Australia
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Kowalczyk A, Zakowska I, Andrzejewska E, Grabowski J, Godycki-Cwirko M, Kosiek K. Improving community-based COPD care in general practice in Poland - a cluster randomized controlled trial. Ann Agric Environ Med 2023; 30:399-406. [PMID: 37772515 DOI: 10.26444/aaem/163200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
INTRODUCTION AND OBJECTIVE Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. The aim of the study was to evaluate the impact of intervention on exacerbations of COPD in elderly patients compared to those receiving usual care. MATERIAL AND METHODS A 12 month, multicentre, three-arm, pragmatic, cluster randomized controlled trial was performed (CRCT). The 97 largest PHC clinics with at least 46 COPD registered patients in the Łódż Province, in central Poland. In total, 27,534 COPD patients aged 65 and over were identified from the National Health Fund (NFZ) electronic health records. A checklist of selected, recommended COPD interventions sent to GPs once or twice by post and shown on their desk in their clinics, in the intervention arms. RESULTS A primary outcome was the difference in exacerbations or deaths between the 3 arms at 12 months. The amounts of specific short- and long-acting drugs purchased by patients were also assessed as secondary outcomes. Only 0.44% (122 of 27 534) COPD patients demonstrated exacerbations after the one-year study period. No statistically significant associations were found between interventions and exacerbations (p=0.1568, Chi-Square) or deaths (p=0.8128, Chi-Square) at 12 months. CONCLUSIONS As this study coincided with the pandemic period, the results should be interpreted with care. The intervention had no association with exacerbations. Future research on interventions aimed at improving chronic illness care are needed.
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Affiliation(s)
- Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Łódź, Łódź, Poland
| | - Izabela Zakowska
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Łódź, Łódź, Poland
| | - Ewa Andrzejewska
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Łódź, Łódź, Poland
| | | | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Łódź, Łódź, Poland
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Johnsen RH, Heerfordt CK, Boel JB, Dessau RB, Ostergaard C, Sivapalan P, Eklöf J, Jensen JUS. Inhaled corticosteroids and risk of lower respiratory tract infection with Moraxella catarrhalis in patients with chronic obstructive pulmonary disease. BMJ Open Respir Res 2023; 10:e001726. [PMID: 37597970 PMCID: PMC10441089 DOI: 10.1136/bmjresp-2023-001726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/28/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Use of inhaled corticosteroids (ICS) is common in patients with chronic obstructive pulmonary disease (COPD) and has been associated with an increased risk of pneumonia. Moraxella catarrhalis is one of the most common bacterial causes of infectious exacerbation in COPD. Currently, to our knowledge, no studies have investigated if ICS increases the risk of lower respiratory tract infection with M. catarrhalis in patients with COPD. OBJECTIVE To investigate if accumulated ICS use in patients with COPD, is associated with a dose-dependent risk of infection with M. catarrhalis. METHODS This observational cohort study included 18 870 persons with COPD who were registered in The Danish Register of COPD. Linkage to several nationwide registries was performed.Exposure to ICS was determined by identifying all prescriptions for ICS, redeemed within 365 days prior to study entry. Main outcome was a lower respiratory tract sample positive for M. catarrhalis. For the main analysis, a Cox multivariate regression model was used.We defined clinical infection as admission to hospital and/or a redeemed prescription for a relevant antibiotic, within 7 days prior to 14 days after the sample was obtained. RESULTS We found an increased, dose-dependent, risk of a lower respiratory tract sample with M. catarrhalis among patients who used ICS, compared with non-users. For low and moderate doses of ICS HR was 1.65 (95% CI 1.19 to 2.30, p=0.003) and 1.82 (95% CI 1.32 to 2.51, p=0.0002), respectively. In the group of patients with highest ICS exposure, the HR of M. catarrhalis was 2.80 (95% CI 2.06 to 3.82, p<0.0001). Results remained stable in sensitivity analyses. 87% of patients fulfilled the criteria for clinical infection, and results remained unchanged in this population. CONCLUSION Our study shows a dose-dependent increased risk of infection with M. catarrhalis associated to ICS exposure.
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Affiliation(s)
- Rikke Helin Johnsen
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Christian Kjer Heerfordt
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Ram Benny Dessau
- Department of Clinical Microbiology, Zealand University Hospital, University of Copenhagen, Slagelse, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Christian Ostergaard
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Josefin Eklöf
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jens-Ulrik Stæhr Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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Pavey H, Polkey MI, Bolton CE, Cheriyan J, McEniery CM, Wilkinson I, Mohan D, Casaburi R, Miller BE, Tal-Singer R, Fisk M. Circulating testosterone levels and health outcomes in chronic obstructive pulmonary disease: results from ECLIPSE and ERICA. BMJ Open Respir Res 2023; 10:e001601. [PMID: 37316306 PMCID: PMC10277522 DOI: 10.1136/bmjresp-2022-001601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/30/2023] [Indexed: 06/16/2023] Open
Abstract
The relationship of circulating testosterone levels with health outcomes in people with chronic obstructive pulmonary disease (COPD) is unknown. AIM To determine whether serum testosterone levels predict hospitalised acute exacerbations of COPD (H-AECOPD), cardiovascular disease outcome, and mortality in people with COPD. METHODS Separate analyses were carried out on two observational, multicentre COPD cohorts, Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) and Evaluation of the Role of Inflammation in Chronic Airways Disease (ERICA), both of which had serum testosterone measured using a validated liquid chromatography assay at the same laboratory. Data from 1296 male participants in ECLIPSE and 386 male, 239 female participants in ERICA were analysed. All analyses were sex-specific. Multivariate logistic regression was used to determine associations with H-AECOPD during follow-up (3 years ECLIPSE, 4.5 years ERICA), a composite endpoint of cardiovascular hospitalisation and cardiovascular death, and all-cause mortality. RESULTS Mean (SD) testosterone levels were consistent across cohorts; 459 (197) and 455 (200) ng/dL for males in ECLIPSE and ERICA, respectively, and in ERICA females: 28 (56) ng/dL. Testosterone was not associated with H-AECOPD (ECLIPSE: OR: 0.76, p=0.329, ERICA males: OR (95% CI): 1.06 (0.73 to 1.56), p=0.779, ERICA females: OR: 0.77 (0.52 to 1.12), p=0.178) or cardiovascular hospitalisation and death. Testosterone was associated with all-cause mortality in Global Initiative for Obstructive Lung Disease (GOLD) stage 2 male patients only, in ECLIPSE (OR: 0.25, p=0.007) and ERICA (OR: (95% CI): 0.56 (0.32 to 0.95), p=0.030). CONCLUSIONS Testosterone levels do not relate to H-AECOPD or cardiovascular outcome in COPD, but are associated with all-cause mortality in GOLD stage 2 COPD male patients, although the clinical significance of this finding is uncertain.
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Affiliation(s)
- Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael I Polkey
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Charlotte E Bolton
- Centre for Respiratory Research, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carmel M McEniery
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ian Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Divya Mohan
- Former employee of GSK, Collegeville, Pennsylvania, USA
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | | | | | - Marie Fisk
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
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Deslee G, Fabry-Vendrand C, Poccardi N, Thabut G, Eteve Pitsaer C, Coriat A, Renaudat C, Maguire A, Pinto T. Use and persistence of single and multiple inhaler triple therapy prescribed for patients with COPD in France: a retrospective study on THIN database (OPTI study). BMJ Open Respir Res 2023; 10:10/1/e001585. [PMID: 37263738 DOI: 10.1136/bmjresp-2022-001585] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION From 2018 single inhaler triple therapy (SITT) became available in France to treat moderate-to-severe chronic obstructive pulmonary disease (COPD). Given its simplified inhaler use compared with multiple inhaler triple therapy (MITT), this therapeutic option has the potential to offer benefit in terms of improved persistence and adherence. Given the lack of real-world evidence of the effectiveness of triple therapy, this study was designed to evaluate the use of MITT and SITT in France and compare persistence. METHODS A retrospective cohort study was performed. Patients with COPD who initiated triple therapy between 1 July 2017 and 31 December 2019 were included from The Health Improvement Network, a large electronic medical database in France, which includes pharmacy data. A 60-day treatment gap defined discontinuation and thereby persistence. RESULTS A total of 3134 patients initiated triple therapy for COPD in the study period, among them 485 with SITT. In 2019, the rate of use of SITT was 28.2%. The mean age (67.3 years) and sex (44.2% female) of patients initiating triple therapy was similar between MITT and SITT, and most patients had escalated from dual therapy (84.1%). However, SITT was more frequently initiated by a pulmonologist (59.8%) and a higher prevalence of comorbid asthma was observed for SITT (47.0% vs 37.9%). Persistence was assessed among patients who did not discontinue after a single dispensation of triple therapy (n=1674). Median persistence was 181 days for SITT and 135 days for MITT, and the covariate-adjusted HR for persistence was 1.47 (p<0.001) and the estimated persistence at 1 year was 33% for SITT compared with 18% for MITT. DISCUSSION This study suggests that persistence was higher for the patients treated with SITT compared with MITT in France. Moreover, most patients initiated with triple therapy were previously treated with dual therapy and had exacerbations in the previous year.
