Long-term Decline In Lung Function Research Articles

ASSESSMENT OF POTENTIAL RISK FACTORS FOR THE DEVELOPMENT OF BRONCHOPULMONARY DYSPLASIA IN DEEPLY PREMATURE CHILDREN

Bronchopulmonary dysplasia (BPD) is one of the diseases that seriously affect the survival and prognosis of premature babies, as it can cause long-term decline in lung function and inhibit the development of the nervous system. Only according to official data, the incidence of this disease in very premature babies can be up to 21%. Currently, the only option for neonatologists to manage this condition is up-to-date assessment and alertness to potential risk factors.

Therapeutic Potential of Vitamin D in Management of Asthma: A Literature Review.

Asthma, a prevalent chronic respiratory illness, affects a substantial number of individuals worldwide, with an estimated occurrence of 358 million cases. Evidence for the benefits of vitamin D in treating asthma is ambiguous and contradictory. The goal of this review article is to emphasize the value of vitamin D supplementation for people with asthma. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on vitamin D supplementation in asthma patients. We selected a comprehensive range of academic writing examples published in English, encompassing various types of texts. The study included a total of 37 papers, of which 18 were randomized controlled trials (RCTs) and five were meta-analyses. The use of a corticosteroid, with or without the inclusion of an adrenergic receptor agonist, improves the disease's symptoms, but it is unable to halt the long-term decline in lung function. Over the past 20 years, vitamin D has developed into a potent immunomodulator, influencing both immunological and structural cells, most notably airway smooth muscle cells. Among adults withlow 25-hydroxyvitamin D levels, the administration of vitamin D supplements was found to have positive effects in a reduction in the likelihood of asthma exacerbations requiring systemic corticosteroids. The provision of vitamin D supplements during pregnancy significantly reduces the risk of asthma in babies. Both children and adults with inadequate vitamin D levels who have been given vitamin D supplements have shown evident preventive effects against asthma. Therefore, we conclude there should bea lower threshold for prescribing vitamin D to patients with asthma who are vitamin D deficient.

Bacteriophage Therapy for Pan-Drug-Resistant Pseudomonas aeruginosa in Two Persons With Cystic Fibrosis.

Cystic fibrosis (CF) is an important monogenic disease that affects more than 70 000 people worldwide. Defects of the CF transmembrane conductance regulator gene lead to dehydrated viscous secretions that result in chronic bacterial colonization. This leads to frequent recurrent lung infections called pulmonary exacerbations, lung inflammation, and resulting structural lung damage called bronchiectasis. Pseudomonas aeruginosa in particular is a common pathogen in persons with CF associated with increased pulmonary exacerbations, long-term lung function decline, and reduced survival. In addition, P. aeruginosa commonly develops antibiotic resistance and forms biofilms, making it difficult to treat. Here, we report the details of two patients with CF with pan-drug-resistant P. aeruginosa who were treated with a novel therapeutic strategy, bacteriophages. These cases highlight the need for further research and development of this treatment modality, including pediatric clinical trials.

Porphyromonas pasteri and Prevotella nanceiensis in the sputum microbiota are associated with increased decline in lung function in individuals with cystic fibrosis.

Although anaerobic bacteria exist in abundance in cystic fibrosis (CF) airways, their role in disease progression is poorly understood. We hypothesized that the presence and relative abundance of the most prevalent, live, anaerobic bacteria in sputum of adults with CF were associated with adverse clinical outcomes. This is the first study to prospectively investigate viable anaerobic bacteria present in the sputum microbiota and their relationship with long-term outcomes in adults with CF. We performed 16S rRNA analysis using a viability quantitative PCR technique on sputum samples obtained from a prospective cohort of 70 adults with CF and collected clinical data over an 8 year follow-up period. We examined the associations of the ten most abundant obligate anaerobic bacteria present in the sputum with annual rate of FEV1 change. The presence of Porphyromonas pasteri and Prevotella nanceiensis were associated with a greater annual rate of FEV1 change; −52.3 ml yr−1 (95 % CI-87.7;−16.9), –67.9 ml yr−1 (95 % CI-115.6;−20.1), respectively. Similarly, the relative abundance of these live organisms were associated with a greater annual rate of FEV1 decline of −3.7 ml yr−1 (95 % CI: −6.1 to −1.3, P=0.003) and −5.3 ml yr−1 (95 % CI: −8.7 to −1.9, P=0.002) for each log2 increment of abundance, respectively. The presence and relative abundance of certain anaerobes in the sputum of adults with CF are associated with a greater rate of long-term lung function decline. The pathogenicity of anaerobic bacteria in the CF airways should be confirmed with further longitudinal prospective studies with a larger cohort of participants.

