Asthma-COPD Overlap in Primary Care: Prevalence and Characteristics

One in five adults diagnosed with asthma, chronic obstructive pulmonary disease (COPD), or both in a primary care setting have asthma-COPD overlap (ACO) based on the criteria established by the Respiratory Effectiveness Group (REG) ACO Working Group, according to a study published in Annals of the American Thoracic Society.

To overcome the scarcity of information about individuals with ACO in primary care, the workgroup conducted a cross-sectional study of patients 40 years old and older with two or more primary care visits during a two-year period.

The data came from the United Kingdom’s Optimum Patient Care Research Database and was used to estimate disease prevalence and describe the characteristics of the condition in patients with COPD, asthma or ACO. The study also compared symptoms among the three.

The study included 2,165 patients (1,015 with COPD, 755 with asthma and 395 with ACO). The overall ACO prevalence was 20% among a patient population with a mean age of 70 among which:

• 40% were women
• 66% were obese or overweight
• 73% were former smokers
• 27% were current smokers.
• 53% had diabetes,
• 36% had cardiovascular disease,
• 30% had hypertension,
• 23% had eczema, and
• 21% had rhinitis.

According to the study, comorbid conditions -- the simultaneous presence of two chronic diseases or conditions in a patient -- were common in patients with ACO:

ACO prevalence was higher in patients diagnosed with both asthma and COPD (32%) compared with patients diagnosed with asthma only (14%) or COPD only (20%). Investigators also found that the significant variation in characteristics of patients with ACO and in the patterns of some of the comorbid conditions suggests that ACO as defined likely comprises a diverse group.

They wrote: “While the use of information recorded by clinicians in primary care offered the opportunity for our results to be more generalizable, our study also highlights the disadvantage of relying on clinical documentation.”

Click here to read the complete article in Pulmonology Advisor.

Determining and Understanding End-Stage COPD

Chronic obstructive pulmonary disease, or COPD, is a progressive condition that gets steadily worse and, over time, causes the body to become less able to take in enough oxygen. Ultimately, this can lead to death. The Centers for Disease Control and Prevention (CDC) says that chronic lower respiratory diseases, including COPD, are the “third leading cause of death in the United States” as of 2014.

Recognizing the end-stage symptoms of COPD can help a person cope and say goodbye to loved ones, make peace with their life, seek hospice care, and discuss their final plans. The following are the signs and symptoms that may indicate that a person is nearing the end of their life.

There are four stages of COPD ranging from mild to end-stage. Until recently, only forced expiratory volume in one second (FEV1) was the test used to show the severity and stage of COPD. FEV1 is a measure of how much air a person can exhale in a single breath. When it falls below 30% of the average amount, a person may be in the end stages of COPD. However, a new standard was adopted after 2011 that examines such factors as shortness of breath, the person's history of acute COPD episodes and the impact of the disease on their life. Per the new stages of COPD, mild stage 1: FEV1, is above 80% -- meaning the individual might not even notice that they have the condition.

Moderate, or stage 2: FEV1, is 50%-80% and is characterized by a chronic cough, excess mucus and shortness of breath. Severe, or stage 3: FEV1, is 30%-50% and is characterized by a chronic cough and struggle to exercise or do daily activities. The individual may also feel tired or sick.

End stage, or stage 4: FEV1, falls below 30%, severely affecting the patient’s daily life. There are two ways to measure this final stage of COPD:

• low blood oxygen, or hypoxemia
• hypoxia, which is low oxygen in the body's tissues
• cyanosis, a bluish hue to the skin due to oxygen deprivation
• chronic respiratory failure, which occurs when the respiratory system cannot take in enough oxygen or release enough carbon dioxide
• difficulty walking
• shortness of breath
• frequent lung infections
• difficulty eating
• confusion or memory loss due to oxygen deprivation
• fatigue and increased sleepiness
• frequent severe flare-ups
• more frequent trips to the hospital
• longer hospital stays
• anxiety or depression
• changes in consciousness
• trouble swallowing
• twitching or muscle weakness
• changes in the way a person breathes, or their pattern of breaths
• increasingly loud breathing

During the latter stages of COPD, a person tends to experience more severe flare-ups. This is often accompanies by more and longer hospital stays.

