Comparison of the clinical characteristics and treatment outcomes of patients requiring hospital admission to treat eosinophilic and neutrophilic exacerbations of COPD

Mucus Plugs as Precursors to Exacerbation and Lung Function Decline in COPD Patients

BACKGROUND

Mucus plugs identified through chest computed tomography (CT) scans have emerged as potential prognostic factors in chronic obstructive pulmonary disease (COPD). This 5-year longitudinal study investigated their impact on exacerbations and FEV1 decline.

METHODS

COPD patients with baseline chest CT and spirometric assessments were categorized based on mucus plug presence. Propensity-score matching yielded balanced groups. Exacerbation rates, time to exacerbation events, hazard ratio (HR) for exacerbations, and annual rates of FEV1 decline were evaluated. Sensitivity analysis was performed with stratification according to mucus plug scores of 0, 1-2, and ≥3.

RESULTS

Among 623 eligible patients, the mucus plug group was 44.3%. Through 1:1 propensity-score matching, each group was comprised of 187 individuals with balanced covariates. The mucus plug group showed higher rates of moderate-to-severe (0.51/year vs. 0.58/year, P=0.035), severe exacerbations (0.21/year vs. 0.24/year, P=0.032), and non-eosinophilic exacerbations (0.45/year vs. 0.52/year, P=0.008). Mucus plugs were associated with increased hazard of moderate-to-severe (adjusted HR=1.502 [95% CI 1.116-2.020]), severe (adjusted HR=2.106 [95% CI, 1.429-3.103]), and non-eosinophilic exacerbations (adjusted HR=1.551 [95% CI, 1.132-2.125]). Annual FEV1 decline was accelerated in the mucus plug group (β-coefficient=-62 [95% CI, -120 to -5], P=0.035). Sensitivity analysis showed higher risk of exacerbations and accelerated FEV1 decline in mucus plug score ≥3 compared to score 0.

CONCLUSIONS

Mucus plugs are associated with increased risks of exacerbations, particularly non-eosinophilic, and accelerated FEV1 declines over 5 years. Our study identified the potential prognostic value of mucus plugs on future exacerbation risks and lung function decline trajectories.

Inter-relationships among neutrophilic inflammation, air trapping and future exacerbation in COPD: an analysis of ECOPD study

BACKGROUND

The inter-relationships among neutrophilic airway inflammation, air trapping and future exacerbation in chronic obstructive pulmonary disease (COPD) remain unclear.

OBJECTIVE

To evaluate the associations between sputum neutrophil proportions and future exacerbation in COPD and to determine whether these associations are modified by significant air trapping.

METHODS

Participants with completed data were included and followed up to the first year in the Early Chronic Obstructive Pulmonary Disease study (n=582). Sputum neutrophil proportions and high-resolution CT-related markers were measured at baseline. Sputum neutrophil proportions were dichotomised based on their median (86.2%) to low and high levels. In addition, subjects were divided into the air trapping or non-air trapping group. Outcomes of interest included COPD exacerbation (separately any, severe and frequent exacerbation, occurring in the first year of follow-up). Multivariable logistic regressions were performed to examine the risk of severe exacerbation and frequent exacerbation with either neutrophilic airway inflammation groups or air trapping groups.

RESULTS

There was no significant difference between high and low levels of sputum neutrophil proportions in the exacerbation in the preceding year. After the first year of follow-up, subjects with high sputum neutrophil proportions had increased risks of severe exacerbation (OR=1.68, 95% CI: 1.09 to 2.62, p=0.020). Subjects with high sputum neutrophil proportions and significant air trapping had increased odds of having frequent exacerbation (OR=3.29, 95% CI: 1.30 to 9.37, p=0.017) and having severe exacerbation (OR=2.72, 95% CI: 1.42 to 5.43, p=0.003) when compared with those who had low sputum neutrophil proportions and non-air trapping.

CONCLUSIONS

We found that subjects with high sputum neutrophil proportions and significant air trapping are prone to future exacerbation of COPD. It may be a helpful predictor of future exacerbation.