PRS31 Modelling Survival of People with Cystic Fibrosis (PWCF) Aged ≥12 YEARS Homozygous for the F508DEL Mutation Treated with Ivacaftor/Tezacaftor/Elexacaftor and Ivacaftor (IVA/TEZ/ELX)

IVA/TEZ/ELX is a novel cystic fibrosis transmembrane conductance modulator (CFTRm) therapy approved by the European Medicines Agency to treat the underlying cause of disease for pwCF aged ≥12 years homozygous for the F508del mutation (F/F) or heterozygous for F508del and a minimal function mutation. A simulation model was used to estimate survival benefit of IVA/TEZ/ELX in F/F pwCF. A validated, lifetime, patient-level simulation model was used to estimate median survival in a simulated cohort of F/F pwCF aged ≥12 years in the United Kingdom (UK) treated with: IVA/TEZ/ELX+best supportive care (BSC), tezacaftor/ivacaftor (TEZ/IVA)+BSC, and BSC-alone. Age-specific mortality hazards from the 2008 UK CF Registry were combined with a Cox proportional hazards model to predict survival based on several risk factors in pwCF. Clinical efficacy inputs for IVA/TEZ/ELX+BSC and TEZ/IVA+BSC were derived from an indirect treatment comparison conducted using data from the IVA/TEZ/ELX Phase 3b study (NCT04105972) and TEZ/IVA Phase 3 study (NCT02347657). CFTRm impact on long-term lung function decline was based on TEZ/IVA data. Median projected survival in BSC-treated pwCF was 37.8 years; median projected survival increased to 47.9 years in TEZ/IVA-treated pwCF and 59.1 years in IVA/TEZ/ELX+BSC-treated pwCF, leading to an incremental survival increase with IVA/TEZ/ELX+BSC of 11.2 years versus TEZ/IVA+BSC and 21.3 years versus BSC-alone. Patients initiating IVA/TEZ/ELX+BSC treatment at age 12 years were projected to live 15.6 years more than TEZ/IVA+BSC-treated (74.4 vs 58.8 years) and 37.5 years more than BSC-alone–treated (74.4 vs 36.9 years) pwCF. At 10 years, 83% of IVA/TEZ/ELX+BSC-treated pwCF were alive versus 73% and 57% of TEZ/IVA+BSC-treated and BSC-alone–treated pwCF, respectively. Based on these simulations, treatment with IVA/TEZ/ELX+BSC is projected to substantially increase survival for pwCF aged ≥12 years with the F/F genotype in the UK. Treatment initiation at the youngest indicated age is projected to provide even greater survival benefit.

PRS2 Modelling Survival of People with Cystic Fibrosis (PWCF) Aged ≥12 YEARS Heterozygous for the F508DEL Mutation with a Minimal Function Mutation Treated with Ivacaftor/Tezacaftor/Elexacaftor and Ivacaftor (IVA/TEZ/ELX)

IVA/TEZ/ELX is a novel cystic fibrosis transmembrane conductance modulator (CFTRm) therapy approved by the European Medicines Agency to treat the underlying cause of disease for pwCF aged ≥12 years homozygous for the F508del mutation or heterozygous for F508del and a minimal function mutation (F/MF). In the absence of long-term real-world data, a simulation model was used to estimate survival in the F/MF population receiving IVA/TEZ/ELX plus best supportive care (BSC) versus BSC-alone. A validated, lifetime, patient-level simulation model was used to estimate median survival of a simulated cohort of F/MF pwCF aged ≥12 years in the United Kingdom (UK) with and without IVA/TEZ/ELX treatment. Age-specific mortality hazards from the 2008 UK CF Registry were combined with a Cox proportional hazards model to predict survival based on several risk factors in pwCF. Clinical efficacy inputs were derived from the Phase 3 study in the F/MF population (NCT03525444). IVA/TEZ/ELX impact on long-term lung function decline was based on other CFTRm data. Outcomes were also evaluated for a simulated cohort initiating treatment at age 12 years and using a 10-year model horizon. Median projected survival in pwCF on BSC was 37.8 years; median projected survival increased to 59.9 years in IVA/TEZ/ELX+BSC-treated pwCF, leading to an increase in incremental survival with IVA/TEZ/ELX+BSC of 22.0 years versus BSC-alone. pwCF initiating IVA/TEZ/ELX+BSC treatment at age 12 years were projected to live 36.9 years more than pwCF receiving BSC-alone (73.8 vs 36.9 years). At 10 years, 83% of pwCF receiving IVA/TEZ/ELX+BSC were projected to be alive versus 56% of patients receiving BSC-alone. Based on these simulations, treatment with IVA/TEZ/ELX+BSC is projected to increase median survival by more than 2 decades for F/MF pwCF aged ≥12 years in the UK. Treatment initiation at the youngest indicated age (i.e., age 12 years) leads to even greater projected survival benefits.

