Management of severe acute exacerbations of COPD: an updated narrative review

Inhaled antibiotics: A promising drug delivery strategies for efficient treatment of lower respiratory tract infections (LRTIs) associated with antibiotic resistant biofilm-dwelling and intracellular bacterial pathogens

Antibiotic-resistant bacteria associated with LRTIs are frequently associated with inefficient treatment outcomes. Antibiotic-resistant Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus, infections are strongly associated with pulmonary exacerbations and require frequent hospital admissions, usually following failed management in the community. These bacteria are difficult to treat as they demonstrate multiple adaptational mechanisms including biofilm formation to resist antibiotic threats. Currently, many patients with the genetic disease cystic fibrosis (CF), non-CF bronchiectasis (NCFB) and chronic obstructive pulmonary disease (COPD) experience exacerbations of their lung disease and require high doses of systemically administered antibiotics to achieve meaningful clinical effects, but even with high systemic doses penetration of antibiotic into the site of infection within the lung is suboptimal. Pulmonary drug delivery technology that reliably deliver antibacterials directly into the infected cells of the lungs and penetrate bacterial biofilms to provide therapeutic doses with a greatly reduced risk of systemic adverse effects. Inhaled liposomal-packaged antibiotic with biofilm-dissolving drugs offer the opportunity for targeted, and highly effective antibacterial therapeutics in the lungs. Although the challenges with development of some inhaled antibiotics and their clinicals trials have been studied; however, only few inhaled products are available on market. This review addresses the current treatment challenges of antibiotic-resistant bacteria in the lung with some clinical outcomes and provides future directions with innovative ideas on new inhaled formulations and delivery technology that promise enhanced killing of antibiotic-resistant biofilm-dwelling bacteria.

Analysis of the total serum IgE levels in patients with acute exacerbations chronic obstructive pulmonary disease: A retrospective study

Currently, few studies have demonstrated the relationship between total serum IgE (T-IgE) and acute exacerbation chronic obstructive pulmonary disease (AECOPD). In this study, T-IgE in AECOPD patients were investigated and jointly analyzed with the clinical characteristics. AECOPD patients hospitalized from July 2018 to July 2019 were included in this study. In this patient cohort, clinical information was investigated. Routine blood tests, C-reactive protein and T-IgE levels of patients were determined along with blood gas analysis. The length of hospital stays, mechanical ventilation during hospitalization, ICU admission, glucocorticoid related clinical information were recorded. A total of 285 AECOPD patients were included in this study, which consisted of a high proportion of males. Of all patients, 49.82% patients exhibited higher T-IgE levels. Based on the reference T-IgE value 60 kU/L, patients were divided into high T-IgE group with T-IgE > 60 kU/L, and low T-IgE group with T-IgE ≤ 60 kU/L. There was no significant difference in the dosage of glucocorticoid between the two groups. Patients in the high T-IgE group had shorter hospital stays and lower probability of mechanical ventilation compared to the low T-IgE group. After adjustment for confounding factors, T-IgE was negatively correlated with the length of hospital stays. AECOPD patients with elevated T-IgE had shorter hospital stays and lower risks of mechanical ventilation and ICU admission. Our results showed that T-IgE might play an important role on evaluating the condition and guiding for treatment decisions in AECOPD patients.

Prognostic Value of Leukocyte-Based Risk Model for Acute Kidney Injury Prediction in Critically Ill Acute Exacerbation of Chronic Obstructive Pulmonary Disease Patients

Purpose

Acute kidney injury (AKI) is a common complication of acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and inflammation is the potential link between AKI and AECOPD. However, little is known about the incidence and risk stratification of AKI in critically ill AECOPD patients. In this study, we aimed to establish risk model based on white blood cell (WBC)-related indicators to predict AKI in critically ill AECOPD patients.

Material and Methods

For the training cohort, data were taken from the Medical Information Mart for eICU Collaborative Research Database (eICU-CRD) database, and for the validation cohort, data were taken from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. The study employed logistic regression analysis to identify the major predictors of WBC-related biomarkers on AKI prediction. Subsequently, a risk model was developed by multivariate logistic regression, utilizing the identified significant indicators.

Results

Finally, 3551 patients were enrolled in training cohort, 926 patients were enrolled in validation cohort. AKI occurred in 1206 (33.4%) patients in training cohort and 521 (56.3%) patients in validation cohort. According to the multivariate logistic regression analysis, four WBC-related indicators were finally included in the novel risk model, and the risk model had a relatively good accuracy for AKI in the training set (C-index, 0.764, 95% CI 0.749-0.780) as well as in the validation set (C-index, 0.738, 95% CI: 0.706-0.770). Even after accounting for other models, the critically ill AECOPD patients in the high-risk group (risk score > 3.44) still showed an increased risk of AKI (odds ratio: 4.74, 95% CI: 4.07-5.54) compared to those in low-risk group (risk score ≤ 3.44). Moreover, the risk model showed outstanding calibration capability as well as therapeutic usefulness in both groups for AKI and ICU mortality and in-hospital mortality of critical ill AECOPD patients.

Conclusion

The novel risk model showed good AKI prediction performance. This risk model has certain reference value for the risk stratification of AECOPD complicated with AKI in clinically.

Glucocorticoid Use in Patients Hospitalized with Chronic Obstructive Pulmonary Disease Exacerbations

Objective of the Study

Systemic glucocorticoid therapy can improve the outcomes of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The study tried to investigate the use of glucocorticoids in AECOPD patients and the factors associated with the physicians' choice.

Methodology

Patients with AECOPD over two periods were divided by the year of 2017 when GOLD and ERS/ATS Guideline for COPD were updated. Data of patients regarding the study was retrieved from medical records. Descriptive statistical analysis was used for the illustration of glucocorticoids use, and hypothesis testing for comparison over the periods.

Results

Between 2010 and 2016, the proportion of ICS use was 522/640 (81.6%) and 341/452 (75.4%) between 2017 and 2020. COPD severity (GOLD C/D classification), bronchial asthma, percentage of neutrophils, and higher PaCO2 were factors associated with physicians' prescription of systemic glucocorticoids between 2010 and 2016. While the use of ICS at the stable stage, counts of neutrophils, and higher PaCO2 were influencing factors between 2017 and 2020. Over the two periods, 1-year recurrent rate decreased from 32.4% to 20.9%, with a significant statistical difference (P<0.001).

Conclusion

The optimized use of glucocorticoids was found after the publishment of 2017 ERS/ATS Guideline for COPD, this improvement was associated with a decreased 1-year recurrence rate among AECOPD patients at our institution, underscoring the positive impact of guideline updates on patient outcomes.

