Chronic Obstructive Pulmonary Diseases-Journal of the Copd Foundation最新文献

Background: Inhalation therapy is the cornerstone of chronic obstructive pulmonary disease (COPD) management. However, errors frequently occur since every type of inhalation device has different characteristics, complicating their use. The clinical pharmacist is an expert on these devices and can be involved in the care and education of inhaler use in patients with COPD.

Objective: The feasibility of a pharmaceutical care protocol specifically for patients with COPD in a rehabilitation hospital was assessed in a quality improvement study (mixed-methods).

Method: First, the clinical pharmacist had 6 contact moments with hospitalized patients between January and April 2022, which contained appropriateness evaluations and educational moments that were focused on inhalation techniques. Subsequently, a focus group discussion with all involved health care professionals (HCPs) took place to evaluate the preliminary results of the protocol's implementation.

Results: A total of 19 patients entered the study with the protocol resulting in a decrease of critical device errors (38.5% at baseline, to 7.7% at discharge). The HCPs concluded that it was feasible to implement the protocol given certain adjustments. A multidisciplinary collaboration between pharmacists and nurses is necessary to permit the practical implementation, as well as an individualization of the protocol based on the patient's needs. In patient follow-up, transmural care is essential including the HCPs in primary care, and the outpatient clinic.

Conclusion: The evaluation of the protocol by the involved HCPs emphasizes the importance of a clinical pharmacist in the care of patients with COPD as part of the multidisciplinary team, not only in the community or in an acute hospital setting, but also in a rehabilitation hospital.

Rationale: Studies have shown that digital inhalers, using remote monitoring data, can improve medication adherence and clinical outcomes, such as prediction of impending asthma exacerbations. There is limited research on the clinical utility of physiologic inhalation parameters and inhaler medication use data captured by a digital inhaler to identify impending acute exacerbations of chronic obstructive pulmonary disease (AECOPDs).

Objectives: The objective was to determine variation in digital inhaler-measured physiologic and inhaler use metrics in ambulatory chronic obstructive pulmonary disease (COPD) patients in advance of an AECOPD.

Methods: This phase 4, open-label, 3-month pilot study was conducted at 2 U.S. centers. Participants used the ProAir Digihaler for primary rescue medication during the study. Participants were contacted monthly for COPD disease assessments. Inhaler metric variations leading up to an AECOPD were evaluated.

Results: The ProAir Digihaler measured key inhalation metrics (mean [standard deviation]) including peak inspiratory flow (PIF) (67.6 [20.3]L/min), inhalation volume (1.40 [0.60]L), and recorded inhaler use from 9649 inhalations among 40 participants. Statistically significant reductions were observed in inhalation volume (1.4L versus 1.1L), inhalation duration (1875msec versus 1492.1msec), and time to peak (500msec versus 376.3msec) (p<0.02 for all comparisons) during the 14 days preceding an AECOPD. There were no significant changes observed in PIF (67.2 versus 63.3, p=0.1) and number of inhalations per day (2.7 versus 3.7, p=0.2).

Conclusion: Physiologic data captured by a digital inhaler may serve as a valuable remote patient monitoring tool to help support the identification of early or impending AECOPDs among ambulatory COPD patients and monitor COPD disease variability.

This corrects the article, "Clinical Implications of Pseudomonas Aeruginosa Colonization in Chronic Obstructive Pulmonary Disease Patients," published in Volume 12, Issue 2, pp. 137-145.

Background: Psychological stress is elevated in individuals with chronic medical conditions, including those with chronic obstructive pulmonary disease (COPD). Nail cortisol may have utility as a marker for testing the biologic effects of stress reduction interventions. The aim of this pilot study is to explore the use of nail cortisol as a marker of chronic psychological stress in individuals with COPD.

Methods: Pearson's correlation was used to test if nail cortisol was correlated with perceived stress, serum cortisol, or inflammatory biomarkers. A multivariable linear regression model was used to evaluate the association between perceived stress and nail cortisol. Stepwise logistic regression modeling was used to determine associations of psychobiologic measures of stress with demographic, clinical, and psychological variables.

Results: A total of 50 participants were included in the study. The mean (standard deviation [SD]) perceived stress score was 12 (+/-6) and mean (SD) nail cortisol level was 0.05 (+/-0.09) nmol/g. Nail cortisol was not correlated with perceived stress, serum cortisol, or inflammatory markers. There was no association between nail cortisol and perceived stress after controlling for confounders. Suboptimal health status and grit score were associated with perceived stress. Higher levels of serum fibrinogen were associated with higher levels of serum cortisol. Experiencing 3 or more negative lifetime events was associated with a decrease in nail cortisol.

