Background:Chronic obstructive pulmonary disease (COPD) management is complex and rapidly evolving. ChatGPT is a large language model (LLM) shown to generate treatment plans for chronic conditions, yet its accuracy, usefulness, and consistency for COPD remain poorly characterized. This study evaluated the accuracy, usefulness, and impact variability of simultaneous ChatGPT-4.0 responses to COPD medication management questions. Methods:Five COPD treatment questions were simultaneously entered into three separate computers using ChatGPT-4.0 during a single session, generating 15 total responses. Three residency-trained, board-certified clinical pharmacists rated each response across three domains - accuracy, usefulness, and impact variability - using a 3-point ordinal scale (0 to 2) via a three-round modified Delphi process. Consensus was defined a priori as unanimous agreement among all three panelists. Results:Of 45 response-domain ratings, consensus was achieved in 40 (88.9%). Accuracy ranged from poor (0) to good (2), usefulness from somewhat (1) to very useful (2), and impact variability from low (0) to high (2). For one question on stable COPD pharmacotherapy, all three simultaneous responses cited a retired clinical practice guideline, resulting in poor accuracy ratings. For two questions - treating exacerbations and managing a complex case - one response per question was rated higher in usefulness than the others. Conclusion:Simultaneous ChatGPT-4.0 responses to identical COPD prompts differed materially in accuracy and potential clinical impact. LLM outputs should augment rather than replace clinician judgment and must be deployed with current guideline grounding and appropriate local oversight.
Objective:To investigate changes in airway microbiota and immune markers across Chronic Obstructive Pulmonary Disease (COPD) stages and their associations with clinical phenotypes and nursing factors, providing a basis for precision nursing. Methods:284 stable COPD patients (GOLD 2-3) were enrolled. Sputum and clinical data were collected at baseline (T0), exacerbation (T1), and recovery (T2). Microbiota structure was analyzed via 16S rRNA sequencing, and levels of immune markers such as interleukin-8 (IL-8) and IL-1β were measured by Enzyme-Linked Immunosorbent Assay (ELISA). Statistical analysis was performed by integrating clinical scale scores and nursing adherence data. Results:At T1, airway microbial α diversity was remarkably lower than at T0 and T2 (p < 0.01). The relative abundances of Haemophilus and Prevotella increased, while those of Veillonella and Lactococcus decreased (p < 0.01). Levels of IL 8, IL 1β, and TNF α were elevated, and Secretory Leukocyte Protease Inhibitor (SLPI) levels were reduced at T1 (p < 0.01). Notable correlations were found between microbiota and immune markers (e.g., Haemophilus abundance with IL 8 levels, r = 0.52, p < 0.01), and these were positively associated with clinical scores such as COPD Assessment Test (CAT) and St. George's Respiratory Questionnaire (SGRQ) (p < 0.05). Patients with >80% inhaler adherence and regular breathing exercises/nutrition had higher microbial diversity and attenuated inflammation (p<0.05). Conclusion:The airway microbiota-immune axis in COPD patients demonstrates a disease stage-dependent imbalance, characterized by microbial dysbiosis and enhanced pro-inflammatory responses during acute exacerbation. Good nursing adherence can modulate this axis's homeostasis, offering novel targets for precision nursing.
Background:COPD is a chronic inflammatory disease where diet-derived carotenoids may counteract inflammation and improve COPD outcomes. Our objective was to evaluate associations between serum carotenoid levels and COPD outcomes. Methods:Low-income individuals with COPD in the Baltimore, Maryland area completed longitudinal assessment including a panel of 10 serum carotenoids, inflammatory and oxidative stress markers and COPD outcomes. A total carotenoid level was created by summing the individual value for each carotenoid. Adjusted regression analyses were performed to analyze the association between total and individual carotenoids and COPD outcomes. Results:Of 98 participants, two-thirds had a household income less than $30,000. In adjusted analyses, each SD increase of total and individual carotenoid levels was significantly associated with better COPD-related health scores and associated with lower frequency of severe exacerbations. Total carotenoid levels had an inverse relationship with tumor necrosis factor-α [TNF-α: -3.0% (-5.1, -0.8)], and interleukin-6 [IL-6: -9.5% (-16.0, -2.5)]. Conclusion:Higher serum carotenoid levels had a positive impact on COPD health status scores, inflammatory markers, and may lower the incidence of exacerbations. Future research should continue to investigate the role of nutrition as a complementary therapy for lung health.
