Die chronisch-obstruktive Lungenerkrankung trägt weltweit erheblich zu Morbidität und Mortalität bei. Charakterisierend sind chronische Atemwegsbeschwerden, persistierende Atemwegsobstruktion und Exazerbationen. Die Diagnose erfolgt spirometrisch nach Bronchodilatation. Für eine erfolgreiche Langzeittherapie ist die strukturierte Erhebung auslösender Noxen, der Symptomlast, der Exazerbationsanamnese sowie relevanter Komorbiditäten essenziell. Therapieziele sind die Prävention von Lungenfunktionsverlust und Exazerbationen sowie die Reduktion der Symptomlast. Dieser Beitrag stellt Konzepte zur Diagnostik und Therapie bei Diagnosestellung, im Langzeitverlauf, bei Exazerbationen und im Rahmen der palliativen Versorgung vor. Ein besonderes Augenmerk liegt auf der individualisierten Inhalationstherapie unter Beachtung von Symptomen, Exazerbationen und der Eosinophilenzahl im Blut sowie auf evidenzbasierten nichtpharmakologischen Interventionen wie Tabakentwöhnung, Rehabilitation, Langzeitsauerstofftherapie, nichtinvasiver Beatmung und Lungenvolumenreduktion.

BACKGROUND:Pulmonary rehabilitation (PR) is beneficial, yet outcome assessment remains inconsistent. A multidisciplinary D-A-CH working group reviewed evidence, introduced new measures, and explored emerging PR concepts. SUMMARY:The meeting emphasized patient-reported and clinician-reported outcome measures. A key focus was the minimal clinically important difference (MCID), a widely used metric which is applied inconsistently and is highly dependent on the baseline value. The "performance score" (T2D = T2 + (T2-T1)) takes baseline status (T1) into account by combining the discharge value (T2) with the improvement (T2-T1) before and after treatment, based on the distribution. This simple descriptive approach results in a baseline-adjusted MCID estimator, with a planned multicenter study to validate its use in chronic obstructive pulmonary disease rehabilitation. Further discussions addressed epistemic trust, crucial for patient adherence and interdisciplinary collaboration, with a study planned to assess its impact. Dysfunctional breathing (DB), often overlooked in PR, was highlighted, emphasizing the need for standardized diagnostic tools. The role of artificial intelligence (AI) in PR, including large language models, was explored, with surveys planned to evaluate patient and provider perceptions. KEY MESSAGES:The T2D performance score offers a dynamic approach to assessing PR progress, addressing MCID limitations. Standardized methods for epistemic trust and DB diagnosis are essential for better recognition and management. AI integration in PR presents opportunities for personalized rehabilitation but requires further evaluation. The D-A-CH working group remains committed to advancing PR through evidence-based strategies and international collaboration.

Chronic obstructive pulmonary disease (COPD) is among the leading causes of death worldwide and is characterized by chronic respiratory symptoms, persistent airflow limitation, and exacerbations. Diagnosis is confirmed by post-bronchodilator spirometry. Effective long-term management requires a structured assessment of relevant exposures, symptom burden, exacerbation history, and comorbidities. Key goals of treatment include reducing both symptom and disease burden and preventing future exacerbations, which are often associated with increased lung function decline. This article summarizes practical concepts for diagnostic work-up and therapeutic decision-making at the time of diagnosis, during follow-up, in acute exacerbations, and in the context of palliative care. It highlights individualized inhaled therapy, guided by symptoms, exacerbations, and blood eosinophil counts, as well as evidence-based non-pharmacological interventions such as smoking cessation, pulmonary rehabilitation, long-term oxygen therapy/non-invasive ventilation, and lung volume reduction strategies.

