CHEST 2018 was the 84th annual meeting for the American College of Chest Physicians, and was held October 6–10, 2018, in San Antonio, Texas. As ever, asthma and chronic obstructive pulmonary disease (COPD), the most common chronic respiratory diseases, were the focus of many presentations. Asthma was the most prevalent chronic respiratory disease worldwide in 2015, with twice the number of cases than COPD; although, deaths from COPD were eight times more common than deaths from asthma.1 This article highlights some of the most important recent studies into these diseases.
COPD is the third most common cause of hospital readmission in the US among Medicare beneficiaries, occurring in 60% of patients within 1 year of hospital discharge and in 30% within 3 months of discharge.2 A prospective cohort study evaluated an evidence-based COPD care bundle which comprised: patient education on COPD by healthcare providers prior to discharge, completion of an individualized self-management COPD action plan to be used by patients after hospital discharge, and timely outpatient follow-up with a pulmonologist. Patients admitted to a medical center with acute exacerbations of COPD were enrolled into one of two groups: a pre-intervention (n=150) and post-intervention (n=221) group. The two groups were similar in terms of clinically relevant patient characteristics. The readmission rate was lower in the post-intervention group at 30 days (22.2% versus 32.7%. p=0.024), 60 days (30.3% versus 56.0%, p<0.001), and 90 days (35.3% versus 62.6%, p<0.001). Hospital length of stay was similar between the two groups (8 versus 7 days, p=0.322). The investigators concluded that such an intervention is easy to implement and should be considered in all hospitals.3
The conference featured a new analysis of the InforMing the PAthway of COPD
Treatment (IMPACT) study, which has demonstrated the benefits of triple versus
dual therapy in patients with COPD.4 In this study, patients were evaluated for baseline reversibility, defined as differences between their pre- and post-albuterol assessments of forced expiratory volume in 1 second (FEV1) of ≥12% and ≥200 mL. Although 18% of patients were found to demonstrate reversibility at baseline, a statistically significant reduction in the rate of moderate and severe exacerbations was found with fluticasone furoate/umeclidinium/vilanterol compared with umeclidinium/vilanterol in all patients, regardless of baseline reversibility. Triple therapy was also associated with a reduced risk of moderate and/or severe exacerbations in both groups of patients. Quality of life was also improved in both reversible and non-reversible patients.4
It has been estimated that up to 70% of patients with COPD suffer from cardiovascular (CV) comorbidities5 and approximately 30% of patients with COPD will die as a result of CV-related disease.6 Despite this high prevalence, patients with CV disorders are often excluded from COPD clinical trials.7 It is, therefore, important to evaluate the safety of COPD therapies in this patient population. Aclidinium bromide (Tudorza®, AstraZeneca, Cambridge, UK) is an inhaled long-acting muscarinic antagonist that is used for the long-term maintenance treatment of COPD-associated bronchospasm, including chronic bronchitis and emphysema. The Aclidinium Bromide on Long‑Term Cardiovascular Safety and COPD Exacerbations in PatieNTs with Moderate to Very Severe COPD (ASCENT COPD) study aims to evaluate the long-term effects of twice‑daily aclidinium 400 µg on major adverse CV events (MACE), overall safety, and COPD exacerbations in patients with moderate to very severe COPD who have a history or significant risk factors for CV comorbidities.8 A post-hoc analysis of the study data showed that aclidinium bromide reduced the rate of exacerbations compared with placebo regardless of CV risk, and was non-inferior to placebo in time to first MACE.9
