Six-year mortality and quality of life in critically ill patients with chronic obstructive pulmonary disease

Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the ICU: An Observational Study From the OUTCOMEREA Database, 1997-2018

OBJECTIVES

Our aim was to describe changes in the management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) by ICUs and patient outcomes.

DESIGN

We extracted data from the OutcomeRea database concerning patients admitted for AECOPD between 1997 and 2018. We analyzed trends in the use of ventilatory support, corticosteroid therapy, antibiotic therapy, and patient survival.

SETTING

ICUs at 32 French sites.

PATIENTS

One thousand eight hundred sixteen patients in the database had a diagnosis of AECOPD.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over time, there was a reduction in the prescription of corticosteroids and antibiotics. In a time-series analysis, these changes in practice were not linked with ICU mortality. The proportion of patients treated with invasive mechanical ventilation (IMV) also gradually declined (from 51% between 1997 and 2002 to 35% between 2013 and 2018) with an association between decrease in IMV use and reduction in ICU mortality in a time series analysis. Rates of noninvasive ventilation (NIV) failure decreased with an increase in NIV use to support weaning from IMV. There was a reduction in the median ICU length of stay (from 8 d in 1997-2002 to 4 d in 2013-2018) and in the median total duration of hospitalization (from 23 d in 1997-2002 to 14 d in 2013-2018). We observed an improvement in prognosis, with decreases in overall hospital mortality (from 24% between 1997 and 2002 to 15% between 2013 and 2018), ICU mortality (from 14% between 1997 and 2002 to 10% between 2013 and 2018), and 90-day mortality (from 41% between 1997 and 2002 to 22% between 2013 and 2018).

CONCLUSIONS

The length of stay and mortality of patients with AECOPD admitted to ICUs has decreased over the last 20 years, with a wider use of NIV and a reduction in antibiotic and corticosteroid prescriptions.

Characteristics and outcomes of patients with chronic obstructive pulmonary disease admitted to the intensive care unit due to acute hypercapnic respiratory failure

BACKGROUND

The study aimed to describe the clinical course, outcomes, and prognostic factors of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure.

METHODS

This retrospective study involved patients with acute hypercapnic respiratory failure due to COPD of any cause admitted to the intensive care unit (ICU) for non-invasive or invasive mechanical ventilation (IMV) support between December 2015 and February 2020.

RESULTS

One hundred patients were evaluated. The main causes of acute hypercapnic respiratory failure were bronchitis, pneumonia, and heart failure. The patients' mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23.0±7.2, and their IMV rate was 43%. ICU, in-hospital, and 90-day mortality rates were 21%, 29%, and 39%, respectively. Non-survivors had more pneumonia, shock within the first 24 hours of admission, IMV, vasopressor use, and renal replacement therapy, along with higher APACHE II scores, lower admission albumin levels and PaO2/ FiO2 ratios, and longer ICU and hospital stays than survivors. Logistic regression analysis identified APACHE II score (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.017-1.317; P=0.026), admission PaO2/FiO2 ratio (OR, 0.989; 95% CI, 0.978-0.999; P=0.046), and vasopressor use (OR, 8.827; 95% CI, 1.650-47.215; P=0.011) as predictors of ICU mortality. APACHE II score (OR, 1.099; 95% CI, 1.021-1.182; P=0.011) and admission albumin level (OR, 0.169; 95% CI, 0.056-0.514; P=0.002) emerged as predictors of 90-day mortality.

CONCLUSIONS

APACHE II scores, the PaO2/FiO2 ratio, vasopressor use, and albumin levels are significant short-term mortality predictors in severely ill COPD patients with acute hypercapnic respiratory failure.

Associations with Post-Consultation Health-Status in Primary Care Managed Acute Exacerbation of COPD

Background

It has been demonstrated that antibiotic prescribing for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) can be safely reduced in primary care when general practitioners have access to C-reactive protein (CRP) rapid testing.

Aim

To investigate the factors associated with post-consultation COPD health status in patients presenting with AECOPD in this setting.

Design and Setting

A cohort study of patients enrolled in a randomised controlled trial. Patients aged 40+ years with a clinical diagnosis of COPD who presented in primary care across England and Wales with an AECOPD were included.

Methods

Participants were contacted for follow-up at one- and two-weeks by phone and attended the practice four weeks after the index consultation. The outcome of interest was the Clinical COPD Questionnaire (CCQ) score. Multivariable multilevel linear regression models fitted to examine the factors associated with COPD health status in the four-weeks following consultation for an AECOPD.

Results

A total of 649 patients were included, with 1947 CCQ total scores analysed. Post-consultation CCQ total scores were significantly higher (worse) in participants with diabetes (adjusted mean difference [AMD]=0.26; 95% confidence interval (CI) 0.08–0.45), obese patients compared to those with normal body mass index (AMD = 0.25, 95% CI 0.07–0.43), and those who were prescribed oral antibiotics in the prior 12 months (AMD = 0.26; 95% CI 0.11–0.41), but only the two latter associations remained after adjusting for other sociodemographic variables.

Conclusion

COPD health status was worse in the four weeks following primary care consultation for AECOPD in patients with obesity and those prescribed oral antibiotics in the preceding year.

[Factors predicting the need for invasive mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD)]

Introduction

the use of invasive mechanical ventilation (IMV) in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) constitutes a negative turning point in the progression of the disease. The purpose of this study is to determine factors predicting the need for IMV in AECOPD.

Methods

we conducted a retrospective study by reviewing the medical records of patients with AECOPD hospitalized in our Department over a 18-year period (2000-2017). We compared 2 groups: G1: patients with AECOPD undergoing at least one IMV and G2: patients who had never undergone IMV following AECOPD.

Results

the study included 1152 patients with COPD: 133 in the G1 group (11.5%), and 1019 in the G2 group (88.5%). G1 patients were more symptomatic (p < 0.001), with more severe bronchial obstruction (p < 0.001). G1 patients had more exacerbations (p < 0.001), more hospitalizations and a higher need for non-invasive ventilation (NIV) (p < 0.001). Similarly, G1 patients more often developed chronic respiratory failure (p < 0.001) and had significantly lower survival rates. Independent risk factors associated with IMV were hypercapnia and decreased pH (in patients with severe AECOPD), a history of NIV, and chronic respiratory failure (CRF).

Conclusion

respiratory function impairment, the severity of exacerbation and the need for NIV in a previous episode are factors predicting the need for IMV and poor outcomes.

Predictors of mortality in COPD exacerbation cases presenting to the respiratory intensive care unit

Background

Studies report high in-hospital mortality of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) especially for those requiring admission to an intensive care unit. Recognizing factors associated with mortality in these patients could reduce health care costs and improve end-of-life care.

Methods

This retrospective study included AECOPD patients admitted to the respiratory intensive care unit of a tertiary hospital in Beijing from Jan 1, 2011 to Dec 31, 2018. Patients demographic characteristics, blood test results and comorbidities were extracted from the electronic medical record system and compared between survivors and non-survivors.

Results

We finally enrolled 384 AECOPD patients: 44 (11.5%) patients died in hospital and 340 (88.5%) were discharged. The most common comorbidity was respiratory failure (294 (76.6%)), followed by hypertension (214 (55.7%)), coronary heart disease (115 (29.9%)) and chronic heart failure (76 (19.8%)). Multiple logistic regression analysis revealed that independent risk factors associated with in-hospital mortality included lymphocytopenia, leukopenia, chronic heart failure and requirement for invasive mechanical ventilation.

Conclusions

The in-hospital mortality of patients with acute COPD exacerbation requiring RICU admission is high. Lymphocytes < 0.8 × 10⁹/L, leukopenia, requirement for invasive mechanical ventilation, and chronic heart failure were identified as risk factors associated with increased mortality rates.

Improvement of quality of life (QOL) between 1 and 3-4 years after traumatic brain injury (TBI) in ICU patients

BACKGROUND

Evaluation of changes in quality of life (QOL) in ICU patients several years after traumatic brain injury (TBI) is not well documented.

