Dispelling Myths and Misconceptions about Chronic Obstructive Pulmonary Disease
Main Article Content
Abstract
Introduction: Chronic obstructive pulmonary disease is one of the major causes of disability and mortality in the world. Despite better efforts to understand this disease, there are still multiple misconceptions regarding the evaluation and management of these complex patients.
Purpose: The purpose of this review article is to utilize four hypothetical patient case presentations to dispel common myths regarding the evaluation and management of patients with chronic obstructive pulmonary disease.
Hypothetical Case Presentations: Natasha, Kevin, Joe and Mary are hypothetical patients with chronic obstructive pulmonary disease, whose cases were developed based on clinical experiences and a literature review in order to discredit common myths and misconceptions among clinicians and patients.
Common Myths and Misconceptions: Four common myths and misconceptions about patients with chronic obstructive pulmonary disease include: myth #1 symptoms of dyspnea are always reported, myth #2 prolonged cough following an upper respiratory infection is trivial, myth #3 therapy with inhaled corticosteroid plus a long-acting beta 2 agonist is ideal for all newly diagnosed patients, and myth #4 all patients with chronic obstructive pulmonary disease have exacerbations without serious consequences. Throughout this article, we will apply the 2024 Global initiative for chronic Obstructive Lung Disease recommendations to these hypothetical patients to debunk each of these myths and misconceptions.
Conclusions and Clinical Implications: Throughout this article, we have applied information from the literature and 2024 Global initiative for chronic Obstructive Lung Disease report to dispel common myths and misconceptions. The reality is that symptoms of chronic obstructive pulmonary disease are variable and not all patients report dyspnea. In addition, initial therapy should include dual long-acting bronchodilator therapy, but inhaled corticosteroids may be added in specific situations, such as patients with documented eosinophilia. Finally, acute exacerbations of this disease often have serious consequences and should be methodically prevented and aggressively treated.
Article Details
How to Cite
OWEIS, Jozef; ADAMS, Sandra G..
Dispelling Myths and Misconceptions about Chronic Obstructive Pulmonary Disease.
Medical Research Archives, [S.l.], v. 12, n. 7, july 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5463>. Date accessed: 15 nov. 2024.
doi: https://doi.org/10.18103/mra.v12i7.5463.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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https://doi.org/10.1164/rccm.202204-0671PP
3. 2024 Gold Report - Global Initiative for Chronic Obstructive Lung Disease. GOLD. November 12, 2023. https://goldcopd.org/2024-gold-report/.
4. Martinez FJ, Han MK, Lopez C, et al. Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings. JAMA. 2023;329 (6):490-501. doi:10.1001/jama.2023.0128
5. Goërtz YMJ, Spruit MA, Van 't Hul AJ, et al. Fatigue is highly prevalent in patients with COPD and correlates poorly with the degree of airflow limitation. Ther Adv Respir Dis. 2019;13:17534666 19878128. doi:10.1177/1753466619878128
6. Wan ES, Fortis S, Regan EA, et al. Longitudinal Phenotypes and Mortality in Preserved Ratio Impaired Spirometry in the COPDGene Study [published correction appears in Am J Respir Crit Care Med. 2023 Oct 1;208(7):824]. Am J Respir Crit Care Med. 2018;198(11):1397-1405. doi:10.1164/rccm.201804-0663OC
7. Wan ES, Balte P, Schwartz JE, et al. Association Between Preserved Ratio Impaired Spirometry and Clinical Outcomes in US Adults. JAMA. 2021;326(22):2287–2298. doi:10.1001/jama.2021.20939
8. Ferris BG. Epidemiology Standardization Project (American Thoracic Society). Am Rev Respir Dis. 1978;118(6 Pt 2):1-120.
9. Celli BR, Fabbri LM, Aaron SD, et al. An Updated Definition and Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbations: The Rome Proposal. Am J Respir Crit Care Med. 2021;204(11):1251-1258.
doi:10.1164/rccm.202108-1819PP
10. Perez-Padilla R, Montes de Oca M, Thirion-Romero I, et al. Trajectories of Spirometric Patterns, Obstructive and PRISm, in a Population-Based Cohort in Latin America. Int J Chron Obstruct Pulmon Dis. 2023;18:1277-1285. Published 2023 Jun 21. doi:10.2147/COPD.S406208
11. Hurst JR, Gale CP; Global Working Group on Cardiopulmonary Risk. MACE in COPD: addressing cardiopulmonary risk. Lancet Respir Med. 2024;12(5):345-348. doi:10.1016/S2213-2600(24)00038-9
12. Daubin C, Valette X, Thiollière F, et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study. Intensive Care Med. 2018;44(4):428-437.
