Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients.

Background: Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design. Methods: A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement. Results: Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event. Conclusions: This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

Inhaled Corticosteroid Exposure and Risk of Cataract in Patients with Asthma and COPD: A Systematic Review and Meta-Analysis.

Purpose: Both systemic and inhaled corticosteroids may increase the risk of cataract in patients with both chronic obstructive pulmonary disease (COPD) and asthma. Our aim was to assess the degree of association between cataract and corticosteroid exposure in patients with asthma and COPD. Methods: A systematic literature review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The odds ratio estimates were extracted from each article. A random effects model was applied for estimate pooling in separate meta-analyses according to study design. Meta-regression was performed to assess the dose-response relationship between corticosteroid exposure and the risk of cataract development. Results: A total of 19 studies met the criteria for inclusion in this review, of which 12 studies provided effect estimates for pooled analyses. All but one of the included observational studies reported a significant association between use of corticosteroids and cataract development in cohorts of asthma and/or COPD patients. Pooled analyses revealed on average a doubled risk of cataract in corticosteroid-exposed asthma and COPD patients. Studies have shown that daily high-dose inhaled corticosteroid (ICS) ≥ 1000 µg is associated with a significant risk of developing cataract and by that predispose to subsequent cataract surgery, although one study showed that systemic corticosteroids increase cataract risk more than ICS. Conclusion: ICS treatment in asthma and COPD patients is a risk factor for cataract development. Our results emphasize a previously underestimated potential long-term risk of treatment with ICS and underline the importance of targeting ICS treatment, and not least dosing, to improve the risk-benefit ratio of maintenance treatment in both asthma and COPD.

Adherence to inhaled corticosteroids in relation to quality of life and symptoms of anxiety and depression in asthma.

Background: Poor asthma control, often caused by non-adherence with controller medication, is a well-known risk factor for impaired quality of life (QoL) and major mood disorders (MMD). Previous studies have shown a relationship between non-adherence, lower QoL, and MMD across chronic diseases, but the relationship remains uncertain in asthma. Methods: All asthma patients followed at the respiratory outpatient clinic at Copenhagen University Hospital - Hvidovre were invited to fill-in the Hospital Anxiety and Depression Scale (HADS) and the Mini Asthma Quality of Life Questionnaire (miniAQLQ). Medication Possession Ratio (MPR) was calculated using pharmacy redemption data. Relationships between questionnaire scores, inhaled corticosteroid MPR and use of rescue medication were investigated using Pearson correlation and multivariable linear regression adjusted for age, sex, FEV1, and GINA Step. Data from scheduled visits were collected from patients' medical records. Results: A total of 308 patients (73% females, median age 51 years (interquartile range (IQR) 37, 62)) completed the questionnaires and had 1-year medication data available. Median adherence to inhaled corticosteroids (ICS) was 57% (35%, 75%) with 18% of patients having adherence above 80%. Of the participating patients, 14% and 27% reported depressive and anxiety-related symptoms, respectively, and 72% reported impaired QoL. In correlation analyses, ICS adherence was not significantly associated with either prevalence of MMD symptoms or impaired QoL in asthma patients. However, a strong correlation was found between ACQ-6 and both MMD symptoms and impaired QoL, as well as between rescue medication use and impaired QoL. In adjusted analysis, however, the latter correlation was no longer statistically significant. Conclusion: Our results suggest that ICS adherence is not directly correlated with either impaired quality of life or major mood disorder symptoms in asthma patients. Self-reported asthma control, on the other hand, is strongly correlated with both QoL and MMD.

Patients' Perspective on Automated Oxygen Administration during Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Qualitative Study Nested in a Randomized Controlled Trial.