A Review of Surgical Managements of Chronic Obstructive Pulmonary Disease

Medical and non-pharmacological treatments continue to be the initial managements for chronic obstructive pulmonary disease (COPD). These managements have evolved over time, but given the high mortality and morbidity of COPD, much work still needs to be done. To date, none of the existing pharmacological therapies for COPD has been shown conclusively to modify the long-term decline in lung function. Several trials have been completed to evaluate options that can improve patient symptoms and quality of life. Optimal management for patients with COPD requires both pharmacologic and non-pharmacologic managements. To date, the only treatments that can modify the course of COPD and potentially cure the disease are surgical treatments. Some of the surgical managements we discussed in this review include Lung Volume Reduction Surgeries (LVRS), Bronchoscopic Volume Reduction Surgery (BVRS), bullectomy and lung transplants. The indications for these surgical managements have also been discussed in this article. Patients for surgical managements have to be appropriately selected to avoid some of the major adverse events that can occur because of some of the treatment modality.

An Overview of the Non- Pharmacological and Non-surgical Management of Chronic Obstructive Pulmonary Disease

Over the years, the management of chronic obstructive pulmonary disease has evolved, but given the high mortality and morbidity of COPD, much work still needs to be done. To date, none of the existing pharmacological therapies for COPD has been shown conclusively to modify the long-term decline in lung function. Several trials have been completed to evaluate options that can improve patient symptoms and quality of life. Optimal management for patients with COPD requires both pharmacological and non-pharmacological managements. Some of the non-pharmacological options for the management of COPD like Oxygen therapy have proven reduction in mortality and mortality, and an improvement in the quality of life. Lung transplant is the only treatment that can stop the decline in lung function. Smoking cessation is the non-pharmacological intervention with the greatest capacity to influence the natural course of COPD. Pulmonary rehabilitation programs are evidence based, multidisciplinary and comprehensive interventions for patients with COPD. These programs involve patient assessment, exercise training, education, nutrition and psychosocial support. Pulmonary rehabilitation programs are designed to reduce symptoms, optimize functional status, increase participation and reduce health care cost through stabilizing or reversing systemic manifestations of the disease. This article discusses the most used non pharmacological management of COPD and their usefulness in relieving symptoms and improving the quality of life for patients with severe COPD. These treatment options are used in addition to optimal pharmacological therapy.

An Overview of the Non- Pharmacological and Non-surgical Management of Chronic Obstructive Pulmonary Disease

Over the years, the management of chronic obstructive pulmonary disease has evolved, but given the high mortality and morbidity of COPD, much work still needs to be done. To date, none of the existing pharmacological therapies for COPD has been shown conclusively to modify the long-term decline in lung function. Several trials have been completed to evaluate options that can improve patient symptoms and quality of life. Optimal management for patients with COPD requires both pharmacological and non-pharmacological managements. Some of the non-pharmacological options for the management of COPD like Oxygen therapy have proven reduction in mortality and mortality, and an improvement in the quality of life. Lung transplant is the only treatment that can stop the decline in lung function. Smoking cessation is the non-pharmacological intervention with the greatest capacity to influence the natural course of COPD. Pulmonary rehabilitation programs are evidence based, multidisciplinary and comprehensive interventions for patients with COPD. These programs involve patient assessment, exercise training, education, nutrition and psychosocial support. Pulmonary rehabilitation programs are designed to reduce symptoms, optimize functional status, increase participation and reduce health care cost through stabilizing or reversing systemic manifestations of the disease. This article discusses the most used non pharmacological management of COPD and their usefulness in relieving symptoms and improving the quality of life for patients with severe COPD. These treatment options are used in addition to optimal pharmacological therapy.