METHODS

A prospective cohort study was conducted in all patients with TBI admitted between 2004 and 2008 to the ICU of Regional Hospital of Malaga (Spain). Functional status was evaluated by Glasgow Outcome Scale (GOS) and QOL by PAECC (Project for the Epidemiologic Analysis of Critical Care patients) questionnaire between 0 (normal QOL) to 29 points (worst QOL).

RESULTS

A total of 531 patients. Median(Quartile1,Quartile 3) age: 35 (22, 56) years. After 3-4 years, 175 died (33%). Survivor QOL was deteriorated (median total PAECC score: 5 (0, 11) points) although 75.76% of patients who survived showed good functional situation (GOS normal or mild dysfunction). An improvement in QOL scores between 1 and 3-4 years was observed (median PAECC score differences between 3-4 years and 1 year: - 1(- 4, 0) points). QOL score improved during this interval of time: 62.6% of patients. Change in QOL was related by multivariate analysis to admission cranial-computed tomography scan (Marshall's classification), age, and Injury Severity Score (ISS), with the biggest improvement seen in younger patients and with more severe ISS. Basic physiological activities were maintained in the majority of patients. Subjective aspects and working activities improved between 1 and 3-4 years but with a high proportion still impaired in these items after 3-4 years.

CONCLUSIONS

ICU patients with TBI after 1 year show improvement in QOL between 1 and 3-4 years, with the biggest improvement in QOL seen in younger patients and in those with more severe ISS.

Long-term outcomes after acute hypercapnic COPD exacerbation : First-ever episode of non-invasive ventilation

BACKGROUND

Non-invasive ventilation (NIV) is used to treat acute hypercapnic respiratory failure (AHRF) in patients with chronic obstructive pulmonary disease (COPD); however, long-term outcomes following discharge are largely unknown. This study aimed to characterize long-term outcomes and identify associated markers in patients with COPD after surviving the first episode of HRF requiring NIV.

METHODS

This study retrospectively analyzed 122 patients, mean age 62 ± 8 years, 52% female and forced expiratory volume in 1 s (FEV1) predicted 30 ± 13%, admitted with an acute hypercapnic exacerbation of COPD and receiving a first-ever NIV treatment between 2000 and 2012.

RESULTS

A total of 40% of the patients required hospital readmission due to respiratory reasons within 1 year. Persistent hypercapnia leading to the prescription of domiciliary NIV, older age and lower body mass index (BMI) were risk factors for readmission due to respiratory reasons. Survival rates were 79% and 63% at 1 and 2 years after discharge, respectively. A shorter time to readmission and recurrent hypercapnic failure, lower BMI and acidemia on the first admission, as well as hypercapnia at hospital discharge were correlated with a decreased long-term survival.

CONCLUSION

Patients with COPD surviving their first episode of AHRF requiring NIV are at high risk for readmission and death. Severe respiratory acidosis, chronic respiratory failure and a lower BMI imply shorter long-term survival.

Acute respiratory failure requiring mechanical ventilation in severe chronic obstructive pulmonary disease (COPD)

There are limited data on the epidemiology of acute respiratory failure necessitating mechanical ventilation in patients with severe chronic obstructive pulmonary disease (COPD). The prognosis of acute respiratory failure requiring invasive mechanical ventilation is believed to be grim in this population. The purpose of this study was to illustrate the epidemiologic characteristics and outcomes of patients with underlying severe COPD requiring mechanical ventilation.A retrospective study of patients admitted to a quaternary referral medical intensive care unit (ICU) between January 2008 and December 2012 with a diagnosis of severe COPD and requiring invasive mechanical ventilation for acute respiratory failure.We evaluated 670 patients with an established diagnosis of severe COPD requiring mechanical ventilation for acute respiratory failure of whom 47% were male with a mean age of 63.7 ± 12.4 years and Acute physiology and chronic health evaluation (APACHE) III score of 76.3 ± 27.2. Only seventy-nine (12%) were admitted with a COPD exacerbation, 27(4%) had acute respiratory distress syndrome (ARDS), 78 (12%) had pneumonia, 78 (12%) had sepsis, and 312 (47%) had other causes of respiratory failure, including pulmonary embolism, pneumothorax, etc. Eighteen percent of the patients received a trial of noninvasive positive pressure ventilation. The median duration of mechanical ventilation was 3 days (interquartile range IQR 2-7); the median duration for ICU length of stay (LOS) was 5 (IQR 2-9) days and the median duration of hospital LOS was 12 (IQR 7-22) days. The overall ICU mortality was 25%. Patients with COPD exacerbation had a shorter median duration of mechanical ventilation (2 vs 4 days; P = .04), ICU (3 vs 5 days; P = .01), and hospital stay (10 vs 13 days; P = .01). The ICU mortality (9% vs 27%; P < .001), and the hospital mortality (17% vs 32%; P = .004) for mechanically ventilated patients with an acute exacerbation of severe COPD were lower than those with other etiologies of acute respiratory failure. A 1-unit increase in the APACHE III score was associated with a 1% decrease and having an active cancer was associated with a 45% decrease in ICU survival (P < .001). A discharge home at the time of index admission was associated an increased overall survival compared with any other discharge location (P < .001).We report good early outcomes, but significant long-term morbidity in patients with severe COPD requiring invasive mechanical ventilation for acute respiratory failure. A higher APACHE score and presence of active malignancy are associated with a decrease in ICU survival, whereas a discharge home is associated with an increase in the overall survival.

Chronic obstructive pulmonary disease exacerbation in the intensive care unit: clinical, functional and quality of life at discharge and 3 months of follow up

Objective:

The purpose of this study was to evaluate the clinical/functional aspects and quality of life of chronic obstructive pulmonary disease patients who were discharged after an intensive care unit admission for acute respiratory failure.

Methods:

This prospective study included chronic obstructive pulmonary disease patients who were admitted to two intensive care units between December of 2010 and August of 2011 and evaluated over three visits after discharge. Thirty patients were included, and 20 patients completed the three-month follow up.

Results:

There was a significant improvement in the following: forced expiratory flow in one second (L) (1.1/1.4/1.4; p = 0.019), six-minute walk test (m) (- /232.8 /272.6; p = 0.04), BODE score (7.5/5.0/3.8; p = 0.001), cognition measured by the Mini Mental State Examination (21/23.5/23.5; p = 0.008) and quality of life measured by the total Saint George Respiratory Questionnaire score (63.3/56.8/51, p = 0.02). The mean difference in the total score was 12.3 (between visits 1 and three). Important clinical differences were observed for the symptom score (18.8), activities score (5.2) and impact score (14.3). The majority of participants (80%) reported they would be willing to undergo a new intensive care unit admission.

Conclusion:

Despite the disease severity, there was a significant clinical, functional and quality of life improvement at the end of the third month. Most patients would be willing to undergo a new intensive care unit admission.

Long-term outcome of chronic obstructive pulmonary disease patients with acute respiratory failure following intensive care unit discharge in Turkey

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) remains a globally significant cause of mortality, although COPD mortality varies from country to country, and across different regions within each country. The primary objective of this study was to determine the mortality rates of COPD patients who present with acute respiratory failure (ARF) to a tertiary care referral center in different stages of their follow-up (ICU, in-hospital and after discharge). The secondary objective was to determine factors associated with mortality in this group of patients.

RESULTS

Medical records of consecutive COPD patients over a 10-year period were reviewed.The study included 147 patients. Of these, 72 were treated initially with noninvasive positive pressure ventilation (NIPPV), and 12 of these required intubation after NIPPV failed. Therefore, 86 patients were intubated for invasive mechanical ventilation (IMV), while NIPPV was succesful in 60 patients. Survival time was independently associated with advanced age, high APACHE II score, co-morbidity and the need for IMV. The cumulative mortality was 27% in the medical ICU and 31% in hospital following ICU discharge. The mortality rate at 1, 2 and 5 years was 54%, 66% and 84%, respectively.

CONCLUSION

COPD patients admitted to the ICU for ARF have an approximately 70% chance of leaving hospital alive, but half of these may die in the first 6 months after discharge. The risk factors related to mortality were advanced age, high APACHE II score, co-morbidity and IMV requirement.

Using modeling to inform patient-centered care choices at the end of life

AIM

Advance directives are often under-informed due to a lack of disease-specific prognostic information. Without well-informed advance directives patients may receive default care that is incongruent with their preferences. We aimed to further inform advance care planning in patients with severe chronic obstructive pulmonary disease by estimating outcomes with alternative advance directives.

