Clinical Diagnosis Of Chronic Obstructive Pulmonary Disease Research Articles

Peak Flow and Mini-spirometry in the Diagnosis of Obstructive Airway Diseases

Background: India is initiating measures to address Chronic Obstructive Pulmonary Disease(COPD) and Asthma, major causes of mortality and morbidity, at the primary care level. The efforts are limited by the lack of access to spirometry. Various alternatives are being tried out in resource limited countries. Methods: A hospital based cross-sectional study was done at two tertiary care hospitals in Trivandrum, South India, in patients with a clinical diagnosis of COPD or Asthma. Spirometry was done by a trained spirometry technician, along with peak-flow recording and a recording on portable mini-spirometer (COPD6 ®). The values obtained by the latter two were compared to those obtained by spirometry. Results: The study included 360 patients. PEFR showed a positive correlation with both FEV1/FVC as well as FEV1 (R2 of 0.35 and 0.65, respectively). FEV1/FEV6 and FEV1 on COPD6 also correlated positivity with FEV1 and FEV1/FVC on spirometry (R2 of 0.68 and 0.89, respectively). Sensitivity and specificity of PEFR to diagnose obstruction was best at a cut-off of 74% of predicted, as determined by ROC, giving sensitivity of 84.8% and specificity of 85.1%. Sensitivity and specificity of COPD6 to detect obstruction was 75.9% and 95.7%, respectively. Conclusion: Mini-spirometry (COPD6) and peak-flow measurement may be used as alternatives to spirometry in resource limited settings as in the primary care centers of India for the diagnosis of obstructive airway diseases.

Automated Diseased Lung Volume Percentage Calculation in Quantitative CT Evaluation of Chronic Obstructive Pulmonary Disease and Idiopathic Pulmonary Fibrosis.

Several software-based quantitative computed tomography (CT) analysis methods have been developed for assessing emphysema and interstitial lung disease. Although the texture classification method appeared to be more successful than the other methods, the software programs are not commercially available, to our knowledge. Therefore, this study aimed to investigate the usefulness of a commercially available software program for quantitative CT analyses. This prospective cohort study included 80 patients with chronic obstructive pulmonary disease (COPD) or idiopathic pulmonary fibrosis (IPF). The percentage of low attenuation volume and high attenuation volume had high sensitivity and high specificity for detecting emphysema and pulmonary fibrosis, respectively. The percentage of diseased lung volume (DLV%) was significantly correlated with the lung diffusion capacity for carbon monoxide in all patients with COPD and IPF patients. The quantitative CT analysis may improve the precision of the assessment of DLV%, which itself could be a useful tool in predicting lung diffusion capacity in patients with the clinical diagnosis of COPD or IPF.

Ethnic Variance in Prevalence of COPD among Smokers in a Real World Setting.

Introduction:Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent and progressive airflow limitation generally caused by prolonged cigarette smoking. Ethnic differences have been reported regarding COPD risk from smoking. The purpose of this study was to compare COPD prevalence in Hispanic and Caucasian smokers in a real-world setting. We studied consecutive patients referred to the community-based pulmonary practice. Hispanic and Caucasian smokers were included in the study.Methods:The clinical diagnosis of COPD was recorded from the chart. COPD was defined by PFT using GOLD criteria. Exclusion criteria were other ethnicities, non-smokers, and patients with a history of asthma /other pulmonary conditions. We reviewed a total of 1,313 consecutive PFTs of which 797 patients met our inclusion criteria.Results and Discussion:The prevalence of COPD among Hispanics was found to be lower by both clinical diagnosis as well as by spirometry compared to Caucasians (41.6% vs 54.2%). In Hispanics, clinical diagnosis was 91% higher by PFT, whereas for Caucasians, it was 6% lower. The odds of developing COPD (diagnosed based on FEV1/FVC ratio <70%) in the Caucasians are 4.1 times higher than Hispanics (Odds Ratio: 4.1; 95%CI: 2.8-5.9). Hispanic smokers have a lower prevalence of COPD both by the clinical diagnosis as well as by PFT. There is a significant disconnection between clinical and PFT diagnosis of COPD in Hispanic patients.Conclusion:The genetic basis of lower COPD risk and prevalence in Hispanics needs to be better understood. Spirometry threshold criteria for confirming a diagnosis of COPD may need to be modified based on ethnicity in clinical practice.

