GOLD Criteria Research Articles

KADAR SURFACTANT PROTEIN-D SERUM PADA PASIEN PENYAKIT PARU OBSTRUKTIF KRONIS BERKEBAHAYAAN KAMBUHAN RENDAH DAN TINGGI

Chronic obstructive pulmonary disease (COPD) cause high morbidity and mortality worldwide. The exacerbations in chronicobstructive pulmonary disease accelerate the decline in lung function and health status, as well as in increasing the treatment cost andmortality risk. The spiro metric measurement has several limitations in assessing the severity as well as the exacerbation risk in COPDpatients. Currently, has been available serum surfactant protein-D, a marker of lung inflammation and lung tissue damage. This proteinis produced by the alveolar type II cells and the Clara cells that play role in maintaining the lung stability and pulmonary immunesystem. The increased level of serum SPD indicates that there is lung epitihelial leakage in line with COPD severity increment and reflectedin COPD exacerbation level of risk according to combined COPD assessment GOLD criteria of the year 2011. The aim of this study wasto know the differences of SP-D serum levels between low and high risk of exacerbation in COPD patients by determination them. Thisstudy was conducted from March to July 2014. The subjects of this study were COPD patients diagnosed by spiro metric measurement.The research was conducted in comparative analytic way with a cross sectional study design. The statistical analysis was performedusing Mann-Whitney non-parametric test. The subjects were 62 COPD patients. The SP-D serum level at low risk of exacerbation groupdiffer significantly compared to the high risk exacerbation group, 1.8–68.4 ng/mL and 3.36–116.4 ng/mL respectively (P=0.018).Based on this study it can be concluded that the SP-D serum levels were higher in COPD patients with high risk exacerbation than thelower risk one. The SP-D serum levels may be considered as a specific marker of lung tissue injury to assess the risk of the exacerbationin COPD patients.

Compatibility of medication with PRISCUS criteria and identification of drug interactions in a large cohort of patients with COPD

Patients with COPD are often of advanced age and have a high number of medications due to their lung disease and comorbidities. Thus they are at risk for unwanted effects from drugs, either due to age or due to interactions between drugs. These issues are not clarified. We therefore assessed the number of medications and potential adverse effects in a large cohort of patients with COPD.The analysis was performed in 2741 patients of the German COPD cohort COSYCONET, using baseline data (visit 1) and follow-up data after about 1.5 years (visit 3). Spirometric GOLD grades 1–4 were found in 8/35/32/9% of patients and GOLD groups ABCD in 7/25/4/48% of patients, while the remaining patients (n = 450, 16.4%) could not be classified according to GOLD criteria. The compatibility of medication with age was evaluated via the PRISCUS list, drug interactions via the AiD clinic system, whereby only drug combinations occurring in at least 10 patients were considered (nine unwanted interactions, one wanted interaction).The median numbers of medications were 5 or more in all patient categories, among them 3 or more non-respiratory medications. In the total population there were 153 patients (10.2%) aged ≥65 years who had any medication of the PRISCUS list with intermediate or low risk. Serious adverse combinations of drugs according to AiD occurred in 114 patients (4.2%), while the number of unwanted but only potentially clinically relevant combinations was 175 (6.4%). The number of wanted combinations was 219 (8.0%). These numbers did not markedly change when restricting the analysis to patients of GOLD grades 1–4. Moreover, the results were similar for visit 1 and visit 3.We conclude that in a large cohort of COPD patients about 10% of patients aged at least 65 years had medications that could interfere with their age and that the proportions of patients with either unwanted or wanted drug interactions were both in the range of 8–10%. These results suggest that problems arising from the high number of medications were not very frequent in the COPD cohort analysed.

Prevalence and Risk Factors of COPD in Karachi, Pakistan: Findings from the Adult Asthma Study-Karachi