METHODS

We designed a Markov microsimulation model estimating outcomes for patients choosing between the Full Code advance directive (permitting invasive mechanical ventilation), and the Do Not Intubate directive (only permitting noninvasive ventilation).

RESULTS

Our model estimates Full Code patients have marginally increased one-year survival after admission for severe respiratory failure, but are more likely to be residing in a nursing home and have frequent rehospitalizations for respiratory failure.

CONCLUSION

Patients with severe chronic obstructive pulmonary disease may consider these potential tradeoffs between survival, rehospitalizations and institutionalization when making informed advance care plans and end-of-life decisions. We highlight outcomes research needs for variables most influential to the model's outcomes, including the risk of complications of invasive mechanical ventilation and failing noninvasive mechanical ventilation.

In-hospital and one-year mortality and their predictors in patients hospitalized for first-ever chronic obstructive pulmonary disease exacerbations: a nationwide population-based study

Introduction

Natural history of chronic obstructive pulmonary disease (COPD) is punctuated by exacerbations; however, little is known about prognosis of the first-ever COPD exacerbation and variables predicting its outcomes.

Materials and Methods

A population-based cohort study among COPD patients with their first-ever exacerbations requiring hospitalizations was conducted. Main outcomes were in-hospital mortality and one-year mortality after discharge. Demographics, comorbidities, medications and in-hospital events were obtained to explore outcome predictors.

Results

The cohort comprised 4204 hospitalized COPD patients, of whom 175 (4%) died during the hospitalization. In-hospital mortality was related to higher age (odds ratio [OR]: 1.05 per year; 95% confidence interval [CI]: 1.03–1.06) and Charlson comorbidity index score (OR: 1.08 per point; 95% CI: 1.01–1.15); angiotensin II receptor blockers (OR: 0.61; 95% CI: 0.38–0.98) and β blockers (OR: 0.63; 95% CI: 0.41–0.95) conferred a survival benefit. At one year after discharge, 22% (871/4029) of hospital survivors were dead. On multivariate Cox regression analysis, age and Charlson comorbidity index remained independent predictors of one-year mortality. Longer hospital stay (hazard ratio [HR] 1.01 per day; 95% CI: 1.01–1.01) and ICU admission (HR: 1.33; 95% CI: 1.03–1.73) during the hospitalization were associated with higher mortality risks. Prescription of β blockers (HR: 0.79; 95% CI: 0.67–0.93) and statins (HR: 0.66; 95% CI: 0.47–0.91) on hospital discharge were protective against one-year mortality.

Conclusions

Even the first-ever severe COPD exacerbation signifies poor prognosis in COPD patients. Comorbidities play a crucial role in determining outcomes and should be carefully assessed. Angiotensin II receptor blockers, β blockers and statins may, in theory, have dual cardiopulmonary protective properties and probably alter prognosis of COPD patients. Nevertheless, the limitations inherent to a claims database study, such as the diagnostic accuracy of COPD and its exacerbation, should be born in mind.

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

The objective of this study was to develop a model to aid clinicians in better predicting 1-year mortality rate for patients with an acute exacerbation of chronic obstructive pulmonary disease admitted to the medical intensive care unit (ICU) with the goal of earlier initiation of palliative care and end-of-life communications in this patient population. This retrospective cohort study included patients from a medical ICU from April 1, 1995, to November 30, 2009. Data collected from the Acute Physiology and Chronic Health Evaluation III database included demographic characteristics; severity of illness scores; noninvasive and invasive mechanical ventilation time; ICU and hospital length of stay; and ICU, hospital, and 1-year mortality. Statistically significant univariate variables for 1-year mortality were entered into a multivariate model, and the independent variables were used to generate a scoring system to predict 1-year mortality rate. At 1-year follow-up, 295 of 591 patients died (50%). Age and hospital length of stay were identified as independent determinants of mortality at 1 year by using multivariate analysis, and the predictive model developed had an area under the operating curve of 0.68. Bootstrap analysis with 1000 iterations validated the model, age, and hospital length of stay, entered the model 100% of the time (area under the operating curve=0.687; 95% CI, 0.686-0.688). A simple model using age and hospital length of stay may be informative for providers willing to identify patients with chronic obstructive pulmonary disease with high 1-year mortality rate who may benefit from end-of-life communications and from palliative care.

Measurement of activities of daily living in patients with COPD: a systematic review

BACKGROUND

The objectives of this systematic review were to synthesize the literature on measures of activities of daily living (ADLs) that have been used in individuals with COPD and to provide an overview of the psychometric properties of the identified measures and describe the relationship of the disease-specific instruments with other relevant outcome measures for individuals with COPD and health-care use.

METHODS

Studies that included a measure of ADLs in individuals with COPD were identified using electronic and hand searches. Two investigators performed the literature search. One investigator reviewed the study title, abstract, and full text of the articles to determine study eligibility and performed the data extraction and tabulation. In cases of uncertainty, a second reviewer was consulted.

RESULTS

A total of 679 articles were identified. Of those, 116 met the inclusion criteria. Twenty-seven ADLs instruments were identified, of which 11 instruments were respiratory disease-specific, whereas 16 were generic. Most instruments combined instrumental ADLs (IADLs) with basic ADLs (BADLs). The majority of the instruments were self-reported; only three instruments were performance based. Twenty-one studies assessed psychometric properties of 16 ADLs instruments in patients with COPD.

CONCLUSIONS

Although several ADLs instruments were identified, psychometric properties have only been reported in a few. Selection of the most appropriate measure should focus on the target construct (BADLs or IADLs or both), type of test (disease-specific vs generic and self-reported vs performance-based), depth of information obtained, and psychometric properties of the instruments. Given the relevance of ADLs to the lives of patients with COPD, its assessment should be more frequently incorporated as a clinical outcome in their management.

Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease

RATIONALE

There is a need to identify clinically meaningful predictors of mortality following hospitalized COPD exacerbation.

OBJECTIVES

The aim of this study was to systematically review the literature to identify clinically important factors that predict mortality after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Eligible studies considered adults admitted to hospital with COPD exacerbation. Two authors independently abstracted data. Odds ratios were then calculated by comparing the prevalence of each predictor in survivors versus nonsurvivors. For continuous variables, mean differences were pooled by the inverse of their variance, using a random effects model.

MEASUREMENTS AND MAIN RESULTS

There were 37 studies included (189,772 study subjects) with risk of death ranging from 3.6% for studies considering short-term mortality, 31.0% for long-term mortality (up to 2 yr after hospitalization), and 29.0% for studies that considered solely intensive care unit (ICU)-admitted study subjects. Twelve prognostic factors (age, male sex, low body mass index, cardiac failure, chronic renal failure, confusion, long-term oxygen therapy, lower limb edema, Global Initiative for Chronic Lung Disease criteria stage 4, cor pulmonale, acidemia, and elevated plasma troponin level) were significantly associated with increased short-term mortality. Nine prognostic factors (age, low body mass index, cardiac failure, diabetes mellitus, ischemic heart disease, malignancy, FEV1, long-term oxygen therapy, and PaO2 on admission) were significantly associated with long-term mortality. Three factors (age, low Glasgow Coma Scale score, and pH) were significantly associated with increased risk of mortality in ICU-admitted study subjects.

CONCLUSION

Different factors correlate with mortality from COPD exacerbation in the short term, long term, and after ICU admission. These parameters may be useful to develop tools for prediction of outcome in clinical practice.

A prospective longitudinal multicentre study of health related quality of life in ICU survivors with COPD

INTRODUCTION

Mortality amongst COPD patients treated on the ICU is high. Health-related quality of life (HRQL) after intensive care is a relevant concern for COPD patients, their families and providers of health care. Still, there are few HRQL studies after intensive care of this patient group. Our hypothesis was that HRQL of COPD patients treated on the ICU declines rapidly with time.

