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BackgroundChronic obstructive pulmonary disease (COPD) is the end result of a susceptible individual being exposed to sufficiently deleterious environmental stimuli. More than 90% of COPD-related deaths occur in low- and middle-income countries (LMICs). LMICs face unique challenges in managing COPD; for example, deficient primary care systems present challenges for proper diagnosis and management. Formal diagnosis of COPD requires quality-assured spirometry, which is often limited to urban health centres. Similarly, standard treatment options for COPD remain limited where few providers are trained to manage COPD. The Global Excellence in COPD Outcomes (GECo) studies aim to assess the performance of a COPD case-finding questionnaire with and without peak expiratory flow (PEF) to diagnose COPD, and inform the effectiveness and implementation of COPD self-management Action Plans in LMIC settings. The ultimate goal is to develop simple, low-cost models of care that can be implemented in LMICs. This study will be carried out in Nepal, Peru and Uganda, three distinct LMIC settings.Methods/designWe aim to assess the diagnostic accuracy of a simple questionnaire with and without PEF to case-find COPD (GECo1), and examine the effectiveness, cost-effectiveness and implementation of a community-health-worker-supported self-management Action Plan strategy for managing exacerbations of COPD (GECo2). To achieve the first aim, we will enrol a randomly selected sample of up to 10,500 adults aged ≥ 40 years across our three sites, with the goal to enrol 240 participants with moderate-to-severe COPD in to GECo2. We will apply two case-finding questionnaires (Lung Function Questionnaire and CAPTURE) with and without PEF and compare performance against spirometry. We will report ROC areas, sensitivity and specificity. Individuals who are identified as having COPD grades B-D will be invited to enrol in an effectiveness-implementation hybrid randomised trial of a multi-faceted COPD self-management Action Plan intervention delivered by CHWs. The intervention group will receive (1) COPD education, (2) facilitated-self management Action Plans for COPD exacerbations and (3) monthly visits by community health workers. The control group will receive COPD education and standard of care treatment provided by local health providers. Beginning at baseline, we will measure quality of life with the EuroQol-5D (EQ-5D) and St. George's Respiratory Questionnaire (SGRQ) every 3 months over a period of 1 year. The primary endpoint is SGRQ at 12 months. Quality-adjusted life years (QALYs) using the Short-Form 36 version 2 will also be calculated. We will additionally assess the acceptability and feasibility of implementing COPD Action Plans in each setting among providers and individuals with COPD.DiscussionThis study should provide evidence to inform the use of pragmatic models of COPD diagnosis and management in LMIC settings.Trial registrationNCT03359915 (GECo1). Registered on 2 December 2017 and NCT03365713 (GECo2). Registered on 7 December 2017. Trial acronym: Global Excellence in COPD Outcomes (GECo1; GECo2).

Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases (CVD) commonly co-exist. Outcomes of people living with both conditions are poor in terms of symptom burden, receiving evidence-based treatment and mortality. Increased understanding of the underlying mechanisms may help to identify treatments to relieve this disease burden. This narrative review covers the overlap of COPD and CVD with a focus on clinical presentation, mechanisms, and interventions. Literature up to December 2023 are cited. 1. What is COPD 2. The co-existence of COPD and cardiovascular disease 3. Mechanisms of cardiovascular disease in COPD. 4. Populations with COPD are at risk of CVD 5. Complexity in the co-diagnosis of COPD in those with cardiovascular disease. 6. Therapy for COPD and implications for cardiovascular events and risk. 7. Cardiovascular risk and exacerbations of COPD. 8. Pro-active identification and management of CV risk in COPD. The prospective identification of co-morbid COPD in CVD patients and of CVD and CV risk in people with COPD is crucial for optimizing clinical outcomes. This includes the identification of novel treatment targets and the design of clinical trials specifically designed to reduce the cardiovascular burden and mortality associated with COPD. Databases searched: Pubmed, 2006–2023. [ABSTRACT FROM AUTHOR]

