High Risk Of Exacerbations Research Articles

The derivation and validation of a scoring system for identifying patients with bronchiectasis at risk of exacerbations

To create and verify a scoring system for identifying patients with bronchiectasis at risk of exacerbations. Derivation of the scoring system used data from a retrospective cohort study enrolling 228 patients with bronchiectasis. Multivariable logistic regression analysis was performed to identify independent predictors associated with exacerbations. β-coefficients derived from the independent predictors in our logistic regression model were applied to create a scoring system (Total score was 8). The scoring system was then validated in a prospective cohort enrolling 334 patients with bronchiectasis. The derivation study showed that age ≥ 60 years (OR=2.583, 95%CI: 1.188-5.613), BMI<18.5 kg/m(2) (OR=2.991, 95%CI: 1.112-8.042), high medical research council dyspnea score (OR=7.905, 95%CI: 4.288-8.309), Pseudomonas aeruginosa colonization (OR=3.227, 95%CI: 1.041-9.004), the lobes involved on high-resolution computed tomography≥3 (OR=3.179, 95%CI: 1.449~6.976), prior intensive care unit admissions (OR=2.499, 95%CI: 1.301-4.801), and FEV1<50% predicted(OR=2.497, 95%CI: 1.421-5.080) were the independent predictors associated with exacerbations. The scoring system predicted exacerbations with an area under the receiver operator characteristic curve (AUC) of 0.79 (95% confidence interval, 0.74-0.84). In the validation cohorts, the total score ranged 0 to 6. There was significant difference in exacerbation frequency and quality of life between patients classified as low(0-2), intermediate(3-4), and high(5-8) risks by the scoring system (P<0.05). A higher score was associated with higher risk of exacerbations and poorer quality of life. Our scoring system was an efficient clinical predictive tool to identify patients with bronchiectasis at risk of exacerbations. It may be useful for early prevention of bronchiectasis exacerbations and for proper management.

Indacaterol–Glycopyrronium versus Salmeterol–Fluticasone for COPD

BackgroundMost guidelines recommend either a long-acting beta-agonist (LABA) plus an inhaled glucocorticoid or a long-acting muscarinic antagonist (LAMA) as the first-choice treatment for patients with chronic obstructive pulmonary disease (COPD) who have a high risk of exacerbations. The role of treatment with a LABA–LAMA regimen in these patients is unclear.MethodsWe conducted a 52-week, randomized, double-blind, double-dummy, noninferiority trial. Patients who had COPD with a history of at least one exacerbation during the previous year were randomly assigned to receive, by inhalation, either the LABA indacaterol (110 μg) plus the LAMA glycopyrronium (50 μg) once daily or the LABA salmeterol (50 μg) plus the inhaled glucocorticoid fluticasone (500 μg) twice daily. The primary outcome was the annual rate of all COPD exacerbations.ResultsA total of 1680 patients were assigned to the indacaterol–glycopyrronium group, and 1682 to the salmeterol–fluticasone group. Indacaterol–glycopyrronium showed not only noninferiority but also superiority to salmeterol–fluticasone in reducing the annual rate of all COPD exacerbations; the rate was 11% lower in the indacaterol–glycopyrronium group than in the salmeterol–fluticasone group (3.59 vs. 4.03; rate ratio, 0.89; 95% confidence interval [CI], 0.83 to 0.96; P=0.003). The indacaterol–glycopyrronium group had a longer time to the first exacerbation than did the salmeterol–fluticasone group (71 days [95% CI, 60 to 82] vs. 51 days [95% CI, 46 to 57]; hazard ratio, 0.84 [95% CI, 0.78 to 0.91], representing a 16% lower risk; P<0.001). The annual rate of moderate or severe exacerbations was lower in the indacaterol–glycopyrronium group than in the salmeterol–fluticasone group (0.98 vs. 1.19; rate ratio, 0.83; 95% CI, 0.75 to 0.91; P<0.001), and the time to the first moderate or severe exacerbation was longer in the indacaterol–glycopyrronium group than in the salmeterol–fluticasone group (hazard ratio, 0.78; 95% CI, 0.70 to 0.86; P<0.001), as was the time to the first severe exacerbation (hazard ratio, 0.81; 95% CI, 0.66 to 1.00; P=0.046). The effect of indacaterol–glycopyrronium versus salmeterol–fluticasone on the rate of COPD exacerbations was independent of the baseline blood eosinophil count. The incidence of adverse events and deaths was similar in the two groups. The incidence of pneumonia was 3.2% in the indacaterol–glycopyrronium group and 4.8% in the salmeterol–fluticasone group (P=0.02).ConclusionsIndacaterol–glycopyrronium was more effective than salmeterol–fluticasone in preventing COPD exacerbations in patients with a history of exacerbation during the previous year. (Funded by Novartis; FLAME ClinicalTrials.gov number, NCT01782326.)