Background/Aim: Limited data is available regarding burden and risk factors of COPD from developing countries through community based epidemiological assessment comprising spirometry. So to determine the prevalence and risk factors of COPD among adult population of Karachi, Pakistan. Methods: A multi-stage, community-based cross-sectional survey was conducted from May 2014-August 2015 comprising of 1630 adult (≥ 18 years) participants from 75 randomly selected (out of 9400) clusters in Karachi. From each cluster, 25 households were selected randomly and all eligible participants were recruited. Data was collected through questionnaire-based interviews in Urdu, consisting of respiratory health related questions (American Thoracic Society questionnaire; ATS-DLD 78A), socio-demographic characteristics and risk factors for asthma. Pre and post-bronchodilator spirometry was performed according to the ATS criteria. COPD was defined as a post-bronchodilator FEV1/FVC ratio < 0.70 according to the GOLD criteria. Results: Among 930 participants with acceptable spirometry we found the overall prevalence of COPD to be 10.9% (n=101; 95%CI: 8.9-12.8). Among them, the prevalence was 19.4% (n=78; 95%CI: 15.5-23.2) among adults aged 40 and above. Out of 101 participants having COPD, 20.8% have mild, 59.4% have moderate, 18.8% have severe and 1% have very severe disease according to the GOLD criteria of airflow limitation severity in COPD. Risk of COPD was increased with increasing age (AOR: 5.2, 95%CI: 3.1-8.5), increase in pack years of smoking (AOR: 3.3, 95%CI: 1.8-5.9) and among participants reporting history of allergies (AOR: 2.2, 95% CI: 1.4-3.4). Risk of COPD was decreased among those categorized as white collar employees compared to those not working or unemployed (AOR: 0.5, 95% CI: 0.3-0.9). Conclusions: This study provides evidence through robust epidemiological assessment regarding the actual burden of COPD among adults in Pakistan. Targeted preventive measures should be taken to reduce smoking habit and promote better environmental conditions at work places.

The prevalence, burden and risk factors associated with chronic obstructive pulmonary disease in Commonwealth of Independent States (Ukraine, Kazakhstan and Azerbaijan): results of the CORE study

In the Commonwealth of Independent States (CIS) countries the epidemiology of chronic obstructive pulmonary disease (COPD) is poorly characterized. The objective of this analysis is to present the prevalence, burden and risk factors associated with COPD in three CIS countries as part of the CORE study (Chronic Obstructive Respiratory Diseases), the rationale and design of which have been described elsewhere. A total of 2842 adults (≥18 years) were recruited (964 in Ukraine, Kiev, 945 in Kazakhstan, Almaty and 933 in Azerbaijan, Baku) between 2013 and 2015 during household visits. Two-step cluster randomization was used for the sampling strategy. All respondents were interviewed about respiratory symptoms, smoking status and medical history, and underwent spirometry with bronchodilator. COPD was defined as (i) “previously diagnosed” when the respondent reported that he/she had previously been diagnosed with COPD by a doctor, (ii) “diagnosed by spirometry” using the GOLD criteria (2011) based on spirometry conducted during the study (FEV1/FVC < 0.70), and (iii) “firstly diagnosed by spirometry”, when the patient had received the COPD diagnosis for the first time based on the spirometry results obtained in this study. The prevalence of “previously diagnosed” COPD was 10.4, 13.8 and 4.3 per 1000, and the prevalence of COPD “diagnosed by spirometry” was 31.9, 66.7 and 37.5 per 1000 in Ukraine, Kazakhstan, and Azerbaijan, respectively. Almost all respondents with COPD were diagnosed for the first time during this study. A statistically significant relationship was shown between smoking and COPD in Kazakhstan (odds ratio, OR: 3.75) and Azerbaijan (OR: 2.80); BMI in Ukraine (OR: 2.10); tuberculosis in Ukraine (OR: 32.3); and dusty work in Kazakhstan (OR: 2.30). Co-morbidities like cardiovascular diseases and a history of pneumonia occurred significantly (p < 0.05) more frequently in the COPD population compared to the non-COPD population across all participating countries. For hypertension, this was the case in Ukraine and Azerbaijan. In CIS countries (Ukraine, Kazakhstan and Azerbaijan), the prevalence of COPD “diagnosed by spirometry” was significantly higher than the prevalence of previously diagnosed COPD. Compared to many other countries, the prevalence of COPD seems to be relatively low in CIS countries. Factors such as limited funding from the government; lack of COPD knowledge and the attitude within the population, and of primary care physicians; as well as low access to high-quality spirometry may play a role in this under-diagnosis of COPD. The information provided in this paper will be helpful for healthcare policy makers in CIS countries to instruct COPD management and prevention strategies and to allocate healthcare resources accordingly.