Association Between Rome Classification Among Hospitalized Patients With COPD Exacerbations and Short-Term and Intermediate-Term Outcomes

BACKGROUND

Recently, the Rome proposal updated the definition of exacerbation of COPD (ECOPD). However, such severity grade has not yet demonstrated intermediate-term clinical relevance.

RESEARCH QUESTION

What is the association between the Rome severity classification and short-term and intermediate-term clinical outcomes?

STUDY DESIGN AND METHODS

We retrospectively grouped hospitalized patients with ECOPD according to the Rome severity classification (ie, mild, moderate, severe). Baseline, clinical, microbiologic, gas analysis, and laboratory variables were collected. In addition, data about the length of hospital stay and mortality (in-hospital and a follow-up time line from 6 months until 3 years) were assessed.

RESULTS

Of the 347 hospitalized patients, 39% were categorized as mild, 31% were categorized as moderate, and 30% were categorized as severe. Overall, patients with severe ECOPD had an extended length of hospital stay. Although in-hospital mortality was similar among groups, patients with severe ECOPD presented a worse prognosis in all follow-up time points. The Kaplan-Meier curves show the role of the severe classification in the cumulative survival at 1 and 3 years (Gehan-Breslow-Wilcoxon test, P = .032 and P = .004, respectively). The multivariable Cox regression analysis showed a higher risk of death at 1 year when patients presented a severe (hazard ratio, 1.99; 95% CI, 1.49-2.65) or moderate grade (hazard ratio, 1.47; 95% CI, 1.10-1.97) compared with a mild grade. Older patients (aged ≥ 80 years), patients requiring long-term oxygen therapy, or patients reporting previous ECOPD episodes had a higher mortality risk. A BMI between 25 and 29 kg/m2 was associated with a lower risk.

INTERPRETATION

The Rome classification makes it possible to discriminate patients with a worse prognosis (severe or moderate) until a 3-year follow-up.

Pulmonary rehabilitation for acute exacerbations of COPD: A systematic review

INTRODUCTION AND OBJECTIVES

This systematic review summarized the evidence on the effects (benefits and harms) of pulmonary rehabilitation for individuals with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

MATERIAL AND METHODS

We included randomized controlled trials comparing pulmonary rehabilitation to either active interventions or usual care regardless of setting. In March 2022, we searched MEDLINE, Scopus, CENTRAL, CINAHL and Web of Sciences, and trial registries. Record screening, data extraction and risk of bias assessment were undertaken by two reviewers. We assessed the certainty of the evidence using the GRADE approach.

RESULTS

This systematic review included 18 studies (n = 1465), involving a combination of mixed settings (8 studies), inpatient settings (8 studies), and outpatient settings (2 studies). The studies were at high risk of performance, detection, and reporting biases. Compared to usual care, pulmonary rehabilitation probably improves AECOPD-related hospital readmissions (relative risk 0.56, 95% CI 0.36 to 0.86; moderate certainty evidence) and cardiovascular submaximal capacity (standardized mean difference 0.73, 95% CI 0.48 to 0.99; moderate certainty evidence). Low certainty evidence suggests that pulmonary rehabilitation may be beneficial on re-exacerbations, dyspnoea, and impact of disease. The evidence regarding the effects of pulmonary rehabilitation on health-related quality of life and mortality is very uncertain (very low certainty evidence).

CONCLUSION

Our results indicate that pulmonary rehabilitation may be an effective treatment option for individuals with AECOPD, irrespective of setting. Our certainty in this evidence base was limited due to small studies, heterogeneous rehabilitation programs, numerous methodological weaknesses, and a poor reporting of findings that were inconsistent with each other. Trialists should adhere to the latest reporting standards to strengthen this body of evidence.

REGISTRATION

The study protocol was registered in Open Science Framework (https://osf.io/amgbz/).

Serum YKL-40 Levels, Leukocyte Profiles, and Acute Exacerbations of Advanced COPD

Little information exists on YKL-40-a key protein in tissue remodeling-and complete blood count (CBC) parameters during acute exacerbations of advanced chronic obstructive pulmonary disease (COPD). This pilot exploratory study (August 2020-January 2021) investigated the connection between serum YKL-40 levels and CBC profile in sex- and age-matched individuals with severe COPD (GOLD stage III, n = 23, median age = 66 years, 65.21% males) and very severe COPD (GOLD stage IV, n = 24, median age = 66.5 years, 74.81% males). The measured parameters were serum YKL-40, absolute leukocyte count (ALLC), absolute neutrophil count (ANC), neutrophil percentage, absolute lymphocyte count (ALC), lymphocyte percentage, neutrophil-to-lymphocyte ratio (NLR), absolute eosinophil count (AEC), eosinophil percentage, absolute monocyte count (AMC), monocyte percentage, absolute basophil count (ABC), basophil percentage, hemoglobin levels, and hematocrit concentrations. No significant inter-group differences were observed. However, high YKL-40 subjects (n = 23)-as stratified via median YKL-40 (3934.5 pg/mL)-showed significantly increased neutrophil percentage and NLR but significantly lower lymphocyte-, eosinophil-, and basophil-related parameters compared to low YKL-40 patients (n = 24). These results reveal multidimensional, YKL-40-associated changes in leukocyte profile of patients with advanced COPD during acute exacerbations, with potential implications for personalized treatment.

A Prediction Model for In-Hospital Mortality of Acute Exacerbations of Chronic Obstructive Pulmonary Disease Patients Based on Red Cell Distribution Width-to-Platelet Ratio

Purpose

To explore the association between red cell distribution width (RDW)-to-platelet ratio (RPR) and in-hospital mortality of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients and establish a prediction model based on RPR and other predictors.

Material and Methods

This cohort study included 1922 AECOPD patients aged ≥18 years in the Medical Information Mart for Intensive Care (MIMIC)-III and MIMIC-IV as well as 1738 AECOPD patients from eICU Collaborative Research Database (eICU-CRD). Possible confounding factors were screened out by univariate logistic regression, and multivariable logistic regression was applied to evaluate the association between RPR and in-hospital mortality of AECOPD patients. The area under the curve (AUC), calibration curve and decision curve analysis (DCA) curve were plotted to evaluate the predictive value of the model. The median follow-up time was 3.14 (1.87, 6.25) day.

