ERS 2022: Evolving Questions in Chronic Obstructive Pulmonary Disease Management
In this session, experts discussed the challenging questions faced by physicians every day when managing patients with COPD and about the latest updates on the diagnosis, management and assessment of COPD covering four areas, namely the role of eosinophils, the pathophysiology of disease exacerbation, the relevance of mortality endpoints and the assessment of COPD patients for comorbidities.
The first talk focused on eosinophilic COPD management and the treatment options where eosinophils infer a response. Eosinophilic COPD is an endotype that can be routinely identified in clinical practice. In the serum of patients with COPD, an increase in eosinophils of up to 40% can be observed. The peripheral blood eosinophil count may help identify patients with COPD who will experience fewer exacerbations when inhaled corticosteroids (ICS). In a study by Bafadhel M et al., a linear relationship was seen with blood eosinophils and exacerbations of COPD in patients, not on ICS. The effect of ICS in eosinophilic COPD is not just limited to exacerbations response but also lung function and quality of life symptoms.
In the KRONOS trial, an association was observed between the blood eosinophil counts and improvements in lung function and COPD exacerbation rates with combinations containing ICS. Blood eosinophils have been used to direct systemic corticosteroids (SCS) during exacerbation. A single centre proof-of-concept placebo-controlled, double-blind, randomized control non-inferiority trial (BEAT: COPD) has demonstrated that peripheral blood eosinophils at the time of a moderate exacerbation of COPD can direct oral corticosteroid (OCS) treatment safely. Multicenter, open-labelled severe exacerbation study has shown non-inferiority between eosinophil-directed OCS and standard care OCS prescriptions. The STARR2 trial showed that eosinophil-directed prescription in primary care is safe and is not associated with worsened outcomes. The blood eosinophil counts in patients with COPD interpret the risk of exacerbations, response to inhaled and probably SCS, mortality, and the differential airway microbiome.
The next talk focused on achieving the best definition of an exacerbation in COPD patients. Exacerbations drive COPD outcomes. COPD exacerbations lead to increased cost, a decline in lung function, worsening health status, and increased risk of hospitalization and mortality. A post hoc cohort analysis using data from SUMMIT randomized clinical trial showed that exacerbations confer an increased risk of subsequent CVD events in patients with COPD or CVD risk factors, particularly in hospitalized patients and within the first 30 days after an exacerbation. Exacerbation of respiratory symptoms in COPD patients may be caused by respiratory infections and/or pollutants that cause acute airway and lung inflammation. These acute events may be correctly defined as exacerbations of COPD, but only after other contributing mechanisms have been ruled out. Acute independent events may cause an exacerbation of respiratory symptoms in patients with COPD and no comorbidities. These acute events should not be defined as exacerbations of COPD, but rather exacerbations of respiratory symptoms in COPD patients, followed by a description of the cause (s). According to the GOLD 2022, COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.
In the Rome proposal for an updated definition and severity classification of COPD exacerbations, the panel agreed to propose the following definition: “In a patient with COPD, an exacerbation is an event characterized by dyspnea and/or cough and sputum that worsens over ≤14 days, which may be accompanied by tachypnea and/or tachycardia and is often associated with increased local and systemic inflammation caused by airway infection, pollution, or other insult to the airways".
This talk focused on mortality and its assessment in COPD patients. COPD is the third leading cause of death worldwide. The proportion of deaths increases with increasing frequency and severity of exacerbations. On average, a lower FEV1 confers the worst prognosis. The machine learning mortality prediction (MLMP)-COPD model demonstrated predictive performance superior to four existing models in patients with moderate to severe COPD across two large cohorts. The GOLD 2019 report recommended using blood eosinophil counts (BEC) as a biomarker to help make pharmacological treatment decisions concerning ICS use in patients with COPD with exacerbations. The GOLD 2022 report now adds additional evidence concerning BEC, including the connections between BEC, T2 inflammation, and lung microbiome, which identify COPD subgroups with increased ICS response (higher BEC) or increased risk of bacterial infection. Thus, mortality assessment can be performed in clinical practice, and targeted interventions can improve prognosis.
The last talk discussed the role of advanced diagnostics in COPD. COPD patients exhibit an increase in residual volume even in the early stages of the disease, but as airflow limitations worsen, total lung capacity increases. Radiographic lung volumes predict COPD progression in smokers with preserved spirometry in SPIROMICS. The US preventive services task force recommends annual low-dose CT scan screening for high-risk individuals (aged 50 to 80 years with a 20-pack-year history and current smoker or quitting within the past 15 years). Body Plethysmography may be considered in patients with forced expiratory volume (FEV1) <45% if they are candidates for lung volume reduction surgery (LVRS) or bronchoscopic lung volume reduction (BLVR). CT imaging can be used for a differential diagnosis, LVRS or BLVR evaluation in patients with frequent exacerbations, and lung cancer screening. Echocardiography may be used in patients with clinical signs of heart failure and visually detected pulmonary artery enlargement or PA to ascending aorta (A) diameter (PA: A) ratio CT> 1.
European Respiratory Society (ERS) International Congress 2022, 3rd-6th Sept. 2022, Barcelona
