Predicting 1-year mortality rate for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease to an intensive care unit: an opportunity for palliative care

A pooled analysis of the risk prediction models for mortality in acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

The prognosis for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is not optimistic, and severe AECOPD leads to an increased risk of mortality. Prediction models help distinguish between high- and low-risk groups. At present, many prediction models have been established and validated, which need to be systematically reviewed to screen out more suitable models that can be used in the clinic and provide evidence for future research.

METHODS

We searched PubMed, EMBASE, Cochrane Library and Web of Science databases for studies on risk models for AECOPD mortality from their inception to 10 April 2022. The risk of bias was assessed using the prediction model risk of bias assessment tool (PROBAST). Stata software (version 16) was used to synthesize the C-statistics for each model.

RESULTS

A total of 37 studies were included. The development of risk prediction models for mortality in patients with AECOPD was described in 26 articles, in which the most common predictors were age (n = 17), dyspnea grade (n = 11), altered mental status (n = 8), pneumonia (n = 6) and blood urea nitrogen (BUN, n = 6). The remaining 11 articles only externally validated existing models. All 37 studies were evaluated at a high risk of bias using PROBAST. We performed a meta-analysis of five models included in 15 studies. DECAF (dyspnoea, eosinopenia, consolidation, acidemia and atrial fibrillation) performed well in predicting in-hospital death [C-statistic = 0.91, 95% confidence interval (CI): 0.83, 0.98] and 90-day death [C-statistic = 0.76, 95% CI: 0.69, 0.82] and CURB-65 (confusion, urea, respiratory rate, blood pressure and age) performed well in predicting 30-day death [C-statistic = 0.74, 95% CI: 0.70, 0.77].

CONCLUSIONS

This study provides information on the characteristics, performance and risk of bias of a risk model for AECOPD mortality. This pooled analysis of the present study suggests that the DECAF performs well in predicting in-hospital and 90-day deaths. Yet, external validation in different populations is still needed to prove this performance.

Azithromycin use prior to ICU admission is associated with a lower short-term mortality for critically ill acute exacerbations of chronic obstructive pulmonary disease patients: A retrospective cohort study

Azithromycin was thought to prevent acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) by anti-microbial and anti-inflammatory effects. However, it's value in the treatment of critically ill patients with AECOPD before ICU admission remains unclear. Our study aimed to find whether azithromycin use prior to ICU admission leads to better clinical outcomes for those individuals. 533 critically ill patients with AECOPD from the MIMIC-IV database were included. Univariate followed multivariate logistic regression was used to select risk factors for short-term mortality. The multivariable logistic regression models were implemented to investigate the association between azithromycin use before ICU admission and short-term mortality. Lower short-term mortality was observed in the azithromycin group (p = .021), independent of differences in demographic data and other clinical outcomes (p>.05). Azithromycin use before ICU admission was proved to have a decreased short-term mortality by multivariable logistic regression (p<.05). The results remained consistent after being stratified by age, SOFA scores, pH, and cancer diagnosis. Azithromycin use prior to ICU admission was associated with lower short-term mortality for critically ill AECOPD patients.

Development and preliminary validation of a scale to assess physicians’ emotional distress intolerance in end-of-life care communication

Context

End-of-life care (EOLC) communication is beneficial but underutilized, particularly in conditions with a variable course such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Physicians’ emotional distress intolerance has been identified as a barrier to EOLC communication. However, studies of emotional distress intolerance in EOLC have largely relied on anecdotal reports, qualitative data, or observational studies of physician–patient communication. A free-standing measure of multiple dimensions of distress tolerance is warranted to enable the identification of individuals experiencing distress intolerance and to facilitate the effective targeting of interventions to improve distress tolerance.

Objectives

This study provides preliminary data on the reliability and validity of the Physician Distress Intolerance (PDI) scale. We examine potential subdimensions of emotional distress intolerance.

Method

Family medicine and internal medicine physicians completed the PDI, read vignettes describing patients with COPD or CHF, and indicated whether they initiated or delayed EOLC communication with their patients with similar conditions.

Results

Exploratory and confirmatory factor analyses were performed on separate samples. Confirmatory factor analysis confirmed that a three-factor solution was superior to a two- or one-factor solution. Three subscales were created: Anticipating Negative Emotions, Intolerance of Uncertainty, and Iatrogenic Harm. The full scale and subscales had adequate internal consistency and demonstrated evidence of validity. Higher scores on the PDI, indicating greater distress intolerance, were negatively associated with initiation and positively associated with delay of EOLC communication. Subscales provided unique information.

Significance of results

The PDI can contribute to research investigating and addressing emotional barriers to EOLC communication.

Referral criteria to palliative care for patients with respiratory disease: a systematic review

BACKGROUND

Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all.

AIM

To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria.

DESIGN

Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease.

DATA SOURCES

A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed).

RESULTS

Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.

