Advanced COPD Research Articles

CHRONIC OBSTRUCTIVE PULMONARY DISEASE - THERAPY AND REHABILITATION

The basis of pharmacological treatment are bronchodilatory drugs, which include sympathomimetic and anticholinergic drugs. Another group of drugs dilating the bronchi is methylxanthines. In the treatment of stable course of COPD, the most common way of administering drugs is by inhalation route. Antibiotic treatment is used when the infection is the cause of COPD intensification. In patients with COPD, controlled oxygen therapy is also used. The methods of COPD surgical treatment include: (1) surgical lung volume reduction (IZOP), that is the removal of the most altered emphysema, (2) emphysema excision (bulelectomy), that is excision of emphysema which helps lung function and reduces dyspnoea, (3) transplantation of lungs is performed in patients with very advanced COPD. Respiratory rehabilitation is a supplement to pharmacological treatment. In order to implement the rehabilitation, rehabilitation programmes developed by medical centers and other healthcare institutions have been created. The current rehabilitation consists of several elements: (1) education, (2) physical exercise, (3) behavioral interaction.

Attitudes to specialist palliative care and advance care planning in people with COPD: a multi-national survey of palliative and respiratory medicine specialists

BackgroundChronic obstructive pulmonary disease (COPD) guidelines recommend early access to palliative care together with optimal, disease-directed therapy for people with advanced disease, however, this occurs infrequently. This study explored the approaches of respiratory and palliative medicine specialists to palliative care and advance care planning (ACP) in advanced COPD.MethodsAn online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom.ResultsFive hundred seventy-seven (33.1%) responses were received, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Most respiratory doctors (140, 80.9%) were very or quite comfortable providing a palliative approach themselves to people with COPD. 113 (63.8%) respiratory doctors recommended referring people with advanced COPD to specialist palliative care, mainly for access to: psychosocial and spiritual care (105, 59.3%), carer support (104, 58.5%), and end-of-life care (94, 53.1%). 432 (98.2%) participants recommended initiating ACP discussions. Palliative medicine doctors were more likely to recommend discussing: what palliative care is (p < 0.0001), what death and dying might be like (p < 0.0001) and prognosis (p = 0.004). Themes highlighted in open responses included: inadequate, fragmented models of care, with limited collaboration or support from palliative care services.ConclusionsWhile both specialties recognised the significant palliative care and ACP needs of people with advanced COPD, in reality few patients access these elements of care. Formal collaboration and bi-directional support between respiratory and palliative medicine, are required to address these unmet needs.

First year experiences with a palliative out-patients structure for patients with COPD: a qualitative study of health professionals\u2019 expectations and experiences

BackgroundTo improve the care of patients with advanced COPD and be able to address their palliative needs a new outpatient organization (CAPTAIN) was developed and implemented. CAPTAIN was inspired by best practice and existing guidelines and changed the traditional organization of an outpatient structure including the roles of nurses and doctors. Only sparse knowledge exists of the health professionals’ expectations and experiences to organizational changes in an outpatient setting. This insight is necessary as health professionals are key stakeholders in implementing new structures and successfully transforming knowledge into practice. The aim of this study was to explore the health professionals’ expectations and experiences of a new palliative out-patients structure for patients with advanced COPD.MethodsThe design was interpretive description as described by Thorne. Focus groups and individual interviews were conducted with pulmonary nurses, pulmonary doctors and municipality nurses from 2014 to 2016.ResultsThe overall theme was dualism. Both nurses and doctors were pending between aspiration and concern in their expectations to the new structure, meanwhile their actual experiences were pending between perceived gain and improvements versus consequences with the new structure. Nurses’ and doctors’ existing practice was altered and the new structure required new ways for them to cooperate and ways in which skills from each profession were most efficiently utilized.ConclusionNurses and doctors considered the new structure as a quality boost and it fulfilled their hope of improving the quality of care offered to patients with advanced COPD, however with increased work-related stress as a derived consequence.