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Affiliation(s)
- Gaétan Deslee
- Service de Pneumologie, INSERM UMRS-1250, CHU de Reims, Université Reims Champagne-Ardenne, CHU de Reims, Reims, France
| | | | | | | | | | | | | | | | - Thomas Pinto
- Médecin généraliste, Chef de clinique universitaire, Université de Paris, Paris, France
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Yang H, Wen X, Wu F, Zheng Y, Dai C, Zhao N, Deng Z, Wang Z, Peng J, Xiao S, Lu L, Huang J, Yu S, Yang C, Chen S, Zhou Y, Ran P. Inter-relationships among neutrophilic inflammation, air trapping and future exacerbation in COPD: an analysis of ECOPD study. BMJ Open Respir Res 2023; 10:10/1/e001597. [PMID: 37028910 PMCID: PMC10083880 DOI: 10.1136/bmjresp-2022-001597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/24/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND The inter-relationships among neutrophilic airway inflammation, air trapping and future exacerbation in chronic obstructive pulmonary disease (COPD) remain unclear. OBJECTIVE To evaluate the associations between sputum neutrophil proportions and future exacerbation in COPD and to determine whether these associations are modified by significant air trapping. METHODS Participants with completed data were included and followed up to the first year in the Early Chronic Obstructive Pulmonary Disease study (n=582). Sputum neutrophil proportions and high-resolution CT-related markers were measured at baseline. Sputum neutrophil proportions were dichotomised based on their median (86.2%) to low and high levels. In addition, subjects were divided into the air trapping or non-air trapping group. Outcomes of interest included COPD exacerbation (separately any, severe and frequent exacerbation, occurring in the first year of follow-up). Multivariable logistic regressions were performed to examine the risk of severe exacerbation and frequent exacerbation with either neutrophilic airway inflammation groups or air trapping groups. RESULTS There was no significant difference between high and low levels of sputum neutrophil proportions in the exacerbation in the preceding year. After the first year of follow-up, subjects with high sputum neutrophil proportions had increased risks of severe exacerbation (OR=1.68, 95% CI: 1.09 to 2.62, p=0.020). Subjects with high sputum neutrophil proportions and significant air trapping had increased odds of having frequent exacerbation (OR=3.29, 95% CI: 1.30 to 9.37, p=0.017) and having severe exacerbation (OR=2.72, 95% CI: 1.42 to 5.43, p=0.003) when compared with those who had low sputum neutrophil proportions and non-air trapping. CONCLUSIONS We found that subjects with high sputum neutrophil proportions and significant air trapping are prone to future exacerbation of COPD. It may be a helpful predictor of future exacerbation.
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Affiliation(s)
- Huajing Yang
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Xiang Wen
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
- Shenzhen Institute of Respiratory Disease, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Fan Wu
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
- Guangzhou Laboratory, Guangzhou, Guangdong, China
| | - Youlan Zheng
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Cuiqiong Dai
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Ningning Zhao
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Zhishan Deng
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Zihui Wang
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jieqi Peng
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
- Guangzhou Laboratory, Guangzhou, Guangdong, China
| | - Shan Xiao
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
- Department of Pulmonary and Critical Care Medicine, Longgang District People's Hospital of Shenzhen, Shenzhen, Guangdong, China
| | - Lifei Lu
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jianhui Huang
- Department of internal medicine, Lianping County People's Hospital, Heyuan, Guangdong, China
| | - Shuqing Yu
- Department of internal medicine, Lianping County People's Hospital, Heyuan, Guangdong, China
- Department of internal medicine, Lianping County Hospital of Traditional Chinese Medicine, Heyuan, Guangdong, China
| | - Changli Yang
- Department of Pulmonary and Critical Care Medicine, Wengyuan County People's Hospital, Shaoguan, Guangdong, China
| | - Shengtang Chen
- Department of Pulmonary and Critical Care Medicine, Wengyuan County People's Hospital, Shaoguan, Guangdong, China
| | - Yumin Zhou
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
- Guangzhou Laboratory, Guangzhou, Guangdong, China
| | - Pixin Ran
- Guangzhou Institute of Respiratory Health & State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease & National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
- Guangzhou Laboratory, Guangzhou, Guangdong, China
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19
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Vilstrup F, Heerfordt CK, Kamstrup P, Hedsund C, Biering-Sørensen T, Sørensen R, Kolekar S, Hilberg O, Pedersen L, Lund TK, Klausen TW, Skaarup KG, Eklöf J, Sivapalan P, Jensen JUS. Renin-angiotensin-system inhibitors and the risk of exacerbations in chronic obstructive pulmonary disease: a nationwide registry study. BMJ Open Respir Res 2023; 10:10/1/e001428. [PMID: 36882221 PMCID: PMC10008458 DOI: 10.1136/bmjresp-2022-001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/04/2023] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVE The renin-angiotensin system (RAS) has been shown to play a role in the pathogenesis of chronic obstructive pulmonary disease (COPD) because of the inflammatory properties of the system. Many patients with COPD use RAS-inhibiting (RASi) treatment. The aim was to determine the association between treatment with RASi and the risk of acute exacerbations and mortality in patients with severe COPD. METHODS Active comparator analysis by propensity-score matching. Data were collected in Danish national registries, containing complete information on health data, prescriptions, hospital admissions and outpatient clinic visits. Patients with COPD (n=38 862) were matched by propensity score on known predictors of the outcome. One group was exposed to RASi treatment (cases) and the other was exposed to bendroflumethiazide as an active comparator in the primary analysis. RESULTS The use of RASi was associated with a reduced risk of exacerbations or death in the active comparator analysis at 12 months follow-up (HR 0.86, 95% CI 0.78 to 0.95). Similar results were evident in a sensitivity analysis of the propensity-score-matched population (HR 0.89, 95% CI 0.83 to 0.94) and in an adjusted Cox proportional hazards model (HR 0.93, 95% CI 0.89 to 0.98). CONCLUSION In the current study, we found that the use of RASi treatment was associated with a consistently lower risk of acute exacerbations and death in patients with COPD. Explanations to these findings include real effect, uncontrolled biases, and-less likely-chance findings.
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Affiliation(s)
- Frida Vilstrup
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark
| | - Christian Kjer Heerfordt
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark
| | - Peter Kamstrup
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark
| | - Caroline Hedsund
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark
| | - Tor Biering-Sørensen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark.,Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Shailesh Kolekar
- Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark.,Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Ole Hilberg
- Department of Medicine, Sygehus Lillebalt Vejle Sygehus, Vejle, Denmark
| | - Lars Pedersen
- Department of Respiratory Medicine and Infectious Diseases, Bispebjerg Hospital, Copenhagen, Denmark
| | - Thomas Kromann Lund
- Section for Lung Transplantation, Dept. of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | - Josefin Eklöf
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark
| | - Pradeesh Sivapalan
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark.,Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Jens-Ulrik Stæhr Jensen
- Department of Medicine, Section of Respiratory Medicine, Gentofte University Hospital, Hellerup, Denmark .,Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
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20
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Murphy PB, Brueggenjuergen B, Reinhold T, Gu Q, Fusfeld L, Criner G, Goss TF, Hart N. Cost-effectiveness of home non-invasive ventilation in patients with persistent hypercapnia after an acute exacerbation of COPD in the UK. Thorax 2023; 78:523-525. [PMID: 36823164 PMCID: PMC10176417 DOI: 10.1136/thorax-2022-219653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/23/2022] [Indexed: 02/25/2023]
Abstract
Home non-invasive mechanical ventilation (HMV) with home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of chronic obstructive pulmonary disease delays hospital readmission. The economic impact of this treatment is unknown. We evaluated the cost-effectiveness of HMV in the UK healthcare system using data from a previously published efficacy trial. Quality-adjusted life-years (QALYs) were computed from EQ-5D-5L. Accounting for all direct patient costs HOT-HMV was £512 (95%CI £36 to £990) more expensive per patient per year than HOT-alone. This small increase in cost was accompanied by increased quality of life leading to an incremental cost-effectiveness ratio of £10 259 per QALY. HOT-HMV was cost-effective in this clinical population. Trial registration number: NCT00990132.
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Affiliation(s)
- Patrick Brian Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Bernd Brueggenjuergen
- Orthopädische Klinik der Medizinischen Hochschule Hannover (MHH) im DIAKOVERE Annastift, Hannover Medical School Affilliated Hospital, Hannover, Germany
| | - Thomas Reinhold
- Institute of Social Medicine, Epidemiology and Health Economics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and HumboldtUniversität zu Berlin, Berlin, Germany
| | - Qing Gu
- Health Economics and Outcomes Research, Boston Healthcare Associates Inc, Boston, Massachusetts, USA
| | - Laura Fusfeld
- Health Economics and Outcomes Research, Boston Healthcare Associates Inc, Boston, Massachusetts, USA
| | - Gerard Criner
- Respiratory Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Thomas F Goss
- Health Economics and Outcomes Research, Boston Healthcare Associates Inc, Boston, Massachusetts, USA
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
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21
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Lewis A, Osadnik CR. Changing practice by changing pressures: a role for oscillating positive expiratory pressure in chronic obstructive pulmonary disease. Thorax 2023; 78:113-115. [PMID: 36167723 DOI: 10.1136/thorax-2022-219451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Adam Lewis
- Department of Health Sciences, Brunel University London, Uxbridge, UK
| | - Christian Robert Osadnik
- Department of Physiotherapy, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
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22
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Muiser S, Imkamp K, Seigers D, Halbersma NJ, Vonk JM, Luijk BHD, Braunstahl GJ, van den Berg JW, Kroesen BJ, Kocks JWH, Heijink IH, Reddel HK, Kerstjens HAM, van den Berge M. Budesonide/formoterol maintenance and reliever therapy versus fluticasone/salmeterol fixed-dose treatment in patients with COPD. Thorax 2023; 78:451-458. [PMID: 36725331 DOI: 10.1136/thorax-2022-219620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Maintenance and reliever therapy (MART) with inhaled corticosteroid (ICS)/formoterol effectively reduces exacerbations in asthma. We aimed to investigate its efficacy compared with fixed-dose fluticasone/salmeterol in chronic obstructive pulmonary disease (COPD). METHODS Patients with COPD and ≥1 exacerbation in the previous 2 years were randomly assigned to open-label MART (Spiromax budesonide/formoterol 160/4.5 µg 2 inhalations twice daily+1 prn) or fixed-dose therapy (Diskus fluticasone propionate/salmeterol combination (FSC) 500/50 µg 1 inhalation twice daily+salbutamol 100 µg prn) for 1 year. The primary outcome was rate of moderate/severe exacerbations, defined by treatment with oral prednisolone and/or antibiotics. RESULTS In total, 195 patients were randomised (MART Bud/Form n=103; fixed-dose FSC n=92). No significant difference was seen between MART and FSC therapy in exacerbation rates (1.32 vs 1.32 /year, respectively, rate ratio 1.05 (95% CI 0.79 to 1.39); p=0.741). No differences in lung function parameters or health status were observed. Total ICS dose was significantly lower with MART than FSC therapy (budesonide-equivalent 928 µg/day vs 1747 µg/day, respectively, p<0.05). Similar proportions of patients reported adverse events (MART Bud/Form: 73% vs fixed-dose FSC: 68%, p=0.408) and pneumonias (MART: 5% vs FSC: 1%, p=0.216). CONCLUSIONS This first study of MART in COPD found that budesonide/formoterol MART might be similarly effective to fluticasone/salmeterol fixed-dose therapy in moderate to severe patients with COPD, at a lower daily ICS dosage. Further evidence is needed about long-term safety.
