clinical topic updates
Outcome Drivers in Chronic Lung Disease: Comorbidities, Vascular Factors, and Parenchymal Factors
Outcomes in patients with chronic lung disease may have one or more drivers of greater relative importance, such as lung parenchymal/fibrotic disease, inflammation, vascular disease, or cardiopulmonary comorbidities. For example, pulmonary fibrosis may be the predominant driver in the disease trajectory of one patient, while pulmonary hypertension (PH) may be the primary driver in another.
Justin Oldham, MD, MS
Assistant Professor of Medicine
“Whether you are talking about pulmonary function test results or a patient’s ability to maintain a favorite activity, important drivers of decline include inflammation, fibrosis, and vascular disease. And each of these drivers can make variable and independent contributions to progression and outcomes in chronic lung disease.”
Outcomes of chronic lung disease that are of importance to physicians and researchers are not always the same as those for patients. No longer being able to hike, for example, can be a devastating outcome for patients who previously were very active. Declining forced vital capacity (FVC), on the other hand, matters significantly more to investigators.
Whether you are talking about pulmonary function test results or a patient’s ability to maintain a favorite activity, important drivers of decline include inflammation, fibrosis, and vascular disease. And each of these drivers can make variable and independent contributions to progression and outcomes in chronic lung disease. Some patients with scleroderma will develop prominent PH with little or no associated interstitial lung disease (ILD). Conversely, patients who develop progressive ILD may have little to no PH. In the former, addressing the vasculopathy is much more important than addressing the minimal ILD that may be observed.
There are a handful of short-term surrogates for long-term outcome. For instance, the requirement for lung transplant is often used as a surrogate. When a lung transplant is required, survival is not expected to exceed approximately 6 months without the transplant. Drivers of poor outcomes include declines in FVC and respiratory hospitalization, both of which have been strongly linked to mortality risk. Death and respiratory hospitalization are considered composite end points in some newer trials, while degree of change in FVC over time is considered the primary end point in most other trials. An FVC decline from baseline of 10% or greater is considered by many to be a strong predictor of future mortality, and this has been studied by Goh et al with respect to ILD associated with systemic sclerosis.
Comorbidities are also recognized drivers of outcomes, as is exemplified by lung cancer incidence and related mortality. In a recent study, patients with chronic obstructive pulmonary disease have greater incidence of developing lung cancer compared with those who had neither chronic obstructive pulmonary disease nor a history of smoking. In a similar vein, pulmonary fibrosis is associated with an elevated risk of thromboembolic disease, pulmonary embolus, and PH, all of which may also reduce survival. As more antifibrotics are approved, our ability to prolong survival should improve. Pulmonary fibrosis may be a bit like cancer in that very few cancers are treated with a single agent; most are treated with multiple drug regimens. Idiopathic pulmonary fibrosis and fibrosing ILD will likely become similar in that regard in the future.
Goh NS, Hoyles RK, Denton CP, et al. Short-term pulmonary function trends are predictive of mortality in interstitial lung disease associated with systemic sclerosis. Arthritis Rheumatol. 2017;69(8):1670-1678. doi:10.1002/art.40130
Kovacs G, Berghold A, Scheidl S, Olschewski H. Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review. Eur Respir J. 2009;34(4):888-894. doi:10.1183/09031936.00145608
Nathan SD, Barbera JA, Gaine SP, et al. Pulmonary hypertension in chronic lung disease and hypoxia. Eur Respir J. 2019;53(1):1801914. doi:10.1183/13993003.01914-2018
Park HY, Kang D, Shin SH, et al. Chronic obstructive pulmonary disease and lung cancer incidence in never smokers: a cohort study. Thorax. 2020;75(6):506-509. doi:10.1136/thoraxjnl-2019-213732
Poms AD, Turner M, Farber HW, Meltzer LA, McGoon MD. Comorbid conditions and outcomes in patients with pulmonary arterial hypertension: a REVEAL registry analysis. Chest. 2013;144(1): 169-176. doi:10.1378/chest.11-3241
Young RP, Duan F, Chiles C, et al. Airflow limitation and histology shift in the national lung screening trial. The NLST-ACRIN cohort substudy. Am J Respir Crit Care Med. 2015;192(9):1060‐1067. doi:10.1164/rccm.201505-0894OC