Chronic airflow obstruction in Tanzania \u2013 a cross-sectional study

BackgroundChronic obstructive pulmonary disease is a global problem and available data from sub-Saharan Africa is very limited.MethodsA cross-sectional facility-based pilot study among patients and visitors to an urban and a rural primary healthcare facility was conducted in coastal Tanzania. The primary outcome was the prevalence of chronic airflow obstruction.ResultsThe final analysis included 598 participants with valid post-bronchodilator spirometry. Applying ATS/ERS spirometric criteria, chronic airflow obstruction was found in n = 24 (4%, CI95 2.7–5.9) participants and in n = 30 (5%, CI95 3.5–7.1) applying GOLD spirometric criteria. To analyse risk factors for chronic airflow obstruction including those not meeting ATS/ERS or GOLD criteria, FEF25–75 and FEV1% predicted was analysed in participants without evidence of pulmonary restriction among those exposed or not exposed to risk factors (n = 552). FEV1% predicted, but in particular FEF25–75 decreased with increasing symptom severity of shortness of breath as well as limitations in daily activities of participants. Cooking in general and cooking with biomass fuels vs. gas or electricity was associated with significantly lower FEF25–75, but not with lower FEV1% predicted. Participants having refrained from taking a job because of shortness of breath exhibited lower FEF25–75 (p < 0.01). A history of prior active TB was the most relevant risk factor associated with a decrease in FEF25–75 as well as FEV1% predicted.ConclusionThis study demonstrated a relevant prevalence of chronic airflow obstruction in primary healthcare attendants and healthy visitors of a Tanzanian hospital. Using the baseline data provided, larger and population-based studies are needed to validate these findings. TB may have more impact on development of chronic airway obstruction than smoking in Africa. Due to the influence of age on the GOLD definition of chronic airflow obstruction, studies should report results using both ATS/ERS and GOLD definitions and include age-stratified analysis. Analysis of FEV1 and in particular FEF25–75 may yield additional information on risk factors and earlier stages of chronic airflow obstruction.

Body plethysmography in chronic obstructive pulmonary disease patients: A cross-sectional study.

Background:Chronic obstructive pulmonary disease (COPD) is the fourth most common cause of death in the world, for which smoking is a common cause. It is preferable to diagnose COPD at an earlier stage and to assess its progression so that mortality and morbidity of the disease could be reduced. Hence, we conducted this study to assess parameters of body plethysmography in Indian population where the data are lacking and to assess whether the use of body plethysmography can detect COPD earlier.Subjects and Methods:The study was approved by the Ethics Committee at B. J Government Medical College, Pune. In this comparative randomized cross-sectional study, healthy control subjects (CN), smokers without COPD diagnosis (SM) who were smoking for more than 5 pack-years and smokers with COPD who were further classified depending upon GOLD criteria as mild COPD (C1), moderate COPD (C2), and severe COPD (C3) (n = 30 each group) were considered. All the participants were males who gave written informed consent. Subject underwent routine spirometry (FEV1, FVC, FEV1/FVC, PEFR, and FEF25-75%) along with body plethysmography where sGaweff, sGawtot, residual volume (RV), total lung capacity (TLC), and inspiratory capacity (IC) were recorded.Statistical Analysis:The differences in lung function were compared between healthy controls and smokers and also between the three groups of COPD severity (GOLD guidelines) employing univariate analysis of variance and Bonferroni's post hoc test.Results:Spirometry could not differentiate between smokers without COPD and healthy controls. However, three parameters on body plethysmography (IC, sGawtot, and sGaweff) were sensitive enough to detect differences between smokers without COPD and healthy controls.Conclusion:Using body plethysmography, the vexed question troubling the clinician, which of the smokers progress to COPD and who do not before they develop irreversible changes can perhaps be answered if further large-scale multicenter studies and long-term follow-up studies confirm the findings in this study.

Real-time mass spectrometric identification of metabolites characteristic of chronic obstructive pulmonary disease in exhaled breath

BackgroundNew mass spectrometry (MS) techniques analysing exhaled breath have the potential to better define airway diseases. Here, we present our work to profile the volatile organic compounds (VOCs) in exhaled breath from patients with chronic obstructive pulmonary disease (COPD), using real-time MS, and relate this disease-specific breath profile to functional disease markers. MethodsIn a matched cohort study, patients with COPD, according to GOLD criteria, were recruited. Exhaled breath analysis by untargeted MS was performed using secondary electrospray ionization – high-resolution MS (SESI-HRMS). ResultsExhaled breath from 22 patients with COPD (mean age 58.6 ± 6.9 years, FEV1 58.5 ± 19.9% predicted, 32.4 ± 19.2 pack years smoking) and 14 controls (mean age 58.1 ± 8.1 years, FEV1 102.5 ± 11.3% predicted, 23.6 ± 12.5 pack years smoking) was analysed using SESI-HRMS. From 1441 different features, 43 markers were identified that allowed discrimination between the two groups with an accuracy of 89% (CI 74–97%), a sensitivity of 93%, and a specificity of 86%. The markers were determined to be metabolites of oxidative stress processes, such as fatty acids, aldehydes and amino acids, resulting from lung muscle degradation. ConclusionReal-time breath analysis by SESI-MS allows molecular profiling of exhaled breath, can distinguish patients with COPD from matched healthy controls and provides insights into the disease pathogenesis.

