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2016 European Respiratory Society (ERS) International Congress 3-7 September, London, UK

Study suggests physical activity reduces anxiety and depression in patients with COPD

A study presented at this year’s European Respiratory Society (ERS) International Congress in London, which brought together the brightest minds in lung health to discuss the latest new and possible breakthroughs, shows that increased physical activity among patients with chronic obstructive pulmonary disease (COPD) reduces their risk of anxiety or depression.

Comorbidities are highly prevalent in patients with COPD and low physical activity (PA), a critical feature of COPD, is believed to be an important risk factor for comorbidities. In this new study, the authors (Drs Milo Puhan, Anja Frei, and Tsung Yu, University of Zurich, Switzerland, and Dr Gerben ter Riet, University of Amsterdam, the Netherlands) assessed the association of PA with the incidence of seven categories of comorbidities in COPD.

The study included 409 patients from primary care practices in the Netherlands and Switzerland. The researchers assessed PA using the Longitudinal Ageing Study Amsterdam Physical Activity Questionnaire at baseline and followed patients for up to five years. During follow-up, patients reported their comorbidities (cardiovascular, neurological, hormonal, musculoskeletal, cancer, and infectious diseases) and completed the Hospital Anxiety and Depression Scale questionnaire for mental health assessment.

The results suggested that higher levels of PA at baseline were associated with an 11 per cent reduced risk of developing anxiety over the next five years, and a 15 per cent reduced risk of becoming depressed. The researchers did not observe statistically significant associations of PA with the other categories of comorbidities.

The authors conclude: “In COPD patients, those with high PA are less likely to develop depression or anxiety over time. PA promotion programmes may be considered to lower the burden of mental disorders in COPD patients.”

They add: “These findings have particular significance since mental disorders are common in patients with COPD. The prevalence of depression and anxiety is approximately 40 per cent in COPD patients, while the corresponding figure is less than 10 per cent in the general population.”

New studies confirm long- and short-term effect of air pollution on the lungs

New research presented at the 2016 ERS International Congress, the first to look at the long-term impact of pollution exposure during childhood, shows that exposure to coal-based pollution experienced over 60 years ago is still putting people at greater risk of dying today.

The study, which was released as part of the Healthy Lungs for Life campaign, looked at the impact of pollution from domestic coal use (black smoke (BS) and sulphur dioxide (SO2)) in the UK and shows people are almost twice as likely to die from a respiratory condition if they were living in the most polluted areas as a child in the 1950s compared to the least polluted areas.

After allowing for socio-economic differences, mortality from respiratory diseases was more than twice as high in urban areas with the highest coal usage (0.7 tons per acre or more), including Manchester, Middlesbrough, and Nottingham, compared with those with the lowest usage (less than 0.2 tons per acre), like Bath, Canterbury, and Exeter.

The findings are echoed by a second longitudinal study presented at the Congress by a team from Imperial College London, which demonstrated a similar long-term impact of exposure to a range of pollutants (BS, SO2, and particulate matter with a diameter less than 10µm (PM10)) on respiratory mortality, that also takes into account migration and changes in air pollution exposure over time.

The study, which analysed data for 368,000 individuals from England and Wales followed over a 38 year period, shows that exposure to BS in 1971 was associated with a 5 per cent increased risk in respiratory mortality per 10µg/m3 in 2002-2009, jumping to 8 per cent for COPD specifically. The data underlines the impact of air pollution on diseases such as COPD, which is now the fifth biggest killer in the UK.

While the UK’s Clean Air Act has led to a reduction in BS and SO2 emissions, largely through increased use of cleaner fuels, levels of nitrogen oxides and small particles (eg, PM10) from transport pollution have increased and become the dominant sources of atmospheric pollution in urban areas.

The ERS used the International Congress to call for more research into how all types of air pollution affect health over a person’s lifetime, pointing out that soaring pollution levels directly reduce lung function.

Meanwhile, a third study presented at the ERS Congress by a team from the Flemish Institute for Technological Research (VITO) highlighted the short-term effects of air pollution on lung function.