BACKGROUND:Eosinopenia has been associated with adverse outcomes in community-acquired pneumonia (CAP). However, its relationship with hospital resource use remains unclear. RESEARCH QUESTION:What is the association between admission eosinophil counts and hospital resource use among adults with CAP? STUDY DESIGN AND METHODS:This prospective multicenter cohort study (Community-Acquired Pneumonia Network of Competence [CAPNETZ]; Identifier: 2024-07-11-CHV6) has enrolled patients ≥ 18 years of age with CAP in university hospitals in Germany since 2017. Associations between admission blood eosinophil counts and hospital resource use-ICU admission, mechanical ventilation, and length of stay-were assessed using multivariable regression models. The optimal eosinophil count threshold for stratifying patients by ICU admission and mechanical ventilation rates was identified, and outcomes were compared between patients above and below this threshold. RESULTS:Lower eosinophil counts at admission were associated with increased ICU admission (n = 1,639; P < .001), including among patients treated with systemic glucocorticoids (P = .002) and those not receiving glucocorticoids (P = .047). Lower eosinophil counts also were associated with higher rates of mechanical ventilation (P = .014) and longer hospital stays (P = .024). An eosinophil count threshold of 10 cells/μL was identified as the cutoff that best distinguished patients with higher vs lower risk of ICU admission and mechanical ventilation. Patients with eosinopenia (≤ 10 cells/μL) showed higher ICU admission rates (14.2% vs 8.5%; P < .001; adjusted OR, 1.78), increased mechanical ventilation rates (9.1% vs 5.2%; P = .003; adjusted OR, 1.82), and longer hospitalization (mean, 10.2 days vs 9.0 days; P = .013). INTERPRETATION:Our results show that admission eosinopenia (≤ 10 cells/μL) was associated with greater hospital resource use and may serve as a practical biomarker for health care resource planning. CLINICAL TRIAL REGISTRATION:German Clinical Trials Register; No.: DRKS00005274; URL: https://drks.de/.

BACKGROUND:Chronic obstructive pulmonary disease (COPD) substantially contributes to morbidity and mortality worldwide. We aimed at estimating Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric grade-specific mortality in COPD for Germany, using data from a large-scale cohort of patients with COPD. METHODS:Using COSYCONET data, a cohort of 2741 patients diagnosed with COPD was followed over up to 9 years. We estimated mortality rates for GOLD grades 1 to 4 and stratified into age and sex groups. An exponential survival model was used to estimate mortality after checking model assumptions. Additionally, a Cox proportional hazards model was estimated as plausibility check for the exponential model. RESULTS:A total of 345 deaths were observed during the follow-up period. The data fitted well to an exponential survival model when the first year of follow-up was excluded, suggesting a "healthy participant effect". GOLD grade was a strong predictor of mortality, with hazard ratios of 1.6, 3.2, and 8.8 for GOLD 2-4 compared to GOLD 1. Hazard ratios of the Cox model were similar (1.7, 3.4, and 10.0 for grades 2-4 compared to grade 1). At a given grade, mortality strongly increased with age. 1-year mortality ranged from 0.5 % (GOLD 1, <55 years, females) to 54.9 % (GOLD 4, 80+ years, males). Mortality was lower among females by approximately 25 %. CONCLUSION:Based on our findings, mortality in COPD depends on GOLD grade, age, sex and smoking status. Parametric estimation allowed to estimate 1-year mortality for each combination of COPD grade and age group, including uncertainty estimates.

Background:Body weight plays an intricate role in COPD, as obesity can impair lung function and thus might affect COPD categorization. We asked to which extent overweight/obesity affects conventional COPD scores taking into account lung function and potential restrictive patterns (PRISm, preserved ratio and impaired spirometry). Methods:Patients of the COSYCONET cohort were included. Outcomes were the modified Medical Research Council (mMRC) questionnaire, the COPD Assessment Test (CAT), CAT question #4 (dyspnea upon exertion), the St George's Respiratory Questionnaire (SGRQ) and its domains, and the EQ-5D-VAS (EuroQoL-5-dimension) questionnaire for generic quality of life. Body mass index (BMI) was categorized into <25, ≥25 to <30, and ≥30 kg/m2. The relationship between outcomes and predictors including airway obstruction, lung hyperinflation, air trapping and CO diffusing capacity was assessed by generalized linear models in a repeated measures design. Results:Data from visits 1, 3, 4 and 5 were available in n=2478, 1855, 1291 and 944 patients, respectively, of whom 169, 132, 95 and 63 fulfilled the PRISm criterion. For mMRC, CAT total, CAT dyspnoea (#4), EQ-5D-VAS, SGRQ total, Activity and Impact, scores were higher in the upper two BMI categories compared to the lower one (p<0.05 each), without further significant dependence on PRISm or an interaction between BMI and PRISm. For SGRQ Symptoms, only the upper BMI category showed a significantly higher score. All scores depended (p<0.05 each) on lung function and exacerbation history in terms of GOLD group E. Conclusion:For common indicators of the burden from COPD, BMI played a significant role by increasing these scores even if confounders were taken into account. Compared to the lowest BMI category, there was a continuous increase with overweight and obesity. Categorization into PRISm did not influence the relationship between BMI and symptom scores. The underlying mechanisms probably involve mechanical but also systemic factors. Based on this, COPD categorizations based on the scores studied probably should consider the effects of BMI. Clinicaltrialsgov:NCT01245933.

