Presently, high flow nasal therapy (HFNT) is generally only available for shorter term use in the inpatient setting as an alternative to noninvasive ventilation. We undertook a study of HFNT in an outpatient COPD population to determine if it was safe and feasible to use this therapy for up to 90 days. If so, then a long-term randomized trial on HFNT could be conducted.

Thirty patients presented for HFNT titration—a process of gradually determining the longest amount of time HFNT can be tolerated with the least amount of side effects. Two dropped out; 1 after receiving a lung transplant and the other was lost to follow-up. The remaining 28 patients completed 90 days of HFNT. No patients withdrew from HFNT due to not being able to tolerate the therapy. The individuals used HFNT an average of 6.8 hours each day.

This study showed that it is possible to use HFNT in the home on a daily basis for up to 3 months in COPD patients following hospitalization for an acute exacerbation. Improvements in quality of life, respiratory symptoms, and the 6-minute walking distance test were observed. These findings suggest the need for a larger multicenter controlled clinical trial.

This study aimed to evaluate the short- and medium-term effectiveness of an 8-week, home-based pulmonary rehabilitation program in COPD patients with chronic respiratory failure. Chronic respiratory failure happens when the lungs are so damaged that the exchange of carbon dioxide for oxygen does not happen correctly, causing either a build up of carbon dioxide and/or a low level of oxygen in the blood. The following were measured in individuals at the beginning of the study and then again at 8 weeks and 8 months after each individual joined the study:

• physical frailty or weakness,
• functional capacity—the ability to perform everyday tasks and activities,
• exercise tolerance—a measurement of how well and how much an individual can exercise,
• health-related quality of life, and
• symptoms of anxiety and depression.

The study showed that doing 8 weeks of pulmonary rehabilitation at home helped improve an individual’s frailty, their functional capacity, and their health-related quality of life. Physical frailty did not keep individuals from receiving positive physical benefits from the pulmonary rehabilitation. In fact, physical frailty was reversed in almost 80% of the COPD patients who were frail prior to the program, and these individuals shifted towards a more robust physical state that lasted for at least 6 months after the end of the program.

In older persons, preventing or delaying functional decline and disability is a public health priority that also needs to be addressed in patients with COPD. Although it is still not clear what is the best way to improve these problems, the present program that was entirely delivered at home showed that functional capacity can be helped with pulmonary rehabilitation even in individuals with chronic respiratory failure.

Alpha-1 antitrypsin deficiency (AATD) is an uncommon and under-recognized genetic disease which leads to chronic obstructive pulmonary disease (COPD). Current treatment recommendations suggesting that all patients with COPD should be tested for AATD are not frequently followed. This study evaluated whether a direct electronic message to patients with COPD would lead to more patients getting tested and more patients being diagnosed with AATD.

Patients on inhaled COPD medications who had not previously been tested for AATD were included. These patients received an electronic message giving them information about AATD and the availability of free test kits for AATD.

Overall, of 5,430 patients who were contacted, 396 (7.3%) indicated that they would like to receive a home testing kit. Of those, 209 (53%) returned the test samples. Out of these 209 patients, 65% had a normal type of alpha-1 antitrypsin, 3% were severely deficient in alpha-1 antitrypsin, and the remainder were carriers of an abnormal gene for alpha-1 antitrypsin. The proportions of severely deficient and carrier patients were much higher than expected. While the response and return rate were lower than expected, the use of electronic messages to engage patients is both feasible and easily adapted to use with even larger groups of patients.

What is the average difference in sedentary or inactive time and physical activity that is associated with better symptoms in patients with advanced COPD? In other words, for individuals with COPD who have better or less troublesome symptoms, how much more active or less inactive are they than individuals with COPD with worse symptoms?

This study used information previously collected from daily activity trackers in 292 patients with moderate to severe, stable COPD. The information was used to predict the average difference in activity in patients with reported differences in symptoms. The study revealed that individuals who reported having less shortness of breath averaged 24.5 fewer minutes of time spent being sedentary or inactive each day. They also did 21.5 more minutes of light physical activity per day and walked, on average, 762 more steps per day. Individuals who reported having less fatigue averaged 12.5 more minutes of light physical activity per day and walked an average of 579 more steps per day. These results show small positive associations between better symptoms and more activity/less sedentarism (inactivity) in individuals with COPD. The level of activity associated with better symptoms appears to be a level that is realistic and doable for individuals with COPD. Future studies should explore whether these observed differences have a cause-and-effect relationship.

The O₂VERLAP study conducted a series of focus groups with patients who have both chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. The goal was to learn more about their experiences in using continuous positive airway pressure (CPAP) therapy and what outcomes or effects of therapy were important to them. The findings of this study were applied to the design of a larger scientific study, funded by the Patient-Centered Outcomes Research Institute.

Three separate focus groups were run using different formats: telephone, in-person, and web-based. Results of the focus groups showed that most participants were concerned about mask fit and comfort. Other key factors affecting CPAP use were nasal dryness and issues concerning insurance. The telephone and web-based formats resulted in greater topical discussions than the in-person group. We believe this could be a result of the customary socializing that tends to occur in-person. By conducting the focus groups, the study team identified barriers and facilitators (i.e., issues that encourage) for CPAP use. Identifying these barriers and facilitators helped the study team plan for the types of interventions or actions that should be studied in the larger study. Through the focus groups, the study team was also able to identify daytime functioning as the outcome or end result most important to patients.