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Affiliation(s)
- Susan Muiser
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands .,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Kai Imkamp
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Dianne Seigers
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Nynke J Halbersma
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Judith M Vonk
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart H D Luijk
- Department of Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | | | - Bart-Jan Kroesen
- Laboratory of Medical Immunology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Janwillem W H Kocks
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,General Practitioners Research Institute, Groningen, The Netherlands.,Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Irene H Heijink
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Pathology and Medical Biology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Helen K Reddel
- Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia
| | - Huib A M Kerstjens
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten van den Berge
- Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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23
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Alghamdi SM, Alsulayyim AS, Alasmari AM, Philip KEJ, Buttery SC, Banya WAS, Polkey MI, Birring SS, Hopkinson NS. Oscillatory positive expiratory pressure therapy in COPD (O-COPD): a randomised controlled trial. Thorax 2023; 78:136-143. [PMID: 35948418 DOI: 10.1136/thorax-2022-219077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/20/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Oscillatory positive expiratory pressure (OPEP) devices are intended to facilitate sputum clearance and reduce cough, but there is limited evidence for their effectiveness in COPD, or to guide patient selection. We aimed to assess the impact of OPEP therapy on quality of life and objective measures of cough and sleep disturbance in patients with COPD with regular sputum production. METHODS We enrolled stable patients with COPD, who reported sputum production every day or most days, into an assessor-blind, parallel-group, randomised controlled trial comparing 3 months of using an Acapella device against usual care (including use of the active cycle of breathing technique). The primary outcome was cough-related quality of life measured using the Leicester Cough Questionnaire (LCQ). Secondary outcomes included fatigue (Functional Assessment of Chronic Illness Therapy, FACIT score) and generic quality of life (EuroQol-5 Dimensions, EQ-5D). In a substudy (n=45), objective monitoring of cough and disturbance/movement during sleep were also available. RESULTS 122 participants (61/61 OPEP/control) were recruited, 40% female, 17% smokers, FEV1 38 (25-56)% predicted, and age 62±10 years. 103 completed the study (55/48 OPEP/control). Use of OPEP was associated with an improvement in LCQ compared with controls; MD (95% CI) 1.03 (0.71 to 2.10); (p=0.03), FACIT score 4.68 (1.34 to 8.02); (p<0.001) and EQ-5D 4.00 (0.49 to 19.75); (p=0.04). There was also an improvement in cough frequency -60 (-43 to -95) coughs/24 hours (p<0.001), but no statistically significant effect on sleep disturbance was identified. CONCLUSIONS Regular use of an Acapella device improves symptoms and quality of life in people with COPD who produce sputum daily or most days. TRIAL REGISTRATION NUMBER ISRCTN44651852.
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Affiliation(s)
- Saeed M Alghamdi
- Clinical Technology, Umm Al-Qura University, Makkah, Saudi Arabia.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Abdullah S Alsulayyim
- National Heart and Lung Institute, Imperial College London, London, UK.,Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Ali M Alasmari
- National Heart and Lung Institute, Imperial College London, London, UK.,College of Medical Rehabilitation, Taibah University, Madinah, Saudi Arabia
| | - Keir E J Philip
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sara C Buttery
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Winston A S Banya
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael I Polkey
- National Heart and Lung Institute, Imperial College London, London, UK
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24
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Gregory A, Xu Z, Pratte K, Lee S, Liu C, Chase R, Yun J, Saferali A, Hersh CP, Bowler R, Silverman E, Castaldi PJ, Boueiz A. Clustering-based COPD subtypes have distinct longitudinal outcomes and multi-omics biomarkers. BMJ Open Respir Res 2022; 9:9/1/e001182. [PMID: 35999035 PMCID: PMC9403129 DOI: 10.1136/bmjresp-2021-001182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 07/31/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) can progress across several domains, complicating the identification of the determinants of disease progression. In our previous work, we applied k-means clustering to spirometric and chest radiological measures to identify four COPD-related subtypes: ‘relatively resistant smokers (RRS)’, ‘mild upper lobe-predominant emphysema (ULE)’, ‘airway-predominant disease (AD)’ and ‘severe emphysema (SE)’. In the current study, we examined the associations of these subtypes to longitudinal COPD-related health measures as well as blood transcriptomic and plasma proteomic biomarkers. Methods We included 8266 non-Hispanic white and African-American smokers from the COPDGene study. We used linear regression to investigate cluster associations to 5-year prospective changes in spirometric and radiological measures and to gene expression and protein levels. We used Cox-proportional hazard test to test for cluster associations to prospective exacerbations, comorbidities and mortality. Results The RRS, ULE, AD and SE clusters represented 39%, 15%, 26% and 20% of the studied cohort at baseline, respectively. The SE cluster had the greatest 5-year FEV1 (forced expiratory volume in 1 s) and emphysema progression, and the highest risks of exacerbations, cardiovascular disease and mortality. The AD cluster had the highest diabetes risk. After adjustments, only the SE cluster had an elevated respiratory mortality risk, while the ULE, AD and SE clusters had elevated all-cause mortality risks. These clusters also demonstrated differential protein and gene expression biomarker associations, mostly related to inflammatory and immune processes. Conclusion COPD k-means subtypes demonstrate varying rates of disease progression, prospective comorbidities, mortality and associations to transcriptomic and proteomic biomarkers. These findings emphasise the clinical and biological relevance of these subtypes, which call for more study for translation into clinical practice. Trail registration number NCT00608764.
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Affiliation(s)
- Andrew Gregory
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zhonghui Xu
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine Pratte
- Department of Biostatistics, National Jewish Health, Denver, Colorado, USA
| | - Sool Lee
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Congjian Liu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert Chase
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeong Yun
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aabida Saferali
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Craig P Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Russell Bowler
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado, USA
| | - Edwin Silverman
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Peter J Castaldi
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adel Boueiz
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA .,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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25
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Hanlon P, Lewsey J, Quint JK, Jani BD, Nicholl BI, McAllister DA, Mair FS. Frailty in COPD: an analysis of prevalence and clinical impact using UK Biobank. BMJ Open Respir Res 2022; 9:e001314. [PMID: 35787523 PMCID: PMC9255399 DOI: 10.1136/bmjresp-2022-001314] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Frailty, a state of reduced physiological reserve, is common in people with chronic obstructive pulmonary disease (COPD). Frailty can occur at any age; however, the implications in younger people (eg, aged <65 years) with COPD are unclear. We assessed the prevalence of frailty in UK Biobank participants with COPD; explored relationships between frailty and forced expiratory volume in 1 second (FEV1) and quantified the association between frailty and adverse outcomes. METHODS UK Biobank participants (n=3132, recruited 2006-2010) with COPD aged 40-70 years were analysed comparing two frailty measures (frailty phenotype and frailty index) at baseline. Relationship with FEV1 was assessed for each measure. Outcomes were mortality, major adverse cardiovascular event (MACE), all-cause hospitalisation, hospitalisation with COPD exacerbation and community COPD exacerbation over 8 years of follow-up. RESULTS Frailty was common by both definitions (17% frail using frailty phenotype, 28% moderate and 4% severely frail using frailty index). The frailty phenotype, but not the frailty index, was associated with lower FEV1. Frailty phenotype (frail vs robust) was associated with mortality (HR 2.33; 95% CI 1.84 to 2.96), MACE (2.73; 1.66 to 4.49), hospitalisation (incidence rate ratio 3.39; 2.77 to 4.14) hospitalised exacerbation (5.19; 3.80 to 7.09) and community exacerbation (2.15; 1.81 to 2.54), as was frailty index (severe vs robust) (mortality (2.65; 95% CI 1.75 to 4.02), MACE (6.76; 2.68 to 17.04), hospitalisation (3.69; 2.52 to 5.42), hospitalised exacerbation (4.26; 2.37 to 7.68) and community exacerbation (2.39; 1.74 to 3.28)). These relationships were similar before and after adjustment for FEV1. CONCLUSION Frailty, regardless of age or measure, identifies people with COPD at risk of adverse clinical outcomes. Frailty assessment may aid risk stratification and guide-targeted intervention in COPD and should not be limited to people aged >65 years.