Impact of Macrolide Antibiotics on Hospital Readmissions and Other Clinically Important Outcomes in Critically Ill Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Propensity Score-Matched Cohort Study

STUDY OBJECTIVE

To assess whether a macrolide-based antibiotic treatment strategy reduces in-hospital mortality, decreases hospital readmissions, or improves other clinically important outcomes compared with a non-macrolide antibiotic treatment strategy in critically ill patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Propensity score-matched pharmacoepidemiologic cohort study.

DATA SOURCE

Premier's Perspective Hospital Database.

PATIENTS

A total of 28,700 adults aged 40 years or older who were admitted to one of 566 United States intensive care units and had the primary diagnosis of AECOPD between January 2010 and December 2014 and received antibiotic treatment within 2 days of hospital admission were included. Patients were divided into macrolide (11,602 patients [40%]) or non-macrolide (17,098 patients [60%]) antibiotic treatment groups. Propensity score analysis successfully matched 8660 patients in each treatment group.

MEASUREMENTS AND MAIN RESULTS

In the matched cohort, the macrolide treatment group was not associated with decreased hospital mortality after day 2 (3.0% vs 3.3%, p=0.28), intensive care unit length of stay (2 days vs 2 days, p=0.12), hospital length of stay (6 days vs 6 days, p=0.86), or length of assisted ventilation (3 days vs 3 days, p=0.71), compared with the non-macrolide treatment group. However, a macrolide-based antibiotic regimen was associated with an overall reduction in 30-day hospital readmissions (7.3% vs 8.8%, p<0.01), increased time to next all-cause (159 vs 130 days, p<0.01) or AECOPD (200 vs 175 days, p=0.03) readmission, and decreased hospital costs ($32,730 vs $34,021, p<0.01).

CONCLUSION

The results of this study suggest that inclusion of a macrolide antibiotic in the treatment regimen may have both acute and sustained benefits in critically ill patients admitted to the intensive care unit with an AECOPD, including reductions in hospital readmissions and improvements in time to next readmission.

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes

BACKGROUND

Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members.

OBJECTIVE

The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps.

METHODS

We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future.

RESULTS

We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions.

CONCLUSIONS

The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.

Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database

Objective

To validate a risk index that estimates the likelihood of overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids.

Subjects and Methods

A case-control analysis of 18,365,497 patients with an opioid prescription from 2009 to 2013 in the IMS PharMetrics Plus commercially insured health plan claims database (CIP). An OIRD event occurred in 7,234 cases. Four controls were selected per case. Validity of the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD), developed previously using Veterans Health Administration (VHA) patient data, was assessed. Multivariable logistic regression was used within the CIP study population to develop a slightly refined RIOSORD. The composition and performance of the CIP-based RIOSORD was evaluated and compared with VHA-based RIOSORD.

Results

VHA-RIOSORD performed well in discriminating OIRD events in CIP (C-statistic = 0.85). Additionally, re-estimation of logistic model coefficients in CIP yielded a 0.90 C-statistic. The resulting comorbidity and pharmacotherapy variables most highly associated with OIRD and retained in the CIP-RIOSORD were largely concordant with VHA-RIOSORD. These variables included neuropsychiatric and cardiopulmonary disorders, impaired drug excretion, opioid characteristics, and concurrent psychoactive medications. The average predicted probability of OIRD ranged from 2% to 83%, with excellent agreement between predicted and observed incidence across risk classes.

Conclusions

RIOSORD had excellent predictive accuracy in a large population of US medical users of prescription opioids, similar to its performance in VHA. This practical risk index is designed to support clinical decision-making for safer opioid prescribing, and its clinical utility should be evaluated prospectively.

Non invasive ventilation in patients with chronic obstructive pulmonary disease in a hospital and at home

Last two decades, active use of non-invasive ventilation (NIV) has provided a significant improvement in the management of chronic obstructive pulmonary disease (COPD), both in patients with acute exacerbation and in stable patients. Currently, NIV is the first-line treatment for patients with acute exacerbation of COPD and acute hypercapnic respiratory failure. This method of respiratory support is also effective after extubation, as it could facilitate weaning from the ventilator and affects positively prevention and treatment of postextubation respiratory failure. Also, NIV has been successfully used in co-morbidity of COPD and sleep apnea syndrome, COPD and pneumonia, and in early postoperative period after thoracic surgery. NIV can be used in COPD patients with chronic respiratory failure. Long-term NIV at home is more reasonable in patients with daytime hypercapnia. The most effective strategy of respiratory support in COPD is thought to be decrease in the partial pressure of carbon dioxide in the arterial blood, i.e. high-intensity NIV. Currently available portable non-invasive ventilators could improve significantly physical activity of patients with severe COPD.

End-of-life prognostic indicators in patients with COPD: part 2

In the UK, chronic respiratory diseases cause 13% of adult disability. The major chronic respiratory disease is chronic obstructive pulmonary disease (COPD), a condition involving chronic airway inflammation that causes airflow obstruction and destruction of lung tissue. This leads to a progressive loss of respiratory membrane, which accounts for the clinical manifestation of COPD, which is difficulty maintaining sufficient gas exchange to meet metabolic demands. The primary cause is smoking, with the vast majority of COPD patients having a past or present history of smoking. However, exposure to industrial pollutants is also a contributing factor, as is a rare genetic predisposition to developing COPD.