Assessment of Diastolic Dysfunction Parameters and Cardiac Chamber Size in Smokers with COPD: A Case Control Study

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a critical health care burden across the globe. Pulmonary Hypertension (PH) is a widespread feature of advanced COPD and is estimated to affect 20% of individuals with advanced COPD.Aim: To compare the variables of cardiac function, chamber size and diastolic parameters across various stages of COPD.Materials and Methods: A prospective case control study was conducted among 50 subjects and 50 controls (convenient sampling) with COPD over a period of two years in kasturba Medical college, Manipal (July 2012-July 2014). Chronic smokers who met the criteria for COPD according to GOLD criteria were included in the study. All patients underwent Pulmonary Function Test (PFT) using spirometer.Results: Twenty seven out of 50 studied patients (54%) had Pulmonary Artery Hypertension (PAH). Nineteen patients had mild PAH (38%). Dimension of cardiac chamber across various stages of COPD were found to have a significant decrease in Left Atrial (LA) area. Our study found an increase in Isovolumic Relaxation Time (IVRT), Pulmonary Artery Pressure (PAP) and TEI index (myocardial performance index) across stages of COPD however it was not statistically significant.Conclusion: Majority of the patients with COPD had PH, with increasing frequency of PAH across the GOLD stages. A decrease in cardiac chamber size was demonstrated with increasing severity of COPD.

Prevalence of chronic obstructive pulmonary disease (COPD) in China in 1990 and 2010.

BackgroundChronic obstructive pulmonary disease (COPD) is set to become the third most frequent cause of death and also the third largest cause of global morbidity by 2020. In China, where the population is aging rapidly, COPD has become one of the leading causes of disability and a large economic burden. An epidemiological assessment of the COPD in China is required, with a focus on the number of cases living with disease, main determinants of the disease and time trends.MethodsWe systematically searched large Chinese bibliographic databases and English databases to identify spirometry–based epidemiological studies of the prevalence of COPD in China diagnosed according to GOLD criteria. We estimated age– and gender–specific prevalence of COPD using a multilevel mixed–effect logistic regression. We also presented the time trends of COPD between 1990 and 2010 by age, gender and setting (urban vs rural).FindingsIn 1990, the prevalence of COPD ranged from 0.49% (95% CI = 0.29–0.85) in <20 years group to 20.95% (95% CI = 14.04–27.04) in> = 80 years group, and the crude prevalence for China was 2.70% (95% CI = 1.86–3.51). In 2010, the prevalence in <20 years was 0.55% (95% CI = 0.37–1.04) and in> = 80 years was 22.89% (95% CI = 18.13–28.96), with the crude prevalence for China of 3.84% (95% CI = 3.30–4.77). The COPD prevalence in males was about two–fold higher than in females, and it increased with increasing age. Between 1990–2010, the total number of Chinese people living with COPD increased by 66.73%, from 30.90 million (95% CI = 21.28–40.02) in 1990 to 51.52 million (95% CI = 44.26–63.93) in 2010. This increase was most striking in middle age, and greater in females than in males from 30 years up to 64 years. Our estimates, which used an independent approach to acquiring data and development of analytical methods, and were based on a more complete data set, are remarkably similar to those produced recently by the GBD 2013 collaboration, differing by only about 5% in the estimated number of COPD cases in 1990 and by 1% in 2010.ConclusionsCOPD is a highly prevalent disease in China and its importance is growing steadily. The number of people living with COPD has increased substantially between 1990 and 2010. COPD is more frequent in males and in rural areas. Optimised primary and secondary prevention and treatment is urgently needed to counter this growing trend. Improved epidemiological studies will be required to assist development of more effective strategies of prevention and treatment of COPD in China in the next decade and beyond.