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Affiliation(s)
- Peter Hanlon
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James Lewsey
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Bhautesh D Jani
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Barbara I Nicholl
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Frances S Mair
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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26
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Williams PJ, Cumella A, Philip KEJ, Laverty AA, Hopkinson NS. Smoking and socioeconomic factors linked to acute exacerbations of COPD: analysis from an Asthma + Lung UK survey. BMJ Open Respir Res 2022; 9:9/1/e001290. [PMID: 35853736 PMCID: PMC9315910 DOI: 10.1136/bmjresp-2022-001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022] Open
Abstract
Background Understanding the factors driving acute exacerbations of chronic obstructive pulmonary disease (COPD) is key to reducing their impact on human health and well-being. Methods 5997 people with COPD, mean 66 years, 64% female, completed an online survey between December 2020 and May 2021 about living with COPD, developed by the charity Asthma + Lung UK. Results The 3731 (62.2%) survey participants reporting frequent (≥2/year) exacerbations were more likely to smoke (adjusted OR (AOR) 1.70, 95% CI 1.470 to 1.98), have lower annual household income (≤£20 000 (AOR 1.72, 95% CI 1.36 to 2.17), live in a cold and damp home (AOR 1.78, 95% CI 1.50 to 2.11) and report previous occupational exposure to dust, fumes and chemicals. Smokers were more likely to report attending hospital to manage their most recent acute exacerbation of COPD compared with ex-smokers (AOR 1.25, 95% CI 0.99 to 1.59). Discussion Strategies to improve COPD outcomes must address issues of deprivation and social justice.
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Affiliation(s)
- Parris J Williams
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Anthony A Laverty
- Department Primary Care and Public Health, Imperial College London School of Public Health, London, UK
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27
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Hedsund C, Nilsson PM, Hoyer N, Rasmussen DB, Holm CP, Sonne TP, Jensen JUS, Wilcke JT. High-pressure NIV for acute hypercapnic respiratory failure in COPD: improved survival in a retrospective cohort study. BMJ Open Respir Res 2022; 9:9/1/e001260. [PMID: 35728841 PMCID: PMC9214373 DOI: 10.1136/bmjresp-2022-001260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Updated treatment guidelines for acute hypercapnic respiratory failure (AHRF) in chronic obstructive pulmonary disease (COPD) with non-invasive ventilation (NIV) in 2016 recommended a rapid increase in inspiratory positive airway pressure (IPAP) to 20 cm H2O with possible further increase for patients not responding. Previous guidelines from 2006 suggested a more conservative algorithm and maximum IPAP of 20 cm H2O. Aim To determine whether updated guidelines recommending higher IPAP during NIV were related with improved outcome in patients with COPD admitted with AHRF, compared with NIV with lower IPAP. Methods A retrospective cohort study comparing patients with COPD admitted with AHRF requiring NIV in 2012–2013 and 2017–2018. Results 101 patients were included in the 2012–2013 cohort with low IPAP regime and 80 patients in the 2017–2018 cohort with high IPAP regime. Baseline characteristics, including age, forced expiratory volume in 1 s (FEV1), pH and PaCO2 at initiation of NIV, were comparable. Median IPAP in the 2012–2013 cohort was 12 cm H2O (IQR 10–14) and 20 cm H2O (IQR 18-24) in the 2017–2018 cohort (p<0.001). In-hospital mortality was 40.5% in the 2012–2013 cohort and 13.8% in the 2017–2018 cohort (p<0.001). The 30-days and 1-year mortality were significantly lower in the 2017–2018 cohort. With a Cox model 1 year survival analysis, adjusted for age, sex, FEV1 and pH at NIV initiation, the HR was 0.45 (95% CI 0.27 to 0.74, p=0.002). Conclusion Short-term and long-term survival rates were substantially higher in the cohort treated with higher IPAP. Our data support the current strategy of rapid increase and higher pressure.
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Affiliation(s)
- Caroline Hedsund
- Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark
| | - Philip Mørkeberg Nilsson
- Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark.,Department of Anesthesiology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nils Hoyer
- Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel Bech Rasmussen
- Pulmonary Research Unit Region Zealand (PLUZ), Department of Respiratory Medicine, Zealand Univsersity Hospital Naestved and Roskilde, Naestved, Denmark.,Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Claire Præst Holm
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tine Peick Sonne
- Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark
| | - Jens-Ulrik Stæhr Jensen
- Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,PERSIMUNE&CHIP: Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jon Torgny Wilcke
- Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark
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28
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Konstantinoudis G, Minelli C, Vicedo-Cabrera AM, Ballester J, Gasparrini A, Blangiardo M. Ambient heat exposure and COPD hospitalisations in England: a nationwide case-crossover study during 2007-2018. Thorax 2022; 77:1098-1104. [PMID: 35459745 PMCID: PMC9606528 DOI: 10.1136/thoraxjnl-2021-218374] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/24/2022] [Indexed: 11/05/2022]
Abstract
Background There is emerging evidence suggesting a link between ambient heat exposure and chronic obstructive pulmonary disease (COPD) hospitalisations. Individual and contextual characteristics can affect population vulnerabilities to COPD hospitalisation due to heat exposure. This study quantifies the effect of ambient heat on COPD hospitalisations and examines population vulnerabilities by age, sex and contextual characteristics. Methods Individual data on COPD hospitalisation at high geographical resolution (postcodes) during 2007–2018 in England was retrieved from the small area health statistics unit. Maximum temperature at 1 km ×1 km resolution was available from the UK Met Office. We employed a case-crossover study design and fitted Bayesian conditional Poisson regression models. We adjusted for relative humidity and national holidays, and examined effect modification by age, sex, green space, average temperature, deprivation and urbanicity. Results After accounting for confounding, we found 1.47% (95% Credible Interval (CrI) 1.19% to 1.73%) increase in the hospitalisation risk for every 1°C increase in temperatures above 23.2°C (lags 0–2 days). We reported weak evidence of an effect modification by sex and age. We found a strong spatial determinant of the COPD hospitalisation risk due to heat exposure, which was alleviated when we accounted for contextual characteristics. 1851 (95% CrI 1 576 to 2 079) COPD hospitalisations were associated with temperatures above 23.2°C annually. Conclusion Our study suggests that resources should be allocated to support the public health systems, for instance, through developing or expanding heat-health alerts, to challenge the increasing future heat-related COPD hospitalisation burden.
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Affiliation(s)
| | - Cosetta Minelli
- NHLI, Imperial College London National Heart and Lung Institute, London, UK
| | - Ana Maria Vicedo-Cabrera
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Oeschger Centre for Climate Change Research, University of Bern, Bern, Switzerland
| | - Joan Ballester
- Climate and Health Program (CLIMA), Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Antonio Gasparrini
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK.,Centre for Statistical Methodology, London School of Hygiene Tropical Medicine, London, UK.,Centre on Climate Change and Planetary Health, London School of Hygiene Tropical Medicine, London, UK
| | - Marta Blangiardo
- MRC Centre for Environment and Health, Imperial College London, London, UK
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29
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Wade RC, Simmons JP, Boueiz A, Gregory A, Wan ES, Regan EA, Bhatt SP, Han MK, Bowler RP, Crapo JD, Silverman EK, Washko GR, Dransfield MT, Wells JM. Pulmonary Artery Enlargement is Associated with Exacerbations and Mortality in Ever-Smokers with Preserved Ratio Impaired Spirometry (PRISm). Am J Respir Crit Care Med 2021; 204:481-485. [PMID: 34014810 DOI: 10.1164/rccm.202103-0619le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- R Chad Wade
- The University of Alabama at Birmingham School of Medicine, 9967, Division of Pulmonary, Allergy, and Critical Medicine, Birmingham, Alabama, United States.,UAB Lung Health Center, Birmingham, Alabama, United States.,The University of Alabama at Birmingham School of Medicine, 9967, Department of Medicine, Birmingham, Alabama, United States
| | - J Patrick Simmons
- The University of Alabama at Birmingham School of Medicine, 9967, Division of Pulmonary, Allergy, and Critical Medicine, Birmingham, Alabama, United States.,UAB Lung Health Center, Birmingham, Alabama, United States.,The University of Alabama at Birmingham School of Medicine, 9967, Department of Medicine, Birmingham, Alabama, United States
| | - Adel Boueiz
- Brigham and Women's Hospital Channing Division of Network Medicine, 1869, Boston, Massachusetts, United States.,Brigham and Women's Hospital Department of Medicine, 370908, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Andrew Gregory
- Brigham and Women's Hospital, 1861, Channing Division of Network Medicine, Boston, Massachusetts, United States
| | - Emily S Wan
- Brigham and Women's Hospital, 1861, Channing Division of Network Medicine, Boston, Massachusetts, United States.,VA Boston Health Care System Jamaica Plain Campus, 20025, Boston, Massachusetts, United States
| | - Elizabeth A Regan
- National Jewish Health Department of Medicine, 551774, Division of Rheumatology, Denver, Colorado, United States
| | - Surya P Bhatt
- The University of Alabama at Birmingham School of Medicine, 9967, Pulmonary, Allergy and Critical Care Medicine, Birmingham, Alabama, United States.,UAB Lung Health Center, Birmingham, Alabama, United States.,The University of Alabama at Birmingham School of Medicine, 9967, Department of Medicine, Birmingham, Alabama, United States
| | - MeiLan K Han
- University of Michigan Michigan Medicine, 21614, Division of Pulmonary and Critical Care Medicine, Ann Arbor, Michigan, United States
| | - Russell P Bowler
- National Jewish Health Department of Medicine, 551774, Division of Pulmonary, Critical Care, and Sleep Medicine, Denver, Colorado, United States
| | - James D Crapo
- National Jewish Health Department of Medicine, 551774, Division of Pulmonary, Critical Care, and Sleep Medicine, Denver, Colorado, United States
| | - Edwin K Silverman
- Brigham and Women's Hospital Channing Division of Network Medicine, 1869, Boston, Massachusetts, United States.,Brigham and Women's Hospital Department of Medicine, 370908, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - George R Washko
- Brigham and Women's Hospital Department of Medicine, 370908, Division of Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Mark T Dransfield
