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Background: Chronic Obstructive Pulmonary Disease (COPD) patients need a caregiver or someone in their lives due to the progressive limitation in their activities of daily living. Objective: The aim was to analyze the relationship between caregiver burden and the limitation of daily activities of care recipients with severe COPD. Methods: This was a cross-sectional study. COPD patients were divided into two groups according to caregiver burden measured with Zarit Burden Interview (ZBI). The limitation of daily activities of severe COPD patients was evaluated with the London Chest Activity of Daily Living (LCADL), the Functional Independence Measure (FIM), and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Results: Sixty-five patients and their caregivers were included in this study. COPD patients showed significant differences between groups in age (p=0.006), and dyspnea perception (p Conclusion: This study showed that dyspnea related to functional status and social participation in activities of daily living of severe COPD patients can predict caregiver burden. Future studies should consider the prevention of caregiver burden based on individual limitation of daily activities of severe COPD patients.

Background: Due to repeated exacerbations a large group of patients with chronic obstructive pulmonary disease (COPD) are often exposed to oral corticosteroids (OCS). Corticosteroids may be thrombogenic. We evaluated the risk of venous thromboembolia and death in patients with acute exacerbation of COPD (AECOPD) according to two different dosing regimens.Method: This was a nationwide observational cohort study of outpatients with COPD with a 6 month follow up time. It was based on a linked administrative registry data between January 1st 2010 and 28th February 2018. In total 30.473 patients treated with either short course (250mg) of OCS for AECOPD were included in the study. Cox proportional hazard regression was used to estimate the risk of VTE hospitalization or all-cause mortality.Results: The incidence of VTE was low. However, long course of OCS was associated with an increased risk of VTE compared to short course, (HR 1.73, CI 1.08 to 2.79; p < 0.0001). Furthermore, we found a higher risk of all-cause mortality in the long course group, HR 1.62 (CI 1.57 to 1.62; p

Precision medicine for chronic obstructive pulmonary disease (COPD) can improve management for those who may have otherwise exhausted conventional therapy. Approximately 40% of patients with COPD have a persistently elevated blood eosinophil count ≥150 cells·μL−1 [1]. Blood eosinophils are reflective of sputum eosinophil count, which is used as a marker of eosinophilic airway inflammation [2, 3]. Debatably, raised blood eosinophils identify a distinct COPD phenotype with increased frequency and severity of exacerbations [4–6]. Guiding corticosteroid treatment according to the level of blood eosinophils results in a reduction in exacerbations, which is indicative of its value as a biomarker of corticosteroid responsiveness [7–9]. However, the use of inhaled corticosteroids has been associated with increased risk of pneumonia [10, 11]., Mepolizumab can reduce exacerbation rates in those with frequently exacerbating, severe COPD and raised blood eosinophils; this represents a further advance in precision medicine for COPD and targeted therapies http://ow.ly/uklu30m4YcU

Exacerbations of COPD remain a leading cause of emergency hospitalisations worldwide, and up to 28% of patients are readmitted within 30 days of discharge [1]. Recent analyses of more than 2.3 million COPD hospitalisations highlight the dynamic and time-dependent nature of readmission risk, which peaks within the first 72 h of discharge [2, 3]. Effective readmission prevention strategies remain elusive and recognition of re-exacerbations beyond daily symptom variability is challenging for both patients and clinicians. Promotion of transitional care services and 30-day readmission penalties implemented by policymakers worldwide have had limited impact [4]. Telemonitoring strategies incorporating symptom and vital observation monitoring (peripheral oxygen saturation (SpO2), heart rate, respiratory frequency) have consistently failed to demonstrate beneficial effects on hospitalisation risk [5]. Objective physiological monitoring has been explored using the forced oscillation technique. However, this also failed to prolong time to first hospitalisation [6]., Physiological phenotyping using daily home-based assessments reveals early improvement in load–capacity–drive imbalance following #AECOPD and feasibility of home parasternal electromyography measurement, which tracks symptoms, health status and spirometry https://bit.ly/3o6I0Ty