Recently, health technology systems offering monitoring of the peripheral oxygen saturation level and automated oxygen administration (AOA) have emerged. AOA has been shown to reduce duration of hypoxemia and the length of hospital stay, but the patients' perspective on AOA has not been investigated. This qualitative study, based on the interpretive description methodology, aimed to explore how patients hospitalized with exacerbation of chronic obstructive pulmonary disease (COPD) experience being treated with AOA. Eighteen patients treated with AOA were included in the study. Data was collected during admission or in the patients' homes using semi-structured interviews focusing on patients' experiences of AOA using the word "robot" as used by patients. The findings revealed two themes "adaptation of behavior to the robot" and "robots can make patients feel safe but not cared for" and six subthemes. Our findings illustrate how patients were willing to compromise their own therapy and thereby safety by avoiding behavior triggering AOA alarms and disturbing their fellow patients and the health care professionals. Adherence, defined as patients' consistency in taking their medications as prescribed, becomes an important point of attention for health professionals when applying individualized robotic therapies such as AOA to patients with COPD. To support patients in the process of managing adherence to therapeutic technology, we propose a person-centered care approach that, through education and communication with the patients, generates an understanding of how they can self-manage AOA and its alarms without activating avoiding behavior that threatens their treatment and recovery.

Physical activity, physical capacity and sedentary behavior among asthma patients.

BACKGROUND: Although exercise and daily physical activity (PA) have long been known to benefit patients with chronic disorders, knowledge is limited regarding asthma. OBJECTIVE: In a Danish setting, our aim was to measure physical activity, sedentary behavior, and physical capacity among patients with asthma. We hypothesized that people with severe asthma would be less active and more sedentary than their mild-moderate counterparts. METHODS: Adults with asthma were recruited through respiratory outpatient clinics and subsequently examined twice, 4 weeks apart. At each visit, participants underwent a series of lung function tests, questionnaires, and maximum oxygen uptake testing (VO2max). Between the visits, participants wore an accelerometer continuously for 4 weeks, measuring sedentary time and daily steps. Sixty patients, 27 with mild-moderate asthma (GINA 1-3) and 33 with severe asthma (GINA 4-5), completed both visits and had valid accelerometer measurements. RESULTS: No significant differences between the two groups were found in sedentary time, number of steps or VO2max.   VO2max was significantly correlated with FeNO (r = -0.30, p < 0.05), Short Form-12 Mental Health (r = 0.37, p < 0.05), Asthma Control Questionnaire (r = -0.35, p < 0.05), and Mini Asthma Quality of Life Questionnaire (r = 0.36, p < 0.05). CONCLUSION: No differences were observed between patients with mild-moderate and severe asthma regarding sedentary behavior, daily steps or level of cardiopulmonary fitness. Furthermore, patients with the highest VO2max had the higher quality of life scores. Abbreviations: VO2max: Maximal Oxygen Uptake; CPET: Cardiopulmonary Exercise Testing; BMI: Body Mass Index; FEV1: Forced Expired Volume in the First Second; FVC: Forced Vital Capacity; PEF: Peak Expiratory Flow; EIB: Exercise-Induced Bronchoconstriction; COPD: Chronic Obstructive Pulmonary Disease; ACQ: Asthma Control Questionnaire; Mini-AQLQ: Mini Asthma Quality of Life Questionnaire; SF-12: Short Form 12 Health Survey; SNOT-22: Sino-Nasal Outcome Test 22; GINA: The Global Initiative for Asthma; CRP: C-reactive Protein; Hgb:Hemoglobin count; EOS: Eosinophil count; EVH: Eucapnic Voluntary Hyperventilation; FeNO: Fractional Exhaled Nitric Oxide; PA: Physical Activity ERS: European Respiratory Society; ATS: American Thoracic Society; CRS: Chronic Rhinosinusitis; AHR: Airway Hyperresponsiveness.

Real World Biologic Use and Switch Patterns in Severe Asthma: Data from the International Severe Asthma Registry and the US CHRONICLE Study.

