Document Type : Original Article
Authors
1 Department of Chest Diseases ,Faculty of Medicine, Al-Azhar University,Cairo,Egypt
2 Chest Diseases, Al-Azhar University.
3 Department of Chest Diseases,Faculty of Medicine,Al-Azhar University,Cairo,Egypt
Abstract
Keywords
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is third cause of death in the world. Exacerbations of COPD affect a significant number of patients. Severe exacerbations are linked to worse outcome.1
An adverse outcome of COPD exacerbation, characterized by the presence of at least one of the following items: mortality from a respiratory cause during hospitalization or within one month of follow-up; admission to Intensive care unit (ICU); mechanical ventilation, invasive or non-invasive; prolonged hospitalization, defined by the upper quartile of hospital stay distribution, and emergency room visit or readmission due to COPD during follow-up. Absence of all the above-mentioned problems considers good outcome. 2
The need for invasive ventilation and complications due to mechanical ventilation (MV) are the most important predictors connected to hospital mortality in COPD exacerbation. Adequate metabolic compensation for respiratory acidosis at admission is linked with better outcome.3
The aim of this study to identify predictors of adverse outcomes in patients who were admitted to the hospital for exacerbation of COPD.
PATIENTS AND METHODS
This study was done at Chest diseases Departments of Al Azhar University Hospitals at March 2019 to March 2021.This study included 120 hospitalized patients with COPD. The patients were divided to 3 groups: Group I: patients with no need for MV. Group II: patients needed noninvasive MV. Group III: patients needed invasive MV.
A written informed consent were obtained from all the studied patients. All patients were subjected to full medical history, full physical examinations, laboratory investigation, calculation of Chronic obstructive pulmonary disease severity score (COPDSS) 4 , calculation of the Glasgow Coma Scale and spirometry including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and FEV1/FVC.
Data were analyzed by the Statistical Package for Social Science (IBM SPSS) version 20. Quantitative data were expressed as mean± standard deviation (SD). Qualitative data were expressed as frequency and percentage. The following tests were done: Chi-square test was used to compare between two groups with qualitative data. The comparison between more than two groups with quantitative data and parametric distribution were done by using One Way Analysis of Variance (ANOVA) test. The p-value was considered significant as the following : P > 0.05: Non-significant (NS), P < 0.05: Significant (S), P < 0.01: Highly significant (HS).
RESULTS
|
Hospital course |
||||||||
Patients improved (No.=84) |
Patients need noninvasive ventilation (No.=22) |
Patients need invasive ventilation (No.=14) |
Chi square test |
||||||
No |
% |
No |
% |
No |
% |
x2 |
p value |
||
Sex |
Female |
6 |
7.1% |
5 |
22.7% |
6 |
42.9% |
14.211 |
0.001 |
Male |
78 |
92.9% |
17 |
77.3% |
8 |
57.1% |
|||
Smoking status |
Non smoker |
7 |
8.3% |
4 |
18.2% |
6 |
42.9% |
12.120 |
0.002 |
smoker |
49 |
58.3% |
12 |
54.5% |
8 |
57.1% |
0.103 |
0.950 |
|
Ex-smoker |
28 |
33.3% |
6 |
27.3% |
0 |
0.0% |
6.581 |
0.037 |
|
Comorbidities |
Ischemic heart disease with hypertension |
1 |
1.2% |
2 |
9.1% |
2 |
14.3% |
6.789 |
0.034 |
Old ischemic stroke with hypertension |
2 |
2.4% |
1 |
4.5% |
4 |
28.6% |
15.066 |
0.001 |
|
Old hemorrhagic stroke with hypertension |
1 |
1.2% |
0 |
0.0% |
2 |
14.3% |
9.133 |
0.001 |
|
Hypertension |
22 |
26.2% |
3 |
13.6% |
0 |
0% |
5.837 |
0.054 |
|
Diabetes mellitus |
4 |
4.8% |
1 |
4.5% |
0 |
0% |
0.691 |
0.708 |
|
No comorbidities |
11 |
13.1% |
1 |
4.5% |
1 |
7.1% |
1.543 |
0.462 |
|
|
Previous exacerbations |
44 |
52.4% |
13 |
59.1% |
14 |
100% |
11.263 |
0.001 |
Hospitalization for COPD exacerbation |
42 |
50.0% |
10 |
45.5% |
14 |
100% |
13.113 |
0.001 |
|
Intubation last 5 years |
6 |
7.1% |
1 |
4.5% |
6 |
42.9% |
16.948 |
<0.001 |
|
Risk factors |
Air pollution |
8 |
9.5% |
6 |
27.3% |
4 |
28.6% |
6.597 |
0.037 |
Pneumonia |
36 |
42.9 |
3 |
13.6% |
6 |
42.9% |
6.545 |
0.038 |
|
Age |
Mean |
SD |
Mean |
SD |
Mean |
SD |
|
|
|
64.02 |
6.31 |
64.64 |
6.51 |
66.57 |
9.92 |
0.843 |
0.433 |
Table 1: characteristics of patients according to hospital course.
