Mortalité intrahospitalière au cours des exacerbations aiguës de BPCO. Étude EABPCO-CPHG du Collège des pneumologues des hôpitaux généraux (CPHG)

Evaluation of exacerbation severity in patients with COPD exacerbations according to the GOLD 2023 report

BACKGROUND

The criteria for COPD exacerbation were redefined in the GOLD 2023 report. This study aimed to evaluate and compare the severity of exacerbations in patients hospitalized with COPD exacerbations [ECOPD] based on the new severity classification defined in the GOLD 2023 report.

RESEARCH DESIGN AND METHODS

A prospective, cross-sectional, and observational study included a total of 513 ECOPD patients from nine university hospitals. Patients were classified into three groups according to the GOLD 2023 COPD exacerbation severity criteria.

RESULTS

The mean age of the total patients was 68.9 ± 8.8 years, with 83.4% being male. The distribution of exacerbation severity was as follows: mild [24.4%], moderate [50.8%], and severe [24.8%]. The rate of ICU admission [0.8%-4.2%-27.5%] and in-hospital mortality [1.6%-3.9%-9.2%] increased progressively from the mild to the severe exacerbation group [p < 0.001; p = 0.012, respectively]. Factors affecting 180-day mortality included age, smoking pack-years, mMRC score, hypoxemia, elevated CRP, low HCT, low eosinophil, CCI, and experiencing moderate to severe exacerbations. Severe exacerbations were associated with COPD duration, smoking pack-years, mMRC score, hypoxemia, low eosinophil, reduced FEV1%, and treatment non-adherence.

CONCLUSIONS

Our study demonstrates that the new ECOPD severity classification is a distinctive and objective tool for predicting ICU admission and in-hospital mortality.

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.

[S.AGES Study. Collection and follow-up of new sleep apnea cases in patients over 70 years of age and diagnosed in pulmonary and geriatric units]

RATIONALE

S.AGES is a prospective cohort of >70-years-old patients with obstructive sleep apnea syndrome having been diagnosed in a pulmonary or a geriatric medical unit.

OBJECTIVES

The main objective of S.AGES is to get a description of older patients with OSAS in France. The secondary objectives will be to prospectively describe the management and the treatment of these patients, to describe their 5-years outcome as compared to younger patients in the literature. It will also contribute to better characterize the compliance and tolerance of the treatment and the incidence of comorbidities like respiratory diseases and cardiovascular disorders.

METHODS

All consecutive ≥70-years-old patients having received a diagnosis of OSAS (after polygraphy or polysomnography) will be included in the study. All patients will be followed in a pulmonary or a geriatric department.

EXPECTED RESULTS

S.AGES should better characterize the OSAS in the elderly patients, the specific management of this disease and its related risk factors. It may also identify the 5-years mortality and morbidity rates in this population.

A clinical in-hospital prognostic score for acute exacerbations of COPD

Background

The use of a severity score to help orientation decisions could improve the efficiency of care for acute exacerbations of COPD (AECOPD). We previously developed a score (‘2008 score’, based on age, dyspnea grade at steady state and number of clinical signs of severity) predicting in-hospital mortality in patients with AECOPD visiting emergency departments (EDs). External validity of this score remained to be assessed.

Objectives

To test the predictive properties of the ‘2008 score’ in a population of patients hospitalized in medical respiratory wards for AECOPD, and determine whether a new score specifically derived from this population would differ from the previous score in terms of components or predictive performance.

Methods

Data from a cohort study in 1824 patients hospitalized in a medical ward for an AECOPD were analyzed. Patients were categorized using the 2008 score and its predictive characteristics for in-hospital mortality rates were assessed. A new score was developed using multivariate logistic regression modeling in a randomly selected derivation population sample followed by testing in the remaining population (validation sample). Robustness of results was assessed by case-by-case validation.

Results

The 2008 score was characterized by a c-statistic at 0.77, a sensitivity of 69% and a specificity of 76% for prediction of in-hospital mortality. The new score comprised the same variables plus major cardiac comorbidities and was characterized by a c-statistic of 0.78, a sensitivity of 77% and specificity of 66%.

Conclusions

A score using simple clinical variables has robust properties for predicting the risk of in-hospital death in patients hospitalized for AECOPD. Adding cardiac comorbidities to the original score increased its sensitivity while decreasing its specificity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-014-0099-9) contains supplementary material, which is available to authorized users.

[Evaluation of the management of COPD exacerbations: an audit in French emergency services]

INTRODUCTION

Acute exacerbations of chronic obstructive pulmonary disease (COPD) patients are major events in the history of this chronic respiratory disease. Their management in French emergency services is unknown, although national guidelines exist.

METHODS

This is a descriptive audit study, over a 10 weeks period (12/01-22/03/2009), of the management of COPD exacerbations in the RESUVal (Réseau des Urgences de la Vallée du Rhône, France) network emergency departments.

RESULTS

The enrollement of 16 emergency units allowed the analysis of 221 exacerbations of COPD. Measurement of respiratory rate and description of the sputum were mentioned in only 99 (45%) medical records. The rest of the initial assessment was generally satisfactory. Regarding the therapeutic management, 215 (97%) patients received oxygen, beta-2-agonist aerosols were administrated for 209 (95%) patients and anticholinergic aerosols were used for 176 (80%) patients. A systemic corticosteroid and antibiotics were respectively prescribed for 116 (52%) and 123 (56%) patients. Non-invasive ventilation (NIV) was used in only 59% of patients presenting a pH<7.35.

CONCLUSIONS

These findings demonstrate that management of exacerbations of COPD could be improved through systematic patients' respiratory rate and sputum characteristics recording or NIV utilization reinforcement.

Midregional proatrial natriuretic peptide predicts survival in exacerbations of COPD

BACKGROUND

Recently, the use of systemic biomarkers to monitor and assess the clinical evolution of respiratory disease has gained interest. We investigated whether midregional proatrial natriuretic peptide (MR-proANP) predicts survival in patients with COPD when they are admitted to the hospital for exacerbation.

METHODS

One hundred sixty-seven patients (mean age 70 years old, 75 men) admitted to the hospital for exacerbation were followed up for 2 years. MR-proANP was measured on admission, after 14 days, and at 6 months. The predictive value of clinical, functional, and laboratory parameters on admission were assessed by Cox regression analyses. The time to death was analyzed by Kaplan-Meier survival curves.

RESULTS

MR-proANP level was significantly higher on admission for exacerbation, compared with recovery and stable state (P = .004 for the comparison among all time points). MR-proANP correlated with the Charlson condition and age-related score (P < .0001), left ventricular ejection fraction (P < .0001), C-reactive protein (P = .037), and FEV(1)% predicted (P = .004). MR-proANP levels were similar in patients requiring ICU treatment and in those treated in the medical ward (P = .086). Thirty-seven patients (22%) died within 2 years. MR-proANP levels were higher in nonsurvivors compared with survivors (median [interquartile range] 185 pmol/L [110-286] vs 92 pmol/L [56-158], P < .001). Mortality was higher across MR-proANP quartiles (log rank P < .0001). Charlson condition and age-related score (P = .001), Paco(2) (P < .0001), and MR-proANP (P = .001) predicted mortality in the univariate Cox-regression model. Both MR-proANP and Paco(2) were independent predictors of mortality in the multivariate Cox regression model.

CONCLUSIONS

MR-proANP at exacerbation is associated with 2-year long-term survival in patients with exacerbation of COPD.