Hyperglycaemia as a predictor of outcome during non-invasive ventilation in decompensated COPD

When to intubate in acute hypoxaemic respiratory failure? Options and opportunities for evidence-informed decision making in the intensive care unit

The optimal timing of intubation in acute hypoxaemic respiratory failure is uncertain and became a point of controversy during the COVID-19 pandemic. Invasive mechanical ventilation is a potentially life-saving intervention but carries substantial risks, including injury to the lungs and diaphragm, pneumonia, intensive care unit-acquired muscle weakness, and haemodynamic impairment. In deciding when to intubate, clinicians must balance premature exposure to the risks of ventilation with the potential harms of unassisted breathing, including disease progression and worsening multiorgan failure. Currently, the optimal timing of intubation is unclear. In this Personal View, we examine a range of parameters that could serve as triggers to initiate invasive mechanical ventilation. The utility of a parameter (eg, the ratio of arterial oxygen tension to fraction of inspired oxygen) to predict the likelihood of a patient undergoing intubation does not necessarily mean that basing the timing of intubation on that parameter will improve therapeutic outcomes. We examine options for clinical investigation to make progress on establishing the optimal timing of intubation.

Mechanisms Linking COPD to Type 1 and 2 Diabetes Mellitus: Is There a Relationship between Diabetes and COPD?

Chronic obstructive pulmonary disease (COPD) patients frequently suffer from multiple comorbidities, resulting in poor outcomes for these patients. Diabetes is observed at a higher frequency in COPD patients than in the general population. Both type 1 and 2 diabetes mellitus are associated with pulmonary complications, and similar therapeutic strategies are proposed to treat these conditions. Epidemiological studies and disease models have increased our knowledge of these clinical associations. Several recent genome-wide association studies have identified positive genetic correlations between lung function and obesity, possibly due to alterations in genes linked to cell proliferation; embryo, skeletal, and tissue development; and regulation of gene expression. These studies suggest that genetic predisposition, in addition to weight gain, can influence lung function. Cigarette smoke exposure can also influence the differential methylation of CpG sites in genes linked to diabetes and COPD, and smoke-related single nucleotide polymorphisms are associated with resting heart rate and coronary artery disease. Despite the vast literature on clinical disease association, little direct mechanistic evidence is currently available demonstrating that either disease influences the progression of the other, but common pharmacological approaches could slow the progression of these diseases. Here, we review the clinical and scientific literature to discuss whether mechanisms beyond preexisting conditions, lifestyle, and weight gain contribute to the development of COPD associated with diabetes. Specifically, we outline environmental and genetic confounders linked with these diseases.

Influencing factors of noninvasive positive pressure ventilation in the treatment of respiratory failure: a 10-year study in one single center

Background

The utilization of noninvasive positive pressure ventilation (NPPV) is becoming more and more common, especially in patients with acute or chronic respiratory failure. The purpose of our study is to analyze the factors that influence the efficacy of NPPV in the treatment of respiratory failure caused by a variety of etiology.

Methods

From May 2011 to April 2020, patients treated with NPPV during hospitalization in the First Affiliated Hospital of Soochow University were enrolled. According to the clinical outcome of NPPV treatment and whether converted to invasive mechanical ventilation, patients were divided into the success group and the failure group. The clinical data and the characteristics of NPPV application were compared between the two groups.

Results

A total of 3312 patients were enrolled, including 2025 patients in the success group and 1287 patients in the failure group. Univariate analysis suggested that there were no statistical differences in patients' age, gender, use of analgesia and/or sedation, complicated with barotrauma, inspiratory positive airway pressure and expiratory positive airway pressure between the success and failure groups (P > 0.05). However, there were statistically significant differences in serum albumin levels, Ca²⁺ concentration, blood glucose levels, duration of NPPV treatment and length of hospital stay between the success and failure groups (P < 0.05). Multivariate logistic regression analysis indicated that serum albumin levels and duration of NPPV treatment had statistical significance on the therapeutic effect of NPPV (P < 0.05).

Conclusion

Serum albumin levels and duration of NPPV treatment were independent risk factors for the efficacy of NPPV treatment in respiratory failure.

Characteristics of prolonged noninvasive ventilation in emergency departments and impact upon effectiveness. Analysis of the VNICat registry

OBJECTIVE

To analyze the characteristics and variables associated with prolonged noninvasive ventilation performed completely in Emergency Departments (NIV-ED) and its influence upon effectiveness.

DESIGN

A prospective, multicenter, observational multipurpose cohort study was carried out.

SETTING

VNICAT Registry.

SUBJECTS

Patients in which NIV-ED was performed in 11 Catalan hospitals in the months of February or March 2015.

INTERVENTION

No.

VARIABLES

The study variable was NIV-ED, which as a function of time was defined as prolonged or not prolonged. The efficacy variable was the success of the technique in terms of patient improvement.

RESULTS

A total of 125 patients were included, with a median NIV-ED duration of 12 h, which was the cut-off point for the comparator groups. In 60 cases (48%) NIV-ED was not prolonged (<12 h), while in 65 cases (52%) ventilation was prolonged (≥12 h). Non-prolonged NIV-ED was associated to the indication of acute heart failure and prolonged ventilation to the presence of diabetes. There were no differences between non-prolonged and prolonged NIV-ED in terms of efficacy, and the success rate in terms of improvement was 68.3% and 76.9%, respectively, with an adjusted odds ratio of 1.49 (95%CI 0.61-3.60).

CONCLUSIONS

Prolonged NIV-ED is a frequent situation, but few variables associated to it have been studied. The presence of prolonged ventilation did not influence the success rate of NIV.

Risk Factors Associated with Late Failure of Noninvasive Ventilation in Patients with Chronic Obstructive Pulmonary Disease

Background

Risk factors for noninvasive ventilation (NIV) failure after initial success are not fully clear in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

Methods

Patients who received NIV beyond 48 h due to acute exacerbation of COPD were enrolled. However, we excluded those whose pH was higher than 7.35 or PaCO2 was less than 45 mmHg which was measured before NIV. Late failure of NIV was defined as patients required intubation or died during NIV after initial success.