“Although a person will get a little better between flare-ups, they tend not to return to their previous condition,” Medical News Today reports. Thus, an individual’s health becomes steadily worse with each flare-up, and each flare-up tends to be worse than the last.

Another late-stage symptom is severe limitations in physical activities, including:

Click here to read the full article in Medical News Today.

Processed Meat Associated with Greater COPD Risk

Middle-aged women may be at an increased risk of developing chronic obstructive pulmonary disease (COPD) when they have a greater intake of processed meat. In a new international study assessing the 87,000-plus registrant Nurses’ Health Study II data, a team of France- and Boston-based investigators found that processed meat—along with other known risk factors including smoking and obesity—significantly increase middle-aged women’s risk of developing COPD.

Investigators sought to interpret the associated increased risk of COPD with processed meat, as well as the significance of increased risk factors in COPD-susceptible women.

This is especially important because the findings closely follow the classification of processed meat as a carcinogenic by the International Agency for Research on Cancer. Previous research has linked processed meat intake to greater risks of chronic diseases and all-cause mortality, investigators said.

“Regarding lung health, eight studies have reported that frequent processed meat intake was associated with decreased lung function, and greater COPD symptoms, exacerbations, or incidence,” researchers wrote.

In the report, the eight studies were cross-sectional or longitudinal with data collected from among various countries, and generated by men or women with a mean age greater than 65 years old.

According to the researchers, they studied 2,296,894 person-years’ worth of data from the nurses database. They identified 634 incident cases of COPD, while separating the average processed meat intake into intervals of “never/almost never;” less than one serving per week; or greater than one servings per week.

After adjusting for smoking and unhealthy diets, investigators said they found a positive association between processed meat intake of ≥1 serving per week and COPD risk versus never/almost never intake.

When arranged according to smoking or unhealthy diet, only people who smoked most of their lives and women with unhealthy diets had an increased risk of COPD. When adjusted for age, the risk for COPD nearly doubled in middle-aged women with two of the three observed unhealthy lifestyle habits. Among women with all three observed habits, COPD risk was raised nearly seven-fold.

Investigators believe their findings carry major public health implications, as the only currently understood metric for primary COPD prevention is avoidance of exposure to tobacco smoke.

“To our knowledge, only one cross-sectional study has assessed the modifying effects of antioxidant and oxidant intake in the association between processed meat and lung function, but without including the combined effect of unhealthy/healthy diet and smoking,” they said.

The nitrites added to meat products can play a role in an increased inflammatory process.

Investigators said processed meat intake is associated with increased COPD risk, and advised clinicians assess dietary interventions as part of their approach to promoting proper lung health.

Click her to read the full article on HCP Live Network.

Fitness In Middle Age Dramatically Cuts Men's COPD Odds

Having good heart-lung fitness in middle age could lower men's long-term risk of developing and dying from chronic obstructive pulmonary disease (COPD), a new study finds.

The study included more than 4,700 healthy middle-aged men in Denmark who were recruited between 1970 and 1971. Their average age at the time was 49. They provided information about their lifestyle habits and medical history, and their heart and lung fitness was assessed. The men were tracked for up to 46 years, with overall follow-up ending in 2016.

When compared to those who had low heart-lung fitness in middle age, COPD risk was 21 percent lower in those who had normal fitness and 31 percent lower in those whose heart-lung fitness was high. The risk of death followed a similar trend. The risk of dying from COPD was also 35 percent lower in those who had normal fitness and 62 percent lower in those whose heart-lung fitness was high. Those who had high fitness levels stayed healthier and had longer lives, as well – up to 1.5 or two years longer, according to the study published online June 18 in the journal Thorax.

The findings suggest that physical activity should be encouraged in adults “to delay development, progression and death from COPD,” said Dr. Gorm Mork Hansen in a journal news release. Hansen is from Herlev-Gentofte University Hospital in Copenhagen, Denmark.

Researchers said their findings add to previous studies that show that high levels of physical activity are associated with a reduced risk of COPD, and that a sedentary lifestyle may speed progression of the disease. However, the study only showed an association and not causation.