Results

At the end of follow-up, there were 1660 patients survived and 262 subjects died. After adjusting for confounders, we found that Log (RPR×1000) was linked with elevated risk of in-hospital mortality of AECOPD patients [odds ratio (OR)=1.36, 95% confidence interval (CI): 1.01-1.84]. The prediction model was constructed using predictors including Log (RPR×1000), age, malignant cancer, atrial fibrillation, ventilation, renal failure, diastolic blood pressure (DBP), temperature, Glasgow Coma Scale (GCS) score, white blood cell (WBC), creatinine, blood urea nitrogen (BUN), hemoglobin, infectious diseases and anion gap. The AUC of the prediction model was 0.785 (95% CI: 0.751-0.820) in the training set, 0.721 (95% CI: 0.662-0.780) in the testing set, and 0.795 (95% CI: 0.762-0.827) in the validation set.

Conclusion

RPR was associated with the in-hospital mortality of AECOPD patients. The prediction model for the in-hospital mortality of AECOPD patients based on RPR and other predictors presented good predictive performance, which might help the clinicians to quickly identify AECOPD patients at high risk of in-hospital mortality.

Clinical evaluation of ventilation mode on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure

BACKGROUND

At present, understanding of the most effective ventilation methods for treating chronic obstructive pulmonary disease (COPD) patients experiencing acute worsening symptoms and respiratory failure remains relatively limited. This report analyzed the efficiency and side effects of various ventilation techniques used for individuals experiencing an acute COPD exacerbation.

AIM

To determine whether pressure-controlled ventilation (PCV) can lower peak airway pressures (PAPs) and reduce the incidence of barotrauma compared to volume-controlled ventilation (VCV), without compromising clinical outcomes and oxygenation parameters.

METHODS

We have evaluated 600 patients who were hospitalized due to a severe COPD exacerbation, with 400 receiving mechanical ventilation for the respiratory failure. The participants were divided into two different groups, who were administered either VCV or PCV, along with appropriate management. We thereafter observed patients' attributes, clinical factors, and laboratory, radiographic, and arterial blood gas evaluations at the start and during their stay in the intensive care unit (ICU). We have also employed appropriate statistical methods for the data analysis.

RESULTS

Both the VCV and PCV groups experienced significant enhancements in the respiratory rate, tidal volume, and arterial blood gas values during their time in the ICU. However, no significant distinctions were detected between the groups in terms of oxygenation indices (partial pressures of oxygen/raction of inspired oxygen ratio) and partial pressures of carbon dioxide improvements. There was no considerable disparity observed between the VCV and PCV groups in the hospital mortality (32% vs 28%, P = 0.53), the number of days of ICU stay [median interquartile range (IQR): 9 (6-14) d vs 8 (5-13) d, P = 0.41], or the duration of the mechanical ventilation [median (IQR): 6 (4-10) d vs 5 (3-9) d, P = 0.47]. The PCV group displayed lower PAPs compared to the VCV group (P < 0.05) from the beginning of mechanical ventilation until extubation or ICU departure. The occurrence of barotrauma was considerably lower in the PCV group in comparison to the VCV group (6% vs 16%, P = 0.03).

CONCLUSION

Both VCV and PCV were found to be effective in treating patients with acute COPD exacerbation. However, PCV was associated with lower PAPs and a significant decrease in barotrauma, thus indicating that it might be a safer ventilation method for this group of patients. However, further large-scale study is necessary to confirm these findings and to identify the best ventilation approach for patients experiencing an acute COPD exacerbation.

The utility of long non-coding RNAs in chronic obstructive pulmonary disease: a comprehensive analysis

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality in the world. However, there are some patients who are not diagnosed early and correctly through routine methods because of inconspicuous or serious symptoms. This study aims to assess the diagnostic role of long non-coding RNA (lncRNA) in COPD.

METHODS

We searched literature from electronic databases, after excluding non-COPD literature, the bibliometric analysis was performed, and VOSviewer software was used to represent the data analyzed. Literature evaluating the diagnostic test accuracy of lncRNA for COPD was eligible, and the QUADAS-2 checklist was used to evaluate the quality. The pooled sensitivity (SEN), specificity (SPE), diagnostic odds ratio (DOR), and summary receiver operating characteristic curve (sROC) were used to analyze the overall diagnostic performance. Subgroup and meta-regression analyses were performed to explore the heterogeneity, and a funnel plot was assessed for publication bias. Also, lncRNAs related to COPD were identified and explored for their potential biological function.

RESULTS

An increased annual growth rate of literature on this subject from 2016 focused on COPD, humans, RNA, and lncRNA. The meta-analysis enrolled 17 literature indicated that the SEN, SPE, and DOR differentiating COPD patients from normal controls (NCs) were 0.86 (95% CI [0.80, 0.90]), 0.78 (95% CI [0.67, 0.86]), and 21.59 (95% CI [11.39, 40.91]), respectively. Meanwhile, lncRNAs had the ability to distinguish acute exacerbations of COPD (AECOPD) patients from COPD; the SEN, SPE, and DOR were 0.75 (95% CI [0.62, 0.85]), 0.81 (95% CI [0.71, 0.89]), and 13.02 (95% CI [7.76, 21.85]), respectively. The area under the sROC were calculated to be greater than 0.8 at least. Subgroup and meta-regression analysis showed that the types of specimens and dysregulated lncRNAs might affect the diagnostic accuracy. The funnel plot showed there was a certain publication bias. 41 lncRNAs related to COPD were identified and mainly located in the nucleus and cytoplasm, associated with proliferation, invasion, and prognosis. These lncRNA-binding proteins were involved in the spliceosome, Rap1 signaling pathway, MAPK signaling pathway, and so on.

CONCLUSION

LncRNA suggests potential diagnostic biomarkers and therapeutic targets for COPD patients.

Changes in tidal breathing biomarkers as indicators of treatment response in AECOPD patients in an acute care setting

PURPOSE

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a complication of COPD that typically necessitates intensified treatment and hospitalization. It is linked to higher morbidity, mortality and healthcare spending. Assessment of therapy response for AECOPD is difficult due to the variability of symptoms and limitations in current measures. Hence, there is a need for new biomarkers to aid in the management of AECOPD in acute care settings.

MATERIALS AND METHODS

Fifteen hospitalized AECOPD patients (GOLD 3-4) were enrolled in this study. Treatment response was assessed daily through clinical evaluations and by monitoring tidal breathing biomarkers (respiratory rate [RR], expiratory time [Tex], inspiratory time [Tin], expiratory pause [Trst], total breath time [Ttot]), using a novel, wearable nanosensor-based device (SenseGuard™).