Body Composition, Functional Status and Clinical Outcomes in Patients with Chronic Obstructive Pulmonary Disease

Objective: To define the correlation between the Fat Free Mass Index (FFMI), the muscle function, degree of airflow obstruction, the respiratory symptoms and the number of exacerbations during the last year in patients with Chronic Obstructive Pulmonary Disease (COPD). Methods: Prospective and cross-sectional study of subjects older than 40 years with a clinical diagnosis of COPD who underwent measurement of the FFMI and muscular function to determine if these were correlated with the variables of severe COPD. Results: 55 patients Participated in the study. The FFMI was below 32.7% (n=18) and the strength diminished in 56.4% (n=31). In the sample, we found a direct and significant correlation between the FFMI and the FEV1* (predicted %), (p= 0,045). When analyzed by sex, men had a direct correlation between FFMI and the FEV1*(predicted %), (p=0,019), an inverse correlation between FFMI and the spirometric classification of the Global Initiative Obstructive Lung Disease (GOLD) (p=0,008) and between the muscular function and the symptoms (p=0, 03). In women no significant correlation was found. Conclusions: The conditions in mass and the muscular function were correlated with clinical variables and pulmonary function in men, but not in women. We did not find a correlation between corporal composition and the number of exacerbations.

2004 chronic obstructive pulmonary disease with and without bronchiectasis in Aboriginal Australians: a comparative study.

Chronic respiratory disorders are highly prevalent in Aboriginal Australian population, including chronic obstructive pulmonary disease (COPD) and bronchiectasis. However, there is paucity of information in the literature among Aboriginal patients with underlying COPD with and without bronchiectasis. In this retrospective study we evaluated the demographic and clinical characteristics of adult Aboriginal Australian patients with a clinical diagnosis of COPD with and without bronchiectasis from the remote communities of the Northern Territory of Australia. Clinical records were reviewed to extract information on demographics, respiratory and medical comorbid conditions, COPD directed treatment, hospital admission frequency and exacerbations. Chest radiology were reviewed to evaluate the presence or absence of bronchiectasis. Spirometry results, sputum culture and cardiac investigations were also recorded. Of the 767 patients assessed in the remote community respiratory outreach clinics 380 (49%) patients had a clinical diagnosis of COPD. Chest X-ray and computed tomography scan were available to evaluate the presence of bronchiectasis in 258 patients. Of the 258/380 patients, 176/258 (68.2%) were diagnosed to have COPD alone and 82/258 (31.8%) had bronchiectasis along with COPD. The mean age was 56 and 59 years among patients with and without bronchiectasis, respectively, and 57% were males with bronchiectasis. Patients with bronchiectasis had lower body mass index (22 vs 24 kg/m2 ), frequent hospital admissions (2.0 vs 1.5/year) and productive cough (32.1% vs 28.9%). Spirometry showed 77% had forced expiratory volume in 1 s (FEV1 )/forced vital capacity ratio <0.7. In 81% and 75% of patients with and without bronchiectasis the FEV1 /forced vital capacity ratio was <0.7 and the mean FEV1 was 39% and 43% respectively. About 32% of Aboriginal Australians had co-existent bronchiectasis with COPD. Lower body mass index, productive cough, frequent hospital admission and marginally more severe reduction in lung function were noted among patients with COPD and bronchiectasis compared to those with COPD in isolation.

PRS48 Prognostic Risk Factors of Moderate-to-Severe Exacerbations in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Systematic Literature Review

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. As COPD exacerbations are associated with a worsening of lung function, increased disease burden and mortality, preventing their occurrence is an important goal of COPD management. This review was conducted to identify the current evidence base regarding risk factors and predictors of moderate-to-severe exacerbations in patients with COPD. A literature review was performed in MEDLINE®, EMBASE®, MEDLINE® In-Process and the Cochrane Central Register of Controlled Trials (CENTRAL). Searches were conducted from January 2015 to July 2019. Eligible publications were journal articles, published in English, which reported risk factors or predictors for the occurrence of moderate-to-severe exacerbations in adult patients (≥40 years of age) with a clinical diagnosis of COPD. The literature review identified 5112 references, of which 134 publications (reporting results for 76 studies) met the eligibility criteria and were included in the review. Among the 76 studies included, 61 were observational and 15 were randomised controlled clinical trials. Exacerbation history was the strongest predictor of future exacerbations, with 34 studies reporting a significant association between history of exacerbations and risk of future moderate or severe exacerbations. Other significant risk factors identified in multiple studies included severe or very severe airflow obstruction (39 studies), comorbidities including respiratory infections (34 studies), symptomatic COPD (17 studies) and blood eosinophil count (16 studies). In this systematic literature review, several demographic and clinical characteristics that predict future risk of COPD exacerbations were identified. These prognostic factors may be useful for clinicians to identify patients at high risk of exacerbations, which are a major driver of the global burden of COPD, including morbidity and mortality.