CT Imaging-Based Low-Attenuation Super Clusters in Three Dimensions and the Progression of Emphysema

Distributions of low-attenuation areas in two-dimensional (2-D) CT lung slices are used to quantify parenchymal destruction in patients with COPD. However, these segmental approaches are limited and may not reflect the true three-dimensional (3-D) tissue processes that drive emphysematous changes in the lung. The goal of this study was to instead evaluate distributions of 3-D low-attenuation volumes, which we hypothesized would follow a power law distribution and provide a more complete assessment of the mechanisms underlying disease progression. CT scans and pulmonary function test results were acquired from an observational database for N= 12 patients with COPD and N= 12 control patients. The data set included baseline and two annual follow-up evaluations in patients with COPD. Three-dimensional representations of the lungs were reconstructed from 2-D axial CT slices, with low-attenuation volumes identified as contiguous voxels< -960 Hounsfield units. Low-attenuation sizes generally followed a power law distribution, with the exception of large, individual outliers termed "super clusters," which deviated from the expected distribution. Super cluster volume was correlated with disease severity (%total low attenuation, ρ = 0.950) and clinical measures of lung function including FEV1 (ρ= -0.849) and diffusing capacity of the lung for carbon monoxide Dlco (ρ= -0.874). To interpret theseresults, we developed a personalized computational model of super cluster emergence. Simulations indicated disease progression was more likely to occur near existing emphysematous regions, giving rise to a biomechanical, force-induced mechanism of super cluster growth. Low-attenuation super clusters are defining, quantitative features of parenchymal destruction that dominate disease progression, particularly in advanced COPD.

EVALUATING PATIENT PREFERENCES OF MAINTENANCE THERAPY FOR THE TREATMENT OF COPD: A DISCRETE CHOICE EXPERIMENT

SESSION TITLE: Obstructive Lung Diseases 3 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: With new single-inhaler triple therapies available for maintenance treatment of advanced COPD and a wide variety of existing treatments, which can vary in terms of regimen and number of inhalers, improved understanding of patient preferences can be used to inform physicians’ prescribing decisions. As part of a wider effort to understand patient preference in both the USA and Europe, a study was conducted in the USA, UK and Germany using discrete choice experiment (DCE) methodology to assess patient treatment preferences in COPD. This abstract presents results from the USA only. METHODS: Following qualitative research in patients with COPD, attributes describing features of COPD maintenance treatments were identified: ease of inhaler use, number of exacerbations, frequency of inhaler use, number of different inhalers used, side-effects, and out of pocket costs. The DCE experimental design comprised 18 choice sets with logical (dominant) choice and consistency checks also included. Demographic and disease history data were collected and the survey was administered online. Cognitive debriefing interviews and a pilot study concluded that the survey was feasible to conduct and easily understood by respondents. The final DCE survey was completed by 150 patients in the USA recruited from patient panels. Responses to the DCE were analysed using mixed-effect logit models with the results expressed as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Of the 150 US respondents, 147 (98%) answered the logical choice check correctly and were included in the final models; 114 (76%) selected the same choice within the consistency check. Patients placed most value on an inhaler reducing exacerbation rates (OR 0.59 [95% CI: 0.54-0.65] per exacerbation per year) and avoiding a lot of side effects (0.12 [0.10-0.16] versus “no side effects”). Patients preferred treatments with fewer inhalers (0.67 [0.61-0.73] per inhaler), taken less frequently (0.78 [0.71-0.85] per daily dose), and were also likely to opt for a cheaper option if the efficacy of their treatment is not compromised (1.22 [1.12-1.33] per 5% decrease in cost). CONCLUSIONS: This study suggests that patients in the USA with COPD may place highest value on the improvement in efficacy and avoidance of side effects when choosing a treatment. They also recognised the benefit of an inhaler that is used less frequently, is less costly, and is easier to use. CLINICAL IMPLICATIONS: Patient inhaler preference is important when selecting COPD treatment as preference for an inhaler may improve treatment compliance. Patients in the USA preferred efficacious and safe, easy to use maintenance therapy for the treatment of their COPD. DISCLOSURES: No relevant relationships by Helen Doll, source=Web Response Employee relationship with GSK Please note: >$100000 Added 03/01/2018 by Necdet Gunsoy, source=Web Response, value=Salary Employee relationship with GSK Please note: $20001 - $100000 Added 03/01/2018 by Necdet Gunsoy, source=Web Response, value=Shares Employee relationship with GlaxoSmithKline Please note: >$100000 Added 03/01/2018 by Afisi Ismaila, source=Web Response, value=Salary Employee relationship with GSK Please note: >$100000 Added 03/01/2018 by Paul Jones, source=Web Response, value=Salary No relevant relationships by Hannah Lewis, source=Web Response No relevant relationships by Samuel Llewellyn, source=Web Response Employee relationship with GSK Please note: $20001 - $100000 Added 03/01/2018 by Melanie Schroeder, source=Web Response, value=Salary