Introduction: Neuromuscular electrical stimulation (NMES) contributes to COPD rehabilitation, but the current NMES therapy only works on inspiratory phase. Objectives: The purpose of this study was to compare the intervention effectiveness of inspiratory plus expiratory NMES (IENMES) with inspiratory NMES (INMES) in COPD patients. Methods: 120 patients (receiving standard treatment) with severe and very severe stable COPD (GOLD3 and GOLD4) were randomly divided into the IENMES group (n=60) and the INMES group (n=60). The IENMES group patients were treated with Respiratory Neuromuscular Stimulator (Yaguo Technology Ltd, Beijing, China). Patients in both groups were given treatment once a day for 30 minutes, and totally for 4 weeks. The 6-min walking distance (6MWD), mMRC, FEV1, FEV1% pred, FEV1% FVC, MVV and PEF were observed before and after treatment. Results: After 4 weeks of treatment, 6MWD was more improved in IENMES group (65.53±39.45m) compared with INMES group (26.66±32.65m); mean between-group difference was 29.07m ([95% CI 16.098 to 42.035]; p Conclusion: Compared with the INMES treatment, IENMES treatment is better in improving the exercise endurance of patients with severe and very severe COPD in stable phase and improving the lung ventilation of patients with very severe COPD, which indicates that IENMES has significant effectiveness in promoting the pulmonary rehabilitation of patients with severe COPD.

Esophageal pressure (Pes) measurement provides a practical means of quantifying respiratory effort during invasive mechanical ventilation and can be used as a clinical tool for assessing patients during the weaning trial. There is little data regarding a similar use in patients with acute hypercapnic respiratory failure (AHRF) under NIV. We aimed to investigate the potential utility of Pes measurement in guiding NIV weaning during AHRF due to severe COPD exacerbation. Methods: A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2018 and 2019. We measured ∆Pes daily, and we registered these values together with patient characteristics, ventilatory function, and other data. The outcome was successful NIV weaning as opposed to the need for home NIV. Our objective was to identify Pes characteristics that would correlate with successful NIV weaning or the need to continue NIV at home. Results: We included 15 patients (8 males, mean age 65 years) with severe COPD exacerbation with AHRF requiring NIV. All patients were successfully managed with NIV. 10 patients could be weaned from NIV and had an average decrease in ∆Pes from admission to discharge of 6.2 cmH2O (SD 3.0, p 0.07) with a mean discharge ∆Pes of 9.3 cmH2O (SD 4.1). 5 patients needed home NIV and had a medium decrease of ∆Pes of 2.5 cmH2O (SD 2.7, p 0.2) with a mean discharge ∆Pes of 15.0 (SD 1.0). Mean difference of ∆Pes at discharge between the 2 groups was 5.7 (p 0.08). Conclusion: In patients with severe COPD exacerbation with AHRF that required NIV, a lack of drop in ∆Pes and a higher discharge ∆Pes could predict a need for home NIV.

Introduction: There is a need for a robust prediction model that identifies patients with acute exacerbation of COPD (AECOPD) at risk for treatment escalation during hospital admission. The DECAF score has been validated to predict in-hospital mortality. It is not known if the DECAF score might predict treatment escalation in AECOPD. Such a score might serve to allocate the level of monitoring on hospital admission. Methods: Prospective cohort study in a single teaching hospital in the Netherlands. The DECAF score was noted in consecutive patients admitted to the hospital with an AECOPD. De sensitivity and specificity of the DECAF score to identify treatment escalation during admission was calculated. Treatment escalation was defined as need for NRM, NIV or transfer to ICU. Results: 83 patients were included in the study. Most patients had severe COPD (mean FEV1 37%). Treatment escalation was seen in 13.1% of patients; 10.7% needed non-invasive ventilation to recover and 2.4% were transferred to the intensive care unit for treatment. No patients died during admission. A low DECAF score could not safely excluded the need for treatment escalation. The sensitivity of a low DECAF score (0-1) to exclude treatment escalation was 59% (95%-CI: 48-71%). Specificity of a low DECAF score to exclude the need for treatment escalation was similarly mediocre, 71% (95%-CI: 29%-96%). Conclusion: The DECAF score on admission cannot be used to predict treatment escalation during admission for an AECOPD.

Background: Whole-body vibration training (WBVT) performed on a vibration platform can significantly improve physical performance in COPD patients. It has been suggested that an important mechanism of this improvement is based on an improvement in balance. Aim of this study was to investigate the effects of WBVT versus conventional balance training on exercise performance. Methods: 48 patients with severe COPD (FEV1: 37±7 %pred.) and low exercise performance (6-minute walk distance (6MWD): 55±10 %pred.) were included in a randomized controlled trial during a 3-week inpatient pulmonary rehabilitation. All patients completed a standardized endurance and strength training program. Additionally, patients performed 4 different balance exercises 3x/week for 2x1 minute each either on a vibration platform (Galileo) at varying frequencies (5 - 26 Hz) (WBVT) or on a conventional therapy tool inducing an instable surface (CON). Results: 6MWD improved significantly in both groups (WBVT: 48±46m, p Conclusion: WBVT can improve balance and muscular performance significantly more compared to conventional balance training.

