The association between chronic airflow obstruction and poverty in 12 sites of the multinational BOLD study.

Poverty is strongly associated with mortality from COPD, but little is known of its relation to airflow obstruction.In a cross-sectional study of adults aged ≥40 years from 12 sites (N=9255), participating in the Burden of Obstructive Lung Disease (BOLD) study, poverty was evaluated using a wealth score (0-10) based on household assets. Obstruction, measured as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) (%) after administration of 200 µg salbutamol, and prevalence of FEV1/FVC

Chronic Airflow Obstruction in a Black African Population: Results of BOLD Study, Ile-Ife, Nigeria.

Global estimates suggest that Chronic Obstructive Pulmonary Disease (COPD) is emerging as a leading cause of death in developing countries but there are few spirometry-based general population data on its prevalence and risk factors in sub-Saharan Africa. We used the Burden of Obstructive Lung Disease (BOLD) protocol to select a representative sample of adults aged 40 years and above in Ile-Ife, Nigeria. All the participants underwent spirometry and provided information on smoking history, biomass and occupational exposures as well as diagnosed respiratory diseases and symptoms. Chronic Airflow Obstruction (CAO) was defined as the ratio of post-bronchodilator (BD) one second Forced Expiratory Volume (FEV1) to Forced Vital Capacity (FVC) below the lower limit of normal (LLN) of the population distribution for FEV1/FVC. The overall prevalence of obstruction (post-BD FEV1/FVC < LLN) was 7.7% (2.7% above LLN) using Global Lung Function Initiative (GLI) equations. It was associated with few respiratory symptoms; 0.3% reported a previous doctor-diagnosed chronic bronchitis, emphysema or COPD. Independent predictors included a lack of education (OR 2.5, 95% CI: 1.0, 6.4) and a diagnosis of either TB (OR 23.4, 95% CI: 2.0, 278.6) or asthma (OR 35.4, 95%CI: 4.9, 255.8). There was no association with the use of firewood or coal for cooking or heating. The vast majority of this population (89%) are never smokers. We conclude that the prevalence of CAO is low in Ile-Ife, Nigeria and unrelated to biomass exposure. The key independent predictors are poor education, and previous diagnosis of tuberculosis or asthma.

Symptomatic chronic obstructive pulmonary disease in clinical trials and in a population-based study.

PURPOSE: Evidence-based medicine promotes the current best evidence from clinical trials to guide decisions for individual patients. We assessed whether chronic obstructive pulmonary disease (COPD) patients included in exercise training studies and pharmacologic trials match those from a non-selected COPD target population sample. METHODS: Exercise training studies were identified in a literature search. Towards a Revolution in COPD Health (TORCH) and Understanding Potential Long-Term Impacts on Function with Tiotropium (UPLIFT) were chosen to represent pharmacologic trials. Burden of Obstructive Lung Disease (BOLD) data were used to characterize target COPD population (BOLD target), defined as the presence of dyspnea (modified Medical Research Council ≥2) and non-reversible airway obstruction (post-bronchodilator FEV1/FVC ≤0.7 and FEV1% predicted ≤70 %). RESULTS: Overall 240 exercise training studies with 13,901, TORCH and UPLIFT with 12,105, and BOLD with 16,218 participants were evaluated. Males were overrepresented in exercise training studies (67.5%) and pharmacologic trials (TORCH 75.8%; UPLIFT 74.6%), whereas in BOLD target 55.8% were males (p < 0.001). In exercise training studies, 7.2% were never-smokers, 0.0% in TORCH and UPLIFT, but 36.0% in BOLD target (p < 0.001). Subjects with cardiac comorbidity were excluded from 75.4% of exercise training studies, entirely from TORCH and UPLIFT, but comprised 24.5% of BOLD target. CONCLUSIONS: COPD patients recruited in exercise training studies and in pharmacologic trials differ from target population of symptomatic COPD. Females, never-smokers, and patients with cardiac comorbidities are more likely excluded from the clinical trials.

COPD uncovered: an international survey on the impact of chronic obstructive pulmonary disease [COPD] on a working age population.

