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Background: It has been demonstrated that antibiotic prescribing for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) can be safely reduced in primary care when general practitioners have access to C-reactive protein (CRP) rapid testing., Aim: To investigate the factors associated with post-consultation COPD health status in patients presenting with AECOPD in this setting., Design and Setting: A cohort study of patients enrolled in a randomised controlled trial. Patients aged 40+ years with a clinical diagnosis of COPD who presented in primary care across England and Wales with an AECOPD were included., Methods: Participants were contacted for follow-up at one- and two-weeks by phone and attended the practice four weeks after the index consultation. The outcome of interest was the Clinical COPD Questionnaire (CCQ) score. Multivariable multilevel linear regression models fitted to examine the factors associated with COPD health status in the four-weeks following consultation for an AECOPD., Results: A total of 649 patients were included, with 1947 CCQ total scores analysed. Post-consultation CCQ total scores were significantly higher (worse) in participants with diabetes (adjusted mean difference [AMD]=0.26; 95% confidence interval (CI) 0.08-0.45), obese patients compared to those with normal body mass index (AMD = 0.25, 95% CI 0.07-0.43), and those who were prescribed oral antibiotics in the prior 12 months (AMD = 0.26; 95% CI 0.11-0.41), but only the two latter associations remained after adjusting for other sociodemographic variables., Conclusion: COPD health status was worse in the four weeks following primary care consultation for AECOPD in patients with obesity and those prescribed oral antibiotics in the preceding year., Competing Interests: Authors DG, NF, HA, KH, PW, ET-J, BS, GN, RL, NK, JB, and CCB report grants from the National Institute for Health Research during the conduct of this study. NF also reports payments from Abbott for chairing and presenting at scientific meeting. CL reports grants from Abbott Diagnostics outside of the submitted work. RP reports grants from Health and Care Research Wales Research for Public and Patient Benefit, grants from Welsh Government/Ser Cymru, grants from Kidney Research UK and British Renal Society, grants from National Institute for Health Research Health Technology Assessment outside the submitted work. All other authors (HS, HM, AC, and MFA) report no potential competing interests., (© 2022 Gillespie et al.)

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Despite a high prevalence of smoking and respiratory symptoms, two recent population-based studies in Russia found a relatively low prevalence of obstructive lung function. Here, we investigated the prevalence of both obstructive lung disease and respiratory symptoms in a population-based study conducted in two Russian cities and compared the findings with a similar study from Norway conducted in the same time period., Methods: The study population was a sub-sample of participants aged 40-69 years participating in the Know Your Heart (KYH) study in Russia in 2015-18 (n=1883) and in the 7th survey of the Tromsø Study (n=5271) carried out in Norway in 2015-16 (Tromsø 7) who participated in spirometry examinations. The main outcome was obstructive lung function (FEV 1 /FVC ratio< lower limit of normal on pre-bronchodilator spirometry examination) with and without respiratory symptoms (chronic cough and breathlessness). In those with obstructive lung function, awareness (known diagnosis) and management (use of medications, smoking cessation) were compared., Results: The age-standardized prevalence of obstructive lung function was similar among men in both studies (KYH 11.0% vs Tromsø 7 9.8%, p=0.21) and higher in the Norwegian (9.4%) than Russian (6.8%) women (p=0.006). In contrast, the prevalence of obstructive lung function plus respiratory symptoms was higher in Russian men (KYH 8.3% vs Tromsø 7 4.7%, p<0.001) but similar in women (KYH 5.9% vs Tromsø 7 6.4%, p=0.18). There was a much higher prevalence of respiratory symptoms in Russian than Norwegian participants of both sexes regardless of presence of obstructive lung function., Conclusion: The prevalence of respiratory symptoms was strikingly high among Russian participants but this was not explained by a higher burden of obstructive lung function on spirometry testing in comparison with Norwegian participants. Further work is needed to understand the reasons and health implications of this high prevalence of cough and breathlessness., Competing Interests: Professor Jennifer K Quint report grants, personal fees from AZ, Bayer, GSK, outside the submitted work. The authors report no other conflicts of interest in this work., (© 2021 Cook et al.)