Annual change in FEV1 in elderly 10-year survivors with established chronic obstructive pulmonary disease

Long-term decline in lung function is generally considered to be progressive in individuals with established chronic obstructive pulmonary disease (COPD), despite the presence of intersubject variation. We hypothesized that the annualized rate of decline in forced expiratory volume in 1 second (FEV1) would not be constant among different time periods in the natural history of established COPD. We compared the annual change rates in FEV1 during the first 5 years and the last 5 years, estimated separately using a linear mixed-effects model in 10-year survivors (n = 110). The subjects were classified into three FEV1 decline groups, based on the 25th and 75th percentile values in each time period. The rates of FEV1 changes, calculated from the first 5 years and the last 5 years, did not correlate with each other among 10-year survivors; the subjects of each FEV1 decline group during the first 5 years did not consistently remain in the same FEV1 decline group during the last 5 years. Smoking status and exacerbation frequency were not associated with decline in FEV1. In conclusion, the disease activity, which is often expressed as annualized change in FEV1, might be changeable either way over years in patients with established COPD.

A Review of the Non Pharmacologic Management of Chronic Obstructive Pulmonary Disease

Over the years, the management of chronic obstructive pulmonary disease has evolved, but given the high mortality and morbidity of COPD, much work still needs to be done. To date, none of the existing pharmacological therapies for COPD has been shown conclusively to modify the long-term decline in lung function. Several trials have been completed to evaluate options that can improve patient symptoms and quality of life. Optimal management of COPD requires both pharmacologic and non-pharmacologic interventions. Some of the non-pharmacologic options for the management of COPD like Oxygen therapy have proven reduction in mortality and mortality, and an improvement in the quality of life. Lung transplant is the only treatment that can stop the decline in lung function. Smoking cessation is the non-pharmacologic intervention with the greatest capacity to influence the natural course of COPD. Pulmonary rehabilitation programs are evidence based, multidisciplinary and comprehensive interventions for patients with COPD. These programs involve patient assessment, exercise training, education, nutrition and psychosocial support. Pulmonary rehabilitation programs are designed to reduce symptoms, optimize functional status, increase participation and reduce health care cost through stabilizing or reversing systemic manifestations of the disease. This article discusses the most used non pharmacologic management of COPD and their usefulness in relieving symptoms and improving the quality of life for patients with severe COPD. These treatment options are used in addition to optimal pharmacologic therapy.

Lung function decline in asthma patients with elevated bronchial CD8, CD4 and CD3 cells.

Which inflammatory markers in the bronchial mucosa of asthma patients are associated with decline of lung function during 14 years of prospective follow-up?To address this question, 19 mild-to-moderate, atopic asthmatic patients underwent spirometry and bronchoscopy at baseline and after 14 years of follow-up (t=14). Baseline bronchial biopsies were analysed for reticular layer thickness, eosinophil cationic protein (EG2), mast cell tryptase (AA1), CD3, CD4 and CD8. Follow-up biopsies were stained for EG2, AA1, neutrophil elastase, CD3, CD4, CD8, CD20, granzyme B, CD68, DC-SIGN, Ki67 and mucins.Decline in forced expiratory volume in 1 s (FEV1) % predicted was highest in patients with high CD8 (p=0.01, both pre- and post-bronchodilator) or high CD4 counts at baseline (p=0.04 pre-bronchodilator, p=0.03 post-bronchodilator). Patients with high CD8, CD3 or granzyme B counts at t=14 also exhibited faster decline in FEV1 (p=0.00 CD8 pre-bronchodilator, p=0.04 CD8 post-bronchodilator, p=0.01 granzyme B pre-bronchodilator, and p<0.01 CD3 pre-bronchodilator).Long-term lung function decline in asthma is associated with elevation of bronchial CD8 and CD4 at baseline, and CD8, CD3 and granzyme B at follow-up. This suggests that high-risk groups can be identified on the basis of inflammatory phenotypes.