Diagnosing Chronic Obstructive Airway Disease on a Smartphone Using Patient-Reported Symptoms and Cough Analysis: Diagnostic Accuracy Study.

BackgroundRapid and accurate diagnosis of chronic obstructive pulmonary disease (COPD) is problematic in acute care settings, particularly in the presence of infective comorbidities.ObjectiveThe aim of this study was to develop a rapid smartphone-based algorithm for the detection of COPD in the presence or absence of acute respiratory infection and evaluate diagnostic accuracy on an independent validation set.MethodsParticipants aged 40 to 75 years with or without symptoms of respiratory disease who had no chronic respiratory condition apart from COPD, chronic bronchitis, or emphysema were recruited into the study. The algorithm analyzed 5 cough sounds and 4 patient-reported clinical symptoms, providing a diagnosis in less than 1 minute. Clinical diagnoses were determined by a specialist physician using all available case notes, including spirometry where available.ResultsThe algorithm demonstrated high positive percent agreement (PPA) and negative percent agreement (NPA) with clinical diagnosis for COPD in the total cohort (N=252; PPA=93.8%, NPA=77.0%, area under the curve [AUC]=0.95), in participants with pneumonia or infective exacerbations of COPD (n=117; PPA=86.7%, NPA=80.5%, AUC=0.93), and in participants without an infective comorbidity (n=135; PPA=100.0%, NPA=74.0%, AUC=0.97). In those who had their COPD confirmed by spirometry (n=229), PPA was 100.0% and NPA was 77.0%, with an AUC of 0.97.ConclusionsThe algorithm demonstrated high agreement with clinical diagnosis and rapidly detected COPD in participants presenting with or without other infective lung illnesses. The algorithm can be installed on a smartphone to provide bedside diagnosis of COPD in acute care settings, inform treatment regimens, and identify those at increased risk of mortality due to seasonal or other respiratory ailments.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12618001521213; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375939

The development of a novel Wellness Assessment Instrument and its use in the assessment of wellness status in patients with chronic obstructive pulmonary disease.

Aims:Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disorder that affects health outcomes on multiple levels including overall wellbeing. More specifically, factors such as spiritual wellbeing, and psychological, mental and motivational status which may be at least as important as others, have been rarely studied. This article reports the method of validating a new wellness assessment questionnaire and the status of several wellness domains in patients with COPD.Methods:The study consisted of two phases: first, the development of a new Wellness Questionnaire with the help of focus groups; second, the validation and use of the questionnaire in a cohort of patients with COPD. For focus groups, healthy people ⩾45 years of age with no known comorbidity as well as people with a clinical diagnosis of COPD were invited to participate in the study.Results:Thematic analysis of findings from focus groups and original cohort respondents highlighted some factors that appear to influence wellness status. Five domains were explored as potential markers of wellness in patients with COPD. Quantitative analysis with Spearman correlation demonstrated a significant correlation between Physical/Personal Wellness and other markers of COPD progression such as Global Initiative Obstructive Lung Disease (GOLD; 0.006), force expiratory volume in 1 s (FEV1%; 0.01), health-related quality of life (0.009), multidimensional BOD score and quartile (0.003 and 0.02).Conclusion:The findings suggest that a combination of personal, physical, emotional, mental and other psychological factors is responsible for negative COPD outcomes. While there is a need to validate this new wellness questionnaire in further research, it incorporates new markers of wellness that could benefit management of COPD.

Pattern of comorbidities and 1-year mortality in elderly patients with COPD hospitalized in internal medicine wards: data from the RePoSI Registry.

