Higher COPD Assessment Test Scores Research Articles

The triad of physiological challenges: investigating the intersection of sarcopenia, malnutrition, and malnutrition-sarcopenia syndrome in patients with COPD - a cross-sectional study.

One of the most prevalent respiratory disorders in modern society is chronic obstructive pulmonary disease (COPD). Frequent comorbidities in patients with COPD are abnormal nutritional status and body composition variations. Malnutrition-sarcopenia syndrome, which occurs when the 2 conditions - malnutrition and sarcopenia - coexist, raises the risk of death more than either condition alone. The current study sought to determine the prevalence of malnutrition, sarcopenia, and malnutrition-sarcopenia syndrome in patients with COPD as well as the association between these diseases and the severity of COPD. The study was an analytical cross-sectional study conducted on hospitalized patients with COPD. The sample size of the study was calculated to be 160. A self-structured questionnaire was used to collect the data, containing sociodemographic characteristics, clinical profiles, anthropometric assessment, and bioimpedance indices. Sarcopenia was diagnosed with low muscle strength and muscle mass by the EWGSOP2 recommendations. Muscle mass is measured by BIA and muscle strength (Handgrip) was measured by a Hand Dynamometer. Assessment of the risk of malnutrition was performed using the Mini Nutritional Assessment-Short Form questionnaire and was confirmed by GLIM criteria. The COPD assessment test (CAT) tool determined the severity of the condition. For the data analysis, comparisons were made using Student's t test and Mann-Whitney test in bivariate analysis. Multivariate logistic regression analyses were performed considering the outcomes of patients with COPD by CAT scores, prolonged length of stay, and hospital readmission 6 months after discharge. The mean age of the participants was 48 ± 5 years. Approximately 61.9% were found to be sarcopenic. Approximately 45.6% of participants had malnutrition. Malnutrition sarcopenia syndrome was diagnosed in 32.5% of patients. The study analysis revealed that patients with COPD with malnutrition-sarcopenia syndrome had more than twice the odds of prolonged hospital stay, re-admission within 6 months, and higher CAT scores. The study revealed a high prevalence of sarcopenia, malnutrition, and malnutrition sarcopenia syndrome in patients with COPD. These conditions were found to be statistically significant with prolonged length of stay, re-admission within 6 months, and CAT scores. The findings highlight the importance of addressing these conditions as part of the management of the patients.

Oscillometry-Defined Small Airway Dysfunction in Patients with Chronic Obstructive Pulmonary Disease.

The prevalence of small airway dysfunction (SAD) in patients with chronic obstructive pulmonary disease (COPD) across different ethnicities is poorly understood. This study aimed to estimate the prevalence of SAD in stable COPD patients. We conducted a cross-sectional study of 196 consecutive stable COPD patients. We measured pre- and post-bronchodilator (BD) lung function and respiratory impedance. The severity of COPD and lung function abnormalities was graded in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. SAD was defined as either difference in whole-breath resistance at 5 and 19 Hz > upper limit of normal or respiratory system reactance at 5 Hz < lower limit of normal. The cohort consisted of 95.9% men, with an average age of 66.3 years. The mean forced expiratory volume 1 second (FEV1) % predicted was 56.4%. The median COPD assessment test (CAT) scores were 14. The prevalence of post-BD SAD across the GOLD grades 1 to 4 was 14.3%, 51.1%, 91%, and 100%, respectively. The post-BD SAD and expiratory flow limitation at tidal breath (EFLT) were present in 62.8% (95% confidence interval [CI], 56.1 to 69.9) and 28.1% (95% CI, 21.9 to 34.2), respectively. COPD patients with SAD had higher CAT scores (15.5 vs. 12.8, p<0.01); poor lung function (FEV1% predicted 46.6% vs. 72.8%, p<0.01); lower diffusion capacity for CO (4.8 mmol/min/kPa vs. 5.6 mmol/min/kPa, p<0.01); hyperinflation (ratio of residual volume to total lung capacity % predicted: 159.7% vs. 129%, p<0.01), and shorter 6-minute walk distance (367.5 m vs. 390 m, p=0.02). SAD is present across all severities of COPD. The prevalence of SAD increases with disease severity. SAD is associated with poor lung function and higher symptom burden. Severe SAD is indicated by the presence of EFLT.

Structural Predictors of Lung Function Decline in Young Smokers with Normal Spirometry.

Chronic obstructive pulmonary disease (COPD) due to tobacco smoking commonly presents when extensive lung damage has occurred. We hypothesised that structural change would be detected early in the natural history of COPD and would relate to loss of lung function with time. We recruited 431 current smokers (median age 39 years, 16 pack-years smoked) and recorded symptoms by the COPD Assessment Test (CAT), spirometry and quantitative thoracic CT (QCT) scans at study entry. These scans results were compared to 67 never smoking controls. 368 participants were followed every six months with measurement of post-bronchodilator spirometry for a median of 32 months. The rate of FEV1 decline, adjusted for current smoking status, age and sex was related to the initial QCT appearances and symptoms, measured with the CAT. There were no material differences in demography or subjective CT appearances between the young smokers and controls, but 55.7% of the former had a CAT score above 10 and 24.2% reported chronic bronchitis. QCT assessments of Disease Probability-defined functional small airways disease, ground glass opacification, bronchovascular prominence and small blood vessel to total pulmonary vessel volume ratio were increased compared to controls and were all associated with a faster FEV1 decline as was a higher CAT score. Radiologic abnormalities on CT are already established in young smokers with normal lung function and is associated with FEV1 loss independently of the impact of symptoms. Structural abnormalities are present early in the natural history of COPD and are markers of disease progression. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Factors affecting work productivity and activity impairment among chronic obstructive pulmonary disease patients.

