To Örebro University

INTRODUCTION: Rapid urbanisation over the past century has led to increased traffic density and higher levels of ambient air pollutants. We aimed to investigate whether the prevalence of respiratory symptoms, asthma, and chronic bronchitis increases with the level of self-reported exposure to traffic and occupational-related pollution.

MATERIAL AND METHODS: The study population comprised 25,889 general population subjects ages 16-75 years participating in the Swedish part of the GA2LEN study. Data were collected in the cities of Umeå, Uppsala, Stockholm, and Gothenburg. Self-reported data on disturbance of fumes from traffic in the residential area or occupational exposure to gas, dust, or smoke, as well as on patient demographics, respiratory symptoms, asthma and chronic bronchitis, were obtained from questionnaires.

RESULTS: The prevalence of respiratory symptoms, asthma, and chronic bronchitis was higher both among participants reporting traffic-related exposure and those with a history of occupational exposure to fumes, smoke, and dust than among those unexposed; (wheeze 27 vs 13%), nocturnal cough (35 vs 22%), asthma (11 vs 6%) and chronic bronchitis (22 vs 8%); all p < 0.0001. When combining traffic and occupational exposure, the highest prevalence was found amongst those exposed to both. Associations with occupational exposure were generally stronger in women, and those with traffic exposure were stronger in men.

CONCLUSION: In this large population-based sample, self-reported residential traffic exposure and occupational exposure to dust, fumes, or smoke were associated with increased prevalence of respiratory symptoms, asthma, and chronic bronchitis. Although causality cannot be inferred, these findings underscore the importance of assessing environmental and occupational exposures in evaluating respiratory health.

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: Long-term oxygen therapy (LTOT) given for at least 15 hours/day improves survival in patients with severe chronic hypoxemia. However, the recent REDOX trial showed that LTOT prescribed for 24 hours/day was not superior to 15 hours/day in terms of death, hospitalizations, or self-reported outcomes. We aimed to examine the cost effectiveness of prescribing LTOT for 24 versus 15 hours/day.

METHODS: A cost minimization analysis of the REDOX trial data on 241 patients with severe hypoxemic respiratory failure randomized 1:1 to either LTOT 24 hours/day (n = 117) or 15 hours/day (n = 124) and followed up to 12 months. Data on medical care consumption including prescribed medication costs, specialized outpatient and inpatient care were retrieved from national registries. Mean differences in healthcare consumption costs (US$2024 prices) between groups were analyzed using generalized linear models. The cost analysis took a healthcare payer perspective and oxygen therapy costs are presented separately as out-of-pocket payments.

RESULTS: During the 12 months of follow-up, patients prescribed LTOT for 24 hours/day had significantly lower mean costs for respiratory specific medications (US$-175; 95% CI, -329 to -29) but higher oxygen therapy costs (US$173; 80 to 268), compared to patients prescribed LTOT 15 hours/day. There were no significant differences between the groups in mean specialized outpatient and inpatient care costs, total medication costs, or in overall total costs (-US$4,951; -10,667 to 443) but numerically favouring usage of LTOT 24/day. A population level projection shows substantial potential cumulative cost savings of US$7.64 million if LTOT 24 h/day is adopted.

CONCLUSION: In addition to previously shown similar treatment efficacy, the overall healthcare costs did not significantly differ between LTOT prescribed 15 h/day and LTOT 24h/day. However, there is an observable numerical difference in favour of usage of LTOT 24 h/day.

BACKGROUND: The use of high-flow oxygen therapy (HFOT) compared with standard low-flow oxygen therapy (LFOT) may improve outcomes in people with oxygen-dependent chronic respiratory failure (CRF). The primary aim of this multicentre trial was to evaluate HFOT in addition to LFOT, compared with regular LFOT in people with CRF due to chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD).

METHODS: Registry-based randomised controlled trial (R-RCT) of people on LFOT for CRF due to COPD (n = 270) and ILD (n = 40), at ten Swedish secondary care centres within the Swedish Register for Respiratory Failure (Swedevox). People with ongoing LFOT are randomised in a 1:1 ratio to standard treatment with LFOT (control) or LFOT with added HFOT during nighttime and at the patient's discretion daytime (intervention). HFOT is provided using the ResMed Lumis HFT system and the AcuCare HFNC Cannula. Primary outcome is time to first hospitalisation or death up to 1 year in people with COPD. Secondary outcomes include symptoms, health-related outcomes (HRQL), health-economics, adverse events, and to explore the effects of HFOT in people with CRF due to ILD. Outcome data will be obtained from national registries and from patient questionnaires at 3 and 12 months.