Background:Airway clearance techniques (ACTs) are required in international bronchiectasis (BE) management guidelines, and high frequency chest wall oscillation (HFCWO) is the only ACT with a Centers for Medicare and Medicaid Services (CMS) reimbursement guideline. Objective:Compare patient demographics and clinical characteristics between BE patients using HFCWO to BE patients not using HFCWO. Methods:Bronchiectasis and Nontuberculous Mycobacteria Research Registry (BRR) (2008-2025) data were retrospectively analyzed. Patients were grouped by baseline HFCWO use and non-users were further stratified by selected CMS eligibility criteria (productive cough or more than two exacerbations per year) and subsequent HFCWO utilization. Results:Of 5,673 patients (median age 69 years), 518 used HFCWO and 5,155 did not. HFCWO users had higher rates of asthma (31.7 vs. 25.3%, P=0.002), gastroesophageal reflux disease (48.5 vs. 41.9%, P=0.004), primary ciliary dyskinesia (5.8 vs. 2.1%, P<0.001), allergic bronchopulmonary aspergillosis (3.3 vs. 1.7%, P=0.013) and nontuberculous mycobacteria (20.1 vs. 15.7%, P=0.011). Symptoms more common in HFCWO users included dyspnea (72.1 vs. 38.5%), fatigue (61.5 vs. 46.8%), cough (90.9 vs. 76.6%,), and hemoptysis (27.1 vs 19.8%) (all P<0.001). Median modified bronchiectasis severity index (mBSI) score was higher in HFCWO users (8 vs. 7, P<0.001), and HFCWO users more frequently received antibiotics, bronchodilators, hypertonic saline, inhaled and oral corticosteroids, indicating greater disease burden. Notably, 58% (2,703/4,679) of non-HFCWO users appeared to meet selected CMS symptom/exacerbation criteria and their characteristics resembled HFCWO users. Conclusion:These findings suggest areas to explore to standardize BE management and motivate clearer treatment guidelines to optimize patient health outcomes.
Objectives:The association between fractional exhaled nitric oxide (FeNO) and airway inflammation is evident. However, the precise relationship of FeNO with pulmonary health and all-cause mortality among participants without airflow limitation remains undisclosed. We investigated the association of FeNO with respiratory symptoms, lung function, and all-cause mortality in this population. Methods:Participants included in the 2007–2012 National Health and Nutrition Examination Survey cycles with complete questionnaire information, quality-controlled prebronchodilator spirometry data, acceptable FeNO data, and full follow-up records until December 31, 2019, were included. The skewed distribution of FeNO was addressed by applying natural logarithmic transformation. Multivariable linear regression, logistic regression, and Cox proportional-hazards regression analyses were used to investigate the relationship of FeNO with spirometry, respiratory symptoms, and all-cause mortality. Subgroup analyses were performed based on sex, age, body mass index, smoking status, and blood eosinophil count to validate the robustness of the results. Results:The data of 5842 eligible participants were analyzed. After adjusting for confounding factors, for each 1-unit increment in natural logarithm (ln) (FeNO), the risk of chronic cough and wheezing decreased by 28% and 22%, respectively. Additionally, forced vital capacity increased by 27.9mL, and forced expiratory volume in 1 second increased by 27.8mL. During the average follow-up of 10 years, 255 participants experienced mortality. There was a nonlinear relationship between FeNO and all-cause mortality. Specifically, when ln (FeNO) was <2.6 (FeNO<13.5ppb), the hazard ratio was 0.45 (95% confidence interval 0.29–0.70; p<0.001). The subgroup analyses demonstrated consistent results. Conclusions:Elevated FeNO was closely associated with fewer respiratory symptoms and improved lung function in a population without airflow limitation. A nonlinear relationship existed between FeNO and all-cause mortality, with mortality initially decreasing as FeNO increased, followed by stabilization.