Rationale: Chronic obstructive pulmonary disease (COPD) is a prevalent and burdensome condition in low- and middle-income countries (LMICs). Challenges to better care include more effective diagnosis and access to affordable interventions. There are no previous reports describing therapeutic needs of populations with COPD in LMICs who were identified through screening. Objectives: To describe unmet therapeutic need in screening-detected COPD in LMIC settings. Methods: We compared interventions recommended by the international Global Initiative for Chronic Obstructive Lung Disease COPD strategy document, with that received in 1,000 people with COPD identified by population screening at three LMIC sites in Nepal, Peru, and Uganda. We calculated costs using data on the availability and affordability of medicines. Measurement and Main Results: The greatest unmet need for nonpharmacological interventions was for education and vaccinations (applicable to all), pulmonary rehabilitation (49%), smoking cessation (30%), and advice on biomass smoke exposure (26%). Ninety-five percent of the cases were previously undiagnosed, and few were receiving therapy (4.5% had shortacting β-agonists). Only three of 47 people (6%) with a previous COPD diagnosis had access to drugs consistent with recommendations. None of those with more severe COPD were accessing appropriate maintenance inhalers. Even when available, maintenance treatments were unaffordable, with 30 days of treatment costing more than a low-skilled worker's daily average wage. Conclusions: We found a significant missed opportunity to reduce the burden of COPD in LMIC settings, with most cases undiagnosed. Although there is unmet need in developing novel therapies, in LMICs where the burden is greatest, better diagnosis combined with access to affordable interventions could translate to immediate benefit. [ABSTRACT FROM AUTHOR]

The article "Breathless and heart broken in COPD" published in the journal Respirology discusses the elevated risk of cardiovascular disease in individuals living with chronic obstructive pulmonary disease (COPD). Shared risk factors such as tobacco smoke exposure contribute to this increased risk, and managing cardiovascular risk in COPD is crucial for improving patient outcomes. The article emphasizes the importance of identifying and mitigating cardiovascular risk factors in COPD patients to prevent premature death, highlighting the need for further research and interventions in this area. [Extracted from the article]

Patients with chronic obstructive pulmonary disease (COPD) may suffer from acute episodes of worsening dyspnea, often associated with increased cough, sputum, and/or sputum purulence. These exacerbations of COPD (ECOPDs) impact health status, accelerate lung function decline, and increase the risk of hospitalization. Importantly, close to 20% of patients are readmitted within 30 days after hospital discharge, with great cost to the person and society. Approximately 25% and 65% of patients hospitalized for an ECOPD die within 1 and 5 years, respectively. Patients with COPD are usually older and frequently have concomitant chronic diseases, including heart failure, coronary artery disease, arrhythmias, interstitial lung diseases, bronchiectasis, asthma, anxiety, and depression, and are also at increased risk of developing pneumonia, pulmonary embolism, and pneumothorax. All of these morbidities not only increase the risk of subsequent ECOPDs but can also mimic or aggravate them. Importantly, close to 70% of readmissions after an ECOPD hospitalization result from decompensation of other morbidities. These observations suggest that in patients with COPD with worsening dyspnea but without the other classic characteristics of ECOPD, a careful search for these morbidities can help detect them and allow appropriate treatment. For most morbidities, a thorough clinical evaluation supplemented by appropriate clinical investigations can guide the healthcare provider to make a precise diagnosis. This perspective integrates the currently dispersed information available and provides a practical approach to patients with COPD complaining of worsening respiratory symptoms, particularly dyspnea. A systematic approach should help improve outcomes and the personal and societal cost of ECOPDs. [ABSTRACT FROM AUTHOR]