β-Blockers for the prevention of acute exacerbations of chronic obstructive pulmonary disease (βLOCK COPD): a randomised controlled study protocol

IntroductionA substantial majority of chronic obstructive pulmonary disease (COPD)-related morbidity, mortality and healthcare costs are due to acute exacerbations, but existing medications have only a modest effect on reducing their...

Hyperoxic Exposure of Immature Mice Increases the Inflammatory Response to Subsequent Rhinovirus Infection: Association with Danger Signals.

Infants with a history of prematurity and bronchopulmonary dysplasia have a high risk of asthma and viral-induced exacerbations later in life. We hypothesized that hyperoxic exposure, a predisposing factor to bronchopulmonary dysplasia, modulates the innate immune response, producing an exaggerated proinflammatory reaction to viral infection. Two- to 3-d-old C57BL/6J mice were exposed to air or 75% oxygen for 14 d. Mice were infected intranasally with rhinovirus (RV) immediately after O2 exposure. Lung mRNA and protein expression, histology, dendritic cells (DCs), and airway responsiveness were assessed 1-12 d postinfection. Tracheal aspirates from premature human infants were collected for mRNA detection. Hyperoxia increased lung IL-12 expression, which persisted up to 12 d postexposure. Hyperoxia-exposed RV-infected mice showed further increases in IL-12 and increased expression of IFN-γ, TNF-α, CCL2, CCL3, and CCL4, as well as increased airway inflammation and responsiveness. In RV-infected, air-exposed mice, the response was not significant. Induced IL-12 expression in hyperoxia-exposed, RV-infected mice was associated with increased IL-12-producing CD103(+) lung DCs. Hyperoxia also increased expression of Clec9a, a CD103(+) DC-specific damaged cell-recognition molecule. Hyperoxia increased levels of ATP metabolites and expression of adenosine receptor A1, further evidence of cell damage and related signaling. In human preterm infants, tracheal aspirate Clec9a expression positively correlated with the level of prematurity. Hyperoxic exposure increases the activation of CD103(+), Clec9a(+) DCs, leading to increased inflammation and airway hyperresponsiveness upon RV infection. In premature infants, danger signal-induced DC activation may promote proinflammatory airway responses, thereby increasing respiratory morbidity.

Determinants and impact of suboptimal asthma control in Europe: The INTERNATIONAL CROSS-SECTIONAL AND LONGITUDINAL ASSESSMENT ON ASTHMA CONTROL (LIAISON) study.

BackgroundAccording to the Global Initiative of Asthma, the aim of asthma treatment is to gain and maintain control. In the INTERNATIONAL CROSS-SECTIONAL AND LONGITUDINAL ASSESSMENT ON ASTHMA CONTROL (LIAISON) study, we evaluated the level of asthma control and quality of life (QoL), as well as their determinants and impact in a population consulting specialist settings.MethodsLIAISON is a prospective, multicentre, observational study with a cross-sectional and a 12-month longitudinal phase. Adults with an asthma diagnosis since at least 6 months, receiving the same asthma treatment in the 4 weeks before enrolment were included. Asthma control was assessed with the 6-item Asthma Control Questionnaire (ACQ) and QoL with the MiniAsthma Quality of Life Questionnaire (MiniAQLQ).ResultsOverall, 8111 asthmatic patients were enrolled in 12 European countries. Asthma control was suboptimal in 56.5 % of patients and it was associated with poorer asthma-related QoL, higher risk of exacerbations and greater consumption of healthcare resources.Variables associated with suboptimal control were age, gender, obesity, smoking and comorbidities. Major determinants of poor asthma control were seasonal worsening and persisting exposure to allergens/irritants/triggers, followed by treatment-related issues.ConclusionsThe cross-sectional phase results confirm that suboptimal control is frequent and has a high individual and economic impact.Trial registrationThe clinicaltrials.gov identifier is NCT01567280.Electronic supplementary materialThe online version of this article (doi:10.1186/s12931-016-0374-z) contains supplementary material, which is available to authorized users.