The association between eosinophilic exacerbation and eosinophilic levels in stable COPD

Background

Blood eosinophil count may predict treatment response in patients with chronic obstructive pulmonary disease (COPD) during acute exacerbations (AE). However, the ability and thresholds of blood eosinophil counts in stable status to predict eosinophilic AECOPD have not been completely investigated.

Methods

This was a retrospective multicenter study performed January 2010 to December 2014. COPD subjects hospitalized with exacerbations, were included. Blood samples were obtained at the time of AE and stable disease at outpatient clinic before or after admission. We identified a blood eosinophil count cut-off point at stable COPD, either taken as a percentage or as absolute value, for identification of eosinophilic exacerbation.

Results

There was significant positive correlation of eosinophil counts between stable COPD and AECOPD. The best cut-off value of blood eosinophil count in stable status for the prediction of eosinophilic COPD exacerbation based on blood eosinophil count ≥ 2% was 300 cells/µL (area under the ROC curve [AUC] 0.614, P = 0.001, 39% sensitivity, 83.8% specificity). When the eosinophilic COPD exacerbation was based on blood eosinophil count ≥ 300 cells/µL, the best cut-off value of blood eosinophil count in stable status for the prediction of eosinophilic COPD exacerbation was also 300 cells/uL (AUC 0.634, P = 0.046, 45.8% sensitivity, 80.9% specificity).

Conclusions

We demonstrated association between blood eosinophil counts at stable COPD and those with AECOPD. The thresholds of blood counts at stable COPD to predict eosinophilic exacerbations was 300 cells/µL. Further and prospective studies in other populations should validate our results.

Epidemiology and issues of NIV-treated AECOPD patients with hypercapnic respiratory failure in Shanghai: A multicentre retrospective survey

OBJECTIVE

To investigate the epidemiology, clinical features, treatment and outcome of Noninvasive ventilation (NIV)-treated acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients in secondary hospitals of Shanghai.

METHOD

Relying on Shanghai alliances for respiratory diseases, a retrospective observational study was performed in 34 secondary hospitals of Shanghai. The AECOPD patients treated with NIV and admitted to the respiratory department or respiratory intensive care unit were recruited between December 1, 2016, and November 30, 2017.

RESULTS

There were 555 patients finally recruited in this study. The age was 75.8 ± 9.6 years old and 380 patients (68.5%) were male. 70.5% of all patients had respiratory acidosis (pH <7.35). 55.3% of all patients received nebulised bronchodilator and 77.7% were treated with systemic or inhaled corticosteroids during hospitalisation. 525 patients (94.6%) recovered successfully and the mortality was 3.2%. The hospitalisation was 15.3 ± 6.7 days and hospital expenses were 22 911 ± 13 595 RMB. Inadequate and nonstandard drug treatments were the most important problems during management.

CONCLUSION

The NIV can be successfully used for AECOP patients in local hospitals of Shanghai, but accompanied by high costs and long hospital stays. However, the treatments for exacerbation and stable COPD patients are still insufficient.

Clinical characteristics of neutrophilic, eosinophilic and mixed-type exacerbation phenotypes of COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) comprises a significant number of emergency department (ED) presentations, and hematological phenotypes may have prognostic significance. The aim of this study was to investigate the effect of hematological phenotypes on serious outcomes in COPD exacerbations.

METHODS

A prospective cohort study was carried out in patients with COPD exacerbation presenting to the ED. The patients were classified into three groups, including neutrophilic, eosinophilic, and mixed-type (including neutrophilic and eosinophilic features) COPD exacerbation. Outcome measures were defined as mortality, hospitalization, and need for intensive care unit (ICU) care within three months, and these outcomes were compared among groups.

RESULTS

A total of 173 COPD patients were assessed for eligibility, and 147 of them were included in the final analysis. The study population consisted of 90 patients with neutrophilic exacerbation (61.2%), 26 patients with eosinophilic exacerbation (17.7%), and 31 patients with mixed-type exacerbation (21.1%). The neutrophilic exacerbation group was older, was more often tachycardic and desaturated, and had more sputum production compared with the eosinophilic exacerbation group. Mortality was seen in 35 patients in the neutrophilic exacerbation group (38.9%), whereas 5 patients in the eosinophilic group (19.2%) and 6 patients in the mixed-type group (19.4%) died (p = .044). No difference was observed among groups in terms of hospital and ICU admission.