• Recovery of exercise capacity is variable after COPD exacerbation. • Quadriceps weakness at hospitalization predicts a poor recovery after 30 days. • No influence of respiratory and handgrip strength was observed. • Early rehabilitation should improve leg strength to accelerate functional recovery. Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) have decreased exercise tolerance, which may persist for months. In this context, little is known about the associations between muscle strength and recovery of exercise capacity. To assess whether respiratory and peripheral muscle strength influence recovery of exercise capacity in patients hospitalized due to AECOPD. Twenty-seven AECOPD patients (aged 69 ± 7 years, 56% male) were included. The following assessments were performed within 24 to 72 h of hospital admission: (i) respiratory muscle strength, measured by maximal inspiratory and expiratory pressures (MIP and MEP); (ii) peripheral muscle strength, assessed by handgrip and quadriceps muscle strength; and (iii) exercise capacity, measured by 6-min walking distance (6MWD). The 6MWD was reassessed 30 days later to determine the recovery of exercise capacity. After 30 days, while 63% of the patients showed clinically important improvement in the 6MWD (recovery ≥ 30 m), 37% showed no change (recovery < 30 m). During hospital stay, the non-recovered group had lower quadriceps muscle strength compared to the recovered group (15 ± 5 vs. 22 ± 6 kgf; P = 0.006), with no significant difference for MIP, MEP and handgrip strength. Only quadriceps muscle strength was associated with recovery of exercise capacity (r = 0.56; P = 0.003). AECOPD patients with quadriceps muscle weakness during hospitalization have poor recovery of exercise capacity after 30 days. This finding suggests the importance of early rehabilitation to improve quadriceps strength and accelerate functional recovery after AECOPD. [ABSTRACT FROM AUTHOR]

Exacerbations of chronic obstructive pulmonary disease are important events to people living with this condition and a common cause of emergency hospital admission. In the absence of a confirmatory biomarker, an exacerbation remains a clinical diagnosis of exclusion and clinicians must be alert to alternative diagnoses. Most exacerbations are caused by airway infection, particularly with respiratory viruses. The mainstay of exacerbation treatment is an increase in the dose and/or frequency of short-acting beta-agonists, with short-course oral corticosteroids and/or antibiotics. Although there have been no new interventions to treat exacerbations in many years, there is still much variation in care and opportunity to improve outcomes. There has been a new focus on both the management of comorbidities and the optimisation of future care to reduce the risk of further events. This review summarises advances in managing exacerbations of chronic obstructive pulmonary disease, focusing on hospitalised patients. [ABSTRACT FROM AUTHOR]

The number of people affected by chronic obstructive pulmonary disease (COPD) is increasing and the hospital readmission rate is remarkably high. Therefore, healthcare professionals and managers have financial and workforce-related pressures. A decision support toolkit (DST) for improving the management and efficiency of COPD care is needed to respond to the needs of patients now and in the future. In collaboration with the COPD team of a hospital and community service in London, we conceptualised the pathway for COPD patients and developed a discrete event simulation model (DES) incorporating the dynamics of patient readmissions. A DES model or operational model at this scale has never been previously developed, despite many studies using other modelling and simulation techniques in COPD. Our model is the first of its kind to include COPD readmissions as well as assessing the quantifiable impact of re-designing COPD services. We demonstrate the impact of post-exacerbation pulmonary rehabilitation (PEPR) policy and observe that PEPR would be cost-effective with improvements in quality-adjusted life years (QALYs), reduction in emergency readmissions and occupied bed days. The DST improves the understanding of the impact of scenarios (activities, resources, financial implications etc.) for key decision makers and supports commissioners in implementing the interventions. [ABSTRACT FROM AUTHOR]

This article discusses the challenges of recruiting individuals with chronic obstructive pulmonary disease (COPD) for clinical trials. The authors highlight the complexity of respiratory trials, including the specific equipment and procedures required for lung function testing and target engagement studies. The unpredictable nature of COPD exacerbations also poses a challenge, as higher-risk patients must be exacerbation-free prior to recruitment. Additionally, there is often a discrepancy between where COPD patients receive care and the location of the necessary equipment and expertise for clinical research. The authors suggest innovative approaches, such as patient-led sign-up services and recruitment from lung cancer screening programs, to support recruitment to COPD clinical trials. [Extracted from the article]