Oropharyngeal swallow physiology and swallowing-related quality of life in underweight patients with concomitant advanced chronic obstructive pulmonary disease.

BackgroundSwallowing impairment (dysphagia) has been associated with COPD and may contribute to exacerbations of this chronic and progressive disease. Further, risk of mortality increases with concomitant presence of cachexia in the COPD population. The purpose of this prospective study was to depict oropharyngeal swallowing physiology in underweight patients with stable but advanced-stage COPD.Patients and methodsTen underweight patients with stable but advanced COPD underwent a modified barium swallow study. Analysis of oropharyngeal swallowing function was completed using the standardized Modified Barium Swallow Impairment Profile and the Penetration–Aspiration Scale. Scores from the Dysphagia Handicap Index and 10-item Eating Assessment Tool were collected to assess patient perception of swallowing difficulty. Findings were compared to age- and sex-matched healthy controls.ResultsSignificantly higher MBSImP oral total scores (P=0.007) were observed in COPD patients compared to matched controls, but no difference was observed in pharyngeal total scores (P=0.105). Patients with COPD had significantly higher maximum PAS scores compared with controls (P=0.030). There was no significant difference in EAT-10 or DHI scores between patients with COPD and controls (P=0.41 and P=0.08, respectively).ConclusionUnderweight patients with severe but stable COPD present with dysphagia that may not be recognized by the patient. Further investigation is needed to elucidate the interaction between the respiratory–swallowing systems, how muscular weakness may contribute to swallowing impairment, and responsiveness to swallowing treatment.

The Effect of Opioid Use on Pulmonary Function Test in Advanced COPD Patients

Background: Opium has previously been shown to increase exercise endurance and decrease breathlessness in patients with chronic obstructive pulmonary disease, but controversy in this issue persists, therefore the role of opium in the management of patients with advanced COPD remains undefined. Method: In order to compare the effects of opium on pulmonary function, we studied two groups of patients with COPD who were attending the chest clinic of Labaffinejad hospital. Group A-consisted of COPD patients with history of smoking alone and group B-patients who consumed opium in addition to cigarette smoking. Patients were matched for their age, and packs/year cigarette smoking habit. Individuals with history of heart disease or occupational lung disease and those with severe COPD who needed hospitalization during 6 months prior to the study were excluded. A complete history and physical examination was done and patients' chest X-ray was taken. For each patient pulmonary function was evaluated by spirometry using Fukuda, Spirometric FVC, FEV 1, FEV 1 / FVC and predicted value for each parameter was recorded, and results were compared between the two groups of patients. Statistical analysis was done by using Kolmogorov - Smirnov test and student t-test. Results: Results shows that there is significant difference (p = 0) between the two groups for FVC and FEVI. We concluded that opium may have a beneficial effect in improving lung function in patients with severe COPD.