Chronic obstructive pulmonary disease (COPD) can negatively affect patients' employment and work-life activities with a significant indirect economic impact. The current study aimed to measure unemployment, work productivity, activity impairment, and their associated factors among COPD patients. A cross-sectional study was conducted in the Chest outpatient clinic, Mansoura University Hospital, Egypt. COPD patients completed an interviewer-administered questionnaire including sociodemographic, occupational data, clinical history, medical research council (mMRC) dyspnea scale, the COPD assessment test (CAT), and work productivity and activity impairment Questionnaire (WPAI-COPD). A total 140 patients were included in the study and 22.1% of them gave up their jobs because of their COPD. Due to COPD, the mean percentage of daily activity impairment was 39.8 among all patients. The mean percentages of absenteeism, presenteeism, and overall work impairment among the 84 working patients were 0.07, 24.4, and 24.5. The CAT score was the significant predictor of all components of WPAI. In conclusion, COPD causes early retirement, high work productivity loss, and impaired daily activities. Higher CAT scores and increased disease severity significantly increase absenteeism, presenteeism, overall work, and activity impairment. Thus, timely diagnosis of COPD with appropriate management can help improve outcomes and lower the disease burden and economic impact.

The clinical characteristics and outcomes of different inhaled therapies in chronic obstructive pulmonary disease patients with frequent cough

Background Cough is a common symptom in patients with chronic obstructive pulmonary disease (COPD). Patients with cough may exhibit various clinical characteristics and experience varying outcomes based on inhaled therapies they receive. Objectives This study aimed to explore the clinical characteristics and outcomes of various inhaled therapies in COPD patients with frequent cough. Methods This was a multicenter, prospective cohort study. Of these patients, the median cough score in COPD assessment test (CAT) was two. Patients were classified into frequent cough group if they scored two or over in the first item of CAT and infrequent cough group otherwise. Patients with frequent cough were then divided into long-acting antimuscarinic (LAMA), long-acting beta2-agonist (LABA)/LAMA, inhaled corticosteroids (ICS)/LABA and ICS/LABA/LAMA groups. Minimum clinically important difference (MCID) (CAT scores decreased ≥2 from baseline) and the improvement of cough (cough score decreased ≥1 from baseline) were collected in the six-month follow-up. Frequent exacerbations (experiencing at least two exacerbations) were collected in the one-year follow-up. Results Of 906 patients, 581 (64.1%) patients reported frequent cough at the initial visit. Frequent cough was associated with the current smokers and CAT scores (p < 0.05). The MCID showed no significant difference between frequent cough and infrequent cough groups in the follow-up. More patients with frequent cough experienced future frequent exacerbations compared to those with infrequent cough. After receiving inhaled therapies, 62% of patients with frequent cough got the cough improved. More patients with frequent cough treated with LABA/LAMA or ICS/LABA/LAMA attained MCID and fewer experienced exacerbations than those treated with LAMA or ICS/LABA (p < 0.05). The change in cough score showed no difference among various inhaled therapies in patients with frequent cough. Conclusion COPD patients with frequent cough were related to current smokers and higher CAT scores. These patients had a higher incidence of frequent exacerbations than those with infrequent cough. Patients with frequent cough who were treated with LABA/LAMA or ICS/LABA/LAMA were more likely to attain MCID and at a lower risk of exacerbation than those treated with LAMA or ICS/LABA.

Assessment of post-COVID-19 fatigue among female survivors 2 years after hospital discharge: a nested case–control study

BackgroundFatigue is a common symptom of long COVID syndrome. Compared to male survivors, females have a higher incidence of post-COVID fatigue. Therefore, long-term follow-up is necessary to understand which groups of females are more vulnerable to post-COVID fatigue.MethodsThis is a nested case–control study of female COVID-19 survivors who were discharged from two designated hospitals in Wuhan, China in 2020, and received 2-year follow-up from March 1 to April 6, 2022. All patients completed the Checklist Individual Strength-subscale subjective fatigue (CIS-fatigue), a chronic obstructive pulmonary disease (COPD) assessment test (CAT), and the Hospital Anxiety and Depression Scale (HADS; including the HADS-Anxiety [HADS-A] and the HADS-Depression [HADS-D]). Individuals with CIS-fatigue scores of 27 or higher were classified as cases. The risk factors for fatigue was analysed with multivariable logistic regression analysis.ResultsA total of 899 female COVID-19 survivors were enrolled for analysis, including 47 cases and 852 controls. Compared with controls, cases had higher CAT, HADS-A and HADS-D scores, and showed a higher prevalence of symptoms, including anxiety (cases vs. controls, 44.7% vs. 4.0%, p < 0.001), chest tightness (21.2% vs. 2.3%, p < 0.001), dyspnoea (19.1% vs. 0.8%, p < 0.001) and so on. In multivariable logistic regression analysis, age (OR, 1.03; 95% CI, 1.01–1.06; p = 0.02) and cerebrovascular disease (OR, 11.32; 95% CI, 2.87–43.00; p < 0.001) were risk factors for fatigue. Fatigue had a statistically significant moderate correlation with depression (r = 0.44, p < 0.001), but not with CAT ≥ 10.ConclusionFemale COVID-19 patients who had cerebrovascular disease and older age have higher risk of fatigue. Patients with fatigue have higher CAT scores, and are more likely to have concurrent depression.

