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Impact of Bronchiectasis On COPD Exacerbations

2018

The presence of bronchiectasis is considered an aggravating factor in COPD patients. In particular, the coexistence of bronchiectasis and COPD was associated with greater frequency and severity of exacerbations. The aim of this study is to investigate the impact of bronchiectasis in patients with COPD exacerbation. We retrospectively collected data from 212 patients admitted to the hospital with diagnosis of COPD exacerbation. In order to detect the presence of bronchiectasis, only patients that had received a chest HRCT scan examination were included in the study. We compared clinical and functional data between COPD patients with bronchiectasis and those without bronchiectasis. The prevalence of bronchiectasis was 31,6% in this study. The presence of bronchiectasis in COPD patients was associated with increased risk for isolation of PPMs in the airway (56,1% vs 28,3%, p 0,02), and in particular of Pseudomonas Aeruginosa (17,5% vs 5,6% p 0,02), and with a longer duration of hospita...

Freely Available Online INTERNATIONAL JOURNAL OF THORAX ISSN: COMING SOON Research DOI : COMING SOON Impact Of Bronchiectasis On COPD Exacerbations Antonio Molino1,*, Carolina Vitale2, Tullio Valente3, Maria D’Amato1, Mauro Mormile1, Pasquale Imitazione1, Angelantonio Maglio2, Alessandro Vatrella2 1 Respiratory Department Federico II University- A.O. "Dei Colli",Naples, Italy 2 Department of Medicine, Surgery and Dentistry, Section of Respiratory Diseases, University of Salerno, Salerno, Italy 3 Division of Radiology, Department of Diagnostic Imaging, Monaldi Hospital Abstract The presence of bronchiectasis is considered an aggravating factor in COPD patients. In particular, the coexistence of bronchiectasis and COPD was associated with greater frequency and severity of exacerbations. The aim of this study is to investigate the impact of bronchiectasis in patients with COPD exacerbation. We retrospectively collected data from 212 patients admitted to the hospital with diagnosis of COPD exacerbation. In order to detect the presence of bronchiectasis, only patients that had received a chest HRCT scan examination were included in the study. We compared clinical and functional data between COPD patients with bronchiectasis and those without bronchiectasis. The prevalence of bronchiectasis was 31,6% in this study. The presence of bronchiectasis in COPD patients was associated with increased risk for isolation of PPMs in the airway (56,1% vs 28,3%, p 0,02), and in particular of Pseudomonas Aeruginosa (17,5% vs 5,6% p 0,02), and with a longer duration of hospitalization (8,22 ±3,67 vs 6,88 ± 3,43 days, p=0.004). These results could encourage efforts to optimize medical care for patients with COPD and bronchiectasis. Clinical trials with treatments for infective component are needed to investigate their impact on the reductions of exacerbations and improvements in the disease course. Corresponding Author: Antonio Molino, Respiratory Department Federico II University- A.O. "Dei Colli" Via Leonardo Bianchi 1, 80131-Naples, Italy. Email: molinotonio@libero.it Keywords: COPD, Bronchiectasis, exacerbations Received: Jan 27, 2018 Accepted: Apr 04, 2018 Published: Apr 07, 2018 Editor: Mohamed Shahat Badawy Ahmed, Assistant Professor of Chest Diseases Head of Chest Department, Qena Faculty of Medicine, South Valley University, Egypt. www.openaccesspub.org IJT CC-license DOI : COMING SOON Vol-1 Issue 1 Pg. no.– 1 Freely Available Online In this study we aim to analyze the impact of Introduction Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality bronchiectasis on patients with COPD exacerbation. Methods In this retrospective study we collected data worldwide with a substantial social and economic burden [1]. It’s a complex disease with different clinical from 212 features and treatment responses [2-6]. In recent years, Pneumology Unit of Monaldi Hospital in Naples between there has been a growing interest in identifying COPD 2010 and 2014, with diagnosis of exacerbation of COPD. phenotypes, in order to provide more individualized In order to detect the presence of bronchiectasis, only treatment strategies [2-6]. High-resolution computed patients tomography (HRCT) of the lungs may provide a way to examination were included in the study. Written define a distinct COPD phenotype by investigating the informed consent was obtained from all of the patients. main