Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis

Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.

Authors Jonkman NH, Westland H, Trappenburg JCA, Groenwold RHH, Bischoff EW, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton MJ, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJC, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ

International Journal of Chronic Obstructive Pulmonary Disease Volume 2016:11(1) Pages 2063—2074

Methods: Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models.
Results: Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes.
Conclusion: Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.


Incident opioid drug use and adverse respiratory outcomes among older adults with COPD

Nicholas T. Vozoris, Xuesong Wang, Hadas D. Fischer, Chaim M. Bell, Denis E. O’Donnell, Peter C. Austin, Anne L. Stephenson, Sudeep S. Gill, Paula A. Rochon
European Respiratory Journal 2016; DOI: 10.1183/13993003.01967-2015


We evaluated risk of adverse respiratory outcomes associated with incident opioid use among older adults with chronic obstructive pulmonary diseases (COPD).

This was a retrospective population-based cohort study using a validated algorithm applied to health administrative data to identify adults aged 66 years and older with COPD. Inverse probability of treatment weighting using the propensity score was used to estimate hazard ratios comparing adverse respiratory outcomes within 30 days of incident opioid use compared to controls.

Incident opioid use was associated with significantly increased emergency room visits for COPD or pneumonia (HR 1.14, 95% CI 1.00–1.29; p=0.04), COPD or pneumonia-related mortality (HR 2.16, 95% CI 1.61–2.88; p<0.0001) and all-cause mortality (HR 1.76, 95% CI 1.57–1.98; p<0.0001), but significantly decreased outpatient exacerbations (HR 0.88, 95% CI 0.83–0.94; p=0.0002). Use of more potent opioid-only agents was associated with significantly increased outpatient exacerbations, emergency room visits and hospitalisations for COPD or pneumonia, and COPD or pneumonia-related and all-cause mortality.

Incident opioid use, and in particular use of the generally more potent opioid-only agents, was associated with increased risk for adverse respiratory outcomes, including respiratory-related mortality, among older adults with COPD. Potential adverse respiratory outcomes should be considered when prescribing new opioids in this population.

In English Care should be taken when considering prescribing opioids to patients with COPD

COPD Respiratory / Asthma Pulmonary System Depression Depression decreases adherence to COPD maintenance medications

Article: Adherence to Maintenance Medications among Older Adults with Chronic Obstructive Pulmonary Disease: The Role of Depression, ennifer S. Albrecht, Yujin Park, Peter Hur, Ting-Ying Huang, Ilene Harris, Giora Netzer, Susan W Lehmann, Patricia Langenberg, Bilal Khokhar, Yu-Jung Wei, Patience Moyo, and Linda Simoni-Wastila, Annals of the American Thoracic Society, doi: 10.1513/AnnalsATS.201602-136OC, published online 22 June 2016.

Rationale: Among individuals with Chronic Obstructive Pulmonary Disease (COPD), depression is one of the most common yet under-recognized and under-treated comorbidities. Although depression has been associated with reduced adherence to maintenance medications used in other conditions, such as diabetes, little research has assessed depression’s role in COPD medication use and adherence. Objectives: The objective of this study was to assess the impact of depression on COPD maintenance medication adherence among a nationally representative sample of Medicare beneficiaries newly diagnosed with COPD. Methods: We used a 5% random sample of Medicare administrative claims data to identify beneficiaries diagnosed with COPD between 2006 and 2010. We included beneficiaries with two years of continuous Medicare Parts A, B, and D coverage and at least two prescription fills for COPD maintenance medications following COPD diagnosis. We searched for prescription fills for inhaled corticosteroids, long-acting β-agonists, and long-acting anticholinergics and calculated adherence starting at the first fill. We modelled adherence to COPD maintenance medications as a function of new episodes of depression using generalized estimated equations. Measurements and Main Results: Our primary outcome was adherence to COPD maintenance medications, measured as proportion of days covered (PDC). The exposure measure was depression. Both COPD and depression were assessed using diagnostic codes in Part A and B data. Covariates included sociodemographics, as well as clinical markers, including comorbidities, COPD severity, and depression severity. Of 31,033 beneficiaries meeting inclusion criteria, 6,227 (20%) were diagnosed with depression following COPD diagnosis. Average monthly adherence to COPD maintenance medications was low, peaking at 57% in the month following first fill and decreasing to 35% within six months. In our adjusted regression model, depression was associated with decreased adherence to COPD maintenance medications (OR 0.93; 95% CI 0.89, 0.98). Conclusions: New episodes of depression decreased adherence to maintenance medications used to manage COPD among older adults. Clinicians who treat older adults with COPD should be aware of the development of depression, especially during the first six months following COPD diagnosis, and monitor patients’ adherence to prescribed COPD medications to ensure best clinical outcomes.

Commentary: This study is saying that COPD patients who are depressed are less likely to keep up with their COPD medications. So two messages here for patients: a) if you are depressed seek help b) it is vital for your COPD that you keep on taking your medication (inhalers) every day without fail.