DISCUSSION: This R-RCT will combine the advantages of a prospective randomised trial and large clinical national registries to improve the evidence-based use of long-term oxygen therapy. Recruitment started in June 2024 and is ongoing.

TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT06247397. Registered 2024-02-07.

Rationale: Cardiopulmonary risk refers to the elevated likelihood of serious cardiovascular or respiratory events among patients with COPD, compared with the general population, beyond what would be attributable to shared risk factors (eg, smoking, older age). This study evaluated healthcare resource utilization and associated costs in patients with COPD who have experienced cardiopulmonary events.

Methods: This retrospective study utilized data from 100% Medicare Fee-for-Service and Inovalon MORE2 Registry® of closed claims from 1/1/2020-3/31/2024. Patients 40+ years old with ≥2 COPD diagnosi scodes in 2021 were categorized based on the presence or absence of a cardiopulmonary event (hospitalization for COPD, acute heart failure, cardiac arrest, myocardial infarction or revascularisation procedure) any time after COPD diagnosis. For those with an event, index date was the earliest event date. Patients without an event were matched according to age, sex, payer type, region of residence, and the Elixhauser Comorbidity Index, and assigned a proxy index date based on the time between the COPD diagnosis and the cardiopulmonary event of their matched counterpart. All patients were required to present 12 months of continuous health plan enrolment preceding and following the index date. All-cause, COPD-related, and cardiovascular disease (CVD)-related healthcare resource utilization, associated costs, and other select clinical outcomes/therapies of interest were assessed during the 12-month follow-up period. Differences were assessed using paired t-tests.

Results: After matching, 138,584 pairs of patients with COPD with and without a cardiopulmonary event (representing 13.5% of the full ABACOS OUTCOMES cohort) were included in the analysis (Table). Patients experiencing a cardiopulmonary event were significantly more likely to have subsequent all-cause, COPD-related, and CVD-related hospital admissions, and all-cause, COPD-related, and CVD-related emergency department visits compared with patients without a cardiopulmonary event during the follow-up period. Similar trends were observed for outpatient utilization. All-cause hospital costs were 433% greater and total direct healthcare costs were 126% greater among patients with a cardiopulmonary event compared with patients without an event. Patients with cardiopulmonary events also experienced significantly more moderate COPD exacerbations, utilization of oxygen therapy, mechanical ventilation, and ICU stays.

Conclusions: Patients with COPD experiencing a cardiopulmonary event exhibit significantly increased CVD- and COPD-related healthcare resource utilization and costs during 1 year of follow-up, as well as higher need for critical care, compared with patients without such an event in a real-world setting. Results highlight the importance of proactive management of COPD to help reduce cardiopulmonary risk and economic burden.

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.

The impact of obstructive sleep apnea (OSA) and positive airway pressure (PAP) treatment on COVID-19 severity is unclear. In this population-based, nationwide study using multi-register data, we aimed to assess if OSA is a risk factor for COVID-19 severity and how adherence to PAP treatment and clinical characteristics affect the risk. Swedish residents with COVID-19 infection January 2020-May 2022 were included. An exposed group of OSA (starting PAP treatment 2015-2019) was identified. COVID-19 severity outcome was defined as mild (non-hospitalised), severe (hospitalised) or critical (intensive care or death). Covariates included comorbidities and sociodemographics. Conditional odds ratios (COR) with 95% confidence intervals (95% CI) were estimated using multinomial logistic regression. Among 8,894,162 individuals in Sweden, 1,932,081 (21.7%) had registered COVID-19 January 2020-May 2022. OSA was identified in 11,407 (0.6%) and was associated with an increased risk of severe (COR 1.34; 95% CI 1.25-1.43) and critical (1.25; 1.11-1.42) COVID-19 after adjustment for age, sex, education and comorbidities. Stratified by PAP adherence, age and COVID-19 wave, OSA was a risk factor for more severe COVID-19 in PAP-adherent and non-adherent individuals, in people aged 40-60 but not > 60 years and not after June 2021. OSA severity, assessed with the oxygen desaturation index (ODI), was independently associated with COVID-19 severity, with the highest risks for severe (1.23; 1.01-1.52) and critical (1.76; 1.17-2.63) COVID-19 observed in ODI ≥ 30 (vs. ODI < 15). We conclude that patients with moderate to severe OSA have an increased risk of severe COVID-19, also when PAP-treated, with an independent dose-response relationship between the severity of intermittent hypoxia and COVID-19 severity.