BACKGROUND: Approximately 210 million people are estimated to have chronic obstructive pulmonary disease [COPD] worldwide. The burden of disease is known to be high, though less is known about those of a younger age. The aim of this study was to investigate the wider personal, economic and societal burden of COPD on a cross country working-age cohort. METHODS: A cross-country [Brazil, China, Germany, Turkey, US, UK] cross-sectional survey methodology was utilised to answer the research questions. 2426 participants aged 45-67 recruited via a number of recruitment methods specific to each country completed the full survey. Inclusion criteria were a recalled physician diagnosis of COPD, a smoking history of > 10 pack years and the use of COPD medications in the previous 3 months prior to questioning. The survey included items from the validated Work Productivity and Activity Impairment [WPAI] scale and the EuroQoL 5 Dimension [EQ-5D] scale. Disease severity was measured using the 5-point MRC [Medical Research Council] dyspnoea scale as a surrogate measure. RESULTS: 64% had either moderate [n = 1012] or severe [n = 521] COPD, although this varied by country. 75% of the cohort reported at least one comorbid condition. Quality of life declined with severity of illness [mild, mean EQ-5D score = 0.84; moderate 0.58; severe 0.41]. The annual cost of healthcare utilisation [excluding treatment costs and diagnostic tests] per individual was estimated to be $2,364 [£1,500]. For those remaining in active employment [n: 677]: lost time from work cost the individual an average of $880 [£556] per annum and lifetime losses of $7,365 [£4,661] amounting to $596,000 [£377,000] for the cohort. 447 [~40%] of the working population had retired prematurely because of COPD incurring individual estimated lifetime income losses of $316,000 [£200,000] or a combined total of $141 m [£89.6 m]. As the mean age of retirees was 58.3 and average time since retirement was 4 years, this suggests the average age of retirement is around 54. This would mean a high societal and economic impact in all study countries, particularly where typical state retirement ages are higher, for example in Brazil, Germany and the UK [65] and the US [65,66,67], compared to Turkey [58 for women, 60 for men] and China [60]. CONCLUSIONS: Although generalisation across a broader COPD population is limited due to the varied participant recruitment methods, these data nevertheless suggest that COPD has significant personal, economic and societal burden on working age people. Further efforts to improve COPD diagnosis and management are required.

Marijuana and chronic obstructive lung disease: a population-based study.

BACKGROUND: Our aim was to determine the combined and independent effects of tobacco and marijuana smoking on respiratory symptoms and chronic obstructive pulmonary disease (COPD) in the general population. METHOD: We surveyed a random sample of 878 people aged 40 years or older living in Vancouver, Canada, about their respiratory history and their history of tobacco and marijuana smoking. We performed spirometric testing before and after administration of 200 microg of salbutamol. We examined the association between tobacco and marijuana smoking and COPD. RESULTS: The prevalence of a history of smoking in this sample was 45.5% (95% confidence interval [CI] 42.2%-48.8%) for marijuana use and 53.1% (95% CI 49.8%-56.4%) for tobacco use. The prevalence of current smoking (in the past 12 months) was 14% for marijuana use and 14% for tobacco use. Compared with nonsmokers, participants who reported smoking only tobacco, but not those who reported smoking only marijuana, experienced more frequent respiratory symptoms (odds ratio [OR] 1.50, 95% CI 1.05-2.14) and were more likely to have COPD (OR 2.74, 95% CI 1.66-4.52). Concurrent use of marijuana and tobacco was associated with increased risk (adjusted for age, asthma and comorbidities) of respiratory symptoms (OR 2.39, 95% CI 1.58-3.62) and COPD (OR 2.90, 95% CI 1.53-5.51) if the lifetime dose of marijuana exceeded 50 marijuana cigarettes. The risks of respiratory symptoms and of COPD were related to a synergistic interaction between marijuana and tobacco. INTERPRETATION: Smoking both tobacco and marijuana synergistically increased the risk of respiratory symptoms and COPD. Smoking only marijuana was not associated with an increased risk of respiratory symptoms or COPD.

Subjects with Discordant Airways Obstruction: Lost between Spirometric Definitions of COPD.

Background. Since the FEV1/FVC ratio declines with age, using the fixed ratio of 0.70 leads to overdiagnosis of COPD in older populations and underdiagnosis among young adults. Objective. To evaluate whether discordant obstructive cases (FEV1/FVC < 0.70 but ≥LLN) are a healthy population or have clinical features that would place them at increased risk. Methods. We used post-bronchodilator spirometry data from the population-based Austrian Burden of Obstructive Lung Disease (BOLD) study. Those with post-bronchodilator FEV1/FVC ratio

COPD in never smokers: results from the population-based burden of obstructive lung disease study.