The study compared air quality monitoring with the results of repeated, yearly lung function testing in a cohort of 2,449 healthy adults over a four-year period. The results show that higher exposure on the day and the day before lung function testing can lead to a direct – and immediate – decreased lung function.

According to the results, there is an average reduction in lung function of 0.5 per cent with every 10µg/m³ increase in PM10 and a 0.2 per cent reduction with every 1µg/m³ increase in nitrogen dioxide (NO2). With levels ranging from 5 to 130µg/m³ and from 5 to 65µg/m³ for PM10 and NO2 respectively, the potential impact could be considerable.

While there have been increasing efforts to raise awareness of the risks of air pollution to at-risk groups, the study shows a clear impact of pollution on healthy individuals as well.

Commenting on the new research, Prof Stephen Holgate, the ERS Science Council Chair, said: “There is an enduring health legacy from the large amounts of coal used in this country well into the 20th century. Not only do these findings have important implications for countries like China and India that still depend on coal, but they should be a wake-up call to our own government to take air pollution from all sources more seriously. We have a ticking time-bomb on our hands.”

Commenting on the studies, Prof Jørgen Vestbo, President of the ERS and Professor of Respiratory Medicine at the University of Manchester, UK, said: “If there’s one clear takeaway from this research it’s that the air we breathe – today, tomorrow, yesterday – matters. While we can’t change historic exposure, we can act now to reduce pollution levels and improve health outcomes in the future. Everyone needs to be aware of what it is, where it is, and the harm it can cause.”

About the UK research

The 50 year follow-up of domestic air pollution is based on a dataset complied by the UK Ministry of Fuel and Power recording the quantities of different types of fuel burnt annually between May 1951 and May 1952 in 1,330 local authority areas of the UK. These were related to current geographical mortality rates for people aged between  35-74 years to determine the extent to which early exposure to air pollution is associated with mortality five to six decades later and its specific causes. Average coal use in urban areas was 0.43 tons per acre.

In the study, respiratory conditions were the most strongly associated with domestic fuel consumption. After adjustment for socio-economic differences, mortality from chronic obstructive airways disease (COAD) was 42 per cent higher, asthma 40 per cent higher, and pneumonia 49 per cent higher in the areas with highest coal consumption. However, the most powerful relationship was with tuberculosis, which was 122 per cent higher. Coal consumption was also linked with increased rates of cancer of the mouth, larynx, and lung.

Artificial intelligence could improve lung function tests

Artificial intelligence could improve the interpretation of lung function tests for the diagnosis of long-term lung diseases, according to the findings of a new study.

The results, presented at the ERS’s 2016 International Congress, are the first to explore the potential use of artificial intelligence for improving the accuracy of the diagnosis of lung diseases.

Current testing requires a series of methods including a spirometry test, followed by a body plethysmography test measuring static lung volumes and airways resistance and finally a diffusion test, which measures the amount of oxygen and other gases that cross the lungs’ air sacs.

Analysis of the results of these tests is largely based on expert opinion and international guidelines, attempting to detect a pattern in the findings.

In this new study, researchers included data from 968 people who were undergoing complete lung function testing for the first time. All participants received a first clinical diagnosis based on lung function tests and all other necessary additional tests (such as CT scans, electrocardiogram, etc). The final diagnosis was validated by the consensus of the large group of expert clinicians.

The researchers subsequently investigated whether a concept known as ‘machine learning’ could be used to analyse the complete lung function tests. Machine learning utilises algorithms that can learn from and perform predictive data analysis.

The team developed an algorithm process in addition to the routine lung function parameters and clinical variables of smoking history, body mass index, and age. Based on the pattern of both the clinical and lung function data, the algorithm makes a suggestion for the most likely diagnosis.

Dr Wim Janssens, senior author of the study from the University of Leuven in Belgium, commented: “We have demonstrated that artificial intelligence can provide us with a more accurate diagnosis in this new study. The beauty of our development is that the algorithm can simulate the complex reasoning that a clinician uses to give their diagnosis, but in a more standardised and objective way so it removes any bias.”