Objective: To assess the impact of interventions for improving the management of chronic obstructive pulmonary disease (COPD), specifically increased use of pulmonary rehabilitation (PR) on patient outcomes and cost-benefit analysis. Data Sources: We used the national Hospital Episode Statistics (HES) datasets in England, local data and experts from the hospital setting, National Prices and National Tariffs, reports and the literature around the effectiveness of PR programs. Study Design: The COPD pathway was modeled using discrete event simulation (DES) to capture the patient pathway to an adequate level of detail as well as randomness in the real world. DES was further enhanced by the integration of a health economic model to calculate the net benefit and cost of treating COPD patients based on key sets of interventions. Data Collection/Extraction Methods: A total of 150 input parameters and 75 distributions were established to power the model using the HES dataset, outpatient activity data from the hospital and community services, and the literature. Principal Findings: The simulation model showed that increasing referral to PR (by 10%, 20%, or 30%) would be cost-effective (with a benefit-cost ratio of 5.81, 5.95, and 5.91, respectively) by having a positive impact on patient outcomes and operational metrics. Number of deaths, admissions, and bed days decreased (ie, by 3.56 patients, 4.90 admissions, and 137.31 bed days for a 30% increase in PR referrals) as well as quality of life increased (ie, by 5.53 QALY among 1540 patients for the 30% increase). Conclusions: No operational model, either statistical or simulation, has previously been developed to capture the COPD patient pathway within a hospital setting. To date, no model has investigated the impact of PR on COPD services, such as operations, key performance, patient outcomes, and cost-benefit analysis. The study will support policies around extending availability of PR as a major intervention. [ABSTRACT FROM AUTHOR]

The secondary care work stream of the National COPD Audit Programme aims to improve care and outcomes for patients with exacerbation of chronic obstructive pulmonary disease (COPD) wherever and whenever they are admitted to hospital. To achieve this, prospective audit is combined with real-time feedback of data to individual units, together with support for quality improvement and high-level change levers. COPD exacerbations comprise a large proportion of the acute take. Only by working collaboratively across emergency, acute and general medicine, respiratory, geriatric and other teams can individual trusts deliver optimal care. This review provides background to the national COPD audit programme, relevant to all those caring for people with COPD exacerbations in secondary care. [ABSTRACT FROM AUTHOR]

Rationale: There are no studies on withdrawal of inhaled corticosteroids in patients on long-term triple therapy in the absence of frequent exacerbations.Objectives: To evaluate the efficacy and safety of direct de-escalation from long-term triple therapy to indacaterol/glycopyrronium in nonfrequently exacerbating patients with chronic obstructive pulmonary disease (COPD).Methods: This 26-week, randomized, double-blind, triple-dummy study assessed the direct change from long-term triple therapy to indacaterol/glycopyrronium (110/50 μg once daily) or continuation of triple therapy (tiotropium [18 μg] once daily plus combination of salmeterol/fluticasone propionate [50/500 μg] twice daily) in nonfrequently exacerbating patients with moderate-to-severe COPD. Primary endpoint was noninferiority on change from baseline in trough FEV1. Moderate or severe exacerbations were predefined secondary endpoints.Measurements and Main Results: A total of 527 patients were randomized to indacaterol/glycopyrronium and 526 to triple therapy. Inhaled corticosteroids withdrawal led to a reduction in trough FEV1 of -26 ml (95% confidence interval, -53 to 1 ml) with confidence limits exceeding the noninferiority margin of -50 ml. The annualized rate of moderate or severe COPD exacerbations did not differ between treatments (rate ratio, 1.08; 95% confidence interval, 0.83 to 1.40). Patients with ≥300 blood eosinophils/μl at baseline presented greater lung function loss and higher exacerbation risk. Adverse events were similar in the two groups.Conclusions: In patients with COPD without frequent exacerbations on long-term triple therapy, the direct de-escalation to indacaterol/glycopyrronium led to a small decrease in lung function, with no difference in exacerbations. The higher exacerbation risk in patients with ≥300 blood eosinophils/μl suggests that these patients are likely to benefit from triple therapy. Clinical trial registered with www.clinicaltrials.gov (NCT 02603393). [ABSTRACT FROM AUTHOR]