BACKGROUND: Never smokers comprise a substantial proportion of patients with COPD. Their characteristics and possible risk factors in this population are not yet well defined. METHODS: We analyzed data from 14 countries that participated in the international, population-based Burden of Obstructive Lung Disease (BOLD) study. Participants were aged ≥ 40 years and completed postbronchodilator spirometry testing plus questionnaires about respiratory symptoms, health status, and exposure to COPD risk factors. A diagnosis of COPD was based on the postbronchodilator FEV1/FVC ratio, according to current GOLD (Global Initiative for Obstructive Lung Disease) guidelines. In addition to this, the lower limit of normal (LLN) was evaluated as an alternative threshold for the FEV1/FVC ratio. RESULTS: Among 4,291 never smokers, 6.6% met criteria for mild (GOLD stage I) COPD, and 5.6% met criteria for moderate to very severe (GOLD stage II+) COPD. Although never smokers were less likely to have COPD and had less severe COPD than ever smokers, never smokers nonetheless comprised 23.3% (240/1,031) of those classified with GOLD stage II+ COPD. This proportion was similar, 20.5% (171/832), even when the LLN was used as a threshold for the FEV1/FVC ratio. Predictors of COPD in never smokers include age, education, occupational exposure, childhood respiratory diseases, and BMI alterations. CONCLUSION: This multicenter international study confirms previous evidence that never smokers comprise a substantial proportion of individuals with COPD. Our data suggest that, in addition to increased age, a prior diagnosis of asthma and, among women, lower education levels are associated with an increased risk for COPD among never smokers.

Six-second spirometry for detection of airway obstruction: a population-based study in Austria.

RATIONALE: The presence of airway obstruction is currently defined by Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines on the basis of the post-bronchodilator (BD) FEV(1)/FVC. It has been proposed that the traditional FVC can be replaced with the shorter and less demanding FEV(6) for detecting airway obstruction. OBJECTIVES: A comparison of FEV(1)/FVC and FEV(1)/FEV(6) for the detection of airway obstruction in population-based post-bronchodilator spirometry data. METHODS: A population-based sample of 1,349 adults participated in the Burden of Obstructive Lung Disease study in Austria. Specially trained and certified technicians conducted pre-BD and post-BD spirometry according to American Thoracic Society guidelines and administered standardized questionnaires. A total of 93% of the post-BD test sessions were acceptable, and were included in this analysis. The Third National Health and Nutrition Examination Survey reference equations were used to calculate predicted values and lower limits of normal (LLN) for FEV(1), FEV(6), FVC, FEV(1)/FVC, and FEV(1)/FEV(6). MEASUREMENTS AND MAIN RESULTS: The post-BD FEV(1)/FVC was below the LLN in 199 (15.8%) subjects. The sensitivity of the FEV(1)/FEV(6) for airway obstruction depended greatly on the threshold of percent predicted FEV(1) also used in the definition. The overall sensitivity of FEV(1)/FEV(6) for a diagnosis of airway obstruction, as defined by FEV(1)/FVC (including participants with an FEV(1) above the LLN), was 72.9%, with 98.8% specificity. The sensitivity increased to 98.0% when a low FEV(1) was also required to diagnose post-BD airway obstruction. The discordant cases had long forced expiratory times, often showed a flow-volume curve pattern consistent with two-compartment emptying, and were more often never-smokers. CONCLUSIONS: Six-second spirometry maneuvers (which measure FEV(6)) are as sensitive and specific for post-BD airway obstruction as traditional (prolonged exhalation time) FVC maneuvers only when the definition of airway obstruction includes a low FEV(1).

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

Sex differences in survival of oxygen-dependent patients with chronic obstructive pulmonary disease.

RATIONALE: Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide. The prevalence of COPD is rising among women and is approaching that of men, but it is not known if sex affects survival. OBJECTIVES: To measure the survival differences between men and women with oxygen-dependent COPD. METHODS: We conducted a 7-yr prospective cohort study of 435 outpatients with COPD (184 women, 251 men) referred for long-term oxygen therapy (LTOT) at two respiratory clinics in Sao Paulo, Brazil. Baseline data were collected on enrollment into oxygen therapy, when patients were clinically stable. MEASUREMENTS: We examined the effect of sex on survival using Kaplan-Meier survival curves, and then used Cox proportional hazards models to control for potential confounders. MAIN RESULTS: In unadjusted analyses, we observed a nonsignificant trend toward increased mortality for women (hazard ratio, 1.28; 95% confidence interval, 0.98-1.68; p = 0.07). After accounting for potential confounders (age, pack-years smoked, Pa(O(2)), FEV(1), body mass index), females were at a significantly higher risk of death (hazard ratio, 1.54; 95% confidence interval, 1.15-2.07; p = 0.004). Other independent predictors of death were lower Pa(O(2)) (p < 0.001) and lower body mass index (p < 0.05). CONCLUSIONS: Among patients with COPD on LTOT, women were more likely to die than men.