CONCLUSION

COPD exacerbations with neutrophilic phenotypes presented to the ED with more serious clinical findings compared with eosinophilic exacerbations. This may also have a possible effect on mortality.

Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease

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

Role of peripheral eosinophilia in acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Eosinophil counts are a promising guide to systemic steroid administration for chronic obstructive pulmonary disease (COPD).

AIM

To study the role of peripheral eosinophilia in hospitalized patients with acute exacerbation of COPD (AECOPD).

METHODS

From January 2014 to May 2017, patients with AECOPD hospitalized in Taipei Tzu Chi Hospital were retrospectively stratified into two groups according to their peripheral eosinophil count: The EOS group (eosinophil count ≥ 2%) and the non-EOS group (eosinophil count < 2%). Demographics, comorbidities, laboratory data, steroid use, length of hospital stay, and COPD-related readmissions were compared between the groups.

RESULTS

A total of 625 patients were recruited, with 176 patients (28.2%) in the EOS group. The EOS group showed a lower prevalence of infection, lower cumulative doses of prednisolone equivalents, shorter length of hospital stay, and higher number of COPD-related readmissions than the non-EOS group. There were significantly linear correlations between eosinophil percentage and number of readmissions and between eosinophil percentage and length of hospital stay (P < 0.001, Pearson's r = 0.147; P = 0.031, Pearson's r = -0.086, respectively). The EOS group and a lower percent-predicted value of forced expiratory volume in one second (FEV1) were associated with shorter time to first COPD-related readmission [adjusted hazard ratio (adj. HR) = 1.488, P < 0.001; adj. HR = 0.985, P < 0.001, respectively].

CONCLUSION

The study findings suggest that the EOS group had the features of a shorter length of hospital stay, and lower doses of systemic steroids, but more frequent readmissions. The EOS group and lower percent-predicted FEV1 values were risk factors for shorter time to first COPD-related readmission.

Elevated blood eosinophils in acute COPD exacerbations: better short- and long-term prognosis

Background: Elevated eosinophils in COPD is recognized as a potential risk factor for exacerbations, but the prognostic role of elevated eosinophils during exacerbations of COPD is unclear. We investigated short-term and long-term outcomes in patients with exacerbations of eosinophilic phenotype, compared with patients with low blood eosinophils. Methods: A single-centre retrospective study of all patients admitted for a COPD exacerbation to Bispebjerg University Hospital in 2010-2011 was established by linking inpatient data with national patient and prescription registries, with a three-year follow-up period. Elevated eosinophils were defined as a blood eosinophil level at admission of ≥0.30 × 10⁹ cells/L. Results: A total of 811 patients were included; 13.2% had an eosinophilic exacerbation. The eosinophilic group had less need for non-invasive ventilation, shorter inpatient stay, and lower in-hospital mortality, compared to the non-eosinophilic group. However, the eosinophilic and non-eosinophilic groups showed similar risks of readmission (incidence rate ratio[95], 0.99 [0.73-1.36]). Three-year mortality was high in both groups, although lower in the eosinophilic group (40% vs. 54%, p = 0.006). Conclusions: COPD exacerbations in patients with high blood eosinophil have a better short-term prognosis without higher risk of subsequent exacerbation. Eosinophilic exacerbations have also a lower three-year mortality.

High suPAR and Low Blood Eosinophil Count are Risk Factors for Hospital Readmission and Mortality in Patients with COPD

Introduction

The biomarker soluble urokinase plasminogen activator receptor (suPAR) has been associated with increased mortality in chronic obstructive pulmonary disease (COPD), while elevated blood eosinophils have been associated with better survival. We hypothesized that suPAR and blood eosinophil count are independent risk factors for readmission and mortality after an acute admission in patients with COPD.