TCT-793 Discrepancy Between GOLD criteria and STS Risk Assessment Score of COPD for Perioperative Evaluation of Transcatheter Aortic Valve Replacement

The degree of preoperative pulmonary compromise, as measured by the PFTs, is an important component of the STS risk score for TAVR. The two most common approaches for assessing lung function are the GOLD for COPD severity and the STS criteria to determine chronic lung disease (CLD). Unfortunately,

Diagnostic efficacy of fractional flow reserve with coronary angiography in dual-source computed tomography scanner

Objective: The management of patients with intermediate coronary lesions is a major clinical issue. Fractional flow reserve (FFR) is considered the gold criterion for the assessment of ischaemic stenosis, but it requires an invasive procedure. Coronary computed tomography angiography (CTA) for fractional flow reserve (FFRCT) is a novel noninvasive alternative for the diagnosis of ischaemic lesions. The aim was to determine the diagnostic efficacy of FFRCT for ischaemic coronary artery stenosis lesions of intermediate severity.Methods: A total of 129 patients underwent 64-row dual-source CTA and invasive coronary angiography (ICA). In all, 156 vessels were identified as intermediate-grade coronary artery stenosis by subsequent ICA, defined as a maximum diameter reduction of 50%–70%. The FFR was also measured during ICA. FFRCT was computed from the three-dimensional dual-source CTA model and coronary flow dynamics data.Results: Per-patient diagnostic sensitivity, specificity, positive predictive values, negative predictive values and accuracy of FFRCT amounted to 89.2%, 81.5%, 66.0%, 94.9% and 83.7%, respectively; and 86.9%, 73.6%, 58.0%, 93.1% and 77.6% on the per-vessel basis, respectively. FFRCT and FFR showed a good positive correlation. Bland–Altman analysis displayed good concordance between FFRCT and FFR. The receiver operating characteristic curve revealed that the area under the curve of FFRCT was 0.918 (95% confidence interval 0.849–0.986) on the per-patient analysis and 0.916 (95% confidence interval 0.863–0.969) on per-vessel analysis, respectively.Conclusions: FFRCT is featured by moderate accuracy in discriminating lesions of intermediate coronary artery stenosis that cause myocardial ischaemia.Impact statementHow to treat intermediate coronary stenosis represents a major clinical issue. FFRCT has recently emerged as a novel noninvasive method evaluating ischemic lesions. In this study, we defined such lesion as 50–70% diameter stenosis. We designed the study to assess the diagnostic efficacy of FFRCT both at per-vessel level and at per-vessel levels for ischemic lesions.

Severity of Airflow Obstruction in Chronic Obstructive Pulmonary Disease (COPD): Proposal for a New Classification

ABSTRACTCurrent classifications of Chronic Obstructive Pulmonary Disease (COPD) severity are complex and do not grade levels of obstruction. Obstruction is a simpler construct and independent of ethnicity. We constructed an index of obstruction severity based on the FEV1/FVC ratio, with cut-points dividing the Burden of Obstructive Lung Disease (BOLD) study population into four similarly sized strata to those created by the GOLD criteria that uses FEV1. We measured the agreement between classifications and the validity of the FEV1-based classification in identifying the level of obstruction as defined by the new groupings. We compared the strengths of association of each classification with quality of life (QoL), MRC dyspnoea score and the self-reported exacerbation rate. Agreement between classifications was only fair. FEV1-based criteria for moderate COPD identified only 79% of those with moderate obstruction and misclassified half of the participants with mild obstruction as having more severe COPD. Both scales were equally strongly associated with QoL, exertional dyspnoea and respiratory exacerbations. Severity assessed using the FEV1/FVC ratio is only in moderate agreement with the severity assessed using FEV1 but is equally strongly associated with other outcomes. Severity assessed using the FEV1/FVC ratio is likely to be independent of ethnicity.

Subjective cognitive complaints and neuropsychological performance in former smokers with and without chronic obstructive pulmonary disease

ABSTRACTObjective: This study examined the association of perceived cognitive difficulties with objective cognitive performance in former smokers. We hypothesized that greater perceived cognitive difficulties would be associated with poorer performance on objective executive and memory tasks.Method: Participants were 95 former smokers recruited from the COPDGene study. They completed questionnaires (including the Cognitive Difficulties Scale [CDS] and the Hospital Anxiety and Depression Scale [HADS]), neuropsychological assessment, and pulmonary function testing. Pearson correlations and t-tests were conducted to examine the bivariate association of the CDS (total score and subscales for attention/concentration, praxis, delayed recall, orientation for persons, temporal orientation, and prospective memory) with each domain of objective cognitive functioning (memory recall, executive functioning/processing speed, visuospatial processing, and language). Simultaneous multiple linear regression was used to further examine all statistically significant bivariate associations. The following covariates were included in all regression models: age, sex, pack-years, premorbid functioning (WRAT-IV Reading), HADS total score, and chronic obstructive pulmonary disease (COPD) status (yes/no based on GOLD criteria).Results: In regression models, greater perceived cognitive difficulties overall (using CDS total score) were associated with poorer performance on executive functioning/processing speed tasks (b = −0.07, SE = 0.03, p = .037). Greater perceived cognitive difficulties on the CDS praxis subscale were associated with poorer performance on executive functioning/processing speed tasks (b = −3.65, SE = 1.25, p = .005), memory recall tasks (b = −4.60, SE = 1.75, p = .010), and language tasks (b = −3.89, SE = 1.39, p = .006).Conclusions: Clinicians should be aware that cognitive complaints may be indicative of problems with the executive functioning/processing speed and memory of former smokers with and without COPD.