Currently, chronic obstructive pulmonary disease (COPD) represents the fourth cause of death worldwide with significant economic burden. Comorbidities increase in number and severity with age and are identified as important determinants that influence the prognosis. In this observational study, we retrospectively analyzed data collected from the RePoSI register. We aimed to investigate comorbidities and outcomes in a cohort of hospitalized elderly patients with the clinical diagnosis of COPD. Socio-demographic, clinical characteristics and laboratory findings were considered. The association between variables and in-hospital, 3-month and 1-year follow-up were analyzed. Among 4696 in-patients, 932 (19.8%) had a diagnosis of COPD. Patients with COPD had more hospitalization, a significant overt cognitive impairment, a clinically significant disability and more depression in comparison with non-COPD subjects. COPD patients took more drugs, both at admission, in-hospital stay, discharge and 3-month and 1-year follow-up. 14 comorbidities were more frequent in COPD patients. Cerebrovascular disease was an independent predictor of in-hospital mortality. At 3-month follow-up, male sex and hepatic cirrhosis were independently associated with mortality. ICS-LABA therapy was predictor of mortality at in-hospital, 3-month and 1-year follow-up. This analysis showed the severity of impact of COPD and its comorbidities in the real life of internal medicine and geriatric wards.Electronic supplementary materialThe online version of this article (10.1007/s11739-020-02412-1) contains supplementary material, which is available to authorized users.

Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting.

Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.

The burden of chronic obstructive pulmonary disease in open heart surgery-a retrospective cohort analysis of postoperative complications: STROBE compliant.

Chronic obstructive pulmonary disease (COPD) has a major impact on mortality and morbidity in patients undergoing cardiac surgery. Mortality risk increases by 50% in patients who were re-intubated or required prolonged mechanical ventilation after the operation. The aim of this study was to assess the impact of COPD on the prediction of postoperative complications and outcome including intensive care unit (ICU) and hospital stay, postoperative morbidity and mortality in patients undergoing all types of cardiac surgery.We performed a retrospective cohort analysis of prospectively collected data from a tertiary cardiac surgery department of a university hospital between 2014 and 2016. We divided patients undergoing cardiac surgery into 2 sub-groups – the first – with a clinical diagnosis of COPD (n = 198) and the second comprised all other non-COPD patients (n = 2980).Among patients with COPD a longer intubation time (P = .039), longer ICU stay (P < .001) and longer hospitalization time (P = .006) was noted as compared with non-COPD patients. Patients with COPD required reintubation more often than non-COPD patients, reintubation occurring twice, 19 (9.60%) versus 144 (4.83%) P = .002, reintubation occurring 3 or more times, 7 (3.54%) versus 34 (1.14%) P = .006. Mortality within 30 days after surgery was higher in patients with pulmonary problems before surgery (P = .003). Multivariable logistic regression analysis corrected for interfering variables showed an increased risk of postoperative bronchoconstriction (odds ratio [OR] = 4.40, P = .002), respiratory failure (OR = 1.67, P = .018), atrial fibrillation (OR = 1.45, P = .023), and use of hemofiltration (OR = 1.60, P = .029) for patients with COPD.Patients with COPD undergoing all types of cardiac surgery are at increased risk of respiratory complications and mortality. The occurrence of COPD was associated with longer ICU and hospital stay. In COPD patients, undergoing cardiac surgery, treatment strategies aimed at preventing reintubation and early weaning mechanical ventilation must be employed to reduce postoperative complications.

The accuracy of FEF25-75/ FVC for primary classification of the pulmonary function test

Introduction: The forced expiratory flow at 25 and 75% of the pulmonary volume/forced vital capacity ratio (FEF25-75/FVC) as a spirometry parameter has been successful in the early diagnosis of chronic obstructive pulmonary disease (COPD) and the methacholine challenge test for assessing airway responsiveness.To determine the accuracy of FEF25-75/FVC for the classification of spirometry lung disease. Materials and Methods: Eighty subjects with clinical diagnosis of COPD and idiopathic pulmonary fibrosis (IPF) were entered into this case-control study. Forty normal volunteers in the control group with a PC20 of more than 8 mg/dl were also enrolled in this study. Spirometry, lung volumes, and diffusing capacity (DLCO) were measured for all the subjects by the body plethysmograph. Final diagnosis of COPD and IPF was confirmed according to patient's history, pulmonary function test, computed tomography of the lungs, and histopathology (in IPF subjects). The FEF25-75/FVC ratio was determined in each group, and test accuracy was compared with lung volumes and DLCO as the gold standard. Results: FEF25-75/FVC was able to divide the subjects into four categories and its agreement with the clinical diagnosis (kappa= 0.486) was more than the ratio of forced expiratory volume in one second per forced vital capacity (FEV1/FVC) and residual volume (RV). Accuracy assessment showed that FEF25-75/FVC had the highest likelihood ratio (133) followed by FEV1/FVC. Mid-expiratory flow parameters including FEF25-75 and FEF25-75/FVC displayed the highest sensitivity, positive predicted value, negative predicted value, and accuracy. Conclusion: FEF25-75/FVC is helpful in diagnosing difficult cases such as mixed-type spirometry or spirometry results that are not matched with clinical findings and require lung volume measurement.

