Background and objectiveA multidimensional assessment of COPD was recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2013 and revised in 2017. We examined the ability of the GOLD 2017 and the new 16 subgroup (1A–4D) classifications to predict clinical outcomes, including exacerbation and mortality, and compared them with the GOLD 2013 classifications.MethodsPatients with COPD were recruited from January 2006 to December 2017. The predictive abilities of grades 1–4 and groups A–D were examined through a logistic regression analysis with receiver operating curve estimations and area under the curve (AUC).ResultsA total of 553 subjects with COPD were analyzed. The mortality rate was 48.6% during a median follow-up period of 5.2 years. Both the GOLD 2017 and the 2013 group A–D classifications had good predictive ability for total and severe exacerbations, for which the AUCs were 0.79 vs 0.77 and 0.79 vs 0.78, respectively. The AUCs for the GOLD 2017 groups A–D, grades 1–4, and the GOLD 2013 group A–D classifications were 0.70, 0.66, and 0.70 for all-cause mortality and 0.73, 0.71, and 0.74 for respiratory cause mortality, respectively. Combining the spirometric staging with the grouping for the GOLD 2017 subgroups (1A–4D), the all-cause mortality rate for group B and D patients was significantly increased from subgroups 1B–4B (27.7%, 50.6%, 53.3%, and 69.2%, respectively) and groups 1D–4D (55.0%, 68.8%, 82.1%, and 90.5%, respectively). The AUCs of subgroups (1A–4D) were 0.73 and 0.77 for all-cause and respiratory mortality, respectively; the new classification was determined more accurate than the GOLD 2017 for predicting mortality (P<0.0001).ConclusionThe GOLD 2017 classification performed well by identifying individuals at risk of exacerbation, but its predictive ability for mortality was poor among COPD patients. Combining the spirometric staging with the grouping increased the predictive ability for all-cause and respiratory mortality.Summary at a glanceWe validate the ability of the GOLD 2017 and 16 subgroup (1A–4D) classifications to predict clinical outcome for COPD patients. The GOLD 2017 classification performed well by identifying individuals at risk of exacerbation, but its predictive ability for mortality was poor. The new 16 subgroup (1A–4D) classification combining the spirometric 1–4 staging and the A–D grouping increased the predictive ability for mortality and was better than the GOLD 2017 for predicting all-cause and respiratory mortality among COPD patients.
Paradoxical bronchospasm refers to the constriction of the airways after treatment with a sympathomimetic bronchodilator. Theoretically, bronchodilators, such as beta-agonist inhalers, act to ease asthma symptoms by relaxing the muscles surrounding the walls of the bronchial tubes, which relieve bronchial constriction. However, in rare instances, some patients develop respiratory distress or even respiratory failure after inhaled bronchodilator use, although the exact mechanism for this adverse effect is unknown. We report a male, with a known asthma history diagnosed for more than one decade, receiving fenoterol (Berotec ®) for wheezing control and the worsening of his clinical condition immediately after bronchodilator administration.
BackgroundThere are numerous biologics for treating patients with severe asthma. A cost-effective method for selecting the most appropriate biologic therapy for a patient is thus important. Bronchoscopy-guided bronchial epithelium sampling may provide information for determining the type of inflammation in the airways of severe asthma patients through immunochemical analysis and thus help clinicians select the correct biologics.Case presentationWe report the case of a female with severe asthma and eosinophilia who initially responded to omalizumab treatment. She developed an allergic reaction after four injections of omalizumab. Omalizumab desensitization was successfully conducted. To select an appropriate biologic agent after this hypersensitivity episode, we performed bronchoscopy-guided bronchial epithelium sampling. Omalizumab treatment was resumed based on the findings of immunohistochemical staining after a successful desensitization procedure, leading to long-term control of her severe asthma.ConclusionsSelecting an adequate biologic agent for severe, uncontrolled asthma is a challenge in clinical medical practice. Although phenotypes, blood eosinophils, and serum IgE levels have been proposed for use as a reference, there is a dissociation between the blood immune-cell level and the airway epithelium immune reaction, as confirmed in previous studies. Airway epithelium immunohistochemistry staining for targeted immune cells has been used to determine various types of airway inflammation; however, this technique is rarely used in a clinical setting. Previous studies have revealed the relative safety of performing bronchoscopy biopsies for patients with severe asthma. Among the sampling techniques used for tissue diagnosis, including nasal biopsies, nasal or bronchial brushing, and bronchoalveolar lavage, bronchoscopy-guided bronchial epithelium sampling provides more accurate information about the epithelial and inflammatory cells in the tissue context. It is thus a powerful tool for selecting the most suitable biologics in difficult clinical conditions.
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