High body mass index and risk of exacerbations and pneumonias in individuals with chronic obstructive pulmonary disease: observational and genetic risk estimates from the Copenhagen General Population Study.

In the clinic, the combination of obesity and chronic obstructive pulmonary disease (COPD) has been increasing. However, whether high body mass index (BMI) affects the risk of exacerbations and pneumonias in individuals with COPD is presently unknown. Genetics can be used to assess the causal role of high BMI in exacerbations and pneumonias in individuals with COPD. We tested the hypothesis that high BMI is associated with an increased risk of exacerbations and pneumonias in individuals with COPD, both observationally and genetically. We genotyped 93 894 individuals of Danish descent, aged 20-100 years, from the Copenhagen General Population Study, for FTO (rs9939609), MC4R (rs17782313) and TMEM18 (rs6548238), and created an allele score. A total of 10883 individuals had spirometric COPD with forced expiratory volume in 1 s (FEV1) / forced vital capacity (FVC) < lower limit of normal (LLN). In these individuals, we observed 1453 exacerbations and 3390 pneumonias during 4.7 years of follow-up. For each increase in allele score, BMI was 0.28 kg/m2 [95% confidence interval (CI): 0.25-0.30) higher. Age- and sex-adjusted genetic hazard ratios (HRs) per one allele score increase in individuals with COPD were 1.13 (1.01-1.27) for exacerbations, 1.10 (1.03-1.19) for pneumonias and 1.12 (1.04-1.21) for exacerbations and/or pneumonias. Corresponding multivariable adjusted observational HRs per unit (kg/m2) BMI increase were 0.98 (0.95-1.01), 0.99 (0.96-1.03) and 0.99 (0.96-1.01), respectively. Genetically determined high BMI was associated with an increased risk of recurrent exacerbations and pneumonias in individuals with COPD, whereas this was not the case for observationally determined high BMI. The genetic data are compatible with the notion that high BMI leads to increased risk of exacerbations and pneumonias in individuals with COPD.

Perspectives of pharmacological therapy of chronic obstructive pulmonary disease: opportunities of dual bronchodilation and a role of inhaled steroids. Expert Council Consensus

The most important symptoms of chronic obstructive pulmonary disease are dyspnea, cough and sputum production. According to results of several studies, 50% – 70% of COPD patients under regular therapy continue to experience dyspnea. Dyspnea has a great prognostic importance, it often correlates to exacerbation rate and the patients’ survival. Symptom reduction is one of the key outcomes of therapy of COPD. Measuring tools for assessment dyspnea are imperfect as dyspnea is a subjective feature. Nevertheless, available quantitative tools allow assessment symptom severity in COPD patients. Such tools (modified Medical Research Council scale and COPD Assessment Test – САТ) should be adopted to a medical care level (primary, secondary or tertiary care). Long-acting bronchodilators are the essential component of treatment COPD independently on COPD phenotype. COPD phenotype should be diagnosed before administration of combined drugs containing inhaled steroids (ICS). Long-term therapy with ICS is appropriate for the following groups of patients: overlap COPD and asthma phenotype; high risk of exacerbations (FEV1 &lt; 50% pred., &gt; 2 non-infectious exacerbations or &gt; 1 hospitalization related to non-infectious exacerbation during the previous year); patients with sputum eosinophilia &gt; 3% and / or blood eosinophilia &gt; 300 cells × ml -1 with consideration of the disease severity. A physician should consider a risk of adverse events of ICS. ICS should not be administered to COPD patients with FEV1 &gt; 50% pred. or having &lt; 2 acute exacerbations or no one hospitalization related to acute exacerbation of COPD during the previous year. ICS could be withdrawn if their administration did not match these criteria. Patients with persistent symptoms under monotherapy with long-acting bronchodilators, ICS / long-acting b2-agonists and who do not match the criteria for treatment with ICS should be treated with indacaterol / glycopyrronium combination.