Introduction: Identifying predictors of bacterial and viral pathogens in sputum from patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) may help direct management., Methods: We used data from a trial evaluating a C-reactive protein (CRP) point of care guided approach to managing COPD exacerbations in primary care. We used regression analyses to identify baseline clinical features, including CRP value in those randomized to testing, associated with bacterial, viral or mixed infections, defined by the presence of bacterial and viral pathogens in sputum, detected by culture or polymerase chain reaction (PCR), respectively., Results: Of 386 participants with baseline sputum samples, 79 (20.5%), 123 (31.9%), and 91 (23.6%) had bacterial, viral/atypical, and mixed bacterial/viral/atypical pathogens identified, respectively. Increasing sputum purulence assessed by color chart was associated with increased odds of finding bacterial and mixed (bacterial and viral/atypical) pathogens in sputum (area under the ROC curve (AUROC) for bacterial pathogens =0.739 (95% CI: 0.670, 0.808)). Elevated CRP was associated with increased odds of finding bacterial pathogens and mixed pathogens but did not significantly increase the AUROC for predicting bacterial pathogens over sputum color alone (AUROC for combination of sputum color and CRP = 0.776 (95% CI: 0.708, 0.843), p for comparison of models = 0.053). We found no association between the presence of sputum pathogens and other clinical or demographic features., Conclusion: Sputum purulence was the best predictor of sputum bacterial pathogens and mixed bacterial viral/atypical pathogens in patients with COPD exacerbations in our study. Elevated CRP was associated with bacterial pathogens but did not add to the predictive value of sputum purulence., Competing Interests: Nick A Francis reports grants from NIHR HTA, during the conduct of the study. David Gillespie reports grants from the National Institute for Health Research, during the conduct of the study. Janine Bates reports grants from NIHR HTA, during the conduct of the study. Kerenza Hood report grants from NIHR HTA, during the conduct of the study; and I am a member of three NIHR funding committees: HTA General Committee, HTA Funding Committee Policy Group and the Research Professors panel. Christopher C Butler reports grants from the National Institute for Health Research Health Technology Assessment Programme, during the conduct of the study. The authors report no other potential conflicts of interest for this work., (© 2020 Francis et al.)

Background: Less smoking should lead to fewer COPD cases. We aimed at estimating time trends in the prevalence and burden of COPD in Norway from 2001 to 2017., Methods: We used pre-bronchodilator spirometry and other health data from persons aged 40-84 years in three surveys of the Tromsø Study, 2001-2002, 2007-2008 and 2015-2016. We applied spirometry lower limits of normal (LLN) according to Global Lung Initiative 2012. Age-standardized prevalence was determined. We defined COPD as FEV 1 /FVC1

Purpose: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations., Methods: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong., Results: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients' perspective: the GPs considered patients' experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients' perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of "wrong decisions" and concerning the negotiation of responsibilities., Conclusion: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs' management decisions. GPs consider a holistic understanding of illness and the patients' own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs' decisions depend on the availability and reliability of other formal and informal carers, and the health care systems' organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients' social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations., Competing Interests: The authors report no conflicts of interest in this work.

Background: When assessing patients with exacerbation of asthma or COPD, it may be useful to know the drop in forced expiratory volume in 1 second (FEV 1 ) compared with stable state, in particular when considering treatment with oral corticosteroids. The objective of the study was to identify indicators of drop in FEV 1 during exacerbations., Methods: In this prospective multicenter study from primary care, patients diagnosed with asthma or COPD were examined at stable state and during exacerbations the following year. Symptoms, chest findings, and pulse oximetry were recorded, and spirometry was performed. A fixed drop in FEV 1 (10% and ≥200 mL) and percentage change in FEV 1 were outcomes when possible indicators were evaluated., Results: Three hundred and eighty patients attended baseline examination, and 88 with a subsequent exacerbation were included in the analysis. Thirty (34%) had a significant drop in FEV 1 (10% and 200 mL). Increased wheezing was the only symptom associated with this drop with a likelihood ratio of 6.4 (95% confidence interval, 1.9-21.7). Crackles and any new auscultation finding were also associated with a significant drop in FEV 1 , as was a ≥2% drop in oxygen saturation (SpO 2 ) to ≤92% in the subgroup diagnosed with COPD. Very bothersome wheezing and severe decrease in SpO 2 were also very strong predictors of change in FEV 1 in linear regression adjusted for age, gender, and baseline FEV 1 % predicted., Conclusion: Increased wheezing, as experienced by the patient, and a decreased SpO 2 value strongly indicated a drop in lung function during asthma and COPD exacerbations and should probably be taken into account when treatment with oral corticosteroids is considered., Competing Interests: The authors report no conflicts of interest in this work.

Background: Patients with COPD have had a lower tendency to quit smoking compared to patients with coronary heart disease (CHD). We wanted to investigate if this is still true in a Norwegian population., Methods: Our data came from the fifth and sixth Tromsø surveys, which took place in 2001-2002 and 2007-2008. The predictors of smoking cessation were evaluated in a cohort of 4,497 participants who had stated their smoking status in both surveys., Results: Of the 4,497 subjects in the cohort, 1,150 (25.6%) reported daily smoking in Tromsø 5. In Tromsø 6, 428 had quit (37.2%). A new diagnosis of obstructive lung disease (asthma or COPD) and CHD were both associated with increased quitting rates, 50.6% (P=0.01) and 52.1% (P=0.02), respectively. In multivariable logistic regression analysis with smoking cessation as outcome, the odds ratios (ORs) of a new diagnosis of obstructive lung disease and of CHD were 1.7 (1.1-2.7) and 1.7 (1.0-2.9), respectively. Male sex had an OR of 1.4 (1.1-1.8) compared to women in the multivariable model, whereas the ORs of an educational length of 13-16 years and ≥17 years compared to shorter education were 1.6 (1.1-2.2) and 2.5 (1.5-4.1), respectively., Conclusion: The general trend of smoking cessation in the population was confirmed. Increased rates of smoking cessation were associated with a new diagnosis of heart or lung disease, and obstructive lung disease was just as strongly linked to smoking cessation as was CHD. This should encourage the pursuit of early diagnosis of COPD.