Results

We enrolled 291 patients in this study. Of them, 48 (16%) patients experienced late NIV failure (45 received intubation and 3 died during NIV). The median time from initiation of NIV to intubation was 4.8 days (IQR: 3.4-8.1). Compared with the data collected at initiation of NIV, the heart rate, respiratory rate, pH, and PaCO2 significantly improved after 1-2 h of NIV both in the NIV success and late failure of NIV groups. Nosocomial pneumonia (odds ratio (OR) = 75, 95% confidence interval (CI): 11-537), heart rate at initiation of NIV (1.04, 1.01-1.06 beat per min), and pH at 1-2 h of NIV (2.06, 1.41-3.00 per decrease of 0.05 from 7.35) were independent risk factors for late failure of NIV. In addition, the Glasgow coma scale (OR = 0.50, 95% CI: 0.34-0.73 per one unit increase) and PaO2/FiO2 (0.992, 0.986-0.998 per one unit increase) were independent protective factors for late failure of NIV. In addition, patients with late failure of NIV had longer ICU stay (median 9.5 vs. 6.6 days) and higher hospital mortality (92% vs. 3%) compared with those with NIV success.

Conclusions

Nosocomial pneumonia; heart rate at initiation of NIV; and consciousness, acidosis, and oxygenation at 1-2 h of NIV were associated with late failure of NIV in patients with COPD exacerbation. And, late failure of NIV was associated with increased hospital mortality.

Impact of diabetes mellitus on the risk of severe exacerbation in patients with chronic obstructive pulmonary disease

INTRODUCTION

Suffering type 2 diabetes mellitus (T2DM) appears to promote the occurrence of respiratory infections. However, studies to evaluate the risk of hospital admission due to exacerbations in patients with chronic obstructive pulmonary disease (COPD) and concomitant T2DM are scarce.

MATERIALS AND METHODS

Prospective, observational study with a maximum follow-up of 18 months. Information on lung function, body mass index, degree of dyspnea, number of exacerbations, comorbidities and pneumococcal vaccination was obtained. Patients were classified into the categories COPD with (COPD/+T2DM) and without T2DM (COPD/-T2DM).

RESULTS

A total of 121 patients with COPD were enrolled. Forty-seven (38%) of the study participants were diabetic. The presence of T2DM increased the risk of hospital admission due to COPD exacerbation (OR 2.66; P = 0.031), but no significant difference in the total number of exacerbations was detected.

CONCLUSIONS

The risk of hospital admission in the course of exacerbation seems to be higher in COPD/+T2DM patients than in COPD/-T2DM subjects.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Characteristics of prolonged noninvasive ventilation in emergency departments and impact upon effectiveness. Analysis of the VNICat registry

OBJECTIVE

To analyze the characteristics and variables associated with prolonged noninvasive ventilation performed completely in Emergency Departments (NIV-ED) and its influence upon effectiveness.

DESIGN

A prospective, multicenter, observational multipurpose cohort study was carried out.

SETTING

VNICat Registry.

SUBJECTS

Patients in which NIV-ED was performed in 11 Catalan hospitals in the months of February or March 2015.

INTERVENTION

No.

VARIABLES

The study variable was NIV-ED, which as a function of time was defined as prolonged or not prolonged. The efficacy variable was the success of the technique in terms of patient improvement.

RESULTS

A total of 125 patients were included, with a median NIV-ED duration of 12hours, which was the cut-off point for the comparator groups. In 60 cases (48%) NIV-ED was not prolonged (<12hours), while in 65 cases (52%) ventilation was prolonged (≥12hours). Non-prolonged NIV-ED was associated to the indication of acute heart failure and prolonged ventilation to the presence of diabetes. There were no differences between non-prolonged and prolonged NIV-ED in terms of efficacy, and the success rate in terms of improvement was 68.3% and 76.9%, respectively, with an adjusted odds ratio of 1.49 (95%CI 0.61-3.60).

CONCLUSIONS

Prolonged NIV-ED is a frequent situation, but few variables associated to it have been studied. The presence of prolonged ventilation did not influence the success rate of NIV.

Diabetic lung disease: fact or fiction?

Diabetes mellitus is a chronic, progressive, incompletely understood metabolic disorder whose prevalence has been increasing steadily worldwide. Even though little attention has been paid to lung disorders in the context of diabetes, its prevalence has recently been challenged by newer studies of disease development. In this review, we summarize and discuss the role of diabetes mellitus involved in the progression of pulmonary diseases, with the main focus on pulmonary fibrosis, which represents a chronic and progressive disease with high mortality and limited therapeutic options.

Time to NIV and mortality in AECOPD hospital admissions: an observational study into real world insights from National COPD Audits

Background

Randomised control trial (RCT)-derived survival figures for acute exacerbation of chronic obstructive pulmonary disease admissions managed with non-invasive ventilation (NIV) have not been replicated in UK clinical audits. Subsequent guidelines have emphasised the need for timely NIV application.

Methods

Data from the 2008 and 2014 national chronic obstructive pulmonary disease audits was used to analyse the association between time to NIV and mortality.

Results

1032 patients received NIV in 2008, and 1612 in 2014. Overall mortality rates reduced between the audits from 24.9% in 2008 to 16.8% in 2014 but time to NIV lengthened. In 2014, 20.9% of patients received NIV within 60 min versus 24.9% in 2008 (p=0.001). The proportion of patients receiving NIV between 3 and 24 hours increased from 31.3% in 2008 to 39% in 2014 (p=0.001). Patients admitted with hypercapnic acidotic respiratory failure who received NIV within 3 hours had lower in-patient mortality than those who received NIV between 3 and 24 hours, 15.9% versus 18.4%, but this did not reach statistical significance (p=0.425), but acidotic patients receiving NIV >24 hours after admission had significantly higher mortality (28.9%, p=0.002). A second cohort admitted with hypercapnia but normal range pH, who developed later acidosis, had higher mortality (24.6%), compared with those acidotic on admission (18% p≤0.001) and an extremely high mortality when NIV was given >24 hours after admission (42.6%).