- The University of Alabama at Birmingham School of Medicine, 9967, Division of Pulmonary, Allergy, and Critical Care Medicine, Birmingham, Alabama, United States.,UAB Lung Health Center, Birmingham, Alabama, United States.,The University of Alabama at Birmingham School of Medicine, 9967, Birmingham, Alabama, United States.,Birmingham VA Medical Center, 19957, Acute Care Service, Birmingham, Alabama, United States
| | - J Michael Wells
- The University of Alabama at Birmingham School of Medicine, 9967, Pulmonary, Allergy, and Critical Care Medicine, Birmingham, Alabama, United States.,UAB Lung Health Center, Birmingham, Alabama, United States.,The University of Alabama at Birmingham School of Medicine, 9967, Department of Medicine, Birmingham, Alabama, United States.,Birmingham VA Medical Center, 19957, Acute Care Service, Birmingham, Alabama, United States;
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30
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Mathioudakis AG, Janssens W, Sivapalan P, Singanayagam A, Dransfield MT, Jensen JUS, Vestbo J. Acute exacerbations of chronic obstructive pulmonary disease: in search of diagnostic biomarkers and treatable traits. Thorax 2020; 75:520-527. [PMID: 32217784 PMCID: PMC7279206 DOI: 10.1136/thoraxjnl-2019-214484] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/21/2020] [Accepted: 03/01/2020] [Indexed: 12/12/2022]
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with a significant mortality, health and economic burden. Their diagnosis, assessment and management remain suboptimal and unchanged for decades. Recent clinical and translational studies revealed that the significant heterogeneity in mechanisms and outcomes of exacerbations could be resolved by grouping them etiologically. This is anticipated to lead to a better understanding of the biological processes that underlie each type of exacerbation and to allow the introduction of precision medicine interventions that could improve outcomes. This review summarises novel data on the diagnosis, phenotyping, targeted treatment and prevention of COPD exacerbations.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Wim Janssens
- Respiratory Division, Department of Clinical and Experimental Medicine, University Hospital Leuven & KU Leuven, Leuven, Belgium
| | - Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Aran Singanayagam
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Jens-Ulrik Stæhr Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark.,PERSIMUNE&CHIP: Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK .,North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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31
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Putman B, Lahousse L, Zeig-Owens R, Singh A, Hall CB, Liu Y, Schwartz T, Goldfarb D, Webber MP, Prezant DJ, Weiden MD. Low serum IgA and airway injury in World Trade Center-exposed firefighters: a 17-year longitudinal study. Thorax 2019; 74:1182-1184. [PMID: 31611340 DOI: 10.1136/thoraxjnl-2019-213715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/19/2019] [Accepted: 09/17/2019] [Indexed: 11/04/2022]
Abstract
Serum IgA ≤70 mg/dL (low IgA) is associated with exacerbations of chronic obstructive pulmonary disease. The association of low IgA with longitudinal lung function is poorly defined. This study included 917 World Trade Center (WTC)-exposed firefighters with longitudinal spirometry measured between September 2001 and September 2018 and IgA measured between October 2001 and March 2002. Low IgA, compared with IgA >70 mg/dL, was associated with lower forced expiratory volume in 1 s (FEV1) % predicted in the year following 11 September 2001 (94.1% vs 98.6%, p<0.001), increased risk of FEV1/FVC <0.70 (HR 3.8, 95% CI 1.6 to 8.8) and increased antibiotic treatment (22.5/100 vs 11.6/100 person-years, p=0.002). Following WTC exposure, early IgA ≤70 mg/dL was associated with worse lung function and increased antibiotic treatment.
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Affiliation(s)
- Barbara Putman
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- Department of Bioanalysis, Ghent University, Gent, Belgium
| | - Lies Lahousse
- Department of Bioanalysis, Ghent University, Gent, Belgium
| | - Rachel Zeig-Owens
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ankura Singh
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Medicine, Montefiore Medical Centre, Bronx, New York, USA
| | - Charles B Hall
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yang Liu
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Medicine, Montefiore Medical Centre, Bronx, New York, USA
| | - Theresa Schwartz
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Medicine, Montefiore Medical Centre, Bronx, New York, USA
| | - David Goldfarb
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Medicine, Montefiore Medical Centre, Bronx, New York, USA
| | - Mayris P Webber
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David J Prezant
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
- Department of Medicine, Montefiore Medical Centre, Bronx, New York, USA
| | - Michael D Weiden
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- The Bureau of Health Services, Fire Department of the City of New York, Brooklyn, New York, USA
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33
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Nagami S, Oku Y, Yagi N, Sato S, Uozumi R, Morita S, Yamagata Y, Kayashita J, Tanimura K, Sato A, Takahashi R, Muro S. Breathing-swallowing discoordination is associated with frequent exacerbations of COPD. BMJ Open Respir Res 2017; 4:e000202. [PMID: 28883930 PMCID: PMC5531308 DOI: 10.1136/bmjresp-2017-000202] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 05/01/2017] [Accepted: 05/02/2017] [Indexed: 12/05/2022] Open
Abstract
Introduction Impaired coordination between breathing and swallowing (breathing–swallowing discoordination) may be a significant risk factor for the exacerbation of chronic obstructive pulmonary disease (COPD). We examined breathing–swallowing discoordination in patients with COPD using a non-invasive and quantitative technique and determined its association with COPD exacerbation. Methods We recruited 65 stable outpatients with COPD who were enrolled in our prospective observational cohort study and did not manifest an apparent swallowing disorder. COPD exacerbation was monitored for 1 year before and 1 year after recruitment. Swallowing during inspiration (the I-SW pattern) and swallowing immediately followed by inspiration (the SW-I pattern) were identified. Results The mean frequency of the I-SW and/or SW-I patterns (I-SW/SW-I rate) was 21.5%±25.5%. During the 2-year observation period, 48 exacerbation incidents (25 patients) were identified. The I-SW/SW-I rate was significantly associated with the frequency of exacerbation. During the year following recruitment, patients with a higher I-SW/SW-I frequency using thicker test foods exhibited a significantly higher probability of future exacerbations (p=0.002, log-rank test). Conclusions Breathing–swallowing discoordination is strongly associated with frequent exacerbations of COPD. Strategies that identify and improve breathing–swallowing coordination may be a new therapeutic treatment for patients with COPD.
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Affiliation(s)
- Shinsuke Nagami
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Physiology, Hyogo College of Medicine, Nishinomiya, Japan.,Clinical Research Center for Medical Equipment Development (CRCMeD), Kyoto University Hospital, Kyoto, Japan
| | - Yoshitaka Oku
- Department of Physiology, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Swallowing Physiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naomi Yagi
- Clinical Research Center for Medical Equipment Development (CRCMeD), Kyoto University Hospital, Kyoto, Japan.,Department of Swallowing Physiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuji Uozumi
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshie Yamagata
- Department of Health Sciences, Prefectural University Hiroshima, Hiroshima, Japan
| | - Jun Kayashita
- Department of Health Sciences, Prefectural University Hiroshima, Hiroshima, Japan
| | - Kazuya Tanimura
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Respiratory Medicine, Chest Disease Clinical and Research Institute, Kishiwada City Hospital, Kishiwada, Japan
| | - Atsuyasu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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34
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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35
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O'Driscoll BR, Howard LS, Earis J, Mak V. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res 2017; 4:e000170. [PMID: 28883921 PMCID: PMC5531304 DOI: 10.1136/bmjresp-2016-000170] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 12/20/2022] Open
Affiliation(s)
- B R O'Driscoll
- Department of Respiratory Medicine, Salford Royal Foundation NHS Trust, Salford, UK
| | - L S Howard
- Department of Respiratory Medicine, Salford Royal Foundation NHS Trust, Salford, UK
| | - J Earis
- Department of Respiratory Medicine, Salford Royal Foundation NHS Trust, Salford, UK
| | - V Mak
- Department of Respiratory Medicine, Salford Royal Foundation NHS Trust, Salford, UK
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36
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Wilkinson TMA, Aris E, Bourne S, Clarke SC, Peeters M, Pascal TG, Schoonbroodt S, Tuck AC, Kim V, Ostridge K, Staples KJ, Williams N, Williams A, Wootton S, Devaster JM. A prospective, observational cohort study of the seasonal dynamics of airway pathogens in the aetiology of exacerbations in COPD. Thorax 2017; 72:919-927. [PMID: 28432209 PMCID: PMC5738531 DOI: 10.1136/thoraxjnl-2016-209023] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 02/14/2017] [Accepted: 03/09/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The aetiology of acute exacerbations of COPD (AECOPD) is incompletely understood. Understanding the relationship between chronic bacterial airway infection and viral exposure may explain the incidence and seasonality of these events. METHODS In this prospective, observational cohort study (NCT01360398), patients with COPD aged 40-85 years underwent sputum sampling monthly and at exacerbation for detection of bacteria and viruses. Results are presented for subjects in the full cohort, followed for 1 year. Interactions between exacerbation occurrence and pathogens were investigated by generalised estimating equation and stratified conditional logistic regression analyses. FINDINGS The mean exacerbation rate per patient-year was 3.04 (95% CI 2.63 to 3.50). At AECOPD, the most common bacterial species were non-typeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis, and the most common virus was rhinovirus. Logistic regression analyses (culture bacterial detection) showed significant OR for AECOPD occurrence when M. catarrhalis was detected regardless of season (5.09 (95% CI 2.76 to 9.41)). When NTHi was detected, the increased risk of exacerbation was greater in high season (October-March, OR 3.04 (1.80 to 5.13)) than low season (OR 1.22 (0.68 to 2.22)). Bacterial and viral coinfection was more frequent at exacerbation (24.9%) than stable state (8.6%). A significant interaction was detected between NTHi and rhinovirus presence and AECOPD risk (OR 5.18 (1.92 to 13.99); p=0.031). CONCLUSIONS AECOPD aetiology varies with season. Rises in incidence in winter may be driven by increased pathogen presence as well as an interaction between NTHi airway infection and effects of viral infection. TRIAL REGISTRATION NUMBER Results, NCT01360398.
