Chronic Obstructive Pulmonary Diseases:Journal of the COPD Foundation

Volume 9, Issue 2 - 2022 | Plain Language Summaries

Short summaries, in non-technical, simple language of articles published in the most recent issue of Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation are provided here. Links to the full, published research article are provided with each summary. The Journal is indexed by PubMed, PubMed Central, Scopus and Web of Science.

All summaries for the current issue are listed below in the order of publication, scroll down.

Forced Expiratory Flow at 25%-75% Links COPD Physiology to Emphysema and Disease Severity in the SPIROMICS Cohort

Bonnie E. Ronish, MD; David J. Couper, PhD; Igor Z. Barjaktarevic, MD, PhD; Christopher B. Cooper, MD; Richard E. Kanner, MD; Cheryl S. Pirozzi, MD, MS; Victor Kim, MD; James M. Wells, MD; MeiLan K. Han, MD, MS; Prescott G. Woodruff, MD, MPH; Victor E. Ortega, MD, PhD; Stephen P. Peters, MD, PhD; Eric A. Hoffman, PhD; Russell G. Buhr, MD, PhD; Brett A. Dolezal, PhD; Donald P. Tashkin, MD; Theodore G. Liou, MD; Lori A. Bateman, MS; Joyce D. Schroeder, MD; Fernando J. Martinez, MD, MS; R. Graham Barr, MD, PhD; Nadia N. Hansel, MD, MPH; Alejandro P. Comellas, MD; Stephen I. Rennard, MD; Mehrdad Arjomandi, MD; Robert Paine III, MD

Diagnosis and the severity of chronic obstructive pulmonary disease (COPD) is determined by lung function tests. In these tests, an individual exhales forcibly while the volume and rate of air flow are measured. To date, the volume of air exhaled in the first second (called “FEV1”) has been the main measurement used in COPD. This measurement is useful but limited in predicting symptoms of COPD or features such as the severity or distribution of emphysema. This study used data from the SubPopulations and InteRmediate Outcome Measures In COPD Study (SPIROMICS) cohort to examine the value of a different lung function parameter: (forced expiratory flow at 25% to 75% of capacity (FEF25-75%,), which measures airflow in the middle portion of an individual’s exhalation and may help detect changes in the small airways of the lungs.

We found that an abnormality in the FEF25-75% lung function test was associated with disease severity in multiple ways. In particular, it was associated with more severe disease as seen on imaging, with a strong association with widespread distribution of emphysema compared to a patchy distribution. This study expands our current understanding of the relationship between the pattern of lung damage in COPD and abnormalities in lung function. It provides insights that go beyond knowledge obtained from the FEV1 and offers a more nuanced approach to understanding COPD.

Disparities in Hospitalized Chronic Obstructive Pulmonary Disease Exacerbations Between American Indians and Non-Hispanic Whites

Huimin Wu, MD, MPH; Dorothy A. Rhoades, MD, MPH; Sixia Chen, PhD; Matt Slief, MD; Carla A. Guy, BS; Adam Warren, BS; Brent Brown, MD

Chronic obstructive pulmonary disease (COPD) occurs frequently among American Indian populations but how these patients compare to non-Hispanic White patients with COPD is not known.

We conducted a retrospective study—in which we reviewed past information—to investigate potential health disparities or differences between American Indian and non-Hispanic White patients who were hospitalized with COPD at one academic medical center between July 2001 and June 2020.

A total of 76 American Indian patients and 304 White patients were included. American Indian patients had more comorbidities (medical conditions or diseases that are present in the patient along with the COPD) than the White patients. American Indian patients were more likely than White patients to need intensive care unit care and ventilator support, have longer intensive care unit stays, and have more days on mechanical ventilator support. However, American Indian race was not associated with discharge to other health facilities, such as long-term acute care, skilled nursing facilities, or rehabilitation facilities.

More studies are needed to identify reasons for these disparities and to design effective ways to reduce them.

Trends and Characteristics of Global Initiative for Chronic Obstructive Lung Disease Guidelines-Discordant Prescribing of Triple Therapy Among Patients with COPD

Surya P. Bhatt, MD, MSPH; Cori Blauer-Peterson, MPH; Erin K. Buysman, MS; Lindsay G.S. Bengtson, PhD, MPH; Swetha R. Palli, MS

Triple therapy is a COPD treatment plan that consists of 2 inhaled bronchodilator medications plus an inhaled steroid medication. It is only recommended for patients with moderate-to-severe COPD who experience multiple or severe flare-ups while taking other treatment. This is because chronic use of inhaled steroid treatment increases the risk of pneumonia and other complications. Yet, a large percentage of patients are prescribed triple therapy without meeting these criteria. This study describes the characteristics of such patients.