METHODS

Fifty-one COPD patients (COPD-ICU group) with an ICU stay longer than 24 hours received a questionnaire at 6, 12 and 24 months after discharge from ICU. HRQL was measured using two generic instruments: the EuroQoL instrument (EQ-5D and EQ-VAS) and the Short Form 36 Health Survey (SF-36). The results were compared to HRQL of two reference groups from the general population; an age- and sex-adjusted reference population (Non-COPD reference) and a reference group with COPD (COPD reference).

RESULTS

HRQL of the COPD-ICU group at 6 months after discharge from ICU was lower compared to the COPD reference group: Median EQ-5D was 0.66 vs. 0.73, P = 0.08 and median EQ-VAS was 50 vs.55, P < 0.05. There were no significant differences in the SF-36 dimensions between the COPD-ICU and COPD-reference groups, although the difference in physical functioning (PF) approached statistical significance (P = 0.059). Patients in the COPD-ICU group who were lost to follow-up after 6 months had low HRQL scores at 6 months. Scores for patients who died were generally lower compared to patients who failed to respond to the questionnaire. The PF and social functioning (SF) scores in those who died were significantly lower compared to patients with a complete follow up. HRQL of patients in the COPD-ICU group that survived a complete 24 months follow up was low but stable with no statistically significant decline from 6 to 24 months after ICU discharge. Their HRQL at 24 months was not significantly different from HRQL in the COPD reference group.

CONCLUSIONS

HRQL in COPD survivors after intensive care was low but did not decline from 6 to 24 months after discharge from ICU. Furthermore, HRQL at 24 months was similar to patients with COPD who had not received ICU treatment.

Palliative care for patients with chronic obstructive pulmonary disease: current perspectives

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory illness with a myriad of disabling symptoms and a decline in the functional parameters that affect the quality of life. The mortality and morbidity associated with severe COPD is high and the patients are mostly housebound and in need of continuous care and support. The uncertain nature of its prognosis makes the commencement of palliative care and discussion of end-of-life issues difficult even in the advanced stage of the disease. This is often compounded by inadequate communication and counseling with patients and their relatives. The areas that may improve the quality of care include the management of dyspnea, oxygen therapy, nutritional support, antianxiety, and antidepressant treatment, and advance care planning. Hence, it is necessary to pursue a holistic care approach for palliative care services along with disease-specific medical management in all such patients to improve the quality of life in end-stage COPD.

Factors influencing physical functional status in intensive care unit survivors two years after discharge

Background

Studies suggest that in patients admitted to intensive care units (ICU), physical functional status (PFS) improves over time, but does not return to the same level as before ICU admission. The goal of this study was to assess physical functional status two years after discharge from an ICU and to determine factors influencing physical status in this population.

Methods

The study reviewed all patients admitted to two non-trauma ICUs during a one-year period and included patients with age ≥ 18 yrs, ICU stay ≥ 24 h, and who were alive 24 months after ICU discharge. To assess PFS, Karnofsky Performance Status Scale scores and Lawton-Instrumental Activities of Daily Living (IADL) scores at ICU admission (K-ICU and L-ICU) were compared to the scores at the end of 24 months (K-24mo and L-24mo). Data at 24 months were obtained through telephone interviews.

Results

A total of 1,216 patients were eligible for the study. Twenty-four months after ICU discharge, 499 (41.6%) were alive, agreed to answer the interview, and had all hospital data available. PFS (K-ICU: 86.6 ± 13.8 vs. K-24mo: 77.1 ± 19.6, p < 0.001) and IADL (L-ICU: 27.0 ± 11.7 vs. L-24mo: 22.5 ± 11.5, p < 0.001) declined in patients with medical and unplanned surgical admissions. Most strikingly, the level of dependency increased in neurological patients (K-ICU: 86 ± 12 vs. K-24mo: 64 ± 21, relative risk [RR] 2.6, 95% CI, 1.8–3.6, p < 0.001) and trauma patients (K-ICU: 99 ± 2 vs. K-24mo: 83 ± 21, RR 2.7, 95% CI, 1.6–4.6, p < 0.001). The largest reduction in the ability to perform ADL occurred in neurological patients (L-ICU: 27 ± 7 vs. L-24mo: 15 ± 12, RR 3.3, 95% CI, 2.3–4.6 p < 0.001), trauma patients (L-ICU: 32 ± 0 vs. L-24mo: 25 ± 11, RR 2.8, 95% CI, 1.5–5.1, p < 0.001), patients aged ≥ 65 years (RR 1.4, 95% CI, 1.07–1.86, p = 0.01) and those who received mechanical ventilation for ≥ 8 days (RR 1.48, 95% CI, 1.02–2.15, p = 0.03).

Conclusions

Twenty-four months after ICU discharge, PFS was significantly poorer in patients with neurological injury, trauma, age ≥ 65 tears, and mechanical ventilation ≥ 8 days. Future studies should focus on the relationship between PFS and health-related quality of life in this population.

Care dependency independently predicts two-year survival in outpatients with advanced chronic organ failure

OBJECTIVE

Previous studies suggest that care dependency may predict survival in hospitalized patients, but the prognostic value of care dependency in clinically stable outpatients with advanced chronic organ failure remains unknown. The objective of this study was to assess whether and to what extent care dependency predicts 2-year survival in patients with advanced chronic organ failure.

DESIGN

Longitudinal observational study.

SETTING

Patients were recruited at the outpatient clinic of one academic and six general hospitals in The Netherlands.

PARTICIPANTS

A total of 265 clinically stable outpatients with advanced chronic obstructive pulmonary disease (n = 105), chronic heart failure (n = 80), and chronic renal failure (n = 80) were included at baseline.

MEASUREMENTS

Care dependency was assessed using the Care Dependency Scale (CDS), a 15-item self-administered questionnaire. In addition, patients performed a Timed Up and Go test to assess mobility. Finally, demographics, clinical characteristics, and 2-year survival were recorded.

RESULTS

At baseline, 116 patients (43.8%) reported a CDS score ≤ 68 points and were considered as care dependent. In total, 66 patients (24.9%) died within 2 years. The Cox regression model showed that a higher CDS score (lower level of care dependency) was associated with a lower probability of dying within 2 years (hazard ratio, 0.95; 95% CI: 0.90-0.97), whereas older age was associated with a greater probability of dying within 2 years (hazard ratio, 1.06; 95% CI, 1.03-1.09).

CONCLUSION

The level of care dependency independently predicts 2-year survival among clinically stable outpatients with advanced chronic organ failure. Therefore, regular assessment of the level of care dependency should be included in clinical care for patients with advanced chronic organ failure.

Capacitação dos técnicos de enfermagem para as melhores práticas no uso de broncodilatadores em pacientes mecanicamente ventilados

A inaloterapia de broncodilatadores é uma das principais terapêuticas no tratamento de doenças respiratórias, desde que a administração seja correta para produzir uma absorção e uma ação medicamentosa efetiva. Assim, realizou-se uma pesquisa quantitativa, quase-experimental, com o delineamento pré e pós-teste, cujos objetivos foram avaliar o conhecimento dos técnicos de enfermagem na administração de broncodilatadores inalatórios, em pacientes mecanicamente ventilados, na Unidade de Terapia Intensiva, e capacitá-los para a correta aplicação desses fármacos. Com base no pré-teste, foi realizada a capacitação de 34 técnicos de enfermagem e, após, um pós-teste para a avaliação da técnica de administração dos broncodilatadores. Aplicou-se um questionário. Os resultados sinalizam que nenhum dos entrevistados descreveu, adequadamente, as etapas da nebulização no paciente mecanicamente ventilado no pré-teste. Já no pós-teste, 44,11% responderam adequadamente. Através da análise dos resultados, avaliando os pré e pós-testes, nota-se um aprendizado balizado nas melhores práticas.

Health-related quality of life of long-term survivors of intensive care: changes after intensive care treatment. Experience of an Austrian intensive care unit

OBJECTIVE

The aim of the study was to determine if health-related quality of life of long-term survivors changes 24 months after intensive care treatment compared to the quality of life before admission.

METHODS

From 281 patients treated at the ICU in 2001, 132 survivors were contacted by phone on average 24 months after discharge. Fernandez questionnaire was used to assess preadmission quality of life prospectively and postdischarge quality of life, retrospectively. In addition, age, sex, admission diagnosis, ICU length of stay, presence of organ failure, and necessity of mechanical ventilation were determined.