Risk factors of chronic obstructive pulmonary disease among rural women, Chittagong, Bangladesh

BackgroundThere are different risk factors for chronic obstructive pulmonary disease (COPD). Village women of developing countries such as Bangladesh are at a risk of COPD.AimThe present study was aimed to find risk factors of COPD among rural women of Bangladesh.Patients and methodsThis observational study was conducted in different villages of Chittagong, Bangladesh, among 250 women who were exposed to different risk factors of COPDWomen aged over 40 years were given a questionnaire adopted from a previous prevalence study of COPD in Bangladesh. Spirometry was performed in all subjects. A postbronchodilator ratio of the forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) was calculated among all women who had FEV1/FVC ratio less than 0.70. Women having postbronchodilator FEV1/FVC ratio less than 0.70 were diagnosed to have COPD (GOLD criteria). After collection, all data were analyzed by SPSS-20.ResultsOverall prevalence of COPD in rural women aged over 40 years was 20.4%. Most (76.9%) of them who did not have COPD were in the age group of 40–49 years and those who had COPD were in the age group of 60–69 years (51.0%). A majority (60%) of the women were poorly educated or not educated. Most women were housewives (86.4%). FEV1/FVC ratio significantly reduced in relation with different risk factors of COPD. Multinomial logistic regression analysis showed that respiratory distress in family members [odds ratio (OR)=0.633], nature of kitchen (1.206), seasonal variation in cooking (OR=1.245), cough in childhood (OR=0.336), tobacco chewing habit (OR=12.491), type of stove (OR=0.191), history of cough (OR=0.130), and life-time smoking history (OR=0.376) influenced the development of COPD. Lung function also was significantly reduced (P<0.05) among women who were using biomass compared with those using cleaner fuels such as natural gas/liquid petroleum gas.ConclusionIn the living conditions existing in the rural areas of Chittagong, Bangladesh, biomass smoke pollution, smoking, and cooking habits are some important risk factors of COPD in rural Bangladesh.

111 Can early introduction of specialized palliative care limit intensive care, emergency and hospital admissions in patients with severe and very severe COPD? A pilot randomized study

Background: COPD is a progressive lung disorder with rates of mortality between 36–50%, within 2 years after admission for an acute exacerbation. While treatment with inhaled bronchodilators and steroids may partially relieve symptoms and oxygen therapy may prolong life, for many patients the course of the disease is one of inexorable decline. Very few palliative care intervention studies are available for this population. This trial seeks to determine the effectiveness of the introduction of specialized palliative care on hospital, intensive care unit and emergency admissions of patients with severe and very severe COPD. Methods/Design: The study is a three year single centre, randomized controlled trial using a 2 arms parallel groups design conducted in a tertiary center (University Hospitals; Geneva). For the intervention group, an early palliative care consultation is added to standard care; the control group benefits from standard care only. Patients with COPD defined according to GOLD criteria with a stage III or IV disease and/or long term treatment with domiciliary oxygen and/or home mechanical ventilation and/or one or more hospital admissions in the previous year for an acute exacerbation are eligible to participate. Allocation concealment is achieved using randomisation by sealed envelopes. Our sample size of 90 patients/group gives the study a 80% power to detect a 20% decrease in intensive care unit and emergency admissions – the primary endpoint. All data regarding participants will be analysed by a researcher blinded to treatment allocation, according to the “Intention to treat” principle. Discussion: Given the trends toward aggressive and costly care near end-of-life among patients with COPD, a timely introduction of palliative care may limit unnecessary and burdensome personal and societal costs, and invasive approaches. The results of this study may provide directions for future palliative care interventions in this particular population. Trial registration: This trial has been registered at clinicaltrials.gov under NCT02223780

Pulmonary function after lung tumor stereotactic ablative radiotherapy depends on regional ventilation within irradiated lung