Mood Monitoring Over One Year for People With Chronic Obstructive Pulmonary Disease Using a Mobile Health System: Retrospective Analysis of a Randomized Controlled Trial

BackgroundComorbid anxiety and depression can add to the complexity of managing treatment for people living with chronic obstructive pulmonary disease (COPD). Monitoring mood has the potential to identify individuals who might benefit from additional support and treatment.ObjectiveWe used data from the sElf-management anD support proGrammE (EDGE) trial to examine: (1) the extent to which the mood-monitoring components of a mobile health system for patients with COPD were used by participants; (2) the levels of anxiety and depression symptoms among study participants; (3) the extent to which videos providing advice about coping with low mood were viewed; and (4) the characteristics of participants with differing levels of mood and utilization of mood monitoring.MethodsA total of 107 men and women with a clinical diagnosis of COPD, aged ≥40 years old, were recruited to the intervention arm of the EDGE trial. Participants were invited to complete the Patient Health Questionnaire-8 and the Generalized Anxiety Disorder-7 test every four weeks using a tablet computer. Mood disturbance based on these measures was defined as a score ≥5 on either scale. Participants reporting a mood disturbance were automatically directed (signposted) to a stress or mood management video. Study outcomes included measures of health status, respiratory quality of life, and symptoms of anxiety and depression.ResultsOverall, 94 (87.9%) participants completed the 12-month study. A total of 80 participants entered at least one response each month for at least ten months. On average, 16 participants (range 8-38 participants) entered ≥2 responses each month. Of all the participants, 47 (50%) gave responses indicating a mood disturbance. Participants with a mood disturbance score for both scales (n=47) compared with those without (n=20) had lower health status (P=.008), lower quality of life (P=.009), and greater anxiety (P<.001) and increased depression symptoms (P<.001). Videos were viewed by 64 (68%) people over 12 months. Of the 220 viewing visualizations, 70 (34.7%) began after being signposted. Participants signposted to the stress management video (100%; IQR 23.3-100%) watched a greater proportion of it compared to those not signposted (38.4%; IQR 16.0-68.1%; P=.03), whereas duration of viewing was not significantly different for the mood management video.ConclusionsMonitoring of anxiety and depression symptoms for people with COPD is feasible. More than half of trial participants reported scores indicating a mood disturbance during the study. Signposting participants to an advisory video when reporting increased symptoms of a mood disturbance resulted in a longer view-time for the stress management video. The opportunity to elicit measures of mood regularly as part of a health monitoring system could contribute to better care for people with COPD.

Profile of patients with chronic obstructive pulmonary disease in Ilorin who were never-smokers.

The most recognized risk factor for chronic obstructive pulmonary disease (COPD) worldwide is cigarette smoking. However, recent surveys have revealed an increasing trend from nonsmoking causes especially from biomass exposure. This study, therefore, aimed to determine the proportion of patients and the clinical pattern of COPD among never-smokers in Ilorin. This is a retrospective study in which case records of patients with clinical diagnosis of COPD from January 2013 to December 2017 were reviewed. Data were collected with respect to their sociodemographic characteristics, clinical details, comorbid illnesses, and severity of the disease. A total of 135 case records of patients with COPD were reviewed, of which 66 had spirometric confirmation of the disease. In all, 38 (57.6%) of them were never-smokers with a male-to-female ratio of 1:1.1. The mean age of the subjects was 64.5 ± 11.7 years. Cough and exertional dyspnea were the most common symptoms (89.5% each), and systemic hypertension was the most common comorbid illness. Firewood exposure constituted the most common nonsmoking risk factor (47.4%), and the majority of the patients had mild COPD. When compared with ever-smokers, the mean post bronchodilator lung function parameters were found to be significantly better in never-smokers. Over half of COPD cases in Ilorin were never-smokers with firewood exposure as the main risk factor. This study has further highlighted the need for increased awareness of the hazards of biomass fuel exposure in our setting.