Background:While bronchiectasis disproportionately affects postmenopausal women, the role of reproductive factors in its pathogenesis is not well characterized. We hypothesized that a shorter reproductive lifespan is associated with higher risk of bronchiectasis. Methods:We studied postmenopausal women in the Women’s Health Initiative study. The exposures included ages at menarche and menopause, and time between the 2 (reproductive lifespan). The outcome was the first incidence of bronchiectasis after Medicare enrollment, as reflected in the Medicare claims data. Incidence rates were calculated and a series of Cox proportional hazards models controlling for demographics, body mass index, smoking, oophorectomy, hormone therapy (HT), oral contraceptives, and comorbid conditions were created. Results:Cumulative incidence of bronchiectasis in the cohort of 96,996 women was 2.7%. Shorter reproductive lifespan was associated with higher bronchiectasis risk (trend p=0.01). Women with the longest reproductive lifespan (≥40 years) were at 12% lower risk than those with the shortest reproductive lifespan (<30 years; adjusted approximate hazard ratio [aHR]=0.88 [95% confidence interval (CI): 0.77, 0.99]). HT modified this relationship (interaction p=0.04): shorter reproductive lifespan was associated with bronchiectasis risk only in the absence of HT (trend p=0.01). Without HT, women with the reproductive lifespans ≥40 years were at 22% lower risk of bronchiectasis than those with the reproductive lifespans <30 years (aHR=0.78 [95% CI: 0.62, 0.94]). The use of HT was associated with a 19% greater risk of bronchiectasis (p<0.01). Conclusion:Longer reproductive lifespan is associated with reduced risk of bronchiectasis in postmenopausal women – but only in those without a history of HT use.
Background:Gene therapy is a promising approach to treating alpha-1 antitrypsin deficiency (AATD). This study is the first to assess knowledge, attitudes, and preferences of the alpha-1 patient community regarding gene therapies and gene therapy clinical trials. Methods:An electronic survey collected demographic and health characteristics among the AlphaNet population and assessed knowledge, attitudes, and preferences related to gene therapy using multiple-choice, Likert-scale, and open-ended questions. Results:Data were provided by 1112 participants (98% on augmentation therapy and 18% with liver disease). The number of correct responses to knowledge-based questions varied (range: 0–12; mean: 5.8/12 ± 3.1; median=6). While participants had generally positive perceptions of AATD gene therapy, attitudes and preferences differed between those at or above the knowledge median and those below. Those with higher knowledge were somewhat/very supportive of gene therapy research and development (56% versus 43%), somewhat/very willing to participate in a gene therapy clinical trial (70% versus 64%), and somewhat/very willing to receive a U.S. Food and Drug Administration-approved gene therapy (87% versus 74%) (all p< 0.001). A gene therapy capable of targeting both liver and lung disease was preferred, along with therapies that require the least frequent re-dosing. Conclusion:This study identifies knowledge, attitudes, and opportunities to correct misconceptions related to gene therapy in the alpha-1 community. Participants indicated desire for additional education, and increased knowledge was associated with more positive attitudes towards gene therapy. Thus, the benefit of educational efforts and materials may extend beyond the individual learner and also facilitate trial enrollment and therapy uptake.