Methods

This retrospective cohort study comprised 4022 patients with prevalent COPD acutely admitted to Hvidovre Hospital, Denmark. Irrespective of cause of admission, suPAR and blood eosinophils were measured, and patients were followed up to 365 days. Associations with 365-day respiratory readmission, all-cause readmission and all-cause mortality were investigated by Cox regression analyses adjusted for age, sex, Charlson score and C-reactive protein.

Results

suPAR was significantly elevated in patients who later experienced readmission or died. At 365 days, hazard ratios (HRs) for all-cause readmission and mortality reached 1.61 (95% CI 1.40–1.85; p<0.0001) and 3.40 (95% CI 2.64–4.39; p<0.0001), respectively, for COPD patients in the fourth suPAR quartile compared to patients in the first suPAR quartile. High blood eosinophils (>300 cells/μL) were associated with lower risk of mortality (HR 0.49, 95% CI 0.39–0.62; p<0.0001) compared with patients with <150 cells/μL. When stratifying patients by suPAR quartiles and blood eosinophil counts, the highest relative mortality rate was found in patients belonging to both the fourth suPAR quartile and the low blood eosinophil (<150 cells/μL) group.

Conclusion

In this cohort of COPD patients acutely admitted to a hospital, elevated suPAR concentrations were associated with both higher risk of all-cause readmission and mortality, whereas higher blood eosinophil count was associated with lower risk of mortality.

Peripheral Blood Eosinophil as a Biomarker in Outcomes of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Purpose

Mounting evidence suggests that eosinophil levels correlate with the effects of therapy and phenotype for chronic obstructive pulmonary disease (COPD). This study aimed to clarify the relationship between eosinophil levels and clinical outcomes in patients with acute exacerbation of COPD (AECOPD).

Methods

A prospective, multicenter, observational cohort study was performed in three teaching hospitals. Patients were grouped by quartile percentage (0, 0.7, 2.55) and absolute blood eosinophils count (0, 0.05×10⁹/L, 0.17×10⁹/L) and divided into four numbered groups ranked from low to high.

Results

The study included 493 AECOPD patients. In the percentile-ranked groups, patients in Group 1 experienced significantly longer hospital stays, higher rates of both noninvasive mechanical ventilation (NIMV), and heart failure than those in Group 4 (12 days vs 10 days, p = 0.005; 29.5% vs 23.6%, p = 0.007; 48.4% vs 28.5%, p = 0.001). Group 1 also had higher frequencies of respiratory failure and pulmonary heart disease compared to Groups 3 and 4 (54.8% vs 34.8%, p = 0.002; 54.8% vs 35%, p = 0.003). In the absolute count-ranked groups, patients in Group 1 had significantly higher rates of NIMV than those in Group 3 (41.1% vs 21.7%, p = 0.001), had higher rates of heart failure, respiratory failure, and pulmonary heart disease than those in Group 3 and 4 (48.1% vs 30.2%, p = 0.003; 48.1% vs 30.4%, p = 0.005; 50.8% vs 32.2%, p = 0.004; 50.8% vs 34.1%, p = 0.008; 51.9% vs 34.1%, p = 0.004; 51.9% vs 33%, p = 0.003). There were outcome differences among the admitting hospital of stays in the absolute count groups (p = 0.002), but the differences were not significant in a pairwise comparison. The proportion of ICU admissions and mortality was different in two cohorts with no difference in a pairwise comparison.

Conclusion

Patients with lower eosinophil counts experienced poorer clinical outcomes. Eosinophil levels may be a helpful marker to predict outcomes in AECOPD.