RESULTS

In the 101 ICU survivors who responded to the questionnaire, the total score of quality of life did not change significantly over time (5.48 ± 5.3 before admission vs. 5.6 ± 5.8 at follow-up; p = 0.9). Similarly, the performance of normal daily activities did not alter (3.0 ± 3.5 vs. 3.39 ± 3.6; p = 0,3). In contrast, the ability to perform basic physiological activities worsened significantly (0.39 ± 0.76 vs. 0.76 ± 1.52; p = 0.037), whereas the emotional state improved significantly after intensive care treatment (2.08 ± 1.78 vs. 1.46 ± 1.56, p = 0.003). In a stepwise multiple regression analysis the total score of quality of life before admission was the only variable which influenced the quality of life 2 years after ICU-stay.

CONCLUSIONS

In the interviewed population the total score of health-related quality of life did not change after intensive care treatment. Surprisingly, emotional state improved significantly although physical performance decreased. Quality of life after ICU discharge was predominantly influenced by preadmission quality of life. However, these results are not reflective of all ICU survivors.

Acetazolamide: a second wind for a respiratory stimulant in the intensive care unit?

Patients with chronic obstructive pulmonary disease (COPD) are affected by episodes of respiratory exacerbations, some of which can be severe and may necessitate respiratory support. Prolonged invasive mechanical ventilation is associated with increased mortality rates. Persistent failure to discontinue invasive mechanical ventilation is a major issue in patients with COPD. Pure or mixed metabolic alkalosis is a common finding in the intensive care unit (ICU) and is associated with a worse outcome. In patients with COPD, the condition is called post-hypercapnic alkalosis and is a complication of mechanical ventilation. Reversal of metabolic alkalosis may facilitate weaning from mechanical ventilation of patients with COPD. Acetazolamide, a non-specific carbonic anhydrase inhibitor, is one of the drugs employed in the ICU to reverse metabolic alkalosis. The drug is relatively safe, undesirable effects being rare. The compartmentalization of the different isoforms of the carbonic anhydrase enzyme may, in part, explain the lack of evidence of the efficacy of acetazolamide as a respiratory stimulant. Recent findings suggest that the usually employed doses of acetazolamide in the ICU may be insufficient to significantly improve respiratory parameters in mechanically ventilated patients with COPD. Randomized controlled trials using adequate doses of acetazolamide are required to address this issue.

The management of asthma and chronic obstructive pulmonary disease: current status and future perspectives

Asthma and chronic obstructive pulmonary disease (COPD) represent the leading chronic respiratory diseases of interest in the word, owing to their high prevalence and burden on the health system. Care of these patients, undergoing frequent exacerbations, is a heavy burden on healthcare systems. In the last few years, large improvements in the management of asthma and COPD have been made, owing to new drugs and management strategies, and to the improvement of the nonpharmacologic treatment of COPD. There are still many unmet needs in the treatment of these diseases. In asthma, strategies to improve control should be implemented. There is a need to use more biomarkers to tailor treatment, in the assessment and choice of appropriate therapy, especially in severe patients. In COPD, there is growing evidence of individual differences in lung function decline rate and associated differences in appropriate management strategies. Early effective and prolonged bronchodilation can slow disease progression and reduce the frequency of exacerbations. New perspectives include the use of biologic drugs (anticytokine monoclonal antibodies) in selected categories of severe asthmatics, potential new inhibitors of chemokines and cytokines involved in the pathobiology of asthma and COPD, and a further improvement of current drugs and better implementation of management strategies, particularly in COPD patients.

Systematic review of noncancer presentations with a median survival of 6 months or less

PURPOSE

We report on clinical indicators of 6-month mortality in advanced noncancer illnesses and the effect of treatment on survival.

METHODS

The MEDLINE database was searched comprehensively to find studies evaluating survival for common advanced noncancer illnesses. We retrieved and evaluated studies that reported a median survival of ≤1 year and evaluated prognostic factors or effect of treatment on survival. We extracted data on presentations with median survivals of ≤6 months for heart failure, chronic obstructive pulmonary disease, dementia, geriatric failure to thrive, cirrhosis, and end-stage renal failure. Independent risk factors for survival were combined and included if their combination was associated with a 6-month mortality of ≥50%.

RESULTS

The search identified 1000 potentially relevant studies, of which 475 were retrieved and evaluated, and 74 were included. We report the common clinical presentations that are consistently associated with a 6-month median survival. Even though advanced noncancer syndromes differ clinically, a universal set of prognostic factors signals progression to terminal disease, including poor performance status, advanced age, malnutrition, comorbid illness, organ dysfunction, and hospitalization for acute decompensation. Generally, a 6-month median survival is associated with the presence of 2-4 of these factors. With few exceptions, these terminal presentations are quite refractory to treatment.

CONCLUSION

This systematic review summarizes prognostic factors common to advanced noncancer illness. There is little evidence at present that treatment prolongs survival at these terminal stages.

Informing shared decisions about advance directives for patients with severe chronic obstructive pulmonary disease: a modeling approach

OBJECTIVE

To estimate the survival and quality-adjusted life-years (QALYs) of Full Code versus Do Not Intubate (DNI) advance directives in patients with severe chronic obstructive pulmonary disease and to evaluate how patient preferences and place of residence influence these outcomes.

METHODS

A Markov decision model using published data for COPD exacerbation outcomes. The advance directives that were modeled were as follows: DNI, allowing only noninvasive mechanical ventilation, or Full Code, allowing all forms of mechanical ventilation including invasive mechanical ventilation with endotracheal tube (ETT) insertion.

RESULTS

In community-dwellers, Full Code resulted in a greater likelihood of survival and higher QALYs (4-year survival: 23% Full Code, 18% DNI; QALYs: 1.34 Full Code, 1.24 DNI). When considering patient preferences regarding complications, however, if patients were willing to give up >3 months of life expectancy to avoid ETT complications, or >1 month of life expectancy to avoid long-term institutionalization, DNI resulted in higher QALYs. For patients in long-term institutions, DNI resulted in a greater likelihood of survival and higher QALYs (4-year survival: 2% DNI, 1% Full Code; QALYs: 0.29 DNI, 0.24 Full Code). In sensitivity analyses, the model was sensitive to the probabilities of ETT complication and noninvasive mechanical ventilation failure and to patient preferences about ETT complications and long-term institutionalization.

CONCLUSION

Our model demonstrates that patient preferences regarding ETT complications and long-term institutionalization, as well as baseline place of residence, affect the advance directive recommendation when considered in terms of both survival and QALYs. Decision modeling can demonstrate the potential trade-off between survival and quality of life, using patient preferences and disease-specific data, to inform the shared advance directive decision.

The prognostic variables predictive of mortality in patients with an exacerbation of COPD admitted to the ICU: an integrative review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) frequently presents with an acute exacerbation (AECOPD). Debate exists as to whether these patients should be admitted to intensive care units (ICUs). An integrative review was performed to determine whether clinical variables available at the time of ICU admission are predictive of the intermediate-term mortality of patients with an AECOPD.

METHODS

An integrative review was structured to incorporate a five-stage review framework to facilitate data extraction, analysis and presentation. The quality of the studies contributing to the integrative review was assessed with a novel scoring system developed from previously published data and adapted to this setting.

RESULTS

The integrative review search strategy identified 28 studies assessing prognostic variables in this setting. Prognostic variables associated with intermediate-term mortality were low Glasgow Coma Scale (GCS) on admission to ICU, cardio-respiratory arrest prior to ICU admission, cardiac dysrhythmia prior to ICU admission, length of hospital stay prior to ICU admission and higher values of acute physiology scoring systems. Premorbid variables such as age, functional capacity, pulmonary function tests, prior hospital or ICU admissions, body mass index and long-term oxygen therapy were not found to be associated with intermediate-term mortality nor was the diagnosis attributed to the cause of the AECOPD.

DISCUSSION

Variables associated with intermediate-term mortality after AECOPD requiring ICU admission are those variables, which reflect underlying severity of acute illness. Premorbid and diagnostic data have not been shown to be predictive of outcome. A scoring system is proposed to assess studies of prognosis in AECOPD.