Impulse oscillometry to differentiate between chronic obstructive pulmonary disease and bronchial asthma

BackgroundThe impulse oscillation system (IOS) yields useful clinical data that predominantly include functional assessment of peripheral airways more than that available from commonly used spirometry. The aim of this study was to differentiate between chronic obstructive pulmonary disease (COPD) and bronchial asthma using IOS.Patients and methodsThis study was carried out on 40 patients; 20 patients were diagnosed with bronchial asthma and the remaining 20 patients had a clinical diagnosis of COPD. All patients underwent baseline IOS and spirometry, and then after 15 min of inhalation of 400 μg salbutamol, spirometry was repeated in all patients.ResultsA highly statistically significant difference was found between asthma patients and COPD patients in R20, whereas no statistically significant difference was found between the two studied groups in R5, X5. There was a statistically significant difference between asthma patients and COPD patients in resistance; 75% of asthmatic patients had increased total airway resistance, mainly proximal, 20% had increased total airway resistance, mainly peripheral, and 5% had normal airway resistance, whereas all COPD patients had increased total airway resistance, mainly peripheral. No significant correlation was found between IOS parameters and spirometric parameters in COPD or asthmatic patients, but in both groups, there was a significant correlation between forced expiratory volume 1 (FEV1) and R5, X5.ConclusionIOS provides useful clinical information that prominently includes functional assessment of small, peripheral airway behavior beyond that available from commonly used pulmonary function tests. IOS also aids differentiation between COPD and bronchial asthma. COPD patients had increased airway resistance, mainly in the peripheral airways, whereas asthmatic patients had increased airway resistance, mainly in the proximal airways. R20 is the best IOS parameter to differentiate between these two diseases.

CT-measured lung air-trapping is associated with higher carotid artery stiffness in individuals with chronic obstructive pulmonary disease.

Early stages of chronic obstructive pulmonary disease (COPD) are characterized by the loss and narrowing of terminal bronchioles in the lung, resulting in "air-trapping," often occurring before overt emphysema manifests. Individuals with an airway-predominant phenotype of COPD display extensive lung air-trapping and are at greater cardiovascular disease (CVD) risk than COPD patients with an emphysema-predominant phenotype. We hypothesized that the degree of computed tomography (CT)-quantified lung air-trapping would be associated with greater aortic and carotid artery stiffness and lower endothelial function, known biomarkers of CVD risk. Lung air-trapping was associated with greater aortic stiffness (carotid femoral pulse wave velocity, CFPWV) (r = 0.60, P = 0.007) and carotid β-stiffness (r = 0.75, P = 0.0001) among adults with (n = 10) and without (n = 9) a clinical diagnosis of COPD and remained significant after adjusting for blood pressure (BP) and smoking history (pack-years) (carotid β-stiffness: r = 0.68, P < 0.01; CFPWV r = 0.53, P = 0.03). The association between lung air-trapping and carotid β-stiffness remained significant after additionally adjusting for age and forced expiratory volume 1(FEV1) (r = 0.64, P = 0.01). In the COPD group only (n = 10), lung air-trapping remained associated with carotid β-stiffness (r = 0.82, P = 0.05) after adjustment for age, pack-years, and FEV1. In contrast, no association was observed between CFPWV and lung air-trapping after adjustment for BP, pack-years, age, and FEV1 (r = 0.12, P = 0.83). Lung air-trapping was not associated with endothelial function (brachial artery flow-mediated dilation) in the entire cohort (P = 0.80) or in patients with COPD only (P = 0.71). These data suggest that carotid artery stiffness may be a mechanism explaining the link between airway-predominant phenotypes of COPD and high CVD risk.NEW & NOTEWORTHY Previous cross-sectional studies have demonstrated greater large elastic artery stiffness and lower endothelium-dependent dilation in chronic obstructive pulmonary disease (COPD) patients compared with controls. Furthermore, COPD patients with emphysema have greater aortic stiffness than non-COPD controls, and the degree of stiffness is associated with emphysema severity. The present study is the first to demonstrate that even before overt emphysema manifests, lung air-trapping is associated with carotid artery stiffness in COPD patients independent of blood pressure, age, or smoking history.