Prevalence and Baseline Clinical Characteristics of Eosinophilic Chronic Obstructive Pulmonary Disease: A Meta-Analysis and Systematic Review

Background: Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with different clinical and pathophysiological characteristics. Cumulative evidence shows that eosinophil levels may be connected to the therapeutic effects and phenotype of COPD. However, the prevalence of eosinophilic inflammation in COPD and the baseline characteristics of eosinophilic COPD remain unknown. Our study investigated the prevalence of COPD with eosinophil levels of >2% and the characteristics of eosinophilic COPD. Methods: We searched the Cochrane Central Library, Medline, Embase, and the Web of Science for trials of eosinophil and COPD published from database inception to May 1, 2019. Results: In total, 40,112 COPD patients that were involved in 19 trials were included in the final analysis. The prevalence of eosinophilic COPD ranged from 18.84 to 66.88%, with an average prevalence of 54.95% across all studies. We found that men, ex-smokers, individuals with a history of ischemic heart disease, and individuals with a higher body mass index (BMI) were at higher risk of eosinophilic COPD (OR 1.36, 95% CI 1.26-1.46, P < 0.00001; OR 1.23, 1.12-1.34, P < 0.0001; OR 1.31, 1.14-1.50, P = 0.001; MD 0.70, 0.27-1.12, P = 0.001). There was, however, a lower proportion of GOLD stage I patients among those with eosinophilic COPD (OR 0.84, 0.73-0.96, P = 0.01). No significant differences were found in terms of age, current smoker status, pack-years smoked, percent of predicted forced expiratory volume in 1 s, hypertension, diabetes, or other GOLD stages between the two groups (P > 0.05). Conclusions: Our analysis suggests that eosinophilic inflammation is prevalent in COPD. Eosinophilic COPD was more likely to occur in men, ex-smokers, those with a higher BMI, and those with a high risk of some comorbidity; however, a lower proportion of patients with eosinophilic COPD experienced mild airflow limitations.

Independent factors associate with hospital mortality in patients with acute exacerbation of chronic obstructive pulmonary disease requiring intensive care unit admission: Focusing on the eosinophil-to-neutrophil ratio

Background

Factors associated with hospital mortality are unclear in patients with acute exacerbation of COPD (AECOPD) requiring intensive care unit (ICU) admission. We aimed to characterize these patients and identify factors associated with hospital mortality.

Patients and methods

We used a retrospective observational case-control design and recruited patients between January 2015 and March 2017. Of 146 patients enrolled, 24 (16.4%) died during their hospital stay, while 122 survived.

Results

Multivariate logistic regression analyses revealed factors associated with hospital mortality: age (adjusted odds ratio [AOR] 1.12, 95% CI: 1.03–1.23), C-reactive protein (CRP) level >7.5 mg/dL at the emergency room (AOR 4.52, 95% CI: 1.27–16.04), peak eosinophil-to-neutrophil ratio (ENR)×10² on days 8–14 of treatment (AOR 0.22, 95% CI: 0.08–0.63), and in-hospital complications (AOR 4.23, 95% CI: 1.12–15.98) (all P<0.05). After receiver operating characteristic curve analyses, cutoff level for peak ENR×10² was 0.224. To examine the synergistic effects of CRP level and peak ENR, we divided patients into four groups: (G0, reference group) Peak ENR×10² >0.224 on days 8–14 and initial CRP <7.5 mg/dL; (G1) Peak ENR×10² >0.224 on days 8–14 and initial CRP >7.5 mg/dL; (G2) Peak ENR×10² <0.224 on days 8–14 and initial CRP <7.5 mg/dL; and (G3) Peak ENR×10² <0.224 on days 8–14 and initial CRP >7.5 mg/dL. For G2 and G3 patients, the AOR of mortality was significantly different from that of the reference group (G2: AOR 10.00, P = 0.020; G3: AOR 61.79, P<0.001). The relationship between 28-day mortality and the four groups was statistically significant (log-rank test, P<0.001).

Conclusion

Older age, initial CRP >7.5 mg/dL, peak ENR on days 8–14, and in-hospital complications were associated with hospital mortality in patients with AECOPD requiring ICU admission. Patients with both biomarkers, initial CRP >7.5 mg/dL, and peak ENR×10² <0.224 on days 8–14 of treatment, had an increased risk of hospital mortality.