RESULTS

Patients who showed significant clinical improvement had substantial changes in ΔTex/Ttot (+14%), ΔTrst/Ttot (-18%), and ΔTin/Tex (+0.09), whereas patients who showed mild or no clinical improvement had smaller changes (+5%, +3%, and -0.03, respectively). Linear regression between change in physician's assessment score and the median change in tidal breathing parameters was significant for Tin/Tex (R2 ​= ​0.449, ∗p ​= ​0.017), Tex/Ttot (R2 ​= ​0.556, ∗p ​= ​0.005) and Trst/Ttot (R2 ​= ​0.446, ∗p ​= ​0.018), while no significant regression was observed for RR, Tin/(Trst ​+ ​Tex) and Tin/Ttot.

CONCLUSIONS

Our study demonstrates the potential of the SenseGuard™ to monitor treatment response in AECOPD patients by measuring changes in tidal breathing biomarkers, which were shown to be associated with significant changes in the patients' respiratory condition as evaluated by physicians. However, further large-scale clinical studies are needed to confirm these findings.

Effects of secretome supplementation on interleukin-6, tumor necrosis factor-α, procalcitonin, and the length of stay in acute exacerbation COPD patients

Acute exacerbation chronic obstructive pulmonary disease (AECOPD) is associated with significant poor survival. Mesenchymal stem cells (MSC) therapy has been a promising treatment for COPD; therefore, it has the potential to be an additional therapy for AECOPD. Its potential is associated with its secretome since it has anti-inflammatory and immunomodulator activities. The aim of this study was to determine the effect of the secretome as an adjuvant therapy in reducing the levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), procalcitonin, and the length of stay in AECOPD patients. A clinical control trial study was conducted among 28 moderate and severe AECOPD patients who were hospitalized from January to February 2023. The control group (n=14) received standard therapy of AECOPD while the treatment group (n=14) received standard therapy plus secretome 1 ml twice daily for three days. The levels of IL-6, TNF-α, and procalcitonin were measured at admission and on the fourth day of treatment. The length of stay was calculated from the time the patient was admitted until the patient was discharged from hospital. The data were compared using a paired Student t-test, chi-squared test and Mann-Whitney test as appropriate. In the treatment group, the levels of IL-6, TNF-α and procalcitonin after the treatment reduced 13.09 pg/mL, 5.00 pg/mL and 751.26 pg/mL, respectively compared to pre-treatment. In contrast, the levels of IL-6, TNF-α and procalcitonin increased 48.56 pg/mL, 44.48 pg/mL and 346.96 pg/mL, respectively after four days of treatment. There was a significant reduction of IL-6, TNF-α and procalcitonin in treatment group compared to the control group with p=0.022, p=0.009 and p=0.001, respectively. However, there was no significant reduction of the length of stay (p=0.072). In conclusion, administration of secretome to AECOPD patients could reduce the levels of IL-6, TNF-α and procalcitonin.

Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions

Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.

ERS International Congress 2022: highlights from the Respiratory Clinical Care and Physiology Assembly

It is a challenge to keep abreast of all the clinical and scientific advances in the field of respiratory medicine. This article contains an overview of the laboratory-based science, clinical trials and qualitative research that were presented during the 2022 European Respiratory Society International Congress within the sessions from the five groups of Assembly 1 (Respiratory Clinical Care and Physiology). Selected presentations are summarised from a wide range of topics: clinical problems, rehabilitation and chronic care, general practice and primary care, mobile/electronic health (m-health/e-health), clinical respiratory physiology, exercise and functional imaging.

COPD Exacerbation: Why It Is Important to Avoid ICU Admission

Chronic obstructive pulmonary disease (COPD) is one of the major causes of morbidity and mortality worldwide. Hospitalization due to acute exacerbations of COPD (AECOPD) is a relevant health problem both for its impact on disease outcomes and on health system resources. Severe AECOPD causing acute respiratory failure (ARF) often requires admission to an intensive care unit (ICU) with endotracheal intubation and invasive mechanical ventilation. AECOPD also acts as comorbidity in critically ill patients; this condition is associated with poorer prognoses. The prevalence reported in the literature on ICU admission rates ranges from 2 to 19% for AECOPD requiring hospitalization, with an in-hospital mortality rate of 20-40% and a re-hospitalization rate for a new severe event being 18% of the AECOPD cases admitted to ICUs. The prevalence of AECOPD in ICUs is not properly known due to an underestimation of COPD diagnoses and COPD misclassifications in administrative data. Non-invasive ventilation in acute and chronic respiratory failure may prevent AECOPD, reducing ICU admissions and disease mortality, especially when associated with a life-threating episode of hypercapnic ARF. In this review, we report on up to date evidence from the literature, showing how improving the knowledge and management of AECOPD is still a current research issue and clinical need.

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

OBJECTIVES

Our aim was to describe changes in the management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) by ICUs and patient outcomes.

DESIGN

We extracted data from the OutcomeRea database concerning patients admitted for AECOPD between 1997 and 2018. We analyzed trends in the use of ventilatory support, corticosteroid therapy, antibiotic therapy, and patient survival.

SETTING

ICUs at 32 French sites.

PATIENTS

One thousand eight hundred sixteen patients in the database had a diagnosis of AECOPD.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over time, there was a reduction in the prescription of corticosteroids and antibiotics. In a time-series analysis, these changes in practice were not linked with ICU mortality. The proportion of patients treated with invasive mechanical ventilation (IMV) also gradually declined (from 51% between 1997 and 2002 to 35% between 2013 and 2018) with an association between decrease in IMV use and reduction in ICU mortality in a time series analysis. Rates of noninvasive ventilation (NIV) failure decreased with an increase in NIV use to support weaning from IMV. There was a reduction in the median ICU length of stay (from 8 d in 1997-2002 to 4 d in 2013-2018) and in the median total duration of hospitalization (from 23 d in 1997-2002 to 14 d in 2013-2018). We observed an improvement in prognosis, with decreases in overall hospital mortality (from 24% between 1997 and 2002 to 15% between 2013 and 2018), ICU mortality (from 14% between 1997 and 2002 to 10% between 2013 and 2018), and 90-day mortality (from 41% between 1997 and 2002 to 22% between 2013 and 2018).

CONCLUSIONS

The length of stay and mortality of patients with AECOPD admitted to ICUs has decreased over the last 20 years, with a wider use of NIV and a reduction in antibiotic and corticosteroid prescriptions.