This table shows that there was statistically significant increase male, non-smoker and ex-smoker in patients improved. There was statistically significant increase in ischemic heart disease with hypertension, old ischemic stroke and old hemorrhagic stroke with hypertension. There was statistically significant increase in previous exacerbations, hospitalization for COPD exacerbation and intubation last 5 years in patients need invasive ventilation. There was statistically significant increase in air pollution and pneumonia in patients needed ventilation.
|
Hospital course |
||||||||
Patients improved (No.=84) |
Patients need noninvasive ventilation (No.=22) |
Patients need invasive ventilation (No.=14) |
Chi square test |
||||||
No |
% |
No |
% |
No |
% |
x2 |
p value |
||
Clinical characters |
Cough |
52 |
61.9% |
6 |
27.3% |
12 |
58.3% |
13.49 |
0.001 |
Dyspnea |
51 |
60.7% |
6 |
27.3% |
11 |
78.6% |
11.037 |
0.004 |
|
Fever |
20 |
23.8% |
11 |
50.0% |
3 |
21.4% |
6.261 |
0.044 |
|
Vital signs |
|
Mean |
SD |
Mean |
SD |
Mean |
SD |
|
|
Respiratory Rate, breath/min |
24.96 |
2.83 |
24.09 |
3.13 |
28.14 |
5.05 |
7.426 |
0.001 |
|
Heart Rate, beat/min |
92.00 |
11.39 |
91.86 |
8.81 |
98.64 |
14.49 |
2.129 |
0.124 |
|
Systolic blood pressure, mmHg |
132.98 |
16.13 |
128.64 |
17.26 |
110.71 |
22.00 |
10.227 |
<0.001 |
|
Diastolic blood pressure, mmHg |
83.69 |
8.92 |
81.82 |
10.97 |
72.14 |
13.11 |
8.238 |
<0.001 |
|
Temperature, °C |
36.71 |
0.74 |
36.81 |
0.98 |
36.87 |
0.92 |
0.312 |
0.733 |
Table 2: clinical characters and vital signs among studied groups.
There was statistically significant increase in dyspnea in patients needed ventilation. There was statistically significant increase respiratory rate in patients need invasive ventilation. There was statistically significant increase systolic blood pressure and diastolic blood pressure in patients improved.