Cohort study to evaluate prognostic factors in idiopathic pulmonary fibrosis patients introduced to oxygen therapy

While high-level evidence is lacking, numerous retrospective studies have depicted the value of supplemental oxygen in idiopathic pulmonary fibrosis (IPF) and other interstitial lung diseases, and its use should be encouraged where necessary. The clinical course and survival of patients with IPF who have been introduced to oxygen therapy is still not fully understood. The objective of this study was to clarify overall survival, factors associated with prognosis, and causes of death in IPF patients after the start of oxygen therapy. This is a prospective cohort multicenter study, enrolling patients with IPF who started oxygen therapy at 19 hospitals with expertise in interstitial lung disease. Baseline clinical data at the start of oxygen therapy and 3-year follow-up data including death and cause of death were assessed. Factors associated with prognosis were analyzed using univariable and multivariable analyses. One hundred forty-seven eligible patients, of whom 86 (59%) were prescribed ambulatory oxygen therapy and 61 (41%) were prescribed long-term oxygen therapy, were recruited. Of them, 111 died (76%) during a median follow-up of 479 days. The median survival from the start of oxygen therapy was 537 ± 74 days. In the univariable analysis, low body mass index (BMI), low forced vital capacity (FVC), low diffusion capacity (DLCO), resting hypoxemia, short 6 min-walk distance, and high COPD assessment test (CAT) score were significantly associated with poor prognosis. Multivariable analysis revealed low BMI, low FVC, low DLCO, low minimum SpO2 on 6MWT, and high CAT score were independent factors for poor prognosis. The overall survival of IPF patients after starting oxygen therapy is about 1.5 years. In addition to pulmonary function tests, 6MWT and patient reported outcomes can be used to predict prognosis more accurately.Clinical Trial Registration: UMIN000009322.

The COPD Assessment Test (CAT) and Depression: A Longitudinal Analysis During the COVID-19 Pandemic.

Chronic obstructive pulmonary disease (COPD) is multifaceted, with some patients experiencing anxiety and depression. Depression in COPD has been associated with worse total scores for the COPD assessment test (CAT). Also, CAT score worsening has been observed during the COVID-19 pandemic. The relationship between the Center for Epidemiologic Studies Depression Scale (CES-D) score and CAT sub-component scores has not been evaluated. We investigated the relationship between CES-D score and CAT component scores during the COVD-19 pandemic. Sixty-five patients were recruited. Pre-pandemic (baseline) was defined as 23rd March 2019-23rd March 2020, CAT scores and information related to exacerbations were collected via telephone at 8-week intervals between 23rd March 2020-23rd March 2021. There were no differences in CAT scores pre- compared to during the pandemic (ANOVA p = 0.97). Total CAT scores were higher in patients with symptoms of depression compared to those without both pre- (p < 0.001) and during-pandemic (eg, at 12 months 21.2 versus 12.9, mean difference = 8.3 (95% CI = 2.3-14.2), p = 0.02). Individual CAT component scores showed significantly higher chest tightness, breathlessness, activity limitation, confidence, sleep and energy scores in patients with symptoms of depression at most time points (p < 0.05). Significantly fewer exacerbations were observed during- compared to pre-pandemic (p = 0.04). We observed that COPD patients with symptoms of depression had higher CAT scores both pre- and during the COVID-19 pandemic. Presence of depressive symptoms was selectively associated with individual component scores. Symptoms of depression may potentially influence total CAT scores.

Malnutrition associated with readmission in elderly patients with chronic obstructive pulmonary disease.