Introduction: Domiciliary High Flow Nasal Cannula (HFNC) has been shown to reduce days of hospitalization in COPD-patients with chronic hypoxic failure (CHF).Aim: To evaluate development in health-related quality of life (HRQoL) and costs related to hospital admissions in HNFC treated COPD patients with CHF compared to controls.Method: In a cohort of 200 COPD patients randomized equally into usual care ± HFNC, complete HRQoL data, judged by St. Georg Respiratory Questionnaire (SGRQ), were available in 140 patients (66 HFNC and 74 controls). The SGRQ data were used to predict EQ-5D utility values using a validated algorithm developed by Starkie et al. Based on this, Quality-Adjusted Life-Years (QALYs) were calculated, and QALYs were corrected for baseline HRQoL and days of treatment.The cost of hospital admission due to COPD exacerbation (AECOPD) was calculated for the same 140 patients during the study period using mean daily admission costs. The cost was corrected for cost of AECOPD admissions in the year prior to inclusion and days of treatment. Costs were valued in British Pounds (£) at price level 2019.Results: HNFC treatment resulted in a QALY improvement of 0.045 (95% CI -0.017; 0.107) and a mean decrease in cost of £ -1290 (95% CI -2710; 131) per patient. No statistically significant differences were observed.Conclusion: HNFC treatment led to a gain in QALYs and resulted in savings in hospital admission costs when compared to usual care. Further analysis will reveal whether HNFC for COPD patients with CHR is a cost-effective treatment when considering all relevant cost categories.

Method: Effectiveness of pulmonary rehabilitation (PR) is still uncertain in elderly people with severe COPD, particularly those with chronic respiratory failure (CRF). The aim of this study was to determine whether being elderly impacts the short and long-term effects of a home-based PR in people with COPD and CRF. Methods: In this retrospective study, 480 people with COPD and CRF were divided into those ≤ 70 (n=341) and those > 70 years of age (n=139). All participants underwent 8-weeks of home-based PR, consisting in one-weekly individualized home session. Six-minute stepper test (6MST), timed-up and go test (TUG), hospital anxiety and depression scale, and visual simplified respiratory questionnaire (VSRQ) were assessed at baseline (T0), and at 2 (T2) and 14 (T14) months after baseline. Individuals improving beyond the clinically important difference for at least one of these variables were considered responders to PR. Results: The older group was characterized by less current smokers (p Conclusion: Regardless of the age, individualized home-based PR was effective for people with COPD and CRF at short and long term, with the exception of VSRQ score whose initial improvement was lost at T14.

Introduction: Severe COPD exacerbations requiring hospitalizations or resulting in death clearly impose a serious prognostic and economic impact on patients and healthcare systems who seek to prevent and treat them. Aims and Objectives: We evaluated the effect of triple therapy with extra-fine beclomethasone dipropionate/formoterol fumarate/glycopyrronium bromide (BDP/FF/GB) pressurized metered dose inhaler (pMDI) on reducing the severe COPD exacerbation rate compared to non-triple (non-TT) including non-ICS-containing maintenance inhalation therapies. Methods: Analysis of pooled data from 3 phase III multinational, randomized, parallel group trials comparing 52 weeks treatment with BDP/FF/GB 100/6/12.5 µg 2 inhalations bid to BDP/FF (TRILOGY), tiotropium (TRINITY) and indacaterol/glycopyrronium (TRIBUTE) in symptomatic patients on prior non-TT with severe or very severe COPD and history of moderate or severe exacerbation in the past year. Results: 445 patients experienced 535 severe exacerbations and were considered in this analysis. 202 received BDP/FF/GB, 243 received non-TT (BDP/FF, TIO, IND/GLY), and of those, 168 received non-ICS-containing therapies (TIO, IND/GLY). The adjusted rate ratio of severe exacerbation with BDP/FF/GB was 0.769 (95%CI: 0.632, 0.936, p=0.009) vs non-TT and 0.745 (95%CI: 0.592, 0.937, p=0.012) vs non-ICS-containing therapies. Conclusions: Treatment with extra-fine BDP/FF/GB pMDI effectively reduced the rate of severe COPD exacerbations vs non-triple (by 23.1%) and non-ICS containing (by 25.5%) therapies in symptomatic patients.