COPD Advanced Patient Management

COPD is the third leading cause of death in the United States, with current rates of both morbidity and mortality persisting and contributing significantly to long-term disability. More than 11 million Americans are diagnosed with COPD, with an additional 13 million people estimated to be living with undiagnosed disease. For patients diagnosed with COPD, the turning point will be hospitalization. It is important, therefore, that new treatment techniques that manage the signs and symptoms of the COPD and impact the prevalence and severity of exacerbations, hospital admissions, quality of life, and activities of daily living, and innovative clinical management strategies that optimize hospital discharge planning, all show promise in improving outcomes for patients with COPD. In particular, readmissions following COPD hospitalization are associated with high morbidity, mortality, and costs of care, and therefore hospital readmissions are receiving close scrutiny as an opportunity to improve patient care. To this end, programs to assess the presence and severity of dyspnea, and secretion burden and clearance, through implementation of a telemedicine program, use of noninvasive ventilation or supplemental oxygen, and development of a comprehensive self-management program have all been found to be variously effective aselements of a posthospitalization treatment plan. Inthis series of multi-media presentations and roundtable discussions published in CHEST (available at http://journal.cme.chestnet.org/copd-advanced-patient), leading international faculties discuss some of these specific interventions in detail to provide clinicians with possible solutions to the challenges of managing their patients with advanced COPD.

Individualized breathlessness interventions may improve outcomes in patients with advanced COPD.

Many patients with advanced COPD experience refractory breathlessness and individualized breathlessness interventions may improve management of this complex symptom. The aims of this study were to develop, implement and assess the efficacy of a breathlessness intervention for patients with COPD and refractory breathlessness and to evaluate patient acceptability. An individualized breathlessness plan, information leaflets, breathlessness education and a hand-held fan were offered to consecutive patients with severe COPD and refractory breathlessness attending a tertiary integrated respiratory and palliative care service. Validated dyspnoea, quality of life and anxiety/depression questionnaires were administered at baseline and after 6 weeks, with change in dyspnoea scores being the primary outcome measure. A subset of patients participated in a structured telephone interview to qualitatively assess the intervention. Twenty-six patients with severe COPD (mean forced expiratory volume in 1 s (FEV1 ) 38%) were included, with a mean age of 74 years. Mean modified Medical Research Council Breathlessness Scale score was 3.5. Anxiety and depression were common, being present in 38% and 35% of participants. At 6 weeks, there was a clinically significant improvement in breathlessness severity as measured by the Numerical Rating Scale. The subset of patients with anxiety/depression also saw significant improvement in all domains of the Self-Administered Standardized Chronic Respiratory Questionnaire (CRQ-SAS). Patients reported that the intervention was highly useful and acceptable. This feasibility study of individualized breathlessness interventions in patients with severe COPD and refractory breathlessness is the first to demonstrate a clinically significant reduction in dyspnoea scores, with high levels of patient acceptability.

Differing Approaches to Managing the Chronic Breathlessness Syndrome in Advanced COPD: A Multi-National Survey of Specialists

This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease. A voluntary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both specialties most commonly recommended a combination of non-pharmacological and pharmacological breathlessness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no specific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches. Integrated services, which combine the complementary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.

The influence of disease severity and lifestyle factors on the peak annual 25(OH)D value of COPD patients.