Multi-component assessment of chronic obstructive pulmonary disease: an evaluation of the ADO and DOSE indices and the global obstructive lung disease categories in international primary care data sets.

Suitable tools for assessing the severity of chronic obstructive pulmonary disease (COPD) include multi-component indices and the global initiative for chronic obstructive lung disease (GOLD) categories. The aim of this study was to evaluate the dyspnoea, obstruction, smoking, exacerbation (DOSE) and the age, dyspnoea, obstruction (ADO) indices and GOLD categories as measures of current health status and future outcomes in COPD patients. This was an observational cohort study comprising 5,114 primary care COPD patients across three databases from UK, Sweden and Holland. The associations of DOSE and ADO indices with (i) health status using the Clinical COPD Questionnaire (CCQ) and St George’s Respiratory Questionnaire (SGRQ) and COPD Assessment test (CAT) and with (ii) current and future exacerbations, admissions and mortality were assessed in GOLD categories and DOSE and ADO indices. DOSE and ADO indices were significant predictors of future exacerbations: incident rate ratio was 1.52 (95% confidence intervals 1.46–1.57) for DOSE, 1.16 (1.12–1.20) for ADO index and 1.50 (1.33–1.68) and 1.23 (1.10–1.39), respectively, for hospitalisations. Negative binomial regression showed that the DOSE index was a better predictor of future admissions than were its component items. The hazard ratios for mortality were generally higher for ADO index groups than for DOSE index groups. The GOLD categories produced widely differing assessments for future exacerbation risk or for hospitalisation depending on the methods used to calculate them. None of the assessment systems were excellent at predicting future risk in COPD; the DOSE index appears better than the ADO index for predicting many outcomes, but not mortality. The GOLD categories predict future risk inconsistently. The DOSE index and the GOLD categories using exacerbation frequency may be used to identify those at high risk for exacerbations and admissions.

Therapy with proton-pump inhibitors for gastroesophageal reflux disease does not reduce the risk for severe exacerbations in COPD.

Gastroesophageal reflux disease (GERD) symptoms are associated with a higher risk of chronic obstructive pulmonary disease (COPD) exacerbation. We hypothesize that treatment with proton pump inhibitors reduces the risk of exacerbation in patients with stable COPD. A total of 638 patients with stable COPD for ≥6 weeks, ≥10 pack-years of smoking and Global Initiative for Chronic Obstructive Lung Disease II-IV seeking care in tertiary hospitals in eight European countries in the Predicting Outcome using Systemic Markers in Severe Exacerbations-COPD cohort was prospectively evaluated by us. Comorbidities including associated medical treatment were assessed at baseline, at exacerbation and at biannual visits. Median observation time was 24 months. The primary study outcomes were exacerbation and/or death. A total of 85 (13.3%) of COPD patients were on anti-GERD therapy. These patients had higher annual and higher severe exacerbation rates (P = 0.009 and P = 0.002), decreased quality of life (SF-36: activity score P = 0.004, St. George's Respiratory Questionnaire: physical functioning P = 0.013 and social functioning P = 0.007), higher body mass airflow obstruction, dyspnea and exercise capacity index (P = 0.033) and Modified Medical Research Council scores (P = 0.002), shorter 6-min walking distance (P = 0.0004) and a higher adjusted Charlson score (P < 0.0001). Anti-GERD therapy was associated with a shorter time to severe exacerbation (HR 2.05 95% CI 1.37-3.08). Using three multivariable Cox-regression models, this association was independent of the following: (i) adjusted Charlson score and FEV1% predicted (HR 1.91 95% CI 1.26-2.90); (ii) adjusted Charlson score, body mass, airflow obstruction, dyspnea and exercise capacity index and Modified Medical Research Council (HR 1.62 95% CI 1.04-2.54); and (iii) adjusted Charlson score, FEV1% predicted and nine classes of medication for comorbidities (HR 1.63 95% CI 1.04-2.53). These findings suggest that patients with stable COPD receiving acid-suppressive therapy with proton pump inhibitors remain at high risk of frequent and severe exacerbations.