Palliative care in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.

Assisted ventilation in COPD - association between previous hospitalizations and mortality

BACKGROUND

In general, previous studies have shown an association between prior exacerbations and mortality in COPD, but this association has not been demonstrated in the subpopulation of patients in need of assisted ventilation. We examined whether previous hospitalizations were independently associated with mortality among patients with COPD ventilated for the first time.

PATIENTS AND METHODS

In the Danish National Patient Registry, we established a cohort of patients with COPD ventilated for the first time from 2003 to 2011 and previously medicated for obstructive airway diseases. We assessed the number of hospitalizations for COPD in the preceding year, age, sex, comorbidity, mode of ventilation, survival to discharge, and days to death beyond discharge.

RESULTS

The cohort consisted of 6,656 patients of whom 66% had not been hospitalized for COPD in the previous year, 18% once, 8% twice, and 9% thrice or more. In-hospital mortality was 45%, and of the patients alive at discharge, 11% died within a month and 39% within a year. In multivariate models, adjusted for age, sex, mode of ventilation, and comorbidity, odds ratios for in-hospital death were 1.26 (95% confidence interval [CI]: 1.11-1.44), 1.43 (95% CI: 1.19-1.72), and 1.56 (95% CI: 1.30-1.87) with one, two, and three or more hospitalizations, respectively. Hazard ratios for death after discharge from hospital were 1.32 (95% CI: 1.19-1.46), 1.76 (95% CI: 1.52-2.02), and 2.07 (95% CI: 1.80-2.38) with one, two, and three or more hospitalizations, respectively.

CONCLUSION

Preceding hospitalizations for COPD are associated with in-hospital mortality and after discharge in the subpopulation of patients with COPD with acute exacerbation treated with assisted ventilation for the first time.

Development of a Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in Veterans' Health Administration Patients

OBJECTIVE

Develop a risk index to estimate the likelihood of life-threatening respiratory depression or overdose among medical users of prescription opioids.

SUBJECTS, DESIGN, AND METHODS

A case-control analysis of administrative health care data from the Veterans' Health Administration identified 1,877,841 patients with a pharmacy record for an opioid prescription between October 1, 2010 and September 30, 2012. Overdose or serious opioid-induced respiratory depression (OSORD) occurred in 817. Ten controls were selected per case (n = 8,170). Items for an OSORD risk index (RIOSORD) were selected through logistic regression modeling, with point values assigned to each predictor. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution.

RESULTS

Fifteen variables most highly associated with OSORD were retained as items, including mental health disorders and pharmacotherapy; impaired drug metabolism or excretion; pulmonary disorders; specific opioid characteristics; and recent hospital visits. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 94% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C-statistic was 0.88 and Hosmer-Lemeshow goodness-of-fit statistic 10.8 (P > 0.05).

CONCLUSION

RIOSORD performed well in identifying medical users of prescription opioids within the Veterans' Health Administration at elevated risk of overdose or life-threatening respiratory depression, those most likely to benefit from preventive interventions. This novel, clinically practical, risk index is intended to provide clinical decision support for safer pain management. It should be assessed, and refined as necessary, in a more generalizable population, and prospectively evaluated.

Trend analysis and outcome prediction in mechanically ventilated patients: a nationwide population-based study in Taiwan

OBJECTIVE

To investigate the relationship between changes in patient attributes and hospital attributes over time and to explore predictors of medical utilization and mortality rates in mechanical ventilation (MV) patients in Taiwan.

BACKGROUND

Providing effective medical care for MV patients is challenging and requires good planning and effective clinical decision making policies. Most studies of MV, however, have only analyzed a single regional ventilator weaning center or respiratory care unit, high-quality population-based studies of MV trends and outcomes are scarce.

METHODS

This population-based cohort study retrospectively analyzed 213,945 MV patients treated during 2004-2009.

RESULTS

During the study period, the percentages of MV patients with the following characteristics significantly increased: age ≦ 65 years, treatment at a medical center, and treatment by a high-volume physician. In contrast, the percentages of MV patients treated at local hospitals and by low-volume physicians significantly decreased (P<0.001). Age, gender, Deyo-Charlson co-morbidity index, teaching hospital, hospital level, hospital volume, and physician volume were significantly associated with MV outcome (P<0.001). Over the 6-year period analyzed in this study, the estimated mean hospital treatment cost increased 48.8% whereas mean length of stay decreased 13.9%. The estimated mean overall survival time for MV patients was 16.4 months (SD 0.4 months), and the overall in-hospital 1-, 3-, and 5-year survival rates were 61.0%, 36.7%, 17.3%, and 9.6%, respectively.

CONCLUSIONS

These population-based data revealed increases in the percentages of MV patients treated at medical centers and by high-volume physicians, especially in younger patients. Notably, although LOS for MV patients decreased, hospital treatment costs increased. Healthcare providers and patients should recognize that attributes of both the patient and the hospital may affect outcomes.