Introduction: The value of monitoring physiological parameters to predict chronic obstructive pulmonary disease (COPD) exacerbations is controversial. A few studies have suggested benefit from domiciliary monitoring of vital signs, and/or lung function but there is no existing systematic review. Objectives: To conduct a systematic review of the effectiveness of monitoring physiological parameters to predict COPD exacerbation. Methods: An electronic systematic search compliant with Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines was conducted. The search was updated to April 6, 2016. Five databases were examined: Medical Literature Analysis and Retrieval System Online, or MEDLARS Online (Medline), Excerpta Medica dataBASE (Embase), Allied and Complementary Medicine Database (AMED), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and the Cochrane clinical trials database. Results: Sixteen articles met the pre specified inclusion criteria. Fifteen of these articules reported positive results in predicting COPD exacerbation via monitoring of physiological parameters. Nine studies showed a reduction in peripheral oxygen saturation (SpO2%) prior to exacerbation onset. Three studies for peak flow, and two studies for respiratory rate reported a significant variation prior to or at exacerbation onset. A particular challenge is accounting for baseline heterogeneity in parameters between patients. Conclusion: There is currently insufficient information on how physiological parameters vary prior to exacerbation to support routine domiciliary monitoring for the prediction of exacerbations in COPD. However, the method remains promising. [ABSTRACT FROM AUTHOR]

Background: Accurate identification of hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) within electronic health care records is important for research, public health, and to inform health care utilization and service provision. We aimed to develop a strategy to identify hospitalizations for AECOPD in secondary care data and to investigate the validity of strategies to identify hospitalizations for AECOPD in primary care data. Methods: We identified patients with chronic obstructive pulmonary disease (COPD) in the Clinical Practice Research Datalink (CPRD) with linked Hospital Episodes Statistics (HES) data. We used discharge summaries for recent hospitalizations for AECOPD to develop a strategy to identify the recording of hospitalizations for AECOPD in HES. We then used the HES strategy as a reference standard to investigate the positive predictive value (PPV) and sensitivity of strategies for identifying AECOPD using general practice CPRD data. We tested two strategies: 1) codes for hospitalization for AECOPD and 2) a code for AECOPD other than hospitalization on the same day as a code for hospitalization due to unspecified reason. Results: In total, 27,182 patients with COPD were included. Our strategy to identify hospitalizations for AECOPD in HES had a sensitivity of 87.5%. When compared with HES, using a code suggesting hospitalization for AECOPD in CPRD resulted in a PPV of 50.2% (95% confidence interval [CI] 48.5%,51.8%) and a sensitivity of 4.1% (95% CI 3.9%,4.3%). Using a code for AECOPD and a code for hospitalization due to unspecified reason resulted in a PPV of 43.3% (95% CI 42.3%,44.2%) and a sensitivity of 5.4% (95% CI 5.1%,5.7%). Conclusion: Hospitalization for AECOPD can be identified with high sensitivity in the HES database. The PPV and sensitivity of strategies to identify hospitalizations for AECOPD in primary care data alone are very poor. Primary care data alone should not be used to identify hospitalizations for AECOPD. Instead, researchers should use data that are linked to data from secondary care. [ABSTRACT FROM AUTHOR]