To the Editor: Compared with non-readmission chronic obstructive pulmonary disease (COPD) patients, the mortality rate of readmission patients is significantly higher (2.3% vs. 13.4%),[1] which undoubtedly causes socio-economic pressures on rehabilitation care and medical resources. The potential factors affecting the risk of readmission are required to be identified. The incidence of malnutrition, occurring frequently in elderly COPD patients, varies from 20% to 45% depending on the screening tools used. As a practical, economical and effective scoring system, the Mini Nutrition Assessment (MNA) is of great value to assessing nutritional status in the elderly. Malnutrition is a state of vulnerability in elder populations and is associated with a poor long-term prognosis. This study aimed to research the impact of nutritional status related risk factors on readmission and assess the value of MNA scoring system and updated sarcopenia diagnostic criteria in predicting readmission risk for elderly COPD patients. This observational prospective study protocol was approved by the Human Research Ethics Committee of Huadong Hospital, Fudan University (No. 2019K125) and has been registered and approved by Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx, chiCTR1900022576). The written informed consent was obtained from each participant. This study was conducted at the Department of Pulmonary and Critical Care Medicine, Huadong Hospital, between November 2018 and December 2019. Inclusion criteria were: (1) COPD patients diagnosed by the Global Initiative for Chronic Obstructive Lung Disease guideline[2]; (2) patients were admitted to hospital due to acute exacerbation of COPD (AECOPD); (3) age ≥65 years; and (4) patients who met the criteria of discharge with stable condition. The exclusion criteria were: (1) patients who were unable to stand steadily or finish the walk test; (2) patients had a history of pacemaker implantation; (3) severe cognitive impairment; (4) clinically visible edema; and (5) patients who declined to participate. All the candidates, who were admitted to hospital for AECOPD, received the first interview in person to obtain baseline data within 48 h before discharge. Follow-up assessments were offered to all the participants by experienced physicians (TZ and JYC) up to 180 days after discharge, and the follow-up information was obtained from digital medical records or telephone calls with permission. At the first interview, the information on demographic characteristics, mid-arm circumference, calf circumference (CC), Charlson Comorbidity Index (CCI), drug usage, and laboratory results such as the level of serum albumin was collected. And the smoking information as well as chronic cough history during childhood was also collected. Additionally, pulmonary function tests were performed according to the American Thoracic Society/European Respiratory Society criteria using standardized equipment (Master Screen PFT System, Jager, Germany) at the time of baseline data collection. Besides, dyspnea and the quality of life were evaluated with the modified scale of the Medical Research Council (mMRC) and the COPD assessment test (CAT) questionnaire, respectively. The mMRC score ranges from 0 to 4, and higher score indicates worse dyspnea. The CAT score ranges from 0 to 40, and a score more than 31.0 points indicates a very serious impact on the quality of life. At the time of monthly follow-up, information on readmission events was recorded. MNA [Supplementary files, https://links.lww.com/CM9/B324] scores were measured to assess nutritional status at baseline. A score <17.0 points was considered as malnutrition, a score between 17.0 points and 23.5 points was considered to be at risk of malnutrition, and well-nourished patients had a MNA score >23.5 points. All participants have completed the assessments within 48 h before discharge. Sarcopenia was defined following the updated Asian Working Group for Sarcopenia (AWGS): 2019 Consensus.[3] Body composition was measured by bioelectrical impedance analysis (InBody 570, InBody Co., Seoul, Korea) using a standard hand-to-foot tetra-polar technique. The skeletal muscle mass index (SMI) was calculated using the appendicular skeletal muscle mass divided by the square of body height in meters. Low muscle mass was defined as SMI <7.0 kg/m2 in men and SMI <5.7 kg/m2 in women. Muscle strength was assessed by digital handgrip strength using a JAMAR Dynamometer (JAMAR Co., Ltd., DuLuth, Minnesota, USA) in a standard posture. Low muscle strength was defined as handgrip strength <28 kg in men and <18 kg in women. Physical performance was measured by gait speed (GS): a 4-m walking test was performed to measure the usual GS. A score of <0.8 m/s was used to identify low GS. Statistical differences between groups were assessed with the chi-squared tests, Fisher's exact tests, Mann-Whitney U tests, or one-way analysis of variance tests as appropriate. We used multivariable logistic regression analysis to measure the independent risk factors of sarcopenia. A Cox regression analysis, was performed to investigate risk factors for readmission. The variables with P values <0.10 in univariable analysis were included in multivariable analysis. We created Kaplan–Meier curve of cumulative risk of readmission with log-rank test. Statistical analyses were performed with IBM SPSS Statistics 25.0 (IBM SPSS Inc., Chicago, IL, USA). A two-sided P-value of <0.05 was considered statistically significant. Also, we had conducted collinearity diagnostics by calculating the variance inflation factor (VIF) between MNA scores and sarcopenia. The results showed that VIF is 1.032, lower than 10, indicating no significant multicollinearity between two variables. Totally 302 COPD patients, including 55.0% (166/302) of male, were enrolled in this study. A total of 54 (17.9%) patients had readmission within 6 months after discharge from hospital. The average age of all patients was 77.0 ± 7.6 years and the mean body mass index (BMI) was 24.3 ± 3.4 kg/m2. Patients with readmission events were significantly elder (79.7 ± 7.9 years vs. 76.4 ± 7.4 years, t = 2.99, P = 0.003), and had lower BMI (23.0 ± 3.2 kg/m2vs. 24.6 ± 3.4 kg/m2, t = −3.14, P = 0.002), skeletal muscle mass index (5.9 ± 1.3 kg/m2vs. 7.2 ± 1.0 kg/m2, in males, t = −6.21, P < 0.001, and 5.4 ± 1.0 kg/m2vs. 5.8 ± 1.3 kg/m2, in females, t = −2.36, P = 0.020) and handgrip strength (22.0 [15.3–31.2] kg vs. 27.0 [22.0–33.2] kg, Z = −3.41, P < 0.001) than those without readmission within 6 months. Higher CAT scores (18.0 [11.8–22.0] vs. 15.0 [10.0–22.0], Z = −1.36, P = 0.001) and lower forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio (57.0 ± 10.4% vs. 61.3 ± 9.1%, t = −2.90, P = 0.004) were also found among patients with readmission events, when compared with patients without readmission within six months. While the levels of serum albumin as well as drug usage were similar between patients with and without readmission. Thirty-one (10.3%) and 84 (27.8%) of all patients were malnourished and at risk of malnutrition according to the MNA score, respectively. Compared with non-readmission group, the CCI was significantly higher in patients with readmission events (3 [2–4) vs. 2 [1–3], Z = −3.74, P < 0.001]. Higher percentages of cerebrovascular diseases (22.2% [12/54] vs. 11.3% [28/248], χ2 = 4.61, P = 0.033), diabetes (25.9% [14/54] vs. 12.9% [32/248], χ2 = 5.82, P = 0.017), and rheumatologic diseases (5.6% [3/54] vs. 0 [0/248], P = 0.005) were found in patients with readmission than those without readmission [Supplementary Table 1, https://links.lww.com/CM9/B324]. Our findings showed that the average time to readmission was 151.2 ± 46.8 days, 157.5 ± 43.3 days, and 171.6 ± 30.1 days among malnourished, risk of malnutrition, and normal nutrition groups, respectively. Also, the mean time from discharge to readmission in sarcopenia patients was significantly shorter than that in non-sarcopenia patients (152.3 ± 49.2 days vs. 172.7 ± 25.6 days; P < 0.001). Moreover, among all readmitted patients, 16.7% (9/54) of patients were hospitalized for no less than twice within 6 months. No statistical significance was found in readmission frequency among different nutritional status groups. A total of 107 (35.4%) participants were diagnosed as sarcopenia according to the 2019 AWGS criteria. The univariate analysis showed that factors such as BMI, FEV1/FVC ratio, FEV1 of predicted, CAT, and malnutritional status were related to sarcopenia. Multivariate logistic regression analyses revealed that malnutrition (odds ratio [OR] = 2.88, 95% confidence interval [CI]: 1.14–7.23, P = 0.025), BMI (OR = 0.90, 95% CI: 0.83–0.98, P = 0.025), and FEV1/FVC ratio (OR = 0.95, 95% CI: 0.92–0.98, P = 0.003) were more likely to be associated with sarcopenia. Our findings showed that 32.3% (10/31) of malnourished patients were readmitted to hospital after discharge, which occurred in 28.6% (24/84) of patients at risk of malnutrition and 10.7% (20/187) of well-nourished patients. Cox regression analysis suggested that poor nutritional status, sarcopenia, and current smoking were associated with risk of readmission. Patients with malnutrition had a 2.97-fold (95% CI: 1.18–7.47, P = 0.021) of readmission risk compared to those who were well-nourished. Current smokers had a 2.82-fold (95% CI: 1.02–7.80, P = 0.046) of readmission risk compared to those who never smoked. By the end of 6 months follow-up, the incidences of readmission were 22% and 18% higher in patients with malnutrition and at risk of malnutrition than well-nourished patients. The incidence of readmission was 24% in patients with sarcopenia, higher than that in non-sarcopenia patients, as shown in Figure 1.Figure 1: Kaplan–Meier curves of the cumulative incidence of non-readmission within 180 days among COPD patients with different nutritional status (A) and with or without sarcopenia (B).Among all the 54 patients, who suffered readmission within 6 months after discharge, 66.7% (36/54) were due to the AECOPD, and 33.3% (18/54) were readmitted for other causes, including cardiovascular disease, disturbance of consciousness, lung cancer, pleural effusion, pulmonary embolism, etc. Among patients admitted due to AECOPD, 69.4% (25/36) were at worse nutritional status (malnutrition or at risk of malnutrition), and 16.7% (6/36) were current smokers. In our study, malnutrition accounted for 10.3% of AECOPD hospitalized patients, besides, 27.8% AECOPD hospitalized patients were at risk of malnutrition. The prevalence of at risk of malnutrition was similar to the study of Min Fang Hsu et al.[4] With the threshold of a score <17 as malnutrition, our study revealed that it occurred in 18.7% (20/107) of patients with sarcopenia, and malnutrition was also an independent risk factor for the presence of sarcopenia. Existing evidence suggested that poor nutritional status among elderly COPD patients, even at risk of malnutrition, would be accompanied with the elevated resting energy consumption, the increased systemic protein turnover and higher levels of adenosine triphosphate consumption during muscle contraction. The disease-related increases in daily metabolism and the energy imbalance of intake and consumption played a role in muscle atrophy and functional decline. Given that skeletal muscle function (muscle strength and endurance), was closely related to muscle mass, COPD patients with either poor nutritional status or sarcopenia may be more vulnerable to weakness as well as the next exacerbation of disease. Existing evidence has demonstrated that sarcopenia is a risk factor for all-cause mortality,[5] and in hospitalized patients with AECOPD, the group with muscle loss had higher in-hospital mortality, longer average hospital stay and higher hospitalization cost. In our study, the mean time to readmission was significantly shorter in patients with sarcopenia, suggesting that sarcopenia, diagnosed by updated sarcopenia diagnostic criteria, can be used as an indicator to predict poor prognosis of COPD patients as well as to offer practical interventions, including dietary modification and rehabilitation strategies to improve nutritional status against sarcopenia. However, the study has some limitations. First, our study was conducted in a single center, with the limited participants focusing on elderly hospitalized patients in a tertiary hospital. Second, the proportion of female participant in this study is relatively higher. Thirdly, the measurements of body composition, muscle strength, and serum sample tests were only performed at baseline due to the limited funds and labor resources. In summary, our findings suggested that worse nutritional status identified by MNA score system as well as sarcopenia which was diagnosed with the updated criteria were supposed to be reliable predictors for readmission of COPD patients, which help to better understand the value of screening for nutritional status and sarcopenia in elderly COPD individuals as well as to provide supporting evidence on the necessity of taking nutritional precautions for preventing readmission of COPD patients. Funding This work was supported by grants from the National Natural Science Foundation of China (Nos. 81900072 and 82170092). Conflicts of interest None