INTRODUCTION: International registries provide opportunities to describe use of biologics for treating severe asthma in current clinical practice. Our aims were to describe real-life global patterns of biologic use (continuation, switches, and discontinuations) for severe asthma, elucidate reasons underlying these patterns, and examine associated patient-level factors. METHODS: This was a historical cohort study including adults with severe asthma enrolled into the International Severe Asthma Registry (ISAR; http://isaregistries.org, 2015-2020) or the CHRONICLE Study (2018-2020) and treated with a biologic. Eleven countries were included (Bulgaria, Canada, Denmark, Greece, Italy, Japan, Kuwait, South Korea, Spain, UK, and USA). Biologic utilization patterns were defined: 1) continuing initial biologic; 2) stopping biologic treatment; or 3) switching to another biologic. Reasons for discontinuation/switching were recorded and comparisons drawn between groups. RESULTS: A total of 3531 patients were included. Omalizumab was the most common initial biologic in 2015 (88.2%) and benralizumab in 2019 (29.6%). Most patients (79%; 2791/3531) continued their first biologic; 10.2% (356/3531) stopped; 10.8% (384/3531) switched. The most frequent first switch was from omalizumab to an anti-IL-5/5R (49.6%; 187/377). The most common subsequent switch was from one anti-IL-5/5R to another (44.4%; 20/45). Insufficient efficacy and/or adverse effects were the most frequent reasons for stopping/switching. Patients who stopped/switched were more likely to have a higher baseline blood eosinophil count and exacerbation rate, lower lung function, and greater health care resource utilization. CONCLUSION: The description of real-life patterns of continuing, stopping, or switching biologics enhances our understanding of global biologic use. Prospective studies involving structured switching criteria could ascertain optimal strategies to identify patients who may benefit from switching.

Beta-Blockers in High-Risk Outpatients with Chronic Obstructive Pulmonary Disease are Associated with All-Cause Mortality - The STATUETTE Cohort Study.

Background: Beta-blockers have been proposed to improve COPD-related outcomes, yet studies report conflicting results. We aimed to investigate the effect of beta blockers on time-to-first exacerbation and all-cause mortality in high-risk COPD outpatients. Methods: All COPD outpatients managed at the Department of Respiratory Medicine, Copenhagen University Hospital - Hvidovre, Denmark in 2016 were followed for 3.5 years in this retrospective, registry-based cohort study. Outcomes were time-to-first acute exacerbation of COPD (AECOPD) or death. The association was estimated using time-varying crude and multivariable Cox proportional hazard regression adjusted for age, sex, BMI, use of COPD medication, smoking status, cardiovascular disease and COPD severity. Results: The cohort comprised 950 COPD outpatients, mean age 71 (SD 11) years, and FEV1 44% predicted (IQR 33%; 57%). The annual exacerbation rate was 0.88 (SD 1.68) and 211 patients (22%) had a history of hospitalization requiring AECOPD within 12 months. Of the enrolled patients, 247 (26%) were prescribed beta blockers. Beta-blocker use was associated, although with borderline significance, with increased all-cause mortality (HR 1.37 (95% CI, 0.99 to 1.89, p = 0.059)). On the other hand, beta blocker use did not reduce the risk of AECOPD (HR = 0.89 (95% CI 0.71 to 1.10; p = 0.270)), which remained non-significant after stratifying for severity of exacerbations. Conclusion: We found an association between beta blocker use and all-cause mortality in high-risk COPD outpatients. No association was found between beta blocker use and risk of AECOPD.

Corticosteroid Resistance in Smokers-A Substudy Analysis of the CORTICO-COP Randomised Controlled Trial.