Background: Some COPD patients are more susceptible to exacerbations than others. Mechanisms underlying these differences in susceptibility are not well understood. We hypothesized that altered cell mediated immune responses may underlie a propensity to suffer from frequent exacerbations in COPD. Methods: Peripheral blood mononuclear cells (PBMCs) were obtained from 24 stable COPD patients, eight frequent exacerbators (≥3 diary-card exacerbations/year) and 16 infrequent exacerbators (< 3 diary-card exacerbations/year). Detailed multi-parameter flow cytometry was used to study differences in innate and adaptive systemic immune function between frequent and infrequently exacerbating COPD patients. Results: The 24 COPD patients had a mean (SD) age of 76.3 (9.4) years and FEV1 1.43 (0.60)L, 53.3 (18.3)% predicted. PBMCs of frequent exacerbators (FE) contained lower frequencies of CD4+ T central memory cells (CD4+ Tcm) compared to infrequent exacerbators (IE) (FE = 18.7%; IE = 23.9%; p = 0.035). This observation was also apparent in absolute numbers of CD4+ Tcm cells (FE = 0.17 × 10∧6/mL; IE = 0.25 × 10∧6/mL; p = 0.035). PBMCs of FE contained a lower frequency of CD8+ T effector memory cells expressing HLA-DR (Human Leukocyte Antigen - D Related) compared to IE COPD patients (FE = 22.7%; IE = 31.5%; p = 0.007). Conclusion: Differences in the adaptive systemic immune system might associate with exacerbation susceptibility in the 'frequent exacerbator' COPD phenotype. These differences include fewer CD4+ T central memory cells and CD8+ T effector memory cells. [ABSTRACT FROM AUTHOR]

Ideally lung cancer screening should comprise a holistic "lung health check", but if programmes are not going to include spirometry then at least they should be reporting back on those with emphysema, who have demonstrable evidence of exposure-related lung disease and are therefore at high risk for COPD. Risk factors for lung cancer and COPD are similar, and COPD itself both increases the risk of cancer and can complicate therapy. Keywords: COPD; lung cancer; screening EN COPD lung cancer screening 75 75 1 12/19/22 20230101 NES 230101 You want value for money, right?. [Extracted from the article]

Proteinase-activated receptor-1 (PAR-1) plays a key role in mediating the interplay between coagulation and inflammation in response to injury. The aim of this study was to investigate the role of the promoter single-nucleotide polymorphism (SNP) rs2227744G>A in modulating PAR-1/F2R gene expression in the context of chronic obstructive pulmonary disease (COPD) and COPD exacerbations. The function of the rs2227744G>A SNP was investigated by using reporter gene assays. The frequency of the polymorphism in the UK population was assessed by genotyping 8,579 healthy individuals from the Whitehall II and English Longitudinal Study of Ageing cohorts. The rs2227744G>A SNP was genotyped in a carefully phenotyped cohort of 203 COPD cases and matched controls. The results were further replicated in two different COPD cohorts. The minor allele of the rs2227744G>A polymorphism was found to increase F2R expression by 2.6-fold (P < 0.001). The rs2227744G>A SNP was not significantly associated with COPD, or with lung function, in all cohorts. The minor allele of the SNP was found to be associated with protection from frequent exacerbations (P = 0.04) in the cohort of COPD patients for which exacerbation frequency was available. Considering exacerbations as a continuous variable, the presence of the minor allele was associated with a significantly lower COPD exacerbation rate (3.03 vs. 1.98 exacerbations/year, Mann-Whitney U-test P = 0.04). Taken together, these data do not support a role for the rs2227744G>A F2R polymorphism in the development of COPD but suggest a protective role for this polymorphism from frequent exacerbations. Studies in separate cohorts to replicate these findings are warranted. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic obstructive pulmonary disease (COPD) can be categorized as having frequent (FE) or infrequent (IE) exacerbations depending on whether they respectively experience two or more, or one or zero exacerbations per year. Although most patients do not change category from year to year, some will, and the factors associated with this behaviour have not been examined. Methods: 1832 patients completing two year follow-up in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) study were examined at baseline and then yearly. Exacerbations were defined by health care utilisation. Patient characteristics compared between those patients who did or did not change exacerbation category from year 1 to year 2. Findings: Between years 1 and 2, 221 patients (17%) changed from IE to FE and 210 patients (39%) from FE to IE. More severe disease was associated with changing from IE to FE and less severe disease from FE to IE. Over the preceding year, small falls in FEV1 and 6-minute walking distance were associated with changing from IE to FE, and small falls in platelet count associated with changing from FE to IE. Conclusion: No parameter clearly predicts an imminent change in exacerbation frequency category. [ABSTRACT FROM AUTHOR]