Among 21,711 patients taking triple therapy between 2014 and 2018, 34% had no previous inhaled therapy before being prescribed triple therapy, and 62% had no prior severe flare-ups. Overall, 74% did not meet either recommended criteria, while 22% did not meet both. It was also observed that generalist physicians are engaged in discordant prescribing—prescribing that does not match COPD guideline recommendations—on a larger scale than specialists. Understanding why patients are receiving triple therapy without meeting recommendations will help identify risk factors and behaviors for such prescribing practices. This will assist in designing and offering solutions to reduce this issue.

Computed Tomography Features of Lung Structure Have Utility for Differentiating Malignant and Benign Pulmonary Nodules

Johanna M. Uthoff, PhD; Sarah L. Mott, MS; Jared Larson, BS; Christine M. Neslund-Dudas, PhD; Ann G. Schwartz, PhD, MPH; Jessica C. Sieren, PhD; and the COPDGene® Investigators

People with chronic obstructive pulmonary disease (COPD) are at an increased risk of developing lung cancer, but this relationship is not clearly understood. Low dose computed tomography (CT) is the main method used to detect lung cancer and it can also be used to evaluate the structure of the lung for signs of COPD.

In this study, we evaluated the CT scans of individuals who had lung lesions detected, some of which were later diagnosed as cancer while others were not cancer. The CT images were used to make measurements of the lung structure and train computer algorithms to predict which of the patients were later diagnosed with cancer. The best performing computer algorithm had an accuracy of 79% in predicting lung cancer and mostly used CT images from the lung lobe with the lung nodule. These measurements included measures of lung density and the size of airways. This study found that CT measures of COPD can be useful in predicting lung cancer diagnosis.

Treatable Traits in Misdiagnosed Chronic Obstructive Pulmonary Disease: Data from the Akershus Cardiac Examination 1950 Study

Nina Faksvåg Caspersen, MD; Vidar Søyseth, MD, PhD; Magnus Nakrem Lyngbakken, MD, PhD; Trygve Berg, MD, PhD; Inger Ariansen, MD, PhD; Arnljot Tveit, MD, PhD; Helge Røsjø, MD, PhD; Gunnar Einvik, MD, PhD

In this study we aimed to investigate how many people in the general population are unaware of having chronic obstructive pulmonary disease (COPD) and to describe clinical traits of these undiagnosed individuals that could potentially be treated. We also reviewed the same clinical traits of individuals who reported having COPD, but who did not meet the criteria for being diagnosed. These individuals were considered overdiagnosed.

We found that 7.1% of 65-year-old Norwegians have COPD, yet more than 70% of these individuals did not know that they had COPD. This undiagnosed group had better lung function and less respiratory symptoms than the group with diagnosed COPD. However, the undiagnosed group had more current smoking, breathlessness, cough, expectorate, wheezing, and respiratory infections than the general population.

On the other hand, 56% of people who reported having COPD did not receive their diagnosis after completing a spirometry lung function test. Overdiagnosed individuals had more obesity, asthma, and sleep apnea than the general population.

This study shows that COPD is often misdiagnosed and that individuals who are undiagnosed or overdiagnosed have clinical traits that could be treated if identified.

Current-Smoking-Related COPD or COPD With Acute Exacerbation is Associated With Poorer Survival Following Oral Cavity Squamous Cell Carcinoma Surgery

Jiaqiang Zhang, MD, PhD; Wei-Chun Lin, MD; Kuo-Chin Chiu, MD; Szu-Yuan Wu, MD, MPH, PhD

Patients with COPD are at increased risk for cancers of the head and neck including oral cavity cancers. This study was the first to estimate how having smoking-related COPD could affect the chances of a patient with oral cavity squamous cell carcinoma to survive the surgery to remove their cancer.

Our study results showed that having smoking-related COPD increased an individual’s chance of dying from surgery to treat oral cancer. In addition, having been hospitalized for at least one COPD flare-up or exacerbation in the year before surgery, also increased an individual’s chance of dying from the oral cancer surgery.

The risk of death was significantly higher in the “currently-still-smoking” COPD group than in the “have-never-smoked” non-COPD group.

Characterizing COPD Symptom Variability in the Stable State Utilizing the Evaluating Respiratory Symptoms in COPD Instrument

Jamuna K. Krishnan, MD, MS; Kayley M. Ancy, MD; Clara Oromendia, MS; Katherine L. Hoffman, MS; Imaani Easthausen, MS; Nancy K. Leidy, PhD; MeiLan K. Han, MD, MS; Russell P. Bowler, MD, PhD; Stephanie A. Christenson, MD; David J. Couper, PhD; Gerard J. Criner, MD; Jeffrey L. Curtis, MD; Mark T. Dransfield, MD; Nadia N. Hansel, MD, MPH; Anand S. Iyer, MD; Robert Paine III, MD; Stephen P. Peters, MD, PhD; Jadwiga A. Wedzicha, MD; Prescott G. Woodruff, MD, MPH; Karla V. Ballman, PhD; Fernando J. Martinez, MD, MS; for the SPIROMICS Investigators

*Co-first authors, both authors contributed equally to the work.