The CORTICO-COP trial showed that eosinophil-guided corticosteroid-sparing treatment for acute exacerbation of chronic obstructive pulmonary disease was non-inferior to standard of care and decreased the accumulated dose of systemic corticosteroids that patients were exposed to by approximately 60%. Smoking status has been shown to affect corticosteroid responsiveness. This post hoc analysis investigated whether eosinophil-guided treatment is non-inferior to conventional treatment in current smokers. The main analysis of current smokers showed no significant difference in the primary endpoint, days alive, and out of hospital within 14 days between the control group (mean, 9.8 days; 95% confidence interval (CI), 8.7-10.8) and the eosinophil-guided group (mean, 8.7 days; 95% CI, 7.5-9.9; p = 0.34). Secondary analyses of the number of exacerbations or deaths, the number of intensive care unit admissions or deaths, lung function improvement, and change in health-related quality of life also showed no significant differences between the two groups. The results of a sensitivity analysis of ex-smokers are consistent with the main analysis. Our results suggest that eosinophil-guided treatment is non-inferior to standard of care in current smokers and ex-smokers. Because data on the impact of smoking status on eosinophil-guided treatments are sparse, more randomised trials are needed to confirm our results.

Update on Asthma-COPD Overlap (ACO): A Narrative Review.

Although chronic obstructive pulmonary disease (COPD) and asthma are well-characterized diseases, they can coexist in a given patient. The term asthma-COPD overlap (ACO) was introduced to describe patients that have clinical features of both diseases and may represent around 25% of COPD patients and around 20% of asthma patients. Despite the increasing interest in ACO, there are still substantial controversies regarding its definition and its position within clinical guidelines for patients with obstructive lung disease. In general, most definitions indicate that ACO patients must present with non-reversible airflow limitation, significant exposure to smoking or other noxious particles or gases, together with features of asthma. In patients with a primary diagnosis of COPD, the identification of ACO has therapeutic implication because the asthmatic component should be treated with inhaled corticosteroids and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. This manuscript aims to summarize the current state-of-the-art of ACO. The definitions, prevalence, and clinical manifestations will be reviewed and some innovative aspects, such as genetics, epigenetics, and biomarkers will be addressed. Lastly, the management and prognosis will be outlined as well as the position of ACO in the COPD and asthma guidelines.

Management of hospitalised adults with coronavirus disease 2019 (COVID-19): a European Respiratory Society living guideline

Hospitalised patients with coronavirus disease 2019 (COVID-19) as a result of SARS-CoV-2 infection have a high mortality rate and frequently require noninvasive respiratory support or invasive ventilation. Optimising and standardising management through evidence-based guidelines may improve quality of care and therefore patient outcomes. A task force from the European Respiratory Society and endorsed by the Chinese Thoracic Society identified priority interventions (pharmacological and non-pharmacological) for the initial version of this "living guideline" using the PICO (population, intervention, comparator, outcome) format. The GRADE approach was used for assessing the quality of evidence and strength of recommendations. Systematic literature reviews were performed, and data pooled by meta-analysis where possible. Evidence tables were presented and evidence to decision frameworks were used to formulate recommendations. Based on the available evidence at the time of guideline development (20 February, 2021), the panel makes a strong recommendation in favour of the use of systemic corticosteroids in patients requiring supplementary oxygen or ventilatory support, and for the use of anticoagulation in hospitalised patients. The panel makes a conditional recommendation for interleukin (IL)-6 receptor antagonist monoclonal antibody treatment and high-flow nasal oxygen or continuous positive airway pressure in patients with hypoxaemic respiratory failure. The panel make strong recommendations against the use of hydroxychloroquine and lopinavir-ritonavir. Conditional recommendations are made against the use of azithromycin, hydroxychloroquine combined with azithromycin, colchicine, and remdesivir, in the latter case specifically in patients requiring invasive mechanical ventilation. No recommendation was made for remdesivir in patients requiring supplemental oxygen. Further recommendations for research are made. The evidence base for management of COVID-19 now supports strong recommendations in favour and against specific interventions. These guidelines will be regularly updated as further evidence becomes available.

ARIA digital anamorphosis: Digital transformation of health and care in airway diseases from research to practice.

Digital anamorphosis is used to define a distorted image of health and care that may be viewed correctly using digital tools and strategies. MASK digital anamorphosis represents the process used by MASK to develop the digital transformation of health and care in rhinitis. It strengthens the ARIA change management strategy in the prevention and management of airway disease. The MASK strategy is based on validated digital tools. Using the MASK digital tool and the CARAT online enhanced clinical framework, solutions for practical steps of digital enhancement of care are proposed.