Clinicians must currently rely on analysing the results using population-based parameters. With artificial intelligence, the machine can observe a combination of patterns at one time to help produce a more accurate diagnosis.

This has previously happened in other fields of health with an automated interpretation of results from an electrocardiogram being routinely used in clinical practice as a decision support system.

Dr Marko Topalovic, first author of the study from the University of Leuven in Belgium, said: “The benefit of this method is a more accurate and automated interpretation of pulmonary function tests and thus better disease detection.

“Not only can this help non-experienced clinicians, but it also has many benefits for healthcare overall as it is time saving in achieving a final diagnosis as it could decrease the number of redundant additional tests clinicians are taking to confirm the diagnosis.”

The next step for the research team will be to test the algorithm in different populations and increase the decision power of the system with continuous updates on lung function data with a validated clinical diagnosis. 

Physical activity found to decrease risk of dying in COPD

Any amount of moderate to vigorous physical activity can effectively reduce the risk of dying after hospitalisation for COPD, according to a new US study highlighted by the ERS.

The research, published earlier this year in ERJ Open Research, significantly adds to the mounting evidence that physical activity should be used to monitor and treat patients with COPD.

Rehospitalisation and death rates are high following any initial hospitalisation and, in addition, hospitalisations due to severe exacerbations of COPD account for up to 70 per cent of the healthcare costs associated with COPD. It is therefore crucial that healthcare professionals can identify patients at a high-risk of readmission.

Researchers studied the health records of 2,370 patients from Kaiser Permanente, Southern California, US, who were hospitalised for COPD for one year, looking at exercise as a vital sign which was self-reported in the clinic as a measure of physical activity, and monitoring deaths from all causes within that time frame.

The results found that patients who were active had a 47 per cent lower risk of death in the 12 months following a COPD hospitalisation, compared to inactive patients. Patients who were active but at insufficient levels still maintained a 28 per cent lower risk of death, compared to inactive patients.

The authors concluded that monitoring levels of physical activity with a simple exercise “vital sign,” and could help healthcare professionals identify, monitor, and treat those patients at a high-risk of death following hospitalisation.

Lead author Dr Marilyn Moy, Assistant Professor at Harvard Medical School, US, commented: “We know that physical activity can have a positive benefit for people with COPD and these findings confirm that it may reduce the risk of dying following hospitalisation for an acute exacerbation. The results also demonstrate the importance of routinely assessing physical activity in clinical care to identify high-risk patients as part of a larger strategy to promote physical activity in this highly sedentary population.”

Beta-blockers could reduce the risk of COPD exacerbations

Beta-blockers could be used to reduce the risk of COPD exacerbations, according to new findings.

While beta-blockers are primarily used to treat stress or heart problems, such as high blood pressure and angina, these findings suggest they could have a potential benefit for patients with COPD.

COPD exacerbations involve a worsening of symptoms, in particular increased breathlessness. Although beta-blockers are suspected to tighten the muscles in the airways, contributing to breathing problems, previous research has suggested beneficial effects of β-blocker use in patients with COPD. This study aimed to understand this link and to analyse if any potential benefit on exacerbations existed for COPD patients taking the drug.

The research, presented at the ERS Lung Science Conference, analysed health records of 1,621 COPD patients included in the Rotterdam Study. Patients were followed until an exacerbation occurred and researchers collected data on the use of different kinds of beta-blockers and whether the patient also experienced heart failure.

The findings revealed that the use of cardio selective beta-blockers, which are primarily used to treat heart disease, reduced the relative risk of exacerbations by 21 per cent. The benefits were increased for patients with heart failure who saw a reduced risk of 55 per cent.

Dr Lies Lahousse, lead author and FWO postdoctoral fellow from Ghent University Hospital in Belgium, commented: “The overlap in symptoms and risk factors associated with lung and heart disease can be complicated and we know that a reduction in lung function is also associated with a reduction in heart function. These preliminary findings offer a useful insight into the potential benefits of beta-blockers for patients living with heart disease at the same time as COPD. If randomised controlled trials confirm our findings, we could see promising clinical implications.”

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