BackgroundThe prevalence of individuals deficient in vitamin D (defined as a serum level of the stable metabolite 25(OH)D <50 nmol/L) is increasing in countries with low annual ultraviolet (UV) radiation and among individuals unable to perform outdoor activities, for example, COPD patients.ObjectiveTo assess the role of vitamin D deficiency, independently of seasonal variation, the peak annual value of 25(OH)D was measured in subjects with advanced COPD ± long-term oxygen therapy (LTOT) and lung healthy control subjects. A method to grade the individual annual UV light exposure was designed and tested.Subjects and methodsSixty-six Caucasians with advanced COPD (28 with LTOT) and 47 control subjects were included, and the levels of 25(OH)D were determined in late summer/early fall when the annual peak was assumed. Questionnaires about COPD symptoms, general health, lifestyle, dietary habits and QoL were used to collect data. Lung function tests and blood sampling were performed.ResultsThe peak annual 25(OH)D of COPD subjects was significantly lower than in the control subjects, but there was no significant difference between COPD patients with and without LTOT. Ongoing vitamin D supplementation was the single most important intervention to maintain 25(OH)D levels ≥50 nmol/L. Among vitamin D-deficient COPD subjects, 25(OH) D correlated positively with forced expiratory volume in 1 second as % predicted, Modified British Medical Research Council score, blood oxygenation, food portion size, Mediterranean Diet Score and Ultraviolet Score.ConclusionVitamin D deficiency was common among healthy individuals and COPD subjects. Peak annual 25(OH)D levels of COPD subjects correlated with clinically important outcomes. The present study emphasizes the need to routinely monitor vitamin D status among patients with advanced COPD and to consider to medicate those with vitamin D deficiency with vitamin D supplementation.

Clinical impact of episodic nocturnal hypercapnia and its treatment with noninvasive positive pressure ventilation in patients with stable advanced COPD

PurposeEpisodic nocturnal hypercapnia (eNH) caused by rapid eye movement (REM) sleep-related hypoventilation is often noted in patients with advanced COPD. The purpose of this study was to clarify the clinical significance of eNH and the effectiveness of eNH-targeted noninvasive positive pressure ventilation (NPPV).Patients and methodsWe enrolled patients with stable, severe, or very severe COPD with daytime arterial partial oxygen pressure PaO2 ≥55 mmHg and daytime arterial partial carbon dioxide pressure PaCO2 <55 mmHg, who underwent overnight transcutaneous carbon dioxide pressure (PtcCO2) monitoring from April 2013 to April 2016. We retrospectively compared clinical characteristics, daytime blood gas analysis, frequency of exacerbation, serum albumin levels, and ratio of pulmonary artery to aorta diameter (PA:A ratio), between patients with COPD with and without eNH. For those with eNH, we applied NPPV and compared these clinical characteristics before and after NPPV.ResultsTwenty-one patients were finally included in this study. Ten patients (47.6%) were evaluated to have eNH. These patients had lower albumin levels (p=0.027), larger PA:A ratio (p=0.019), and higher frequency of exacerbations during the last year (p=0.036). NPPV for the patients with eNH improved daytime PaCO2 compared with that 12 months after NPPV (p=0.011). The frequency of exacerbations 1 year before NPPV decreased 1 year after NPPV (p=0.030). Serum albumin levels improved 1 year after NPPV (p=0.001).ConclusionIn patients with stable severe or very severe COPD, eNH may be a risk factor of exacerbations, hypoalbuminemia, and pulmonary hypertension. NPPV may be effective against hypoalbuminemia and acute exacerbations. However, further study is necessary to validate these findings.

The FULFIL trial: Twitter discussions from a respirology journal club (@respandsleepjc, #rsjc)

In patients with advanced COPD with persistent symptoms and at risk of exacerbations, triple inhaled therapy (ICS/LAMA/LABA) may improve lung function and patient-reported outcomes,1 although limit...

Single inhaler triple therapy (ICS/LAMA/LABA) in patients with advanced COPD: German responder results for patient reported symptom E-RS and subscale analyses from the FULFIL trial

Single inhaler triple therapy (ICS/LAMA/LABA) in patients with advanced COPD: German responder results for patient reported symptom E-RS and subscale analyses from the FULFIL trial

The contribution of symptoms and comorbidities to the economic impact of COPD: an analysis of the German COSYCONET cohort.