Chronic Obstructive Pulmonary Disease: An Overview of Epidemiology, Pathophysiology, Diagnosis, Staging and Management

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease. It is among the fastest growing chronic diseases diagnosed in the world today. COPD is the third most common cause of death in the United States. It is characterized by the development of an inflammatory response of the lungs to noxious substances such as tobacco or air pollution. If the exposure becomes recurrent or persistent, the lungs develop chronic inflammatory response leading to lung parenchymal damage, air trapping and progressive airflow limitation. The Diagnosis of COPD is usually made in the context of symptoms and spirometry evidence of airway obstruction with post bronchodilator spirometry FEV1/FVC < 0.70. Most patients with COPD first seek medical attention when they develop dyspnea. Once the diagnosis of COPD is confirmed, the treatment is geared mainly towards preventing exacerbations and eliminating risk factors and exposures. Several treatment combinations can be used in patients with stable COPD to prevent exacerbations and to improve their quality of life. Patients with COPD exacerbations have to be appropriately diagnosed and promptly treated to prevent complications. Patient’s symptoms, the degree of airflow limitation, risk of exacerbations and the presence of comorbidities have to be assessed. Both pharmacological and non-pharmacological interventions have been used in the management of COPD. Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. None of the existing medications for COPD have been shown conclusively to modify the long-term decline in lung function.

Inhaled antibiotics in Cystic Fibrosis (CF) and non-CF bronchiectasis.

Bronchiectasis is a pathological diagnosis describing dilatation of the airways and is characterized by chronic lung sepsis. Bronchiectasis has multiple etiologies, but is usually considered in terms of whether it is due to the genetic disorder cystic fibrosis (CF) or secondary to other causes (non-CF bronchiectasis, NCFB). Inhaled antibiotics are used in bronchiectasis to suppress bacterial pathogens and reduce long-term lung function decline. The majority of the literature on inhaled antibiotics comes from studies on CF where the dominant bacterial pathogen in the airway is usually Pseudomonas aeruginosa. Thus, most aerosolized antibiotic regimens target this bacterium, but the emergence of molecular diagnostic methods has questioned this approach and more tailored strategies may need to be considered in CF based on the community composition of the lung microbiome. Similarly, the lung microbiome in NCFB has been found to be a complex polymicrobial one and the current practice of employing the same inhaled antibiotic regimes as are used in CF may no longer be appropriate in many patients. In this article, the use of inhaled antibiotics in CF and NCFB is considered in the light of improved understanding of the lung microbiome and why more tailored therapy may be needed based on molecular identification of the microbial pathogens present. The evidence for the use of currently available inhaled antibiotics and advances in inhaled drug packaging and delivery devices are discussed. Finally, the urgent need for prospective randomized clinical trials in CF and NCFB is highlighted and areas for future research identified.

Stratégie thérapeutique au long cours dans la bronchopneumopathie chronique obstructive : comment modifier le cours de la maladie

COPD is a pulmonary disease with a systemic impact. The goals of COPD assessment are to determine the severity of the disease to guide management. Smoking cessation is a prime objective at all the stages of the disease to modify the long-term decline in lung function, reduce the COPD symptoms, and the frequency of exacerbations, improve health status and reduce mortality. The bronchodilators are central in the pharmacologic management of COPD. Long-acting bronchodilators are indicated as maintenance treatment to relieve COPD symptoms (particularly dyspnea) despite regular use of short-acting bronchodilators. Long-acting bronchodilators reduce the exacerbation rate. The choice between a long-acting β2-adrenergic and an anticholinergic depends on the patient's perception of symptom relief. The inhaled corticoids are only indicated in COPD combined with long-acting β2-adrenergic in patients with severe COPD and a history of repeated exacerbations, who have significant symptoms despite therapy with bronchodilators. The combination of an inhaled corticosteroid with a long-acting β2-agonist reduces the exacerbation rate. The rehabilitation should be offered to all patients with dyspnea, exercise intolerance, or limitation in everyday activities related to COPD despite optimal pharmacological therapy and management of co-morbidities. Pulmonary rehabilitation is a multidisciplinary and tailored management of the COPD patients which enable to optimize exercise capacity, social reintegration, autonomy, reduce health care costs by decreasing the exacerbation rate, urgent visits and duration of hospitalisation. The rehabilitation is not just focusing on the improvement of exercise capacity, but also seeks sustained behavioural changes that are needed to achieve real improvement in health status and quality of life. Pulmonary rehabilitation is also an excellent opportunity for education which is critical in the healthcare pathway.

Short-term lung function decline in tunnel construction workers

ObjectivesTunnel construction workers are exposed to particulate and gaseous air contaminants. Previous studies carried out in the 1990s showed that tunnel construction workers were at increased risk of both short-term...

Social, economic, and health impact of the respiratory syncytial virus: a systematic search.