Background: The reduction of quantity of chronic obstructive pulmonary disease (COPD) exacerbations is key element for control of this disease. The aim of the study was to improve the adherence to COPD treatment and to decrease the quantity of COPD exacerbations because of it. Methods: The 156 patients with severe to very severe COPD were included into study. The information about exacerbations during 1 year before participation in the study was collected from routine medical records. The COPD exacerbations during 1 year in study were registered during the patients’ unscheduled visits to site. During the study patients were trained to use inhaler due to COPD correctly, they had to demonstrate correct technique of its use. The necessity to be within the regimen of basis therapy was discussed with them. T-test for independent samples and T-test for dependent samples were used for statistic processing. Results: During 1 year adherence to COPD treatment increased from 44.41 ± 1.07% to 75.21 ± 0.78%, i.e. on 30.8% (p The total duration of exacerbations diminished from 20.06 ± 0.80 to 8.60 ± 0.61 days, i.e. by 57.1%. The total quantity of hospitalizations due to COPD exacerbations fell from 1.26 ± 0.10 to 0.48 ± 0.07, i.e. by 61.9%. Conclusion: Although the final level of adherence to treatment did not exceed 80%, the parameters that characterize COPD exacerbations burden can be decreased by more than 50%.

Introduction: In severe emphysema, endoscopic and surgical lung volume reduction (resp. ELVR; LVRS) are treatment options improving lung function and physical functioning. Whether lung volume reduction (LVR) enhances the success of physical activity (PA) coaching is unknown. Methods: To investigate the effect of LVR preceding a 3-month PA coaching, 42 patients were included. Patients were allocated to ELVR (n=23) or standard of care (SOC) (n=19) based on collateral ventilation (measured by Chartis). All patients received PA coaching with step counter and smartphone application from 3 to 6m post allocation. PA was measured objectively; patients’ experience with PA was measured by the PROactive tool. After 6m, patients in SOC (n=14) underwent LVRS, again followed by PA coaching. Results: At 6 months, PA in both ELVR (p= 0.01) and SOC (p=0.01) improved within group, with no significant between-group differences (p=0.46) (fig 1). Perceived difficulty with PA at 6 months improved in ELVR (p Conclusion: In contrast to our hypothesis, lung volume reduction is no prerequisite for PA coaching; response to coaching seems independent of lung function improvement. LVR tends to improve perceived difficulty with PA.

Introduction: Improving patient-ventilator interaction during mechanical ventilation with acute hypercapnic respiratory failure (AHRF) reduces mortality. The esophageal pressure (Pes) measurement is an established way of detecting asynchronies in mechanically ventilated patients. This study aimed to evaluate the potential of Pes measurement in detecting patient-ventilator asynchronies in patients with AHRF due to severe COPD exacerbation requiring NIV. Methods: A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2018 and 2019. Pes and ventilator pressure (Paw) curves and other data were recorded. The signal analysis comprised of artifact elimination and measurement of the phase difference between Pes and Paw curves. The objective was to assess the potential of using the phase difference value as an indicator of asynchrony. Results: 15 patients (8 males, mean age 65 years) with severe COPD exacerbation with AHRF requiring NIV were included. All patients were successfully managed with NIV. Patient-ventilator asynchrony was clinically detected in 3 patients at admission. The signal analysis identified all episodes of asynchrony with phase difference values of 10-15° during asynchrony and value of 170-180° during synchrony period for the same patient. Conclusion: Pes measurement can be used to detect patient-ventilator asynchronies in severe COPD exacerbation with AHRF that requires NIV.