|
Patients improved (No.=84) |
Patients need noninvasive ventilation (No.=22) |
Patients need invasive ventilation (No.=14) |
|
|
||||
Mean |
SD |
Mean |
SD |
Mean |
SD |
One way ANOVA |
p value |
||
Glasgow Coma Score(GCS) |
14.48 |
1.52 |
13.91 |
1.54 |
10.00 |
2.60 |
42.54 |
< 0.001 |
|
COPD Severity score (COPDSS) |
13.00 |
2.08 |
13.45 |
2.06 |
14.57 |
1.70 |
3.675 |
0.028 |
|
ABG |
Arterial pH |
7.36 |
0.06 |
7.27 |
0.07 |
7.28 |
0.11 |
18.254 |
< 0.001 |
PaO2, mmHg |
61.04 |
24.57 |
64.64 |
24.61 |
46.86 |
21.93 |
2.525 |
0.084 |
|
PaCo2, mmHg |
50.09 |
9.87 |
76.18 |
16.22 |
65.50 |
16.69 |
44.516 |
< 0.001 |
|
HCO3, mEq/L |
28.05 |
5.17 |
32.22 |
7.74 |
31.93 |
8.54 |
5.493 |
0.005 |
|
Spirometry |
FEV/FVC |
0.63 |
0.06 |
0.61 |
0.06 |
0.59 |
0.04 |
4.962 |
0.009 |
FVC |
73.45 |
6.62 |
72.41 |
3.89 |
68.29 |
2.46 |
4.669 |
0.011 |
|
FEV1 |
46.37 |
5.42 |
44.32 |
4.65 |
40.07 |
3.45 |
9.587 |
< 0.001 |
|
Chest X-ray |
|
No |
% |
No |
% |
No |
% |
Chi square test |
p value |
Hyperinflation |
58 |
69% |
17 |
77.2% |
8 |
57.1% |
1.627 |
0.443 |
|
Left Pleural effusion |
0 |
0% |
0 |
0% |
1 |
7.1% |
7.633 |
0.022 |
|
Bronchiectasis |
0 |
0% |
0 |
0% |
1 |
7.1% |
7.635 |
0.022 |
This table shows that there was statistically significant increase COPDSS, PaCo2, HCO3 and respiratory rate in
Table 3: Glasgow Coma Score, COPD Severity score (COPDSS), ABG, spirometry & chest x ray findings among studied patients.
patients need invasive ventilation. Also there was statistically significant increase in left pleural effusion and bronchiectasis in patients need mechanical ventilation. While there was an increase in GSC, arterial pH and spirometry valuesin patients improved.
|
Item |
No. |
% |
Indications of intubations |
Apnea |
3 |
21.4 |
Low Glasgow coma score |
5 |
35.7 |
|
Acute cardio vascular instability |
2 |
14.3 |
|
Failure of NIV with confusion |
3 |
21.4 |
|
Indications of intubation at time of admission |
Low Glasgow coma score |
4 |
66 |
Apnea |
2 |
33 |
|
|
Number of intubated patients at time of admission |
6 |
42% |
Table 4: Intubations among studied patients.
This table shows that most of studied patients were intubated due to low Glasgow coma score and 42% of the intubated patients were intubated at time of admission.
|
Patients improved (No.=84) |
Patients need noninvasive ventilation(No.=22) |
Patients need invasive ventilation(No.=14) |
Total |
Test |
p-value |
||||
|
No. |
% |
No. |
% |
No. |
% |
No. |
% |
|
|
Discharge |
77 |
91.7 |
21 |
95.9 |
4 |
28.6 |
102 |
85 |
39.7 |
000 |
Readmission |
7 |
8.3 |
1 |
4.5 |
6 |
42.9 |
14 |
11.7 |
15.2 |
000 |
Death |
0 |
0 |
0 |
0 |
4 |
28.6 |
4 |
3.3 |
31.3 |
000 |
Table 5: Outcome among all studied groups.
This table shows that there was high significance increase regarding discharge in patients improved and there was high significance increase regarding readmission and death in patients needed ventilation.
DISCUSSION
We studied 120 patients with COPD. Their mean age is 64.43±6.83 years old. This is correlating with reports from Ucgun et al in which mean age was 65.1 years. 3 85.8% of them were male. This result agrees with the results of several studies. 3, 5 the high prevalence of COPD in men is due to higher prevalence of smoking in this sex, and males are also more exposed to smoking than females. 6
Regarding smoking status 57.5% of patients were smokers, 28.3% of them were ex-smoker which is coping with results of the study done by Said et al. 7Approximately 50% of smokers developing COPD during their lifetime .8
In the present study patients were divided according to hospital course to three groups group I including 84 (70%) of studied patients who were improved, group II including 22 (18.3%) of studied patients who needed noninvasive ventilation and group III including 14 (11.7%) of studied Patients who needed invasive ventilation.