Patients admitted to the ICU for acute exacerbation of COPD: two-year mortality and functional status

OBJECTIVE

To assess ICU patients with COPD, in terms of in-hospital characteristics, two-year mortality and two-year functional status of survivors.

METHODS

A prospective cohort study involving patients with acute exacerbation of COPD admitted to the ICUs of two hospitals in the city of Porto Alegre, Brazil, between July of 2005 and July of 2006. At two years after discharge, survivors were interviewed by telephone in order to determine Karnofsky scores and scores on a scale regarding activities of daily living (ADL).

RESULTS

The sample comprised 231 patients. In-hospital mortality was 37.7%, and two-year post-discharge mortality was 30.3%. Of the 74 survivors, 66 were interviewed (89%). The mean age at ICU admission was 74 ± 10 years, and the mean Acute Physiology and Chronic Health Evaluation II score was 18 ± 7. Two or more comorbidities were present in 87.8% of the patients. Of the 66 interviewees, 57 (86.3%) lived at home, 58 (87.8%) were self-sufficient, 12 (18.1%) required oxygen therapy, and 4 (6.1%) still required ventilatory support. There was a significant reduction in the quality of life and autonomy of the survivors, as evidenced by the Karnofsky scores (85 ± 9 vs. 79 ± 11, p = 0.03) and ADL scale scores (29 ± 5 vs. 25 ± 7; p = 0.01), respectively.

CONCLUSIONS

In this patient sample, two-year mortality was quite high. Although there was a noticeable reduction in the functional status of the survivors, they remained self-sufficient.

Characteristics of COPD patients admitted to the ICU of a referral hospital for respiratory diseases in Brazil

OBJECTIVE

To report data regarding COPD patients admitted to the ICU of a referral hospital for respiratory diseases, including outcomes and treatment evaluation.

METHODS

Study of a series of patients with respiratory failure and COPD admitted to the ICU of Nereu Ramos Hospital, located in the city of Florianópolis, Brazil, between October of 2006 and October of 2007. Data related to demographics, causes of hospitalization, pharmacological treatment, ventilatory support, length of hospital stay, in-hospital complications, ICU mortality, and 28-day mortality were obtained from the medical charts of the patients. Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated. Mortality at 18 months was assessed by subsequent telephone calls.

RESULTS

During the study period, 192 patients were admitted to the ICU, 24 (12.5%) of whom were diagnosed with respiratory failure and COPD. The mean length of ICU stay was 12.0 ± 11.1 days. Noninvasive ventilation was used in 10 of the 24 patients (41.66%) and failed in 5 of those 10. Invasive mechanical ventilation (IMV) was used in a total of 15 patients (62.5%). Overall ICU mortality and 28-day mortality were 20.83% and 33.33%, respectively. However, 18-month mortality was 62.5%.

CONCLUSIONS

Respiratory failure associated with COPD was responsible for 12.5% of the ICU admissions. Orotracheal intubation and IMV were necessary in 62.5% of the cases. The ICU mortality rate was in accordance with that predicted by the APACHE II scores. However, late mortality was high.

Skeletal morbidity among survivors of critical illness

OBJECTIVES

To describe the incident fracture rate in survivors of critical illness and to compare fracture risk with population-matched control subjects.

DESIGN

Retrospective longitudinal case-cohort study.

SETTING

A tertiary adult intensive care unit in Australia.

PATIENTS

All patients ventilated admitted to intensive care and requiring mechanical ventilation for ≥48 hrs between January 1998 and December 2005.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

New fractures were identified in the study population for the postintensive care unit period (intensive care unit discharge to January 2008). The incident fracture rate and age-adjusted fracture risk of the female intensive care unit population were compared with the general population adult females derived from the Geelong Osteoporosis Study. Over the 8-yr period, a total of 739 patients (258 women, 481 men) were identified. After a median follow-up of 3.7 yrs (interquartile range, 2.0-5.9 yrs) for women and 4.0 yrs (interquartile range, 2.1-6.1 yrs) for men, incident fracture rates (95% confidence interval) per 100 patient years were 3.84 (2.58-5.09) for females 2.41 (1.73-3.09) for males. Compared with an age-matched random population-based sample of women, elderly women were at increased risk for sustaining an osteoporosis-related fracture after critical illness (hazard ratio, 1.65; 95% confidence interval, 1.08-2.52; p = .02).

CONCLUSIONS

The increase in fracture risk observed in postintensive care unit older females suggests an association between critical illness and subsequent skeletal morbidity. The explanation for this association is not explored in this study and includes the effects of pre-existing patient factors and/or direct effects of critical illness. Prospective research evaluating risk factors, the relationship between critical illness and bone turnover, the extent and duration of bone loss, and the associated morbidity in this population is warranted.

Predicting outcomes following hospitalization for acute exacerbations of COPD

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a frequent cause of hospital admission and are associated with significant morbidity, mortality, high readmission rates and high resource utilization. More accurate prediction of survival and readmission in patients hospitalized with AECOPD should help to optimize clinical management and allocation of resources, including targeting of palliative care and strategies to reduce readmissions. We have reviewed the published retrospective and prospective studies in this field to identify the factors most likely to be of value in predicting in-hospital and post-discharge mortality, and readmission of patients hospitalized for AECOPD. The prognostic factors which appear most important vary with the particular outcome under consideration. In-hospital mortality is related most clearly to the patient's acute physiological state and to the development of acute comorbidity, while post-discharge mortality particularly reflects the severity of the underlying COPD, as well as specific comorbidities, especially cardiac disease. Important factors influencing the frequency of readmission include functional limitation and poor health-related quality of life. Large prospective studies which incorporate all the potentially relevant variables are required to refine prediction of the important outcomes of AECOPD and thus to inform clinical decision making, for example on escalation of care, facilitated discharge and provision of palliative care.

Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: a multicenter, inception cohort study

PURPOSE

The aim of the study was to investigate 5-year survival stratified by mechanical ventilation modality in chronic obstructive pulmonary disease (COPD) patients treated in the ICU.

MATERIALS AND METHODS

Prospective, observational study of COPD patients with acute respiratory failure admitted to 9 multidisciplinary ICUs in Sweden. Characteristics on admission, including illness severity scores and the first blood gas, and survival were analyzed stratified by ventilation modality (noninvasive [NIV] vs invasive mechanical ventilation).

RESULTS

Ninety-three patients, mean age of 70.6 (SD, 9.6) years, were included. Sixteen patients were intubated immediately, whereas 77 were started on NIV. Patients who were started on NIV had a lower median body mass index (BMI) (21.9 vs 27.0; P < .01) and were younger compared to those who were intubated immediately (median age, 70 vs 74.5 years; P < .05). There were no differences in the initial blood gas results between the groups. Long-term survival was greater in patients with NIV (P < .05, log rank). The effect of NIV on survival remained after including age, Acute Physiology and Chronic Health Evaluation II score, and BMI in a multivariate Cox regression model (NIV hazard ratio, 0.44; 95% confidence interval, 0.21-0.92). Fifteen patients with failed NIV were intubated and mechanically ventilated. Long-term survival in patients with failed NIV was not significantly different from patients who were intubated immediately.

CONCLUSION

The short-term survival benefit of NIV previously found in randomized controlled trials still applies after 5 years of observation.

Age, duration of mechanical ventilation, and outcomes of patients who are critically ill

BACKGROUND

Age and duration of mechanical ventilation (MV) are strongly associated with mortality and hospital discharge disposition.

METHODS

Electronic administrative records from a 425-bed community teaching hospital were obtained for 9,912 patients who were admitted to hospital ICUs between 2003 and 2008. Risk estimates of age and duration of MV for in-hospital mortality and discharge to home vs extended-care facilities (ECFs) also were obtained.

RESULTS

Of 9,912 patients, 37 were discharged to hospice care, and 668 were < 18 years of age. Of the remaining 9,207 patients, 4,238 received invasive MV. Mortality or hospital discharge to ECFs increased consistently for each decade of age > 65 years and as the duration of MV increased. Although only 11.7% of patients < 65 years age who received MV for 1 or 2 days died during hospitalization, the mortality rate increased to 72.1% for patients > 85 years of age who had received MV for > 7 days. For patients requiring MV for >or= 7 days, < 10% of the >or= 65 years of age and < 5% of patients >or= 85 years of age survived to be discharged home from the hospital. Multivariate logistic regression analyses showed that age > 65 years and duration of MV remained significantly associated with outcomes, even after adjustment for hospital discharge diagnoses (Charlson scores).