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Affiliation(s)
- Tom M A Wilkinson
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK.,Wessex Investigational Sciences Hub, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
| | | | - Simon Bourne
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Stuart C Clarke
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Wessex Investigational Sciences Hub, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
| | | | | | | | - Andrew C Tuck
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Viktoriya Kim
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK
| | - Kristoffer Ostridge
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK
| | - Karl J Staples
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Wessex Investigational Sciences Hub, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
| | - Nicholas Williams
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.,Southampton NIHR Respiratory Biomedical Research Unit, Southampton General Hospital, Southampton, UK
| | - Anthony Williams
- Wessex Investigational Sciences Hub, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK
| | - Stephen Wootton
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, Wijesinghe M, Harrison RN, Steen N, Simpson AJ, Gibson GJ, Bourke SC. The PEARL score predicts 90-day readmission or death after hospitalisation for acute exacerbation of COPD. Thorax 2017; 72:686-693. [PMID: 28235886 PMCID: PMC5537524 DOI: 10.1136/thoraxjnl-2016-209298] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/03/2017] [Accepted: 01/17/2017] [Indexed: 12/23/2022]
Abstract
Background One in three patients hospitalised due to acute exacerbation of COPD (AECOPD) is readmitted within 90 days. No tool has been developed specifically in this population to predict readmission or death. Clinicians are unable to identify patients at particular risk, yet resources to prevent readmission are allocated based on clinical judgement. Methods In participating hospitals, consecutive admissions of patients with AECOPD were identified by screening wards and reviewing coding records. A tool to predict 90-day readmission or death without readmission was developed in two hospitals (the derivation cohort) and validated in: (a) the same hospitals at a later timeframe (internal validation cohort) and (b) four further UK hospitals (external validation cohort). Performance was compared with ADO, BODEX, CODEX, DOSE and LACE scores. Results Of 2417 patients, 936 were readmitted or died within 90 days of discharge. The five independent variables in the final model were: Previous admissions, eMRCD score, Age, Right-sided heart failure and Left-sided heart failure (PEARL). The PEARL score was consistently discriminative and accurate with a c-statistic of 0.73, 0.68 and 0.70 in the derivation, internal validation and external validation cohorts. Higher PEARL scores were associated with a shorter time to readmission. Conclusions The PEARL score is a simple tool that can effectively stratify patients' risk of 90-day readmission or death, which could help guide readmission avoidance strategies within the clinical and research setting. It is superior to other scores that have been used in this population. Trial registration number UKCRN ID 14214.
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Affiliation(s)
- C Echevarria
- North Tyneside General Hospital, North Shields, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - J Steer
- North Tyneside General Hospital, North Shields, Newcastle upon Tyne, UK
| | - K Heslop-Marshall
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK.,Royal Victoria Hospital, Newcastle upon Tyne, UK
| | - S C Stenton
- Royal Victoria Hospital, Newcastle upon Tyne, UK
| | - P M Hickey
- Northern General Hospital, Sheffield, South Yorkshire, UK
| | - R Hughes
- Northern General Hospital, Sheffield, South Yorkshire, UK
| | | | - R N Harrison
- University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
| | - N Steen
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - A J Simpson
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - G J Gibson
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - S C Bourke
- North Tyneside General Hospital, North Shields, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
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Gillett K, Lippiett K, Astles C, Longstaff J, Orlando R, Lin SX, Powell A, Roberts C, Chauhan AJ, Thomas M, Wilkinson TM. Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service. BMJ Open Respir Res 2016; 3:e000145. [PMID: 28074134 PMCID: PMC5174798 DOI: 10.1136/bmjresp-2016-000145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/14/2016] [Accepted: 09/23/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating. Methods To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review. Results 82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting β2-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86. Conclusions Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.
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Affiliation(s)
- K Gillett
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme , Southampton , UK
| | - K Lippiett
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme , Southampton , UK
| | - C Astles
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme , Southampton , UK
| | - J Longstaff
- Wessex Academic Health Sciences Network (AHSN) , Portsmouth , UK
| | - R Orlando
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Methodological Hub , Southampton , UK
| | - S X Lin
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Methodological Hub , Southampton , UK
| | - A Powell
- West Hampshire Clinical Commissioning Group (CCG) , Eastleigh , UK
| | - C Roberts
- Wessex Academic Health Sciences Network (AHSN) , Portsmouth , UK
| | - A J Chauhan
- Wessex Academic Health Sciences Network (AHSN) , Portsmouth , UK
| | - M Thomas
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme, Southampton, UK; Department of Primary Care and Populations Sciences, University of Southampton, Southampton, UK
| | - T M Wilkinson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Respiratory Theme, Southampton, UK; Department of Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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Affiliation(s)
- Heidi A Ridsdale
- Central and North West London NHS Foundation Trust, London, UK.,The Camden COPD Service
| | - John R Hurst
- The Camden COPD Service.,UCL Respiratory, UCL Medical School, University College London, London, UK.,Royal Free London NHS Foundation Trust, London, UK
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40
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Affiliation(s)
- William D-C Man
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK.,Hillingdon Integrated Respiratory Service (HIRS), London, UK
| | - Ruth Barker
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK
| | | | - Samantha S C Kon
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK.,Hillingdon Integrated Respiratory Service (HIRS), London, UK.,The Hillingdon Hospitals NHS Foundation Trust, London, UK
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Ospina MB, Mrklas K, Deuchar L, Rowe BH, Leigh R, Bhutani M, Stickland MK. A systematic review of the effectiveness of discharge care bundles for patients with COPD. Thorax 2016; 72:31-39. [PMID: 27613539 DOI: 10.1136/thoraxjnl-2016-208820] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/28/2016] [Accepted: 08/13/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND A COPD discharge bundle is a set of evidence-based practices aimed at improving patient outcomes after discharge from acute care settings following an exacerbation. We conducted a systematic review on the effectiveness of COPD discharge bundles and summarised their individual care elements. METHODS Biomedical electronic databases and clinical trial registries were searched from database inception through April 2016 to identify experimental studies evaluating care bundles offered to patients with COPD at discharge. Random-effects meta-analyses of clinical trials data were conducted for hospital readmissions, mortality, and quality of life (QoL). RESULTS The review included 14 studies (5 clinical trials, 7 uncontrolled trials, and 2 interrupted time series). A total of 26 distinct elements of care were included in the bundles of individual studies. Evidence from four clinical trials with moderate-to-high risk of bias showed that COPD discharge bundles reduced hospital readmissions (pooled risk ratio (RR): 0.80; 95% CI 0.65 to 0.99). There was insufficient evidence that care bundles influence long-term mortality (RR: 0.74; 95% CI 0.43 to 1.28; four trials) or QoL (mean difference in St. George's Respiratory Questionnaire: 1.84; 95% CI -2.13 to 5.8). CONCLUSIONS Discharge bundles for patients with COPD led to fewer readmissions but did not significantly improve mortality or QoL. Future studies should employ higher quality research methods, fully report care bundle elements, implementation strategies and intervention fidelity to better evaluate the effectiveness of packaging evidence-based interventions together to improve outcomes of patients with COPD discharged from acute care settings.
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Affiliation(s)
| | - Kelly Mrklas
- Alberta Health Services, Edmonton, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Brian H Rowe
- Alberta Health Services, Edmonton, Alberta, Canada.,Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Leigh
- Division of Respirology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael K Stickland
- Alberta Health Services, Edmonton, Alberta, Canada.,Division of Pulmonary Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.,G.F. MacDonald Centre for Lung Health, Covenant Health, Edmonton, Alberta, Canada
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Citgez E, van der Palen J, Koehorst-Ter Huurne K, Movig K, van der Valk P, Brusse-Keizer M. Statins and morbidity and mortality in COPD in the COMIC study: a prospective COPD cohort study. BMJ Open Respir Res 2016; 3:e000142. [PMID: 27403321 PMCID: PMC4932311 DOI: 10.1136/bmjresp-2016-000142] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 02/07/2023] Open
Abstract
Background Both chronic inflammation and cardiovascular comorbidity play an important role in the morbidity and mortality of patients with chronic obstructive pulmonary disease (COPD). Statins could be a potential adjunct therapy. The additional effects of statins in COPD are, however, still under discussion. The aim of this study is to further investigate the association of statin use with clinical outcomes in a well-described COPD cohort. Methods 795 patients of the Cohort of Mortality and Inflammation in COPD (COMIC) study were divided into statin users or not. Statin use was defined as having a statin for at least 90 consecutive days after inclusion. Outcome parameters were 3-year survival, based on all-cause mortality, time until first hospitalisation for an acute exacerbation of COPD (AECOPD) and time until first community-acquired pneumonia (CAP). A sensitivity analysis was performed without patients who started a statin 3 months or more after inclusion to exclude immortal time bias. Results Statin use resulted in a better overall survival (corrected HR 0.70 (95% CI 0.51 to 0.96) in multivariate analysis), but in the sensitivity analysis this association disappeared. Statin use was not associated with time until first hospitalisation for an AECOPD (cHR 0.95, 95% CI 0.74 to 1.22) or time until first CAP (cHR 1.1, 95% CI 0.83 to 1.47). Conclusions In the COMIC study, statin use is not associated with a reduced risk of all-cause mortality, time until first hospitalisation for an AECOPD or time until first CAP in patients with COPD.