relevant morphological findings such as the The study was approved by hospital Ethic Committee. presence of emphysema, bronchial wall thickening, and bronchiectasis [9-12]. Bronchiectasis is defined as irreversible and that had patients received a admitted chest to HRCT the scan Clinical characteristics were recorded for each patient, generally progressive dilation of the airways, usually as consecutive including lung function, smoking history, comorbidities and number of COPD exacerbations in the previous year. a result of chronic airway inflammation and/or infection. COPD was confirmed by the presence of a The impact of bronchiectasis on COPD was post-bronchodilator forced expiratory volume in 1 assessed in several studies [13-16]. Determining the second/forced precise prevalence of bronchiectasis in COPD is difficult; according to the criteria published by the GOLD existing data indicate a huge variability in bronchiectasis document [1]. prevalence, ranging from 4 to 72%. However, there is agree to consider bronchiectasis an aggravating factor in COPD patients [11-16]. properly suggest a different clinical COPD phenotype [1,15,21]. In particular, the presence of bronchiectasis in COPD has been associated with greater frequency and severity of exacerbations [22-24]. An exacerbation of COPD or increased defined sputum volume or treatment with oral corticosteroids or antibiotics [1,25]. Patients with mild or moderate COPD exacerbation can be managed at home, while patients with severe may need hospitalization [1,25]. Hospitalizations for COPD exacerbation are associated with increased mortality and impaired health-related quality of life. Furthermore hospitalizations for COPD exacerbation account for more than 70% of all COPD-related health care costs [1,25]. www.openaccesspub.org IJT 70% symptoms that results in additional therapy [1]. The diagnosis of bronchiectasis was confirmed by a chest HRCT scan. High-resolution images were obtained in full inspiration at 1-mm collimation and 10-mm intervals from the apex to the base of the lungs. Based on the morphology, bronchiectasis was defined as as purulence beyond the basal variability and that required symptoms < cylindrical, cystic and mixed. is sustained worsening of respiratory symptoms, such as breathlessness (FEV1/FVC) event characterized by a worsening of the patient’s COPD [1], nevertheless this definition may be reductive. In fact, the coexistence of bronchiectasis and COPD may capacity COPD exacerbation was defined as an acute respiratory Bronchiectasis was defined as a comorbidity of vital CC-license α1-antitrypsin deficiency, serum immunoglobulin deficiencies, IgE and IgG to Aspergillus fumigatus and cystic fibrosis were excluded in all patients with bronchiectasis. During hospitalization each patient was requested to collect samples of spontaneous mornig sputum for the microbiologic analysis. Samples were processed by the reference clinical microbiology laboratory using standard procedure [26-29]. The suitability of the sputum sample for the culture was assessed with Q score, examining leukocytes and epithelia cells by gram stain (Q1: 0 epithelial cells and 1-9 leukocytes per field or < 10 epithelial cells and DOI : COMING SOON Vol-1 Issue 1 Pg. no.– 2 Freely Available Online 10-24 leukocytes per field or < 25 epithelial cells and Clinical and functional data were compared between the >25 leukocytes. Q2: 0 epithelial cells and 10-24 two groups. leukocytes per field or 1-9 epithelial cells and > 25 leukocytes per field. Q3: 0 epithelial cells and > 25 leukocytes per field) [26,27]. Samples with a Q score ≥ 1 were considered representative of distal airways and subsequently processed for culture. Bacterial growth was assessed at 48 hours and fungal growth at 72 hours. The airway bacteria cultured were classified into potential pathogenic microorganisms (PPMs) and non-PPMs, as previously described [28]. Based on previously published methods, sputum cultures were expressed as colony-forming units (CFUs) per mL and a cutoff point of 103 CFUs/mL or more was defined as significant for the identification of abnormal positive culture results for PPM [29]. Isolated bacterial agents were classified into PPMs strains, including Pseudomonas Aeruginosa, Streptoccocus Pneumoniae, Moraxella Catarralis, Staphiloccocus Aureus, Haemophilus Klebsiella Influenzae, pneumonia, Escherichia coli, Mycobacterium tubercolosis, Candida albicans and other pathogenic microorganisms. The entire