Elevated troponin I (TnI) has been reported in patients with chronic obstructive pulmonary disease (COPD) without cardiovascular disease (CVD), suggesting non-ischaemic mechanisms. We assessed this association in a population-based cohort of 22 526 individuals without known CVD or significant coronary artery calcification. TnI showed no association with COPD (adjusted OR 0.87, 95% CI 0.60 to 1.26; highest category vs below limit of detection) or with forced expiratory volume in 1 s/forced vital capacity (adjusted difference 0.002, 95% CI -0.001 to 0.004). Median TnI was 2.2 ng/L in both obstructive and non-obstructive groups. These findings do not support a pulmonary source of TnI elevation in mild to moderate, stable COPD and suggest that TnI elevations should prompt cardiovascular evaluation rather than being attributed to pulmonary disease alone.

PURPOSE: The study aimed to investigate the associations between impaired spirometry such as obstructive pattern and preserved ratio impaired spirometry (PRISm) and occurrent cardiovascular events and deaths in patients with acute myocardial infarction.

PATIENTS AND METHODS: Cohort study of 517 patients with age ≥40 years and ≥10 pack-years of smoking, hospitalized for myocardial infarction at eight sites in Sweden and the United Kingdom. The Vitalograph® COPD-6 device was used to assess the ratio of forced expiratory volume in 1 and 6 seconds (FEV1/FEV6) and FEV1 as a percentage of the predicted value (FEV1%pred). Obstructive pattern was defined as FEV1/FEV6 <0.7, PRISm as FEV1/FEV6 >0.7 and FEV1%pred <80, and normal findings as FEV1/FEV6 ≥0.7 and FEV1%pred ≥80. Follow-up data were obtained from national registers or follow-up visits. Multivariable Cox regression was used to analyze the associations of obstructive pattern and PRISm with the incidence of acute ischemic cardiovascular events or major adverse cardiovascular events (MACE), respectively, within one year.

RESULTS: Obstructive pattern was found in 95 (18%), PRISm in 192 (37%) and normal spirometry in 230 (45%) patients. A cardiovascular event occurred in 21 (4%) and MACE in 28 (5%). Compared with normal spirometry, PRISm was independently associated with both new cardiovascular events (HR (95% CI) 3.44 (1.07-11.0)) and MACE (4.94 (1.63 to 15.0)), and obstructive pattern with MACE (3.87 (1.08-13.8)). Further adjustment for cardiac or COPD treatment did not substantially change the results.

CONCLUSION: About half of patients with acute myocardial infarction and a ≥10 pack-year smoking history have abnormal spirometry findings. Both obstructive pattern and PRISm are independently associated with increased risk for MACE within one year. We suggest that spirometry should be considered as a routine assessment in patients with smoking history and recent myocardial infarction.

Recent studies have established an association between COPD exacerbations and cardiopulmonary risk. However, the general burden of cardiopulmonary events remains poorly characterized among COPD patients; further investigation is needed to understand underlying risks and event rates.

This study used the Inovalon More 2 Registry® and Medicare Fee-for-Service (MFFS) claims data. Patients identified between 1/1/20 and 12/31/22 were ≥40 yrs and had: ≥2 Dx for COPD, ≥12-mos history and ≥1 day follow-up post index date (1st COPD diagnosis). Outcomes were incidence rates of cardiopulmonary events stratified by sub-groups. Cardiopulmonary events included hospitalizations for COPD exacerbations and cardiovascular (CV) events. Rates are presented separately for severe COPD exacerbations and CV events.

2.08M patients with COPD were identified: mean age 72 yrs, 57% female, 70% MFFS, and 31.4% low-income. Overall, incidence of cardiopulmonary events was 19.64 per 100-PYs (95% CI:19.59–19.68); ranging between 13.24 (13.15–13.34) for newly diagnosed COPD patients to 49.75 (49.60–49.90) for patients with baseline heart failure (Table). Overall, the incidence of severe exacerbations and CV events was 7.64 (7.61–7.67) and 12.00 (11.94–12.05), respectively.

Among patients with COPD, real-world incidence of cardiopulmonary events was highest among those with baseline heart failure; even newly diagnosed patients with COPD experienced events