Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the ICU: An Observational Study From the OUTCOMEREA Database, 1997-2018

Use of Noninvasive vs Invasive Ventilation for Patients Hospitalized With Acute Exacerbation of COPD, 2010 to 2019

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) contribute to morbidity and mortality. Noninvasive ventilation (NIV), a resource-intensive intervention, decreases mortality and the need for invasive mechanical ventilation.

OBJECTIVE

To study NIV and mechanical ventilation use, NIV failure, and hospital NIV case volumes for inpatients with AECOPD from 2010 to 2019.

METHODS

This retrospective cohort study used the Nationwide Readmissions Database (2010-2019) for adults (≥40 years old) hospitalized for AECOPD. Rates of NIV and mechanical ventilation use and NIV failure were compared per year. Multivariable hierarchical regression models were used. Hospital case volumes of NIV use (overall and for patients with AECOPD) were compared across years.

RESULTS

Patients with AECOPD accounted for 3.35% of admissions in 2010 and 3.20% in 2019. Risk-adjusted rate (95% CI) of mechanical ventilation use decreased from 6.0% (5.6%-6.4%) to 4.5% (4.2%-4.8%); NIV use increased from 6.2% (5.6%-6.9%) to 10.9% (9.9%-12.0%). Noninvasive ventilation failure rate (95% CI) decreased from 7.8% (6.9%-8.7%) to 5.6% (5.0%-6.2%). Mean (SD) hospital case volume for NIV increased overall from 207.3 (237.0) in 2010 to 360.4 (447.4) in 2019 (P < .001); for patients with AECOPD, from 39.5 (37.8) to 79.0 (78.7) (P < .001).

CONCLUSIONS

From 2010 to 2019, mechanical ventilation use and NIV failure decreased; NIV use and hospital NIV case volumes increased. These results indicate greater need for monitored beds, equipment, and trained staff.

A Retrospective Evaluation of the Cardiometabolic Profile of Patients with COPD-Related Type 2 Respiratory Failure in the Intensive Care Unit

Background and Objectives: Chronic obstructive pulmonary disease (COPD) is a notable cause of morbidity and mortality worldwide and can become complicated by Type 2 respiratory failure. This study aimed to analyze the cardiological and metabolic comorbidities of patients admitted to the intensive care unit (ICU) due to COPD-related Type 2 respiratory failure and evaluate their effects on clinical outcomes. Materials and Methods: A retrospective analysis was conducted on 258 patients admitted to the secondary-level pulmonary disease intensive care unit between January 2022 and January 2024. Patients' demographic data, cardiological and metabolic comorbidities, laboratory parameters, and ICU-related variables were evaluated using statistical analysis methods. Results: The most common comorbidities were hypertension (57.0%), congestive heart failure (48.1%), diabetes mellitus (31.4%), and obesity (37.6%). Female patients had significantly higher rates of hypothyroidism, hypertension, obesity, and congestive heart failure compared to males. Patients diagnosed with chronic kidney disease (CKD) had markedly higher cardiothoracic ratios and proBNP levels. ICU length of stay was considerably longer in patients with acute kidney injury (AKI) and coronary artery disease (CAD). Cardiomegaly and obstructive sleep apnea syndrome (OSAS) were more frequently observed in obese patients. Additionally, in COPD patients, a body mass index (BMI) threshold of 25.5 was determined as a cutoff value for radiological cardiomegaly findings with a sensitivity of 69.9% and a specificity of 59.5%. Elevated pCO2 and bicarbonate levels in patients receiving long-term oxygen therapy (LTOT) were associated with advanced-stage COPD. Conclusions: Metabolic and cardiological comorbidities notably impact the clinical prognosis and ICU management of patients diagnosed with COPD and Type 2 respiratory failure. This study, which aims to provide a snapshot of the comorbidities in patients requiring ICU admission due to COPD exacerbation-related Type 2 respiratory failure but without a fatal course, seeks to highlight the key areas where preventive and protective healthcare services should be focused in this patient group. Special attention should be given to monitoring female and obese patients. Future studies should explore how individualized and preventive follow-ups and treatment approaches can improve patient outcomes, with a particular emphasis on these identified areas.

Management of severe exacerbations of COPD by French intensivists and adherence to guidelines

BACKGROUND

Severe exacerbations of chronic obstructive pulmonary disease (ECOPD) require hospitalization in intensive care unit (ICU) in 10 % of cases. This study aims to describe current practices for the management of severe ECOPD in the ICU and to evaluate adherence to the 2017 French guidelines.

METHODS

From March to May 2019, we conducted a cross-sectional multicenter survey across 80 ICUs in France. A 9-item questionnaire exploring physicians practices in terms of diagnostic workup and management of severe ECOPD was sent to participating centers.

RESULTS

Four hundred and thirty-eight physicians responded to the survey, 75 % were senior physicians, 39 % were certified medical intensivists and 67 % worked in a medical or respiratory ICU. Nebulized short-acting beta agonists prescription was mostly driven by the presence of wheezing, silent chest or respiratory failure, even though guidelines recommend them systematically for ECOPD (moderate adhesion to guidelines). Antibiotic prescription was mostly driven by increased sputum purulence and volume, fever, signs of respiratory distress or the severity of the underlying COPD, but was not deemed systematic in case of severity signs (poor adhesion to guidelines). Regarding the use of biomarkers for antibiotics prescription, adhesion to guidelines was moderate. The prescription of systemic corticosteroids was not deemed systematic but was rather considered if no improvement was observed 72 h after admission (good adhesion to guidelines).