Medication Adherence Assessment and Cost Analysis of COPD Treatment Under Out-Patient Clinic in Vietnam.

Chronic obstructive pulmonary disease (COPD) out-patient clinic is for stable patients but it requires patient's adherence to medicine and medical checkups. Our study aimed to assess COPD out-patient clinics management efficacy with respect to medication adherence and treatment costs at 3 out-patient clinics. Data were collected through 514 patient interviews and from medical records for statistical analysis. The most common comorbidity was hypertension (28.8%), and 52.9% of patients had experienced exacerbations in the past year requiring 75.7% of them to be hospitalized. According to the Morisky scale, 78.8% had high adherence and 82.9% were using inhaled corticosteroids regimens. The mean cost per year among different cohorts varied, with the out-patient cohort at $305.93, the acute exacerbations of COPD non-hospital cohort at $247.39, the standard admission cohort at $1275.3, and the emergency department cohort at $2132.5. Patients with low medication adherence had significantly lower annual costs ($238.25 vs $325.04, P = .001). In Vietnam, economic constraints have made Inhaled corticosteroids/ Long-acting β-2 agonists the main mode of treatment. However, the exclusion of Long-acting β-2 agonists/Long-acting anti-muscarinic antagonists drugs from health insurance coverage poses a challenge to Global Initiative for Chronic Obstructive Lung Disease-based prescription practices and increases the importance of monitoring medication adherence, particularly in patients with higher COPD Assessment Test scores.