Background: Worsening of pulmonary diseases is associated with a decrease in oxygen saturation (SpO2). Such a decrease in SpO2 and associated factors has not been previously evaluated in a general adult population., Aim: We sought to describe SpO2 in a sample of adults, at baseline and after 6.3 years, to determine whether factors predicting low SpO2 in a cross-sectional study were also associated with a decrease in SpO2 in this cohort., Methods: As part of the Tromsø Study, 2,822 participants were examined with pulse oximetry in Tromsø 5 (2001/2002) and Tromsø 6 (2007/2008). Low SpO2 by pulse oximetry was defined as an SpO2 ≤ 95%, and SpO2 decrease was defined as a ≥ 2% decrease from baseline to below 96%., Results: A total of 139 (4.9%) subjects had a decrease in SpO2. Forced expiratory volume in 1 second (FEV1) <50% of the predicted value and current smoking with a history of ≥ 10 pack-years were the baseline characteristics most strongly associated with an SpO2 decrease in multivariable logistic regression (odds ratio 3.55 [95% confidence interval (CI) 1.60-7.89] and 2.48 [95% CI 1.48-4.15], respectively). Male sex, age, former smoking with a history of ≥ 10 pack-years, body mass index ≥ 30 kg/m(2), and C-reactive protein ≥ 5 mg/L were also significantly associated with an SpO2 decrease. A significant decrease in FEV1 and a new diagnosis of asthma or chronic obstructive pulmonary disease during the observation period most strongly predicted a fall in SpO2. A lower SpO2 decrease was observed in those who quit smoking and those who lost weight, but these tendencies were not statistically significant., Conclusion: A decrease in SpO2 was most strongly associated with severe airflow limitation and a history of smoking. Smoking cessation and reducing obesity seem to be important measures to target for avoiding SpO2 decreases in the general population.

Background: Although proven to be associated with bronchial obstruction, chest signs are not listed among cues that should prompt spirometry in the early diagnosis of chronic obstructive pulmonary disease (COPD) in established guidelines., Aims: We aimed to explore how chest findings add to respiratory symptoms and a history of smoking in the diagnosis of COPD., Methods: In a cross-sectional study, patients aged 40 years or older, previously diagnosed with either asthma or COPD in primary care, answered questionnaires and underwent physical chest examination and spirometry., Results: Among the 375 patients included, 39.7% had forced expiratory volume in 1 second/forced vital capacity <0.7. Hyperresonance to percussion was the strongest predictor of COPD, with a sensitivity of 20.8, a specificity of 97.8, and likelihood ratio of 9.5. In multivariate logistic regression, where pack-years, shortness of breath, and chest findings were among the explanatory variables, three physical chest findings were independent predictors of COPD. Hyperresonance to percussion yielded the highest odds ratio (OR = 6.7), followed by diminished breath sounds (OR = 5.0), and thirdly wheezes (OR = 2.3). These three chest signs also gave significant diagnostic information when added to shortness of breath and pack-years in receiver operating-characteristic curve analysis., Conclusion: We found that chest signs may add to respiratory symptoms and a history of smoking in the diagnosis of COPD, and we conclude that chest signs should be reinstated as cues to early diagnosis of COPD in patients 40 years or older.

Aims: To describe symptoms and lung function in patients registered with asthma or chronic obstructive pulmonary disease (COPD) in primary care and to examine how spirometry findings fit with general practitioners' (GPs) diagnoses., Methods: Patients aged ≥40 years with a diagnosis of asthma or COPD registered in the electronic medical record during the previous 5 years were recruited at seven GP offices in Norway in 2009-2010. Registered diagnosis, spirometry results, comorbidity, and reported symptoms were compared., Results: Among 376 patients, 62% were women. Based on Global Initiative for Chronic Obstructive Lung Diseases criteria, a spirometry diagnosis of COPD could be made in 68.1% of the patients with a previous COPD diagnosis and in 17.1% of those diagnosed with asthma only (P < 0.001). The κ agreement between last clinical diagnosis of COPD and COPD based on spirometry was 0.50. A restrictive spirometry pattern was found in 19.4% and more frequently in patients diagnosed with both asthma and COPD (23.9%) than in patients diagnosed with COPD only (6.8%, P = 0.003)., Conclusion: The ability of GPs to differentiate between asthma and COPD seems to have considerably improved during the last decade, probably due to the dissemination of spirometry and guidelines for COPD diagnosis. A diagnosis of COPD that cannot be confirmed by spirometry represents a challenge in clinical practice, in particular when a restrictive pattern on spirometry is found.