Conclusion

Survival rates for those treated with NIV has improved between the two audits but remains lower than reported in RCTs. Patients who developed acidosis after admission and received NIV later in the hospital stay have even higher mortality and deserve further study and clinical attention.

Pathobiological mechanisms underlying metabolic syndrome (MetS) in chronic obstructive pulmonary disease (COPD): clinical significance and therapeutic strategies

Chronic obstructive pulmonary disease (COPD) is a major incurable global health burden and is currently the 4th largest cause of death in the world. Importantly, much of the disease burden and health care utilisation in COPD is associated with the management of its comorbidities (e.g. skeletal muscle wasting, ischemic heart disease, cognitive dysfunction) and infective viral and bacterial acute exacerbations (AECOPD). Current pharmacological treatments for COPD are relatively ineffective and the development of effective therapies has been severely hampered by the lack of understanding of the mechanisms and mediators underlying COPD. Since comorbidities have a tremendous impact on the prognosis and severity of COPD, the 2015 American Thoracic Society/European Respiratory Society (ATS/ERS) Research Statement on COPD urgently called for studies to elucidate the pathobiological mechanisms linking COPD to its comorbidities. It is now emerging that up to 50% of COPD patients have metabolic syndrome (MetS) as a comorbidity. It is currently not clear whether metabolic syndrome is an independent co-existing condition or a direct consequence of the progressive lung pathology in COPD patients. As MetS has important clinical implications on COPD outcomes, identification of disease mechanisms linking COPD to MetS is the key to effective therapy. In this comprehensive review, we discuss the potential mechanisms linking MetS to COPD and hence plausible therapeutic strategies to treat this debilitating comorbidity of COPD.

New aspects in the management of pneumonia

Despite improvements in the management of community-acquired pneumonia (CAP), morbidity and mortality are still high, especially in patients with more severe disease. Early and appropriate antibiotics remain the cornerstone in the treatment of CAP. However, two aspects seem to contribute to a worse outcome: an uncontrolled inflammatory reaction and an inadequate immune response. Adjuvant treatments, such as corticosteroids and intravenous immunoglobulins, have been proposed to counterbalance these effects. The use of corticosteroids in patients with severe CAP and a strong inflammatory reaction can reduce the time to clinical stability, the risk of treatment failure, and the risk of progression to acute respiratory distress syndrome. The administration of intravenous immunoglobulins seems to reinforce the immune response to the infection in particular in patients with inadequate levels of antibodies and when an enriched IgM preparation has been used; however, more studies are needed to determinate their impact on outcome and to define the population that will receive more benefit.

Noninvasive and invasive positive pressure ventilation for acute respiratory failure in critically ill patients: a comparative cohort study

BACKGROUND

Noninvasive positive pressure ventilation (NPPV) for acute respiratory failure in the intensive care unit (ICU) is associated with a marked reduction in intubation rate, complications, hospital length of stay and mortality. Multiple studies have indicated that patients failing NPPV have worse outcomes compared with patients with successful NPPV treatment; however limited data is available on risks associated with NPPV failure resulting in (delayed) intubation and outcomes compared with initial intubation. The purpose of this study is to assess rates and predictors of NPPV failure and to compare hospital outcomes of patients with NPPV failure with those patients primarily intubated without a prior NPPV trial.

METHODS

A retrospective observational study using data from patients with acute respiratory failure admitted to the ICU in the period 2013-2014. All patients treated with NPPV were evaluated. A sample of patients who were primarily intubated was randomly selected to serve as controls for the group of patients who failed NPPV.

RESULTS

NPPV failure was recorded in 30.8% of noninvasively ventilated patients and was associated with longer ICU stay [OR, 1.16, 95% confidence interval (95% CI): 1.04-1.30] and lower survival rates (OR, 0.10, 95% CI: 0.02-0.59) compared with NPPV success. Multivariate analysis showed presence of severe sepsis at study entry, higher Simplified Acute Physiology II Score (SAPS-II) score, lower ratio of arterial oxygen tension to fraction of inspired oxygen (PF-ratio) and lower plasma glucose were predictors for NPPV failure. After controlling for potential confounders, patients with NPPV failure did not show any difference in hospital outcomes compared with patients who were primarily intubated.

CONCLUSIONS

Patients with acute respiratory failure and NPPV failure have worse outcomes compared with NPPV success patients, however not worse than initially intubated patients. An initial trial of NPPV therefore may be suitable in selected cases of patients with acute respiratory failure, since NPPV could be potentially beneficial and does not seem to result in worse outcome in case of NPPV failure compared to primary intubation. A prospective trial is warranted to confirm findings.

Factors associated with the incidence of serious adverse events in patients admitted with COPD acute exacerbation

BACKGROUND

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause of hospitalization. Patient outcome and prognosis following AECOPD are variable. The aim of this study is to identify the factors associated with the incidence of serious adverse events (SAE), defined as need for ICU admission, noninvasive ventilation, death during hospitalization or early readmission, in those patients admitted with AECOPD.

METHODS

We conducted a retrospective study by reviewing the medical records of all patients admitted with AECOPD in the University Hospital Complex of Santiago de Compostela in 2007 and 2008. To identify variables independently associated with SAE incidence, we conducted a logistic regression including those variables which proved to be significant in the univariate analysis.

RESULTS

757 patients were assessed (mean age 74.8 years, SD 11.26), 77.2 % male, and 186 (24.6 %) of the patients assessed experienced an SAE. Factors associated with SAE in multivariate analysis were anticholinergic therapy (OR 3.19; CI 95 %: 1.16; 8.82), oxygen therapy at home (OR 3.72; CI 95 %: 1.62; 8.57), oxygen saturation at admission (OR 0.93; CI 95 %: 0.88; 0.99) and serum albumin (OR 0.26; CI 95 %: 0.1; 0.66).

