Mesa 1. Epidemiología, Diagnóstico y Seguimiento del Paciente con EPOC
Dr. Agustín Valido Morales
Hospital Universitario Virgen Macarena. Sevilla.
Is The Absence Of Purulence Sputum At Exacerbation Useful For Guiding Long-Term Therapy?
James P. Allison, Gavin C. Donaldson, Jadwiga A. Wedzicha
Abstract
Rationale: Data from the INSPIRE study (AJRCCM 2008: 117: 19-26) suggests LABA/ICS, compared to a LAMA, reduces exacerbations requiring treatment with oral corticosteroid. Thus, non-purulent exacerbations that generally do not involve antibiotic therapy could be an indication for prescribing LABA/ICS.
Methods: COPD patients enrolled in the London COPD cohort between 3/10/2005 and 1/3/2016 recorded worsening in respiratory symptoms and oral exacerbation treatment on daily diary cards. Exacerbations were defined as two or more consecutive days with increase in two symptoms, one or more was major (major increased dyspnoea, sputum purulence or sputum volume; minor: cold, sore throat, increased wheeze or cough). Treatment was also recorded at clinic visits.
Results: We examined data from 282 patients who had completed diary cards for at least one year. They were 69.9 (SD 8.6) years old, with a predicted FEV., = 50.1% (SD 16.1) and FEVi/FVC ratio of 47.0% (SD 12.2); 173 (61.4%) were male. 26 patients never experienced an exacerbation. The remaining 256 patients experienced 2531 exacerbations, over a median 1225.5 days (IQR 813-1967), of which 1247 (49.3%) did not involve symptoms of sputum purulence, 1217 (48.1%) did, and symptoms were unknown for 67 (2.6%).
The annualized rate of exacerbations for the 256 patients was 2.14/year (IQR 1.28-3.49) and of treated exacerbations 1.58/year (IQR 0.84-2.65). The rates for non-purulent exacerbations were 0.99/year (IQR 0.59-1.68) and those treated exacerbations 0.63/year (IQR 0.26-1.16). Purulence was absent for 130 of 252 first exacerbations (data missing for 4).
Sub-divided by the 1st exacerbation, rates for non-purulenct exacerbations were 1.18/year (IQR 0.68-1.80), if the first exacerbation was non-purulent, and 0.87/year (IQR 0.45-1.53) if the first exacerbation was purulent (Mann-Whitney; p=0.0059). For treated exacerbations, rates were 0.90/year (IQR 0.49-1.47) and 0.55/year (IQR 0.15-0.90) respectively; p<0.0001. However, whether patients fell into the top 50% of non-purulent exacerbators (> 0.99 exacerbations/year) was not predicted well. 72 of 130 in the top 50% (55.4%) and 69 of 122 (56.6%) in the bottom 50% were identified correctly based on the first exacerbation (p=0.058; ROC AUC=0.56) For treated exacerbations, 63 of 99 (63.4%) of the top 50% of non-purulent treated exacerbators (>0.63 exacerbations per year) and 81 of 142 (57.0%) in the bottom 50% were predicted correctly; p=0.002, ROC AUC=0.60.
Conclusion: Absence of purulent sputum at exacerbation is predictive of future exacerbation character but sensitivity and specificity are poor.
Radiological Features of Structural Basis Where Cancer Develops in COPD Lungs
Shotaro Chubachi , Saeko Takahashi , Hidehiro Irie , Akihiro Tsutsumi , Naofumi Kameyama , Mamoru Sasaki , Katsuhiko Naoki , Kenzo Soejima , Hidetoshi Nakamura , Koichiro Asano , Tomoko Betsuyaku
Abstract
Rationale: Lung cancer accounts for 5-38% of cause of death in COPD patients, and screening using computed tomography (CT) scans is important. Few studies have evaluated the radiological features of the pre-existing structural abnormalities where a lung cancer develop later.
Objectives: In our multicenter, longitudinal cohort study, called the K-CCR, the specific aim of this study is to analyze the background lung images on CT at enrollment in COPD patients who were newly diagnosed as lung cancer during 3 years.
Methods: In this 3-year cohort, the incidence of lung cancer among COPD patients (n=435) was assessed, in which the imaging analysis of emphysema and interstitial abnormalities were limited in 240 patients whose baseline CT scans were applicable. Further, the local lung density of pre-lung cancer area were individually quantified for the patients who developed lung cancer afterward (AZE Ltd., Tokyo, Japan).
Results: Lung cancer was newly diagnosed in 21 participants during the 3-year follow-up period, consisting 4 in the first, 10 in the second, and 7 in the third year. Emphysema was observed in 129 out of 240 COPD patients (53.7%), and the incidence was higher in subjects who developed lung cancer than those who did not. (85.7 vs. 51.8%, p =0.0134)
The low attenuation area % of the patients who developed lung cancer was higher than the others at enrolment. (20.0 vs. 10.4%, p=0.0138) Interstitial lung abnormalities were observed in 30 out of 240 COPD patients (12.5%).
The incidence was also higher in subjects who developed lung cancer than those who did not (64.3% vs. 9.3%, p <0.0001). The presence of emphysema (odds ratio (OR) 4.2, p=0.0486) or interstitial lung abnormalities (OR 15.6, p<0.0001) independently increased the risk of lung cancer development.
For the 14 COPD patients whose lungs turned to be the background of the lung cancer, in the lungs with heterogeneous emphysema without interstitial abnormalities, the local density of pre-lung cancer area was likely near to median of whole lung density distribution (4 out of 5 patients), while it was far high in 6 out of 9 patients who had both emphysema and interstitial abnormalities, and in the remaining 3 patients the local density was not low, but near to median.
Conclusions: Having emphysema, interstitial abnormalities, or both are marked risk factor for lung cancer development in COPD patients. Furthermore, lung cancer most often develops in non-emphysematous area or in interstitial abnormalities, if they are present.