Atrial fibrillation (AF) frequently occurs in patients with chronic obstructive pulmonary disease (COPD) and is associated with adverse clinical outcomes. We aimed to identify patients at risk for AF using amplified p-wave duration (APWD) analysis on electrocardiogram (ECG) as non-invasive tool to diagnose an atrial cardiomyopathy (AtCM) which is an established risk factor for AF. This subgroup analysis of the prospective COSYCONET cohort included 2,385 COPD patients from 31 study centers with baseline sinus rhythm ECG and at least one follow-up examination. Of these, 73 patients showed AF during follow-up and were propensity-score matched to controls. APWD was measured at baseline and future major adverse cardiac and cerebrovascular events (MACCE) and health related outcome were assessed. 219 COPD patients (70 [64–74] years, 79.5

INTRODUCTION:Long-term studies as well as adequate methods accounting for attrition are necessary to measure the longitudinal change in health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). The aim of this analysis was to evaluate the change in HRQoL, measured by the EQ-5D-3L, over 6 years, while adequately accounting for dropouts. METHODS:We examined 6-year mean changes in HRQoL for 2701 COPD patients from the COSYCONET cohort study, based on data from baseline and follow-up visits after 1.5, 3, 4.5, and 6 years. Patients who dropped out during the 6-year follow-up were included in the analysis by imputing missing values using multiple imputation. We incorporated information on dropout reason in the imputation model and used additional information on HRQoL for dropouts to assess the imputation model. RESULTS:Average EQ-5D-3L deteriorated significantly by -0.121 (95 %-CI: 0.125; -0.117) over 6 years for all patients and by -0.047 (95 %-CI: 0.049; -0.045) when patients who dropped out because of death were excluded. Patients with impaired forced expiratory volume in 1 s (FEV1) in percent of predicted normal values at baseline had a more pronounced 6-year mean decline in HRQoL. Inclusion of dropout information in the imputation model was informative. Assessment of the imputed data revealed that performing multiple imputation produced less biased results compared to complete case analysis. CONCLUSION:The HRQoL decreased significantly over time for COPD patients. We propose a method to include all dropouts as well as additional information on dropouts to reduce bias in the results.

Rationale: In chronic obstructive pulmonary disease (COPD), impaired left ventricular (LV) filling might be associated with coexisting heart failure with preserved ejection fraction (HFpEF) or due to reduced pulmonary venous return indicated by small LV size. Objectives: We investigated the all-cause mortality associated with small LV or HFpEF and clinical features discriminating between both patterns of impaired LV filling in patients with COPD. Methods: We performed transthoracic echocardiography (TTE) in patients with stable COPD from the COSYCONET (COPD and Systemic Consequences and Comorbidities Network) cohort to define small LV as LV end-diastolic diameter below the normal range and HFpEF features according to recommendations of the European Society of Cardiology. We assessed the ratio of early to late ventricular filling velocity (E/A), ratio of early mitral inflow velocity to annular early diastolic velocity (E/e'), serum N-terminal pro-brain natriuretic peptide, high-sensitivity troponin I, airflow limitation (FEV1), lung hyperinflation (residual volume), and gas transfer capacity (DlCO) and discriminated patients with small LV from those with HFpEF features or no relevant cardiac dysfunction as per TTE (normalTTE). The primary outcome was all-cause mortality after 4.5 years. Measurements and Main Results: In 1,752 patients with COPD, the frequency of small LV, HFpEF features, and normalTTE was 8%, 16%, and 45%, respectively. Patients with small LV or HFpEF features had higher all-cause mortality rates than patients with normalTTE: hazard ratio, 2.75 (95% confidence interval, 1.54-4.89) and 2.16 (95% confidence interval, 1.30-3.61), respectively. Small LV remained an independent predictor of all-cause mortality after adjusting for confounders including exacerbation frequency and measures of residual lung volume, DlCO, or FEV1. Compared with normalTTE, patients with small LV had reduced LV filling, as indicated by lowered E/A. Yet, in contrast to patients with HFpEF features, patients with small LV had normal LV filling pressure (E/e') and lower concentrations of N-terminal pro-brain natriuretic peptide and high-sensitivity troponin I. Conclusions: In COPD, both small LV and HFpEF features are associated with increased all-cause mortality and represent two distinct patterns of impaired LV filling. Clinical trial registered with www.clinicaltrials.gov (NCT01245933).