BackgroundAlthough patients with COPD often have various comorbidities and symptoms, limited data are available on the contribution of these aspects to health care costs. This study analyzes the association of frequent comorbidities and common symptoms with the annual direct and indirect costs of patients with COPD.MethodsSelf-reported information on 33 potential comorbidities and symptoms (dyspnea, cough, and sputum) of 2,139 participants from the baseline examination of the German COPD cohort COSYCONET was used. Direct and indirect costs were calculated based on self-reported health care utilization, work absence, and retirement. The association of comorbidities, symptoms, and COPD stage with annual direct/indirect costs was assessed by generalized linear regression models. Additional models analyzed possible interactions between COPD stage, the number of comorbidities, and dyspnea.ResultsUnadjusted mean annual direct costs were €7,263 per patient. Other than COPD stage, a high level of dyspnea showed the strongest driving effect on direct costs (+33%). Among the comorbidities, osteoporosis (+38%), psychiatric disorders (+36%), heart disease (+25%), cancer (+24%), and sleep apnea (+21%) were associated with the largest increase in direct costs (p<0.01). A sub-additive interaction between advanced COPD stage and a high number of comorbidities reduced the independent cost-driving effects of these factors. For indirect costs, besides dyspnea (+34%), only psychiatric disorders (+32%) and age (+62% per 10 years) were identified as significant drivers of costs (p<0.04). In the subsequent interaction analysis, a high number of comorbidities was found to be a more crucial factor for increased indirect costs than single comorbidities.ConclusionDetailed knowledge about comorbidities in COPD is useful not only for clinical purposes but also to identify relevant cost factors and their interactions and to establish a ranking of major cost drivers. This could help in focusing therapeutic efforts on both clinically and economically important comorbidities in COPD.

A case series of an off-the-shelf online health resource with integrated nurse coaching to support self-management in COPD.

BackgroundCOPD has significant psychosocial impact. Self-management support improves quality of life, but programs are not universally available. IT-based self-management interventions can provide home-based support, but have mixed results. We conducted a case series of an off-the-shelf Internet-based health-promotion program, The Preventive Plan (TPP), coupled with nurse-coach support, which aimed to increase patient activation and provide self-management benefits.Materials and methodsA total of 19 COPD patients were recruited, and 14 completed 3-month follow-up in two groups: groups 1 and 2 with more and less advanced COPD, respectively. Change in patient activation was determined with paired t-tests and Wilcoxon signed-rank tests. Benefits and user experience were explored in semistructured interviews, analyzed thematically.ResultsOnly group 1 improved significantly in activation, from a lower baseline than group 2; group 1 also improved significantly in mastery and anxiety. Both groups felt significantly more informed about COPD and reported physical functioning improvements. Group 1 reported improvements in mood and confidence. Overall, group 2 reported fewer benefits than group 1. Both groups valued nurse-coach support; for group 1, it was more important than TPP in building confidence to self-manage. The design of TPP and lack of motivation to use IT were barriers to use, but disease severity and poor IT skills were not.DiscussionOur findings demonstrate the feasibility of combining nurse-coach support aligned to an Internet-based health resource, TPP, in COPD and provide learning about the challenges of such an approach and the importance of the nurse-coach role.

Once-Daily Triple Therapy in Patients with Advanced COPD: Healthcare Resource Utilization Data and Associated Costs from the FULFIL Trial.