Our results indicated that patients suffered from ischemic heart disease with hypertension, old ischemic stroke and old hemorrhagic stroke with hypertension had bad hospital course which is coping with several studies that showed that patients with bad outcome of COPD exacerbation had more than two comorbidities, mostly cardiovascular comorbidities.5, 9 Anzueto et al reported that cardiovascular comorbidities are risk factors for bad outcome in COPD patients. 9
Table 1shows that there were statistically significant increase previous exacerbations (p value 0.001), hospitalization for COPD exacerbation (p value 0.001) and intubation last 5 years (p value <0.001) in patients need invasive ventilation. That is consistent with the results of Soler et al whitch shows increased risk of death with frequent exacerbations. 10These results can be explained by the increase of severity of exacerbations over time, and also sputum purulence increases throughout the disease. This suggests that patients with more severe exacerbations have more inflammation. 11
56.6% of patients were presented with dyspnea at admission, this finding is similar to results from Mohan et al. 12 In this work most of patients were presented with cough and dyspnea, reports from Grolimund et al and roche et al agreed with these results. 13, 14
Table 2 shows as regard to risk factors of COPD exacerbations among all studied groups there was statistically significant increase in air pollution and pneumonia in patients needed ventilation with p value of 0.037 and 0.038 respectively that may be due to complications of pneumonia and presence of air pollution that worsen the lung function.
As regard COPDSS there was statistically significant increase COPDSS in patients need invasive ventilation. Miravitlles et al showed that COPDSS was found to be a predictor for failure of treatment in COPD exacerbation.4
In this study ABG was statistically significant in patients need MV as regard lower PH and higher Co2, this correlate with results from Matkovic et al that assumed that ABG analysis had a high predictive value for outcome for patients hospitalized for COPD exacerbation5, also this result is coping with several studies that shows that higher Co2 was related to bad outcome of COPD patients. 15
In the current study the mean of FEV1/FVC was 0.62, mean of FVC was 72.66, mean of FEV1 was 45.26. There was statistically significant increase in spirometry values in patients improved, that is consistent with study by Matkovic et al which shows there is increased spirometry values in patients with good outcome. 5 Similar results have been found in many studies and may be explained by the degree of ventilatory impairment and also exposure to the risk of colonization by aggressive bacteria which causes exacerbation.16
Our study shows that 14 patients needed intubation. 35.7% of them was intubated due to Low Glasgow coma score, while 21.4% of patients was intubated due to apnea and 21.4% was intubated due to Failure of NIV with confusion that is coping with. 3 In this work 6 patients were intubated at time of admission. 66% was intubated due to low Glasgow coma score, 33% of them was intubated due to apnea.
Our results indicate that as regard outcome of all studied groups there was high significance increase regarding discharge in patients improved (p value 0.000) and there was high significance increase regarding readmission and death in patients needed ventilation (p value 0.000). That is coping with results of Mohan et al. 12The lowest readmission rate (4.5%) was with patients needed NIV. this result is attributed to that NIV increases alveolar ventilation and improves gas exchanges. also NIV reduces the patients’ effort, dyspnea, the need for intubation, length of stay in ICU and the mortality rate. 17
CONCLUSION
The need for invasive ventilation and complications due to mechanical ventilation (MV) are the most important predictors connected to hospital mortality in COPD exacerbation. Comorbidities with Cardio vascular diseases, previous exacerbations, hospitalization for COPD exacerbation, intubation last 5 years, exposure to air pollution and pneumonia, dyspnea at time of admission, increase COPDSS and increase respiratory rate, pleural effusion, and bronchiectasis had highest risks to invasive ventilation. There was increase regarding readmission and death in patients needed ventilation.