Early Desaturation During 6-Minute Walk Test is a Predictor of Mortality in COPD.

BACKGROUND: Oxygen desaturation during exercise is mainly observed in severe cases of chronic obstructive pulmonary disease (COPD) and is associated with a worse prognosis, but little is known about the type of desaturation that causes the greatest risk of mortality. MATERIAL AND METHODS: We studied all of the 6-min walk tests performed periodically at a tertiary hospital over a period of 12 years in patients with moderate or severe COPD. We classified patients as non-desaturators if they did not suffer a drop in oxygen saturation (SpO2 < 88%) during the test, early desaturators if the time until desaturation was < 1 min, and non-early desaturators if it was longer than 1 min. The average length of follow-up per patient was 5.6 years. RESULTS: Of the 319 patients analyzed, 126 non-desaturators, 91 non-early desaturators and 102 early desaturators were identified. The mortality analysis showed that early desaturators had a mortality of 73%, while it was 38% for non-early desaturators and 28% for non-desaturators, with a survival of 5.9 years compared to 7.5 years and 9.6 years, respectively (hazard ratio of 3.50; 95% CI 2.3-5.3; p < 0.0001). CONCLUSIONS: The early desaturation seen in patients with chronic obstructive pulmonary disease is associated with greater mortality and is likely responsible for the poor prognosis shown globally in patients who desaturate. The survival of patients with early desaturation is almost 4 years less with respect to non-desaturators, and they, thus, require closer observation.

Trajectories of Severe Exacerbations of Chronic Obstructive Pulmonary Disease and Their Relationship with Mortality Risk.

PURPOSE: Acute exacerbations of COPD (AECOPD) are important factors contributing to mortality risk. The rate of exacerbations varies overtime. An inconsistent pattern of exacerbation occurrence is a common finding. The mortality risk associated with such a pattern is not entirely clear. Our objective was to assess the risk of mortality associated with various possible patterns of AECOPD trajectories. METHODS: This is a multicenter historical cohort study. Four different exacerbation trajectories were defined according to the incidence of severe AECOPD requiring hospital admission 2 years before and after the date of the first visit to the respiratory clinic-Consistent non-exacerbators (NEx): no AECOPD before or after the index date; consistent exacerbators (Ex): at least one AECOPD both before and after the index date; converters to exacerbators (CONV-Ex): no exacerbations before and at least one AECOPD after the index date; converters to non-exacerbators (CONV-NEx): at least one AECOPD before the index date, and no exacerbations after said date. All-cause mortality risk for these trajectories was assessed. RESULTS: A total of 1713 subjects were included in the study: NEx: 1219 (71.2%), CONV-NEx: 225 (13.1%), CONV-Ex: 148 (8.6%), Ex: 121 (7.1%). After correcting for confounding variables, the group with the highest mortality risk was Ex. The CONV-Ex and CONV-Nex groups had a mortality risk between Ex and NEx, with no significant differences between them. CONCLUSION: Different possible trajectories of severe AECOPD before and after a first specialized consultation are associated with different mortality risks. An inconsistent pattern of exacerbations has a mortality risk between Ex and NEx, with no clear differences between CONV-Ex and CONV-NEx.

The COPD Comorbidome in the Light of the Degree of Dyspnea and Risk of Exacerbation.

The BODE group designed a bubble chart, analogous to the solar system, which depicts the prevalence of each disease and its association with mortality and called it a "comorbidome". Although this graph was used to represent mortality and, later, the risk of needing hospital admission, it was not applied to visualize the association between a set of comorbidities and the categories of the GOLD 2017 guidelines, neither according to the degree of dyspnea nor to the risk of exacerbation. For the purpose of knowing to which extent each comorbidity associates with each of the two conditions-most symptomatic group (groups B and D) and highest risk of exacerbation (groups C and D)-we performed a analysis based on the comorbidome. 439 patients were included. Cardiovascular comorbidity (especially cardiac and renal disease) is predominantly observed in patients with a higher degree of dyspnea, whereas bronchial asthma and stroke occur more frequently in subjects at higher risk of exacerbation. This is the first time that the comorbidome is presented based on the categories of the GOLD 2017 document, which we hope will serve as a stimulus for scientific debate.