CONCLUSION

Oxygen therapy at home, anticholinergic therapy as baseline treatment, lower oxygen saturation at admission and lower serum albumin level seem to be associated with higher incidence of SAE in patients with AECOPD.

Metformin in severe exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial

Background

Severe exacerbations of COPD are commonly associated with hyperglycaemia, which predicts adverse outcomes. Metformin is a well-established anti-hyperglycaemic agent in diabetes mellitus, possibly augmented with anti-inflammatory effects, but its effects in COPD are unknown. We investigated accelerated metformin therapy in severe COPD exacerbations, primarily to confirm or refute an anti-hyperglycaemic effect, and secondarily to explore its effects on inflammation and clinical outcome.

Methods

This was a multicentre, randomised, double-blind, placebo-controlled trial testing accelerated metformin therapy in non-diabetic patients, aged ≥35 years, hospitalised for COPD exacerbations. Participants were assigned in a 2:1 ratio to 1 month of metformin therapy, escalated rapidly to 2 g/day, or matched placebo. The primary end point was mean in-hospital blood glucose concentration. Secondary end points included the concentrations of fructosamine and C reactive protein (CRP), and scores on the COPD Assessment Test and Exacerbations of Chronic Pulmonary Disease Tool.

Results

52 participants (mean (±SD) age 67±9 years) were randomised (34 to metformin, 18 to placebo). All were included in the primary end point analysis. The mean blood glucose concentrations in the metformin and placebo groups were 7.1±0.9 and 8.0±3.3 mmol/L, respectively (difference −0.9 mmol/L, 95% CI −2.1 to +0.3; p=0.273). No significant between-group differences were observed on any of the secondary end points. Adverse reactions, particularly gastrointestinal effects, were more common in metformin-treated participants.

Conclusion

Metformin did not ameliorate elevations in blood glucose concentration among non-diabetic patients admitted to hospital for COPD exacerbations, and had no detectable effect on CRP or clinical outcomes.

Trial registration number

ISRCTN66148745 and NCT01247870.

Effects of Different Blood Glucose Levels on Critically Ill Patients in an Intensive Care Unit

AIMS

We explore the infection incidence and possible prognostic outcome relevance for patients with different blood glucose levels in an intensive care unit (ICU).

METHODS

A total of 98 cases were enrolled and divided into three groups based on average fasting blood glucose levels (group A: ≤ 6.1 mmol/l; group B: 6.1-10 mmol/l; group C: ≥ 10 mmol/l).

RESULTS

There were no statistical differences in the time to ICU admission, the indwelling durations of gastric tubes, urinary or deep vein catheters, tracheal intubations and tracheotomies, or the length of ventilator use (all p > 0.05). No evident difference in the multiple organ dysfunction syndrome rate was found between the three groups (p = 0.226). The infection and mortality rates between the groups showed significant differences (all p < 0.05). Furthermore, the difference of respiratory system infections was statistically significant among the three groups (p = 0.008), yet no such statistical difference was observed among groups regarding nonrespiratory system infections (p = 0.227).

CONCLUSIONS

Critically ill patients with a high blood glucose level were positively correlated with a relatively high APACHE II score and more serious degree of disease, as well as a higher incidence of respiratory infection during their ICU stay than those with lower blood glucose levels (<10 mmol/l).

Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit

Studies report high in-hospital and post-discharge mortality of chronic obstructive pulmonary disease (COPD) exacerbations varying depending upon patient characteristics, hospital resources and treatment standards. This study aimed to investigate the patient, resource and organisational factors associated with in-hospital and 90-day post-discharge mortality and readmission of COPD exacerbations within the European COPD Audit. The audit collected data of COPD exacerbation admissions from 13 European countries.On admission, only 49.7% of COPD patients had spirometry results available and only 81.6% had blood gases taken. Using logistic regression analysis, the risk associated with in-hospital and post-discharge mortality was higher age, presence of acidotic respiratory failure, subsequent need for ventilatory support and presence of comorbidity. In addition, the 90-day risk of COPD readmission was associated with previous admissions. Only the number of respiratory specialists per 1000 beds, a variable related to hospital resources, decreased the risk of post-discharge mortality.The European COPD Audit identifies risk factors associated with in-hospital and post-discharge mortality and COPD readmission. Addressing the deficiencies in acute COPD care such as making spirometry available and measuring blood gases and providing noninvasive ventilation more regularly would provide opportunities to improve COPD outcomes.

Early failure of noninvasive ventilation in chronic obstructive pulmonary disease with acute hypercapnic respiratory failure

Noninvasive ventilation (NIV) in the management of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure is considered a first-line therapy. However, patients who fail NIV and then require invasive mechanical ventilation have been found to have higher mortality than patients initially treated with invasive mechanical ventilation. We tried to find parameters associated with early NIV failure (need for intubation or death <24 h of starting NIV) in patients presenting to the ED with acute exacerbation of COPD. A retrospective analysis was conducted of the medical records of 218 patients with acute exacerbation of COPD visiting Asan Medical Center and managed with NIV during their stay in the ED from January 2007 to December 2013. NIV was successful in 200 (91.7%) and 18 (8.3%) had early NIV failure. Of the variables obtained before NIV treatment, heart rate (≥120/min: OR 2.5, 95% CI 1.2-7.0) and pH (7.25-7.29: OR 2.1, 95% CI 1.0-8.8; <7.25: OR 11.7, 95% CI 3.5-38.6) were significant factors associated with early NIV failure. Of the variables obtained after 1 h of NIV treatment, heart rate (≥120/min: OR 7.5, 95% CI 2.3-24.3) and pH (7.25-7.29: OR 4.7, 95% CI 1.5-15.1; <7.25: OR 20.9, 95% CI 5.4-61.2) were still significant. The presence of tachycardia and severe acidosis before NIV treatment and persistence of tachycardia and severe acidosis after 1 h of NIV treatment were associated with early NIV failure.