As we know that so many inhalers are prescribed but not taken, this is one thing that could be done to increase compliance and reduce exacerbations. Look out for the COPD patient who is depressed.


Increased Risk of Death at and During Hospitalization for an Acute Exacerbation of COPD

Clinical Factors Associated with an Increased Risk of Death at and During Hospitalization for an Acute Exacerbation of COPD (AECOPD) and for a Short Period after Discharge

Ernesto Crisafulli, Veronica Alfieri, Antoni Torres, Alfredo Chetta

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Acute exacerbation of COPD (AECOPD) is an unfavourable event interrupting the stable phase of disease and that in some cases require admission to hospital; this aspect may influence the general prognosis during hospitalization and for a short period after discharge. In this editorial, we have highlighted some aspects related to the close link between AECOPD and all-cause mortality; we report several clinical factors that may be defined as risk factors for mortality at admission, during hospitalization and for a short period after discharge. These predictors of death in AECOPD may help physicians to accurately predict prognosis and therefore, behave differently in the clinical management of COPD patients.

Crisafulli E, Alfieri V, Torres A, Chetta A. Clinical Factors Associated with an Increased Risk of Death at and During Hospitalization for an Acute Exacerbation of COPD (AECOPD) and for a Short Period after Discharge. Journal of Respiratory Research 2016; 2(2): 44-46 Available from: URL:

One-year Mortality in COPD Exacerbation: The Effect of Physical Activity

One-year Mortality in COPD After an Exacerbation: The Effect of Physical Activity Changes During the Event (2016) Cristóbal Esteban , Susana Garcia-Gutierrez , Maria J Legarreta , Ane Anton-Ladislao , Nerea Gonzalez , Iratxe Lafuente , Nerea Fernandez de Larrea , Silvia Vidal , Marisa Bare , José M. Quintana , IRYSS -COPD group COPD: Journal of Chronic Obstructive Pulmonary Disease 


Mortality is one of the most important outcomes in patients with chronic obstructive pulmonary disease (COPD). Different predictors have been associated with mortality, including the patient’s level of physical activity (PA).

The objective of this work was to establish the relationship between changes in PA during a moderate-to-severe COPD exacerbation (eCOPD) and 1-year mortality after the index event. This was a prospective observational cohort study with recruitment of 2,484 patients with an eCOPD attending the emergency department (ED) of 16 participating hospitals. Variables recorded included clinical and sociodemographic data from medical records, dyspnea, health-related quality of life, and PA before the index eCOPD and 2 months after the hospital or ED discharge, as reported by the patient.

In the multivariate analysis worsening changes in PA from baseline to 2 months after the ED index visit [odds ratio (ORs) from 2.78 to 6.31] was related to 1-year mortality, using the age-adjusted Charlson comorbidity index (OR: 1.22), and previous use of long-term domiciliary oxygen therapy or non-invasive mechanical ventilation at home (OR: 1.68). The same variables were also predictive in the validation sample. Areas under the receiver operating characteristic curve in the derivation and validation sample were 0.79 and 0.78, respectively.

In conclusion, PA is the strongest predictor of dying in the following year, i.e., those with worsened PA from baseline to 2 months after an eCOPD or with very low PA levels have a higher risk.

Takeaway for patients

Being physically active improves the likelihood of you surviving a moderate-to-severe COPD exacerbation.

Response to pulmonary rehabilitation: toward personalised programmes? | European Respiratory Society –


Personalised pulmonary rehabilitation with multidimensional response profiling could aid efficiency and effectiveness

Clinical practice should be based on the best scientific evidence, which does not always correspond to evidence-based medicine, involving guidelines, meta-analyses and protocols as a basis for clinical approach [1, 2]. There is no need of further randomised controlled trials (RCTs) for evidence that pulmonary rehabilitation (PR) improves daily symptoms, exercise performance and health status in patients with chronic obstructive pulmonary disease (COPD), independently of disease stage and complexity [3]. Although the direct demonstration of a clear benefit in survival is lacking (as is also true for most therapies used in COPD), PR is well recognised as a fundamental part of the integrated care of these patients and it has been incorporated in most guidelines for their management [4].

Due to the current restraints in healthcare resources and the different opportunities in healthcare policies all over the world [5], we need solid outcomes to decide how to optimally invest money in this field. Clinical observations have attempted to define predictors of PR success, evaluating outcome measures able to discriminate responders from nonresponders to treatment [68]. Nevertheless, the improvement of a single outcome measure like exercise tolerance in an RCT may not be enough to catch the real and/or perceived benefit that the individual patient may achieve, just like the glycaemia control might not be a perfect or unique index of control of diabetes and related complications in different environments and stages along the natural history of this disease [9].