Azithromycin use prior to ICU admission is associated with a lower short-term mortality for critically ill acute exacerbations of chronic obstructive pulmonary disease patients: A retrospective cohort study

Azithromycin was thought to prevent acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) by anti-microbial and anti-inflammatory effects. However, it's value in the treatment of critically ill patients with AECOPD before ICU admission remains unclear. Our study aimed to find whether azithromycin use prior to ICU admission leads to better clinical outcomes for those individuals. 533 critically ill patients with AECOPD from the MIMIC-IV database were included. Univariate followed multivariate logistic regression was used to select risk factors for short-term mortality. The multivariable logistic regression models were implemented to investigate the association between azithromycin use before ICU admission and short-term mortality. Lower short-term mortality was observed in the azithromycin group (p = .021), independent of differences in demographic data and other clinical outcomes (p>.05). Azithromycin use before ICU admission was proved to have a decreased short-term mortality by multivariable logistic regression (p<.05). The results remained consistent after being stratified by age, SOFA scores, pH, and cancer diagnosis. Azithromycin use prior to ICU admission was associated with lower short-term mortality for critically ill AECOPD patients.

Trends in the Bacterial Prevalence and Antibiotic Resistance Patterns in the Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Hospitalized Patients in South India

Exacerbation due to antimicrobial-drug-resistant bacteria among chronic obstructive pulmonary disease (AECOPD) patients contributes to mortality and morbidity. We examined the prevalence of the bacterial organisms and trends in drug resistance in AECOPD. In this retrospective study, between January 2016 to December 2020, among 3027 AECOPD patients, 432 (14.3%) had bacteria isolated. The regression and generalized estimating equations (GEE) were used for trends in the resistance patterns over five years, adjusting for age, gender, and comorbidities. Klebsiella pneumoniae (32.4%), Pseudomonas aeruginosa (17.8%), Acinetobacter baumannii (14.4%), Escherichia coli (10.4%), and Staphylococcus aureus (2.5%) were common. We observed high levels of drug resistance in AECOPD patients admitted to ICU (87.8%) and non-ICU (86.5%). A Cox proportional hazard analysis, observed infection with Acinetobacter baumannii and female sex as independent predictors of mortality. Acinetobacter baumannii had 2.64 (95% confidence interval (CI): 1.08−6.43) higher odds of death, compared to Klebsiella pneumoniae. Females had 2.89 (95% CI: 1.47−5.70) higher odds of death, compared to males. A high proportion of bacterial AECOPD was due to drug-resistant bacteria. An increasing trend in drug resistance was observed among females.

Impact of Acute Exacerbation and Its Phenotypes on the Clinical Outcomes of Chronic Obstructive Pulmonary Disease in Hospitalized Patients: A Cross-Sectional Study

Acute exacerbations of COPD (AECOPD) are clinically significant events having therapeutic and prognostic consequences. However, there is a lot of variation in its clinical manifestations described by phenotypes. The phenotypes of AECOPD were categorized in this study based on pathology and exposure. In our cross-sectional study, conducted between 1 January 2016 to 31 December 2020, the patients were categorized into six groups based on pathology: non-bacterial and non-eosinophilic; bacterial; eosinophilic; bacterial infection with eosinophilia; pneumonia; and bronchiectasis. Further, four groups were classified based on exposure to tobacco smoke (TS), biomass smoke (BMS), both, or no exposure. Cox proportional-hazards regression analyses were performed to assess hazard ratios, and Kaplan-Meier analysis was performed to assess survival, which was then compared using the log-rank test. The odds ratio (OR) and independent predictors of ward admission type and length of hospital stay were assessed using binomial logistic regression analyses. Of the 2236 subjects, 2194 were selected. The median age of the cohort was 67.0 (60.0 to 74.0) and 75.2% were males. Mortality rates were higher in females than in males (6.2% vs. 2.3%). AECOPD-B (bacterial infection) subjects [HR 95% CI 6.42 (3.06-13.46)], followed by AECOPD-P (pneumonia) subjects [HR (95% CI: 4.33 (2.01-9.30)], were at higher mortality risk and had a more extended hospital stay (6.0 (4.0 to 9.5) days; 6.0 (4.0 to 10.0). Subjects with TS and BMS-AECOPD [HR 95% CI 7.24 (1.53-34.29)], followed by BMS-AECOPD [HR 95% CI 5.28 (2.46-11.35)], had higher mortality risk. Different phenotypes have different impacts on AECOPD clinical outcomes. A better understanding of AECOPD phenotypes could contribute to developing an algorithm for the precise management of different phenotypes.

A detailed analysis of possible efficacy signals of NTHi-Mcat vaccine against severe COPD exacerbations in a previously reported randomised phase 2b trial

BACKGROUND

An investigational vaccine containing non-typeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis (Mcat) surface proteins did not show vaccine efficacy (VE) against combined moderate and severe (moderate/severe) exacerbations in a randomised, observer-blinded, placebo-controlled phase 2b trial of patients with chronic obstructive pulmonary disease (COPD). Nevertheless, observations on rates of severe exacerbations and hospitalisations encouraged further evaluation.

METHODS

Patients with stable COPD (moderate to very severe airflow limitation, Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 2-4), 40-80 years and at least one moderate/severe exacerbation in the last year received two doses of NTHi-Mcat vaccine or placebo plus standard care. Secondary analyses were conducted on VE against exacerbations according to severity. Potential predictive factors at baseline for VE against severe exacerbations were explored in post-hoc analyses.

RESULTS

Of 606 patients enrolled, 571 were included in the efficacy analysis (279 in NTHi-Mcat vaccine group, 292 in placebo group). VE against severe acute exacerbations of COPD (AECOPD) in various subgroups was 52.11 % (p = 0.015; frequent exacerbators), 65.43 % (p = 0.015; baseline GOLD grade 4), 38.24 % (p = 0.034; previous pneumococcal and/or influenza vaccination). VE was 52.49 % (p = 0.044) for the 6-12 months period after 1 month post-dose 2. Multivariable analysis identified two factors (frequent exacerbator status plus inhaled corticosteroid use at baseline) associated with significant VE against severe AECOPD; in this subpopulation, VE was 74.99 % (p < 0.001).

CONCLUSION

Results suggest potential efficacy with the NTHi-Mcat vaccine against severe exacerbations in certain patients with COPD, in particular those who have frequent exacerbations and use inhaled corticosteroids. This potential signal requires confirmation in an appropriately designed prospective clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03281876.

Compound Ipratropium Bromide plus Budesonide Inhalation in the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Its Effect on Heparin-Binding Protein

Objective

To analyze the clinical effect of compound ipratropium bromide combined with budesonide atomization inhalation on acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and its effect on the heparin-binding protein.