Health Status in Patients with COPD According to GOLD 2017 Classification: Use of the COMCOLD Score in Routine Clinical Practice.

The COMCOLD score was developed to quantify the impact of comorbidities on health status in patients with chronic obstructive pulmonary disease (COPD). The objective of this study is to evaluate the association between health status in outpatients with COPD according to COMCOLD score and the GOLD 2017 groups according to symptoms (B and D vs. A and C) and exacerbations (C and D vs. A and B). 439 patients were included. The average score was 2.4 ± 3. 48% of cases had a COMCOLD score >0. The most symptomatic patients (B and D vs. A and C) had a higher score: 3 ± 3.3 vs. 1.3 ± 2.1 (p < 0.001), in contrast with the groups with a higher risk of exacerbation (C and D vs. A and B) in which there was no significant difference: 3 ± 3.5 vs. 2.2 ± 3.0 (p = 0.055). The most symptomatic patients (B and D) showed a greater prevalence of depression, peripheral artery disease and heart disease with an adjusted OR of 3.04 [CI95%: 1.36; 6.86], 2.49 [CI95%: 1.17; 5.29], and 4.41 [CI95%: 2.50; 7.75], respectively. Moreover, no relationship was found between the comorbidities defined by the COMCOLD score and the GOLD 2017 groups with the greatest risk of exacerbation (C and D). The greatest effect on health status was found in those patients with COPD belonging to the most symptomatic groups (B and D), with depression, peripheral artery disease, and heart disease being the main comorbidities involved.

Change in physical activity related to admission for exacerbation in COPD patients.

INTRODUCTION: The aim of this study was to determine the impact of hospitalizations on levels of physical activity (PA) and whether other factors were associated with subsequent changes in PA. METHODS: Prospective observational cohort study with a nested case-control study, with follow-up 60 days from the index hospital admission. Nine hospitals participated in the study. Patients were recruited consecutively. Several variables and questionnaires of the clinical baseline status of the patients were recorded including: the COPD Assessment Test (CAT), the Hospital Anxiety-Depression scale (HADS), comorbidities and the Yale Physical Activity Survey. Patients' data related to admission and up to two months after discharge were also recorded. RESULTS: 883 patients were studied: 79.7% male; FEV1 48%; Charlson index 2; 28.7% active smokers. The baseline PA level for the total sample was 23 points. A statistically significant difference in PA was found between patients readmitted up to 2 months after the index admission and those not readmitted (17vs. 27, p < 0.0001). Multivariable linear regression analysis identified the following as predictors of the decrease of PA from baseline (index admission) up to 2 months follow-up: admission for COPD exacerbation in the two months prior to the index admission; readmission up to 2 months after the index admission; baseline HAD depressive symptoms, worse CAT score, and patient-reported "need for help". CONCLUSIONS: In a cohort of admitted COPD patients, we identified a strong relationship between hospitalization for exacerbation and PA. In addition, some other potentially modifiable factors were found associated with the change in PA level after an admission.

Physical activity and sedentary behaviour in patients admitted with COPD: Associated factors.

AIM: To establish amongst a cohort of patients admitted with Chronic Obstructive Pulmonary Disease which factors were associated with their level of Physical Activity and Sedentary Behavior prior to the admission event. METHODS: Prospective observational cohort study. Nine Spanish hospitals participated. Patients were recruited consecutively. Variables relating to the patients' clinical baseline status were recorded, including the COPD Assessment test, the HADS anxiety-depression test, comorbidities and the Yale Physical Activity Survey. Data relating to admission and up to two months after discharge were also recorded. RESULTS: 1638 COPD patients were studied, with a mean age of 72.39 (SD 10.33), 76.56 % male, FEV1 49.41 % (SD19.19), Charlson index 2. The level of PA at baseline was 30.79 points (SD 22.43). Multivariable linear regression analysis identified the following as being associated with low PA: older age, obesity, higher level of hemoglobin, lower score of Barthel index, which means disability, health related quality of life (EuroQoL-5d and CAT) and dyspnea. Variables associated with sedentary behavior were: older age, presence of obstructive apnea syndrome, higher disability, presence of depressive symptoms and dyspnea. CONCLUSIONS: In a cohort of hospitalized COPD patients, we have found several variables, some of them modifiable, associated with physical activity/inactivity and sedentary behavior.

