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Treatable traits qualifying for nonpharmacological interventions in COPD patients upon first referral to a pulmonologist: the COPD sTRAITosphere

Alex J. van ’t Hul, Eleonore H. Koolen, Jeanine C. Antons, Marianne de Man, Remco S. Djamin, Johannes C.C.M. in ’t Veen, Sami O. Simons, Michel van den Heuvel, Bram van den Borst, Martijn A. Spruit
ERJ Open Research 2020 6: 00438-2020; DOI: 10.1183/23120541.00438-2020
Alex J. van ’t Hul
1Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
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  • For correspondence: alex.vanthul@radboudumc.nl
Eleonore H. Koolen
1Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
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Jeanine C. Antons
1Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
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Marianne de Man
2Bernhoven, Dept of Respiratory Diseases, Uden, The Netherlands
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Remco S. Djamin
3Dept of Respiratory Diseases, Amphia Hospital, Breda, The Netherlands
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Johannes C.C.M. in ’t Veen
4Dept of Respiratory Diseases, STZ Centre of Excellence for Asthma & COPD, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
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Sami O. Simons
5Dept of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
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Michel van den Heuvel
1Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
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Bram van den Borst
1Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
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Martijn A. Spruit
5Dept of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
6Dept of Research and Development, CIRO+, Horn, The Netherlands
7REVAL-Rehabilitation Research Center, BIOMED-Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
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  • FIGURE 1
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    FIGURE 1

    Frequencies of the nine treatable traits. SM: self-management.

  • FIGURE 2
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    FIGURE 2

    Total number of treatable traits (TTs). a) 151 unique combinations of TTs are illustrated in relation to the total number of TTs per patient. Red represents the presence of a particular TT whereas green represents the absence. The blue lines mark the subgroups with a corresponding total number of TTs. b) Frequencies of the number of TTs present per patient displayed. c) and d) A scatter-plot is presented of the total number of TTs and the Clinical COPD Questionnaire (CCQ) total score (c) and forced expiratory volume in 1 s (FEV1) % predicted (d), respectively. SM: self-management.

  • FIGURE 3
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    FIGURE 3

    a) The COPD sTRAITosphere. A severely impaired health status (Clinical COPD Questionnaire (CCQ) total score >2 points) is at the very centre of the sTRAITosphere and each treatable trait (TT) is presented as sphere. The size of the spheres is proportional to the prevalence of the TT and the distance to the centre reflects the OR of having a severely impaired health status. b) Validation of the COPD sTRAITosphere.

Tables

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  • TABLE 1

    Examined treatable traits, measurement instruments, cut-off values applied and appropriate evidence-based nonpharmacological interventions

    Treatable traitMeasurement instrumentCut-off valuePossible (combinations of) intervention(s)
    1Current smokingMedical historyPositive on historySimple advice, combination of behavioural treatment and pharmacotherapy [17]
    2Activity-related dyspnoea [18]Medical Research Council dyspnoea scaleGrade ≥3exercise training, pulmonary rehabilitation [19]
    3Frequent exacerbations [13]Medical history≥2 exacerbations or ≥1 hospitalisation past yearExacerbation action plan [20], pulmonary rehabilitation [19]
    4Poor nutritional status [21]BMIBMI<21 or BMI>30 kg·m−2Nutritional support [22], dietary counselling and calorie restriction plus resistance exercise training [23]
    5Severe fatigue [24]Checklist individual strength-fatigue≥36 pointsPulmonary rehabilitation [19]
    6Depressed mood [25]Beck depression inventory≥4 pointsCognitive behavioural therapy [26], pulmonary rehabilitation [19]
    7Poor exercise capacity [27]Six-minute walk test<70% predictedExercise training, pulmonary rehabilitation [19]
    8Low habitual physical activity [27]Move monitor<5000 steps·day−1Exercise training plus physical activity counselling [28]
    9Patient activation for self-management [29]Patient activation measureLevel 1–2Self-management program [30]
  • TABLE 2