Independent factors associated with pneumonia among hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease

Acute exacerbations (AE) affect the prognosis of hospitalized patients with chronic obstructive pulmonary disease (COPD). Pneumonia further affects their prognosis and early diagnosis of pneumonia in AECOPD is important to initiate treatments. This study aimed to examine the differences between hospitalized AECOPD patients with and without pneumonia in order to identify risk factors of pneumonia among hospitalized patients with AECOPD.This was a retrospective case-control study of patients with COPD hospitalized at the respiratory ward of Beijing Shijitan Hospital, Capital Medical University, from October 2010 to October 2013. Patients were divided into the pneumonia and nonpneumonia groups based on exudations or opacities on chest computed tomography (CT) at admission. Data were analyzed using the chi-square test and independent 2-sample ANOVA in SPSS 20.0. Logistic regression analysis was used to identify the factors independently associated with pneumonia. P < .05 was considered statistically significant.A total of 164 patients were included. Smoking history (OR = 2.646, 95%CI 1.153-6.074, P = .022), use of drugs during the stable stage (OR = 0.435, 95%CI 0.216-0.877, P = .020), D-dimer levels (OR = 1.001, 95%CI 1.000-1.002, P = .049), percentage of neutrophils (OR = 0.271, 95%CI 0.078-0.940, P = .040), and magnitude of neutrophils increase (OR = 0.946, 95%CI 0.896-0.999, P = .046) were independently associated with pneumonia in patients with AECOPD. For severe and very severe COPD patients, smoking history (OR = 4.426, 95%CI 1.458-13.435, P = .009), use of drugs during the stable stage (OR = 0.384, 95%CI 0.168-0.877, P = .042), and fever (OR = 0.426, 95%CI 0.187-0.969, P = .023) were independently associated with pneumonia.Smoking history, use of drugs during the stable stage, and percentage of neutrophils are independently associated with CT-diagnosed pneumonia among hospitalized AECOPD patients.

Clinical features, bacteriology of endotracheal aspirates and treatment outcomes of patients with chronic obstructive pulmonary disease and community-acquired pneumonia in an intensive care unit in Taiwan with an emphasis on eosinophilia versus non-eosinophilia: a retrospective case-control study

OBJECTIVES

The clinical implications of blood eosinophil level in patients with chronic obstructive pulmonary disease (COPD) and community-acquired pneumonia (CAP) requiring invasive mechanical ventilation (IMV) and intensive care unit (ICU) admission are still unknown. Thus, this study aimed to compare the features of such patients with and without blood eosinophilia.

DESIGN

This was a retrospective case-control study.

SETTING

An ICU of a medical centre in central Taiwan.

PARTICIPANTS

A total of 262 patients with COPD and CAP requiring IMV and ICU admission.

RESULTS

Of all participants (n=262), 32 (12.2%) had an eosinophil percentage (EP) >2% and 169 (64.5%) had an absolute eosinophil count (AEC) >300 cells/µL. Regardless of whether 2% or 300 cells/µL was used as a cut-off value, the eosinophilia group were slightly older (years) (82.9±5.4 vs 78.1±9.1, p=0.000 and 79.2±8.4 vs 77.6±9.6, p=0.246, respectively), and had a higher forced expiratory volume in 1 s/forced vital capacity (%) (56.0±8.0 vs 51.3±11.6, p=0.005 and 53.1±11.2 vs 49.5±11.2, p=0.013, respectively), less severe spirometric classification (p=0.008 and p=0.001, respectively), and lower white cell count 109/L (8.8±3.2 vs 11.1±4.9, p=0.009 and 10.3±4.4 vs 11.8±5.3, p=0.017, respectively) than the non-eosinophilia group. The bacteriology of endotracheal aspirates showed that Pseudomonas aeruginosa and other gram-negative bacilli were the most common organisms in all study groups. Participants with an EP >2% had a shorter ICU length of stay (OR=12.13, p=0.001) than those with an EP ≤2%, while an AEC >300 cells/µL was not associated with any in-ICUoutcomes.

CONCLUSIONS

The results of this study have significant clinical implications and should be considered when making treatment decisions for the management of patients with COPD and CAP requiring IMV and ICU admission.

