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Patients with COPD and comorbid depression/anxiety are at risk of reduced health status. This study aimed to assess health status in COPD patients with depression/anxiety, the occurrence of severely reduced health status in this group, and to investigate associations between severely reduced health status and patient-related clinical factors. This cross-sectional study included 2245 randomly selected COPD patients from primary care and hospital outpatient clinics in Sweden. The COPD Assessment Test (CAT) and the Clinical COPD Questionnaire (CCQ) were used to assess health status. Severely reduced health status was defined as CAT >= 20 or CCQ >= 2. The 524 patients (23.3%) who reported depression/anxiety had higher mean CAT scores (18.3 vs. 15.2, p < 0.001) and CCQ scores (2.37 vs. 1.83, p < 0.001) than patients without depression/anxiety. In this group, 48% had CAT >= 20 and 57% had CCQ >= 2. In patients with depression/anxiety, factors associated with CAT >= 20 were: onset of COPD symptoms before 60 years of age (OR = 2.62 [95% CI 1.37-5.04]), frequent symptoms of depression in the previous three months (2.59 [1.55-4.30]), one or more COPD exacerbations in the previous six months (2.37 [1.41-4.00]) and physical inactivity (1.89 [1.11-3.22]). Apart from physical inactivity, factors associated with CCQ >= 2 were the same as for CAT >= 20. Approximately half of the COPD patients with comorbid depression/anxiety reported severely reduced health status. Exacerbations, frequent depressive symptoms and physical inactivity were factors associated with severely reduced health status, and constitute important treatable and preventable traits of COPD.

Background

Swallowing dysfunction (dysphagia) is increasingly recognised in chronic obstructive pulmonary disease (COPD) and has been associated with aspiration, exacerbations, and impaired health status. However, longitudinal data on dysphagia in COPD are limited.

Aim

To investigate the 2-year stability of self-perceived dysphagia in a COPD cohort and to identify factors associated with persistent dysphagia.

Methods

This prospective cohort study included 438 patients with spirometry-confirmed COPD from the Swedish Tools for Identifying Exacerbations (TIE) study. Self-reported swallowing symptoms were assessed at baseline and at 2-year follow-up using three questions. Dysphagia was defined as the presence of at least one symptom. Clinical assessments included lung function, dyspnoea (mMRC), health status (CAT), physical performance, body mass index (BMI), and exacerbation history. Dysphagia trajectories over time were analysed.

Results

The prevalence of patient-reported dysphagia remained stable over the 2-year period (32% at baseline vs. 33% at follow-up). Four dysphagia trajectories were identified: no dysphagia (59%), incident dysphagia (8%), remission (8%), and persistent dysphagia (25%). Participants with dysphagia at follow-up had higher dyspnoea and CAT scores, poorer physical performance, higher BMI, and more frequent exacerbations. Persistent dysphagia was associated with a consistently higher symptom burden and poorer functional outcomes over time. In multivariate analysis, CAT ≥10 remained independently associated with dysphagia.

Conclusion

Self-perceived dysphagia affects approximately one-third of individuals with COPD and remains stable over two years. Persistent dysphagia may identifiy a more symptomatic COPD phenotype and warrants clinical attention. These findings support the inclusion of simple swallowing screening in routine COPD follow-up.