The lung function profile of once-daily tiotropium and olodaterol via Respimat(®) is superior to that of twice-daily salmeterol and fluticasone propionate via Accuhaler(®) (ENERGITO(®) study).

BackgroundTiotropium + olodaterol has demonstrated improvements beyond lung function benefits in a large Phase III clinical program as a once-daily maintenance treatment for COPD and may be a potential option for the initiation of maintenance treatment in COPD. Despite guideline recommendations that combined long-acting β2-agonists and inhaled corticosteroids should only be used in individuals at high risk of exacerbation, there is substantial use in individuals at lower risk. This raises the question of the comparative effectiveness of this combination as maintenance treatment in this group compared to other combination regimens.ObjectiveThe study aimed to assess the effect on lung function of once-daily tiotropium + olodaterol versus twice-daily salmeterol + fluticasone propionate in all participants with Global initiative for chronic Obstructive Lung Disease 2 or 3 (moderate to severe) COPD.MethodsThis was a randomized, double-blind, double-dummy, four-treatment, complete crossover study in which participants received once-daily tiotropium + olodaterol (5/5 µg and 2.5/5 µg) via Respimat® and twice-daily salmeterol + fluticasone propionate (50/500 µg and 50/250 µg) via Accuhaler® for 6 weeks. The primary end point was change in forced expiratory volume in 1 second (FEV1) area under the curve from 0 hour to 12 hours (AUC0–12) relative to the baseline after 6 weeks.ResultsTiotropium + olodaterol 5/5 µg and 2.5/5 µg demonstrated statistically significant improvements in FEV1 AUC0–12 compared to salmeterol + fluticasone propionate (improvements from baseline were 317 mL and 295 mL with tiotropium + olodaterol 5/5 µg and 2.5/5 µg, and 188 mL and 192 mL with salmeterol + fluticasone propionate 50/500 µg and 50/250 µg, respectively). Tiotropium + olodaterol was superior to salmeterol + fluticasone propionate in lung function secondary end points, including FEV1 area under the curve from 0 hour to 24 hours (AUC0–24).ConclusionOnce-daily tiotropium + olodaterol in participants with moderate-to-severe COPD provided superior lung function improvements to twice-daily salmeterol + fluticasone propionate. Dual bronchodilation can be considered to optimize lung function in individuals requiring maintenance treatment for COPD.

Impact of GOLD groups of chronic pulmonary obstructive disease on surgical complications.

PurposeChronic obstructive pulmonary disease (COPD) is associated with increased postoperative complications. Recently, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classified COPD patients into four groups based on spirometry results and the severity of symptoms. The objective of this study was to evaluate the impact of GOLD groups on postoperative complications.Patients and methodsWe reviewed the medical records of COPD patients who underwent preoperative spirometry between April and August 2013 at a tertiary hospital in Korea. We divided the patients into GOLD groups according to the results of spirometry and self-administered questionnaires that assessed the symptom severity and exacerbation history. GOLD groups, demographic characteristics, and operative conditions were analyzed.ResultsAmong a total of 405 COPD patients, 70 (17.3%) patients experienced various postoperative complications, including infection, wound, or pulmonary complications. Thoracic surgery, upper abdominal surgery, general anesthesia, large estimated blood loss during surgery, and longer anesthesia time were significant risk factors for postoperative complications. Patients in high-risk group (GOLD groups C or D) had an increased risk of postoperative complications compared to those in low-risk group (GOLD groups A or B).ConclusionCOPD patients in GOLD groups representing a high exacerbation risk have an increased risk of postoperative complications compared to those with low risk.