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Affiliation(s)
- Emanuel Citgez
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Research Methodology, Measurement, and Data analysis, University of Twente, Enschede, The Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Research Methodology, Measurement, and Data analysis, University of Twente, Enschede, The Netherlands
| | | | - Kris Movig
- Department of Clinical Pharmacy , Medisch Spectrum Twente , Enschede , The Netherlands
| | - Paul van der Valk
- Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , The Netherlands
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Tang FSM, Hansbro PM, Burgess JK, Ammit AJ, Baines KJ, Oliver BG. A novel immunomodulatory function of neutrophils on rhinovirus-activated monocytes in vitro. Thorax 2016; 71:1039-1049. [PMID: 27287090 PMCID: PMC5099217 DOI: 10.1136/thoraxjnl-2015-207781] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 05/15/2016] [Indexed: 01/24/2023]
Abstract
Background Rhinovirus (RV) infections are the major precipitant of asthma exacerbations. While neutrophilic lung inflammation occurs during such infections, its role remains unclear. Neutrophilic inflammation is associated with increased asthma severity and steroid refractory disease. Neutrophils are vital for controlling infections but also have immunomodulatory functions. Previously, we found that neutrophils respond to viral mimetics but not replication competent RV. We aimed to investigate if neutrophils are activated and/or modulate immune responses of monocytes during RV16 infection. Methods Primary human monocytes and autologous neutrophils were cocultured with or without RV16, in direct contact or separated by transwells. RV16-stimulated monocytes were also exposed to lysed neutrophils, neutrophil membrane components or soluble neutrophil intracellular components. Interleukin 6 (IL-6) and C-X-C motif (CXC)L8 mRNA and proteins were measured by quantitative PCR and ELISA at 24 hours. Results RV16 induced IL-6 and CXCL8 in monocytes, but not neutrophils. RV16-induced IL-6 and CXCL8 from monocytes was reduced in the presence of live neutrophils. Transwell separation abolished the inhibitory effects. Lysed neutrophils inhibited RV16-induced IL-6 and CXCL8 from monocytes. Neutrophil intracellular components alone effectively inhibited RV16-induced monocyte-derived IL-6 and CXCL8. Neutrophil intracellular components reduced RV16-induced IL-6 and CXCL8 mRNA in monocytes. Conclusions Cell contact between monocytes and neutrophils is required, and preformed neutrophil mediator(s) are likely to be involved in the suppression of cytokine mRNA and protein production. This study demonstrates a novel regulatory function of neutrophils on RV-activated monocytes in vitro, challenging the paradigm that neutrophils are predominantly proinflammatory.
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Affiliation(s)
- Francesca S M Tang
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia Discipline of Pharmacology, Faculty of Medicine, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip M Hansbro
- Priority Research Centre for Asthma and Respiratory Disease, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Janette K Burgess
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia Discipline of Pharmacology, Faculty of Medicine, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia Department of Pathology and Medical Biology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Alaina J Ammit
- Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katherine J Baines
- Priority Research Centre for Asthma and Respiratory Disease, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Brian G Oliver
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia Centre for Health Technologies and Molecular Biosciences, School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
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Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, Wijesinghe M, Harrison RN, Steen N, Simpson AJ, Gibson GJ, Bourke SC. Validation of the DECAF score to predict hospital mortality in acute exacerbations of COPD. Thorax 2016; 71:133-40. [PMID: 26769015 PMCID: PMC4752621 DOI: 10.1136/thoraxjnl-2015-207775] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Hospitalisation due to acute exacerbations of COPD (AECOPD) is common, and subsequent mortality high. The DECAF score was derived for accurate prediction of mortality and risk stratification to inform patient care. We aimed to validate the DECAF score, internally and externally, and to compare its performance to other predictive tools. Methods The study took place in the two hospitals within the derivation study (internal validation) and in four additional hospitals (external validation) between January 2012 and May 2014. Consecutive admissions were identified by screening admissions and searching coding records. Admission clinical data, including DECAF indices, and mortality were recorded. The prognostic value of DECAF and other scores were assessed by the area under the receiver operator characteristic (AUROC) curve. Results In the internal and external validation cohorts, 880 and 845 patients were recruited. Mean age was 73.1 (SD 10.3) years, 54.3% were female, and mean (SD) FEV1 45.5 (18.3) per cent predicted. Overall mortality was 7.7%. The DECAF AUROC curve for inhospital mortality was 0.83 (95% CI 0.78 to 0.87) in the internal cohort and 0.82 (95% CI 0.77 to 0.87) in the external cohort, and was superior to other prognostic scores for inhospital or 30-day mortality. Conclusions DECAF is a robust predictor of mortality, using indices routinely available on admission. Its generalisability is supported by consistent strong performance; it can identify low-risk patients (DECAF 0–1) potentially suitable for Hospital at Home or early supported discharge services, and high-risk patients (DECAF 3–6) for escalation planning or appropriate early palliation. Trial registration number UKCRN ID 14214.
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Affiliation(s)
- C Echevarria
- Department of Respiratory Medicine, North Tyneside General Hospital, North Shields, UK Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - J Steer
- Department of Respiratory Medicine, North Tyneside General Hospital, North Shields, UK
| | - K Heslop-Marshall
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK Chest Clinic, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - S C Stenton
- Chest Clinic, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - P M Hickey
- Department of Respiratory Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - R Hughes
- Department of Respiratory Medicine, Northern General Hospital, Sheffield, South Yorkshire, UK
| | - M Wijesinghe
- Department of Respiratory Medicine, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - R N Harrison
- Department of Respiratory Medicine, University Hospital of North Tees, Hardwick Hall, Stockton-on-Tees, Cleveland, UK
| | - N Steen
- Institute of Health and Society, Baddiley-Clark Building, Newcastle University, Newcastle Upon Tyne, UK
| | - A J Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - G J Gibson
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - S C Bourke
- Department of Respiratory Medicine, North Tyneside General Hospital, North Shields, UK Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
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O'Driscoll BR, Bakerly ND, Caress AL, Roberts J, Gaston M, Newton M, Yorke J. A study of attitudes, beliefs and organisational barriers related to safe emergency oxygen therapy for patients with COPD (chronic obstructive pulmonary disease) in clinical practice and research. BMJ Open Respir Res 2016; 3:e000102. [PMID: 27252870 PMCID: PMC4879340 DOI: 10.1136/bmjresp-2015-000102] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/05/2015] [Accepted: 09/07/2015] [Indexed: 02/03/2023] Open
Abstract
Background Patients can be harmed by receiving too little or too much oxygen. There is ongoing disagreement about the use of oxygen in medical emergencies. Methods This was a mixed methods study (survey, telephone interviews and focus groups) involving patients, the public and healthcare professionals (HCPs). Results 62 patients with chronic obstructive pulmonary disease (COPD), 65 members of the public, 68 ambulance crew members, 22 doctors, 22 nurses and 10 hospital managers took part. For five factual questions about oxygen therapy, the average score for correct answers was 28% for patients with COPD, 33% for the general public and 75% for HCPs. The HCPs had an average score of 66% for five technical questions. Patients (79%) and members of the public (68%) were more likely than HCPs (36%) to believe that oxygen was beneficial in most medical emergencies and less likely to have concerns that it might harm some people (35%, 25% and 68%). All groups had complex attitudes about research into oxygen use in medical emergencies. Many participants would not wish for themselves or their loved ones to have their oxygen therapy determined by a randomised protocol, especially if informed consent was not possible in an emergency situation. Conclusions We have found low levels of factual knowledge about oxygen use among patients with COPD and the general public and many false beliefs about the potential benefits and harms of using oxygen. HCPs had a higher level of factual knowledge. All groups had complex attitudes towards research into emergency oxygen use.