Fertility Treatment Resulting in Live Births in Women with Asthma - Associated with Perennial Allergy?

BACKGROUND: Asthma has been linked with prolonged time to pregnancy compared to healthy controls, also asthma has been linked to a higher need for fertility treatment. However, knowledge of the possible association between allergy and need for fertility treatment is limited. Our aim was to explore a possible difference in having had fertility treatment in women with asthma and live births in those with perennial allergy (animals, fungi and dust mites) compared to no allergy/seasonal allergy. The primary outcome of interest was fertility treatment. PATIENTS AND METHODS: Women enrolled in the Management of Asthma during Pregnancy (MAP) program at Hvidovre Hospital, DK, were included in the present analysis provided they fulfilled the following criteria: 1) diagnosed with asthma and current anti-asthma therapy and 2) first visit to the respiratory outpatient clinic within the first 18 weeks of pregnancy. Participants were divided into two groups: asthma with perennial allergy (cases) and asthma with seasonal/no allergy (controls). Logistic regression analysis was applied, and findings expressed as odds ratios (OR). RESULTS: Among women with asthma and perennial allergy (n=544 cases), 13.8% (n=75) had fertility treatment, compared to only 10.1% (n=39) among women with asthma and seasonal/no allergy (n=388, controls) (OR 1.43, 95% CI 0.95-2.16, p=0.087). This association remained statistically insignificant after adjusting for confounders, including BMI (OR 1.19, 95% CI 0.77-1.84, p=0.433). In women ≥35 years of age, 28% (n=44) and 20% (n=19), respectively, among cases and controls had fertility treatment (OR 1.60, 95% CI 0.87-2.94, p=0.132), and likewise, statistically insignificant after adjusting for confounders (OR 1.41, 95% CI 0.74-2.69, p<0.293). CONCLUSION: In women with asthma and live births, our study revealed a trend towards an association between perennial allergy and a higher need for fertility treatment compared to seasonal/no allergy.

Assessment of fitness for recreational scuba diving in candidates with asthma: a pilot study.

BACKGROUND: Asthma may be regarded as a contraindication to scuba diving. PURPOSE: A clinical algorithm to assess fitness to dive among individuals with asthma was developed and tested prospectively in clinical practice. STUDY DESIGN: Cohort study. METHODS: All patients with possible asthma referred to Hvidovre Hospital, Denmark, for assessment of fitness to dive over a 5-year period (2013-2017) were included. Fitness to dive was assessed by case history, spirometry and mannitol challenge test. All patients with ≥10% decline in forced expiratory volume in 1 s (FEV1) (at any point during the challenge test) were offered step-up asthma therapy and rechallenge after at least 3 months. Patients with <10% decline in FEV1 after administration of a maximum dose of mannitol at the latest challenge were classified as having no medical contraindications to scuba diving. RESULTS: The study cohort comprised 41 patients (24 men; mean age 33 years), of whom 71% and 63% of men and women, respectively, were treated with rescue bronchodilator and inhaled corticosteroid. After the first mannitol challenge test, 21 patients were classified as having no medical contraindications to scuba diving, of whom 16 were currently prescribed asthma medication. After step-up asthma therapy and rechallenge test, an additional seven patients were classified as having no medical contraindications to scuba diving. Overall, using this clinical algorithm, 28 (68%) of the referred patients were finally assessed as having no medical contraindications to scuba diving. CONCLUSION: Using a clinical algorithm with mannitol challenge to assess fitness to dive among patients with possible asthma and allowing a rechallenge test after step-up asthma therapy increased the proportion of individuals classified as having no medical contraindications to scuba diving. However, as this algorithm has so far not been evaluated against actual scuba diving safety, further studies are clearly needed before it can be implemented with confidence for use in clinical practice. CLINICAL RELEVANCE: An algorithm to assess fitness for scuba diving among individuals with possible asthma using bronchial challenge test, with the option of step-up asthma therapy and rechallenge for reassessment, has been developed for clinical use.