Eosinophilic and non-eosinophilic COPD patients with chronic respiratory failure: neutrophil-to-lymphocyte ratio as an exacerbation marker

Aim

Increased dyspnea, sputum volume, and purulence are subjective symptoms in COPD patients. To diagnose COPD exacerbations with chronic respiratory failure (CRF) and to assess the requirement for antibiotic treatment, physicians require more objective criteria. We aimed to investigate whether neutrophil-to-lymphocyte ratio (NLR) can be used as an infectious exacerbation marker in COPD patients with CRF.

Patients and methods

This retrospective cross-sectional study was performed in the intensive care outpatient clinic of a tertiary training hospital between 2014 and 2015. Patients admitted with CRF due to COPD and who had complete blood count (CBC) results were enrolled. CBC results and C-reactive protein (CRP) levels were obtained from the hospital online database. The “modified exacerbation model (MEM)” was defined as follows: exacerbation A, leukocytes ≥12,000/mm³, CRP >10 mg/dL; exacerbation B, leukocytes ≥10,000/mm³, CRP >10 mg/dL; exacerbation C, leukocytes ≥10,000/mm³, CRP >8 mg/dL; exacerbation D, leukocytes ≥10,000/mm³, CRP >5 mg/dL. The cutoff value of NLR was defined for each model. Patients were split into two groups based on the NLR cutoff value according to the “NLR exacerbation model” and further subgrouped according to peripheral eosinophil percentage (eosinophils ≥2% and <2%) and compared with the MEM.

Results

A total of 1,066 COPD patients (430 females, 40.3%), with a mean age of 66±13 years, were included. A NLR cutoff value of 3.54 (NLR ≥3.54, n=366, 34%) showed the highest sensitivity and specificity for model A (78%, 69%), model B (63%, 71%), model C (61%, 72%), and model D (58%, 72%). Peripheral eosinophilia (PE ≥2%) was present in 48 patients (4.5%). The ratio of patients with PE <2% in the NLR ≥3.54 group was significantly higher in the MEM (P<0.001).

Conclusion

The NLR presents an attractive option as an exacerbation marker in COPD patients with CRF due to its simplicity and cost-effectiveness. In COPD patients with CRF, where the NLR is ≥3.54, PE levels are <2%, and subjective symptoms are present, antibiotic treatment should be considered.

Bringing Stability to the Chronic Obstructive Pulmonary Disease Patient: Clinical and Pharmacological Considerations for Frequent Exacerbators

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are critical events associated with an accelerated loss of lung function, increased morbidity, and excess mortality. AECOPD are heterogeneous in nature and this may directly impact clinical decision making, specifically in patients with frequent exacerbations. A 'frequent exacerbator' is a sub-phenotype of chronic obstructive pulmonary disease (COPD) and is defined as an individual who experiences two or more moderate-to-severe exacerbations per year. This distinct subgroup has higher mortality and accounts for more than half of COPD-related hospitalizations annually. Thus, it is imperative to identify individuals at risk for frequent exacerbations and choose optimal strategies to minimize risk for these events. New paradigms for using combination inhalers and the introduction of novel oral compounds provide expanded treatment options to reduce the risk and frequency of exacerbations. The goals of managing frequent exacerbators or patients at risk for AECOPD are: (1) maximizing bronchodilation; (2) reducing inflammation; and (3) targeting specific molecular pathways implicated in COPD and AECOPD pathogenesis. Novel inhaler therapies including combination long-acting muscarinic agents plus long-acting beta agonists show promising results compared with monotherapy or a long-acting beta agonist inhaled corticosteroid combination in reducing exacerbation risk among individuals at risk for exacerbations and among frequent exacerbators. Likewise, oral medications including macrolides and phosphodiesterase-4 inhibitors reduce the risk for AECOPD in select groups of individuals at high risk for exacerbation. Future direction in COPD management is based on the identification of various subtypes or 'endotypes' and targeting therapies based on their pathophysiology. This review describes the impact of AECOPD and the challenges posed by frequent exacerbators, and explores the rationale for different pharmacologic approaches to preventing AECOPD in these individuals.