PurposeTo determine if regional ventilation within irradiated lung volume predicts change in pulmonary function test (PFT) measurements after stereotactic ablative radiotherapy (SABR) of lung tumors. MethodsWe retrospectively identified 27 patients treated from 2007 to 2014 at our institution who received: (1) SABR without prior thoracic radiation; (2) pre-treatment 4-dimensional computed tomography (4-D CT) imaging; (3) pre- and post-SABR PFTs <15months from treatment. We defined the ventilation ratio (VR20BED3) as the quotient of mean ventilation (mean Jacobian-based per-voxel volume change on deformably registered inhale/exhale 4-D CT phases) within the 20Gy biologically effective dose (α/β=3Gy) isodose volume and that of the total lung volume (TLV). ResultsMost patients had moderate to very severe COPD by GOLD criteria (n=19, 70.1%). Higher VR20BED3 significantly predicted worse change in Forced Expiratory Volume/s normalized by baseline value (ΔFEV1/FEV1pre, p=0.04); n=7 had VR20BED3>1 (high regional ventilation) and worse ΔFEV1/FEV1pre (median=−0.16, range=−0.230 to −0.20). Five had VR20BED3<1 (low regional ventilation) and improved ΔFEV1/FEV1pre (median=0.13, range=0.07 to 0.20). In a multivariable linear model, increasing VR20BED3 and time to post-SABR PFT predicted decreasing ΔFEV1/FEV1pre (R2=0.25, p=0.03). ConclusionsAfter SABR to high versus low functioning lung regions, we found worsened or improved global pulmonary function, respectively. If pre-SABR VR20BED3 is validated as a predictor of eventual post-SABR PFT in larger studies, it may be used for individualized treatment planning to preserve or even improve pulmonary function after SABR.

Bronchoscopy Safety in Patients With Chronic Obstructive Lung Disease.

Flexible bronchoscopy is a safe and minimally invasive diagnostic tool used by pulmonologists, but few studies have prospectively compared outcomes in patients with objectively defined obstructive lung disease to those without obstruction. We determined whether complications in patients undergoing moderate sedation bronchoscopy differ in those without obstruction compared with chronic obstructive pulmonary disease (COPD). We prospectively followed all patients undergoing moderate sedation bronchoscopy in an inpatient or outpatient setting. Over 12 months, data were collected prospectively in 258 patients. A total o 151 patients had pulmonary function testing with classification of COPD according to GOLD Criteria. Sixty-seven of those patients (44%) had COPD: 6 mild (9%), 29 moderate (42%), 27 severe (41%), and 5 very severe (8%). COPD patients were more likely to receive outpatient inhaled corticosteroids and long-acting bronchodilators and anticholinergics (P<0.001) as would be clinically appropriate. Among all patients with COPD, there were 13% minor complications and 5% major complications, with no deaths. Respiratory complications occurred more often in patients with severe to very severe COPD (22%) compared with patients without COPD (6%) (P=0.018). When adjusted for age, body mass index, and use of home oxygen, this difference was still significant (P=0.045). Bronchoscopy is generally safe with few complications in most patients with COPD. Patients with objectively confirmed severe to very severe COPD had more frequent respiratory complications than patients without COPD. The risks were not prohibitively high, but should be taken into consideration for COPD patients undergoing moderate sedation flexible bronchoscopy.

Impact of airflow limitation in chronic heart failure.

BackgroundComorbidities are common in chronic heart failure (HF) patients, but diagnoses are often not based on objective testing. Chronic obstructive pulmonary disease (COPD) is an important comorbidity and often neglected because of shared symptoms and risk factors. Precise prevalence and consequences are not well known. Therefore, we investigated prevalence, pulmonary treatment, symptoms and quality of life (QOL) of COPD in patients with chronic HF.Methods205 patients with stable HF for at least 1 month, aged above 50 years, were included from our outpatient cardiology clinic, irrespective of left ventricular ejection fraction. Patients performed post-bronchodilator spirometry, a six-minute walk test (6-MWT) and completed the Kansas City Cardiomyopathy Questionnaire (KCCQ). COPD was diagnosed according to GOLD criteria. Restrictive lung function was defined as FEV1/FVC ≥0.70 and FVC <80% of predicted value. The BODE and ADO index, risk scores in COPD patients, were calculated.ResultsAlmost 40% fulfilled the criteria of COPD and 7% had restrictive lung disease, the latter being excluded from further analysis. Noteworthy, 63% of the COPD patients were undiagnosed and 8% of those without COPD used inhalation therapy. Patients with COPD had more shortness of breath despite little difference in HF severity and similar other comorbidities. KCCQ was significantly worse in COPD patients. The ADO and BODE indices were significantly different.ConclusionCOPD is very common in unselected HF patients. It was often not diagnosed and many patients received treatment without being diagnosed with COPD. Presence of COPD worsens symptoms and negatively effects cardiac specific QOL.

