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      Thoracic Imaging at Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review

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          Exacerbations of chronic obstructive pulmonary disease (COPD) are currently diagnosed based on changes in respiratory symptoms. Characterizing the imaging manifestation of exacerbations could be useful for objective diagnosis of exacerbations in the clinic and clinical trials, as well as provide a mechanism for monitoring exacerbation treatment and recovery. In this systematic review, we employed a comprehensive search across three databases (Medline, EMBASE, Web of Science) to identify studies that performed imaging of the thorax at COPD exacerbation. We included 51 from a total of 5,047 articles which met all our inclusion criteria. We used an adapted version of the Modified Newcastle-Ottawa Quality Assessment Scale for cohort studies to assess the quality of the included studies. Conclusions were weighted towards higher-quality articles. We identified a total of 36 thoracic imaging features studied at exacerbation of COPD. Studies were generally heterogeneous in their measurements and focus. Nevertheless, considering studies which performed consecutive imaging at stable state and exacerbation, which scored highest for quality, we identified salient imaging biomarkers of exacerbations. An exacerbation is characterized by airway wall and airway calibre changes, hyperinflation, pulmonary vasoconstriction and imaging features suggestive of pulmonary arterial hypertension. Most information was gained from CT studies. We present the first ever composite imaging signature of COPD exacerbations. While imaging during an exacerbation is comparatively new and not comprehensively studied, it may uncover important insights into the acute pathophysiologic changes in the cardiorespiratory system during exacerbations of COPD, providing objective confirmation of events and a biomarker of recovery and treatment response.

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          Most cited references 50

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          Impact of exacerbations on COPD.

           A Anzueto (2010)
          Exacerbations of chronic obstructive pulmonary disease (COPD) determine disease-associated morbidity, mortality, resource burden and healthcare costs. Acute exacerbation care requirements range from unscheduled primary care visits to emergency room, inpatient or intensive care, generating significant costs in COPD. Even after an exacerbation resolves, respiratory, physical, social and emotional impairment may persist for prolonged time. Frequent exacerbations, mainly in patients with severe COPD, accelerate disease progression and mortality. Thus, patients with frequent exacerbations have a more rapid decline in lung function, worse quality of life and decreased exercise performance. Management of COPD directed to reduce incidence and severity of exacerbations improves long-term health status and conserves health care resources and costs.
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            A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact.

            Acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease (COPD) can have a similar clinical presentation, and X-ray examination does not always solve the problem of differential diagnosis. The potential of lung ultrasound to distinguish these two disorders was assessed. Prospective clinical study. The medical ICU of a university-affiliated teaching hospital. We investigated 66 consecutive dyspneic patients: 40 with pulmonary edema and 26 with COPD. In addition, 80 patients without clinical and radiologic respiratory disorders were studied. The sign studied was the comet-tail artifact arising from the lung wall interface, multiple and bilaterally disseminated to the anterolateral chest wall. The feasibility was 100%. The length of the examination was always under 1 min. The described pattern was present in all 40 patients with pulmonary edema. It was absent in 24 of 26 cases of COPD as well as in 79 of 80 patients without respiratory disorders. The sign studied had a sensitivity of 100% and a specificity of 92% in the diagnosis of pulmonary edema when compared with COPD. With a described pattern present in 100% of the cases of pulmonary edema and absent in 92% of the cases of COPD and in 98.75% of the normal lungs, ultrasound detection of the comet-tail artifact arising from the lung-wall interface may help distinguish pulmonary edema from COPD.
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              Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease.

              To identify factors affecting the short-term prognosis of patients with acutely exacerbated chronic obstructive pulmonary disease (COPD). The 590 patients having COPD as primary disease who were hospitalized in the pneumology unit of a university hospital from 1981 to 1990 were studied. A standardized protocol for the treatment of acutely exacerbated COPD was adopted for all the patients. The patient records were retrospectively analyzed by two observers, and 23 clinical and laboratory variables defining the patient status on admission were collected. Age and arterial gas data were also taken into account, and the outcome mortality was recorded. Interobserver reproducibility was tested by computing the kappa coefficient and Spearman's rho for dichotomous and continuous variables, respectively. The relationship of clinical and laboratory factors to the outcome was assessed first by univariate analysis and then by a logistic regression analysis assessing the independent predictive role of variables previously shown to be univariately correlated with mortality. The mortality rate was 14.4%. The logistic regression analysis identified four independent predictors of death: age (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.04 to 1.11), alveolar-arterial oxygen gradient greater than 41 mm Hg (OR 2.33; 95% CI 1.39 to 3.90), ventricular arrhythmias (OR 1.91; 95% CI 1.10 to 3.31), and atrial fibrillation (OR 2.27; 95% CI 1.14 to 4.51). Patients with acutely exacerbated COPD having a high risk of death can be identified at the time of admission. Variables reflecting heart dysfunction are important determinants of this risk. Among pulmonary function data, only alveolar-arterial oxygen gradient contributes to the predictive model.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                22 July 2020
                : 15
                : 1751-1787
                [1 ]Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London , London, UK
                [2 ]Department of Computer Science, University College London , London, UK
                [3 ]Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King’s College London , London, UK
                [4 ]UCL Respiratory, University College London , London, UK
                [5 ]GlaxoSmithKline Research and Development , Stevenage, UK
                [6 ]Amallis Consulting LTD , London, UK
                Author notes
                Correspondence: John R Hurst Email
                © 2020 Rangelov et al.

                This work is published by Dove Medical Press Limited, and licensed under a Creative Commons Attribution License. The full terms of the License are available at The license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 3, Tables: 1, References: 61, Pages: 37
                Funded by: EPSRC Centre For Doctoral Training in Medical Imaging
                Funded by: industrial CASE studentship with funding from GlaxoSmithKline Research and Development
                Funded by: Industrial Fellowship from the Royal Commission for the Exhibition of 1851
                Funded by: MRC Skills Development Fellowship
                Funded by: Wellcome Trust Clinical Research Career Development Fellowship
                BAR is supported by the EPSRC Centre For Doctoral Training in Medical Imaging with grant EP/L016478/1 and an industrial CASE studentship with funding from GlaxoSmithKline, with studentship agreement number BIDS3000032413. BAR is also holding an Industrial Fellowship from the Royal Commission for the Exhibition of 1851. ALY is supported by an MRC Skills Development Fellowship. JJ was supported by a Wellcome Trust Clinical Research Career Development Fellowship 209553/Z/17/Z. APC and FJW are employees of GlaxoSmithKline. SL is a consultant to GlaxoSmithKline.

                Respiratory medicine

                copd, radiology and other imaging, emphysema


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