The Impact of CT Reconstruction Parameters on Emphysema Index Quantification, HU‐Based Measurements, and Goddard Score in COPD Assessment: A Prospective Study

Objective: This study aimed to evaluate the characteristics of emphysema in patients with Chronic Obstructive Pulmonary Disease (COPD) using quantitative computed tomography (QCT) and to investigate the relationship between the extent of emphysema, clinical phenotypes, lung function, and plasma concentrations of Vascular Endothelial Growth Factor (VEGF) and Interleukin-1β (IL-1β) in COPD patients. Methods: A prospective cross-sectional study was conducted on 30 male patients with stable COPD at Military Hospital 175. The emphysema index (EI) was quantified using QCT of the chest and categorized into levels from 0 to 4. Data on acute exacerbation frequency, COPD Assessment Test (CAT) scores, modified Medical Research Council (mMRC) dyspnea scale, pulmonary function indices (FEV1%, FEV1/FVC%), arterial blood gas measurements, and plasma concentrations of VEGF and IL-1β were collected and analyzed to determine their relationship with EI. Results: The study found an average EI of 12.8 ± 11.64%, with 96.7% of patients exhibiting a bronchitis-dominant phenotype (EI < 35%). Among the patients, 46.7% had level 2 emphysema, 16.6% had level 1, and 36.7% had level 0. The severity of airflow obstruction, as classified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), along with blood PaCO2 levels, mMRC scores, and the number of exacerbations per year, increased with the degree of emphysema. Conversely, FEV1% and the FEV1/FVC ratio significantly decreased with increasing emphysema severity. A significant inverse relationship was observed between EI and lung function (p < 0.01). Additionally, plasma VEGF concentration was inversely correlated with the EI (r = -0.5, p = 0.02), suggesting that reduced VEGF may play a critical role in pulmonary vascular destruction and remodeling, leading to more severe emphysema. Conclusion: The emphysema index (EI) determined by QCT is a valuable tool for identifying COPD phenotypes and assessing disease severity. It can also provide insights into the prognosis regarding the risk of exacerbations, clinical symptom burden, and lung function decline. The significant inverse correlation between plasma VEGF concentration and EI indicates that decreased VEGF levels may be a crucial factor in the pathogenesis of emphysema, suggesting a potential target for research on "treatable" factors in COPD management. Trial Registration: The study was approved by an independent ethics committee (Ethics Committee of Military Hospital 175, No. 003/QĐ-IRB-VN01.055) and conducted in accordance with the Declaration of Helsinki and Guidelines for Good Clinical Practice.

Background This study aimed to evaluate the efficacy of the emphysema index (EI) in distinguishing chronic bronchitis (CB) from chronic obstructive pulmonary disease (COPD) and its role, combined with the COPD Assessment Test (CAT) score, in the evaluation of COPD. Methods A total of 92 patients with CB and 277 patients with COPD were enrolled in this study. Receiver operating characteristic (ROC) curves were analyzed to evaluate whether the EI can preliminarily distinguish chronic bronchitis from COPD. Considering the heterogeneity of COPD, there might be missed diagnosis of some patients with bronchitis type when differentiating COPD patients only by EI. Therefore, patients with COPD were classified according to the CAT score and EI into four groups: Group 1 (EI < 16%, CAT < 10), Group 2 (EI < 16%, CAT ≥ 10), Group 3 (EI ≥ 16%, CAT < 10), and Group 4 (EI ≥ 16%, CAT ≥ 10). The records of pulmonary function and quantitative computed tomography findings were retrospectively analyzed. Results ROC curve analysis showed that EI = 16.2% was the cutoff value for distinguishing COPD from CB. Groups 1 and 2 exhibited significantly higher maximal voluntary ventilation (MVV) percent predicted (pred), forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC), maximal midexpiratory flow of 25–75% pred, carbon monoxide-diffusing capacity (DLCO)/alveolar ventilation (VA), FEV1 % pred (p ≤ 0.013), and maximal expiratory flow 50% pred (all p < 0.05) than Group 4. FEV1/FVC and DLCO/VA were significantly lower in Group 3 than in Group 2 (p=0.002 and p < 0.001, respectively). The residual volume/total lung capacity was higher in Group 3 than in Groups 1 and 2 (p < 0.05). Conclusions The combination of EI and CAT was effective in the evaluation of COPD.