IntroductionChronic obstructive pulmonary disease is associated with a high healthcare resource and cost burden. Healthcare resource utilization was analyzed in patients with symptomatic chronic obstructive pulmonary disease at risk of exacerbations in the FULFIL study. Patients received either once-daily, single inhaler triple therapy (fluticasone furoate/umeclidinium/vilanterol) 100 µg/62.5 µg/25 µg or twice-daily dual inhaled corticosteroid/long-acting beta agonist therapy (budesonide/formoterol) 400 µg/12 µg.MethodsFULFIL was a phase III, randomized, double-blind, double-dummy, multicenter study. Unscheduled contacts with healthcare providers were recorded by patients in a daily electronic diary; the costs of healthcare resource utilization were calculated post hoc using UK reference costs.ResultsOver 24 weeks, slightly fewer patients who received fluticasone furoate/umeclidinium/vilanterol (169/911; 18.6%) required contacts with healthcare providers compared with budesonide/formoterol (180/899; 20.0%). Over 52 weeks in an extension population, fewer patients who received fluticasone furoate/umeclidinium/vilanterol required unscheduled contacts with healthcare providers compared with budesonide/formoterol (25.2% vs. 32.7%). Non-drug costs per treated patient per year were lower in the fluticasone furoate/umeclidinium/vilanterol group than the budesonide/formoterol group over 24 and 52 weeks (£653.80 vs. £763.32 and £749.22 vs. £988.03, respectively), with the total annualized cost over 24 weeks being slightly greater for fluticasone furoate/umeclidinium/vilanterol than budesonide/formoterol (£1,289.35 vs. £1,267.45).ConclusionsThis healthcare resource utilization evidence suggests that, in a clinical trial setting over a 24- or 52-week timeframe, non-drug costs associated with management of a single inhaler fluticasone furoate/umeclidinium/vilanterol are lower compared with twice-daily budesonide/formoterol.Trial RegistrationClinicalTrials.gov number: NCT02345161.FundingGSKElectronic supplementary materialThe online version of this article (doi:10.1007/s12325-017-0604-x) contains supplementary material, which is available to authorized users.

Spreading improvements for advanced COPD care through a Canadian Collaborative.

BackgroundA year-long pan-Canadian quality improvement collaborative (QIC) led by the Canadian Foundation for Healthcare Improvement (CFHI) supported the spread of the successful Halifax, Nova Scotia-based INSPIRED COPD Outreach Program™ to 19 teams in the 10 Canadian provinces. We describe QIC results, addressing two main questions: 1) Can the results of the Nova Scotia INSPIRED model be replicated elsewhere in Canada? 2) How did the teams implement and evaluate their versions of the INSPIRED program?MethodsCollaborative faculty selected measures that were evidence-based, relatively simple to collect, and relevant to local context. Chosen process and outcome measures are related to four quality domains: 1) patient- and family-centeredness, 2) coordination, 3) efficiency, and 4) appropriateness. Evaluation of a complex intervention followed a mixed-methods approach.ResultsMost participants were nurse managers and/or COPD educators. Only 8% were physicians. Fifteen teams incorporated all core INSPIRED interventions. All teams carried out evaluation. Thirteen teams actively involved patients and families in customized, direct care planning, eg, asking them to complete evaluative surveys and/or conducting interviews. Patients consistently reported greater self-confidence in symptom management, a return to daily activities, and improvements to quality of life. Twelve teams collected data on care transitions using the validated three-item Care Transitions Measure (CTM-3). Twelve teams used the Lung Information Needs Questionnaire (LINQ). Admissions, emergency room visits, and patient-related costs fell substantially for two teams described in detail (combined enrollment 208 patients). Most teams reported gaining deeper knowledge around complexities of COPD care, optimizing patient care through action plans, self-management support, psychosocial support, advance care planning, and coordinating community partnerships.ConclusionQuality-of-care gains are achievable in the short term among different teams across diverse geographical and social contexts. A well-designed, adequately funded public–private partnership can deliver widespread beneficial outcomes for the health care system and for those living with advanced COPD.