Prins HJ, et al. CRP-guided antibiotic treatment in acute exacerbations of COPD in hospital admissions. Eur Respir J 2019; 53: 1802014., C-reactive protein (at values ≥50 mg/L) is a useful and cheap biomarker for making antibiotic decisions in patients hospitalised for an acute exacerbation of COPD with no additional risk of adverse effect or treatment failure #AECOPD http://bit.ly/342p0Nj

Patients with severe chronic obstructive pulmonary disease (COPD) have a chaotic trajectory towards death. Research has focused on identifying a “transition point” that would allow identification of those patients who may benefit from a palliative approach to their care, or referral to a specialist palliative care service. This article aims to outline difficulties in identifying this transition point, summarise current literature on this topic and suggests a model based on clinical milestones. Educational aims To outline the difficulties associated with identifying patients with severe COPD who are at risk of dying. To summarise current research on this topic. Key points A specific transition point is difficult to identify in severe COPD. Tools are available that may assist the physician in identifying those at risk of dying. It is essential that the patient voice is heard, patients can describe specific events that may be used as a “trigger” for a palliative approach. Specialist palliative care services may only be required for a subgroup of patients whose needs cannot be managed by the primary care team., Patient voice and experiences have started to change the delivery of palliative care in severe COPD http://ow.ly/m4GU30fquoS

In the IMPACT trial, triple inhalation therapy resulted in a lower rate of moderate or severe COPD exacerbations compared with either dual therapy with ICS/LABA or LAMA/LABA, but pneumonia rates were increased. http://ow.ly/pYJn30mgpFp

Objective: To assess the prevalence, incidence, comorbidities, exacerbation frequency and mortality associated with moderate-to-very severe COPD across countries. Methods: A systematic literature review was conducted to identify epidemiological data in patients with moderate-to-very severe COPD (GOLD stages 2–4 [FEV1 Results: 100 studies were identified across the nine countries of interest. Differences in study populations, follow-up durations and assessment methods resulted in substantial variation in findings across studies. The weighted prevalence of COPD (GOLD 2–4) was 4.4%–8.7% across countries. Studies assessing COPD incidence were lacking. The most frequent comorbidities of COPD were cardiovascular diseases, with hypertension being the most common. The proportion of patients experiencing any COPD exacerbation ranged from 26.5%–62.3%, with rates of 0.53–2.64 events/person-year. Risk factors associated with mortality included age, male sex, BMI, comorbidities, hospital admissions and dyspnoea. Comorbidity prevalence, exacerbation frequency and mortality generally increased with the severity of COPD. Conclusions: Moderate-to-very severe COPD presents a substantial burden across countries, partly due to comorbidities, COPD exacerbations and high mortality in these patients. Additional epidemiological studies are needed to assess COPD incidence and reconcile differing methodology across studies.

Aim: This study aimed to investigate the relation between exacerbation severity and quality of life, dyspnea level, exacerbation frequency in the past and in the future. Methods: The patients that treated with SABDs plus antibiotics and/or oral corticosteroids were considered moderate;the hospitalized ones were considered to have severe exacerbation. Dyspnea level, pulmonary functions, number of exacerbations and quality of life scores were compared by exacerbation severity. Results: A total of 103 patients with exacerbation were enrolled in this prospective study between May-December 2018. There were 38 moderate, and 65 severe exacerbations. The mean number of exacerbations in the last year was 2.45±2.06. The number of exacerbations (p Conclusion: Patients with severe exacerbations had an accelerated decline of lung function, a worse quality of life, and an increased risk of experiencing frequent exacerbations.

Nasal cannula delivered high-flow (HFNC) has previously been shown to reduce exacerbations (AECOPD) in patients with severe COPD and chronic hypoxic failure. This post hoc study investigates whether there are subgroups in whom HFNC would be of special value in terms of reduction of AECOPD. Method: In a 12 month randomized controlled trial 100 patients were randomized to HFNC . Poisson regression analysis was made to investigate the influence of: PCO2 and mMRC at baseline; AECOPD and number of hospital admissions (ADM) one year prior to inclusion, on the number of AECOPD in study, corrected for time of use of HFNC. Patients were subgrouped into 0-1 AECOPD 1 year prior to inclusion (N=32) vs ≥2 and 0-2 (N=51) vs ≥ 3. Poisson regression analysis was made for each subgroup to investigate the effect on the number of AECOPD in study, corrected for time of use. Results: Mean AECOPD 1 year pre study was 0.5(+/-0.5) in group 0-1, 4.54(+/-3) in group >2; at 12 months 1.5(+/-2) resp 3.55(+/-3). There was a significant correlation between AECOPD and ADM pre study and a reduction in number of exacerbations in study (p Conclusion: In patients with severe COPD and chronic hypoxic failure HFNC should be considered part of personalized medicine in patients with ≥2 exacerbations per year or previous COPD-related hospital admissions in order to reduce number of exacerbations.