Conclusion: We found no correlation between nail cortisol and levels of perceived stress, serum cortisol, or inflammatory biomarkers and there were no similar associations of variables across psychobiologic measures of stress.

Background: The burden of chronic obstructive pulmonary disease (COPD) is well established, but opportunities for earlier diagnosis and improved management are still missed. Compared to the general COPD population, patients with a history of exacerbations and suboptimal treatment ("modifiable high-risk") are at greater risk of future exacerbations and adverse health outcomes. To date there is no systematic approach for identifying and treating this patient group.

Method: Two cluster randomized controlled trials (CRTs) in the United Kingdom and United States will assess the impact of a primary care-based quality improvement program (COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care [CONQUEST]), compared to routine care. In each trial, 126 primary care clusters will be randomized 1:1 to intervention or control arms. Three groups of modifiable high-risk patients will be identified using electronic medical records: undiagnosed with potential COPD, newly diagnosed COPD, and already diagnosed COPD. Eligible patients will be aged ≥40 years, have experienced ≥2 moderate/≥1 severe exacerbation(s) in the prior 24 months, including ≥1 in the last 12 months, and not be prescribed inhaled triple therapy. Patients in the undiagnosed group will also be required to have a positive smoking history. Primary trial outcomes will be the annual rate of exacerbations and the annual rate of major adverse cardiac or respiratory events, comparing the quality improvement program against routine care.

Discussion: These will be the first CRTs assessing such a comprehensive primary care-based COPD quality improvement program. Intention-to-treat analysis of trial outcomes after 24 months will inform its effectiveness in targeting the identification, assessment, treatment, and follow-up of patients with modifiable high-risk COPD.

Trial registration: UK trial: ISRCTN15819828; US trial: NCT05306743.

Virtual pulmonary rehabilitation (PR) is a proven yet underutilized intervention in chronic obstructive pulmonary disease (COPD) patients. However, neither the safety nor the effectiveness of virtual PR is established for patients with advanced disease and higher disease severity, particularly those requiring supplemental oxygen. We performed a retrospective review of 167 patients to evaluate the feasibility, safety, and effectiveness of virtual PR in oxygen-dependent versus nonoxygen-dependent COPD patients. Our primary outcome, attendance, was high (88% of sessions were attended by both groups). Adverse events occurred in only 2 (1%) participants, one in each group. Both groups showed significant postintervention improvements in dyspnea and depression scores (COPD Assessment Test [CAT], modified Medical Research Council [mMRC], Patient Health Questionnaire-9 [PHQ-9]) and functional exercise capacity (1-minute sit-to-stand [1MSTS]), with the improvements approaching or exceeding the established minimal clinically important difference values. When comparing the oxygen-dependent and nonoxygen groups, there were no significant differences in the degree of improvement for CAT, PHQ-9, and 1MSTS. For mMRC, those on oxygen did improve by 0.3 less than those not on oxygen (P=0.052). These findings suggest virtual PR is safe and effective for COPD patients requiring oxygen. To our knowledge, this is the first study to compare outcomes of virtual PR in patients on and off oxygen. Future research should explore patient-specific factors that can further individualize care.

Objective: Acute exacerbations of COPD(AECOPD) can have severe impacts on patients with the disease and a heavy burden on health care resources. Electronic health records (EHRs) are a valuable resource for identifying cases of AECOPD and research. Studies have attempted to validate case definitions of AECOPD and this review aims to summarize validated AECOPD definitions in EHRs and to provide guidance on the best algorithms to use to ensure accurate cohorts of AECOPD cases are available for researchers using EHRs.

Methods: MEDLINE and Embase were searched and studies that met the inclusion criteria were reviewed by ≥2 reviewers. Data extracted included the algorithms used to identify AECOPD, the reference standards used to compare against the algorithm, and measures of validity. The risk of bias was assessed using QUADAS-2 adapted for this review.

Results: Out of 2784 studies found by the search strategy, 12 met the inclusion criteria. The clinical terminology used to build algorithms to detect AECOPD included codes from the International Classification of Diseases (ICD) Ninth Revision, Clinical Modification and Tenth Revision (ICD-9-CM and ICD-10), along with the Read codes from United Kingdom general practices. AECOPD can be identified within EHRs using validated definitions, however, the validity of AECOPD definitions varies considerably depending on the algorithm used and the settings to which they are applied.

Conclusion: Although there are validated definitions that can be used to identify AECOPD, there is no clear consensus on which provides the highest validity or the most sensitive and specific definition to use.