The influence of adverse drug effects on health-related quality of life in chronic obstructive pulmonary disease patients.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Concerns have been raised about the influence of adverse drug effects on patient's health-related quality of life (HRQoL) in COPD patients. This study aimed to evaluate the impact of COPD treatment-related adverse effects on HRQoL in COPD patients. In a cross-sectional study, COPD patients aged 40 years or older were identified and interviewed during their hospital visits. The EuroQol 5 Dimension 5 Level (EQ-5D-5L) questionnaire was used for evaluating HRQoL. Potential treatment adverse effects were evaluated as experienced by participants during the last 2 weeks preceding the interview. The intensity of adverse effects was reported in the following categories: never, mild, moderate and severe. Multivariable linear regression model was performed to evaluate the influence of adverse drug effects on utility scores as an indicator of HRQoL. A total of 203 patients diagnosed with COPD were recruited in the current study. The mean utility score of the study sample was 0.68 (SD = 0.36). Moderate-severe constipation, moderate-severe confusion, mild urinary hesitation, moderate-severe urinary hesitation, moderate-severe dry eyes and moderate-severe drowsiness were significant predictors/determinants for the average utility scores (coefficients were -0.099, -0.191, -0.111, -0.157 and -0.144, respectively). In addition, having higher COPD Assessment Test scores and severe disease was negatively associated with average utility scores (coefficients were -0.287 and -0.124, respectively). Higher intensity of COPD treatment-related adverse effects has a negative influence on HRQoL in COPD patients. Anticholinergic drug effects are of concern in COPD adults' population.

Predictors of respiratory failure after thoracic surgery: a retrospective cohort study with comparison between lobar and sub-lobar resection.

ObjectiveOnly approximately 15% of patients with lung cancer are suitable for surgery and clinical postoperative outcomes vary. The aim of this study was to investigate variables associated with post-surgery respiratory failure in this patient cohort.MethodsPatients who underwent surgery for lung cancer were retrospectively studied for respiratory function. All patients had undergone lung resection by a mini-thoracotomy approach. The study population was divided into two subgroups for comparison: lobectomy group, who underwent lobar resection; and sub-lobar resection group.ResultsA total of 85 patients were included, with a prevalence of lung cancer stage IA and adenocarcinoma histotype. Lobectomy (versus sub-lobar resection), the presence of chronic obstructive pulmonary disease (COPD), and a COPD assessment test (CAT) score >10, were all associated with an increased risk of respiratory failure. The partial pressure of arterial oxygen decreased more in the lobectomy group than in the sub-lobar resection group following surgery, with a significant postoperative between-group difference in values. Postoperative CAT scores were also better in the sub-lobar resection group.ConclusionsPost-surgical variations in functional parameters were greater in the group treated by lobectomy. COPD, high CAT score and surgery type were associated with postoperative development of respiratory failure.

Characteristics of Patients with Chronic Obstructive Pulmonary Disease Treated with Long-Acting Bronchodilators in a Real-World Setting in Singapore: A Single-Center Observational Study.

IntroductionThere is limited real-world evidence regarding clinical practice for chronic obstructive pulmonary disease (COPD) in Singapore. We compared baseline clinical characteristics and evaluated outcomes in patients with COPD who initiated treatment with either a long-acting muscarinic antagonist (LAMA) or a LAMA and a long-acting β2-agonist (LAMA+LABA).MethodsThis was a single-center observational study at Changi General Hospital, Singapore. Routine clinical data (hospital visits, case management, lung function, laboratory/imaging results, medication orders) were collected and compiled into a data warehouse. Eligible patients with COPD were ≥40 years old and newly prescribed LAMA or LAMA+LABA during the enrollment period. Patient characteristics in the baseline period (6 months) were compared between treatments. Clinical worsening was measured as a composite endpoint, defined as the first of a change in maintenance treatment class or a moderate-to-severe exacerbation during follow-up (12 months).ResultsIn total, 261 patients were included in the baseline period (LAMA: 73; LAMA+LABA: 188). In the baseline period, patients receiving LAMA+LABA versus LAMA had significantly lower body mass index, higher COPD Assessment Test score and worse lung function, and numerically higher exacerbation history. Prevalence of comorbidities was similar between treatment groups. In follow-up, high rates of clinical worsening were observed regardless of treatment regimen (LAMA: 38/73 [52%]; LAMA+LABA: 86/188 [46%]). Median time-to-clinical worsening was 340 days for the LAMA cohort and the raw median 154 days (interquartile range: 44–225) for the LAMA+LABA cohort. Median medication dispensation rate (0.86; interquartile range: 0.56–1.00) was similar between treatments.ConclusionPatients initiating treatment with LAMA+LABA had more severe COPD than patients prescribed LAMA. The proportion of patients experiencing clinical worsening was similarly high in both cohorts, suggesting that early identification and treatment optimization are necessary.

How to Utilize CAT and mMRC Scores to Assess Symptom Status of Patients with COPD in Clinical Practice?

Objective:In this study, we aimed to investigate the compatibility of modified Medical Research Council (mMRC) and COPD assessment test (CAT) scores of chronic obstructive pulmonary disease (COPD) patients in terms of evaluation of their symptom status.Methods:The study was planned as a single-center, cross-sectional study. Statistically four separate receiver operating characteristic (ROC) curves of CAT scoring were generated for mMRC scores of 1 to 4.Results:Two hundred twenty eight patients with stable COPD, mean age 64.2±8.2 and 88.6% male were included. A strong positive correlation was detected between CAT and mMRC (r=0.60, p<0.001). However, it was observed that 32 patients had mMRC<2 but CAT≥10, while 21 patients had CAT<10 but mMRC≥2. Thus, in 53 patients CAT and mMRC scores were not identical in terms of assessed symptom status. According to the ROC analysis, the mMRC scores of 1 to 4 were most compatible with the CAT scores of 10, 10, 15, and 20, respectively.Conclusions:Expanding current data represents that CAT score of 10 could be more compatible with mMRC score of 1. Moreover we think although a high mMRC or CAT score may be sufficient to assign patients to high symptom groups, it is needed to evaluate mMRC and CAT together to assign a patient to a low symptom group. In this way misclassification of the patients with high symptoms due to insufficient symptom evaluation as if they have low symptoms can be prevented.

