Bronchiectasis in COPD patients: more than a comorbidity?

Figures & data

Table 1 Characteristics of the studies analyzing the prevalence and outcomes related to the presence of bronchiectasis in COPD patients

Study (year)	Selection criteria	n	Study design	Age (years)/gender	Main objective	Imaging technique	COPD criteria and severity	BCH criteria	BCH prevalence	Main outcomes related to BCH
O’Brien et al (2000)^Citation13	Primary care diagnosis of COPD with acute exacerbation	110	Prospective 2 years follow-up 30% were not COPD	66.5 58% males	Diagnosis of COPD in primary care	Consecutive HRCT	BTS guidelines No COPD: 30% Mild: 18% Moderate: 33% Severe: 19%	Naidich and Hansell	29% Cystic: 15.5% Varicose: 12.5% Tubular 72%	– Increased sputum purulence – Decreased FEV1 in cystic BCH
Patel et al (2004)^Citation17	Stable moderate-to-severe COPD	54	Prospective 1,197 days follow-up	69 years	Prevalence and extent of BCH and emphysema	Consecutive HRCT	ATS/ERS criteria	Naidich (diagnosis) and Smith (0–4 points grading) Score <2 was considered normal	50% 66.7% lower lobes	– Increased airway inflammation and bacterial load – Prolonged exacerbations
Roche et al (2007)^Citation18	Hospitalized COPD	118	Prospective 2 years follow-up	68.4 (12.1) 74% males	Sputum examination analysis	Consecutive HRCT in 98% of patients	GOLD FEV1: 40.2%	Bronchi/vessel (diameter) >1	19.8%	– Positive sputum culture
Garcia-Vidal et al (2009)^Citation19	Hospitalized COPD (previous BCH was excluded)	88	Prospective 1 year follow-up	72.1 (10) 95% males	Incidence and risk factors for PA	Consecutive HRCT in 88 randomized patients out of 188	GOLD GOLD II: 34.6% GOLD III: 50.5% GOLD IV: 14.9% FEV1: 44%	Less than two affected segments were considered normal	52%	– No relationship with FEV1, BODE index, PA isolation or 6MWT
Agusti et al (2010)^Citation20	ECLIPSE cohort of GOLD II–IV stable COPD (previous BCH was excluded)	2,164	Prospective 3 years follow-up	63.4 (7.1) 65% males	Characterization of COPD heterogeneity	Consecutive low-dose CT scan	GOLD GOLD II: 44.1% GOLD III: 42.1% GOLD IV: 13.7% FEV1: 48.3%	No criteria available	4% Stage II: 1%–2% Stage III: 3%–6% Stage IV: 7%–9%	– CT scan performed to analyze emphysema quantification
Bafadhel et al (2011)^Citation4	Stable COPD (only if previous CT scan)	75	Cross-sectional	67 (43–88) 58% males	CT scan COPD phenotypes	Non-consecutive HRCT	GOLD FEV1: 46%	Naidich (diagnosis) and 0–4 points (grading)	27%	– No relationship with lung function, exacerbations or bacterial load
Martinez-Garcia et al (2011)^Citation16	Stable moderate-to-severe COPD Previous BCH was excluded	92	Prospective 3 years follow-up	71.3 (9.3) 99% males	Factors associated with BCH	Consecutive HRCT	GOLD Moderate: 44.6% Severe: 55.4%	Naidich More than one segment	57.6% 34.7% moderate 72.5% severe 90.6% cylindrical 60.4% lower lobes	– Risk factors for BCH were severe COPD, PPM isolates, and at least one hospital admission in the previous year
Arram and Elrakhawy (2012)^Citation21	Moderate-to-severe stable COPD	69	Cross-sectional	59.4–60.4 95% males	Incidence of BCH	Consecutive HRCT	GOLD FEV1: 56% Moderate FEV1: 45% Severe	No criteria available	47.8% Moderate 31.3% Severe 62.2% 82% cylindrical 67% lower lobes 73% bilateral	– Severe exacerbations – Time to recovery – Decreased FEV1 – Bacterial colonization
Steward et al (2012)^Citation22	Stable COPD GOLD II–IV COPD Gene	3,752	Prospective	62.8–65.5 55% males	Prevalence and clinical impact of BCH	Consecutive CT	GOLD	Visual assessment	20.8% GOLD II: 18.8% GOLD III: 24% GOLD IV: 24%	– Increased age, exacerbations, BODE and GOLD stage – Decreased FEV1 and BMI
Martinez-Garcia et al (2013)^Citation23	Stable moderate-to-severe COPD. Previous BCH was excluded	201	Prospective 48 months follow-up	70.3 (8.9) 90.5% males	Prognostic value of BCH	Consecutive HRCT	GOLD GOLD II: 49.2% GOLD III: 42.3% GOLD IV: 8.5% FEV1: 49%	Naidich More than one segment Bhalla (grading)	57.2% 87% cylindrical 81% lower lobes 8.3 Bhalla score	– Increased mortality, exacerbations, bacterial isolation including PA and CRP levels
Tulek et al (2013)^Citation24	Stable COPD (BCH or clinical evidence of BCH was excluded)	80	Cross-sectional	68 (8) 95% males	Radiological COPD phenotypes	Consecutive HRCT	GOLD FEV1: 57.1%: Moderate: 46% Severe: 30%	Naidich Modified Bhalla (grading)	33.8% − 40% in moderate-to-severe patients	– Increased exacerbations, Bhalla score, CRP and ESR concentrations – Decreased FEV1
Gallego et al (2014)^Citation15	Exacerbation of COPD with exacerbator phenotype	118	Prospective 1,003 (306) days follow-up	69.5 (8.2) Predominantly males	Prevalence and risk factors for PA	Consecutive HRCT	GOLD FEV1 34% GOLD IV: 60%	Naidich (diagnosis) and Smith (grading) Score ≤1 was considered normal	47% – 52% only in lower lobes – 25% in more than 4 lobes – BCH score: 4.2	– BCH (score >5) was a risk factor for PA isolation – Mortality was higher in the PA group – CC by mucoid PA was associated with BCH (score >5)
Gatheral et al (2014)^Citation25	First hospitalized COPD	406	Retrospective	71 (11) 56% males	Impact of BCH on clinical outcomes	Non-Consecutive HRCT (406/2,414). Not all HRCT (41%)	ICD-10 code j440/1/8/9	Naidich 0 (absent) −4 severe BCH points (no reference)	69% Minor (40%) Mild (29%) Moderate (22%) Severe (8%) Increase with age and male gender	– BCH severity correlates with BWT but not with emphysema – BCH related to PA and NTM isolation, and annual respiratory admissions, lower Charlson index and in-patient days but not survival
Jairam et al (2015)^Citation26	COPD without previous exacerbations and CT performed because of non-pulmonary causes	338	Prospective 4.4 years follow-up	71 (61–76) 54% males	Incidental CT findings and risk of hospitalization or death due to COPD exacerbation	Non-consecutive CT	GOLD	Fleischner Society Criteria (diagnosis) Lobe-based visual grading system (0–3 points per lobe)	32.5% Score = 1: 14% Score = 2: 9% Score >2: 9%	– No relationship with future exacerbations or death
Mao et al (2015)^Citation27	Stable COPD (only if previous CT scan)	896	Retrospective 21 months follow-up	66.2 (9.6) 85% males	Prognostic value of BCH	Non-consecutive HRCT	GOLD	Naidich	34.7%	– PA colonization – Increased all-cause mortality
da Silva et al (2016)^Citation28	Stable COPD (previous BCH was excluded)	65	Retrospective 2.5 years follow-up	64.2 (8.5) 66% males	COPD phenotypes on HRCT	Consecutive HRCT	GOLD	Bhalla system	33.8%	– No relationship with functional variables
Tan et al (2016)^Citation30	Stable COPD (Canadian cohort)	451	Prospective	62.8–69 46%–50% males	CT abnormalities	Non-consecutive HRCT	Spirometric values (LLN)	Fleischner Society Criteria	Mild: 14.1% Moderate: 22.2% Severe: 35.1%	– BCH related to higher dyspnea, chronic cough, and wheeze – CAT score ≥10 No relationship with exacerbation frequency