Introduction: Self-management programs aim to teach patients the skills needed to carry out medical regimens to guide behavior changes to help patients control their own condition, and it is the least implemented and most challenging area of chronic disease management. Objective: The main objective of this study was to evaluate the results of an in-hospital Self-Management program in patients with Chronic Obstructive Pulmonary Disease (COPD) compared to a control group. Methods: In this randomized clinical trial, acute exacerbated COPD patients were included and were randomly divided into two groups. The Control group received standard medical treatment and the Self-management group received a Self- Management program, which included educational information complemented with a problem-based session, neuromuscular stimulation therapy on the quadriceps muscle accompanied by lower limb exercises, breathing exercises and relaxation exercises. The main outcomes measured were health-related quality of life evaluated by EuroQol-5D and functionality measured by Functional independence measure. Results: Finally, a total of 44 acute exacerbated COPD patients were included in this randomized controlled trial. Self-Management group obtained significant betterments in all the variables compared with the control group (p Conclusion: An individualized Self-Management program administered once a day improves health-related quality of life and functionality compared to a Control Group in hospitalized severe COPD patients.

Background: Non-invasive ventilation (NIV) is a standard therapy for patients with chronic respiratory insufficiency and it has been shown that there is a reduction of dyspnoea for patients with severe COPD under the application of inspiratory airway pressure under load. It has been shown that NIV reduces dyspnoea and extends the walking distance. However, the applicability in the clinical routine is limited and could not be established so far. For this reason a portable NIV device could be able to improve endurance capacity of patients with severe COPD. Methods: This trial will investigate the effect of a mobile BiPAP device on dyspnoea, endurance capacity, blood gases and walking distance. During a six-minute-walking trial (6MWT) with and without the VitaBreath device 23 COPD patients were randomised in a cross-over setting. The primary endpoint was the average difference of the Borg dyspnoea scale before and after a 6MWT. Results: Mean dyspnoea scale difference was 4.4(IQR 6-8) without using mobile device to 4.5(IQR 6-7) using mobile device. The analysis showed no statistical significant difference of dyspnoea reduction (p=0.548). The walking distance decreased from 291.5m(CI 246.1-336.9) to 258.4m(CI 213.0-303.8) when walking with VitaBreath. Additionally, the arterial oxygen tension was significantly lower when using the device during 6MWT 56.5mmHg(CI 52.6-60.4) to 60.1mmHg(CI 56.2-64.1) without. Conclusion: The results don’t show a dyspnoea reduction under load by using the device in patients with respiratory insufficiency already using NIV. It remains unclear if less severe COPD patients might benefit.

Background: This is an extension study of the Predictive Ability of COPD Assessment Test (CAT) in acute Exacerbations of COPD (PACE) study. Aims and Objective: We want to find out if there is a positive relationship between CAT and exacerbation in COPD. Method: This study was an extension study of GSK sponsored study (SAM114169). Between Aug 2010 and Dec 2011, a total of 162 subjects visited institutions over 52 wks. At every visit, they completed the CAT, MRC, Exacerbation Check List (ECL), and spirometry. Telephone calls were made at every eight weeks intervals to collect information on exacerbation episodes in the previous month. Baseline CAT scores were categorized into 4 categories (0-9, 10-19, 20-29, 30-40). Age, gender, MRC, post BD FEV1, COPD exacerbation history, smoking history, flu vaccination history, etc. were adjusted. Results: In the adjusted analysis, categorized baseline CAT score showed a positive relationship with COPD exacerbation, not statistically significant but numerically increasing tendency (p=0.057). The patients with the highest category (CAT score 30-40) showed a trend towards higher risk of COPD exacerbations(aRR:1.16; p=0.043) than those in the lowest category (CAT score 0-9). Meanwhile, in the moderate/severe COPD exacerbation, this relationship remained as statistically significant after adjustment (p=0.002). The patients in the highest category showed higher risk of having meaningful COPD exacerbations (aRR:1.69; p=0.004) than those in the lowest category. Conclusion: The baseline CAT score showed a positive relationship with COPD exacerbation. We can conclude that CAT can be used as a useful tool for physicians to predict COPD exacerbations. Funding: GSK (NCT01254032)