Background: Hospitalisations are important events in COPD, and exacerbation prevention strategies are not completely effective. Experience with our research cohort suggested that availability of 24-hour telephone advice may reduce hospital admission. Aim: To examine the use and utility of a 24-hour Telephone Support Service for high-risk NHS COPD patients. Method: 74 patients with 'high-risk' COPD had therapy optimised, were educated about exacerbations, given home 'emergency' therapy, and had 24-hour access to telephone advice. Results: Patients had a mean (SD) age of 70.4 (9.1) years and severe disease (mean FEV1 1.00 (0.37) litre; 30% had home oxygen and 46% lived alone). There were 258 telephone calls in 22,074 follow-up days. 76% of calls were received between 0800 and 1700 hours. The proportion of possible exacerbation ('appropriate') calls (overall 56%) was higher at weekends and overnight. Overnight calls (2100-0800) were rare: to expect one appropriate call per shift would require 2453 patients. A third of appropriate overnight calls could be managed without further emergency assessment. Mean (SD) length of follow-up was 298 (117) days/patient. Patients completing one year of follow-up (n=52) demonstrated a 45% reduction in admissions and 37% reduction in bed days. Patient satisfaction was high. Conclusions: We report data on the use and utility of a 24-hour Telephone Support Service in COPD. The service was associated with a reduction in hospital admission. Call volume was low, thus giving information on the size and cost-effectiveness of such service provision. [ABSTRACT FROM AUTHOR]

There is an unmet need in the diagnosis, phenotyping, and staging of COPD that could potentially be fulfilled by a validated molecular biomarker. Many promising candidates have been investigated, and some have been shown to be useful in certain situations. However, to date there is no outstanding disease-specific biomarker for widespread clinical application for patients in the stable state. Given the functional, social, and financial importance of exacerbations of COPD, it would be very useful to be able to employ a biomarker to aid optimal treatment and predict clinical outcome from the acute episode. Although serum C-reactive protein (CRP) is not specific to COPD, its use as a molecular biomarker in the stable state and at exacerbation has been studied extensively, and it remains the most commonly measured molecular biomarker in routine secondary care practice. Utilizing biomarkers in combinations may ultimately prove more useful. Airway-derived biomarkers and their relationships with outcome measures require further longitudinal study as well as refinement of sampling techniques to make them more broadly applicable. There is substantial ongoing investigation of many biomarkers that we are hopeful will advance the field for the benefit of our patients. [ABSTRACT FROM AUTHOR]

Summary: Rationale: The perception of fatigue in COPD has been associated with reduced health status. We have shown that exacerbations are associated with reduced activity and health status. However, the relationship between fatigue and exacerbation is unknown. Objectives: To investigate the hypothesis that increased fatigue is related to physical inactivity and COPD exacerbations. Methods: Fatigue was studied in COPD and age-matched control subjects. The relationship between fatigue and stable patient characteristics in COPD, and the effect of exacerbation on fatigue were evaluated. Measurements: 107 COPD patients mean age 69 years (range 43–86), FEV1 53% (SD 21), and 30 aged-matched control subjects; Functional Assessment of Chronic Illness Therapy-Fatigue Scale, Centre for Epidemiological Studies Depression Scale. Main results: Fatigue in COPD patients was significantly increased compared to control subjects (mean 35.3 units (SD 11.0) versus 43.2 (10.5), p =0.001). Increase in fatigue in COPD was related to reduced time spent outdoors (r =−0.43, p <0.001), increase in depression (r =−0.59, p <0.001) and annual exacerbation frequency (r =−0.27, p =0.005). Fatigue increased at exacerbation in 31/32 patients. Overall, fatigue increased by 8.3 units (5.9), p <0.001. Change in fatigue at exacerbation was related to increase in depression (r =−0.46, p =0.008). Fatigue recovered at 6 weeks following exacerbation. Conclusions: The perception of fatigue increased in patients with COPD compared to age-matched control subjects, and associated with morbidity when patients were stable and at exacerbation. [Copyright &y& Elsevier]