Patients with COPD have been previously shown to have fluctuation or variation in the severity of their daily symptoms. However, there is no standard way to measure this symptom fluctuation. To measure symptom variability, we asked participants in the SPIROMICS study to use the Evaluating Respiratory Symptoms in COPD (E-RS) diary to record their daily symptom scores. We calculated the standard deviation of daily symptoms scores for each participant based on a week’s worth of diary data. We called this the “within-subject standard deviation” (WS-SD). Participants with a higher measured symptom variability (WS-SD) had worse quality of life. However, we were unable to find a relationship between symptom fluctuation and exacerbations or flare-ups. This may be because of the low number of overall exacerbations.

Our study identified calculation of WS-SD as a way to measure daily symptom changes in patients. This metric should be evaluated in future studies to further understand the impact of symptom fluctuation on the lives of patients with COPD.

Evaluation of COPD Chronic Care Management Collaborative to Reduce Emergency Department and Hospital Revisits Across U.S. Hospitals

Valerie G. Press, MD, MPH; Kelly Randall, BA; Amber Hanser, MHA

Chronic obstructive pulmonary disease (COPD) is the third leading cause of early readmissions and is a recent target of financial penalties for excessive readmissions instituted by the Centers for Medicare and Medicaid. Thus, hospitals are attempting to implement effective strategies to reduce readmissions. We evaluated a 6-month COPD Chronic Care Management Collaborative to support hospitals in reducing preventable COPD-related revisits. The Collaborative used performance improvement initiatives, subject matter expert content, and peer-to-peer support to assist with the implementation of effective strategies. Hospitals participating in the Collaborative submitted data on the number of individuals receiving intervention and information on emergency department and hospital revisits.

Forty-seven hospitals were enrolled in the Collaborative, of which 23 submitted data. The majority (n=19/23, 83%) reduced rates of COPD-related emergency department and/or hospital revisits. The Collaborative successfully supported the majority of sites in reducing COPD-related emergency department and/or hospital revisits by using subject matter experts and coaching strategies to support hospitals' use of COPD quality improvement plans.

Heart Rate Variability on 10-Second Electrocardiogram and Risk of Acute Exacerbation of COPD: A Secondary Analysis of the BLOCK COPD Trial

David M. MacDonald, MD, MS; Takudzwa Mkorombindo, MD; Sharon X. Ling, BS; Selcuk Adabag, MD, MS; Richard Casaburi, MD, PhD; John E. Connett, PhD; Erika S. Helgeson, PhD; Janos Porszasz, MD, PhD; Harry B. Rossiter, PhD; William W. Stringer, MD; Helen Voelker, BA; Dongxing Zhao, PhD, MD; Mark T. Dransfield, MD; Ken M. Kunisaki, MD, MS

People with COPD often have flare-ups of their disease, known as exacerbations. Factors that increase an individual’s chances of having an exacerbation include worse lung function, more respiratory symptoms, tobacco smoking, and a history of exacerbations. Understanding other risk factors for exacerbations may help identify those individuals who are at the highest risk of having exacerbations and help direct specific treatments to them.

The autonomic nervous system controls unconscious functions of the body, like the heart and lungs. Abnormalities in the autonomic nervous system are common in individuals with COPD. Heart rate variability measures changes in the time between heart beats and is one measure of autonomic nervous system activity. In general, people with higher heart rate variability are healthier and less prone to disease.

In this study we measured heart rate variability using 10-second electrocardiograms conducted on participants in a COPD trial. We tested whether people with a higher heart rate variability had a decreased risk of exacerbations. We found a slight signal that people with COPD who have higher heart rate variability may be at decreased risk of being hospitalized for exacerbations of COPD. Future studies should study heart rate variability collected for longer periods of time and using more advanced analytic techniques.

Home Non-Invasive Ventilation in COPD: A Global Systematic Review

Janine Dretzke, MSc; Jingya Wang, PhD; Mi Yao, MSc; Naijie Guan, MSc; Myra Ling; Erica Zhang; Deyashini Mukherjee, MBBS; James Hall, PhD; Sue Jowett, PhD; Rahul Mukherjee, MBBS, FRCP; David J Moore, PhD; Alice M Turner, MBChB, PhD

Chronic obstructive pulmonary disease (COPD) is a lung condition that causes breathing difficulties. As well as using medication, some people with COPD use a machine at home which delivers oxygen through a face mask to help them breathe. This is called non-invasive ventilation (NIV). NIV may prevent them from going to the hospital with flare-ups, while also improving their well-being, and possibly lengthening their life.