Whether COPD should be diagnosed using the lower limit of normal (LLN) or a fixed FEV₁/FVC ratio <0.70 (FR) is debated. We compared symptom and disease burden in COPD patients with FEV₁/FVC below both thresholds (FR + /LLN + ) versus those between them (FR + /LLN-). This cohort study included 572 COPD patients from primary and secondary care in the central Swedish regions of Dalarna, Gävleborg, and Uppsala. FR + /LLN + COPD patients with FEV₁ ≥ 60% predicted (n = 194) was compared to FR + /LLN- COPD patients (n = 85) in order to have similar FEV₁ levels in both groups. The symptom burden was assessed using the modified British Medical Research Council scale of dyspnoea (mMRC), the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ). The disease burden was assessed by exacerbations and hospital admissions over the subsequent three years. The 279 studied patients (57% females) had a mean age of 68.2 years and a mean FEV₁% predicted of 73.0%. The FR + /LLN+ group had comparable clinical characteristics to the FR + /LLN- group regarding FEV₁% predicted (72.5 vs 74.2%), use of inhaled medicines (76.3 vs 76.5%), and previous exacerbations (23.2 vs 18.8%), all p-values > 0.05. Moreover, comparable prevalence of exacerbations and hospital admissions were found during the subsequent three years (31.7 vs 37.7%, and 4.8 vs 2.6%, respectively, all p-values > 0.05). Symptom burden was comparable for mMRC and CCQ, but the FR + /LLN- group had a higher CAT score than the FR + /LLN+ group (10.6 vs 12.6, p = 0.038), a finding also confirmed in adjusted analyses. FR + /LLN+ and FR + /LLN- COPD patients had relatively comparable symptom and disease burden, suggesting that not meeting the LLN criteria does not indicate a milder disease in clinically diagnosed COPD with comparable FEV₁.

BACKGROUND AND AIM: Patients with COPD and concurrent depression and/or anxiety are known to have an increased risk of exacerbations, morbidity, mortality, and deteriorated quality of life. Early detection of depression/anxiety may enable early interventions. The aims of this study were to describe the occurrence of depression and anxiety in primary care patients with COPD in Sweden, and to investigate age and gender differences together with other clinical factors associated with this comorbidity.

METHODS: A cross-sectional study was performed on a cohort of patients with doctor's diagnoses of COPD. Patients were randomly selected based on the patients' contact with 98 primary healthcare centers and 13 hospitals in Sweden in 2014. Information about self-reported depression/anxiety, patient characteristics, symptoms, and comorbidity, were collected using patient self-completion questionnaires. Lung function data were extracted from medical records.

RESULTS: Of the 2245 patients recruited, 23% (n = 524) reported depression/anxiety, 29% in women and 16% in men (p <0.001). Factors associated with depression/anxiety were being a woman (OR = 2.06 [95% CI 1.56-2.72]), current smoking (1.83 [1.37-2.43]), comorbid asthma (1.77 [1.32-2.37]), dyspnea (the modified Medical Research Council dyspnea scale ≥2 points) (1.58 [1.17-2.13]) and age <65 years (1.57 [1.17-2.10]). The youngest age groups had the highest proportions of patients with depression/anxiety.

CONCLUSIONS: Healthcare professionals need to be particularly aware of depression/anxiety in patients with COPD who are younger, women, current smokers, have comorbid asthma, or dyspnea.

Objective We aimed to examine the variability of chronic obstructive pulmonary disease (COPD) exacerbations and mortality, between primary healthcare centres, and their associations with comorbid diseases and body mass index, during an 8-year follow-up.Design This was a cohort study using multilevel modelling with follow-up from 2014 to 2022. Data came from questionnaires in 2014 and 2022 and medical record reviews between 2004 and 2014. The main outcomes were exacerbations in 2022 and mortality by 2022. Exacerbations were defined as any emergency visit, and/or use of oral steroids or antibiotics due to worsening of COPD symptoms during the previous 6 months.Setting The PRAXIS study included patients at 76 primary healthcare centres in central Sweden.Participants Primary care patients aged <= 75 years and with a diagnosis of COPD in their medical records between 2007 and 2010 were included in 2014 (n=1163) and followed up in 2022 (n=906). There were no other exclusion criteria.Results The 809 patients with complete data attended 70 primary care centres. Multilevel multinomial regression estimated risks of exacerbations and mortality, calculating relative risk ratios (RRRs) with 95% CIs. The intraclass correlation coefficient (ICC) quantified the proportion of variance attributed to variability between centres. The ICC was 0.024, indicating 2.4% of the variation was explained by differences between centres. Patients with a history of depression in 2014 had an increased risk of subsequent exacerbations (RRR 1.95, 95% CI 1.13 to 3.39). For mortality, there were associations with history of anxiety, RRR 3.71 (95% CI 2.06 to 6.87), or cardiovascular disease, especially chronic heart failure, RRR 2.69 (95% CI 1.36 to 5.33). Body mass index had a U-shaped association with mortality.Conclusions The variability between centres was small and patient factors appear to be of more importance for COPD exacerbations and mortality than differences between these primary care settings. As expected, pre-existing cardiovascular disease is associated with future excess mortality risk, but, notably, anxiety may also be an important risk factor. Individualised care and management of comorbidity is thus essential among patients in primary care with COPD.