Links between heart-lung fitness and COPD aren't clear, but inflammation linked to inactivity may play an important role, according to the researchers.

COPD includes respiratory conditions that narrow the airways, such as emphysema and bronchitis. Smoking is the main risk factor for COPD, the fourth-leading cause of death worldwide, according to the World Health Organization.

Click here to read the full article on WebMD.

Study: Air Pollution Ages Lungs Faster, Increases Risk of COPD

Air pollution does a lot more damage to people’s lungs than scientists realized, according to a new study recently published in the European Respiratory Journal. Researchers say that they found that pollution ages lungs more quickly and putting people at higher risk of COPD.

Lung function declines as a part of natural aging, but exposure to particulate matter pollution ages lungs even faster – and the more pollution people are exposed to, the quicker their lungs age. For each additional five micrograms per cubic meter of particle pollution a person is exposed to on average annually, the lungs showed an equivalent of two years of aging, and a reduction in lung function.

Particle pollution is the mix of solid and liquid droplets in the air, according to the US Environmental Protection Agency, coming from dirt, dust, soot or smoke. It comes from coal- and natural gas-fired plants, cars, agriculture, unpaved roads and construction sites. For people living with air that has more than 10 micrograms per cubic meter of particle pollution, their lungs are much worse off. Among those in the most polluted areas, the number of COPD cases was four times higher than if a person lived with smokers, and half that of people who had been smokers.

COPD, chronic obstructive pulmonary disease, is a series of lung diseases that block airflow and make it difficult to breathe. It's the third leading cause of death in the world. Although many with COPD smoked at one point in their lives, it can also be genetic, and it can be caused by a person's environment.

Researchers surveyed more than 300,000 people and participants were given tests to determine their actual lung function. The study went on between 2006 and 2010. The researchers then conducted multiple tests to see how long-term exposure to higher levels of air pollution was linked to the changes in how people could breathe. They factored for people's occupations that may expose them to pollution and to people's exposure to cigarette smoke.

Air pollution causes inflammation in the lungs, which narrows airways and makes it harder to breathe. Air pollution also increases the risk of heart disease, strokes and lung cancer. The test results were even worse for people living in low-income households because of poorer housing conditions, worse diets and more limited access to healthcare.

"Air pollution had approximately twice the impact on lung function decline and three times the increased COPD risk on lower-income participants compared to higher-income participants who had the same air pollution exposure," said study author Anna Hansell, a professor of environmental epidemiology in the Centre for Environmental Health and Sustainability at the University of Leicester.

The number of COPD cases is expected to increase dramatically over the next 10 years, and the rising levels of pollution will likely play a large role in that.

In the United States, earlier studies showed that 141 million Americans living in counties with unhealthy levels of particle pollution or ozone.

Click here to read the full article on CNN.

Patients with COPD Require More Care than Elderly Heart Failure Patients in a Hospital-based Home Care Setting

The elderly population is rapidly growing, while lifespans also increase. At the same time, the prevalence of chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) is also expanding.

In Sweden, the prevalence of heart failure among people age 80 or older is currently estimated at 10 percent while the prevalence of COPD is 8 percent among those aged 50—and increases by age.

Exacerbations of their condition without early treatment intervention often land elderly patients with advanced stages of COPD or CHF in the emergency room and/or hospital. CHF patients often are relieved of their condition through a combination of fluid restriction and diuretics, while moderate and severe exacerbation of COPD often is associated with an inflammatory response in the respiratory tract to an infection and demands antibiotics alone or a combination of antibiotics and steroids.

To gauge the effects of patient education and remote-based care technology on outcomes, researchers in Europe recently set about to determine if telemonitoring supported by hospital-based home care (HBHC) could detect exacerbations early and reduce the number of hospitalizations for patients with these conditions.

Researchers said that during the previous 15 years, a growing number of telehealth studies and reviews have included patients with CHF and/or COPD. Some of these studies have shown reduced morbidity and mortality, as well as positive effects on exacerbation and hospitalizations. However, to become successful, the introduction of a new home telemonitoring system in healthcare needs to be accepted by professional caregivers and their patients.