Nutritional Risk Screening 2002 as a Predictor of Outcome During General Ward-Based Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease with Respiratory Failure

BACKGROUND Noninvasive ventilation (NIV) may reduce the need for intubation and mortality associated with chronic obstructive pulmonary disease (COPD) with type II respiratory failure. Early and simple predictors of NIV outcome could improve clinical management. This study aimed to assess whether nutritional risk screening 2002 (NRS2002) is a useful outcome predictor in COPD patients with type II respiratory failure treated by noninvasive positive pressure ventilation (NIPPV). MATERIAL AND METHODS This prospective observational study enrolled COPD patients with type II respiratory failure who accepted NIPPV. Patients were submitted to NRS2002 evaluation upon admission. Biochemical tests were performed the next day and blood gas analysis was carried out prior to NIPPV treatment and 4 hours thereafter. Patients were divided into NRS2002 score ≥3 and NRS2002 score <3 groups and NIV failure rates were compared between both groups. RESULTS Of the 233 patients, 71 (30.5%) were not successfully treated by NIPPV. The failure rate was significantly higher in the NRS2002 score ≥3 group (35.23%) in comparison with patients with NRS2002 score <3 (15.79%) (p<0.05). Multivariate analysis indicated that PaCO2 (OR 1.25, 95%CI 1.172-1.671, p<0.05) prior to NIPPV treatment and NRS2002 score ≥3 (OR 1.76, 95%CI 1.303-2.374, p<0.05) were independent predictive factors for NIPPV treatment failure. CONCLUSIONS NRS2002 score ≥3 and PaCO2 values at admission may predict unsuccessful NIPPV treatment of COPD patients with type II respiratory failure and help to adjust therapeutic strategies. NRS2002 is a noninvasive and simple method for predicting NIPPV treatment outcome.

The association between glucose levels and hospital outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Corticosteroids used for chronic obstructive pulmonary disease (COPD) exacerbations can cause hyperglycemia in hospitalized patients, and hyperglycemia may be associated with increased mortality, length of stay (LOS), and re-admissions in these patients.

MATERIALS AND METHODS

We did three retrospective studies using charts from July 2008 through June 2009, January 2006 through December 2010, and October 2010 through March 2011. We collected demographic and clinical information, laboratory results, radiographic results, and information on LOS, mortality, and re-admission.

RESULTS

Glucose levels did not predict outcomes in any of the studied cohorts, after adjustment for covariates in multivariable analysis. The first database included 30 patients admitted to non-intensive care unit (ICU) hospital beds. Six of 20 non-diabetic patients had peak glucoses above 200 mg/dl. Nine of the ten diabetic patients had peak glucoses above 200 mg/dl. The maximum daily corticosteroid dose had no apparent effect on the glucose levels. The second database included 217 patients admitted to ICUs. The initial blood glucose was higher in patients who died than those who survived using bivariate analysis (P = 0.015; odds ratio, OR, 1.01) but not in multivariable analysis. Multivariable logistic regression analysis also demonstrated that glucose levels did not affect LOS. The third database analyzing COPD re-admission rates included 81 patients; the peak glucose levels were not associated with re-admission.

CONCLUSIONS

Our data demonstrate that COPD patients treated with corticosteroids developed significant hyperglycemia, but the increase in blood glucose levels did not correlate with the maximum dose of corticosteroids. Blood glucose levels were not associated with mortality, LOS, or re-admission rates.

Chronic obstructive pulmonary disease and diabetes mellitus: a systematic review of the literature

The objective of this systematic review was to discuss our current understanding of the complex relationship between chronic obstructive pulmonary disease (COPD) and type-2 diabetes mellitus (T2DM). We performed a systematic search of the literature related to both COPD and diabetes using PubMed. Relevant data connecting both diseases were compiled and discussed. Recent evidence suggests that diabetes can worsen the progression and prognosis of COPD; this may result from the direct effects of hyperglycemia on lung physiology, inflammation or susceptibility to bacterial infection. Conversely, it has also been suggested that COPD increases the risk of developing T2DM as a consequence of inflammatory processes and/or therapeutic side effects related to the use of high-dose corticosteroids. In conclusion, although there is evidence to support a connection between COPD and diabetes, additional research is needed to better understand these relationships and their possible implications.

Systemic corticosteroids in acute exacerbation of COPD: a meta-analysis of controlled studies with emphasis on ICU patients

Guidelines on systemic corticosteroids in chronic obstructive pulmonary disease (COPD) exacerbation rely on studies that excluded patients requiring ventilatory support. Recent publication of studies including ICU patients allows estimation of the level of evidence overall and in patients admitted to the ICU. We included RCTs evaluating the efficacy and safety of systemic corticosteroids in COPD exacerbation, compared to placebo or standard treatment. The effect size on treatment success was computed by a random effects model overall and in subgroups of non-ICU and ICU patients. Effects on mortality and on the rate of adverse effects of corticosteroids were also computed. Twelve RCTs (including 1,331 patients) were included. Pooled analysis showed a statistically significant increase in the treatment success rate when using systemic corticosteroids: odds ratio (OR) = 1.72, 95% confidence interval (CI) = 1.15 to 2.57; p = 0.01. Subgroup analysis showed different patterns of effect in ICU and non-ICU subpopulations: a non-significant difference of effect in the subgroup of ICU patients (OR = 1.34, 95% CI = 0.61 to 2.95; p = 0.46), whereas in the non-ICU patients, the effect was significant (OR = 1.87, 95% CI = 1.18 to 2.99; p = 0.01; p for interaction = 0.72). Among ICU patients, there was no difference in the success whether patients were ventilated with tracheal intubation (OR = 1.85, 95% CI = 0.14 to 23.34; p = 0.63) or with non-invasive ventilation (OR = 4.88, 95% CI = 0.31 to 75.81; p = 0.25). Overall, there was no difference in the mortality rate between the steroid-treated group and controls: OR = 1.07, 95% CI = 0.67 to 1.71; p = 0.77. The rate of adverse events increased significantly with corticosteroid administration (OR = 2.36, 95% CI = 1.67 to 3.33; p < 0.0001). In particular, treatment with systemic corticosteroids significantly increased the risk of hyperglycemic episodes requiring initiation or alteration of insulin therapy (OR = 2.96, 95% CI = 1.69 to 5; p < 0.0001). We found corticosteroids to be beneficial in the whole population (non-critically ill and critically ill patients) in terms of treatment success rate. However, subgroup analysis showed that this effect of corticosteroids was only observed in non-critically ill patients whereas critically ill patients derived no benefit from systemic corticosteroids regardless of the chosen ventilatory mode (invasive or non-invasive ventilation). Further analyses showed no effect on mortality of corticosteroids, but higher side effects, such as hyperglycemic episodes requiring the initiation or alteration of insulin therapy.