The article focuses on a study to determine whether interactions between bacterial and viral infection can affect changes in airway bacterial load. It also examined the hypothesis that these interactions can affect inflammatory responses of exacerbations in patients with COPD. Results of the study, which used polymerase chain reaction detection for rhinovirus and quantitative microbiology, concluded that clinical severity and inflammatory responses in COPD exacerbations are regulated nature of the infecting organism.

This article presents information on a study which describes the relationship between airway and systemic inflammatory markers and FEV1 decline in COPD over a prolonged period of follow-up in a well- characterized patient cohort. FEV1 is easily measurable and is the strongest spirometric predictor of mortality in patients with COPD. Factors that affect decline in FEV1 are therefore of prognostic importance in COPD. Long-term studies of FEV1 decline have shown the importance of cigarette smoking and exacerbation frequency as some of the factors that affect FEV1 decline.

Study objective: The upper and lower airways are continuous. While upper airway symptoms are common in COPD patients, with accumulating evidence to suggest increased nasal inflammation, the relationships among upper airway, lower airway, and systemic inflammatory indexes have not been studied. We aimed to confirm that there is heightened nasal inflammation in COPD patients, to test the hypothesis that the degree of upper airway inflammation relates to the degree of lower airway inflammation, and to investigate the underlying associations with bacterial carriage and the systemic inflammatory response. Design: Prospective cohort study. Setting: Outpatient Department, London Chest Hospital, London, UK. Participants: Forty-seven patients with COPD and 12 control subjects of similar age, sex, and smoking status. Measurements: Serum, nasal wash fluid, and sputum samples were obtained from 47 stable patients with COPD for the analysis of inflammatory indexes and bacterial colonization. Nasal wash fluid specimens were obtained from 12 control subjects. Results: COPD patients had an increased nasal interleukin (IL)-8 concentration compared to control subjects (difference, 97.2 pg/mL; p = 0.009). The nasal IL-8 concentration in COPD patients correlated with that in sputum (r = 0.30; p = 0.039). In both the upper and lower airways of patients with COPD, the IL-8 concentration was associated with indexes of bacterial colonization. Patients colonized with a sputum potentially pathogenic microorganism had a higher total nasal bacterial load (difference, 1.5 log cfu/mL; p = 0.016). We did not find significant relationships between the degree of upper or lower airway inflammation, or bacterial carriage, and the systemic inflammatory response. Conclusions: COPD is associated with an increased nasal concentration of the neutrophil chemoattractant protein IL-8, the degree of which reflects that present in the lower airway. A relationship between lower airway bacterial colonization, postnasal drip, and higher nasal bacterial load may suggest a mechanism underlying this finding. This study is the first to report a correlation between the degree of upper and lower airway inflammation in COPD. [ABSTRACT FROM AUTHOR]

Twenty percent of chronic obstructive pulmonary disease (COPD) patients admitted to hospital because of an ‘exacerbation’ will have consolidation visible on a chest X-ray. The presence of consolidation is associated with higher mortality. Imperfect definitions of COPD exacerbation and pneumonia, and incomplete and imperfect diagnostic tests, have resulted in a debate about whether these episodes are best thought of as ‘exacerbation with consolidation’ or ‘pneumonia in a person with COPD’. With the current views that exacerbations are not all identical, and that they can be ‘phenotyped’ to identify episodes with different prognosis and treatment response, perhaps these episodes are best-considered a phenotype of exacerbation. Whatever the terminology, the important clinical message is to recognise that those with consolidation have higher mortality, and likely different responses to treatment. [ABSTRACT FROM AUTHOR]