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Affiliation(s)
- B Ronan O'Driscoll
- Salford Royal NHS Foundation NHS Trust, Manchester Academic Health Science Centre, University of Manchester , Salford , UK
| | - Nawar Diar Bakerly
- Salford Royal NHS Foundation NHS Trust, Manchester Academic Health Science Centre, University of Manchester , Salford , UK
| | - Ann-Louise Caress
- University Hospital of South Manchester Foundation NHS Trust and University of Manchester, Manchester Academic Health Science Centre , Manchester , UK
| | - June Roberts
- Salford Royal NHS Foundation NHS Trust, Manchester Academic Health Science Centre, University of Manchester , Salford , UK
| | - Miriam Gaston
- University Hospital of South Manchester Foundation NHS Trust and University of Manchester, Manchester Academic Health Science Centre , Manchester , UK
| | - Mark Newton
- North West Ambulance Service NHS Trust , Manchester , UK
| | - Janelle Yorke
- University Hospital of South Manchester Foundation NHS Trust and University of Manchester, Manchester Academic Health Science Centre , Manchester , UK
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Çolak Y, Afzal S, Nordestgaard BG, Lange P. Majority of never-smokers with airflow limitation do not have asthma: the Copenhagen General Population Study. Thorax 2016; 71:614-23. [PMID: 27015799 DOI: 10.1136/thoraxjnl-2015-208178] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/23/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND A substantial proportion of individuals with airflow limitation are never-smokers. However, whether never-smokers with airflow limitation have undiagnosed asthma is unknown. We hypothesised that the majority of never-smokers with respiratory symptoms and airflow limitation but without known asthma have undiagnosed asthma by comparing characteristics and prognosis in never-smokers with airflow limitation and asthma (NS+AFL+A) with never-smokers with airflow limitation but without asthma (NS+AFL-A). METHODS Among 94 079 participants aged 20-100 years from the general population, 39 102 (42%) were never-smokers. In this group, 13 719 (35%) reported to have respiratory symptoms of whom 1610 (12%) had airflow limitation. We investigated characteristics and risk of complications (asthma or COPD exacerbations, pneumonias and all-cause mortality) and comorbidities (lung cancer, ischaemic heart disease, myocardial infarction, deep venous thrombosis and PE) during 4.5 years median follow-up. RESULTS NS+AFL-A compared with NS+AFL+A reported less allergy and respiratory symptoms, and had higher FEV1 and lower levels of eosinophils and IgE in peripheral blood. NS+AFL+A had increased risk of asthma and COPD exacerbations, but not of pneumonias; adjusted HRs in NS+AFL+A compared with NS+AFL-A were 16 (95% CI 3.7 to 73) for asthma exacerbations and 15 (2.8 to 80) for COPD exacerbations. Still, NS+AFL-A had increased risk of COPD exacerbations and pneumonias, but not of asthma exacerbations; adjusted HRs in NS+AFL-A compared with never-smokers without airflow limitation or asthma (NS-AFL-A) were 7.7 (2.8 to 21) for COPD exacerbations and 1.7 (1.3 to 2.3) for pneumonias. Risk of comorbidities or all-cause mortality was not increased in NS+AFL-A or NS+AFL+A compared with NS-AFL-A. CONCLUSIONS Majority of NS+AFL-A do not seem to have undiagnosed asthma and may instead have airflow limitation caused by other risk factors.
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Affiliation(s)
- Yunus Çolak
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Department of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Shoaib Afzal
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Børge G Nordestgaard
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Peter Lange
- Department of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark Medical Unit, Respiratory Section, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
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Fraser JF, Spooner AJ, Dunster KR, Anstey CM, Corley A. Nasal high flow oxygen therapy in patients with COPD reduces respiratory rate and tissue carbon dioxide while increasing tidal and end-expiratory lung volumes: a randomised crossover trial. Thorax 2016; 71:759-61. [PMID: 27015801 PMCID: PMC4975837 DOI: 10.1136/thoraxjnl-2015-207962] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 02/26/2016] [Indexed: 01/05/2023]
Abstract
UNLABELLED Patients with COPD using long-term oxygen therapy (LTOT) over 15 h per day have improved outcomes. As inhalation of dry cold gas is detrimental to mucociliary clearance, humidified nasal high flow (NHF) oxygen may reduce frequency of exacerbations, while improving lung function and quality of life in this cohort. In this randomised crossover study, we assessed short-term physiological responses to NHF therapy in 30 males chronically treated with LTOT. LTOT (2-4 L/min) through nasal cannula was compared with NHF at 30 L/min from an AIRVO through an Optiflow nasal interface with entrained supplemental oxygen. Comparing NHF with LTOT: transcutaneous carbon dioxide (TcCO2) (43.3 vs 46.7 mm Hg, p<0.001), transcutaneous oxygen (TcO2) (97.1 vs 101.2 mm Hg, p=0.01), I:E ratio (0.75 vs 0.86, p=0.02) and respiratory rate (RR) (15.4 vs 19.2 bpm, p<0.001) were lower; and tidal volume (Vt) (0.50 vs 0.40, p=0.003) and end-expiratory lung volume (EELV) (174% vs 113%, p<0.001) were higher. EELV is expressed as relative change from baseline (%Δ). Subjective dyspnoea and interface comfort favoured LTOT. NHF decreased TcCO2, I:E ratio and RR, with a concurrent increase in EELV and Vt compared with LTOT. This demonstrates a potential mechanistic rationale behind the improved outcomes observed in long-term treatment with NHF in oxygen-dependent patients. TRIAL REGISTRATION NUMBER ACTRN12613000028707.
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Affiliation(s)
- John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Amy J Spooner
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Kimble R Dunster
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia Biomedical Engineering and Medical Physics, Science and Engineering Faculty, Queensland University of Technology, Brisbane, Australia
| | - Chris M Anstey
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia Intensive Care Unit, Nambour General Hospital, Nambour, Australia
| | - Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
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Hitchings AW, Lai D, Jones PW, Baker EH. Metformin in severe exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. Thorax 2016; 71:587-93. [PMID: 26917577 PMCID: PMC4941151 DOI: 10.1136/thoraxjnl-2015-208035] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/29/2016] [Indexed: 11/24/2022]
Abstract
Background Severe exacerbations of COPD are commonly associated with hyperglycaemia, which predicts adverse outcomes. Metformin is a well-established anti-hyperglycaemic agent in diabetes mellitus, possibly augmented with anti-inflammatory effects, but its effects in COPD are unknown. We investigated accelerated metformin therapy in severe COPD exacerbations, primarily to confirm or refute an anti-hyperglycaemic effect, and secondarily to explore its effects on inflammation and clinical outcome. Methods This was a multicentre, randomised, double-blind, placebo-controlled trial testing accelerated metformin therapy in non-diabetic patients, aged ≥35 years, hospitalised for COPD exacerbations. Participants were assigned in a 2:1 ratio to 1 month of metformin therapy, escalated rapidly to 2 g/day, or matched placebo. The primary end point was mean in-hospital blood glucose concentration. Secondary end points included the concentrations of fructosamine and C reactive protein (CRP), and scores on the COPD Assessment Test and Exacerbations of Chronic Pulmonary Disease Tool. Results 52 participants (mean (±SD) age 67±9 years) were randomised (34 to metformin, 18 to placebo). All were included in the primary end point analysis. The mean blood glucose concentrations in the metformin and placebo groups were 7.1±0.9 and 8.0±3.3 mmol/L, respectively (difference −0.9 mmol/L, 95% CI −2.1 to +0.3; p=0.273). No significant between-group differences were observed on any of the secondary end points. Adverse reactions, particularly gastrointestinal effects, were more common in metformin-treated participants. Conclusion Metformin did not ameliorate elevations in blood glucose concentration among non-diabetic patients admitted to hospital for COPD exacerbations, and had no detectable effect on CRP or clinical outcomes. Trial registration number ISRCTN66148745 and NCT01247870.
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Affiliation(s)
- Andrew W Hitchings
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Dilys Lai
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paul W Jones
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George's, University of London, London, UK
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Affiliation(s)
- Richard W Costello
- Department of Respiratory Medicine, Royal College of Surgeons in Ireland (RCSI), Beaumont Hospital, Dublin, Ireland
| | - Breda Cushen
- Department of Respiratory Medicine, Royal College of Surgeons in Ireland (RCSI), Beaumont Hospital, Dublin, Ireland
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Mandal S, Suh E, Thompson A, Connolly B, Ramsay M, Harding R, Puthucheary Z, Moxham J, Hart N. Comparative study of linear and curvilinear ultrasound probes to assess quadriceps rectus femoris muscle mass in healthy subjects and in patients with chronic respiratory disease. BMJ Open Respir Res 2016; 3:e000103. [PMID: 26835132 PMCID: PMC4716191 DOI: 10.1136/bmjresp-2015-000103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/17/2015] [Accepted: 10/19/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction Ultrasound measurements of rectus femoris cross-sectional area (RFCSA) are clinically useful measurements in chronic obstructive pulmonary disease (COPD) and critically ill patients. Technical considerations as to the type of probe used, which affects image resolution, have limited widespread clinical application. We hypothesised that measurement of RFCSA would be similar with linear and curvilinear probes. Methods Four studies were performed to compare the use of the curvilinear probe in measuring RFCSA. Study 1 investigated agreement of RFCSA measurements using linear and curvilinear probes in healthy subjects, and in patients with chronic respiratory disease. Study 2 investigated the intra-rater and inter-rater agreement using the curvilinear probe. Study 3 investigated the agreement of RFCSA measured from whole and spliced images using the linear probe. Study 4 investigated the applicability of ultrasound in measuring RFCSA during the acute and recovery phases of an exacerbation of COPD. Results Study 1 showed demonstrated no difference in the measurement of RFCSA using the curvilinear and linear probes (308±104 mm2 vs 320±117 mm2, p=0.80; intraclass correlation coefficient (ICC)>0.97). Study 2 demonstrated high intra-rater and inter-rater reliability of RFCSA measurement with ICC>0.95 for both. Study 3 showed that the spliced image from the linear probe was similar to the whole image RFCSA (308±103.5 vs 263±147 mm2, p=0.34; ICC>0.98). Study 4 confirmed the clinical acceptability of using the curvilinear probe during an exacerbation of COPD. There were relationships observed between admission RFCSA and body mass index (r=+0.65, p=0.018), and between RFCSA at admission and physical activity levels at 4 weeks post-hospital discharge (r=+0.75, p=0.006). Conclusions These studies have demonstrated that clinicians can employ whole and spliced images from the linear probe or use images from the curvilinear probe, to measure RFCSA. This will extend the clinical applicability of ultrasound in the measurement of muscle mass in all patient groups.
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Affiliation(s)
- S Mandal
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - E Suh
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - A Thompson
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - B Connolly
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, London, UK
| | - M Ramsay
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - R Harding
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust , London , UK
| | - Z Puthucheary
- Division of Respiratory and Critical Care Medicine , University Medicine Cluster, National University Health Systems , Singapore
| | - J Moxham
- Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre , London , UK
| | - N Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, London, UK
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