doi:10.1007/s00134-018-5141-9
13. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941-1947. doi:10.1056/NEJM199906243402502
14. Simon S, Joean O, Welte T, Rademacher J. The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus. Eur Respir Rev. 2023;32(169):230034. Published 2023 Sep 6. doi:10.1183/16000617.0034-2023
15. Willemse BW, Postma DS, Timens W, ten Hacken NH. The impact of smoking cessation on respiratory symptoms, lung function, airway hyperresponsiveness and inflammation. Eur Respir J. 2004;23(3):464-476.
doi:10.1183/09031936.04.00012704
16. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–64. https://doi.org/10.1164/rccm.201309-1634ST.
17. Oczkowski S, Ergan B, Bos L, et al. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022;59(4): 2101574. Published 2022 Apr 14. doi:10.1183/13993003.01574-2021
18. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355(9219):1931-1935. doi:10.1016/s0140-6736(00)02323-0
19. Bertoletti L, Quenet S, Laporte S, et al. Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry. Respir Res. 2013;14(1):75. Published 2013 Jul 18. doi:10.1186/1465-9921-14-75
20. Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141: e195S–226S.
21. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes NC. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403. Published 2006 Apr 19. doi:10.1002/14651858.CD004403.pub2
22. Vogelmeier C, Paggiaro PL, Dorca J, et al. Efficacy and safety of Aclidinium/formoterol versus Salmeterol/Fluticasone: A Phase 3 COPD study. European Respiratory Society. October 1, 2016. Accessed May 14, 2024. https://erj.ersjournals.com/content/48/4/1030.
23. Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med. 2016;374 (23):2222-2234. doi:10.1056/NEJMoa1516385
24. Yang IA, Clarke MS, Sim EH, Fong KM. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;2012(7):CD002991. Published 2012 Jul 11. doi:10.1002/14651858.CD002991.pub3
25. Rabe KF, Martinez FJ, Ferguson GT, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med. 2020;383(1):35-48. doi:10.1056/NEJMoa1916046
26. Lipson DA, Crim C, Criner GJ, et al. Reduction in All-Cause Mortality with Fluticasone Furoate/Umeclidinium/Vilanterol in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2020;201(12):1508-1516. doi:10.1164/rccm.201911-2207OC
27. Rice KL, Rubins JB, Lebahn F, et al. Withdrawal of chronic systemic corticosteroids in patients with COPD: a randomized trial. Am J Respir Crit Care Med. 2000;162(1):174-178. doi:10.1164/ajrccm.162.1.9909066
28. Pleasants RA, Wang T, Xu X, et al. Nebulized Corticosteroids in the Treatment of COPD Exacerbations: Systematic Review, Meta-Analysis, and Clinical Perspective. Respir Care. 2018; 63(10):1302-1310. doi:10.4187/respcare.06384
29. Van Geffen WH, Douma WR, Slebos DJ, Kerstjens HA. Bronchodilators delivered by nebuliser versus pMDI with spacer or DPI for exacerbations of COPD. Cochrane Airways Group, ed. Cochrane Database Syst Rev. 2016;2016(8). doi:10.1002/14651858.CD011826.pub2
30. Sahardin SN, Jailaini MFM, Abeed NNN, et al. Impact of Aerobika® oscillating positive expiratory pressure in improving small airway resistance, lung function, symptoms and exercise capacity in chronic obstructive pulmonary disease. Front Med. 2023;10:1202380. doi:10.3389/fmed.2023.1202380
31. Quon BS, Gan WQ, Sin DD. Contemporary Management of Acute Exacerbations of COPD. Chest. 2008;133(3):756-766. doi:10.1378/chest.07-1207
32. Van Eerd EA, Van Der Meer RM, Van Schayck OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Airways Group, ed. Cochrane Database Syst Rev. 2016;2019(3). doi:10.1002/14651858.CD010744.pub2
33. Elbehairy AF, Ciavaglia CE, Webb KA, et al. Pulmonary Gas Exchange Abnormalities in Mild Chronic Obstructive Pulmonary Disease. Implications for Dyspnea and Exercise Intolerance. Am J Respir Crit Care Med. 2015;191(12):1384-1394. doi:10.1164/rccm.201501-0157OC
34. Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ. 2010;341(oct18 2):c5462-c5462. doi:10.1136/bmj.c5462
35. Roca O, Hernández G, et al. Current evidence for the effectiveness of heated and humidified high flow nasal cannula supportive therapy in adult patients with respiratory failure. Crit Care. 2016;20(1):109. doi:10.1186/s13054-016-1263-z
36. Jackson H. Detecting chronic obstructive pulmonary disease using peak flow rate: cross sectional survey. BMJ. 2003;327(7416):653-654. doi:10.1136/bmj.327.7416.653
37. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 1995;333(13):817-822. doi:10.1056/NEJM199509283331301
38. Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med. 1995;151(6): 1799-1806. doi:10.1164/ajrccm.151.6.7767523
39. Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. 2002;28(12):1701-1707. doi:10.1007/s00134-002-1478-0
40. Jordan RE, Majothi S, Heneghan NR, et al. Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis. Health Technol Assess. 2015;19(36):1-516. doi:10.3310/hta19360
41. Couturaud F, Bertoletti L, Pastre J, et al. Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. JAMA. 2021; 325(1):59. doi:10.1001/jama.2020.23567
2. Celli, B., Fabbri, L., Criner, G., Martinez, F. J., Mannino, D., Vogelmeier, C., Montes de Oca, M., Papi, A., Sin, D. D., Han, M. K., & Agusti, A. (2022). Definition and Nomenclature of Chronic Obstructive Pulmonary Disease: Time for Its Revision. American journal of respiratory and critical care medicine, 206(11), 1317–1325.
