Ad Saleh

How to assess the severity of bronchiectasis.

Wait long enough for a bus and two arrive at once. As with buses, so with bronchiectasis scoring systems. In this issue of the European Respiratory Journal Martinez-Garcia et al. [1] report the development of a “FACED” bronchiectasis prognostic score. This follows the recent publication by Chalmers et al. [2] of the “Bronchiectasis Severity Index” (BSI). Bronchiectasis is a neglected disease and research in the area is to be welcomed, especially when it enables us to manage our patients more appropriately. But, like any good research, these studies raise as many questions as answers: most importantly, what do we even mean when we talk about bronchiectasis “severity”? Current definitions of bronchiectasis have two components. The landmark British Thoracic Society guidance emphasises the concept of “clinically significant” bronchiectasis [3]; the presence of “symptoms of persistent or recurrent bronchial sepsis”, in addition to the permanent airway structural damage that represents the accepted pathology definition. Tools to grade the degree and extent, or “severity” of the radiological component already exist; e.g. scoring systems described by Reiff et al. [4] and Bhalla et al. [5]. These are not without problems. Importantly, patients can have similar severity scores arising from structurally more abnormal but localised disease, or …

The Effect of Incidental Consolidation on Management and Outcomes in COPD Exacerbations: Data from the European COPD Audit

Objective There is controversy regarding the significance of radiological consolidation in the context of COPD exacerbation (eCOPD). While some studies into eCOPD exclude these cases, consolidation is a common feature of eCOPD admissions in real practice. This study aims to address the question of whether consolidation in eCOPD is a distinct clinical phenotype with implications for management decisions and outcomes. Patients and Methods The European COPD Audit was carried out in 384 hospitals from 13 European countries between 2010 and 2011 to analyze guideline adherence in eCOPD. In this analysis, admissions were split according to the presence or not of consolidation on the admission chest radiograph. Groups were compared in terms of clinical and epidemiological features, existing treatment, clinical care utilized and mortality. Results 14,111 cases were included comprising 2,714 (19.2%) with consolidation and 11,397 (80.8%) without. The risk of radiographic consolidation increased with age, female gender, cardiovascular diseases, having had two or more admissions in the previous year, and sputum color change. Previous treatment with inhaled steroids was not associated. Patients with radiographic consolidation were significantly more likely to receive antibiotics, oxygen and non-invasive ventilation during the admission and had a lower survival from admission to 90-day follow-up. Conclusions Patients admitted for COPD exacerbation who have radiological consolidation have a more severe illness course, are treated more intensively by clinicians and have a poorer prognosis. We recommend that these patients be considered a distinct subset in COPD exacerbation.

Correlates and assessment of excess cardiovascular risk in bronchiectasis

Patients with bronchiectasis are at increased risk of cardiovascular disease. We aimed to identify factors associated with elevated cardiovascular risk in bronchiectasis, measured using aortic stiffness and cardiac biomarkers. In addition, we sought to compare these direct measures against calculated QRISK2 scores. Aortic stiffness, cardiac biomarkers and systemic inflammation were measured in 101 adults with stable bronchiectasis. In addition, clinical and demographic data were collected to allow calculation of QRISK2 score and the bronchiectasis severity index (BSI) for each patient. The BSI score correlated with measured cardiovascular risk assessments, partly due to greater exacerbation frequency and lower forced expiratory volume in 1 s. Pulse-wave velocity was significantly higher in frequent exacerbators (≥3 events·year-1) than infrequent exacerbators (<3 events·year-1; 10.5 versus 9.2 m·s−1, p=0.01). In addition, frequent exacerbators had elevated serum C-reactive protein concentration, suggesting increased systemic inflammation (4.8 versus 2.2 mg·L−1, p=0.005). QRISK2 systematically underestimated cardiovascular risk in this population (median change in relative risk 1.29). Underestimation was associated with frequent exacerbations and male sex. Patients with bronchiectasis have greater cardiovascular risk than published reference populations. Excess cardiovascular risk is associated with exacerbation frequency and impaired lung function. Cardiovascular risk assessment in bronchiectasis should be individualised, as calculation tools are likely to underestimate the risk in this population. Bronchiectasis is associated with elevated cardiovascular risk, which is greatest in frequent exacerbators http://ow.ly/pFgg30eXEXY

S97 Severity of lung but not liver disease impacts cardiovascular risk in alpha-1 antitrypsin deficiency

Introduction Alpha-1 antitrypsin deficiency (AATD) is a genetic condition associated with COPD; patients homozygous for the mutant ‘Z’ allele (PiZZ) are predisposed to severe, early-onset emphysema of the lung, and also progressive fibrosis and cirrhosis of the liver. There is a well-known association between COPD and cardiovascular disease, with around 1 in 3 COPD deaths attributed to a cardiac cause.1 We hypothesised that cardiovascular risk in AATD may be independently modified by the severity of lung and liver disease, through common or related pathophysiological processes. Methods Cardiovascular risk was ascertained in 43 patients with PiZZ AATD using QRISK2 score and aortic pulse wave velocity (aPWV). These values were correlated with indicators of lung (FEV1, DLCO, KCO, RV) and structural liver disease (transient elastography and liver ultrasound). Results The severity of airflow obstruction (FEV1), emphysema (gas transfer) and gas trapping (RV) all related to cardiovascular risk as assessed by aPWV and QRISK2, Table 1. In contrast, there was no significant association between the presence or increased severity of structural liver disease, as assessed by ultrasound and transient elastography respectively, and either indicator of cardiovascular risk (p < 0.05).Abstract S97 Table 1 FEV1(l) DLCO (mmol/min/kPa) KCO (mmol/min/kPa/l) RV (l) r/rho p r/rho p r/rho p r/rho p aPWV (m/s) -0.459 0.002 -0.516 <0.001 -0.454 0.002 0.485 0.002 QRISK2 (% risk) -0.335 0.043 -0.462 0.004 -0.336 0.042 0.388 0.026 Conclusions These findings demonstrate that the severities of emphysema and airflow obstruction are associated with increased cardiovascular risk in AATD. In contrast, there was no association between the severity of structural liver disease and cardiovascular risk. Therefore, in conclusion, cardiovascular risk varies in PiZZ A1AD patients according to disease phenotype. Reference 1 McGarvey LP, et al. Thorax 2007;62(5):411–15