Note: HRCT: 1 mm collimation at 10 mm intervals from the lung apex to the diaphragm.

Abbreviations: BCH, bronchiectasis; CT, computed tomography; HRCT, high-resolution computed tomography; ESR, erythrocyte sedimentation rate; PA, Pseudomonas aeruginosa; CC, chronic colonization; BMI, body mass index; PPM, potentially pathogenic microorganism; 6MWT, 6-minute walking test; FEV₁, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; CRP, C-reactive protein; ATS/ERS, American Thoracic Society/European Respiratory Society; ICD-10, International Statistical Classification of Diseases and Related Health Problems 10th Revision; BODE, BMI, obstruction, dyspnea, exercise; BTS, British Thoracic Society; BWT, bronchial wall thickening; NTM, non-tuberculous mycobacteria; LLN, lower limit of normal; CAT, COPD assessment test.

Table 2 Characteristics of patients with COPD and bronchiectasis compared with COPD patients without bronchiectasis

General characteristics

–Older patients

–Higher frequency of males

–Heavier smokers

Clinical features

–Increased daily sputum production

–Increased number of exacerbations

Lung function parameters

–More severe airflow obstruction (measured by FEV1/FVC and FEV1% predicted)

Inflammatory markers

–Higher levels of peripheral CRP

–Lower concentration of albumin

Microbiological profile

–Increased prevalence of PPM colonization

–Increased prevalence of Pseudomonas aeruginosa colonization

Prognostic features

–Doubled risk of all-cause mortality

Notes: Based on two meta-analyses by Ni et al³¹ and Du et al.³² Variables in bold are those with the highest odds ratios in the meta-analysis.

Abbreviations: CRP, C-reactive protein; FEV₁/FVC, forced expiratory volume in 1 second/forced vital capacity; PPM, potentially pathogenic microorganism.

Figure 1 Development of bronchiectasis in a patient with severe COPD.

Notes: (A) HRCT scan without bronchiectasis in 2007 and (B) HRCT scan from the same patient and slide in 2015.
Abbreviation: HRCT, high-resolution computed tomography.

Figure 2 Pathophysiological hypothesis of the development of bronchiectasis in patients with COPD.

Notes: Reproduced from Martinez-Garcia MA, Maiz L, De la Rosa D. The overlap with bronchiectasis. In: Anzueto A, Heijdra Y, Hurst JR, editors. Controversies in COPD. European Respiratory Society; 2015:105.⁴³ With permission from European Respiratory Society. © 2015, European Respiratory Society.

Figure 3 Relationship between COPD-bronchiectasis overlap phenotype and infective and chronic bronchitis and exacerbator phenotypes.

Abbreviation: BCH, bronchiectasis.

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