Background

Comorbid conditions and breathlessness are associated with poor outcomes in chronic obstructive pulmonary disease (COPD). We evaluated the associations of comorbid heart disease and depression/anxiety with breathlessness in daily life among people with COPD.

Methods

Cross-sectional analysis from the PRAXIS cohort in central Sweden. Data on patient characteristics and the modified Medical Research Council (mMRC) and Dyspnea-12 breathlessness instruments (D-12) were obtained from questionnaires in 2022. Lung function data were collected from record review. Outcome variables were clinically significant breathlessness defined as mMRC≥2 and D-12 total (>2.7), physical (>1.4) and affective (>1.2) scores above published minimal clinical important differences. Associations of heart disease and depression/anxiety with each outcome were analyzed using multivariable Poisson regression adjusted for relevant confounders.

Results

In 522 included patients, mMRC ≥2 was present in 59 % and increased D-12 total, physical and affective domain scores in 69 %, 74 %, and 50 %, respectively. Heart disease was independently associated with mMRC (relative risk ratio [95 % confidence interval] 1.34 [1.17–1.53]), D12 physical domain (1.12[1.02–1.24]) and D-12 affective domain (1.20[1.02–1.42]). Depression/anxiety was independently associated with increased D-12 affective domain (1.25[1.04–1.49]). In addition, previous exacerbations and GOLD stage 3–4 were associated with mMRC and D-12, respectively.

Conclusion

In COPD, comorbid heart disease is associated with both activity-related breathlessness and with physical and affective domains of breathlessness while depression/anxiety is associated with the affective domain of breathlessness. As the influence of different dimensions of breathlessness may differ according to comorbidity the D-12 instrument adds more information when assessing breathlessness in patients with COPD.

Diagnostik och uppföljning av majoriteten av patienter med astma sker i primärvården. 

Den varierande luftvägsobstruktionen gör att astmadia­gnostik kan vara svår. Anamnes och lungfunktionsmätningar är grundstenen. 

Även de med enbart sporadiska symtom ska ges behandling med inhalationssteroider (steg 1). 

Patientutbildning är avgörande för god astmakontroll.

Optimal astmakontroll innebär normal lungfunktion, symtomfrihet och avsaknad av exacerbationer. Detta ska alltid bedömas. 

Vid okontrollerad astma bör behandlingsbarriärer såsom bristande inhalationsteknik, otillräcklig följsamhet till behandling, exponering för utlösande faktorer och eventuell påverkan av samsjuklighet bedömas.

Background: In 2017, Burgel and colleagues developed an algorithm to identify clinical phenotypes that predict mortality in COPD. Our study aimed to 1) investigate whether the phenotypes can predict acute exacerbations of COPD (AECOPD) and 2) validate their ability to predict mortality.

Methods: The Tools Identifying Exacerbations (TIE) cohort study recruited participants with spirometry-verified COPD from primary and secondary care in three Swedish regions. Participants were allocated to phenotypes 1–5 using the previously developed algorithm containing comorbidities (heart failure, coronary artery disease, hypertension, and/or diabetes), dyspnoea, age, forced expiratory volume in 1 s (FEV1), and body mass index (BMI). Data on AECOPDs and deaths during the three-year follow-up were collected from medical records and analysed with Cox proportional hazards regressions. Harrel's C-index was used to assess the models' discriminative ability.