CONCLUSIONS

This study suggests that age and duration of MV are strongly associated with mortality and posthospital disposition. If confirmed, the simple combination of age and duration of MV provides prognostic information that could be used with trajectory of illness and in the context of patients' values to inform end-of-life discussions with patients or their surrogates during a trial of critical care.

[Variations in health-related quality of life in critical patients]

OBJECTIVE

To determine the changes in the health-related quality of life (hRQOL) six months after discharge from the ICU and the conditions associated to them.

DESIGN

A prospective cohort study.

SETTING

14 beds medical-surgical intensive care unit (ICU).

PATIENTS

A total of 247 patients admitted to our ICU for more than 24 hours with a follow-up of 6 months were study. Those admitted with acute coronary syndrome or for monitoring purposes were excluded.

INTERVENTION

A quality of life survey was conducted using the score developed by the PAEEC group (project of the epidemiological analysis of critical illness) to assess hRQOL before ICU admission and 6 months after discharge.

RESULTS

The hRQOL deteriorated, going from a median value of 3 to 6 (p < 0.001). The multivariate analysis showed less deterioration of hRQOL in patients with chronic health conditions registered on the APAChE-II score (regression coefficient [RC] = -1.4; 95% CI, -2.5 to -0.2; p < 0.02) and in those with a hRQOL > or = 10 points (RC = -4,4; 95% CI, -5.9 to -2.8; p < 0.001). There was more deterioration in polytraumatized patients (RC = 1.9; 95% CI, 0.6-3.3; p = 0.01) or with renal failure (RC = 3.9; 95% CI, 1.9-5.9; p < 0.001) or in those with a stay duration longer than 10 days (RC = 1.9; 95% CI, 0.6-3.2; p < 0.001).

CONCLUSIONS

Most patients experience deterioration of hRQOL. Patients with chronic diseases or with worst previous hRQOL who survive 6 months experience less deterioration of hRQOL than those who are polytraumatized or have renal failure or a longer ICU stay.

[Causes of death and risk factors for mortality in patients with severe chronic obstructive pulmonary disease]

OBJECTIVE

The objective of this study was to assess the causes of death and risk factors for mortality in a cohort of patients with severe chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

We studied 203 patients with severe COPD (forced expiratory volume in 1 second [FEV(1)] <50%), who were attended in our respiratory department day hospital (2001-2006). Clinical variables were recorded on inclusion, and clinical course and causes of death were retrospectively reviewed.

RESULTS

The mean (SD) age of patients was 69 (8) years and the mean FEV(1) was 30.8% (8.2%). One-hundred and nine patients died (53.7%); death was attributed to respiratory causes in 72 (80.9%), with COPD exacerbation being the most frequent specific cause within this category (48.3%). During follow-up, 18.7% required admission to the intensive care unit (ICU). Survival at 1, 3, and 5 years was 80%, 53%, and 26%, respectively. The multivariate analysis showed that mortality was associated with age, stage IV classification according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), cor pulmonale, and hospital admission during the year prior to inclusion. Need for admission to the ICU during follow-up was a factor independently associated with higher mortality.

CONCLUSIONS

Mortality in patients with severe COPD was high and exacerbation of the disease was one of the most frequent causes of death. Age, GOLD stage, cor pulmonale, prior admission to hospital, and need for admission to the ICU during follow-up were independent predictors of mortality.

Bacteriology in acute exacerbation of chronic obstructive pulmonary disease in patients admitted to hospital

We investigated the bacterial flora and antimicrobial sensitivity in sputum from patients admitted to hospital with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in order to recommend the best empirical treatment for these patients. The survey was a retrospective study of all patients admitted to Hvidovre hospital with the diagnosis AECOPD during 2004. A total of 118 patients were included. Microscopy, culture and sensitivity testing investigated their sputums. Clinical and paraclinical features were collected from the patients' files. Among the 118 patients, 59 (50%) had a positive sputum culture. The group with positive cultures had a higher blood neutrophil count (p=0.03). There were no other clinical differences between the groups with and without positive sputum culture. The majority of patients with positive sputum cultures were infected with bacteria other than S. pneumonia, mostly H. influenzae and Moraxella catarrhalis. Patients with low FEV(1)<1.0 litre were more likely to be infected with Pseudomonas aeruginosa (p=0.03). The sensitivity patterns of the bacteria showed that the majority were resistant to penicillin. If antibiotics are initiated empirically for AECOPD we recommend either cefuroxime for intravenous treatment or amoxicillin-clavulanate for oral treatment.

[Changes in health-related quality of life after ICU according to diagnostic category. Comparison of two measurement instruments]

OBJECTIVE

Assessment of health related quality of life (HRQOL) before and 12 months after discharge from a mixed intensive care unit (ICU) according to diagnostic category and the relationship between both instruments.

DESIGN

Prospective observational study.

SETTING

The combined medical/surgical ICU in a secondary university hospital with 450 beds.

PATIENTS

Patients admitted to the ICU over an 18-month period.

MAIN VARIABLES

Variables on demography, diagnosis on admission, severity of acute illness score (APACHE II), length of stay, procedures, mortality and the HRQOL were collected using the Short Form SF-36 and EQ-5D questionnaires. Health status prior to admission was evaluated retrospectively.

RESULTS

Both questionnaires were answered by 189 patients. A significant deterioration in the quality of life was observed 12 months after ICU discharge. Head injury and neurological patients had worse HRQOL one year after discharge. Multiple trauma patients presented severe physical limitations and pain, but without significant differences on the emotional level. The EQ Visual Analogue Scale and the EQ Index score showed clinically relevant differences in these three groups. Respiratory patients are the only group in whom the HRQOL improved. Comparison between both measurement instruments showed a strong correlation on the physical functioning level, but a weaker correlation on the emotional functioning one.

CONCLUSIONS

HRQOL assessment of ICU patients must be done according to a diagnostic category. Both instruments (the EQ-5D and SF-36) are capable of detecting changes in HRQOL. Despite differences in structure and content, both measure similar aspects of quality of life.

Health-related quality of life as a prognostic factor of survival in critically ill patients

OBJECTIVE

To evaluate whether health-related quality of life prior to admission into an intensive care unit (ICU) is a prognostic factor of hospital and 1 year mortality.

DESIGN

Prospective cohort study.

SETTING

Fourteen-bed medical-surgical ICU.

PATIENTS

A total of 377 patients admitted to the ICU for more than 24 h with 1-year follow-up after discharge from the hospital.

INTERVENTION

A health-related quality of life (HRQoL) survey was conducted, using the questionnaire developed by the "Project for the Epidemiological Analysis of Critical Care Patients", to assess patient's quality of life 1 month before ICU hospitalization.

RESULTS

Hospital mortality was independently associated with severity assessed by APACHE II, odds ratio (OR) 1.14 [95% confidence interval (CI) 1.08-1.2; P < 0.001], high workload assessed by Nine Equivalents of Nursing Manpower Score > 30 OR 3.6 (95% CI 1.4-9.0; P = 0.006), hospital length of stay prior to ICU admission of more than 2 days OR 2.6 (95% CI 1.3-5.4; P = 0.008), and bad quality of life prior to ICU admission assessed by a HRQoL score > or = 8 points OR 2.2 (95% CI 1.03-4.5; P = 0.04). Patients who scored > or =8 on the HRQoL survey presented a risk of demise 12 months after discharge almost twofold that of those who had good previous HRQoL (0-2 points), Hazard Ratio 1.9 (95% CI 1.3-2.8; P = 0.001).

CONCLUSION

Bad quality of life is associated with hospital mortality and survival 12 months after hospital discharge.

What is the Health-Related Quality of Life of Patients with Chronic Obstructive Pulmonary Disease after Invasive Ventilation?