External Validation of the COmorbidity Test

ABSTRACTThe COmorbidity TEst (COTE) is a Chronic Obstructive Pulmonary Disease (COPD)-specific co-morbidity score created to predict mortality. Before its wide application at the University of New Mexico we intended to validate it. The study was conducted at the University of New Mexico Hospital (UNMH) in Albuquerque, NM, USA, a tertiary academic hospital. Consecutive patients with the clinical diagnosis of COPD were identified using the hospital's medical records system and included if they were older than 40 years, had smoked at least 20 pack-years and their post bronchodilator forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) was <0.7 without an alternative diagnosis. The data collected included demographics, co-morbidities as described in the COTE, COPD-specific therapies, spirometry results and mortality. Of 317 patients 51.4% were male, average age was 65.6 ± 9.6 years and the mean post-bronchodilator FEV1 percent predicted (FEV1%) was 52.9 ± 16.9%. 31 (9.8%) patients were on triple long-acting bronchodilator inhaler therapy, 88 (27.8%) on two long-acting bronchodilators and 163 (51.4%) on at least one long-acting bronchodilator. The median follow-up was 3.5 years (IQR = 1.9–6.9). Fifty four patients died by the end of the follow-up period and their median COTE of 4 (IQR = 1–8) was significantly higher than for the survivors with COTE = 1 (IQR = 0–6; p = 0.002). In univariable analyses COTE was positively associated while FEV1%, body mass index (BMI) and gender were negatively associated with all-cause mortality. In multivariable analysis BMI, FEV1% and COTE remained independent predictors for mortality. The COTE is an independent predictor of mortality for COPD patients at UNMH.

Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease.

Exacerbations of chronic obstructive pulmonary disease (COPD) are a major driver of decline in health status and impose high costs on healthcare systems. Action plans offer a form of self-management that can be delivered in the outpatient setting to help individuals recognise and initiate early treatment for exacerbations, thereby reducing their impact. To compare effects of an action plan for COPD exacerbations provided with a single short patient education component and without a comprehensive self-management programme versus usual care. Primary outcomes were healthcare utilisation, mortality and medication use. Secondary outcomes were health-related quality of life, psychological morbidity, lung function and cost-effectiveness. We searched the Cochrane Airways Group Specialised Register along with CENTRAL, MEDLINE, Embase and clinical trials registers. Searches are current to November 2015. We handsearched bibliographic lists and contacted study authors to identify additional studies. We included randomised controlled trials (RCT) and quasi-RCTs comparing use of an action plan versus usual care for patients with a clinical diagnosis of COPD. We permitted inclusion of a single short education component that would allow individualisation of action plans according to management needs and symptoms of people with COPD, as well as ongoing support directed at use of the action plan. We used standard methodological procedures expected by Cochrane. For meta-analyses, we subgrouped studies via phone call follow-up directed at facilitating use of the action plan. This updated review includes two additional studies (and 976 additional participants), for a total of seven parallel-group RCTs and 1550 participants, 66% of whom were male. Participants' mean age was 68 years and was similar among studies. Airflow obstruction was moderately severe in three studies and severe in four studies; mean post bronchodilator forced expiratory volume in one second (FEV1) was 54% predicted, and 27% of participants were current smokers. Four studies prepared individualised action plans, one study an oral plan and two studies standard written action plans. All studies provided short educational input on COPD, and two studies supplied ongoing support for action plan use. Follow-up was 12 months in four studies and six months in three studies.When compared with usual care, an action plan with phone call follow-up significantly reduced the combined rate of hospitalisations and emergency department (ED) visits for COPD over 12 months in one study with 743 participants (rate ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.79; high-quality evidence), but the rate of hospitalisations alone in this study failed to achieve statistical significance (RR 0.69, 95% CI 0.47 to 1.01; moderate-quality evidence). Over 12 months, action plans significantly decreased the likelihood of hospital admission (odds ratio (OR) 0.69, 95% CI 0.49 to 0.97; n = 897; two RCTs; moderate-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) 19 (11 to 201)) and the likelihood of an ED visit (OR 0.55, 95% CI 0.38 to 0.78; n = 897; two RCTs; moderate-quality evidence; NNTB over 12 months 12 (9 to 26)) compared with usual care.Results showed no significant difference in all-cause mortality during 12 months (OR 0.88, 95% CI 0.59 to 1.31; n = 1134; four RCTs; moderate-quality evidence due to wide confidence interval). Over 12 months, use of oral corticosteroids was increased with action plans compared with usual care (mean difference (MD) 0.74 courses, 95% CI 0.12 to 1.35; n = 200; two RCTs; moderate-quality evidence), and the cumulative prednisolone dose was significantly higher (MD 779.0 mg, 95% CI 533.2 to 10248; n = 743; one RCT; high-quality evidence). Use of antibiotics was greater in the intervention group than in the usual care group (subgrouped by phone call follow-up) over 12 months (MD 2.3 courses, 95% CI 1.8 to 2.7; n = 943; three RCTs; moderate-quality evidence).Subgroup analysis by ongoing support for action plan use was limited; review authors noted no subgroup differences in the likelihood of hospital admission or ED visits or all-cause mortality over 12 months. Antibiotic use over 12 months showed a significant difference between subgroups in studies without and with ongoing support.Overall quality of life score on St George's Respiratory Questionnaire (SGRQ) showed a small improvement with action plans compared with usual care over 12 months (MD -2.8, 95% CI -0.8 to -4.8; n = 1009; three RCTs; moderate-quality evidence). Low-quality evidence showed no benefit for psychological morbidity as measured with the Hospital Anxiety and Depression Scale (HADS). Use of COPD exacerbation action plans with a single short educational component along with ongoing support directed at use of the action plan, but without a comprehensive self-management programme, reduces in-hospital healthcare utilisation and increases treatment of COPD exacerbations with corticosteroids and antibiotics. Use of COPD action plans in this context is unlikely to increase or decrease mortality. Whether additional benefit is derived from periodic ongoing support directed at use of an action plan cannot be determined from the results of this review.

