Factors associated with mortality in patients with exacerbation of chronic obstructive pulmonary disease hospitalized in General Medicine departments

Prognostic indicators for in-hospital mortality in COPD with acute exacerbation in Thailand: a retrospective cohort study

Background

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common and deteriorating event leading to in-hospital morbidity and mortality. Identification of predictors for in-hospital mortality of AECOPD patients could aid clinicians in identifying patients with a higher risk of death during their hospitalisation.

Objective

To explore potential prognostic indicators associated with in-hospital mortality of AECOPD patients.

Setting

General medical ward and medical intensive care unit of a university-affiliated tertiary care centre.

Methods

A prognostic factor research was conducted with a retrospective cohort design. All admission records of AECOPD patients between October 2015 and September 2016 were retrieved. Stratified Cox’s regression was used for the primary analysis.

Results

A total of 516 admission records of 358 AECOPD patients were included in this study. The in-hospital mortality rate of the cohort was 1.9 per 100 person-day. From stratified Cox’s proportional hazard regression, the predictors of in-hospital mortality were aged 80 years or more (HR=2.16, 95% CI: 1.26 to 3.72, p=0.005), respiratory failure on admission (HR=2.50, 95% CI: 1.12 to 5.57, p=0.025), body temperature more than 38°C (HR=2.97, 95% CI: 1.61 to 5.51, p=0.001), mean arterial pressure lower than 65 mm Hg (HR=4.01, 95% CI: 1.88 to 8.60, p<0.001), white blood cell count more than 15 x 10⁹/L (HR=3.51, 95% CI: 1.90 to 6.48, p<0.001) and serum creatinine more than 1.5 mg/dL (HR=2.08, 95% CI: 1.17 to 3.70, p=0.013).

Conclusion

Six independent prognostic indicators for in-hospital mortality of AECOPD patients were identified. All of the parameters were readily available in routine practice and can be used as an aid for risk stratification of AECOPD patients.

Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) often suffer acute exacerbations (AECOPD) and community-acquired pneumonia (CAP), named nonpneumonic and pneumonic exacerbations of COPD, respectively. Abnormal host defense mechanisms may play a role in the specificity of the systemic inflammatory response. Given the association of this aspect to some biomarkers at admission (e.g., C-reactive protein), it can be used to help to discriminate AECOPD and CAP, especially in cases with doubtful infiltrates and advanced lung impairment. Fever, sputum purulence, chills, and pleuritic pain are typical clinical features of CAP in a patient with COPD, whereas isolated dyspnea at admission has been reported to predict AECOPD. Although CAP may have a worse outcome in terms of mortality (in hospital and short term), length of hospitalization, and early readmission rates, this has only been confirmed in a few prospective studies. There is a lack of methodologically sound research confirming the impact of severe AECOPD and COPD + CAP. Here, we review studies reporting head-to-head comparisons between AECOPD and CAP + COPD in hospitalized patients. We focus on the epidemiology, risk factors, systemic inflammatory response, clinical and microbiological characteristics, outcomes, and treatment approaches. Finally, we briefly discuss some proposals on how we should orient research in the future.

Efficacy of Various Scoring Systems for Predicting the 28-Day Survival Rate among Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Requiring Emergency Intensive Care

We aimed to investigate the efficacy of four severity-of-disease scoring systems in predicting the 28-day survival rate among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) requiring emergency care. Clinical data of patients with AECOPD who required emergency care were recorded over 2 years. APACHE II, SAPS II, SOFA, and MEDS scores were calculated from severity-of-disease indicators recorded at admission and compared between patients who died within 28 days of admission (death group; 46 patients) and those who did not (survival group; 336 patients). Compared to the survival group, the death group had a significantly higher GCS score, frequency of comorbidities including hypertension and heart failure, and age (P < 0.05 for all). With all four systems, scores of age, gender, renal inadequacy, hypertension, coronary heart disease, heart failure, arrhythmia, anemia, fracture leading to bedridden status, tumor, and the GCS were significantly higher in the death group than the survival group. The prediction efficacy of the APACHE II and SAPS II scores was 88.4%. The survival rates did not differ significantly between APACHE II and SAPS II (P = 1.519). Our results may guide triage for early identification of critically ill patients with AECOPD in the emergency department.

Impact of chronic inflammatory airway disease on stroke severity and long-term survival after ischemic stroke--a retrospective analysis

Background

Chronic inflammatory airway disease (CIAD) has emerged as independent risk factor for cardiovascular mortality and ischemic stroke but the impact of co-existing CIAD in patients with ischemic stroke is less clear.