Patients with chronic obstructive pulmonary disease (COPD) make up a large proportion of hospital in-patients; they account for 12% of general medical admissions. Decisions to ventilate a patient with an exacerbation of COPD are partly based on the physician's prediction of future quality of life. In this systematic review, Pubmed, Medline, Embase, Biomed Central and the Cochrane library were electronically searched for observational and interventional studies of health-related quality of life (HRQoL) in patients with COPD, who were invasively ventilated, survived to hospital discharge and were followed up for HROoL measurements to be made. The results of the nine studies included showed that HROoL does deteriorate after invasive ventilation in intensive care, but is similar to that of patients who are on long-term oxygen therapy (LTOT) or in pulmonary rehabilitation programmes. Despite the high long-term mortality of patients with COPD, the HROoL in patients who do survive is reasonable. Identifying these patients remains a significant challenge.

Characteristics and long-term outcome of acute exacerbations in chronic obstructive pulmonary disease: an analysis of cases in the Swedish Intensive Care Registry during 2002-2006

BACKGROUND

Chronic obstructive pulmonary disease (COPD) represents a major and growing health problem. The purpose of this work was to examine characteristics, resource use and long-term survival in patients with an acute exacerbation of COPD that were admitted to Swedish intensive care units (ICU).

METHODS

Patient characteristics at admission, length of stay (LOS), resource use and outcome were collected for admissions due to COPD during 2002-2006 in the database of the Swedish Intensive Care Registry. Vital status was secured for 99.6% of the patients. Kaplan-Meier survival estimates were computed for index admissions only.

RESULTS

We identified 1009 patients with 1199 admissions due to COPD (1.3% of all intensive care admissions). The mean (SD) age was 70.2 (9.1) years and the proportion of women were 61.5%. Mean (SD) Acute Physiology and Chronic Health Evaluation II probability of hospital death was 0.31 (0.19). Median LOS was 28 (interquartile range 52) h. The number of readmissions was 190 during the 5-year study. Older patients had fewer readmissions (OR 0.96, 95% CI: 0.95-0.98/year increase in age). ICU mortality was 7.3% (87 of 1199 admissions) and 30-day mortality was 26.0% (262 of 1009 index admissions). Median survival was 14.5 months and 31% of patients survived 3 years after the index admission.

CONCLUSIONS

Short (30 days) and long-term survival is poor in acute COPD. Readmissions are frequent reflecting the severity of this chronic illness. Patients are less likely to be readmitted with increasing age which may be due to withholding of further intensive care.

Quality of life before surgical ICU admission

BACKGROUND

Examining the quality of life (QOL) of patients before ICU admission will allow outcome variables to be compared and analyzed in relation to it. The objective of this study was to analyze QOL of patients before admission to a surgical ICU and to study its relationship to outcome and to the baseline characteristics of the patients.

METHODS

All adult patients consecutively admitted to the surgical ICU between November 2004 and April 2005, who underwent non-cardiac surgery, were enrolled in this observational and prospective study. The following patient characteristics were recorded: age, gender, body mass index, ASA physical status, type and magnitude of surgical procedure, length of stay (LOS), in ICU and in hospital, mortality, Simplified Acute Physiology Score II (SAPS), history of co-morbidities and quality of life survey score (QOLSS). The relationships between QOLSS and ICU variables and outcome were evaluated. The relationship between the total QOLSS and each variable or outcome was assessed by multiple linear regression.

RESULTS

One hundred eighty seven patients completed the study. The preadmission QOLSS of the patients studied was 4.43 +/- 4.90; 28% of patients had a normal quality of life (0 points), 38% had between 1 and 5 points (considered mild deterioration), 21% had between 6 and 10 points (moderate deterioration), 10% had between 11 and 15 points (considered major deterioration) and 3% had more than 15 points (severe limitation of quality of life). A worse preadmission QOLSS was associated with higher SAPS II scores, with older patients (age> 65 years) and with ASA physical status (ASA III/IV). Total QOLSS was significantly worse in elderly patients and in patients with co-morbidities and in patients more severely ill at ICU admission. Patients who died in the ICU and in hospital had worse QOLSS scores compared to those who survived. However, no statistical differences in QOLSS were found in relation to longer ICU stays (ICU LOS).

CONCLUSION

Preadmission QOL correlates with age and severity of illness. Patients with co-morbidities and those who died during ICU or hospital stay had worse QOLSS scores.

The clinical management in extremely severe COPD

Chronic obstructive pulmonary disease (COPD) affects 6% of the general population and is the fourth-leading cause of death in the United States with severe and very severe disease accounting for 15% and 3% of physician diagnoses of COPD. Guidelines make few recommendations regarding providing the provision of care for the most severe stages of disease, namely Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure. The effectiveness of inhaled drug therapy in very severe patients has not been assessed yet. Health care systems in many countries include public funding of long-term oxygen therapy for eligible candidates. Currently, there is little evidence for the use of mechanical ventilatory support in the routine management of hypercapnic patients. Pulmonary rehabilitation should be considered as a significant component of therapy, even in the most severe patients. Although Lung Volume Reduction Surgery has been shown to improve mortality, exercise capacity, and quality of life in selected patients, this modality is associated with significant morbidity and an early mortality rate in the most severe patients. Despite significant progress over the past 25 years, both short- and long-term outcomes remain significantly inferior for lung transplantation relative to other "solid" organ recipients. Nutritional assessment and management is an important therapeutic option in patients with chronic respiratory diseases. Morphine may significantly reduce dyspnoea and does not significantly accelerate death. No consistent improvement in dyspnoea over placebo has been shown with anxiolytics. Supplemental oxygen during exercise reduces exertional breathlessness and improves exercise tolerance of the hypoxaemic patient. Non-invasive ventilation has been used as a palliative treatment to reduce dyspnoea. Hypoxaemic COPD patients, on long-term oxygen therapy, may show reduced health-related quality of life, cognitive function, and depression. Only a small proportion of patients with severe COPD discuss end-of-life issues with their physicians.

Quality of life after stay in surgical intensive care unit

BACKGROUND

In addition to mortality, Health Related Quality of Life (HRQOL) has increasingly been claimed as an important outcome variable. The aim of this study was to assess HRQOL and independence in activities of daily living (ADL) six months after discharge from an Intensive Care Unit (ICU), and to study its determinants.

METHODS

All post-operative adult patients admitted to a surgical ICU between October 2004 and July 2005, were eligible for the study. The following variables were recorded on admission: age, gender, American Society of Anesthesiologists physical status (ASA-PS), type and magnitude of surgical procedure, ICU and hospital length of stay (LOS), mortality and Simplified Acute Physiology Score II (SAPS II). Six months after discharge, a Short Form-36 questionnaire (SF-36) and a questionnaire to assess dependency in ADL were sent to all survivors. Descriptive statistics was used to summarize data. Patient groups were compared using non-parametric tests. A logistic regression analysis was performed to identify covariate effects of each variable on dependency in personal and instrumental ADL, and for the change-in-health question of SF-36.

RESULTS

Out of 333 hospital survivors, 226 completed the questionnaires. Fifty-nine percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients with greater co-morbidities (ASA-PS III/IV), had lower SF-36 scores in all domains and were more frequently dependent in instrumental and personal ADL. Logistic regression showed that SAPS II was associated with changes in general level of health (OR 1.06, 95%CI, 1.01-1.11, p = 0,016). Six months after ICU discharge, 60% and 34% of patients, respectively, were dependent in at least one activity in instrumental ADL (ADLI) and personal ADL (ADLP). ASA-PS (OR 3.00, 95%CI 1.31-6.87, p = 0.009) and age (OR 2.36, 95%CI, 1.04-5.34, p = 0.04) were associated with dependency in ADLI. For ADLP, only ASA-PS (OR 4.58, 95%CI, 1.68-12.46, p = 0.003) was associated with higher dependency.

CONCLUSION

ASA-PS, age, type of surgery, ICU LOS and SAPS II could be seen as determinants of HRQOL.

Recently published papers: pneumonia, hypothermia and the elderly

Pneumonia (hospital-acquired and community-acquired) is commonly encountered in intensive care. Several papers recently published on this subject have shed more light on different aspects of this important topic. Hypothermia has been shown to improve post-arrest outcome, but how often do we use it? And finally, several papers have recently appeared in the journals related to the admission of the elderly to the critical care area and their outcome.