Background:Lung sound analysis may capture chronic obstructive pulmonary disease (COPD) related physiology, but many methods are hard to interpret clinically. We developed a multidimensional acoustic physiology map using 4 indices from digital lung sounds: median respiratory frequency (MRF), long-term energy index (LTEI), subharmonic index (SubH), and harmonicity deviation index (HDI). Methods:In this single-center retrospective study, 235 adults were classified as Healthy (n=62), Stable COPD (n=85), or COPD Exacerbation (n=88). We analyzed 1403 posterior thoracic 15-second recordings. Between-group differences in the 4 indices were tested with the Kruskal–Wallis test; when significant, Dunn posthoc pairwise comparisons were performed with Holm adjustment. Multidimensional separation was evaluated in the z-scored 4-index space using principal component analysis and permutational multivariate analysis of variance. All tests were 2-sided with a P-value < 0.05 considered significant. Results:Overall group differences were significant for MRF (P-value =1.36×10-5), SubH (P-value =3.29×10-6), and HDI (P-value =4.74×10-8), whereas LTEI did not show a statistically significant overall effect (P-value =0.086). Posthoc analyses indicated that MRF and SubH primarily separated Stable COPD from both Healthy and COPD Exacerbation, while HDI primarily separated COPD Exacerbation from Healthy and Stable COPD. Group distributions were visualized with triangular heatmaps and summarized in a 3-axis model. Conclusion:Complementary acoustic indices reflect distinct domains of COPD-related sound generation and transmission. Although standalone classification performance was limited, the proposed map provides an interpretable framework for digital auscultation phenotyping and future composite scoring.
Background and objectives:The ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC), and the proportion of FEV1 percentage predicted are used to diagnose and determine disease severity in chronic obstructive pulmonary disease (COPD). This study investigated the prognostic capabilities of borderline FEV1 to FVC and low FEV1 on disease progression among a population at high risk for COPD. Methods:This study utilized 2-year follow-up data from the National COPD Screening Program. Participants were divided into 4 groups according to FEV1 to FVC and FEV1: normal ratio with normal FEV1, borderline ratio with normal FEV1, normal ratio with low FEV1, and borderline ratio with low FEV1. The outcomes were FEV1 decline and progression to airway obstruction. Results:This study included a total of 2969 patients at high risk for COPD. Compared with the normal ratio with normal FEV1 group, the borderline ratio with normal FEV1 (adjusted odds ratio [OR]=1.81, 95% confidence interval [CI]: 1.34 to 2.44) and borderline ratio with low FEV1 (adjusted OR=2.32, 95%CI: 1.46 to 3.69) groups showed higher risks of developing airway obstruction, while the normal ratio with low FEV1 group showed no significant change in risk (adjusted OR=1.31, 95% CI: 0.83 to 2.07). Further, the findings also were proven true in the general population with longer follow years by using data from the U.K. Biobank (the borderline ratio with normal FEV1 group: adjusted hazard ratio [HR] = 2.92, 95% CI: 2.28 to 3.74; and borderline ratio with low FEV1 group: adjusted HR = 4.53, 95% CI: 3.21 to 6.38). Conclusion:Participants with borderline FEV1/FVC have a higher risk of developing airway obstruction, regardless of a decline in FEV1.
Background:Multidisciplinary management of chronic obstructive pulmonary disease (COPD) that combines pharmacotherapy, patient education, and pulmonary rehabilitation (PR) is recommended to optimize outcomes. Virtual pulmonary rehabilitation (VPR) offers a novel approach to expanding access to care by addressing geographic barriers. Methods:We conducted a retrospective cohort study involving patients with COPD who were referred to a VPR program from the pulmonary clinic of a single academic center. Demographic information was collected. The Social Vulnerability Index (SVI) was determined and the mean distance to the nearest in-person PR program. The primary objective was to describe the characteristics of patients referred to VPR who enrolled in the program compared with those who did not. The secondary objectives were to understand reasons patients choose not to enroll in VPR and to evaluate changes in clinical outcomes before and after participation in the program, with comparisons across SVI. Results:A total of 278 patients were referred, of whom 63 (22.7%) either completed or were actively participating in the program. Of the patients referred, 23 (8.3%) were ineligible, and another 45 (16.2%) declined enrollment. The average age of enrolled patients was 76.7 (8.4) years, and most patients were female (N=38, 60.3%). The average SVI was 0.53 (medium social vulnerability). The average distance to an in-person PR center was 12.6 miles. There were no significant differences in SVI, distance to PR center, language, or race between enrolled and nonenrolled patients. Conclusion:VPR may serve as an effective, accessible option for patients with COPD to improve functional and patient-centered outcomes. However, despite mitigating geographic barriers through VPR, obstacles to expanding PR program enrollment persist.