Efficacy of Influenza and Pneumococcal Vaccination in Preventing COPD Exacerbation

BackgroundCommon causes of exacerbations in chronic obstructive airway disease (COPD) are due to infections by respiratory viruses and bacteria. Influenza vaccine and pneumococcal vaccine have demonstrated decrease in infective exacerbations in this population.MethodsIn this prospective study over 2 years, 146 COPD patients confirmed by spirometry in accordance with GOLD criteria and who received both influenza and pneumococcal polysaccharide vaccine were compared with 146 unvaccinated controls. Number of acute exacerbations, hospitalizations, ICU admissions, need for invasive mechanical ventilation, mortality difference for 1 year following vaccination were compared.ResultsIn vaccinated group there was statistically significant reduction in number of exacerbations of COPD, requirement of hospitalization, ICU admissions and mortality which is depicted in the table. Requirement of mechanical ventilation was higher among cases compared with controls more so among GOLD 3 and 4, which is statistically significant.COPDVaccinatedUnvaccinatedP valueNumber of exacerbations3.234.5<0.001Hospitalization requirement36.3%50%0.018ICU admissions17.8%30.1%0.014Requirement of mechanical ventilation14.2%6.2%0.021Mortality3170.01Subgroup analysis showed a significantly less hospitalization, ICU admission and mortality among vaccinated belonging to GOLD 1 and GOLD 2 as compared with matched controls. Also more exacerbations, hospitalizations, ICU admissions and mortality were observed in GOLD 3 and GOLD 4 who were not vaccinated. But this difference was not statistically significant.ConclusionOverall there was significantly lesser number of exacerbations, hospitalizations, ICU admissions, requirement of mechanical ventilation and mortality among vaccinated group as compared with controls. Subgroup analysis showed a significant benefit from vaccination in COPD GOLD 1 and 2.Disclosures All authors: No reported disclosures.

P1.01-013 Emphysematous Changes and Pulmonary Function for Asbestos-Related Lung Cancer in Japan

Smoking accelerates the incidence of asbestos-related lung cancer. We evaluated emphysematous changes by chest CT and pulmonary function for asbestos-related lung cancer in Japan. Two hundred and twenty-two patients of asbestos-related lung cancer compensated by Japanese compensation law were evaluated as age, gender, smoking index, histology, survival, therapy and occupational history including first asbestos exposed age, asbestos exposing terms and latency from the first asbestos exposure to lung cancer． Radiographic evaluation was done by chest CT using Goddard classification of emphysema. Pulmonary function test was done by spirometry and flow-volume curve. Ages range from 49 to 92 years with a median of 75 years. Male occupied 97.7%. Non-smoker is only 13 patients and other 209 are smokers with Brinkman Index ranges from 45 to 3000 of a median of 900. For histology of lung cancer, 60.4% are adenocarcinoma and 22.4% of squamous cell carcinoma, 12.6% of small cell carcinoma and 1.8 of large cell carcinoma and 2.6% of pleomorphic carcinoma et al. Eighty seven patients were operated and other 87 patients performed chemotherapy. Best supportive therapy is 34 patients. Median survival was 15.8 months. For asbestos histories, median first exposed age was 23 years, asbestos exposing term was 32 years and the latency of lung cancer was 50 years. For Goddard score of emphysematous changes, 28% showed 0 point and 33% of 1∼4 points and more than 21 points occupied only 4%, which means very low percentages of emphysematous changes for these asbestos-related lung cancer, nonetheless of high percentages of heavy smokers. For pulmonary function test, FEV1.0% is 70.5%±11.3% and % FEV1.0 is 85.6±22.2%. More than half patients are normal pulmonary function except more than 1,000 of Brinkman index or more than 15 points of Goddard score. From the classification of GOLD criteria, 54.1% are normal, stage 1 is 20.7%, stage 2 is 22.5 % stage 3 is 1.8% and stage 4 is only 0.9%. Almost all of asbestos-related lung cancer in Japan are heavy smoker, but 61% showed none or low grade of emphysematous changes by chest CT and only 2.7% had severe pulmonary dysfunction.