Despite prior improvement efforts, the quality of COPD care provided in outpatient settings (physician’s offices, clinics, emergency departments, etc.) is poor. Hoping to learn information that could be used in the future to create plans or programs to improve care, we performed a study to identify the characteristics of both patients and their primary care providers that might be associated with high-quality outpatient COPD care.

We identified a group of patients who had been diagnosed with COPD by a physician and who had received care at 2 University of Washington-affiliated primary care clinics between June 1, 2011, and June 1, 2013. Among these patients, we looked at whether they received, over a 1-year period, the specific outpatient COPD care measures that are recommended in expert COPD guidelines. We also studied whether specific characteristics of the patient or the primary care provider had an impact on the overall quality of the outpatient COPD care they received.

We found that in the group we studied, the quality of care provided in the outpatient setting was poor and patients, on average, only received 66% of the care recommended in COPD guidelines. Patients who saw a pulmonologist received 1-2 additional COPD quality measures when compared with patients who did not.

Other patient characteristics (e.g., comorbidities [other illnesses], insurance status, number of outpatient visits) and provider factors (e.g., years in practice, highest degree attained) were not associated with the receiving of the COPD care recommended in expert COPD guidelines.

Our findings suggest the need for future studies to investigate if involving pulmonary specialty providers in the management of patients with COPD can improve outpatient COPD care quality.

The COPD Assessment Test (CAT) is a patient questionnaire that asks 8 questions, with scores ranging from 0 to 40, to understand the impact of COPD on patients’ wellbeing and daily life. Higher CAT scores indicate worse COPD burden and can predict future exacerbations or flare-ups. However, information on how CAT scores and treatments affect the risk of future exacerbations is limited.

This study was an analysis of the IMPACT study in patients with COPD with a history of exacerbations in the past year. It examined the relationship between a patient’s CAT score at the beginning of the study and the use of a single-inhaler triple therapy (fluticasone furoate/umeclidinium/vilanterol). This was compared to using a dual therapy (fluticasone furoate/vilanterol or umeclidinium/vilanterol). Patients with higher CAT scores (which means a worse health status) in the beginning of the study had a higher rate of exacerbations during the study. Triple therapy reduced the exacerbation rate and improved lung function regardless of patients’ CAT scores. When compared with the dual therapy of fluticasone furoate/vilanterol, patients on the triple therapy had improved lung function regardless of their CAT scores. Triple therapy also reduced the rate of exacerbations in patients who had a lower CAT score before taking the therapy. These results suggest that patients will benefit from triple therapy more than dual therapy regardless of their CAT score.

Noninvasive ventilation (NIV) is therapy that improves respiratory distress of patients experiencing a COPD exacerbation or flare-up. NIV treatment is uncomfortable; a mask which covers the nose and mouth is placed on the patient’s face and air is pushed with force into the mask. Patient cooperation and tolerance are essential to NIV success. In this study, we interviewed 16 patients who were treated with NIV for a COPD exacerbation to understand their experience and perspective while being treated with NIV.

We found that patients want a clear explanation of why NIV is needed, how it works and how it helps their breathing, and to have some idea of how long the mask needs to be used. Patients want health care providers to be more sympathetic about the emotional distress they are experiencing related to the respiratory difficulty and the significant physical and psychological discomfort caused by the mask. Most patients felt confined and claustrophobic with the mask unless they used it in the past or if they were able to use mindfulness to diffuse the stress. Understanding the reality of patients with COPD treated with NIV will help refine strategies that can improve their experience and tolerance with NIV.

Because emphysema – the breakdown of the lungs’ air sacs – can result from several different causes, the question naturally arises as to whether all of the conditions that can cause emphysema are the same. The best described genetic risk factor for emphysema is called alpha-1 antitrypsin deficiency (AATD), which is the absence of a protein (AAT) in the bloodstream and lungs that protects the lungs against the breakdown that is emphysema. Emphysema that is due to AATD and so-called “regular” emphysema—emphysema that occurs in individuals with normal levels of AAT—are similar in that both are very debilitating, under-recognized, and life-threatening. Yet, there are also important differences between these 2 different types of emphysema. In addition to some differences in the way the 2 conditions are treated, another important difference is how studies are designed to evaluate and find treatments for the conditions. In the case of “regular” emphysema, which affects approximately 12 million Americans, large numbers of individuals can be recruited to participate in clinical studies designed to evaluate current and new treatments. In the case of AATD-associated emphysema, for which fewer than 20,000 Americans have been identified, clinical trials require special designs and, in particular, careful choice of outcome measures. (Outcomes or endpoints measure how the health of the group studied changed as a result of the treatment, action, or process studied in the clinical trial.) This perspective article argues for the use of computerized tomography (CT) densitometry – measuring the density of the lung by a special X-ray procedure called CT – as the only currently available endpoint or outcome for trials in AATD-associated emphysema that is feasible.