Methods

We retrospectively analyzed 1013 patients with acute ischemic stroke who were consecutively admitted to the Department of Neurology, Charité - Universitätsmedizin Berlin, Germany within one year. Mean follow-up was 80 months (IQR 32–85 months). Using multivariable regression models we analyzed the impact of CIAD (defined as chronic obstructive pulmonary disease or asthma bronchiale) on stroke severity and outcome.

Results

Co-existing CIAD was evident in 7.1 % (n = 72) of all patients with acute ischemic stroke. Baseline characteristics of stroke patients with CIAD did not differ significantly from ischemic stroke patients without CIAD. Age (OR 1.17 [95 % CI 1.03-1.37] per decade), atrial fibrillation (OR 3.43 [95 % CI 2.47-4.78]) and coronary artery disease (OR 1.51 [95 % CI 1.07–2.14]) but not a history of CIAD (p = 0.30) were associated with severe stroke (NIHSS≥11) on hospital admission. Age (HR 1.70 [95 % CI 1.53-1.87] per decade), peripheral artery disease (HR 1.91 [95 % CI 1.35-2.7]), stroke severity at hospital admission (NIHSS per point HR 1.08 [95 % CI 1.06-1.10]), and history of CIAD (HR 1.43 [95 % CI 1.02-2.00]) were independently associated with mortality during long-term follow-up. However, CIAD was not significantly associated with short-term mortality after stroke.

Conclusion

Co-existing CIAD showed no significant association with stroke severity at hospital admission and early mortality after ischemic stroke. CIAD was negatively associated with long-term survival after ischemic stroke.

Which individuals are at increased risk of pneumococcal disease and why? Impact of COPD, asthma, smoking, diabetes, and/or chronic heart disease on community-acquired pneumonia and invasive pneumococcal disease

Pneumococcal disease (including community-acquired pneumonia and invasive pneumococcal disease) poses a burden to the community all year round, especially in those with chronic underlying conditions. Individuals with COPD, asthma or who smoke, and those with chronic heart disease or diabetes mellitus have been shown to be at increased risk of pneumococcal disease compared with those without these risk factors. These conditions, and smoking, can also adversely affect patient outcomes, including short-term and long-term mortality rates, following pneumonia. Community-acquired pneumonia, and in particular pneumococcal pneumonia, is associated with a significant economic burden, especially in those who are hospitalised, and also has an impact on a patient's quality of life. Therefore, physicians should target individuals with COPD, asthma, heart disease or diabetes mellitus, and those who smoke, for pneumococcal vaccination at the earliest opportunity at any time of the year.

Serial Measurements of Arterial Oxygen Tension are Associated with Mortality in COPD

BACKGROUND

Knowledge on factors associated with mortality can help identify patients with COPD that might benefit from close monitoring and intervention. Arterial blood gases (ABGs) are related to mortality, but both arterial tension of oxygen (PaO2) and arterial tension of carbon dioxide (PaCO2) vary over time. The aim of our study was to investigate the association between repeatedly measured ABGs and mortality in men and women with COPD.

METHODS

A cohort of 419 Norwegian subjects with COPD, GOLD stage II-IV, aged 40-75, was followed up with up to seven ABGs, measured during stable phase for three years. Cox proportional hazard models were used to quantify the relationship between both single and repeatedly measured ABGs and all-cause mortality after five years, adjusting for age, sex, and the updated BODE index.

RESULTS

A total of 64 subjects died during follow-up. Mean initial arterial oxygen tension (standard deviation) was significantly higher in survivors compared to deceased, with PaO2 (in kPa) 9.4 (1.1) versus 8.8 (1.2), p<0.001. Corresponding numbers for PaCO2 were 5.3 (0.5) and 5.5 (0.7), p < 0.001. In analyses adjusting for age, sex, and the updated BODE index hazard ratios - HR(95% confidence intervals) - for all-cause mortality were 0.73 (0.55, 0.97) and 1.58 (0.90, 2.76) for repeated measures of PaO2 and PaCO2, respectively.

CONCLUSION

Both arterial oxygen and carbon dioxide tension were related to mortality in this study, and arterial oxygen tension added prognostic information to the updated BODE index in COPD.

Risk factors associated with chronic obstructive pulmonary disease early readmission

BACKGROUND

The 31 day readmission rate is deemed to be an important indicator of the quality of medical care in China. The objectives of this study were to identify the readmission rate of acute exacerbation for chronic obstructive pulmonary disease (COPD) and to evaluate associated risk factors.

METHODS

We retrospectively reviewed charts for patients with acute exacerbation of COPD (AECOPD) admitted to our hospital between January 2011 and November 2012. The early-readmission group and non-early-readmission group were determined by whether patients were readmitted within 31 days after discharge. Logistic regression analysis was performed to identify risk factors for early readmission following an AECOPD.