A new, three-dimensional approach to the GOLD COPD assessment tool.

BACKGROUND: The 2-dimensional, 4-quadrant 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD A-D assessment tool (GOLD2017) does not include lung function variables to classify patients into different risk groups. The previous 2011 tool (GOLD2011) classified cases in the upper-quadrants (higher risk groups) regardless of whether they had a history of exacerbations or worse lung function. We hypothesized that a modified, three-dimensional classification (GOLD3D) that separately includes assessment of lung function and exacerbations history would improve the ability to predict adverse events. METHODS: A total of 1303 COPD patients were included in a historical cohort study. The ability of GOLD3D to predict outcomes (all-cause death and hospitalizations due to severe exacerbation) was compared with GOLD2017 and GOLD2011. RESULTS: Mean follow-up was 45.0 ± 28.0 months. Two hundred and twenty-eight patients (17.5%) died and 337 (25.9%) subjects suffered at least a severe exacerbation that required hospital admission. The area under the receiver-operating characteristics curve for mortality prediction was slightly but significantly higher for GOLD3D than for GOLD2011. The area under the curve for prediction of severe exacerbations was significantly higher for GOLD3D than for GOLD2011 and GOLD2017. A worse ventilatory obstruction was associated in most cases with a higher mortality risk and a higher exacerbation risk for the GOLD2017 A-D groups. CONCLUSIONS: The proposed GOLD3D classification system upgrades the previous ones, and is advantageous in predicting future adverse events.

Evaluation of the multimorbidity network and its relationship with clinical phenotypes in chronic obstructive pulmonary disease: The GALAXIA study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition, in which taking into consideration clinical phenotypes and multimorbidity is relevant to disease management. Network analysis, a procedure designed to study complex systems, allows to represent connections between the distinct features found in COPD. METHODS: Network analysis was applied to a cohort of patients with COPD in order to explore the degree of connectivity between different diseases, taking into account the presence of two phenotypic traits commonly used to categorize patients in clinical practice: chronic bronchitis (CB+ /CB- ) and the history of previous severe exacerbations (Ex+ /Ex- ). The strength of association between diseases was quantified using the correlation coefficient Phi (ɸ). RESULTS: A total of 1726 patients were included, and 91 possible links between 14 diseases were established. Although the four phenotypically defined groups presented a similar underlying comorbidity pattern, with special relevance for cardiovascular diseases and/or risk factors, classifying patients according to the presence or absence of CB implied differences between groups in network density (mean ɸ: 0.098 in the CB- group and 0.050 in the CB+ group). In contrast, between-group differences in network density were small and of questionable significance when classifying patients according to prior exacerbation history (mean ɸ: 0.082 among Ex- subjects and 0.072 in the Ex+ group). The degree of connectivity of any given disease with the rest of the network also varied depending on the selected phenotypic trait. The classification of patients according to the CB- /CB+ groups revealed significant differences between groups in the degree of conectivity between comorbidities. On the other side, grouping the patients according to the Ex- /Ex+ trait did not disclose differences in connectivity between network nodes (diseases). CONCLUSIONS: The multimorbidity network of a patient with COPD differs according to the underlying clinical characteristics, suggesting that the connections linking comorbidities between them vary for different phenotypes and that the clinical heterogeneity of COPD could influence the expression of latent multimorbidity. Network analysis has the potential to delve into the interactions between COPD clinical traits and comorbidities and is a promising tool to investigate possible specific biological pathways that modulate multimorbidity patterns.