Introduction: Randomized studies on pulmonary tele-rehabilitation (PTR) in people with COPD has shown positive short-term effects on physical capacity compared to conventional PR. No data on the potential for long-term sustainability from PTR exist. Aim: To investigate if PTR has long-term superiority to conventional PR on walking capacity (6MWD) and secondarily on the following outcomes: symptoms (CAT, HADS), quality of life (EQ-5D), physical activity level (accelerometer), mortality and hospitalizations. Methods: In a multicenter RCT, people with severe COPD (FEV1 Results: 134 participants (74 females, mean±SD age 68±9 years, FEV1 33±9 % predicted, 6MWD 327±103) were randomized 1:1. Intention-to-treat analysis showed no between-group differences for 6MWD at 12-month follow-up [5.7meters (95%CI: -24.8; 36.1)], similar to our previously published short-term effects. None of the within group short-term improvements after intervention were maintained. There were no statistical between-groups difference in respiratory hospitalization [HR: 1.08 (0.57; 1.99), all-cause hospitalization [HR: 1.16 (0.76; 1.78)] or mortality. Conclusion: Pulmonary tele-rehabilitation was not superior to conventional PR at 12-month follow-up. PTR has similar limitations regarding long-term sustainability as conventional PR.

Background: Expiratory flow limitation (EFL) is an hallmark of COPD. However has not implemented in the baseline routine functional assessment yet. Aim: to evaluate if the measurement of EFL by FOT could contribute to highlight pathophysiological mechanisms of improvement after PR. Method: in 75 stable moderate to very severe COPD patients, before and after PR, EFL as the within-breath change in reactance (DXrs), pulmonary function tests and rehabilitation outcomes were evaluated. Results: In the patients as a whole, after PR, DXrs decreased significantly (p 2.81 [cmH2O/(L/s)], patients were divided into two groups: flow-limited (FL, 36 patients, DXrs 5.14±2.6) and not flow-limited (NFL, 39 patients, DXrs 1.04±0.9) patients. Before PR FL patients were more severely obstructed (FEV1% 34.6±9.6 vs 52.0±20.6, p Conclusions: FOT measures provide new supplementary information to pulmonary functional evaluation in COPD patients enrolled in PR. These preliminary data show that the change in EFL could contribute to the effect of PR in severe patients.

Introduction: Bronchoscopic lung volume reduction with endobronchial valves (EBV) has been shown to improve lung function and quality of life (QoL) in emphysema patients with severe hyperinflation. Because of increased mortality rates in surgical LVR, patients with a diffusing capacity (DLCO) lower than 20%pred are often excluded from BLVR-treatment. Aims and Objectives: To explore whether EBV treatment in emphysema patients with a DLCO Methods: This single-center retrospective analysis included COPD patients with a DLCO Results: Ten patients with severe COPD (9 female, median age 67 (59-78) years, median FEV1 0.56 (0.41-0.97)L, median DLCO 17.4 (14.5-19.6)%pred) were analyzed. No patients died during the 45 day follow up. Treatment outcome data are shown in table 1. Conclusion: Short term follow up of COPD patients with a DLCO

Background: The pharmacological treatment of chronic obstructive pulmonary disease (COPD) is dominated by drug inhalation through handheld devices. Sometimes you see the recommendation to change from dry powder inhalers to spray-inhalers when lung function deteriorate and flow rates decline. However, lung function is primarily assessed by forced exhalations, where the dynamic compression of the airway causes a dramatic decrease in achieved flow rates in compared to forced inhalations. The aim of this study was therefore to investigate whether patients with COPD, with FEV1 Methods: The study included 18 patients who performed inhalation maneuvers through two empty inhalers. The pressure drop over the inhaler (i.e. the negative pressure at the mouth) was measured at 100 Hz using a pressure transducer connected to a measurement software via an A/D converter. In this way inhalation flow rates and volumes could be calculated. Results: All participants, could perform correct inhalations with the two inhalers. There was no statistically significant difference in inhalation ability between COPD stages 3 and 4, nor between the first and last inhalation trial. In conclusion, patients with severe COPD have the inhalation ability required for proper inhalations with Ellipta and Respimat. There was no clear difference in inhalation ability between COPD stage 3 and 4, and repeated attempts do not significantly improve or impair inhalation. Conclusion: A general recommendation to switch from powder inhalers to spray in severe COPD was not supported by the findings in this preliminary study.