Determination of Low Muscle Mass by Muscle Surface Index of the First Lumbar Vertebra Using Low-Dose Computed Tomography.

The muscle index of the first vertebra (L1MI) derived from computed tomography (CT) is an indicator of total skeletal muscle mass. Nevertheless, the cutoff value and utility of L1MI derived from low-dose chest CT (LDCT) remain unclear. Adults who received LDCT for health check-ups in 2017 were enrolled. The cutoff values of L1MI were established in subjects aged 20–60 years. The cutoff values were used in chronic obstructive pulmonary disease (COPD) patients to determine muscle quantity. A total of 1780 healthy subjects were enrolled. Subjects (n = 1393) aged 20–60 years were defined as the reference group. The sex-specific cutoff values of L1MI were 26.2 cm2/m2 for males and 20.9 cm2/m2 for females. Six subjects in the COPD group (6/44, 13.6%) had low L1MI. COPD subjects with low L1MI had lower forced expiratory volume in one second (0.81 ± 0.17 vs. 1.30 ± 0.55 L/s, p = 0.046) and higher COPD assessment test scores (19.5 ± 2.6 vs. 15.0 ± 4.9, p = 0.015) than those with normal L1MI. In conclusion, LDCT in health assessments may provide additional information on sarcopenia.

Explainable Machine Learning Model for Predicting First-Time Acute Exacerbation in Patients with Chronic Obstructive Pulmonary Disease.

Background: The study developed accurate explainable machine learning (ML) models for predicting first-time acute exacerbation of chronic obstructive pulmonary disease (COPD, AECOPD) at an individual level. Methods: We conducted a retrospective case–control study. A total of 606 patients with COPD were screened for eligibility using registry data from the COPD Pay-for-Performance Program (COPD P4P program) database at Changhua Christian Hospital between January 2017 and December 2019. Recursive feature elimination technology was used to select the optimal subset of features for predicting the occurrence of AECOPD. We developed four ML models to predict first-time AECOPD, and the highest-performing model was applied. Finally, an explainable approach based on ML and the SHapley Additive exPlanations (SHAP) and a local explanation method were used to evaluate the risk of AECOPD and to generate individual explanations of the model’s decisions. Results: The gradient boosting machine (GBM) and support vector machine (SVM) models exhibited superior discrimination ability (area under curve [AUC] = 0.833 [95% confidence interval (CI) 0.745–0.921] and AUC = 0.836 [95% CI 0.757–0.915], respectively). The decision curve analysis indicated that the GBM model exhibited a higher net benefit in distinguishing patients at high risk for AECOPD when the threshold probability was <0.55. The COPD Assessment Test (CAT) and the symptom of wheezing were the two most important features and exhibited the highest SHAP values, followed by monocyte count and white blood cell (WBC) count, coughing, red blood cell (RBC) count, breathing rate, oral long-acting bronchodilator use, chronic pulmonary disease (CPD), systolic blood pressure (SBP), and others. Higher CAT score; monocyte, WBC, and RBC counts; BMI; diastolic blood pressure (DBP); neutrophil-to-lymphocyte ratio; and eosinophil and lymphocyte counts were associated with AECOPD. The presence of symptoms (wheezing, dyspnea, coughing), chronic disease (CPD, congestive heart failure [CHF], sleep disorders, and pneumonia), and use of COPD medications (triple-therapy long-acting bronchodilators, short-acting bronchodilators, oral long-acting bronchodilators, and antibiotics) were also positively associated with AECOPD. A high breathing rate, heart rate, or systolic blood pressure and methylxanthine use were negatively correlated with AECOPD. Conclusions: The ML model was able to accurately assess the risk of AECOPD. The ML model combined with SHAP and the local explanation method were able to provide interpretable and visual explanations of individualized risk predictions, which may assist clinical physicians in understanding the effects of key features in the model and the model’s decision-making process.

Higher COPD Assessment Test Score Associated With Greater Exacerbations Risk: A Post Hoc Analysis of the IMPACT Trial.

In the InforMing the PAthway of COPD Treatment (IMPACT) trial, single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) reduced moderate/severe exacerbation rates versus FF/VI and UMEC/VI in patients with chronic obstructive pulmonary disease (COPD). This post hoc analysis tested the relationship between baseline health status, risk of future exacerbations, and efficacy outcomes. IMPACT was a Phase 3, double-blind, 52-week trial in patients with symptomatic COPD (COPD Assessment Test [CAT] score ≥10) and ≥1 moderate/severe exacerbation in the prior year randomized 2:2:1 to FF/UMEC/VI 100/62.5/25mcg, FF/VI 100/25mcg, or UMEC/VI 62.5/25mcg. Annual rate of on-treatment moderate/severe exacerbations, lung function, and safety were analyzed by continuous baseline CAT score. Moderate/severe exacerbation rates increased with increasing baseline CAT scores in FF/UMEC/VI and UMEC/VI arms. There was a very small increase in on-treatment pneumonia rates at higher baseline CAT scores across all treatment arms. FF/UMEC/VI reduced moderate/severe exacerbation rates versus UMEC/VI (i.e., the inhaled corticosteroid effect) consistently across the range of CAT scores. The reduction with FF/UMEC/VI versus FF/VI (i.e., the long-acting muscarinic antagonist effect) was greatest at lower CAT scores and appeared lesser at higher CAT scores. Improvements in lung function were observed with FF/UMEC/VI versus FF/VI and UMEC/VI, regardless of baseline CAT score. The CAT score was predictive of exacerbation risk. Worse baseline health status was associated with higher moderate/severe exacerbation and pneumonia rates. Irrespective of baseline CAT score, FF/UMEC/VI improved lung function, and reduced the annual moderate/severe exacerbation rates versus dual therapy. Results indicate an overall favorable benefit-risk profile of triple versus dual therapy, irrespective of CAT score. Clinical Trial Registration:GSK (CTT116855/NCT02164513).