patient population had moderate to severe COPD. The presence of bronchiectasis was associated with a higher number of exacerbations in the previous year (p 0,00001). The smoking history, expressed as pack/years, was significant in COPD patients without bronchiectasis (p 0,0001). FEV1, FVC, PaO2, PaCO2 of patients, as well as the Charlson Index score, didn’t significantly vary between the two groups. An average of 3 valid sputum samples was collected from patients who had daily sputum production during the hospitalization. COPD patients with bronchiectasis had a higher prevalence of PPMs colonization (p=0,02). Candida Albicans was the most frequently isolated PPM in the entire patient population (62 patients). The isolation of Pseudomonas Aeruginosa was significantly most frequent in COPD patients with bronchiectasis than in those without bronchiectasis (p=0,02), while the isolation of other PPMs was not significant different between the two Statistics groups. Mycobacterium tuberculosis and nontuberculosis The statistical software SPSS, version 20, was mycobacteria weren’t detected in any samples. used for the statistical analysis. The Student T test for indipendent variables was used to analyze variables that were normally distributed and the Mann-Whitney U test was used to analyze variables that were non-normally distributed. The chi-square test was used to compare qualitative variables. A p-value less than 0.05 was considered to be statistically significant. Overall, data from 212 patients with COPD exacerbation were retrospectively analyzed (mean age ± SD 71,3 ± 8,5; 79,2% men). Based on HRCT evidence of bronchiectasis, the patients were divided into two groups: patients with bronchiectasis (n=67, 31,6%) and patients without bronchiectasis (n=145, 69,4%). Other conditions that can trigger bronchiectasis were excluded deficiency, serum No samples or unqualified samples were collected from 49 patients (23,1%). The presence of bronchiectasis in patients with COPD was associated with a longer duration of hospitalization (8,22 ±3,67 vs 6,88 ± 3,43 days, p=0.004) The differential characteristics of the two groups Results (α1-antitrypsin more immunoglobulin deficiencies, IgE and IgG to Aspergillus fumigatus, cystic fibrosis). Bronchiectasis was cylindrical in 85% of cases. are reported in tables 1 and 2. Discussion In this small study, we evaluated the impact of bronchiectasis on patients with COPD exacerbation. The prevalence of bronchiectasis in COPD patients was 31,6%. This finding is similar to the percentage reported in previous studies [6-11]. 85% of patients had cylindrical bronchiectasis. Although there is still much to understand about the interaction between COPD and bronchiectasis, the high rate of coexistence of bronchiectasis and COPD could be explained by shared www.openaccesspub.org IJT CC-license DOI : COMING SOON Vol-1 Issue 1 Pg. no.– 3 Freely Available Online Table 1. Baseline and clinical characteristics of subjects with COPD, with and without bronchiectasis. Data are presented as n (%) or mean ± SD.(Statistical tests: T-student test, Mann-Whytney Test) Whole Group COPD with COPD without Bronchiectasis Bronchiectasis p Subjects 212 67 (31,6%) 145 (68,39%) Sex, M/F 168/44 119/26 49/18 Age,Y 71,33 ± 8,48 69,97 ± 9,8 71,48 ± 9,61 0,11 Smoking History-pack/years 24,95± 10,78 20,3 ± 10,19 27,18 ± 10,28 0,0001 1,14 ±0,8 1,57±0,74 0,94±0,75 0,00001 FVC 63,33 ± 14,66 60,94 ± 12 64,44 ± 15,66 0,1 FEV1 46,84 ± 13,55 46,59 ± 10,53 46,96 ± 14,75 0,85 pO2 mmHg 62,97 ± 11,4 62,08 ± 10,38 63,39 ± 11,34 0,42 pCO2 mmHg 57,04 ± 13,91 43,30 ± 7,58 44,32 ± 7,15 0,34 Charlson Index 2,16 ± 0,68 2,06 ± 0,69 2,21 ± 0,66 0,15 Length of hospitalization 7,30 ± 3,55 8,22 ± 3,67 6,88 ± 3,43 0,004 Number of Exacerbations in the previous year Table 2. Microbiological characteristics of subjects with COPD, with and without bronchiectasis. Data are presented as n (%) or mean ± SD. (Statistical test : Chi-Square) Whole Group 163 COPD with COPD without Bronchiectasis 57 Bronchiectasis 106 p Haemophilus Influenzae 26 (15,9%) 8(14%) 18 (16,9%) 0,6 Streptococcus Pneumoniae 17 (10,4%) 5 (8,7%) 12 (11,3%) 0,6 Moraxella Catarrhalis 16 (9,8%) 5(8,7%) 11(10,3%) 0,7 Pseudomonas Aeruginosa 16 (9,8%) 10 (17,5%) 6 (5,6%) 0,02 Staphiloccocus Aureus 7 (4,2%) 4(7%) 3 (2,8%) 0,2 Escherichia Coli 6 (3,6%) 3 (5,2%) 3 (2,8%) 0,4 Klebsiella Pneumoniae 4 (2,4%) 2 (3,5%) 2 (1,8%) 0,5 Candida Abicans 62 (38%) 18 (31,5,8%) 44(41,5%) 0,3 62 (38%) 32 (56,1%) 30 (28,3%) 0,02 Patients with at least one PPM isolate www.openaccesspub.org IJT CC-license DOI : COMING SOON Vol-1 Issue 1 Pg. no.