Background:Acute exacerbations of COPD (AECOPDs) may cause exercise-induced desaturation (EID), affecting recovery and rehabilitation outcomes. The prevalence and clinical implications of EID during early postexacerbation pulmonary rehabilitation are unclear. This study aimed to determine the prevalence of EID in COPD patients recovering from AECOPDs, with and without long-term oxygen therapy (LTOT) at rest, and to compare clinical, functional, and physiological characteristics. Methods:This retrospective, multicenter study included 262 COPD patients admitted for inpatient pulmonary rehabilitation after AECOPDs. Participants were stratified by resting oxygen therapy status. EID was defined as a ≥4% fall in peripheral oxygen saturation from baseline with nadir <90% during the 6-minute walking test. Clinical, functional, and physiological parameters were compared across subgroups. Results:Overall, 132 patients (50.4%) exhibited EID. Prevalence was higher in patients on oxygen at rest (61.5%) than in those breathing room air (33.9%, p <0.0001). Patients on oxygen therapy had greater lung function impairment, reduced exercise capacity, and higher dyspnea-related disability. EID was associated with greater heart rate response in patients on supplemental oxygen but not consistently with perceived dyspnea or fatigue, highlighting the importance of objective oximetry during exercise testing. Regardless of EID, individuals on oxygen walked shorter distances than those on room air. Conclusions:EID is common in COPD patients recovering from AECOPD, especially those receiving LTOT, and is linked to more severe functional impairment. Systematic EID assessment using objective oximetry during early pulmonary rehabilitation may support individualized oxygen titration and exercise prescriptions. Prospective studies are needed to clarify its prognostic implications.
Despite compelling epidemiological evidence linking vitamin D deficiency to adverse outcomes in chronic obstructive pulmonary disease (COPD), asthma, and cystic fibrosis, randomized controlled trials have consistently failed to demonstrate clinically meaningful benefits from oral vitamin D supplementation. This disconnect between observational associations and interventional evidence represents a significant paradox in pulmonary medicine. Recent meta-analyses have found limited protective or therapeutic effects of oral supplementation on exacerbation rates, lung function, hospitalizations, or quality-of-life measures. We propose that this therapeutic failure reflects not a lack of vitamin D's efficacy but rather a fundamental limitation in the route of delivery. Oral vitamin D supplementation undergoes hepatic metabolism and systemic dilution before reaching respiratory tissues. High expression of cytochrome P450 family 24 subfamily A member 1, the vitamin D-inactivating enzyme, in pulmonary vasculature suggests that orally delivered vitamin D may be degraded before reaching the lung lumen. The respiratory epithelium possesses complete machinery for vitamin D activation, and vitamin D receptors are expressed throughout airway epithelial and immune cells, making direct pulmonary delivery mechanistically feasible. Preclinical studies demonstrate that nebulized or inhaled vitamin D reduces inflammation, protects epithelial barrier function, and improves lung function in murine models of respiratory disease without producing off-target systemic effects or hypercalcemia. Direct lung delivery of vitamin D represents an unexplored therapeutic strategy that could transform management of chronic respiratory diseases, like COPD, by achieving local therapeutic concentrations while minimizing systemic exposure. Clinical trials investigating safety, dosing optimization, and efficacy are warranted.