Usefulness of mannitol challenge testing for diagnosing asthma in everyday clinical practice.

Background: The mannitol test is widely used for assessment of airway responsiveness in patients with possible asthma, but our knowledge of the value in everyday clinical practice is limited.Objective: To investigate the diagnostic value of the mannitol test in a clinical setting.Methods: All patients having a mannitol challenge test as part of their diagnostic work-up for asthma at the respiratory outpatient clinic, Hvidovre Hospital, over a 5-year period were included in the present analysis. Case history, including previous diagnoses, spirometry, exhaled nitric oxide (FENO) was obtained. The mannitol challenge was performed according to guidelines, i.e. increasing doses of mannitol (from 5 to 635 mg) until maximum dose or a 15% decline in FEV1 (PD15) was achieved (positive test defined as a PD15 < 635 mg).Results: Our cohort comprised 566 patients (210 men). Post-challenge, 247 patients were diagnosed with asthma by a specialist in respiratory medicine, of whom 138 (56%) had a positive mannitol test. A diagnosis of asthma was ruled out by the specialist in 319 individuals, of whom 18 (6%) had a positive mannitol test and 77 (24%) previous doctor-diagnosed asthma (but with no evidence of a confirmatory test). The specificity and sensitivity of the test was 94% and 56%, respectively. Female gender (p = 0.005), increasing BMI (p < 0.001), exercise-induced cough (p = 0.002), night-time respiratory symptoms (p = 0.002), low FEV1/FVC ratio (p = 0.008) and high FENO (p < 0.001) were determinants for a positive mannitol test.Conclusion: In everyday clinical work-up of patients with possible asthma, the sensitivity and specificity of the mannitol challenge test is comparable to previous controlled trials.

Do telemedical interventions improve quality of life in patients with COPD? A systematic review.

OBJECTIVE: Telehealth is an approach to disease management, which may hold the potential of improving some of the features associated with COPD, including positive impact on disease progression, and thus possibly limiting further reduction in quality of life (QoL). Our objective was, therefore, to summarize studies addressing the impact of telehealth on QoL in patients with COPD. DESIGN: Systematic review. METHODS: A series of systematic searches were carried out using the following databases: PubMed, EMBASE, Cochrane Controlled Trials Register, and ClinicalTrials.gov (last updated November 2015). A predefined search algorithm was utilized with the intention to capture all results related to COPD, QoL, and telehealth published since year 2000. OUTCOME MEASURES: Primary outcome was QoL, assessed by validated measures. RESULTS: Out of the 18 studies fulfilling the criteria for inclusion in this review, three studies found statistically significant improvements in QoL for patients allocated to telemedical interventions. However, all of the other included studies found no statistically significant differences between control and telemedical intervention groups in terms of QoL. CONCLUSION: Telehealth does not make a strong case for itself when exclusively looking at QoL as an outcome, since statistically significant improvements relative to control groups have been observed only in few of the available studies. Nonetheless, this does not only rule out the possibility that telehealth is superior to standard care with regard to other outcomes but also seems to call for more research, not least in large-scale controlled trials.

Aclidinium Bromide: Clinical Benefit in Patients with Moderate to Severe COPD.