Objective To investigate the clinical values of nutritional status and chest CT phenotypes in the assessment of chronic obstructive pulmonary disease(COPD). Methods A total of 256 patients with stable COPD were enrolled from Peking Union Medical College Hospital and Civil Aviation General Hospital from June 2017 to June 2018.Demographic data,height,weight,smoking history,and number of exacerbations were collected.Pulmonary function tests and COPD assessment test(CAT)questionnaire-based survey were performed.The correlations of Goddard score with pulmonary function,CAT score,and number of exacerbations were analyzed.The clinical features of COPD patients with different body mass index(BMI)grades and CT phenotype were analyzed. Results The forced expiratory volume in one second as percentage of predicted value(FEV1%pred)was significantly higher in normal body mass group(t=-2.701,P=0.0080),overweight group(t=-3.506,P=0.001),and obese group(t=-4.323,P=0.000)than in low body mass group and was significantly higher in obese group than in normal body mass group(t=-3.096,P=0.002).The forced vital capacity as percentage of predicted value(FVC%pred)of normal body mass group(t=-3.081,P=0.002)and overweight group(t=-2.766,P=0.006)were significantly higher than that of low body mass group.The forced expiratory volume in one second(FEV1)/forced vital capacity(FVC)was significantly higher in overweight group than in normal body mass group(t=-3.702,P=0.001)and significantly higher in obese group than in low body mass group(t=-4.742,P=0.000),normal body mass group(t=-5.785,P=0.000),and overweight group(t=-2.984,P=0.003).In addition,the carbon monoxide diffusing capacity as percentage of predicted value(DLco%pred)was significantly higher in overweight group than in underweight(t=-3.042,P=0.003)and normal body mass groups(t=-3.128,P=0.002)and significantly higher in obese group than in underweight group(t=-4.742,P=0.000)and normal body mass group(t=-5.785,P=0.000).The Goddard scores of overweight(Z=4.535,P=0.000)and obese groups(Z=5.422,P=0.000)were significantly lower than that of normal body mass group.Partial correlation analysis showed that Goddard score was negatively correlated with FEV1/FVC(r =-0.230,P = 0.022)and DLco%pred(r =-0.531,P = 0.000)and positively correlated with CAT score(r = 0.244,P = 0.021).BMI of phenotype E(t=3.467,P=0.001)and M(t=3.031,P=0.003),FEV1/FVC of phenotype E(t=2.484,P=0.015)and M(t=2.969,P=0.004)as well as DLco%pred of phenotype E(t=4.928,P=0.000)and M(t=2.489,P=0.0163)were significantly lower than those of phenotype A.Patients with phenotype M had worse FEV1%pred,FVC%pred,residual volume/total lung capacity and number of acute exacerbations than patients with phenotypes A and E,but the differences were not statistically significant(all P >0.05). Conclusions The nutritional status is closely related to lung function,severity of emphysema,and number of exacerbations in COPD patients.Chest CT phenotype is clinically valuable in the assessment of COPD.

Background:Quantitative computed tomography has emerged as a crucial tool for assessing the severity of emphysema in chronic obstructive pulmonary disease (COPD) patients. Vascular endothelial growth factor (VEGF) levels are significantly elevated in patients with chronic bronchitis but reduced in those with emphysema. Chronic inflammation is a key factor in the pathogenesis and progression of COPD, with cytokines such as Interleukin-1 beta playing a significant role.Objective:This study aimed to evaluate the characteristics of emphysema in patients with COPD using quantitative computed tomography (QCT) and to investigate the relationship between the extent of emphysema, clinical phenotypes, lung function, and plasma concentrations of VEGF and IL-1β in COPD patients.Design:A prospective cross-sectional study was conducted on 30 male patients with stable COPD at Military Hospital 175.Methods:The emphysema index (EI) was quantified using QCT of the chest and categorized into levels from 0 to 4. Data on acute exacerbation frequency, CAT scores, mMRC, pulmonary function indices, arterial blood gas measurements, and plasma concentrations of VEGF and IL-1β were collected and analyzed to determine their relationship with EI.Results:The study found an average EI of 12.8% ± 11.64%, with 96.7% of patients exhibiting a bronchitis-dominant phenotype. The severity of airflow obstruction, PaCO2 levels, mMRC scores, and the number of exacerbations per year increased with the degree of emphysema. Conversely, FEV1% and the FEV1/FVC ratio significantly decreased with increasing emphysema severity. Plasma VEGF concentration was inversely correlated with the EI. In GOLD 3 and 4 stages, plasma VEGF levels decreased in proportion to emphysema severity, indicating that more advanced emphysema was associated with a more rapid decline in VEGF concentrations. Notably, when emphysema exceeded 25%, a significant reduction in both VEGF and IL-1β concentrations was observed.Conclusion:The EI determined by QCT is a valuable tool for identifying COPD phenotypes and assessing disease severity. It can also provide insights into the prognosis regarding the risk of exacerbations, clinical symptom burden, and lung function decline. The significant inverse correlation between plasma VEGF concentration and EI indicates that decreased VEGF levels may be a crucial factor in the pathogenesis of emphysema, suggesting a potential target for research on “treatable” factors in COPD management.Trial registration:The study was approved by an independent ethics committee (Ethics Committee of Military Hospital 175, No. 003/QĐ-IRB-VN01.055) and conducted in accordance with the Declaration of Helsinki and Guidelines for Good Clinical Practice.

