26th ERS international congress 2016, London

    Ceelen, J.J.M. | NUTRIM School of Nutrition and Translation Research in Metabolism Maastricht University Department: Respiratory medicine | 14 november 2016 | (

The goal of the ERS congress is to promote new scientific knowledge and put a spotlight on respiratory research by presenting cutting-edge research alongside informative educational sessions. Oral and poster presentation highlights concerning COPD comorbidities and phenotyping as well as new insights in predicting exacerbations are described below.

Christian Lo Cascio suggested in his presentation that there are two distinct but overlapping phenotypes; emphysema characterized by activity limitation and increased mortality and an airway disease with respiratory symptoms and frequent exacerbations. Manu Madan showed that patients with emphysema have a poorer lung function, a greater impact on patient-centered outcomes and carry more adverse risk predictions like BODE and ADO scores, than those without emphysema. They stress that evidence of emphysema should be sought in all patients with COPD as it identifies a clinical phenotype that is more severe and has poorer outcomes.

High resolution computed tomography has become an important tool for determining emphysema, where the amount of low attenuation area determines the degree of emphysema. However, Karimi et al. showed that attenuation based quantification of emphysema was not sensitive for detection of mild emphysema and that criteria on chest x-ray indicating hyperinflation may be useful in selection of patients for further CT examination.

Acute exacerbations in COPD are associated with poor quality of life and increased mortality. Treatment management and patient outcomes could be improved by identifying patients who are at increased risk of exacerbations. Fridlander et al. investigated whether the degree of emphysema could predict exacerbations. However, they found that emphysema had no significant correlation with the rate of exacerbation, suggesting that the rate/severity of exacerbations are not dependent on the level of emphysema. Bigazzi et al. had similar results. By principal component analysis of CT values of parenchymal destruction and airway wall thickness, they quantitatively assessed the CT predominant phenotype (airway disease or emphysema) and the overall severity of COPD. In their study they defined frequent exacerbators and severe exacerbators and found that exacerbation characteristics only correlated with COPD severity, but not with CT predominant phenotype.

Several researchers found that exacerbation history is better predictor of the risk of future exacerbations. Juan luis García Rivero showed that the main predictor of being a frequent exacerbator was a history of frequent exacerbations in the previous year, with the highest association found in GOLD1 patients, suggesting a higher susceptibility in these patients. Vogelmeier et al. showed in the WISDOM study (a 12-month, randomized, parallel-group study), that patients with prior ICS (inhaled corticosteroids) treatment and an exacerbation history were significantly associated with exacerbation risk. They also found that higher baseline FEV1 were associated with a significantly decreased risk of exacerbation.

The COPD assessment test (CAT) has been shown to be a sensitive tool for evaluation of patient’s health status during COPD exacerbation and correlates with changes in pulmonary function and inflammatory markers. Dimitrina Stoyanova showed that frequent compared to non- frequent exacerbators have higher values of CAT during exacerbation. Aliaksei Kadushkin proposed a model to assess the risk of future COPD exacerbations which includes the CAT score and plasma concentrations of vascular endothelial growth factor and C-reactive protein. They showed that their model is robust and easily applicable to individual patients.

In conclusion, the correct phenotyping of COPD patients with regard to degree of emphysema and the risk of future exacerbations is important in order to improve treatment management and tailored, personalized treatments. Several tools like high resolution computed tomography and models for risk assessment have been developed to aid herein. However, more studies are needed to investigate whether the use of these tools will improve treatment options in the clinic.

Keyword: COPD Penotyping Emphysema

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