Methods

A total of 110 patients with AECOPD who were admitted to our hospital between January 2020 and January 2021 were enrolled and assigned into control group (conventional treatment + compound ipratropium bromide) and combined group (conventional treatment + compound ipratropium bromide + budesonide) in a 1 : 1 ratio according to different treatment methods. The clinical effects, pulmonary function indexes, and heparin-binding protein levels before and after treatment were compared between the two groups.

Results

The treatment with oxygen-driven nebulization of ipratropium bromide combined with budesonide led to a significantly higher total effective rate versus the treatment with ipratropium bromide alone (P < 0.001). After treatment, remarkably higher arterial oxygen partial pressure (PaO2), arterial oxygen saturation (SaO2), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1/FVC in the combined group vs. the control group were observed (P < 0.001). The carbon dioxide partial pressure (PaCO2) levels in the two groups were significantly lower than those before treatment, and the decrease in the combined group was greater (P < 0.001). A significantl reduction was observed in heparin-binding protein in both groups after treatment, and the decrease in the combined group was greater versus the control group (P < 0.001).

Conclusion

Compound ipratropium bromide plus budesonide via aerosol inhalation therapy might be a preferable approach for AECOPD patients. It exhibits a synergistic effect on inhibiting inflammatory mediators and cytokine networks, significantly reduces airway hyperresponsiveness, and improves blood gas indicators and lung function.

Effect of humidified high-flow nasal cannula oxygen therapy on respiratory function recovery in stable COPD patients

OBJECTIVE

To investigate the effect of humidified high-flow nasal cannula oxygen therapy (HFNC) on the application effect and respiratory functional recovery of stable COPD patients.

METHODS

The data of 116 patients with stable COPD treated in our hospital from March 2019 to January 2021 were analyzed retrospectively. Among them, 54 patients treated with conventional oxygen therapy (COT) were enrolled into the control group (CG), and the remaining 62 treated with HFNC were divided to the experimental group (EG). The clinical efficacy and adverse reactions of both groups were assessed, and the blood gas analysis indexes pH, PaO₂, PaCO₂, respiratory function indexes FEV1, FEV1%, FEV1/FVC, quality of life and motor recovery were compared.

RESULTS

After treatment, compared with the CG, the FEV1, FEV1% and FEV1/FVC in the EG were obviously higher (P<0.05). Besides, the pH and PaO₂ in the EG were markedly higher (P<0.05), while PaCO₂ was lower (P<0.05). The total effective rate, SGRQ scores and 6MWT in the EG were markedly higher than those in the CG (P<0.05), while the incidence of adverse reactions in the EG was lower (P<0.05).

CONCLUSION

HFNC can improve respiratory function and quality of life of stable COPD patients, with higher safety.

Clinician Perspectives on How to Hold Earlier Discussions About Palliative and End-of-Life Care With Chronic Obstructive Pulmonary Disease Patients: A Qualitative Study

Chronic obstructive pulmonary disease is associated with progressive symptoms and increased treatment burden, especially at the end of life. However, most patients do not receive palliative care until late in their lives or discuss their end-of-life preferences with clinicians. This study explored clinicians' perspectives on the timing and nature of palliative care discussions. Qualitative interviews were conducted with 7 physicians and 7 nurses working in primary and secondary care settings. Data were analyzed using a thematic analysis. Participants advocated for early, gradual, and informed palliative and future care discussions, because these discussions were thought to be less traumatic and better accepted by patients. Despite this, patient- and clinician-related barriers severely affected clinicians' ability to start discussions at earlier stages. Participants felt many patients were not ready for these discussions and feared damaging hope if the subject was broached. Therefore, clinicians delayed discussions until patients approached the end of life. Stand-alone conversations about and near the end of life were described as current practice; however, clinicians believed these discussions reduced patients' hope and were potentially upsetting. Instead, individualized early, regular, and gradual discussions about immediate and long-term care plans were thought to be less negative and be better accepted.

Statins Associated with Better Long-Term Outcomes in Aged Hospitalized Patients with COPD: A Real-World Experience from Pay-for-Performance Program

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally. Previous studies have addressed the impact of comorbidity on short-term mortality in patients with COPD. However, the prevalence of cardiovascular disease (CVD) and the association of statins prescription with mortality for aged COPD patients remains unclear. We enrolled 296 aged, hospitalized patients who were monitored in the pay-for-performance (P-4-P) program of COPD. Factors associated with long-term mortality were identified by Cox regression analysis. The median age of the study cohort was 80 years old, and the prevalence of coronary artery disease (CAD) and statins prescriptions were 16.6% and 31.4%, respectively. The mortality rate of the median 3-year follow-up was 51.4%. Through multivariate analysis, body mass index (BMI), statin prescription, and events of respiratory failure were associated with long-term mortality. A Cox analysis showed that statins prescription was associated with lower mortality (hazard ratio (HR): 0.5, 95% Confident interval, 95% CI: 0.34–0.73, p = 0.0004) and subgroup analysis showed that rosuvastatin prescription had protective effect on long-term mortality (HR: 0.44; 95% CI: 0.20–0.97; p < 0.05). Statin prescriptions might be associated with better long-term survival in aged COPD patients, especially those who experienced an acute exacerbation of COPD (AECOPD) who require hospitalization.

Early Pulmonary Rehabilitation in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Meta-Analysis of Randomized Controlled Trials

Pulmonary rehabilitation (PR) is an essential method for Acute exacerbation in chronic obstructive pulmonary disease (AECOPD) recovery. We perform a meta-analysis to compare early PR with usual care. A literature search was performed through these databases: PubMed, MEDLINE database, Google Scholar, Cochrane, Embase from inception to July 2021. Eligible trials were clinical randomized controlled trials comparing the effects of early PR and usual care in AECOPD patients. The primary endpoint of this meta-analysis was FEV1% predicted, 6-min walk test (6MWD), modified Medical Research Council (mMRC) and George Respiratory Questionnaire-total (SGRQ-total). The secondary outcomes were borg dyspnea score, short-form 36 health survey questionnaire physical (SF-36 physical) and SF-36 mental. We included 13 RCTs with a total of 866 patients. There were no significant effects of the PR group on measures of FEV1% predicted (MD = 0.50, 95%CI -1.43 to 2.44, Z = 0.51, p = 0.61), borg dyspnea score (MD = -0.88, 95%CI -1.89 to 0.13, Z = 1.71, p = 0.09) and SF-36 mental (MD = 4.34, 95%CI -1.64 to 10.32, Z = 1.42, p = 0.16) compared with usual care. PR group achieved better 6MWD (MD = 97.58, 95%CI 17.21 to 177.96, Z = 2.38, p = 0.02), mMRC (MD = -0.36, 95%CI -0.52 to -0.21, Z = 4.56, p ˂ 0.00001), SGRQ-total (MD= -9.67, 95%CI -16.23 to -3.11, Z = 2.89, p = 0.004) and SF-36 physical (MD = 4.98, 95%CI 0.60 to 9.35, Z = 2.23, p = 0.03) compared with usual care group. Early PR in AECOPD patients would lead to better 6MWD, mMRC, SGRQ-total and SF-36 physical. But there were no significant effects of the PR group on measures of FEV1% predicted, borg dyspnea score and SF-36 mental.