BACKGROUND AND AIM: Long-acting bronchodilators are the mainstay of pharmacological treatment for patients with chronic obstructive pulmonary disease (COPD). The aim of this review is to provide an overview of the clinical studies evaluating the safety and efficacy of inhaled aclidinium bromide, a novel long-acting anticholinergic bronchodilator, for the treatment of COPD. METHOD: This systematic review explored the efficacy and safety of aclidinium bromide in comparison with placebo and other long-acting bronchodilators for treatment of moderate to severe COPD. Randomised controlled trials were identified through systematic searches of different databases of published trials. RESULTS: Ten trials (3.922 participants) were included. Aclidinium bromide appears to be a safe and well-tolerated long-acting anti-cholinergic bronchodilator with a relatively fast onset of action. Compared with other long-acting bronchodilators, including tiotropium bromide, aclidinium bromide leads to at least similar clinically important improvements in level of FEV(1), health status, use of rescue medication, and day-time dyspnea scores in patients suffering from moderate to severe COPD. With twice-daily dosing, aclidinium bromide may have clinically important effect on night-time symptom scores in COPD patients, but further studies are needed in order to permit valid conclusions with regard to this point. The effect of aclidinium bromide on exercise tolerance, as assessed by exercise endurance time, and dynamic hyperinflation in patients with moderate to severe COPD seems to be at least comparable to other long-acting bronchodilators, incl. tiotropium bromide and indacaterol. Aclidinium bromide might reduce the rate of exacerbations in COPD patients, but conclusions must await further long-term controlled trials. CONCLUSION: Aclidinium bromide has effects on relevant COPD outcome measures, including level of FEV(1), similar to other long-acting bronchodilators, and therefore seems to have the potential for a significant role in the future management of moderate to severe COPD.

Nutritional status and long-term mortality in hospitalised patients with chronic obstructive pulmonary disease (COPD).

Patients with chronic obstructive pulmonary disease (COPD) often have difficulties with keeping their weight. The aim of this investigation was to study nutritional status in hospitalised Nordic COPD patients and to investigate the association between nutritional status and long-term mortality in this patient group. In a multicentre study conducted at four university hospitals (Reykjavik, Uppsala, Tampere and Copenhagen) hospitalised patients with COPD were investigated. Patient height, weight and lung function was recorded. Health status was assessed with St. George's Hospital Respiratory Questionnaire. After 2 years, mortality data was obtained from the national registers in each country. Of the 261 patients in the study 19% where underweight (BMI <20), 41% were of normal weight (BMI 20-25), 26% were overweight (BMI 25-30) and 14% were obese. FEV(1) was lowest in the underweight and highest in the overweight group (p=0.001) whereas the prevalence of diabetes and cardio-vascular co-morbidity went the opposite direction. Of the 261 patients 49 (19%) had died within 2 years. The lowest mortality was found among the overweight patients, whereas underweight was related to increased overall mortality. The association between underweight in COPD-patients, and mortality remained significant after adjusting for possible confounders such as FEV(1) (hazard risk ratio (95% CI) 2.6 (1.3-5.2)). We conclude that COPD patients that are underweight at admission to hospital have a higher risk of dying within the next 2 years. Further studies are needed in order to show whether identifying and treating weight loss and depletion of fat-free mass (FFM) is a way forward in improving the prognosis for hospitalised COPD patients.

Depression, anxiety and health status after hospitalisation for COPD: a multicentre study in the Nordic countries.

Patients with chronic obstructive pulmonary disease (COPD) often report anxiety, depression and poor health status, not least if they experience repeated hospitalisations due to acute exacerbations. The aim of this study was to analyse the interrelationships between health status, anxiety, depression and physical status in COPD patients being discharged after hospitalisation. This was a prospective study of 416 patients in five university hospitals in each of the Nordic countries. Data included demographic information, lung function and co-morbidity. The Hospital Anxiety and Depression Scale and St. George's Respiratory Questionnaire (SGRQ) were applied to all patients. Both anxiety and depression were common among these patients. Anxiety was more common in women than in men (47% vs. 34%, P=0.009) and current smokers had a higher prevalence of both anxiety (54% vs. 37%) and depression (43% vs. 23%) than non-smokers (P<0.01). In general, the studied COPD patients had poor health status, especially those with anxiety, depression or both. Psychological status was independently related to all dimensions of SGRQ. Higher GOLD stages were significantly associated with increasing impairment in health status. In conclusion this multicentre study showed that anxiety and depression are common in patients with COPD, and, furthermore, that patients with psychological disorders have poor health status. Screening for depression and anxiety may help to identify patients with poor quality of life and an urgent need for intervention in order to improve their health status.