BRONCHIAL ASTHMA THERAPY IN SMART-REGIME: STUDIES IN REAL CLINICAL PRACTICE

Despite considerable progress in development of effective therapeutic means, numerous studies are indicative of the insufficient BA control level resulting in reduction of patient life quality as well as to the high risk of disease exacerbations. The major therapeutic approach aimed at achievement of control and reduction of damage from disease is anti-inflammatory therapy based on modern inhalation glucocorticosteroids (IGCC) complemented if required by long-acting beta-2-adrenergic agonists (LABA).

Predictors of asthma exacerbation among patients with poorly controlled asthma despite inhaled corticosteroid treatment

BackgroundAsthma exacerbations are associated with decreased quality of life and increased health care usage. Identification of characteristics that predict increased risk of future exacerbations in patients with suboptimal control of asthma could guide treatment decisions. ObjectiveTo examine patient characteristics associated with risk of asthma exacerbations in patients with uncontrolled persistent asthma. MethodsA retrospective analysis of adults and children with inadequately controlled asthma despite asthma controller therapy and enrolled in 2 randomized trials was conducted. Baseline characteristics of subjects who experienced an asthma exacerbation during the treatment period were compared with those of subjects who did not experience an exacerbation. ResultsOf 718 subjects (402 adults and 295 children), 108 adults (27%) and 110 children (37%) experienced an asthma exacerbation during the study period. Unscheduled health care visits for asthma or use of oral corticosteroids in the previous year were significantly associated with asthma exacerbation during the study period (P < .01). Adult subjects who experienced an exacerbation had significantly lower forced expiratory volume in 1 second compared with those who did not (2.3 vs 2.5 L, respectively, P = .02). Children who experienced an exacerbation had lower baseline pre- and post-bronchodilator ratios of forced expiratory volume in 1 second to forced vital capacity (77% vs 81%, P < .01; 82% vs 86%, P < .001, respectively). Symptom scores on validated questionnaires were significantly worse in adults but not in children who developed an exacerbation. ConclusionSpirometric measurements can help identify adults and children at increased risk for asthma exacerbation. Symptom scores could be helpful in identifying adults who are at high risk for exacerbations but could be less helpful in children.

New opportunities for treatment of severe bronchial asthma: from clinical studies to portraits of patients

The proportion of patients with controlled asthma has increased over the last 15 years, however, still there is a significant proportion of patients who do not achieve control of the disease, and therefore have a high risk of exacerbations, hospitalizations, and poor quality of life. Patients with severe asthma, for which there were limited additional pharmacotherapy are the major problem. For the first time in recent years in the treatment of asthma a new class of drugs appeared: longacting anticholinergics - tiotropium which had been entered in stepwise therapy of asthma by GINA 2015. The definition of severe asthma, the role of the cholinergic nervous system in bronchial asthma, mechanism of action and clinical efficacy of tiotropium in severe bronchial asthma adults are described in the article.

Risk of exacerbation in chronic obstructive pulmonary disease: a primary care retrospective cohort study.

BackgroundThe risk of exacerbation in chronic obstructive pulmonary disease (COPD) depends on the severity of disease and other less well known factors. Predictive models of exacerbation are more accurate than the forced expiratory volume in one second (FEV1). The objective was to design a model that predicts the risk of exacerbation in COPD.MethodsRetrospective cohort study with data from the electronic medical records of patients diagnosed with COPD in the province of Lleida (Spain). A total of 2501 patients were followed during 3 years. The dependent variable was acute exacerbation; independent variables were: clinical parameters, spirometry results, severity of disease, influenza and 23-valent pneumococcal immunisation, comorbidities, smoking and history of exacerbation. The association of these variables with disease exacerbation was measured by the adjusted odds ratio using a logistic regression model.ResultsMean age at the start of the study was 68.38 years (SD = 11.60) and 74.97 % patients were men; severity of disease was considered mild in 50.82 % of patients, moderate in 35.31 %, severe in 9.44 % and very severe in 4.44 %. During the three year study period up to 83.17 % of patients experienced at least one exacerbation. Predictive factors in the model were age, gender, previous exacerbations, influenza and 23-valent pneumococcal immunisations, number of previous visits to the General Practice and severity (GOLD), with an area under the ROC curve (AUROC) of 0.70.ConclusionsThis model can identify patients at high risk of acute exacerbation. Preventive measures and modification of treatment in these high-risk patients would improve survival.