BackgroundBronchiolitis caused by the respiratory syncytial virus (RSV) and its related complications are common in infants born prematurely, with severe congenital heart disease, or bronchopulmonary dysplasia, as well as in immunosuppressed infants. There is a rich literature on the different aspects of RSV infection with a focus, for the most part, on specific risk populations. However, there is a need for a systematic global analysis of the impact of RSV infection in terms of use of resources and health impact on both children and adults. With this aim, we performed a systematic search of scientific evidence on the social, economic, and health impact of RSV infection.MethodsA systematic search of the following databases was performed: MEDLINE, EMBASE, Spanish Medical Index, MEDES-MEDicina in Spanish, Cochrane Plus Library, and Google without time limits. We selected 421 abstracts based on the 6,598 articles identified. From these abstracts, 4 RSV experts selected the most relevant articles. They selected 65 articles. After reading the full articles, 23 of their references were also selected. Finally, one more article found through a literature information alert system was included.ResultsThe information collected was summarized and organized into the following topics: 1. Impact on health (infections and respiratory complications, mid- to long-term lung function decline, recurrent wheezing, asthma, other complications such as otitis and rhino-conjunctivitis, and mortality; 2. Impact on resources (visits to primary care and specialists offices, emergency room visits, hospital admissions, ICU admissions, diagnostic tests, and treatments); 3. Impact on costs (direct and indirect costs); 4. Impact on quality of life; and 5. Strategies to reduce the impact (interventions on social and hygienic factors and prophylactic treatments).ConclusionsWe concluded that 1. The health impact of RSV infection is relevant and goes beyond the acute episode phase; 2. The health impact of RSV infection on children is much better documented than the impact on adults; 3. Further research is needed on mid- and long-term impact of RSV infection on the adult population, especially those at high-risk; 4. There is a need for interventions aimed at reducing the impact of RSV infection by targeting health education, information, and prophylaxis in high-risk populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-014-0544-x) contains supplementary material, which is available to authorized users.

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a major cause of hospital admission and mortality. They contribute to long-term decline in lung function, physical capacity and quality of life. The most common causes are infective, and treatment includes antibiotics, bronchodilators and systemic corticosteroids as anti-inflammatory agents. To assess the effects of corticosteroids administered orally or parenterally for treatment of acute exacerbations of COPD, and to compare the efficacy of parenteral versus oral administration. We carried out searches using the Cochrane Airways Group Specialised Register of Trials, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials), and checked references of included studies and trials registries. We conducted the last search in May 2014. Randomised controlled trials comparing corticosteroids administered orally or parenterally with an appropriate placebo, or comparing oral corticosteroids with parenteral corticosteroids in the treatment of people with acute exacerbations of COPD. Other interventions (e.g. bronchodilators and antibiotics) were standardised for both groups. We excluded clinical studies of acute asthma. We used standard methodological procedures expected by The Cochrane Collaboration. Sixteen studies (n = 1787) met inclusion criteria for the comparison systemic corticosteroid versus placebo and 13 studies contributed data (n = 1620). Four studies (n = 298) met inclusion criteria for the comparison oral corticosteroid versus parenteral corticosteroid and three studies contributed data (n = 239). The mean age of participants with COPD was 68 years, median proportion of males 82% and mean forced expiratory volume in one second (FEV1) per cent predicted at study admission was 40% (6 studies; n = 633). We judged risk of selection, detection, attrition and reporting bias as low or unclear in all studies. We judged risk of performance bias high in one study comparing systemic corticosteroid with control and in two studies comparing intravenous corticosteroid versus oral corticosteroid.Systemic corticosteroids reduced the risk of treatment failure by over half compared with placebo in nine studies (n = 917) with median treatment duration 14 days, odds ratio (OR) 0.48 (95% confidence interval (CI) 0.35 to 0.67). The evidence was graded as high quality and it would have been necessary to treat nine people (95% CI 7 to 14) with systemic corticosteroids to avoid one treatment failure. There was moderate-quality evidence for a lower rate of relapse by one month for treatment with systemic corticosteroid in two studies (n = 415) (hazard ratio (HR) 0.78; 95% CI 0.63 to 0.97). Mortality up to 30 days was not reduced by treatment with systemic corticosteroid compared with control in 12 studies (n = 1319; OR 1.00; 95% CI 0.60 to 1.66).FEV1, measured up to 72 hours, showed significant treatment benefits (7 studies; n = 649; mean difference (MD) 140 mL; 95% CI 90 to 200); however, this benefit was not observed at later time points. The likelihood of adverse events increased with corticosteroid treatment (OR 2.33; 95% CI 1.59 to 3.43). Overall, one extra adverse effect occurred for every six people treated (95% CI 4 to 10). The risk of hyperglycaemia was significantly increased (OR 2.79; 95% CI 1.86 to 4.19). For general inpatient treatment, duration of hospitalisation was significantly shorter with corticosteroid treatment (MD -1.22 days; 95% CI -2.26 to -0.18), with no difference in length of stay the intensive care unit (ICU) setting.Comparison of parenteral versus oral treatment showed no significant difference in the primary outcomes of treatment failure, relapse or mortality or for any secondary outcomes. There was a significantly increased rate of hyperglycaemia in one study (OR 4.89; 95% CI 1.20 to 19.94). There is high-quality evidence to support treatment of exacerbations of COPD with systemic corticosteroid by the oral or parenteral route in reducing the likelihood of treatment failure and relapse by one month, shortening length of stay in hospital inpatients not requiring assisted ventilation in ICU and giving earlier improvement in lung function and symptoms. There is no evidence of benefit for parenteral treatment compared with oral treatment with corticosteroid on treatment failure, relapse or mortality. There is an increase in adverse drug effects with corticosteroid treatment, which is greater with parenteral administration compared with oral treatment.