Spectrum and outcome predictors of central nervous system infections in a neurological critical care unit in India: a retrospective review

BACKGROUND

There are few published studies on the spectrum and outcome of central nervous system (CNS) infection in the neurology intensive care unit (NICU). We report the spectrum of CNS infections in the NICU and the predictors of outcome.

METHODS

During 2011 to 2012, 235 critically ill neurological patients were admitted to a 12-bed NICU in a tertiary-care teaching hospital in Lucknow, northern India; 76 (32.3%) of them had CNS infections and were included in the present study. The patients' demographic and clinical details were noted, together with the underlying aetiology, Glasgow Coma Scale (GCS) score, Acute Physiology and Chronic Health Evaluation (APACHE II) score, systemic inflammatory response syndrome (SIRS) and complications during mechanical ventilation. Deaths were recorded, and 3-month functional outcome in the surviving patients assessed by the modified Rankin Scale (mRS).

RESULTS

The median age of the patients was 37.5 (4-75) years and 31 were females; 36/76 (47%) patients had tuberculous meningitis, 28/76 (37%) viral encephalitis, 8/76 (11%) pyogenic meningitis and 4/76 (5%) fungal meningitis. Seven of these patients had AIDS. The median duration of mechanical ventilation was 8 (1-121) days and 39/76 patients (51.3%) died. Duration of hospital stay (OR 1.2, 95% CI 1.05-1.37, p=0.006) and duration of mechanical ventilation (OR 0.81, 95% CI 0.68-0.95, p=0.01) were independent predictors of death. At 3-month follow-up, 23/37 patients (62%) had recovered well, 10/37 (27%) were severely disabled and 4/37 (11%) had died.

CONCLUSION

Of patients admitted to the NICU during the study period, one-third had a CNS infection. Half of those with a CNS infection survived, and predictors of death were prolonged mechanical ventilation and prolonged hospital stay.

Stress hyperglycaemia in hospitalised patients and their 3-year risk of diabetes: a Scottish retrospective cohort study

BACKGROUND

Hyperglycaemia during hospital admission is common in patients who are not known to have diabetes and is associated with adverse outcomes. The risk of subsequently developing type 2 diabetes, however, is not known. We linked a national database of hospital admissions with a national register of diabetes to describe the association between admission glucose and the risk of subsequently developing type 2 diabetes.

METHODS AND FINDINGS

In a retrospective cohort study, patients aged 30 years or older with an emergency admission to hospital between 2004 and 2008 were included. Prevalent and incident diabetes were identified through the Scottish Care Information (SCI)-Diabetes Collaboration national registry. Patients diagnosed prior to or up to 30 days after hospitalisation were defined as prevalent diabetes and were excluded. The predicted risk of developing incident type 2 diabetes during the 3 years following hospital discharge by admission glucose, age, and sex was obtained from logistic regression models. We performed separate analyses for patients aged 40 and older, and patients aged 30 to 39 years. Glucose was measured in 86,634 (71.0%) patients aged 40 and older on admission to hospital. The 3-year risk of developing type 2 diabetes was 2.3% (1,952/86,512) overall, was <1% for a glucose ≤ 5 mmol/l, and increased to approximately 15% at 15 mmol/l. The risks at 7 mmol/l and 11.1 mmol/l were 2.6% (95% CI 2.5-2.7) and 9.9% (95% CI 9.2-10.6), respectively, with one in four (21,828/86,512) and one in 40 (1,798/86,512) patients having glucose levels above each of these cut-points. For patients aged 30-39, the risks at 7 mmol/l and 11.1 mmol/l were 1.0% (95% CI 0.8-1.3) and 7.8% (95% CI 5.7-10.7), respectively, with one in eight (1,588/11,875) and one in 100 (120/11,875) having glucose levels above each of these cut-points. The risk of diabetes was also associated with age, sex, and socio-economic deprivation, but not with specialty (medical versus surgical), raised white cell count, or co-morbidity. Similar results were obtained for pre-specified sub-groups admitted with myocardial infarction, chronic obstructive pulmonary disease, and stroke. There were 25,193 deaths (85.8 per 1,000 person-years) over 297,122 person-years, of which 2,406 (8.1 per 1,000 person-years) were attributed to vascular disease. Patients with glucose levels of 11.1 to 15 mmol/l and >15 mmol/l had higher mortality than patients with a glucose of <6.1 mmol/l (hazard ratio 1.54; 95% CI 1.42-1.68 and 2.50; 95% CI 2.14-2.95, respectively) in models adjusting for age and sex. Limitations of our study include that we did not have data on ethnicity or body mass index, which may have improved prediction and the results have not been validated in non-white populations or populations outside of Scotland.

CONCLUSION

Plasma glucose measured during an emergency hospital admission predicts subsequent risk of developing type 2 diabetes. Mortality was also 1.5-fold higher in patients with elevated glucose levels. Our findings can be used to inform patients of their long-term risk of type 2 diabetes, and to target lifestyle advice to those patients at highest risk. Please see later in the article for the Editors' Summary.