The most common barrier to telehealth tools was that patients had “no interest” and thought that the technology was too complicated. Considering this lack of familiarity to internet use, researchers employed a telemonitoring system—the Health Diary—based on digital pen technology. In a previous pilot study utilizing the digital pen technology, exacerbations of CHF were detected early, treatment was initiated at home by a specialized hospital-based home care unit, and hospitalization was avoided. In fact, none of the included subjects were hospitalized during the surveillance period of 13 months.

Considering the disease characteristics of CHF and COPD, researchers hypothesized that subjects in an HBHC setting of fragile, elderly patients with advanced stages of CHF or CPOD would exhibit differences regarding exacerbation frequency and subsequent need of healthcare. They set about to determine the healthcare utilization of elderly, sick patients with frequent hospitalizations, and which condition might dominate the need for care.

Additionally, patients with the most advanced form of COPD commonly present with right-heart failure. Primary outcome was exacerbation frequency and home healthcare contacts appearing during the intervention, thus, comparing COPD and CHF subjects. Secondary outcome was the number of hospitalizations during a one-year intervention, compared to the number of hospitalizations of the same subjects the one-year prior inclusion.

The causes behind hospitalization, whether urgent or planned, were of interest, as were the subjects’ experiences handling the technology, their participation in their own care, and heir knowledge of the illness and their feelings of security. Ninety-four patients with advanced diseases were enrolled (36 COPD and 58 CHF subjects) of which 53 subjects (19 COPD and 34 CHF subjects) completed the one-year study period. Death was the major reason for not finalizing the study. Compared to the one-year prior inclusion, the telehealth intervention significantly reduced hospitalization. Although COPD subjects were younger with less comorbidity, exacerbations and HBHC contacts were significantly greater in this group.

Thus, COPD subjects exhibit exacerbations more frequently, mainly because of disease characteristics, thus, demanding much more HBHC.

Click here to read the full study on Dove Press.

COPD Associated with Poorer Survival in Patients With NSCLC

Researchers have found that the impact of pre-existing chronic obstructive pulmonary disease (COPD) in patients with non-small cell lung cancer (NSCLC), that COPD is associated with shorter survival and marked differences in early stages of lung cancer.

Among the 66,963 patients diagnosed with NSCLC, the 22,497 with pre-existing COPD had poorer median overall survival (192 days) compared with patients without comorbid disease (206 days) and an 11 percent higher risk of death.

Median survival decreased among patients with COPD for all stages. The elevated risk of death associated with pre-existing COPD decreased with each stage of NSCLC; stage 1 patients had a 39 percent increased risk of death, stage 2 patients a 20 percent higher risk, stage 3 a 9 percent higher risk, and stage 4 patients had a 4 percent higher risk.

Older age, gender, race, comorbidity score and tumor grade were all significantly associated with higher risk of mortality.

“One potential explanation for worse prognosis of lung cancer patients with COPD could be because of inadequate cancer treatments, poor pulmonary function and lower quality of life,” researchers said. “Studies have also shown that COPD was an important predisposing factor for the development of respiratory-related complications and poorer long-term survival outcomes.”

The researchers relied on data from the Surveillance, Epidemiology and End Results-Medicare database, focusing on patients aged 66 years and older with COPD who were diagnosed with NSCLC at any stage between 2006 and 2010, and those individuals who were continuously enrolled in Medicare parts A and B in the 12 months prior to diagnosis.

The researchers determined that those with chronic bronchitis had a more significant impact on time-to-death compared with emphysema for all stages of cancer.

The increased risk of death associated with chronic bronchitis compared with emphysema followed similar patterns seen among the COPD and non-COPD cohorts, with risk of death decreasing with each stage of NSCLC. Stage 1 patients had a 40 percent higher risk of death, stage 2 had a 28 percent higher risk, stage 3 a 10 percent higher risk, and stage 4 patients had a 6 percent higher risk.

Click here to read the full article on AJMC.

Living With COPD: Tips

For those people who struggle with chronic obstructive pulmonary disease (COPD), the simple act of breathing can be a struggle. For many, COPD becomes a way of life, so steps must be taken to manage it.