Introduction: The aim of the study was to assess the impact of decreased 6MWT and exercise-induced desaturation (EID) on long-term survival and mortality related to Czech and Spanish phenotypes in patients with severe COPD. Methods: CMRD is a prospective, observational and multicentre study focussing on the collection and analysis of data on real mortality and morbidity in an unselected population of COPD. Results: A total of 598 patients with performed 6MWT were analysed. Overall 5-year mortality was 33.8% (202 patients). Using the ROC analyses, the statistically significant cut-off value for the 6MWD was 312.5 m (AUC 0.667; p Conclusion: In our cohort, the cachexy phenotype was significantly associated with lower long-term survival in the groups with decreased 6MWT and EID. We believe that identifying the clinical relevant phenotypes within COPD can guide us to a more personalised treatment.

COPD is the 2nd leading cause of deaths and DALYs in India and likely contributes to a huge economic burden. Most health care expenditure in India is out-of-pocket and little is contributed by the government and medical insurance. In this study, we aimed to examine out-of-pocket expenditure for patients of COPD visiting government, semi-private and private hospitals/clinics. Methods: 239 doctor diagnosed and spirometry confirmed (168 Males, Mean age 66.9 ± 8.9 years) mild-to-very severe COPD patients (8 mild, 76 moderate, 130 severe-very severe) on medications for at least one year were recruited from different hospital settings. One year expenditure was calculated retrospectively which included direct costs (physician consultation, Investigations, drugs and hospitalization costs) and indirect costs (travel, work days lost and professional caretaker cost) were captured using a detailed questionnaire. Results: The annual mean out-of-pocket expenditure for patients visiting government hospital was Indian Rupees (INR) 11835.85 ± 10799.64, Semi-private hospitals was INR 44003.02 ± 54146.75, private hospitals & clinics was INR 50805.24 ± 172916.43 (Fig). 49.3% of the out-of-pocket expenditure was accounted for by hospitalization cost. Conclusion: Out-of-pocket expenditure for COPD in India is very high and is largely driven by hospitalisaiton costs and drug costs.

Introduction: Chronic obstructive pulmonary disease(COPD) is an increasing cause of morbidity and mortality worldwide and has been strongly related to tobacco smoking. Aims and Objective: Most studies on COPD have concentrated on smokers. Our data demonstrated that the risk of COPD in non smokers is higher than previously believed. Methods: This is a retrospective observational study.180 non-smoker COPD patients were selected from the year 2016-2018. History with questionnaires was taken and subsequent spirometry results were evaluated. They were categorized into Mild, Moderate, Severe and Very Severe COPD according to GOLD Guidelines followed by questionnaires. Results: Out of 180 non-smoker COPD patients, 54% were females. The percentage of mild, moderate, severe and very severe patients according to GOLD Guidelines was 26%, 53%, 58% and 43% respectively. The distribution of patients according to exposure was biomass gas-83 patients (46.11%), toxic gases(26.66%). The most common co-morbidity among non-smoker COPD was hypertension(34.4%) followed by diabetes mellitus(17.77%). In our study 61% patients belonged to rural areas and 38% belonged to urban areas.(Image1). Conclusions: The study shows non-smokers form an important part of COPD patients. Exposure to industrial smoke, environmental pollution and household smoke are major contributors for COPD in non-smokers. There is a need to study this subset of non-smokers having COPD.

Background: It remains a challenge to identify best target lobe with the highest outcomes in severe COPD following endoscopic lung volume reduction (ELVR). Aim and Objectives: We analyzed the outcomes after ELVR though using lobar ventilation (V) and perfusion (Q) quantitation combing with HRCT to identify the targeted lobe. Methods: Patients with severe COPD were prospectively recruited and underwent unilateral ELVR between Feb 2013 and Oct 2018 at Macquarie University Hospital. 19 patients in the study group were used the lower lobar VQ combing with HRCT and 44 patients in the control group performed planar VQ scan only reliant upon fissures on HRCT to identify the targeted lobe. Complex full pulmonary function tests(PFTs) and VQ scans were performed at baseline and at 3 months post-ELVR. Results: The improvements of prFEV1, prFEV1%, psFEV1 and RV/TLC between pre and post ELVR in the study group (0.19±0.04L, 7.77±1.57%, 0.16±0.03L, -7.25±1.63%) were much better than in the control group (0.05±0.02L, 2.41±0.99％, 0.05±0.02L,-2.13±1.09%, p Conclusions: Selecting the lower lobar VQ for the targeted lobe was associated with the better improvements in PFTs for ELVR. The lobar VQ redistribution to the non-targeted contralateral upper lobe is a likely mechanism of action in ELVR.