RESULTS

There were 692 patients with 925 admissions during the 23 month period; 63 (6.8%) admissions met our criteria for early readmission. Multivariate analysis showed that chronic cor pulmonale (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.26-3.64, p = 0.005), hypoproteinemia (OR 2.02, 95% CI 1.03-3.95, p = 0.040) and an elevated PaCO2 (OR 1.03, 95% CI 1.00-1.06, p = 0.027) were identified as risk factors for early readmission of AECOPD.

CONCLUSION

The readmission rate for AECOPD was 6.8%. AECOPD patients with chronic cor pulmonale, hypoproteinemia, and a high PaCO2 are at higher risk for readmission with 31 days of hospital discharge, and medical care of these patients warrants greater attention.

Factors associated with hospital admission in patients reaching the emergency department with COPD exacerbation

BACKGROUND

The aim of this study was to determine the frequency of COPD exacerbations in our Emergency Department, as well as the hospitalization-related factors.

METHODS

Prospective observational study conducted in the Emergency Department of Salnés County Hospital among patients admitted for COPD exacerbation. Admission predictors were determined by multivariate analysis.

RESULTS

There were 409 exacerbations in 239 patients (79% male, mean age 75). 57% of exacerbations required hospitalization. Hospitalization-related factors were impaired oxygenation (p < 0.001), presence of neutrophilia (p < 0.01) and prescription of antibiotics in the Emergency Department (p < 0.05).

CONCLUSIONS

COPD exacerbation accounts for over 1% of all visits to our Emergency Department. 57% of them required hospitalization. Impaired oxygenation, greater neutrophilia and prescription of antibiotics in the Emergency Department were associated with greater probability of admission.

Factors affecting chronic obstructive pulmonary disease early rehospitalization

The Centers for Medicare and Medicaid Services has identified early rehospitalization of patients with chronic obstructive pulmonary disease (COPD) exacerbations as a performance measure for hospital care. We retrospectively reviewed patients with COPD who were admitted to University Medical Center, Lubbock, Texas, USA, between October 2010 and March 2011. There were 81 COPD patients with 103 hospitalizations. The mean age was 73.9 years. Pulmonary function tests using the Global initiative for chronic Obstructive Lung Disease criteria had been done in 36 patients (44.4%) and revealed 1 mild (2.8%), 7 moderate (19.4%), 20 severe (55.6%), and 8 very severe (22.2%) cases. Only 38.4% of the patients had prior influenza vaccine. Most patients were treated with antibiotics (81.8%) and corticosteroids (87.9%). The mean length of stay was 4.9 days, and 4 patients died. Most of the patients were discharged home (63.6%) with a median follow-up interval of 14 days. Thirty-two percent did not have long-acting bronchodilators and/or inhaled corticosteroids prescribed on discharge. There were 14 early rehospitalizations within 30 days. Logistic regression analysis indicated that a history of coronary artery disease (odds ratio (OR) 6.4, 95% confidence interval (CI) 1.1–37.4) and unilateral pulmonary infiltrates (OR 12.8, 95% CI 1.9–86.4) significantly increased the early rehospitalization rates. Acute exacerbations of COPD in patients with a history of ischemic heart disease or unilateral pulmonary infiltrates are at increased risk for early readmission. These risk factors should be identified during hospitalization; early follow-up or other interventions may reduce readmissions. Influenza vaccine, maintenance bronchodilators and/or inhaled corticosteroids, and pulmonary function tests were underused, and these standards of care should be provided to improve care.

Neurological and endocrinological disorders: orphans in chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) are often characterised by a range of characteristic co-morbidities that interfere with their pulmonary disease. In addition to a mere association with co-morbidities, a complex pathophysiological interaction and mutual augmentation occurs between COPD and its co-morbidities that may result in disease progression and increased morbidity and mortality. An interdisciplinary approach is required both for diagnosis and treatment to target co-morbidities early in the course of the disease. This review summarizes the current knowledge of the interaction with cerebrovascular disease and endocrinological co-morbidities in COPD patients. There is growing evidence that COPD is an independent risk factor for ischemic stroke, increasing the risk about twofold. Stroke risk in COPD patients increases with the severity of the disease as measured by the degree of airflow limitation. The presence of cardiovascular risk factors is of particular importance for stroke prevention in COPD patients. Endocrinological co-morbidities are also important and many are associated with increased cardiovascular risk. Impaired glucose metabolism ranges from insulin resistance to overt diabetes mellitus, which is a frequent finding and is associated with worse outcome.