CONCLUSION

Reported management of severe ECOPD does not follow all guidelines. Future works should focus on understanding barriers to clinical practice guidelines implementation.

A worldwide assessment of the mechanical ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease. Analysis of the VENTILAGROUP over time. A retrospective, multicenter study

BACKGROUND

The trend over time and across different geographical areas of outcomes and management with noninvasive ventilation or invasive mechanical ventilation in patients admitted for acute exacerbations of chronic obstructive pulmonary disease and treated with ventilatory support is unknown. The purpose of this study was to describe outcomes and identify variables associated with survival for patients admitted to an intensive care unit (ICU) with acute exacerbation of chronic obstructive pulmonary disease [aeCOPD] who received noninvasive or invasive mechanical ventilation worldwide.

METHODS

Retrospective, multi-national, and multicenter studies, including four observational cohort studies, were carried out in 1998, 2004, 2010, and 2016 for the VENTILAGROUP following the same methodology.

RESULTS

A total of 1,848 patients from 1,253 ICUs in 38 countries admitted for aeCOPD and need of ventilatory support were identified in the four study cohorts and included in the study. The overall incidence of aeCOPD as a cause for ventilatory support at ICU admission significantly decreased over time and varied widely according to the gross national income. The mortality of patients admitted to ICU for aeCOPD and ventilatory support significantly decreased over time regardless of the geographical area and gross national income; however, there is a remarkable variability in ICU mortality according to geographical area and gross national income. The use of NPPV as the first attempt at ventilatory support has significantly increased over time, with a parallel reduction of invasive mechanical ventilation regardless of gross national income.

CONCLUSION

In this worldwide observational study, including four sequential cohorts of patients over 18 years from 1998 to 2016, the mortality of patients admitted to ICU for aeCOPD and ventilatory support significantly decreased regardless of the geographical area and gross national income. Future research will need to investigate the reason for the remarkable variability in ICU mortality according to the geographical area, gross national income, and methods to select patients for the appropriate ventilatory support.

Prediction Model of In-Hospital Death for Acute Exacerbation of Chronic Obstructive Pulmonary Disease Patients Admitted to Intensive Care Unit: The PD-ICU Score

INTRODUCTION

Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) admitted to intensive care unit (ICU) are exposed to poor clinical outcomes, and no specific prognostic models are available among this population. We aimed to develop and validate a risk score for prognosis prediction for these patients.

METHODS

This was a multicenter observation study. AECOPD patients admitted to ICU were included for model derivation from a prospective, multicenter cohort study. Logistic regression analysis was applied to identify independent predictors for in-hospital death and establish the prognostic risk score. The risk score was further validated and compared with DECAF, BAP-65, CURB-65, and APACHE II score in another multicenter cohort.

RESULTS

Five variables were identified as independent predictors for in-hospital death in APCOPD patients admitted to ICU, and a corresponding risk score (PD-ICU score) was established, which was composed of procalcitonin >0.5 μg/L, diastolic blood pressure <60 mm Hg, need for invasive mechanical ventilation, disturbance of consciousness, and blood urea nitrogen >7.2 mmol/L. Patients were classified into three risk categories according to the PD-ICU score. The in-hospital mortality of low-risk, intermediate-risk, and high-risk patients was 0.3%, 7.3%, and 27.9%, respectively. PD-ICU score displayed excellent discrimination ability with an area under the receiver-operating characteristic curve (AUC) of 0.815 in the derivation cohort and 0.754 in the validation cohort which outperformed other prognostic models.

CONCLUSION

We derived and validated a simple and clinician-friendly prediction model (PD-ICU score) for in-hospital mortality among AECOPD patients admitted to ICU. With good performance and clinical practicability, this model may facilitate early risk stratification and optimal decision-making among these patients.

Respiratory Infection Triggering Severe Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Background

Data are scarce on respiratory infections during severe acute exacerbation of chronic obstructive pulmonary disease (COPD). This study aimed to investigate respiratory infection patterns in the intensive care unit (ICU) and identify variables associated with infection type and patient outcome.

Methods

A retrospective, single-centre cohort study. All patients admitted (2015-2021) to our ICU for severe acute exacerbation of COPD were included. Logistic multivariable regression analysis was performed to predict factors associated with infection and assess the association between infection and outcome.

Results

We included 473 patients: 288 (60.9%) had respiratory infection and 139 (29.4%) required invasive mechanical ventilation. Eighty-nine (30.9%) had viral, 81 (28.1%) bacterial, 34 (11.8%) mixed, and 84 (29.2%) undocumented infections. Forty-seven (9.9%) patients died in the ICU and 67 (14.2%) in hospital. Factors associated with respiratory infection were temperature (odds ratio [+1°C]=1.43, P=0.008) and blood neutrophils (1.07, P=0.002). Male sex (2.21, P=0.02) and blood neutrophils were associated with bacterial infection (1.06, P=0.04). In a multivariable analysis, pneumonia (cause-specific hazard=1.75, P=0.005), respiratory rate (1.17, P=0.04), arterial partial pressure of carbon-dioxide (1.08, P=0.04), and lactate (1.14, P=0.02) were associated with the need for invasive MV. Age (1.03, P=0.03), immunodeficiency (1.96, P=0.02), and altered performance status (1.78, P=0.002) were associated with hospital mortality.

Conclusions

Respiratory infections, 39.9% of which were bacterial, were the main cause of severe acute exacerbation of COPD. Body temperature and blood neutrophils were single markers of infection. Pneumonia was associated with the need for invasive mechanical ventilation but not with hospital mortality, as opposed to age, immunodeficiency, and altered performance status.