COPD affects more than 16 million Americans, according to the Center of Disease Control and Prevention. However, millions more have COPD, but have not been diagnosed and are not being treated.

Symptoms of COPD include frequent coughing or wheezing, excess phlegm or sputum and shortness of breath. Adults who have COPD are more likely to be unable to work and have trouble with daily activities—symptoms that can be exacerbated for those who smoke and who aren’t physically active.

The impacts of COPD affect a person’s day-to-day life enormously, and they must be addressed. Per the CDC, one in four adults with COPD say they are not able to work while others are forced to miss work because of symptoms. Additionally, half of adults with COPD say they limit their activities because of health problems, and more than 33 percent say they have trouble walking or climbing stairs. Finally, long-term medical costs tend to be higher for adults with COPD than those without.

Mitigating COPD impacts

There are things that individuals can do to make living with COPD easier. The most important is to quit smoking, if you are. If help is needed, speak with your doctor. There are solutions that may be able to help you in your journey to help you breathe easier.

Secondly, ask your doctor about participating in pulmonary rehabilitation. It is a personalized treatment program – as mentioned above – that is designed to manage COPD symptoms to improve quality of life. For example, these plans may include learning to breathe better and conserve physical energy, and may include specific advice regarding the best foods and exercise.

Nearly important as participating in a pulmonary rehabilitation program is properly taking medications, which can help control symptoms such as coughing or wheezing.

Finally, though it is not really something an individual can control, try to avoid lung infections, which can cause serious problems in people with COPD. The CDC recommends some vaccines, such as flu and pneumonia, for people with COPD.

Click here for more information about living with COPD.

Takeaways for Primary Care Physicians Treating COPD

Chronic obstructive pulmonary disease (COPD) is complicated and requires intensive and specialized treatment, more so than some may have previously thought. That’s according to University of Pittsburgh investigators who

Decreasing and withdrawing from inhaler use should also be conducted an analysis of the current literature to synthesize the discussion about the current diagnosis and treatments for COPD.

In their brief, the researchers wrote that 30 million adults in the U.S. have COPD, and most of these patients have been diagnosed by a primary care physician—despite the complicated and specialized nature of the disease.

The study, “Diagnosis and Outpatient Management of Chronic Obstructive Pulmonary Disease,” was published in JAMA. In it, investigators identified 90 applicable studies and, from those, 26 included clinical trials, 21 were meta-analyses, 25 were observational studies and 18 included guidelines and other reports.

The authors of the new study found that the primary risk factor for COPD diagnosis is tobacco smoke. They did note that other exposure to inhaled particles, such as indoor cooking or smoke from wood and other fuels, could also play a role.

Researchers noted that a patient’s misuse of inhaler devices for COPD pharmacotherapy is “both incredibly common and oftentimes unnoticed by healthcare providers.” Additionally, the authors believe that better screening for and correcting improper use of inhalers could lead to improved disease control and reduced care costs.

Craig Riley, MD, lead researcher of the review, told MD Magazine, “An inordinately large number of patients are either diagnosed presumptively without spirometry (and may not have COPD) or are diagnosed with other conditions (and may not have them) despite having exposures and symptoms consistent with possible COPD. Incorrect diagnoses lead to incorrect and ineffective treatments.”

Riley noted that people’s understanding of how inhaler devices work should allow providers to screen patients for proper use. Likewise, if a patient is unable to adequately draw medication into their lungs, they will not see a benefit and are at higher risk of clinical deterioration.

considered, especially in patients who are able to maintain stability of two years or longer without a moderate to severe exacerbation of symptoms.

Pulmonary rehabilitation has a greater comparative benefit on COPD symptoms, hospitalizations and death than pharmacotherapies, Riley said. He also noted that a majority of COPD patients are never made aware of these pulmonary rehabilitation programs, which are meant to combine strength and endurance training with educational, nutritional and psychosocial support. As well, the programs are designed to help patients improve cardiovascular fitness, physical activity levels and symptoms in COPD patients.

“Greater availability and utilization of pulmonary rehabilitation has the potential to improve quality of life, decrease hospitalization costs and has been suggested to improve mortality following hospitalization,” Riley said.

Click here to review all of the findings in MD Magazine.