As reported in this issue of the European Respiratory Journal, SPRUIT et al. [10] looked for a profile of multidimensional response to PR in >2000 COPD patients based on eight different outcome measures, including symptoms, exercise performance, health and mood status, and activities of daily life. Analysis led to clustering of patients into four groups with different response profiles and different prevalence: “very good responder” (18.3%), “good responder” (35.9%), “moderate responder” (35.4%) and “poor responder” (10.5%). The “very good responder” had more severe dyspnoea, more hospitalisations per year, worse exercise tolerance, worse performance and satisfaction scores for activities of daily life, more severe anxiety and depression, worse health status, and was more likely to follow an inpatient PR programme compared with the other three categories. Interestingly, even the “poor responder” may show that PR is a therapy of clinical value in those COPD patients who are symptomatic despite optimal medical therapy.

Overall, it seems that the best responders are the most severe patients, as probably expected.

More: Response to pulmonary rehabilitation: toward personalised programmes? | European Respiratory Society –

Respiratory Qol Worse in Breathless Patients With COPD Than Cancer

Respiratory health-related quality of life (HRQoL) is worse in breathless COPD patients than in breathless cancer patients, researchers have found.

Although breathlessness is common in patients with advanced chronic obstructive pulmonary disease (COPD) and in patients with advanced cancers of all primary sites, little is known about the impact of breathlessness on HRQoL.

Dr. Morag Farquhar and colleagues from the University of Cambridge, U.K., used the Chronic Respiratory Questionnaire-Original (CRQ-Original) to examine differences in respiratory HRQoL between 139 patients with breathlessness due to advanced COPD or advanced cancer who were referred for palliative care.

Patients with advanced COPD had lower median scores for all four CRQ domains, compared with patients with advanced cancer, though the differences were statistically significant only for three domains: dyspnea, emotional function, and mastery.

The differences in emotional function and mastery exceeded the minimally clinically important difference of 0.5 (on a scale of 0-7), the researchers report in BMJ Supportive & Palliative Care, online December 18.

Source: Respiratory Qol Worse in Breathless Patients With COPD Than Cancer

Interruption of Inhaled Corticosteroid Therapy in COPD Can Reduce Risk of Pneumonia Lung Disease News

Researchers from McGill University in Canada showed that interruption of inhaled corticosteroid therapy in Chronic Obstructive Pulmonary Disease may lead to significant reduction in the risk of serious pneumonia. The study entitled “Discontinuation of inhaled corticosteroids in COPD and the risk reduction of pneumonia” was published this June in Chest.

Chronic Obstructive Pulmonary Disease (COPD) is a general designation that includes several progressive lung conditions like emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchiectasis. COPD is characterized generally by increasing breathing difficulty.

In COPD, the widespread use of inhaled corticosteroids as a form of therapy has been questioned. Recent studies on the effect of interrupting the use of inhaled corticosteroids in COPD patients revealed little or no decrease on adverse effects when compared to long-acting bronchodilators. However, is not clear if the suspension of inhaled corticosteroids contributes to the reduction of the high risk of pneumonia linked with these drugs.

More: Interruption of Inhaled Corticosteroid Therapy in COPD Can Reduce Risk of Pneumonia Lung Disease News

NICE ‘should modify’ COPD diagnosis guideline

NICE should redraw COPD diagnosis guidelines because they are likely causing overdiagnosis in men and underdiagnosis in women, respiratory experts have said.

Dr Mark Levy, a GPSI in respiratory medicine based in Harrow, and Professor Martin Miller, from the University of Birmingham, warn up to 13% of people thought to have COPD may have been misdiagnosed with the condition, while one in eight cases are likely to be missed.

NICE adopted use of a single, ‘pragmatic’ measure of airways obstruction from the Global Initiative for Obstructive Lung Disease (GOLD) in 2010, which means people are diagnosed with COPD if they have a post-bronchodilator ratio of FEV1/FVC cut-off of less than 0.7, regardless of any other factors.

More: NICE ‘should modify’ COPD diagnosis guideline | News Article | Pulse Today

Royal Brompton study finds innovative COPD treatment improves lung function – Royal Brompton & Harefield NHS Foundation Trust

A study at Royal Brompton Hospital has found that using airway valves to treat people with chronic obstructive pulmonary disease (COPD) can improve lung function and exercise capacity.

It is estimated that more than three million people in the UK are living with COPD, an umbrella term for a collection of lung conditions including emphysema and chronic bronchitis. The progressive disease makes it difficult for patients to breathe due to damaged airways and air sacs in the lungs.

Despite best treatment with standard medicines and pulmonary rehabilitation, many people with the condition experience increasing breathlessness and are limited in what they can do on a day-to-day basis.

The trial at Royal Brompton, called BeLieVeR-HIFi (bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures), involved placing one-way endobronchial valves into the most damaged part of the lung using a bronchoscope (a thin, flexible, fibre-optic tube).

More: Royal Brompton study finds innovative COPD treatment improves lung function – Royal Brompton & Harefield NHS Foundation Trust