Background:The forced expiratory volume in 3 seconds (FEV3) to forced expiratory volume in 6 seconds (FEV6) ratio is a novel spirometry measure that identifies early airflow abnormalities, but its long-term prognosis value in the general population remains unclear. We aimed to evaluate the long-term all-cause mortality risk among participants with a reduced FEV3/FEV6. Methods:Data were obtained from the National Health and Nutrition Examination Survey cycles 1988–1994 and 2007–2012. Reduced FEV3/FEV6 was defined as an FEV3/FEV6 less than the lower limit of normal. Multivariable logistic regression was used to assess the relationship of reduced FEV3/FEV6 with comorbidities and chronic respiratory symptoms. The relationship between reduced FEV3/FEV6 and all-cause mortality was evaluated using Cox regression models. The nonlinear relationship between FEV3/FEV6 and all-cause mortality was assessed using restricted cubic splines. Subgroup analyses were conducted to validate the robustness of the relationship. Results:Overall, 25,159 participants were enrolled in the 308-month median follow-up analysis, of whom 8.8% (2225/25,159) had reduced FEV3/FEV6. Participants with reduced FEV3/FEV6 exhibited increased risks of congestive heart failure, asthma, chronic bronchitis, emphysema, respiratory symptoms, and all-cause mortality risk (adjusted hazard ratio=1.23, 95% confidence interval: 1.13–1.34, P<0.001). The findings remained consistent across subgroups. A nonlinear U-shaped association was observed between FEV3/FEV6 and all-cause mortality, with the turning point at 1.04. Conclusion:Participants with reduced FEV3/FEV6 had worse respiratory health outcomes, suggesting that FEV3/FEV6 can be used as a prognostic spirometry indicator.
Background:Individuals with chronic obstructive pulmonary disease (COPD) often face direct and indirect medical costs from unplanned emergency department visits and hospitalizations for acute exacerbations, out-of-pocket expenses for inhaled bronchodilators, and income loss from disability. Yet financial toxicity, which describes the objective burden and subjective distress resulting from medical costs, has not been studied in COPD. Individual experiences of financial toxicity in COPD offer insight into challenges that may be unique to this population. Methods:We conducted semistructured interviews with 30 purposively sampled individuals with physician-diagnosed COPD. Transcripts were analyzed using inductive coding by 2 independent coders, and codes and were categorized through thematic analysis. Results:Thirty participants completed semistructured interviews, of whom 56% were women, 43% non-Hispanic White, and 43% non-Hispanic Black. The mean age was 69.5 years, and 24 (70%) had public health insurance only. Several themes emerged including: (1) the sources of material burden in COPD; (2) adjustments to disease management, such as medication nonadherence or foregoing treatments; (3) adjustments to financial planning, including both changes to day-to-day spending and disruptions in major financial plans; (4) emotional impact; and (5) communication with health care providers. Conclusion:Our findings are the first, to our knowledge, to describe the impact of financial toxicity in individuals with COPD. Financial toxicity in COPD is common and may adversely impact disease self-management, financial self-management, and psychological well-being. Additional research is needed to examine its impact on patient-reported outcomes and to develop interventions to reduce its burden.
Background:Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of death in Canada. The Efficacy and Safety of Triple Therapy in Obstructive Lung Disease (NCT02465567) and Informing the Pathway of COPD Treatment (NCT02164513) randomized controlled trials demonstrated reduced exacerbations and all-cause mortality for patients with COPD on single-inhaler triple therapy (SITT). The 2023 Canadian Thoracic Society (CTS) COPD pharmacotherapy guidelines recommend triple therapy, and preferably SITT use, in patients with moderate to severe symptom burden and high future risk of exacerbations. The clinical impact of broader SITT use in Canada has not yet been studied. Aim:We aimed to estimate the benefit of appropriate SITT use according to CTS COPD guidelines on mortality, exacerbations, and their corresponding costs in Canada. Methods:We used a stochastic model using literature-derived characteristics (e.g., incidence, changes in COPD severity, treatment, mortality, and exacerbations) that simulated the Canadian COPD population. Patients were assigned percentage of forced expiratory volume in 1 second predicted levels, and their annual characteristics were modeled for 2025–2034 under 2 scenarios: “status quo” (current practice) and “increased SITT” (following CTS guidelines). Results:Based on our simulated results for the flagged population, “Increased SITT” use over 10 years compared to current treatment reduced moderate and severe exacerbation rates by 23% and 12%, respectively, for a reduction of 159,000 severe and 2.81 million moderate exacerbations and reduced the all-cause mortality rate by 22%. In the flagged population alone, this reduction in exacerbations would equate to a savings of CA$3.9 billion over 10 years. Conclusion:Appropriate use of SITT, informed by the 2023 CTS COPD guidelines, could lower mortality, exacerbation frequency, and their corresponding costs in patients with COPD.