Current drug treatment, chronic and acute

The appropriate management of chronic obstructive pulmonary disease (COPD) involves more than taking prescription medicines. The key components have been set out in detail in many treatment guidelines, both national and international. They include the avoidance of identified risk factors, especially tobacco smoking, and the optimization of daily physical activity. This article reviews the key components of the pharmacologic treatment of COPD, both acute and chronic, with an emphasis on those recent studies, which are likely to change practice in the next few years.

Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies

Background

Identifying the predictors of noninvasive ventilation (NIV) failure has attracted significant interest because of the strong link between failure and poor outcomes. However, very little attention has been paid to the timing of the failure. This narrative review focuses on the causes of NIV failure and risk factors and potential remedies for NIV failure, based on the timing factor.

Results

The possible causes of immediate failure (within minutes to <1 h) are a weak cough reflex, excessive secretions, hypercapnic encephalopathy, intolerance, agitation, and patient-ventilator asynchrony. The major potential interventions include chest physiotherapeutic techniques, early fiberoptic bronchoscopy, changing ventilator settings, and judicious sedation. The risk factors for early failure (within 1 to 48 h) may differ for hypercapnic and hypoxemic respiratory failure. However, most cases of early failure are due to poor arterial blood gas (ABGs) and an inability to promptly correct them, increased severity of illness, and the persistence of a high respiratory rate. Despite a satisfactory initial response, late failure (48 h after NIV) can occur and may be related to sleep disturbance.

Conclusions

Every clinician dealing with NIV should be aware of these risk factors and the predicted parameters of NIV failure that may change during the application of NIV. Close monitoring is required to detect early and late signs of deterioration, thereby preventing unavoidable delays in intubation.

Determinants of noninvasive ventilation outcomes during an episode of acute hypercapnic respiratory failure in chronic obstructive pulmonary disease: the effects of comorbidities and causes of respiratory failure

Objectives. To investigate the effect of the cause of acute respiratory failure and the role of comorbidities both acute and chronic on the outcome of COPD patients admitted to Respiratory Intensive Care Unit (RICU) with acute respiratory failure and treated with NIV. Design. Observational prospective study. Patients and Methods. 176 COPD patients consecutively admitted to our RICU over a period of 3 years and treated with NIV were evaluated. In all patients demographic, clinical, and functional parameters were recorded including the cause of acute respiratory failure, SAPS II score, Charlson comorbidity index, and further comorbidities not listed in the Charlson index. NIV success was defined as clinical improvement leading to discharge to regular ward, while exitus or need for endotracheal intubation was considered failure. Results. NIV outcome was successful in 134 patients while 42 underwent failure. Univariate analysis showed significantly higher SAP II score, Charlson index, prevalence of pneumonia, and lower serum albumin level in the failure group. Multivariate analysis confirmed a significant predictive value for pneumonia and albumin. Conclusions. The most important determinants of NIV outcome in COPD patients are the presence of pneumonia and the level of serum albumin as an indicator of the patient nutritional status.

Anemia and performance status as prognostic markers in acute hypercapnic respiratory failure due to chronic obstructive pulmonary disease

BACKGROUND

In patients with acute hypercapnic respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with respiratory acidosis due to COPD.

METHODS

COPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV1), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded.

RESULTS

In total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS ≥ 3, long-term oxygen therapy, anemia, diastolic blood pressure < 70 mmHg, Early Warning Score ≥ 3, severe acidosis (pH < 7.20), and serum albumin < 35 g/L. On multivariate analysis, only anemia and WHO-PS ≥ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%.

CONCLUSION

WHO-PS ≥ 3 and anemia are prognostic factors in AHRF with respiratory acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.

Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes

Pharmacologic doses of glucocorticoids and chronic renal failure are challenging comorbidities and complications for safe and effective dosing of insulin for the management of hospitalized patients with diabetes. Glucocorticoids are used widely in hospitalized patients and will commonly provoke new-onset hyperglycemia in patients without a prior history of diabetes or will provoke severely uncontrolled hyperglycemia in patients with known diabetes. Insulin therapy is invariably necessary for the treatment of glucocorticoid-induced hyperglycemia and must be tailored to the pharmacodynamics of the glucocorticoid being given. Renal failure causes a decrease in the clearance of insulin, especially exogenous injected insulin. Dosing algorithms for hospitalized patients should be adjusted for patients with renal failure in order to minimize hypoglycemia. Many patients with type 2 diabetes will need little or no therapy after the development of end-stage renal failure. Care must be taken to avoid the overtreatment of hyperglycemia.

Chronic obstructive pulmonary disease and glucose metabolism: a bitter sweet symphony

Chronic obstructive pulmonary disease, metabolic syndrome and diabetes mellitus are common and underdiagnosed medical conditions. It was predicted that chronic obstructive pulmonary disease will be the third leading cause of death worldwide by 2020. The healthcare burden of this disease is even greater if we consider the significant impact of chronic obstructive pulmonary disease on the cardiovascular morbidity and mortality. Chronic obstructive pulmonary disease may be considered as a novel risk factor for new onset type 2 diabetes mellitus via multiple pathophysiological alterations such as: inflammation and oxidative stress, insulin resistance, weight gain and alterations in metabolism of adipokines. On the other hand, diabetes may act as an independent factor, negatively affecting pulmonary structure and function. Diabetes is associated with an increased risk of pulmonary infections, disease exacerbations and worsened COPD outcomes. On the top of that, coexistent OSA may increase the risk for type 2 DM in some individuals. The current scientific data necessitate a greater outlook on chronic obstructive pulmonary disease and chronic obstructive pulmonary disease may be viewed as a risk factor for the new onset type 2 diabetes mellitus. Conversely, both types of diabetes mellitus should be viewed as strong contributing factors for the development of obstructive lung disease. Such approach can potentially improve the outcomes and medical control for both conditions, and, thus, decrease the healthcare burden of these major medical problems.