Hypercapnia Inhibits Host Defense Against Influenza A Virus by Potentiating Virus‐induced Activation of the PI3K/Akt Pathway

RationaleHypercapnia, the elevation of CO2 in blood and tissue, commonly develops in advanced COPD and is associated with frequent and potentially fatal pulmonary bacterial and viral infections, including influenza. We previously reported that hypercapnia downregulates several innate immune genes and increases the mortality of bacterial pneumonia and influenza A virus (IAV) infection in mice. High CO2 also increases viral nucleoprotein (NP) expression in the mouse lung, primarily in alveolar macrophages (MØs). In the current study, we explored the effect of hypercapnia on the PI3K/Akt pathway during IAV infection in MØs. In addition, using pharmacologic PI3K and Akt inhibitors we studied the role of hypercapnia‐induced activation of Akt on the expression of antiviral proteins, including MX dynamin like GTPase 1 (MX1), 2′‐5′‐oligoadenylate synthetase 1 (OAS1) and viperin; viral nonstructural 1 protein 1 (NS1) and NP.MethodsHuman alveolar and PMA‐differentiated THP‐1 MØs as well as murine alveolar and bone marrow derived MØs were cultured in 5% CO2 (PCO2 36 mmHg; normocapnia) or 15% CO2 (PCO2 108 mmHg; hypercapnia) and infected with IAV. Akt activation was assessed by immunoblot and immunofluorescence microscopy (IF). MX1, OAS1 and viperin mRNA and protein levels were determined using qPCR and immunoblot or IF, respectively. IAV replication was assessed using MDCK plaque assay, and NS1 and NP expression were determined by immunoblot or IF. For in vivo studies, mice were pre‐exposed to normoxic hypercapnia (10% CO2/21% O2) for 3 days, or air as control, then infected with IAV. Mice were sacrificed 4 days after infection for determination of antiviral and viral proteins expression in lung tissue by immunoblot and IF.ResultsHypercapnia potentiated IAV‐induced Akt activation in MØs in vivo and in vitro, an effect blocked by the PI3K inhibitor LY294002 and the Akt inhibitor MK2206. In addition, elevated CO2 decreased MX1, OAS1 and viperin mRNA and protein expression and increased viral replication and NS1 and NP proteins in IAV infected human and mouse MØs. Hypercapnia also increased viral protein expression in alveolar MØs, and decreased antiviral proteins and augmented viral titers in the lungs of IAV‐infected mice. We also found that the PI3K and Akt inhibitors blocked the hypercapnia‐induced suppression of antiviral proteins and the increase on viral proteins and IAV replication in vitro.ConclusionHypercapnia decreases antiviral proteins and increases viral NS1 and NP proteins and virus replication in MØs following IAV infection in vivo and in vitro. The effect of elevated CO2 on the macrophage antiviral response and virus production can be blocked by small molecule inhibitors of PI3K and Akt, suggesting a link between hypercapnia‐induced activation of the PI3K/Akt pathway and an impaired antiviral host response. Therefore, PI3K/Akt inhibitors may hold promise as pharmacotherapy to improve antiviral host defense in patients with advanced lung disease and hypercapnia.Support or Funding InformationR01HL107629, R56HL131745, P01AG049665

Spiritual Well-Being and Correlated Factors in Subjects With Advanced COPD or Lung Cancer

Spiritual care for patients with COPD has rarely been discussed, and thus much remains unknown about their needs. The aims of this study were to identify the factors associated with spiritual well-being and to compare the levels of spiritual well-being between subjects with advanced COPD and those with inoperable lung cancer. A total of 96 subjects with COPD or lung cancer participated in this study, which was conducted between December 2014 and April 2016. Measures included the Japanese version of the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp-12) scale, the McGill Quality of Life Questionnaire (MQOL), the modified Medical Research Council (mMRC) dyspnea scale, and various other medico-social factors. No significant differences were found between subjects with COPD and those with lung cancer in median FACIT-Sp-12 scores (COPD, 27; lung cancer, 26; P = .81). However, significant differences were found in the 2 MQOL domains, suggesting that subjects with COPD had a better psychological state (P = .01) and that subjects with lung cancer had a better support state (P = .002). Multiple regression analysis revealed that mMRC was significantly associated with FACIT-Sp-12 scores in subjects with COPD. These results suggest that subjects with advanced COPD experience spiritual well-being similar to that of subjects with inoperable lung cancer.