    General and COPD-specific patient characteristics

    AttributePatients with a valid registration
    Sociodemographic features
     Age years63±9402 (100)
     Female %50402 (100)
     Partnered %71402 (100)
    Pulmonary function
     FEV1 % predicted55±18402 (100)
     FVC % predicted91±17402 (100)
     FEV1/FVC ratio %48±12402 (100)
     FEV1 reversibility % patients36402 (100)
     GOLD class I/II/III/IV %9/48/36/7402 (100)
    Blood gas analysis
     Hb, mmol·L−18.9±0.9182 (45)
     Hb<8.5 (male) or <7.5 (female) %22/891/91 (45)
     pH7.42±0.32245 (61)
     PaCO2 kPa5.15±0.66245 (61)
      PaCO2 >6.5 kPa %3245 (61)
      PaO2 kPa9.46±1.51245 (61)
      PaO2 <8.0 kPa %16245 (61)
     BIC, mmol·L−124.7±2.7245 (61)
     Base excess0.67±2.33245 (61)
     SaO2 %94±3245 (61)
    Comorbidities
     Number of comorbidities (0/1/2/3/4/5/6/7) %19/30/22/15/9/2/1/1402 (100)
     Cardiovascular %49402 (100)
     Metabolic%11402 (100)
     Musculoskeletal %17402 (100)
     Psychiatric %13402 (100)
     Others %51402 (100)
    Pulmonary medication
     Short-acting bronchodilator(s) %46402 (100)
     Long-acting bronchodilator(s) %71402 (100)
     Inhalation steroids %52402 (100)
     Maintenance systemic steroids %1402 (100)
    Burden of disease
     GOLD class (CCQ-based) A/B/C/D %11/33/9/47363 (90)
     CCQ total score points1.95±1.05363 (90)
     CCQ symptom subscore points2.36±1.18359 (89)
     CCQ functional limitation subscore points1.84±1.21359 (89)
     CCQ mental subscore points1.28±1.44359 (89)
     CCQ total score >1.0 %80363 (90)
     BODE index points2.8±1.6333 (83)
     BODE quartile 1/2/3/4 %28/54/12/6333 (83)
    Nonpharmacological interventions in primary care past 12 months
     Patients receiving physiotherapy %20402 (100)
     Patients receiving care from dietician %10402 (100)
     Patients receiving occupational therapy %1402 (100)
     Patients receiving care from psychologist %4402 (100)
    Treatable traits
     Smoking status, current/ex/never %44/54/2402 (100)
     Activity-based dyspnoea, MRC I/II/III/IV/V %31/31/25/9/4363 (90)
     Number of exacerbation past year, 0/1/≥2 or ≥1 hospitalisation %52/18/30379 (94)
     Nutritional status, BMI<21/BMI 21–25/BMI 25–30, BMI 30–35, BMI >35 %20/31/28/16/5392 (98)
     Fatigue, CIS-F score points39±12362 (90)
     Depressed mood, BDI score points2.2±2.5360 (90)
     Physical capacity
      6MWD m461±123382 (95)
      6MWD % predicted71±18382 (95)
     Habitual physical activity, steps·day−15465±3029366 (91)
      Activation for self-management
       PAM score points52±10365 (91)
      PAM level I/II/III/IV %34/28/31/7365 (91)

    Data are presented as %, n (%) or mean±sd. FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; GOLD: Global Initiative on Obstructive Lung Disease; Hb: haemoglobin; CCQ: Clinical COPD Questionnaire; BODE: BMI, airflow obstruction, dyspnoea, exercise capacity; MRC: Medical Research Council dyspnoea scale; BMI: body mass index; BDI: Beck depression inventory; CIS-F: checklist individual strength-fatigue; 6MWD: 6-minute walking distance; PAM: patient activation measure.

    Supplementary Materials

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    • Supplementary Material

      Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

      Supplementary material 00438-2020.SUPPLEMENT

      Figure E1 00438-2020.FigureE1

      FIgure E2 00438-2020.FIgureE2

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    Treatable traits qualifying for nonpharmacological interventions in COPD patients upon first referral to a pulmonologist: the COPD sTRAITosphere
    Alex J. van ’t Hul, Eleonore H. Koolen, Jeanine C. Antons, Marianne de Man, Remco S. Djamin, Johannes C.C.M. in ’t Veen, Sami O. Simons, Michel van den Heuvel, Bram van den Borst, Martijn A. Spruit
    ERJ Open Research Oct 2020, 6 (4) 00438-2020; DOI: 10.1183/23120541.00438-2020

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    Treatable traits qualifying for nonpharmacological interventions in COPD patients upon first referral to a pulmonologist: the COPD sTRAITosphere
    Alex J. van ’t Hul, Eleonore H. Koolen, Jeanine C. Antons, Marianne de Man, Remco S. Djamin, Johannes C.C.M. in ’t Veen, Sami O. Simons, Michel van den Heuvel, Bram van den Borst, Martijn A. Spruit
    ERJ Open Research Oct 2020, 6 (4) 00438-2020; DOI: 10.1183/23120541.00438-2020
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