Usefulness of COPD Assessment Test as valuable predictor of depression in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, including depression, which carries a higher risk of exacerbation and hospitalization in patients with stable COPD. A newly developed questionnaire, the COPD Assessment Test (CAT), was developed as an alternative to other complex, time-consuming tools for quantifying the symptom burden of COPD in routine practice. It is possible that the correlation between the CAT and depression scales could be useful for early evaluation and management of depression in COPD patients. Thus, we investigated the relationship between the CAT and depression as measured by the Patient Health Questionnaires-9 (PHQ-9). We performed a retrospective observational COPD cohort study. A total of 97 patients were enrolled. The Korean versions of the CAT and PHQ-9 were completed for stable patients. A correlation analysis was performed between the PHQ-9 and CAT scores. Significant depression among the groups based on the 2011 GOLD guidelines occurred only in class Gold B and D patients (40% and 60%, respectively). The frequency of depression was significantly higher in the group with higher CAT scores (20~29 versus ≥30; odds ratio: 5.67 versus 22.66). Significant association was observed between the PHQ-9 and CAT scores (r=0.545 and P<0.001). As a result, the PHQ-9 score was significantly higher in COPD patients with a higher CAT score. The CAT is a simple and valuable predictor of depression in COPD patients, and it should be frequently used to detect COPD patients with depression in clinical practice.

Reducing Exacerbations in the Inner City: Lessons from the Inner-City Asthma Consortium (ICAC)

Asthma exacerbations are important components of asthma morbidity. The Inner-City Asthma Consortium was established in the early 1990s to identify risk factors for and to evaluate treatments to reduce asthma symptoms and exacerbations. Early studies identified atopy and inadequate treatment as important drivers of asthma morbidity. Later studies demonstrated that good adherence to guidelines-based asthma care could virtually eliminate symptoms and reduce but not eliminate exacerbations. Looking at exacerbations by season, risk factors were found to vary across the different seasons. Of the 7 factors identified, allergic status and pulmonary functions were found to be important for exacerbations in all seasons, but allergy had its strongest effect in the fall season. Therefore, additional therapy directed at reducing the role of allergy was evaluated and found to significantly reduce exacerbations even in participants with good symptom control when receiving guidelines-based therapy. Despite this year around aggressive therapy, exacerbations remain albeit at a lower level and with less seasonal variation. Another strategy, the short term use of therapy aimed at reducing the role of allergy begun before the fall season and focused on individuals at high risk for exacerbations, was found to be an effective approach to minimize exacerbations and to limit the amount of therapy necessary.

Patient-centered physical activity coaching in COPD (Walk On!): A study protocol for a pragmatic randomized controlled trial

BackgroundPhysical inactivity is significantly associated with more frequent hospitalizations and increased mortality in COPD even after adjusting for disease severity. While practice guidelines recommend regular physical activity for all patients with COPD, health systems are challenged in operationalizing an effective and sustainable approach to assist patients in being physically active. MethodsA pragmatic randomized controlled trial design was used to determine the effectiveness of a 12-month home and community-based physical activity coaching intervention (Walk On!) compared to standard care for 1650 patients at high risk for COPD exacerbations from a large integrated health care system. Eligible patients with a COPD-related hospitalization, emergency department visit, or observational stay in the previous 12months were automatically identified from the electronic medical records (EMR) system and randomized to treatment arms. The Walk On! intervention included collaborative monitoring of step counts, semi-automated step goal recommendations, individualized reinforcement from a physical activity coach, and peer/family support. ResultsThe primary composite outcome included all-cause hospitalizations, emergency department visits, observational stays, and death in the 12months following randomization. Secondary outcomes included COPD-related utilization, cardio-metabolic markers, physical activity, symptoms, and health-related quality of life. With the exception of patient reported outcomes, all utilization and clinical variables were automatically captured from the EMR. ConclusionsIf successful, findings from this multi-stakeholder driven trial of a generalizable and scalable physical activity intervention, carefully designed with sufficient flexibility, intensity, and support for a large ethnically diverse sample could re-define the standard of care to effectively address physical inactivity in COPD.