Background:Exacerbation risk of patients with COPD is thought to be influenced by type 2 inflammation, with blood eosinophil counts and fractional concentration of exhaled nitric oxide (Feno) as potential biomarkers. Research Question:Are there different associations of blood eosinophils and Feno with exacerbation risk and severity in COPD, indicating a different role of local inflammation vs systemic factors? Study Design and Methods:Data were taken from 3 visits (1.5 years apart) of the longitudinal COPD and Systemic Consequences-Comorbidities Network (COSYCONET) cohort, comprising a broad range of clinical and functional assessments. We determined the relationships between eosinophil counts and Feno vs exacerbations, defined either via categorization to Global Initiative for Chronic Obstructive Lung Disease group E (≥ 2 moderate or ≥ 1 severe), or as ≥ 1 severe exacerbation in the year before each visit. Analyses were performed via generalized linear models. Results:The final data set included 384, 255, and 206 patients at visits 6, 7, and 8, respectively. According to the multivariable analyses, exacerbation risk defined via Global Initiative for Chronic Obstructive Lung Disease group E was associated with elevated values (≥ 25 ppb) of Feno (P = .003; OR, 1.90), but not eosinophil counts. In contrast, the risk for severe exacerbations was linked to eosinophils, but not to Feno. This relationship was expressed as either elevated risk with counts ≥ 100 and < 300 M/L (P = .017; OR, 1.98) or as reduced risk (P = .046; OR, 0.57) < 100 M/L. The results were robust against the inclusion of patients who actively smoke or with the comorbidity of asthma. Interpretation:Our observations suggest a differential role of type 2-related biomarkers Feno and eosinophils for exacerbation risk and severity. Feno seemed superior regarding a broad range of exacerbations predominantly involving local airway events, whereas systemic eosinophils played a larger role in severe exacerbations. The findings also suggest that a low eosinophil count might indicate a low risk of severe exacerbations, whereas highly elevated counts did not play a statistical role. Clinical Trial Registration:ClinicalTrials.gov; No.: NCT01245933; URL: www.clinicaltrials.gov.

Zusammenfassung Einleitung Wie bei anderen chronischen Erkrankungen ist auch bei der chronisch-obstruktiven Lungenerkrankung (COPD) zu erwarten, dass der Verlauf positiv beeinflusst wird, wenn die Patienten gut über ihre Erkrankung informiert sind und angemessen damit umgehen. Hierbei dürfte eine vergleichbare Einschätzung des Wissensstands und Umgangs von strukturierten, systematisch entwickelten Fragebögen profitieren, die allerdings bislang in Deutschland nicht publiziert sind. Methoden Zur Entwicklung der Fragebögen wurden insgesamt 310 Patienten mit COPD in drei pneumologischen Praxen und einer Klinik rekrutiert. Basierend auf statistischen Kriterien und inhaltlichen Bewertungen durch Fachärzte wurden durch Auswahl und Modifikation aus publizierten Studien und Schulungsunterlagen jeweils zwei Fragebögen zum Wissen (17 Fragen) bzw. Umgang (25 Fragen) erstellt. Aus diesen Fragebögen wurden darüber hinaus zwei kurze Versionen mit 5 bzw. 3 Fragen erstellt, um eine extrem schnelle Einschätzung des Wissens und des Umgangs der Patienten zu ermöglichen. Alle Fragebögen beinhalteten außerdem eine visuelle Analogskala zur Selbsteinschätzung von Wissen und Umgang. Als statistische Verfahren zur systematisch geleiteten Auswahl wurden Korrelations- und Regressionsanalysen eingesetzt. Ergebnisse Die Fragebögen zeigten teils erhebliche Wissensdefizite und v.a. ein unsystematisches, wenig zusammenhängendes Wissen. Der Umfang dieses Wissens war mit dem Lebensalter negativ und mit der Teilnahme an Schulungen positiv korreliert. Dies galt ebenfalls für den Umgang mit der Erkrankung. Auch der Zusammenhang der Antworten auf die Wissensfragen profitierte von der Teilnahme an Schulungen. In jedem Fall korrelierten die visuellen Analogskalen der Selbsteinschätzung von Wissen und Umgang mit den Gesamtpunktzahlen korrekter Antworten. Diskussion Die Fragebögen zu Wissen und Umgang mit der COPD könnten u.a. im ambulanten Bereich eingesetzt werden, gegebenenfalls auch durch nicht-ärztliches Personal, um Defizite rasch zu erkennen und zu beheben oder als Anlass zu nehmen, eine Schulung zu empfehlen. Die Kurzversionen sowie die Analogskalen der Selbsteinschätzung erlauben zumindest eine orientierende Einschätzung. Möglicherweise sollten Schulungen mehr darauf abzielen, den Zusammenhang des Wissens durch besseres Verständnis zu fördern, da dies vermutlich das Memorieren begünstigt. Hierbei erscheinen ältere Patienten und solche mit geringem Bildungsstand auf sie angepasster Schulungen besonders bedürftig.