Characteristics of patients referred to Canary Island pneumology outpatient services for chronic obstructive pulmonary disease: the EPOCan study.

OBJECTIVE: Assessing patients with chronic obstructive pulmonary disease (COPD) accounts for 30% of all pneumology outpatient evaluations. COPD is a heterogeneous disease and generates a massive public health problem. Overall morbidity, particularly cardiovascular disease, challenges patient management. This is an observational, multicentre study, performed at four hospitals in the Canary Islands (Spain), aimed at characterising patients with COPD referred to pneumology outpatient services. Demographic variables, lung function, and morbidity were assessed. RESULTS: Of the 877 included patients, 44.9% were active smokers with a mean (± SD) age of 68.2 ± 10.3 years. The median (IQR) score for the Charlson comorbidity index was 2 (2), and 70.6% of the patients were assigned high risk according to the Spanish Guidelines for COPD (GesEPOC) 2021. The degree of airflow obstruction defined by the GOLD 2021 stages 1, 2, 3, and 4 corresponded to 13.6%, 49%, 31%, and 6.3% of patients, respectively. The most frequently associated morbidities were arterial hypertension (59.5%), dyslipidaemia (54.3%), and type 2 diabetes mellitus (31.2%); 32% of the patients suffered heart disease. There is a high prevalence of active smoking, type 2 diabetes mellitus, and heart disease in patients referred for COPD to Canary Island pneumology outpatient services.

Time to desaturation less than one minute predicts the need for long-term home oxygen therapy.

BACKGROUND: Exercise desaturation in patients with COPD is a pathophysiological phenomenon that is not wholly understood and whose clinical consequences are still unclear. METHODS: Eighty-three patients with moderate to severe COPD and P(aO(2)) > 60 mm Hg who desaturated during the 6-min walk test were followed for 5 years. Forty-eight patients had early desaturation (S(pO(2)) fell below 90% less than one minute after starting the walk test). Spirometry, blood-gas measurements, and 6-min walk tests were performed every 6 months. We recorded 6-min walk distance, baseline S(pO(2)), lowest S(pO(2)), and the time to S(pO(2)) < 90%. In each control, stable patients with severe hypoxia at rest who required long-term oxygen therapy were identified. RESULTS: Upon completion of the study, 65% of the early desaturators had developed severe hypoxemia and required long-term home oxygen, versus 11% in the non-early desaturators (P < .001). CONCLUSIONS: In patients with moderate to severe COPD, desaturation within the first minute of the 6-min walk test predicts the need for long-term home oxygen at 5-year follow-up.

Impact of diabetes mellitus on the risk of severe exacerbation in patients with chronic obstructive pulmonary disease.

INTRODUCTION: Suffering type 2 diabetes mellitus (T2DM) appears to promote the occurrence of respiratory infections. However, studies to evaluate the risk of hospital admission due to exacerbations in patients with chronic obstructive pulmonary disease (COPD) and concomitant T2DM are scarce. MATERIALS AND METHODS: Prospective, observational study with a maximum follow-up of 18 months. Information on lung function, body mass index, degree of dyspnea, number of exacerbations, comorbidities and pneumococcal vaccination was obtained. Patients were classified into the categories COPD with (COPD/+T2DM) and without T2DM (COPD/-T2DM). RESULTS: A total of 121 patients with COPD were enrolled. Forty-seven (38%) of the study participants were diabetic. The presence of T2DM increased the risk of hospital admission due to COPD exacerbation (OR 2.66; P = 0.031), but no significant difference in the total number of exacerbations was detected. CONCLUSIONS: The risk of hospital admission in the course of exacerbation seems to be higher in COPD/+T2DM patients than in COPD/-T2DM subjects.

Prognostic ability of the distance-saturation product in the 6-minute walk test in patients with chronic obstructive pulmonary disease.