https://doi.org/10.1164/rccm.202204-0671PP
3. 2024 Gold Report - Global Initiative for Chronic Obstructive Lung Disease. GOLD. November 12, 2023. https://goldcopd.org/2024-gold-report/.
4. Martinez FJ, Han MK, Lopez C, et al. Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings. JAMA. 2023;329 (6):490-501. doi:10.1001/jama.2023.0128
5. Goërtz YMJ, Spruit MA, Van 't Hul AJ, et al. Fatigue is highly prevalent in patients with COPD and correlates poorly with the degree of airflow limitation. Ther Adv Respir Dis. 2019;13:17534666 19878128. doi:10.1177/1753466619878128
6. Wan ES, Fortis S, Regan EA, et al. Longitudinal Phenotypes and Mortality in Preserved Ratio Impaired Spirometry in the COPDGene Study [published correction appears in Am J Respir Crit Care Med. 2023 Oct 1;208(7):824]. Am J Respir Crit Care Med. 2018;198(11):1397-1405. doi:10.1164/rccm.201804-0663OC
7. Wan ES, Balte P, Schwartz JE, et al. Association Between Preserved Ratio Impaired Spirometry and Clinical Outcomes in US Adults. JAMA. 2021;326(22):2287–2298. doi:10.1001/jama.2021.20939
8. Ferris BG. Epidemiology Standardization Project (American Thoracic Society). Am Rev Respir Dis. 1978;118(6 Pt 2):1-120.
9. Celli BR, Fabbri LM, Aaron SD, et al. An Updated Definition and Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbations: The Rome Proposal. Am J Respir Crit Care Med. 2021;204(11):1251-1258.
doi:10.1164/rccm.202108-1819PP
10. Perez-Padilla R, Montes de Oca M, Thirion-Romero I, et al. Trajectories of Spirometric Patterns, Obstructive and PRISm, in a Population-Based Cohort in Latin America. Int J Chron Obstruct Pulmon Dis. 2023;18:1277-1285. Published 2023 Jun 21. doi:10.2147/COPD.S406208
11. Hurst JR, Gale CP; Global Working Group on Cardiopulmonary Risk. MACE in COPD: addressing cardiopulmonary risk. Lancet Respir Med. 2024;12(5):345-348. doi:10.1016/S2213-2600(24)00038-9
12. Daubin C, Valette X, Thiollière F, et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study. Intensive Care Med. 2018;44(4):428-437.
doi:10.1007/s00134-018-5141-9
13. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340(25):1941-1947. doi:10.1056/NEJM199906243402502
14. Simon S, Joean O, Welte T, Rademacher J. The role of vaccination in COPD: influenza, SARS-CoV-2, pneumococcus, pertussis, RSV and varicella zoster virus. Eur Respir Rev. 2023;32(169):230034. Published 2023 Sep 6. doi:10.1183/16000617.0034-2023
15. Willemse BW, Postma DS, Timens W, ten Hacken NH. The impact of smoking cessation on respiratory symptoms, lung function, airway hyperresponsiveness and inflammation. Eur Respir J. 2004;23(3):464-476.
doi:10.1183/09031936.04.00012704
16. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–64. https://doi.org/10.1164/rccm.201309-1634ST.