Background:A translation gap exists in how patients with chronic obstructive pulmonary disease (COPD) utilize mitigation strategies to limit exposure to wildfire smoke. This study examines patients’ points of view about barriers and facilitators of strategy uptake. Methods:We performed semistructured, virtual interviews with members of Kaiser Permanente Northern California until thematic saturation. We recruited participants aged ≥65 in the lowest quartile of socioeconomic status because they are disproportionately exposed to air pollution with fewer resources to mitigate exposure. Qualitative analysis was performed using inductive and deductive approaches. Results:Of 90,696 adults, we interviewed 31 in January 2025. Participants were racially and ethnically diverse (19% Black, 10% Hispanic, 3% Native American, 68% non-Hispanic White), from 10 counties. Three major themes were: (1) patients tended to get wildfire and air quality information from internet and smartphone apps, not clinical encounters, but expressed openness to receiving information from clinicians, (2) there appeared to be modifiable barriers to uptake of mitigation strategies, such as education and supplying equipment (e.g., masks, air cleaners), and (3) patients preferred real-time alerts sent to their phones from trusted sources, such as health care entities, to change their behavior during periods of poor air quality. Conclusion:By understanding patients’ perspectives about their relationship with wildfire smoke, we gained practical information to begin designing interventions to protect patients’ health during periods of poor air quality.
Background:The Chronic Obstructive Pulmonary Disease (COPD) Exacerbation Recognition Tool (CERT) was developed to improve patients’ recognition of COPD exacerbations. This validation study concerned the cross-cultural and linguistic validation of 46 CERT translations across 25 countries and 6 continents. Methods:This study employed a rigorous, certified (International Organization for Standardization-17100) methodology. Dual forward translations for each language were developed by independent translators who were native speakers of the target language and then reconciled by a linguistic validation consultant (LVC). Independent linguists provided a back translation of the reconciled translation, which was reviewed by the LVC and project manager. Linguistic validation was performed for each language through cognitive debriefing interviews with at least 5 participants with COPD who were native speakers of the target language. These participants also reviewed 7 sets of images produced for different global regions to reflect patients from a diversity of cultures, countries, and religions, to determine if the images were representative of themselves and/or other people living with COPD. The images were amended as needed and reshown to the participants for approval. Results:The translations were found to be conceptually equivalent to the original CERT and harmonized with each other. Participants found the CERT easy to use and understand and confirmed that the images were representative of themselves and/or other people living with COPD. Conclusion:CERT translations were created using a patient-centric approach and appear to be easily understandable and valid across many languages and cultures.
Rationale:Nebulizers are an alternative to handheld devices for inhaled therapies in chronic obstructive pulmonary disease (COPD). Understanding nebulizer utilization patterns is essential to developing therapy guidelines. Objectives:We aimed to describe characteristics of nebulizer users versus nonusers and factors associated with baseline nebulizer use and longitudinal uptake. Methods:We analyzed the Subpopulations and Intermediate Outcome Measures in COPD Study, a prospective cohort of 2973 participants with or without tobacco use and/or COPD. We used cross-sectional multivariable logistic regression and interval-censored proportional hazard models to analyze factors associated with nebulizer use and uptake among tobacco-exposed participants with preserved spirometry (TEPS) and COPD from enrollment (Visit 1) through 4–7 years of follow-up (Visit 5). Results:Nebulizer utilization was highest in advanced COPD, 49% of Global initiative for chronic Obstructive Lung Disease (GOLD) Group D participants at baseline. Nebulizer treatments were primarily as-needed short-acting bronchodilators. Baseline nebulizer use was associated with respiratory exacerbations in the prior year (1, odds ratio [OR] 1.81, 95% confidence interval [CI] [1.24, 2.64]; 2, OR 1.86, 95% CI [1.07, 3.22]; 3 or more, OR 1.87, 95% CI [1.07, 3.28]), lower forced expiratory volume in 1 second (FEV1) (OR 2.81 per liter decrease, 95% CI [2.09, 3.77]), COPD Assessment Test (CAT) score >10 (OR 1.89, 95% CI [1.17, 3.03]), 6-minute walk distance (6MWD) (OR 1.03 per 10 meter lower 6MWD, 95% CI [1.02, 1.05]), and a history of asthma (OR 2.41, 95% CI [1.76, 3.30]). Longitudinal uptake was similarly associated with exacerbations, lower FEV1, CAT score >10, and asthma. Patterns were consistent between TEPS and COPD. Conclusion:Nebulizers were predominantly used by participants with frequent exacerbations, high symptom burden, and advanced COPD, and long-acting nebulized medications were underutilized. Randomized controlled trials are needed to compare nebulizers with hand-held devices.