Results: Among the 566 participants, 59 % were female, and the mean ± SD FEV1 was 57 ± 18 % of predicted. The hazard ratios (HRs) [95 % CI] for time to AECOPD were 3.04 [1.93–4.79], 2.38 [1.54–3.66], and 3.52 [1.73–7.15] in phenotypes 1, 2, and 4 compared with 5 (C-index = 0.61). When AECOPD history was used to predict future AECOPD the C-index was 0.65.The HRs [95 % CI] for mortality were 8.24 [1.93–35.3], 6.26 [1.40–28.0], and 16.7 [3.25–86.3] in phenotypes 1, 3, and 4 compared to 5 (C-index = 0.68). For AECOPD history, the C-index was 0.55.

Conclusion: Clinical COPD phenotypes based on comorbidities, dyspnoea, age, FEV1, and BMI predict AECOPDs but do not perform better than AECOPD history. However, they perform better than AECOPD history in predicting mortality.

Background: Prevention of lung attacks (LAs)/exacerbation is an important treatment goal in both asthma and chronic obstructive pulmonary disease (COPD). However, LAs are often not registered as such in medical records.Objectives: Development and evaluation of CodeX Asthma and COPD.Design: An electronic medical record-based algorithm to identify LAs in Dutch primary care patients with asthma or COPD was developed. The algorithms were evaluated in nine general practices in the Netherlands.Results: A total of 479 LAs (in 1164 patients) were identified with CodeX Asthma in the past year, of which only 16% were registered. CodeX COPD identified 321 LAs (in 242 patients) in the past 3 years, of which two were registered.Conclusion: CodeX algorithms are capable of identifying unrecorded LAs and high-risk/uncontrolled patients in an easy way. This offers primary care providers a simple solution to easily identify and closely manage high-risk patients with asthma or COPD by identifying LAs' frequency and potential under- or overtreatment.

Background

We aimed to examine if patients with COPD and comorbid type 2 diabetes, or COPD with comorbid depression or anxiety, had disproportionally raised excess risks of subsequent cardiovascular disease and mortality.

Methods

This general population-based cohort study used data from Swedish national registers, with follow-up during 2005-2018. Cox regression estimated risks of cardiovascular disease or mortality, producing hazard ratios (HR) with (95% confidence intervals). Interaction testing quantified disproportionally increased excess risks.

Results

Among 5,624,306 individuals, 332,549 had a COPD diagnosis. Compared with individuals who did not have COPD or type 2 diabetes, all-cause mortality risk was higher for individuals who had either COPD or type 2 diabetes, with HR 2.68 (2.66-2.69) and 1.70 (1.69-1.71), respectively. Having both conditions produced an HR of 3.72 (3.68-3.76). Among cardiovascular outcomes, the highest risks were found for chronic heart failure: COPD only, HR 2.87 (2.84-2.90); type 2 diabetes only, 1.86 (1.84-1.88); and both, 4.55 (4.46-4.64). Having both COPD and type 2 diabetes was associated with disproportionally higher excess risks than expected from the sum of the individual diseases, except for cerebrovascular disease or ischemic heart disease. For COPD and depression/anxiety, all-cause mortality risk was associated with COPD only, HR 2.74 (2.72-2.76); depression/anxiety only, 2.39 (2.38-2.40); and both 4.72 (4.68-4.75). Chronic heart failure was associated with COPD only, HR 2.74 (2.71-2.78); depression/anxiety only, 1.31 (1.30-1.32); and both, 3.45 (3.40-3.50). This disease combination was associated with disproportionally higher excess risks than expected, except for atrial fibrillation.

Conclusions

Type 2 diabetes or depression/anxiety in COPD patients were associated with disproportionally excess risks for cardiovascular disease and mortality. It is important for clinicians to be aware of these greater than expected risks, to prevent further cardiovascular morbidity and mortality.