We conducted a systematic review which uses specific methods to find relevant studies, and then evaluate and combine the results in an objective way. We searched for studies in any language, including those published in Chinese language databases. All studies which compared home NIV with no home NIV in COPD were evaluated.

We found 103 studies, a far greater number than in previous reviews. Overall, studies found there was a small benefit to using NIV at home for avoiding hospital stays (or shortening the length of stay) and improving well-being. Most studies found that using NIV at home has no effect on extending people’s lives. This was the case both for people in a stable disease state and for those who had experienced a recent flare-up. As most of the studies included quite broad COPD populations, we still do not know if there are people with certain disease features who may benefit more from NIV home use.

Attitudes Towards Vaccination for Coronavirus Disease 2019 in Patients with Severe Alpha-1 Antitrypsin Deficiency

Oliver J. McElvaney, MD, PhD; Brian Cleary, MD; Daniel D. Fraughen, MD; Geraldine Kelly, MBA; Mark P. Murphy, PhD; Oisín F. McElvaney, MD, PhD; Peter Branagan, MD; Cedric Gunaratnam, MD; Tomás P. Carroll, PhD; Noel G. McElvaney, MD

Although vaccines against coronavirus disease 2019 (COVID-19) have decreased the number of deaths dramatically, vaccine uptake in many regions has been slow. To promote vaccines effectively, we must understand the factors that influence people to accept a vaccine.

In this study, we surveyed individuals with severe alpha-1 antitrypsin deficiency (AATD) (a rare genetic condition that can cause COPD) receiving their first COVID-19 vaccine dose. We wanted to understand their attitudes towards vaccination and their motivations for getting vaccinated. We later revisited the group to evaluate their attitudes towards booster vaccination.

For AATD individuals >50 years old, the major factor influencing the decision to accept a vaccine was a fear of death from COVID-19. In contrast, younger AATD individuals were motivated primarily by a desire to socialize and travel. When it came to boosters, death was less of a concern for older individuals than it had been at the time of their first dose. Across all ages, AATD individuals were reluctant to get a booster if they did not stand to gain additional social freedoms compared to those who did not get the extra shot.

Current efforts to encourage vaccination among AATD patients are more likely to succeed if they address issues that are meaningful to these individuals.

A Conceptual Framework for Use of Increased Endurance Time During Constant Work Rate Cycle Ergometry as a Patient-Focused Meaningful Outcome in COPD Clinical Trials

Richard Casaburi, MD, PhD; Debora D. Merrill, MBA; Gale Harding, MA; Nancy Kline Leidy, PhD; Harry B. Rossiter, PhD; Ruth Tal-Singer, PhD; Alan Hamilton, PhD; on behalf of the CBQC Constant Work Rate Exercise Working Group

Limitation in physical function or activity in everyday life is one of the most troubling features of chronic obstructive pulmonary disease (COPD). A major goal of COPD therapies is to improve physical function. However, the evaluation of therapies by regulatory authorities has been hindered by the lack of qualified ways to measure physical activity .

In this paper, we focus on an important aspect of physical function: exercise endurance. This is the ability to sustain a given level of exertion. We propose that the time it takes to reach symptoms that are intense enough to limit exertion while doing exercise testing on a cycle ergometer, is a valid measure of exercise endurance. Furthermore, the analysis we present shows that cycle ergometer work rates or exertion levels, which are standardized, can be directly related to everyday tasks that are commonly performed by COPD patients.

We conclude that an improvement in the ability to tolerate exercise at a standardized work rate, while on a cycle ergometer, is a meaningful, patient-focused outcome. We propose that this outcome is suitable for use as an endpoint in clinical trials that evaluate the benefit of COPD therapies.

Adding Granularity of COPD Self-Management to Impact Quality of Life

Maria V. Benzo, MD; Paul Novotny, MS; Roberto P. Benzo, MD

This study aimed to investigate the association between self-management behaviors and the most common symptoms in a large group of individuals with chronic obstructive pulmonary disease (COPD). We use the sections of the Chronic Respiratory Questionnaire as the main COPD symptoms (dyspnea/breathlessness, emotional function, fatigue and mastery) and the self-management behaviors from the Self-Management Assessment Scale.

We found an association between dyspnea/breathlessness scores and self-management behaviors such as exercising and self-care. Emotional function (how the individual copes emotionally with his/her disease and its limitations) was associated with good relationships, self-care, positivity, and participating in agreeable activities. Fatigue scores were associated with self-care, exercising, and participating in agreeable activities. Mastery (the confidence to manage COPD effectively)was associated with self-care, positivity, exercising, and participating in agreeable activities. Enhancing self-management abilities are key for living well with COPD.

Our findings provide specific self-management behaviors that are associated with common COPD symptoms that may help improve self-management programs.