Background:Chronic obstructive pulmonary disease (COPD) may influence bleeding in atrial fibrillation (AF). We evaluated bleeding and all-cause death risks under warfarin versus direct oral anticoagulants (DOACs). Methods:Based on a retrospective cohort from 12 centers of patients with AF on oral anticoagulation, we evaluated the associations of COPD and anticoagulant class with clinical outcomes using overlap-weighted logistic regression. Prespecified sensitivity and subgroup analyses were performed. Results:COPD was associated with higher bleeding risk only among patients treated with warfarin (total bleeding: odds ratio [OR] 2.53, 95% confidence interval [CI] 1.00–6.45; risk difference [RD] 9.05%, 95% CI 0.15%–22.50%; minor bleeding: OR 3.00, 95% CI 1.09–8.24; RD 8.53%, 95% CI 0.56%–21.53%). Among patients with AF and COPD, DOACs were associated with reduced risks of total bleeding (OR 0.08, 95% CI 0.01–0.50; RD –8.4%, 95% CI -22.0% to -5.3%) and minor bleeding (OR 0.01; RD -9.5%, 95% CI -23.1% to -4.5%) compared with warfarin. Subgroup analyses suggested that DOACs were associated with increased mortality at estimated glomerular filtration rate (eGFR) ≥60mL/min/1.73m² (OR 3.07, 95% CI 0.78–12.03; RD 9.9%) but lower mortality at eGFR <60mL/min/1.73m² (OR 0.20, 95% CI 0.05–0.78; RD -24.1%). Factor Xa inhibitors were associated with a higher major bleeding risk compared with dabigatran (OR 4.56, 95% CI 1.70–12.26; RD 10.2%, 95% CI 0.2%–20.1%; with a number needed to harm of 10). Conclusion:In AF with comorbid COPD, DOACs minimize bleeding versus warfarin and may confer survival benefit in renal impairment. Differential bleeding risk should be considered when choosing among DOACs.
Background:Individuals with chronic obstructive pulmonary disease (COPD) rely on inhaler-based medications to treat and control symptoms. Most patients do not use correct technique. Teach-to-goal (TTG) inhaler education programs have been found to improve inhaler technique. There is limited understanding as to whether TTG inhaler education is effective when delivered over the phone. Ojjective:We aimed to find out the effect of a phone-based TTG inhaler technique education program among Medicare Advantage beneficiaries with COPD. Study Design and Methods:Beneficiaries with a diagnosis of COPD within the prior 2 years, who had filled at least one maintenance inhaler prescription at least once in the prior year, had a value-based insurance design plan, and received the inhaler education component of the COPD intervention program were evaluated. Inhaler technique was measured by validated checklists, and patients self-reported their technique. Results:Of 1876 patients analyzed, n=13 used more than one inhaler. At the initial assessment, 39.4% of participants were using their inhalers incorrectly. By the end of the first education session, the percentage of participants who were using their inhaler incorrectly decreased to 6.9%. Interpretation:A phone-based TTG inhaler education program offered by a large national health plan demonstrated improvements in inhaler technique across different inhaler devices and subpopulations. The multiple-session approach was likely critical for longer-term retention of correct technique, though further study is needed to confirm this. Some subgroup populations are also at greater risk for baseline inhaler misuse and/or post-training inhaler misuse indicating a need for further evaluation of how to tailor inhaler education by individuals’ needs.