Factors Associated With Acute Exacerbation in COPD Patients With Mild-to-Moderate Airflow Limitation

SESSION TITLE: COPD Posters III SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: The aim of this study was to compare the clinical characteristics of patients with mild-to-moderate airflow limitation according to the experience the acute exacerbation. METHODS: The patients included in the present study were from the Korean COPD Subtype Study (KOCOSS) cohort. The patients were recruited from 37 referral hospitals in Korea. The definition of COPD was adopted by the GOLD guideline. We obtained the clinical data from the medical record and compared the clinical, spirometric data according to the development of exacerbation during the follow-up period RESULTS: A total of 570 patients with mild-to-moderate airflow limitation were enrolled. A total of 9.3% had FEV1>80% of predicted value. The mean CAT score was 13.9 ± 6.9. The mean SGRQ-c was 30.4 ± 6.5. There were 114 patients (20%) who had experienced one year before enrollment. A total of 17.4% and 14.2% of patients had history of measles and pneumonia, respectively. When adopting 2011 GOLD classification, 24.9% and 74.7% of the patients were classified as GOLD A and B, respectively. During the first 2 years of follow-up period, 17.5% of patients experienced acute exacerbation. SGRQ-c and CAT score were significantly higher in patients with exacerbation than patients without exacerbation (36.3 ± 2.0 vs. 25.6±1.5, 16.6±79 vs. 12.1±6.0, respectively). Patient with exacerbation had allergic rhinitis, hyperlipidemia more frequently, which is statistically significant. A total of 83.3% of patients with history of exacerbation at enrollment experienced exacerbation during the follow-up period. A total 22.0% and 24.1% of the patients with exacerbation had history of pneumonia and measles, which is higher than that of patients without exacerbation (p=0.014 and 0.044, respectively). CONCLUSIONS: A total of 17.5% of mild to moderate COPD patients experienced acute exacerbation during 2 years of follow up. Development of acute exacerbations is associated with poor quality of life, hyperlipidemia, allergic rhinitis, history of acute exacerbation, history of pneumonia and history of measles CLINICAL IMPLICATIONS: A subsequent number of patients with mild-to-moderate airflow limitation experienced exacerbations. Presence of co-morbidities, quality of life and past medical history should be assessed meticulously in order to differentiate patients with high risk of exacerbation. DISCLOSURE: The following authors have nothing to disclose: Yong Il Hwang, Chang Youl Lee, Sunghoon Park, Joo Hee Kim, Yong Bum Park, Seung Hun Jang, Kwang Ha Yoo, Chin Kook Rhee, Hyoung Kyu Yoon, Ki-Suck Jung No Product/Research Disclosure Information

Cost effectiveness of bronchial thermoplasty in patients with severe uncontrolled asthma

Rationale: Based on its clinical effectiveness, bronchial thermoplasty (BT) was approved by the Food and Drug Administration in 2010 for the treatment of severe persistent asthma in patients 18 years and older whose asthma is not well-controlled with inhaled corticosteroids and long-acting beta-agonist medicines. Objective: Assess the 10 year cost-effectiveness of BT for individuals with severe uncontrolled asthma. Methods: Using a Markov decision analytic model, the cost-effectiveness of BT was estimated. The patient population involved a hypothetical cohort of 41-year-old patients comparing BT to usual care over a 10-year time frame. The main outcome measure was cost in 2013 dollars per additional quality adjusted life year (QALY). Results: Treatment with BT resulted in 6.40 QALYs and $7512 in cost compared to 6.21 QALYs and $2054 for usual care. The incremental cost-effectiveness ratio for BT at 10 years was $29 821/QALY. At a willingness to pay per QALY of $50 000, BT continues to be cost effective unless the probability of severe asthma exacerbation drops below 0.63 exacerbation per year or the cost of BT rises above $10 384 total for all three bronchoscopic procedures needed to perform thermoplasty and to cover the entire bronchial tree (baseline = $6690). Conclusions: BT is a cost-effective treatment for asthmatics at high risk of exacerbations. Continuing to follow asthmatics treated with BT beyond 5 years will help inform longer efficacy and support its cost-effectiveness.