– 4 Freely Available Online pathological mechanisms. In fact, chronic inflammation frequency of exacerbations, it’s clear that the detection of airway has a key role in the pathogenesis of both of bronchiectasis in COPD by performing an HRCT scan conditions and tobacco exposure is considered a causal should be encouraged in order to identify these patients factor in both diseases[30-33]. and The presence of provide the most effective treatment. The bronchiectasis in COPD patients was associated with a coexistence of bronchiectasis and COPD should expect greater number of exacerbations in the previous year. more appropriate treatment for the infective component The association between bronchiectasis and a greater of the disease. Unfortunately, data about therapies for frequency of exacerbations is widely recognized [22-24]. COPD complicated by bronchiectasis are not available, This is probably due to permanent dilatation of the due to the lack of clinical trials in this population. Based airways and impairment of mucociliary clearance that on trials on bronchiectasis, including smokers with can lead to bacterial colonization. Bacterial colonization airflow obstruction which is not fully reversible and can trigger an intense inflammatory response which similar to COPD, some Authors have suggested that the damages local defense mechanism. This interaction use of long-term macrolides or inhaled antibiotics could between systemic be beneficial in reducing exacerbations in COPD patients inflammation may lead to frequent exacerbations, as with bronchiectasis. Physiotherapy should also be well as other distinctive clinical features as more sputum considered production [24]. patients [15,36,37]. chronic PPM colonization and About pulmonary function data, the entire patient population had moderate to severe COPD. as an useful groups. This result is opposite to the findings of previous studies in which bronchiectasis was associated with more severe bronchial obstruction[18-20]. This discrepancy may be explained by several reasons. Firstly, the small sample size in the present study economic burden on the healthcare system. related to exacerbations, hospitalization[1,39]. Based health care costs (longer Conclusion presence of bronchiectasis was associated with increased prevalence of PPMs colonization and in particular of Pseudomonas Aeruginosa. The association of chronic PPMs colonization, as well as P. Aeruginosa isolation, with bronchiectasis was confirmed by several studies [22-24,34]. The presence of PPMs and the consequent chronic inflammation result in remodeling of the airways and facilitate the persistence of PPMs in the bronchial mechanism tree. that These factors generates may trigger bronchiectasis the [15,35]. Furthermore, Pseudomonas Aeruginosa was isolated from 3% to 20% of patients with COPD and, more frequently, from patients with severe disease and during exacerbations [37]. COPD patients with bronchiectasis had a longer length of hospitalization. This is may be justified by the need of more prolonged antibiotic therapies. Considering these data and the higher www.openaccesspub.org IJT CC-license in on particular to results, the our coexistence of bronchiectasis and COPD leads to higher study, COPD patients with bronchiectasis had a less The A substantial portion of the total burden of COPD is provides insufficient statistical power. Secondly, in this history. these The presence of bronchiectasis in COPD patients prolonged antibiotic therapies]. smoking in has a significant impact on disease course as well as on FEV1 didn’t significantly vary between the two significant strategy hospitalizations, more In conclusion, data obtained from the present study indicate that the presence of bronchiectasis in patients with COPD exacerbation was associated with an increased risk of isolation of PPMs, in particular of Pseudomonas Aeruginosa, and with a longer duration of hospital stay. These results could encourage efforts to optimize medical care for patients with COPD and bronchiectasis. Clinical trials with treatments for infective component are needed to investigate their impact on the reductions of exacerbations and improvements in the disease course. References 1. Global Strategy for the Diagnosis Management, and Prevention of Chronic Obstructive Pulmonary Disease. 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