Managing hospitalized patients with a COPD exacerbation: the role of hospitalists and the multidisciplinary team

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with high rates of hospitalizations, costs, and morbidity. Therefore, hospitalists and the multidisciplinary team (hospital team) need to take a proactive approach to ensure patients are effectively managed from hospital admission to postdischarge. Comprehensive screening and diagnostic testing of patients at admission will enable an accurate diagnosis of COPD exacerbations, and severity, as well as other factors that may impact the length of hospital stay. Depending on the exacerbation severity and cause, pharmacotherapies may include short-acting bronchodilators, systemic corticosteroids, and antibiotics. Oxygen and/or ventilatory support may benefit patients with demonstrable hypoxemia. In preparation for discharge, the hospital team should ensure that patients receive the appropriate maintenance therapy, are counseled on their medications including inhalation devices, and proactively discuss smoking cessation and vaccinations. For follow-up, effective communication can be achieved by transferring discharge summaries to the primary care physician via an inpatient case manager. An inpatient case manager can support both the hospitalist and the patient in scheduling follow-up appointments, sending patient reminders, and confirming that a first outpatient visit has occurred. A PubMed search (prior to 26 January 2021) was conducted using terms such as: COPD, exacerbation, hospitalization. This narrative review focuses on the challenges the hospital team encounters in achieving optimal outcomes in the management of patients with COPD exacerbations. Additionally, we propose a novel simplified algorithm that may help the hospital team to be more proactive in the diagnosis and management of patients with COPD exacerbations.

Effects of Air Pollutants on Airway Diseases

Air pollutants include toxic particles and gases emitted in large quantities from many different combustible materials. They also include particulate matter (PM) and ozone, and biological contaminants, such as viruses and bacteria, which can penetrate the human airway and reach the bloodstream, triggering airway inflammation, dysfunction, and fibrosis. Pollutants that accumulate in the lungs exacerbate symptoms of respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD). Asthma, a heterogeneous disease with complex pathological mechanisms, is characterized by particular symptoms such as shortness of breath, a tight chest, coughing, and wheezing. Patients with COPD often experience exacerbations and worsening of symptoms, which may result in hospitalization and disease progression. PM varies in terms of composition, and can include solid and liquid particles of various sizes. PM concentrations are higher in urban areas. Ozone is one of the most toxic photochemical air pollutants. In general, air pollution decreases quality of life and life expectancy. It exacerbates acute and chronic respiratory symptoms in patients with chronic airway diseases, and increases the morbidity and risk of hospitalization associated with respiratory diseases. However, the mechanisms underlying these effects remain unclear. Therefore, we reviewed the impact of air pollutants on airway diseases such as asthma and COPD, focusing on their underlying mechanisms.

The MAGENTA model for individual prediction of in-hospital mortality in chronic obstructive pulmonary disease with acute exacerbation in resource-limited countries: A development study

BACKGROUND

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common undesirable event associated with significant morbidity and mortality. Several clinical prediction tools for predicting in-hospital mortality in patients with AECOPD have been developed in the past decades. However, some issues concerning the validity and availability of some predictors in the existing models may undermine their clinical applicability in resource-limited clinical settings.

METHODS

We developed a multivariable model for predicting in-hospitality from a retrospective cohort of patients admitted with AECOPD to one tertiary care center in Thailand from October 2015 to September 2017. Multivariable logistic regression with fractional polynomial algorithms and cluster variance correction was used for model derivation.

RESULTS

During the study period, 923 admissions from 600 patients with AECOPD were included. The in-hospital mortality rate was 1.68 per 100 admission-day. Eleven potential predictors from the univariable analysis were included in the multivariable logistic regression. The reduced model, named MAGENTA, incorporated seven final predictors: age, body temperature, mean arterial pressure, the requirement of endotracheal intubation, serum sodium, blood urea nitrogen, and serum albumin. The model discriminative ability based on the area under the receiver operating characteristic curve (AuROC) was excellent at 0.82 (95% confidence interval 0.77, 0.86), and the calibration was good.

CONCLUSION

The MAGENTA model consists of seven routinely available clinical predictors upon patient admissions. The model can be used as an assisting tool to aid clinicians in accurate risk stratification and making appropriate decisions to admit patients for intensive care.

The Effect of Intravenous Magnesium Sulphate as an Adjuvant in the Treatment of Acute Exacerbations of COPD in the Emergency Department: A Double-Blind Randomized Clinical Trial

Background

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are serious complications that often require immediate intervention in an emergency department (ED). The aim of this study was to investigate the effect of intravenous magnesium sulphate as an adjuvant in the treatment of AECOPD in the ED.

Methods

In a double-blind, randomized clinical trial, a total of 60 patients with AECOPD presenting to the ED of Imam Khomeini Hospital in Sari, Iran, were included. The study was conducted between September 2016 and February 2018. Eligible patients were randomly allocated into two groups of intervention and control. Patients in the intervention and control groups received intravenous infusion of magnesium sulfate (2 gr) or normal saline over 30 minutes, respectively. For all patients, Borgdyspnea score, forced expiratory volume in one second (FEV1) result and clinical variables of interest were evaluated before the beginning of the intervention, and also 45 minutes and 6 hours after the commencement of intervention.

Results

Regardless of time of evaluation, pulse rate (PR), respiratory rate (RR) and Borg score in intervention group was lower than control group. Also, FEV1 and SPO2 were greater in intervention group compared to control group. However, these differences were not statistically significant (between-subject differences or group effect) (p<0.001). The trends of FEV1, SPO2, PR, RR and Borg score were similar between two groups of study (no interaction effect; P>0.05).

Conclusion

According to the results of this study, it seems that using intravenous magnesium sulfate has no significant effect on SPO2, FEV1, RR, and PR of patients with AECOPD who presented to ED.

