Predictors of Adverse Outcome in Patients Hospitalised for Exacerbation of Chronic Obstructive Pulmonary Disease

Abstract

Background: It is crucial to identify risk factors for poor evolution of patients admitted to hospital with chronic obstructive pulmonary disease (COPD) in order to provide adequate intensive therapy and closer follow-up. Objectives: To identify predictors of adverse outcomes in patients hospitalised for exacerbation of COPD. Methods: A prospective, observational study was conducted in patients admitted for exacerbation of COPD. Demographic and clinical parameters were evaluated, including different multidimensional prognostic scores. Adverse outcomes included the following: death during hospitalisation or 1-month follow-up, intensive care unit admission, invasive or non-invasive mechanical ventilation, prolonged hospitalisation (>11 days) and COPD-related emergency visit or readmission within 1 month after discharge. Univariate and multivariate analysis were performed. Results: Of 155 patients included, an adverse outcome occurred in 69 (45%). Patients with an adverse outcome had lower forced expiratory volume in 1 s (p = 0.004) and more frequent exacerbations (p = 0.011), more frequently used oxygen at home (p = 0.042) and presented with lower pH (p < 0.001), lower ratio of arterial oxygen pressure to the fraction of inspired oxygen (p = 0.006), higher arterial carbon dioxide pressure (p < 0.001) and a worse score on several prognostic indices at admission. Independent predictors of adverse outcome were exacerbation of COPD in the previous year [odds ratio 3.9, 95% confidence interval (CI) 1.6–9.9; p = 0.004], hypercapnia (odds ratio 9.4, 95% CI 3.7–23.6; p < 0.001) and hypoxaemia (odds ratio 4.3, 95% CI 1.5–12.6; p = 0.008). In the presence of all three characteristics, the probability of an adverse outcome was 95%, while hypercapnia was the strongest prognostic factor with a risk of 54%. Conclusions: Patients with previous exacerbation of COPD, hypercapnia and hypoxaemia had the highest risk of an unfavourable evolution. The calculation of prognostic indices did not provide additional discriminative power.

Predictors of the Need to Initiate Noninvasive Ventilation in Stable Outpatients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

“…Additionally, according to a univariate analysis, we detected two statistically significant predictors of the need to initiate NIV: PaCO2 and FEV1% predicted. It is reasonable that both the PaCO2 and FEV1% predicted, which are established prognostic factors in patients with COPD, are also predictors of the need to initiate NIV during exacerbation, given that the need for NIV support implies the development of severe respiratory failure associated with a poor prognosis (1,(24)(25)(26)(27)(28)(29). However, it is noteworthy that, in the multivariate logistic regression analysis, the severity of airway obstruction assessed according to the FEV1% predicted was no longer identified as a predictor.…”

“…Consequently, the PaCO2 is regarded to be a poor prognostic indicator in general and has been demonstrated to be associated with the development of COPD-AE (1,7,(24)(25)(26)(27)(28)(29)(30). However, the majority of studies have focused on severely hypoxemic patients requiring NIV or patients who had previously experienced COPD-AE.…”

Two cases of COPD benefitting from therapy with roflumilast

“…The combination of all these factors leads to diminished QoL, reduced exercise tolerance, increased risk of cardiovascular morbidity and greater risk of death [10]. In addition, it has been demonstrated that patients with previous exacerbation of COPD, hypercapnia and hypoxemia had the highest risk of an unfavorable evolution of the disease [11].…”

Clinical Factors Associated with an Increased Risk of Death at and During Hospitalization for an Acute Exacerbation of COPD (AECOPD) and for a Short Period after Discharge

“…Moreover, general blood gas alterations [12,14,16,[18][19] , in particular hypercapnia [12,14,19] or hypoxaemia [18,19] , have been found to be strong predictors of mortality. Notably, a very recent study [12] demonstrates that the severity of respiratory acidosis in AECOPD increases progressively the risk of death during hospitalization (pH = 7.25-7.35 versus pH > 7.35 Odds Ratio-OR = 1.58 with a 95% Confidence Interval-CI 1.28-1.94; pH < 7.25 versus pH > 7.35 OR = 2.31, 95% CI 1.72-3.10).…”

“…Starting from the concept that a predictor of a 30-day readmission is the variable ≥ 2 previous exacerbation in a period of 1-year prior to index hospitalization (Hazard Ratio-HR = 2.47, 95% CI 1.51-4.05, p < 0.001) [23] , the relationship in the events of AECOPD between the past and the prognosis is very close. Moreover, a study published in 2012 reported the presence of at least one previous exacerbation of COPD in the previous year [OR = 3.9, 95% CI 1.6-9.9, p = 0.004)] [19] as an independent predictor of adverse outcome defined by death during hospitalisation or the 1-month follow-up.…”