The use of complementary alternative medicine (CAM) in patients with respiratory disease is controversial, primarily due to the lack of clinical evidence to support the use of these therapies. An analysis of the 2012 National Health Interview Survey investigated the relationship between CAM use (including acupuncture, herbal remedies, homeopathy, massage, and yoga) and asthma exacerbations across the general population as well as among different racial/ethnic groups. The study found differences in both asthma control and CAM use across different racial/ethnic groups. A higher proportion of black and Hispanic patients with asthma visited the emergency department for asthma exacerbation compared with white patients (16.0%, 10.2%, 6.1%, respectively). White patients with asthma were more likely to use CAM compared with black and Hispanic patients (40.2%, 23.7%, 31.6%, respectively). Of particular interest, adjusting for age, gender, and having a healthcare provider, CAM use was associated with a lower risk (odds ratio [OR] 0.59 [0.43–0.83]) of having an emergency department visit for asthma exacerbation. Among Hispanic patients, herbal medicine use was strongly associated with a decreased risk of having an emergency department visit for asthma exacerbation (OR 0.20 [0.09–0.44]). While sociodemographic factors may contribute to these findings, this is an important study that may lead to increased healthcare resource utilization.10
A major concern among parents of children with asthma is whether exposure in the home to pets and secondhand tobacco smoke can trigger asthma symptoms. A study from the Nationwide Children’s Hospital followed 395 children aged 2–17 years, who were receiving asthma care according to the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines.11 Of these 25% were exposed to secondhand tobacco smoke and 55% were exposed to a dog or cat at home. In the total patient cohort, hospital admissions, emergency department visits, urgent care visits, primary care visits, school days missed, short courses of oral steroids and number of days requiring albuterol, mean percent predicted FEV1, and mean asthma symptoms improved significantly by 3–6 month follow up (p<0.001) and these improvements persisted over a 3-year follow-up. These improvements were independent of exposure to pets or secondhand smoke. The authors concluded that following the recommended treatment guidelines is more important than certain environmental exposures.12
Although much of the burden associated with asthma and COPD is either preventable or treatable with affordable interventions, these diseases have, in the past, received less attention than other noncommunicable diseases.1 The presentations of CHEST 2018 reflect the commitment of the medical community to improve the management of these highly prevalent diseases.
1. GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med. 2017;5:691–706.
2. Dalal AA, Shah M, D’Souza AO, et al. Costs of COPD exacerbations in the emergency department and inpatient setting. Respir Med. 2011;105:454–60.
3. Kendra M, Shah C, Landry L, et al. A discharge care bundle reduces readmissions in patients with acute exacerbation of COPD. 2018 CHEST. 154 Suppl:1118A–9A.
4. Wise R, van der Valk R, Hilton E, et al. Treatment effects of FF/UMEC/VI vs FF/VI and UMEC/VI in reversible and nonreversible COPD patients: analyses of the IMPACT study. 2018. CHEST. 154 Suppl:729A–31A.
5. Mullerova H, Agusti A, Erqou S, et al. Cardiovascular comorbidity in COPD: systematic literature review. CHEST. 2013;144:1163–78.
6. Sin DD, Anthonisen NR, Soriano JB, et al. Mortality in COPD: Role of comorbidities. Eur Respir J. 2006;28:1245–57.
7. Lahousse L, Verhamme KM, Stricker BH, et al. Cardiac effects of current treatments of chronic obstructive pulmonary disease. Lancet Respir Med. 2016;4:149–64.
8. Wise RA, Chapman KR, Scirica BM, et al. Long-term evaluation of the effects of aclidinium bromide on major adverse cardiovascular events and COPD exacerbations in patients with moderate to very severe COPD: rationale and design of the ASCENT COPD study. Chronic Obstr Pulm Dis. 2018;5:5–15.
9. Chapman K, Wise R, Scirica B, et al. Effect of aclidinium bromide on major adverse cardiovascular events and exacerbations in patients with COPD and different cardiovascular risk factor levels. 2018. CHEST. 154 Suppl:1115A–17A.
10. Simonson J, Kim EJ, Jacome S, et al. Association between complementary alternative medicine use and emergency department visits for asthma exacerbation across the American population and among racial minority groups. CHEST. 154 Suppl:1132A.
11. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Report No.: 07-4051. Available at: https://www.ncbi.nlm.nih.gov/books/NBK7232/ (accessed October 17, 2018).
12. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183:788–824.