INTRODUCTION: The product (DSP) of the distance walked (meters) and minimum oxygen saturation obtained during the 6-minute walk test (6MWT) has been proposed as a predictor of mortality in idiopathic pulmonary fibrosis and in bronchiectasis not related to cystic fibrosis. OBJECTIVE: The aim of this study was to determine the DSP's ability to predict mortality in patients with chronic obstructive pulmonary disease (COPD) at the outpatient level and compare it to the BODE index and meters walked in the 6MWT. MATERIAL AND METHODS: Descriptive observational study in a cohort of patients with COPD being treated at outpatient pulmonology clinics. Each of the patients completed the 6MWT following ATS/ERS protocols and their BODE index and DSP were calculated. RESULTS: About 103 patients were included. The average length of follow-up was 36 months. Patients who died showed a lower number of meters walked in the 6MWT (P < 0.001), as well as a lower DSP (P < 0.001). A 6MWT < 334 m, a DSP < 290 and a BODE ≥ 4 showed good prognostic ability at 3 years (AUC 71%, 69% and 70.4%, respectively). The 6MWT was superior to the BODE index in predicting mortality during the first year of follow-up (P = 0.023). We did not find any differences between DSP and meters walked in the 6MWT. CONCLUSIONS: The DSP is a good predictor of mortality, although it does not offer a better prognostic ability than that of meters walked in the 6MWT.

Comparison of the prognostic capability of two comorbidity indices in patients with chronic obstructive pulmonary disease, in real-life clinical practice.

BACKGROUND: Comorbidities are a major cause of death in chronic obstructive pulmonary disease (COPD). The COPD-comorbidity test (COTE) index was designed to measure comorbidity burden in this disease. The objective of this study was to compare the capability of COTE and the non-COPD specific Charlson comorbidity index (CCI) to predict all-cause mortality in real-life conditions. METHODS: Retrospective observational study, carried out in two different series of consecutive COPD patients including, respectively, 790 and 439 subjects. The COTE and non-age-adjusted CCI indices were calculated and the values of the C-statistic for predicting all-cause mortality were compared for both indices. RESULTS: Median follow-up was 54 months and there were 321 deaths within this period of time. The value of the C-statistic for the CCI was significantly higher than for the COTE index in both groups. CONCLUSION: When used in real-life clinical practice, the value of the CCI to predict all-cause mortality in COPD seems higher than that of the COTE index.

Time to desaturation in the 6-min walking distance test predicts 24-hour oximetry in COPD patients with a PO2 between 60 and 70mmHg.

BACKGROUND: The 6-min walking distance (6MWD) test is a useful tool for assessing patients with chronic obstructive pulmonary disease (COPD), but little is known about the changes in oxygen saturation that occur during the test. OBJECTIVE: To predict the oximetry profile during daily living activities by the time to desaturation in the 6MWD test in COPD-affected patients. PATIENTS AND METHODS: We studied 67 COPD patients with moderate hypoxemia performing a 6MWD test and a 24-hour ambulatory pulse oximetry (24-hr PO). We determined the time to desaturation (SatO290%) in the 6MWD test, in the daytime, nighttime and 24-hr PO. We then estimated the time to desaturation that better predicts desaturation in diurnal, nocturnal and 24-hour oximetries using the ROC type II analysis. RESULTS: The patients who desaturated after 3'30min have a 100% probability not to desaturate during diurnal, nocturnal and 24-hr PO. Those patients who desaturated during the first minute of the 6MWD test have a 74% probability to desaturate in these oximetries. CONCLUSIONS: The time to desaturation in the 6MWD test can discriminate early desaturators who desaturate during their daily living activities and late desaturators who do not desaturate. Ambulatory oximetry would thus only be necessary in patients with a time to desaturation that ranges between 1 and 3'30''.

Relación de la clasificación GesEPOC 2021 de niveles de riesgo y fenotipos con la incidencia de eventos adversos / Relationship Between the GesEPOC 2021 Classification of Risk Levels and Phenotypes and the Incidence of Adverse Events

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[Translated article] Relationship Between the GesEPOC 2021 Classification of Risk Levels and Phenotypes and the Incidence of Adverse Events / Relación de la clasificación GesEPOC 2021 de niveles de riesgo y fenotipos con la incidencia de eventos adversos

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