New Treatments for COPD in the Elderly

In elderly people the respiratory function is affected by anatomical and physiological modifications caused by aging. Elderly COPD patients are characterized by a complexity due to an increasing prevalence of comorbidities related to the age that suggest peculiar care in prescribing the therapy in those patients, also considering other disabilities that are not related with respiratory disorders as physical and mental limitations. Nowadays a therapy that allows modifying the long-term decline in lung function of patients suffering from COPD does not yet exist and, therefore, the treatment of this disease is mainly focused on the administration of bronchodilators and the use of inhaled glucocorticoids. As for younger subjects, also in elderly patients the main classes of bronchodilators used in the treatment of COPD include β2-agonists, anticholinergics and methylxanthines. The inflammatory response suppression represents another mechanistic approach for treating COPD in the elderly, although the use of inhaled corticosteroids is limited to specific indications. Indeed, nowadays there is a strong medical need for novel treatments of COPD in the elderly. These are mainly represented by agents that reduce the spillover of inflammatory mediators from the lung and by compounds that inhibit the chronic systemic inflammatory syndrome. The therapeutic approach of COPD in elderly patients remains a topic of increasing interest, however the development of novel compounds for preventing the COPD progression in the elderly, other than bronchodilators and corticosteroids, remains a challenge.

Warm homes for older people: aims and methods of a randomised community-based trial for people with COPD

BackgroundChronic Obstructive Pulmonary Disease (COPD) is of increasing importance with about one in four people estimated to be diagnosed with COPD during their lifetime. None of the existing medications for COPD has been shown to have much effect on the long-term decline in lung function and there have been few recent pharmacotherapeutic advances. Identifying preventive interventions that can reduce the frequency and severity of exacerbations could have important public health benefits. The Warm Homes for Elder New Zealanders study is a community-based trial, designed to test whether a NZ$500 electricity voucher paid into the electricity account of older people with COPD, with the expressed aim of enabling them to keep their homes warm, results in reduced exacerbations and hospitalisation rates. It will also examine whether these subsidies are cost-beneficial.MethodsParticipants had a clinician diagnosis of COPD and had either been hospitalised or taken steroids or antibiotics for COPD in the previous three years; their median age was 71 years. Participants were recruited from three communities between 2009 to early 2011. Where possible, participants’ houses were retrofitted with insulation. After baseline data were received, participants were randomised to either ‘early’ or ‘late’ intervention groups. The intervention was a voucher of $500 directly credited to the participants’ electricity company account. Early group participants received the voucher the first winter they were enrolled in the study, late participants during the second winter. Objective measures included spirometry and indoor temperatures and subjective measures included questions about participant health and wellbeing, heating, medication and visits to health professionals. Objective health care usage data included hospitalisation and primary care visits. Assessments of electricity use were obtained through electricity companies using unique customer numbers.DiscussionThis community trial has successfully enrolled 522 older people with COPD. Baseline data showed that, despite having a chronic respiratory illness, participants are frequently cold in their houses and economise on heating.Trial RegistrationThe clinical trial registration is http://NCT01627418