This study was performed to compare standard- and low-radiation-dose techniques in the CT quantification of emphysema. The study population consisted of 36 men and 20 women who were current or former heavy smokers and underwent standard-dose (effective tube current, 100-250 mAs) chest CT at our institution within 6 months of having undergone low-dose (effective tube current, 30-60 mAs) chest CT. All CT scans were reconstructed at 5-mm slice thickness with a smooth filter. CT-measured lung volume, mean and median lung attenuation, and percentage of lung volume with attenuation lower than multiple thresholds (emphysema index values) were compared by Pearson correlation, two-tailed and paired Student's t tests, and regression analysis. There were no significant differences in mean attenuation (-848 vs -846 H, p > 0.35) for the low dose and the standard dose or in median lung attenuation (-879 vs -878 H, p > 0.66). Low- and standard-dose emphysema indexes were correlated at all attenuation thresholds (r = 0.86-0.97). Mean emphysema indexes were higher on the low-dose scans, but the mean difference at all thresholds was less than 3%. The differences were significant (p < 0.05) only at the lower index thresholds, correlated with differences in lung volume (r < or = 0.86), and increased with greater differences in dose. Low-dose technique has minimal effect on CT quantification of emphysema.

Background:Studies have identified health literacy (HL) as an important determinant of asthma and chronic obstructive pulmonary disease (COPD) management. There are, however, limited data on patients' and health care professionals (HCPs') insights about the link between HL and management of asthma and COPD.Objective:The aim of this study was to elicit patients' and HCPs' perspectives with respect to factors affecting HL in the context of asthma and COPD management.Methods:A total of 16 semi-structured focus groups (10 in English and 6 in French) with patients with asthma or COPD (n = 93) and 45 interviews with HCPs, researchers, and policymakers were conducted between June 2015 and April 2017. Participants were asked to share their perspectives with respect to five predefined HL domains—accessing, understanding, evaluating, communicating, and using health-related information—in relation to disease self-management practices. Data were analyzed qualitatively, using a content analysis approach.Key Results:Most patients and HCPs reflected on factors hampering HL in relation to asthma and COPD management. Thoughts such as “not having enough time during medical consultations,” “not receiving consistent messages from different health care professionals,” and “language or cultural differences” were frequently mentioned by both patients and HCPs.Conclusions:We identified multiple factors affecting communication between patients and HCPs as it relates to the self-management of their disease. These included inconsistent messages from different providers, limited consultation time, use of technical language, failure to account for cultural differences, and reduced health literacy, especially as it related to written communication. Future interventions that aim to enhance HL skills in the context of asthma and COPD self-management should consider these issues. [HLRP: Health Literacy Research and Practice. 2021;5(3):e179–e193.]Plain Language Summary:The current study advances the health literacy (HL) knowledge base by adding patients' and health care professionals' valuable insights on factors that hamper or facilitate HL in relation to asthma and chronic obstructive pulmonary disease (COPD) management. An important insight from this study is that receiving conflicting information from different health care professional's hampers HL in patients with asthma and/or COPD.