New bronchodilators in treatment of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Clinical diagnosis of COPD should be considered in any individual, who has dyspnea, chronic cough, sputum production, and positive history of risk factors. Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. After cessation of smoking and life style modification, bronchodilator therapy is the first step in COPD treatment. Beside commonly used bronchodilator therapy newly developed bronchodilators started to be preferred. These drugs consist of long-acting beta2 agonist (Indacatarol, Vilanterol, Olodaterol, Abediterol), long acting muscarinic antagonism (Umeclidinium), long-acting beta2 agonist with inhaled steroid (combination of fluticasone furoate and vilanterol), long-acting beta2 agonist with a long-acting muscarinic antagonist (Fixeddose combination of indacaterol with glycopyrronium by means of breezhaler device).

Cardiac safety of tiotropium in patients with COPD: a combined analysis of Holter-ECG data from four randomised clinical trials.

BackgroundTiotropium is generally well tolerated; however, there has been debate whether antimuscarinics, particularly tiotropium administered via Respimat® Soft Mist™ Inhaler, may induce cardiac arrhythmias in a vulnerable subpopulation with cardiovascular comorbidity. The aim of this study was to provide evidence of the cardiac safety of tiotropium maintenance therapy.MethodsCombined analysis of Holter electrocardiogram (ECG) data from clinical trials of tiotropium in chronic obstructive pulmonary disease (COPD). Trials in the Boehringer Ingelheim clinical trials database conducted between 2003 and 2012, involving tiotropium HandiHaler® 18 μg and/or tiotropium Respimat® (1.25-, 2.5-, 5.0- and 10-μg doses) were reviewed. All trials involving Holter-ECG monitoring during this period were included in the analysis. Men and women aged ≥ 40 years with a smoking history of ≥ 10 pack-years, and a clinical diagnosis of COPD were included. Holter ECGs were evaluated for heart rate (HR), supraventricular premature beats (SVPBs), ventricular premature beats (VPBs) and pauses. Quantitative and categorical end-points were derived for each of the Holter monitoring days.ResultsFour trials (n = 727) were included in the analysis. Respimat® (1.25–10 μg) or HandiHaler® (18 μg) was not associated with changes in HR, SVPBs, VPBs and pauses compared with placebo or the pretreatment baseline period. In terms of cardiac arrhythmia end-points, there was no evidence for an exposure–effect relationship.ConclusionsIn this analysis, tiotropium maintenance therapy administered using Respimat® (1.25–10 μg) or HandiHaler® (18 μg) once daily for periods of up to 48 weeks was well tolerated with no increased risk of cardiac arrhythmia in patients with COPD.