How to write research papers and grants: 2011 Asian Pacific Society for Respirology Annual Scientific Meeting Postgraduate Session

This review article summarizes the content of a series of interrelated workshop presentations from the Annual Scientific Meeting of the Asian Pacific Society of Respirology held in Shanghai in November, 2011. The article describes tips and strategies for writing research papers and research grant applications and includes discussion of: the role of pulmonologists in research; the debates around the use of the journal impact factor; tips for writing manuscripts and publishing research in high-impact journals; how journals assess manuscripts and the most common reasons editors reject manuscripts; how to write grant applications and what grant panels look for in successful proposals; and how to undertake research in resource-limited countries.

Extrapulmonary comorbidities in chronic obstructive pulmonary disease: state of the art

Extrapulmonary comorbidities are common and significant in chronic obstructive pulmonary disease (COPD), often contributing to symptoms, exacerbations, hospital admissions and mortality. Cardiovascular, musculoskeletal and psychological conditions are among the most prevalent and important of these. In particular, ischemic heart disease is a leading cause of death in the COPD population as a whole. Here, we provide a state-of-the-art summary of key comorbidities observed in COPD patients in terms of their prevalence, impact, pathophysiology and prognosis. In addition, we review clinical, diagnostic and management strategies that may differ in COPD patients from the rest of the population.

Systemic biomarkers in exacerbations of COPD: the evolving clinical challenge

BACKGROUND

Exacerbations of COPD (ECOPD) remain a major cause of mortality and morbidity. Despite advances in the understanding of their pathophysiology, their assessment relies primarily on clinical presentation, which can be variable and difficult to predict. A large number of biomarkers already have been assessed in this context, and some appear to be promising.

METHODS

An online search for articles published until December 2010 was conducted using three terms for ECOPD, five terms for biomarkers, and five terms for the sampling method. Biomarkers were evaluated for their potential role in the establishment and confirmation of the diagnosis of ECOPD, the evaluation of etiology and severity, the prediction of prognosis, and the guidance of treatment decisions.

RESULTS

Several systemic biomarkers have been measured in the context of ECOPD, and most have been found to increase at ECOPD onset and to subside during the course of exacerbations. Correlations have been reported among these biomarkers, but direct associations with clinical variables have been more difficult to establish. Although there are several limitations yet to be addressed, some of the biomarkers, most notably C-reactive protein for the identification of an ECOPD and procalcitonin for antibiotic guidance, may provide clinically relevant information.

CONCLUSIONS

So far, no single biomarker has been able to gain wide acceptance, but some provide clinically useful information. The evaluation of such biomarkers in large decision-making studies is expected to become an area of intense investigation in the near future.

Phase II study of tight glycaemic control in COPD patients with exacerbations admitted to the acute medical unit

BACKGROUND

Hyperglycaemia is associated with poor outcomes from exacerbations of chronic obstructive pulmonary disease (COPD). Glycaemic control could improve outcomes by reducing infection, inflammation and myopathy. Most patients with COPD are managed on the acute medical unit (AMU) outside intensive care (ICU).

OBJECTIVE

To determine the feasibility, safety and efficacy of tight glycaemic control in patients on an AMU.

DESIGN

Prospective, non-randomised, phase II, single-arm study of tight glycaemic control in COPD patients with acute exacerbations and hyperglycaemia admitted to the AMU. Participants received intravenous, then subcutaneous, insulin to control blood glucose to 4.4-6.5 mmol/l. Tight glycaemic control was evaluated: feasibility, protocol adherence; acceptability, patient questionnaire; safety, frequency of hypoglycaemia (capillary blood glucose (CBG) <2.2 mmol/l and 2.2-3.3 mmol/l); efficacy, median CBG, fasting CBG, proportion of measurements/time in target range, glycaemic variability.

RESULTS

were compared with 25 published ICU studies. Results 20 patients (10 females, age 71 ± 9 years; forced expiratory volume in 1 s: 41 ± 16% predicted) were recruited. Tight glycaemic control was feasible (78% CBG measurements and 89% of insulin-dose adjustments were adherent to protocol) and acceptable to patients. 0.2% CBG measurements were <2.2 mmol/l and 4.1% measurements 2.2-3.3 mmol/l. The study CBG and proportion of measurements/time in target range were similar to that of ICU studies, whereas the fasting CBG was lower, and the glycaemic variability was greater.

CONCLUSIONS

Tight glycaemic control is feasible and has similar safety and efficacy on AMU to ICU. However, as more recent ICU studies have shown no benefit and possible harm from tight glycaemic control, alternative strategies for blood glucose control in COPD exacerbations should now be explored. Trial registration number ISRCTN: 42412334. http://Clinical.Trials.gov NCT00764556.

COPD exacerbation: mortality prognosis factors in a respiratory care unit

OBJECTIVE

The aim of our study was to investigate the mortality predictive factors after a severe exacerbations of COPD admitted to a Spanish respiratory intermediate care unit (IRCU).

PATIENTS AND METHODS

Prospective observational 2 years study, where we included all episodes of acute exacerbations of COPD with hypercapnic respiratory failure admitted in an IRCU. We analyzed different sociodemographic, functional and clinical variables including physical activity.

RESULTS

We collected data from 102 consecutive episodes admitted to IRCU (90.1% men). Mean age was 69.4±10.6. The mean APACHE II was 19.6±5.0 and 9.5% presented a failure of other non respiratory organ. Non invasive ventilation was applied in 75.3% of the episodes and this treatment failed in 11.6% of them. The duration of stay in the IRCU was 3.5±2.1 days and 8.0±5.3 days in the hospital. The hospital mortality rate was 6.9%, and another 12.7% after 90 days of discharged. In order to predict hospital mortality, multivariant statistics identified a model with AUC of 0.867, based in 3 variables: the number of previous year admission for COPD exacerbation (p=0,048), the respiratory rate after 2 hours of treatment in the IRCU (p=0.0484) and the severity of the disease established with ADO score (p=0.0241).

CONCLUSIONS

The number of previous year admission for COPD exacerbation, the severity of the disease established with ADO score, the respiratory rate after 2 hours of treatment, allow us to identify what patients with a COPD exacerbation admitted in a IRCU can die during this episode.

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.