Background In Denmark, general practitioners (GPs) have the main responsibility for chronic obstructive pulmonary disease (COPD) management. Internationally, COPD appears to be significantly under-treated, which could be explained by ‘therapeutic nihilism’ or lack of knowledge. Aim To investigate: (1) To what extent COPD management provided by GPs includes the core elements of pharmacological treatment, smoking cessation and physical activity, and (2) To what extent GPs need educational support and consulting with a specialist in pulmonary medicine. Design A national cross-sectional web-based survey conducted in April–June 2019. The survey included items on COPD management and educational support needs. Setting Danish general practice. Subjects A population of approximately 3400 GPs (all GPs in Denmark). Results We received response from 470 GPs (14% response rate). Overall, the respondents reported that they offered COPD management including all relevant treatment elements. Smoking cessation was supported in 58% and physical activity was supported in 23% of the respondents. Future consultations on smoking cessation were planned by 35% and physical activity by 15% respondents. GPs responded to ‘needing educational support in COPD management’ to a ‘high degree’ in 8% and to ‘some degree’ in 43%. Conclusion The survey suggested that COPD maintenance support provided by GPs seemed to be inadequate regarding smoking cessation and physical activity. Moreover, some GPs expressed a need for educational support in COPD management. More research is needed to understand the potential barriers to evidence-based delivery of COPD-management. Key points In Denmark, general practitioners (GPs) have the main responsibility for the management of chronic obstructive pulmonary disease (COPD). The present study shows that non-pharmacological interventions such as supporting smoking cessation and particularly promoting physical activity received less attention than pharmacological treatment. The study suggests a need for educational support of the GPs in COPD management.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs’ satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs’ COPD-related knowledge from a median (interquartile range) score of 12 (3–16) before to 21 (21–22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs’ training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.

Quantification of emphysema with preoperative computed tomography has stronger association with pulmonary complications than pulmonary function test results after pulmonary lobectomy

To explore the effect of different reconstruction algorithms (ASIR-V and DLIR) on image quality and emphysema quantification in chronic obstructive pulmonary disease (COPD) patients under ultra-low-dose scanning conditions. This prospective study with patient consent included 62 COPD patients. Patients were examined by pulmonary function test (PFT), standard-dose CT (SDCT) and ultra-low-dose CT (ULDCT). SDCT images were reconstructed with filtered-back-projection (FBP), while ULDCT images were reconstructed using FBP, 30%ASIR-V, 60%ASIR-V, 90%ASIR-V, low-strength (DLIR-L), medium-strength (DLIR-M) and high-strength DLIR (DLIR-H) to form 8 image sets. Images were analysed using a commercial computer aided diagnosis (CAD) software. Parameters such as image noise, lung volume (LV), emphysema index (EI), mean lung density (MLD) and 15th percentile of lung density (PD15) were measured. Two radiologists evaluated tracheal and pulmonary artery image quality using a 5-point scale. Measurements were compared and the correlation between EI and PFT indices was analysed. ULDCT used 0.46 ± 0.22 mSv in radiation dose, 93.8% lower than SDCT (P < .001). There was no difference in LV and MLD among image groups (P > .05). ULDCT-ASIR-V90% and ULDCT-DLIR-M had similar image noise and EI and PD15 values to SDCT-FBP, and ULDCT-DLIR-M and ULDCT-DLIR-H had similar subjective scores to SDCT-FBP (all P > .05). ULDCT-DLIR-M provided the best correlation between EI and the FEV1/FVC and FEV1% indices in PFT, and the lowest deviations with SDCT-FBP in both EI and PD15. DLIR-M provides the best image quality and emphysema quantification for COPD patients in ULDCT. Ultra-low-dose CT scanning combined with DLIR-M reconstruction is comparable to standard dose images for quantitative analysis of emphysema and image quality.

Severe vitamin D deficiency is associated with emphysema progression in male patients with COPD.

The chronic obstructive pulmonary disease (COPD) Assessment Test (CAT) is a questionnaire used for COPD symptom assessment that is valid, reliable, and evidence based; yet, few specialty or primary care practices have formally implemented it in practice. The University of Colorado's pulmonary division has consistently been rated the best in the country by US News and World Reports; however, the dedicated multidisciplinary COPD clinic at the University had yet to formally implement any COPD Assessment tools for COPD symptom management. This quality improvement project focused on the successful implementation of the CAT for management of COPD and whether its use impacts symptom management. Plan-Do-Study-Act cycles were used to implement the CAT questionnaire in the outpatient COPD clinic from April 16 to September 30, 2019. Weekly retrospective chart evaluation was completed to evaluate CAT completion, documentation, and associated medical intervention rates. Weekly patient phone surveys were completed on qualifying COPD patients to garner patient opinion on the utility of the CAT in symptom management. The CAT was administered to all COPD patients in University of Colorado Hospital's COPD clinic. Cat-themed signs, decorations, and treats were provided to staff on COPD clinic days to increase staff buy-in. The CAT was completed on 217 of 245 (89%) patients with COPD. Of patients surveyed, 81% (n = 53) noted that their symptoms were better managed after CAT implementation. Implementation and utilization of COPD assessment tools, like the CAT, are practical and sustainable in a specialty practice setting. Moreover, the CAT helps with COPD symptom management.