Association Between Vitamin D Levels and FEV1, Number of Exacerbations, and CAT Score in Stable COPD Patients in Indonesia

PurposeThis study aimed to assess the association between vitamin D levels and forced expiratory volume in one second (FEV1), number of exacerbations, and symptoms based on COPD assessment test (CAT) scores in stable COPD patients in Indonesia.Patients and MethodsAn observational cross-sectional study was conducted. Subjects were stable COPD patients who were treated at a pulmonary clinic in a tertiary referral hospital in West Java from March to June 2018.ResultsThirty subjects were recruited this study with an average age 62±8 years. The mean vitamin D level was 20.17±8.91 ng/mL. Half of the patients had low vitamin D level (<20ng/mL) (50%). The mean FEV1 (%) predicted value was 37.2±14. The median exacerbation per year was 1 (0–5) and symptoms based on CAT score was 14 (3–34). No correlation was found between vitamin D levels and FEV1 (%) predicted value (r=0.126, p=0.253). Vitamin D level was inversely correlated with number of exacerbations (r=−0.639, p<0.001) and CAT (r= −0.802, p<0.001).ConclusionLow level of vitamin D was associated with more frequent exacerbation and higher CAT scores but was not associated with FEV1 (%) predicted.

Predictors of 30- and 90-Day COPD Exacerbation Readmission: A Prospective Cohort Study.

BackgroundReadmission following COPD exacerbation is a common and challenging clinical problem. New approaches to predicting readmissions are required to help mitigate risk and develop novel interventions.MethodsWe conducted a prospective cohort study in 82 COPD patients admitted due to an exacerbation of COPD. Lung function measures [spirometry, forced oscillation technique (FOT) indices and peak inspiratory flow rate (PIFR)], inflammatory biomarkers and patient-reported outcomes including previous exacerbation history, breathlessness, quality of life and frailty were measured at admission and discharge. We prospectively followed patients for 30 and 90 days to identify predictors for readmission.ResultsThe readmission rate within 30 days was 38%, and 56% within 90 days. Previous exacerbations, higher COPD Assessment Test score at discharge, frailty, reduced PIFR and increased length of stay were significantly associated with 30-day readmission. PIFR at discharge and frailty had the highest predictive ability for 30-day readmission using area under receiver operating characteristic curves (AUC 0.86, 95% CI 0.78–0.95, p < 0.001 and AUC 0.81, 95% CI 0.71–0.90, p < 0.001, respectively). Ninety-day readmissions were significantly associated with previous exacerbations and hospitalisations, higher CAT score at discharge, frailty, depression, lower PIFR and greater expiratory flow limitation (EFL) in the supine position. The best predictive variable in multivariable analysis for both 30- and 90-day readmission was PIFR at discharge.ConclusionPIFR, CAT score, frailty, and EFL were found to be associated with 30- and 90-day readmission following COPD exacerbation. These findings help identify those at highest risk and to optimise care prior to discharge.

Symptoms and Health Outcomes Among Survivors of COVID-19 Infection 1 Year After Discharge From Hospitals in Wuhan, China

The long-term health outcomes and symptom burden of COVID-19 remain largely unclear. To evaluate health outcomes of COVID-19 survivors 1 year after hospital discharge and to identify associated risk factors. This retrospective, multicenter cohort study was conducted at 2 designated hospitals, Huoshenshan Hospital and Taikang Tongji Hospital, both in Wuhan, China. All adult patients with COVID-19 discharged between February 12 and April 10, 2020, were screened for eligibility. Of a consecutive sample of 3988 discharged patients, 1555 were excluded (796 declined to participate and 759 were unable to be contacted) and the remaining 2433 patients were enrolled. All patients were interviewed via telephone from March 1 to March 20, 2021. Statistical analysis was performed from March 28 to April 18, 2021. COVID-19. All patients participated in telephone interviews using a series of questionnaires for evaluation of symptoms, along with a chronic obstructive pulmonary disease (COPD) assessment test (CAT). Logistic regression models were used to evaluate risk factors for fatigue, dyspnea, symptom burden, or higher CAT scores. Of 2433 patients at 1-year follow-up, 1205 (49.5%) were men and 680 (27.9%) were categorized into the severe disease group as defined by the World Health Organization guideline; the median (IQR) age was 60.0 (49.0-68.0) years. In total, 1095 patients (45.0%) reported at least 1 symptom. The most common symptoms included fatigue, sweating, chest tightness, anxiety, and myalgia. Older age (odds ratio [OR], 1.02; 95% CI, 1.01-1.02; P < .001), female sex (OR, 1.27; 95% CI, 1.06-1.52; P = .008), and severe disease during hospital stay (OR, 1.43; 95% CI, 1.18-1.74; P < .001) were associated with higher risks of fatigue. Older age (OR, 1.02; 95% CI, 1.01-1.03; P < .001) and severe disease (OR, 1.51; 95% CI, 1.14-1.99; P = .004) were associated with higher risks of having at least 3 symptoms. The median (IQR) CAT score was 2 (0-4), and a total of 161 patients (6.6%) had a CAT score of at least 10. Severe disease (OR, 1.84; 95% CI, 1.31-2.58; P < .001) and coexisting cerebrovascular diseases (OR, 1.95; 95% CI, 1.07-3.54; P = .03) were independent risk factors for CAT scores of at least 10. This study found that patients with COVID-19 with severe disease during hospitalization had more postinfection symptoms and higher CAT scores.