17. Oczkowski S, Ergan B, Bos L, et al. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022;59(4): 2101574. Published 2022 Apr 14. doi:10.1183/13993003.01574-2021
18. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355(9219):1931-1935. doi:10.1016/s0140-6736(00)02323-0
19. Bertoletti L, Quenet S, Laporte S, et al. Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry. Respir Res. 2013;14(1):75. Published 2013 Jul 18. doi:10.1186/1465-9921-14-75
20. Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, Cook DJ, Balekian AA, Klein RC, Le H, Schulman S, Murad MH. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141: e195S–226S.
21. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes NC. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403. Published 2006 Apr 19. doi:10.1002/14651858.CD004403.pub2
22. Vogelmeier C, Paggiaro PL, Dorca J, et al. Efficacy and safety of Aclidinium/formoterol versus Salmeterol/Fluticasone: A Phase 3 COPD study. European Respiratory Society. October 1, 2016. Accessed May 14, 2024. https://erj.ersjournals.com/content/48/4/1030.
23. Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med. 2016;374 (23):2222-2234. doi:10.1056/NEJMoa1516385
24. Yang IA, Clarke MS, Sim EH, Fong KM. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;2012(7):CD002991. Published 2012 Jul 11. doi:10.1002/14651858.CD002991.pub3
25. Rabe KF, Martinez FJ, Ferguson GT, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD. N Engl J Med. 2020;383(1):35-48. doi:10.1056/NEJMoa1916046
26. Lipson DA, Crim C, Criner GJ, et al. Reduction in All-Cause Mortality with Fluticasone Furoate/Umeclidinium/Vilanterol in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2020;201(12):1508-1516. doi:10.1164/rccm.201911-2207OC
27. Rice KL, Rubins JB, Lebahn F, et al. Withdrawal of chronic systemic corticosteroids in patients with COPD: a randomized trial. Am J Respir Crit Care Med. 2000;162(1):174-178. doi:10.1164/ajrccm.162.1.9909066
28. Pleasants RA, Wang T, Xu X, et al. Nebulized Corticosteroids in the Treatment of COPD Exacerbations: Systematic Review, Meta-Analysis, and Clinical Perspective. Respir Care. 2018; 63(10):1302-1310. doi:10.4187/respcare.06384
29. Van Geffen WH, Douma WR, Slebos DJ, Kerstjens HA. Bronchodilators delivered by nebuliser versus pMDI with spacer or DPI for exacerbations of COPD. Cochrane Airways Group, ed. Cochrane Database Syst Rev. 2016;2016(8). doi:10.1002/14651858.CD011826.pub2
30. Sahardin SN, Jailaini MFM, Abeed NNN, et al. Impact of Aerobika® oscillating positive expiratory pressure in improving small airway resistance, lung function, symptoms and exercise capacity in chronic obstructive pulmonary disease. Front Med. 2023;10:1202380. doi:10.3389/fmed.2023.1202380
31. Quon BS, Gan WQ, Sin DD. Contemporary Management of Acute Exacerbations of COPD. Chest. 2008;133(3):756-766. doi:10.1378/chest.07-1207
32. Van Eerd EA, Van Der Meer RM, Van Schayck OC, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Airways Group, ed. Cochrane Database Syst Rev. 2016;2019(3). doi:10.1002/14651858.CD010744.pub2
33. Elbehairy AF, Ciavaglia CE, Webb KA, et al. Pulmonary Gas Exchange Abnormalities in Mild Chronic Obstructive Pulmonary Disease. Implications for Dyspnea and Exercise Intolerance. Am J Respir Crit Care Med. 2015;191(12):1384-1394. doi:10.1164/rccm.201501-0157OC
34. Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ. 2010;341(oct18 2):c5462-c5462. doi:10.1136/bmj.c5462
35. Roca O, Hernández G, et al. Current evidence for the effectiveness of heated and humidified high flow nasal cannula supportive therapy in adult patients with respiratory failure. Crit Care. 2016;20(1):109. doi:10.1186/s13054-016-1263-z
36. Jackson H. Detecting chronic obstructive pulmonary disease using peak flow rate: cross sectional survey. BMJ. 2003;327(7416):653-654. doi:10.1136/bmj.327.7416.653
37. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 1995;333(13):817-822. doi:10.1056/NEJM199509283331301
38. Kramer N, Meyer TJ, Meharg J, Cece RD, Hill NS. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med. 1995;151(6): 1799-1806. doi:10.1164/ajrccm.151.6.7767523
39. Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial. Intensive Care Med. 2002;28(12):1701-1707. doi:10.1007/s00134-002-1478-0
40. Jordan RE, Majothi S, Heneghan NR, et al. Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis. Health Technol Assess. 2015;19(36):1-516. doi:10.3310/hta19360
41. Couturaud F, Bertoletti L, Pastre J, et al. Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. JAMA. 2021; 325(1):59. doi:10.1001/jama.2020.23567