To further validate the ability of ultrashort echo-time (UTE) magnetic resonance imaging (MRI) in quantifying lung density in patients diagnosed with chronic obstructive pulmonary disease (COPD) and to develop an MRI-based emphysema index (EI). Ten subjects clinically diagnosed with COPD (5M/5F, age 62.6 ± 8.5 years) and ten healthy subjects (2M/8F, age 48.9 ± 19.2 years) were imaged via UTE MRI at 3T (4 mm slices, 1.39 × 1.39 mm2 pixels). Chest computed tomography (CT) images (generally 5 mm slices, ≈0.55 × 0.55 mm2 pixels), acquired retrospectively, were compared to UTE MRI. CT lung densities, MR lung-signal density, and EI were quantified from both CT and UTE MR images via a quantitative automated analysis and compared to the percent predicted forced expiratory volume in 1 second (FEV1 % predicted). EI quantified in controls via CT and UTE MRI was 0.23 ± 0.78% and 2.40 ± 1.50%, respectively; in COPD subjects it was 13.3 ± 14.9% (P = 0.021) and 12.0 ± 9.8% (P = 0.013), respectively. Bland-Altman determined the mean differences and 95% limits of agreement for COPD subjects and healthy controls were 0.06 (12.50 to -12.38). Strong correlation (R2 = 0.79, P < 0.0001) existed between EIs quantified from both CT and UTE MRI. There was a slightly higher correlation between FEV1 % predicted and the UTE MRI EI (R2 = 0.65, P < 0.0001) compared to CT EI (R2 = 0.49, P < 0.0001). Our results demonstrate a significant positive correlation between lung density and EI assessed with CT and MRI. Furthermore, UTE MRI exhibits its potential as a diagnostic alternative to CT for assessing the extent and the severity of emphysema, particularly for longitudinal studies. J. Magn. Reson. Imaging 2016;44:1656-1663.

General Practice/Family Medicine (GP/FM) has an important role in the management of chronic obstructive pulmonary disease (COPD), which is receiving an increasing interest in primary care. A literature review was made with the aim of comparing the clinical practice guidelines for COPD with a relevance to GP/FM and exploring any potential sources of discrepancy among their recommendations. We searched the computerized database MEDLINE (PubMed) (from 1990 to 2001) using a combination of key words. Six leading journals (New England Journal of Medicine, Lancet, JAMA, BMJ, Thorax and Chest) were thoroughly searched manually. All clinical practice guidelines for COPD and research papers in relation to their dissemination or their implementation in General Practice, written in English, French or German were included in our review. Each paper was independently reviewed twice. The reviewers examined the guidelines and research papers for specific components regarding the management of COPD in GP. 24 articles fulfilled our review criteria. We found significant disagreement among clinical practice guidelines regarding the assessment of COPD. Furthermore, evidence based knowledge in GP, as this was reflected from the selected research papers, often contrasted with the recommendations. Key issues from these discrepancies are presented and discussed. Although interest in the management of COPD in primary care is on the increase, evidence based clinical practice guidelines for COPD in General Practice is still a neglected subject.

Introduction: Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of osteoporosis. In these patients, the relationship between osteoporosis measured by bone density in chest computed tomography (CT) and dual-energy X-ray absorptiometry (DXA) is not well established. Objectives: To determine the association between the bone mineral density (BMD) measured in the first lumbar vertebra (L1) of a low dose chest CT (LDCT) with the one measured in a bone DXA. We also aim at exploring the possible association of this measurement with the severity of radiological emphysema. Methods: 43 COPD patients with emphysema were evaluated. In a LDCT we determined BMD in the central part of L1 body. DXA was in all patients. The quantification of emphysema in CT was performed using a specific software (Volume, Siemens Healthcar) considering 3 different thresholds: -900, -950 and -960 Hounsfield Units (HU), and the emphysema index (EI) was calculated. Spearman correlation coefficient was used for the statistical analysis. Results: The correlation between the BMD in L1 by CT and the lumbar spine (L1-L4) density by DXA was 0.40 (p Conclusions: There is a weak correlation between BMD measured in CT and DXA. In the same way, there is a weak inverse correlation between IE and BMD determined by CT. Further studies are needed to establish the relationship between these two diseases processes.