Hyponatremia is an independent predictor of emergency department revisits in acute exacerbation of COPD

INTRODUCTION

Hyponatremia is shown to prolong hospitalization and increase mortality. The role of hyponatremia in chronic obstructive pulmonary disease is widely studied with a focus on hospitalized patients.

OBJECTIVES

To investigate whether hyponatremia increases the probability of re-exacerbations in non-hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

METHODS

Patients with AECOPD who required an emergency department (ED) visit and who were discharged home were included in this single-center, retrospective study. Demographics and laboratory values were compared between patients with hyponatremia (<135 mmol/L) and normonatremia (135-145 mmol/L). The predictors of the patients' ED revisit in the course of one year were analyzed.

RESULTS

Of all the 3274 patients, baseline sodium values were classified as hyponatremia in 720 (22%). Hyponatremia was most frequently present as mild (85%). Patients with hyponatremia had higher Charlson comorbidity scores, higher leucocytes, lower hemoglobin, lower platelet, higher neutrophil to lymphocyte ratios, lower eosinophilia, higher aspartate aminotransferase and C-reactive protein values (P < 0.001, for all), and higher frequency of 1-month revisit (36.7% vs. 31.5%, P = 0.009). Independent predictors of revisits within 1 year after the index visit were detected as long-term oxygen treatment requirement (HR: 0.768 CI: 0.695-0.848, P < 0.0001), higher urea levels (HR: 0.997 CI: 0.995-0.999, P = 0.003), and baseline hyponatremia (HR: 0.786 CI: 0.707-0.873, P < 0.001). Revisit interval was median 78 ± 3.4 days in patients with normonatremia and 51 ± 4.8 days in hyponatremia.

CONCLUSION

In non-hospitalized AECOPD, hyponatremia is relatively frequent and correlates with inflammatory markers. The presence of hyponatremia is an independent predictor of an earlier ED return visit within 1 year. For patients with AECOPD, sodium values may present guidance on discharge versus longer observation decisions.

Therapeutic gases used in balneotherapy and rehabilitation medicine - scientific relevance in the last ten years (2011 – 2020) - Synthetic literature review

ABSTRACT: Background. The medical relevance of therapeutic gases can range from use in burns and stroke victims to hypoxia therapy in children. However, medical gases such as oxygen, hydrogen, helium and xenon have recently come under increased exploration for their potential therapeutic use on various brain disease states, including traumatic brain injuries, hypoxia-ischemia and, cerebral hemorrhages. Objective. This synthetic review aims to rigorously select related articles and identify within their content the main possible uses of therapeutic gases and physiological mechanisms. The objective of this article is to present the various therapeutic mechanisms that have been proposed in the current literature and the medical relevance of various therapeutic gases used in balneotherapy or medical rehabilitation. Methods. To elaborate our synthesis review, we have searched for relevant open access articles in 6 international databases: Cochrane, Elsevier, NCBI/PubMed, NCBI/PMC, PEDro, and ISI Web of Knowledge/Science, published from January 2011 until December 2020. The contextually quested keywords combinations/ syntaxes used specified on this page. The eligible articles were analyzed in detail regarding pathologies addressed by therapeutic gases. All articles with any design (reviews, randomized controlled trials, non-randomized controlled trials, case-control studies, cross-sectional studies), if eligible according to the above-mentioned selection methodology, containing in the title or abstract the above-mentioned combinations, were included in the analysis. Articles were excluded in the second phase if they did not reach the relevance criterion. Results. Our search identified, first, 225 articles. After eliminating the duplicates, remained 180 articles. In the second phase, we applied a relevance criterion. Although our team - including the authors of this paper – have quite long and consistent expertise in achieving systematic literature reviews, the marked heterogeneity of both the item composing the subject we have approached and inherently the wase of presentations in the respective quite vast and diverse domain of medical gases, prevented us to fulfil, at least regarding this initial work, a systematic literature review. Instead, we succeeded to make a hopefully interesting and valuable narrative synthetic-related literature review. At the end of the second phase, 63 articles passed the relevance criterion and were included in this synthetic review. Conclusions. Therapeutic gases are not fully understood and used adequately for sanogenic or medical purposes. More research is needed to fully understand the mechanisms and importance of therapeutic gases. The link between balneotherapy and medical rehabilitation regarding the usage of therapeutical gases emphasises the unity for this medical speciality. Keywords: "Therapeutic gas"/ "Oxygen therapy"/ "Carbon dioxide"/ "CO2 therapy"/ "Carbon monoxide"/ "Mofette"/ "Hydrogen Sulfide"/ "H2S"/ "Helium"/ "Xenon"/ "Ozone therapy"/ "Radon"/ "Hydrogen therapy"/ "Nitric oxide"/ "Heliox" AND "Rehabilitation".

Age is a determinant of short-term mortality in patients hospitalized for an acute exacerbation of COPD

Several factors worsen the prognosis of hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Little is known about the specific contribution of age. Study aim was to evaluate the impact of age on early mortality (90-days).

METHODS

this observational prospective study considered hospitalized AECOPD patients. Three groups were created according to tertiles of age distribution: group 1 (≤ 67 years), group 2 (68-76 years) and group 3 (≥ 77 years). Baseline, clinical, microbiological, gas analysis and laboratory variables were collected at admission. The primary outcome was mortality at 90 days from admission. Multivariate regression models and receiver-operating characteristic (ROC) curves were used to evaluate the predictive power of age versus early mortality and adjusted for gender, comorbidities, staging and disease severity.

RESULTS

we enrolled 449 patients, 33 (7%) of whom died within 90 days from admission. Older patients were predominantly male, with more comorbidities, and higher dyspnoea grade and disease severity. The multivariate logistic regression demonstrated a significant predictive role of age as a continuous variable [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.10; p = 0.046]. The Cox regression analysis found that group 2 [hazard ratio (HR) 6.6; 95% CI 1.5-28.8; p = 0.013], group 3 (HR 7.2; 95% CI 1.6-32.6; p = 0.010) and acute severe hypoxemia at admission (HR 2.7; 95% CI 1.2-6; p = 0.012) were independent significant predictors of mortality. The Kaplan-Meier curves showed a significant role of age in cumulative survival (Gehan-Breslow-Wilcoxon test p = 0.010). ROC curves highlighted 70 years as the best discriminating cut-off.

CONCLUSIONS

age is a determinant of worse prognosis among hospitalized patients with AECOPD.

Associations between ambient air pollution and hospitalizations for acute exacerbation of chronic obstructive pulmonary disease in Jinhua, 2019

Most cities in China are experiencing severe air pollution due to rapid economic development and accelerated industrialization. Exposure to various air pollutants has been related to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, less is known about the spatial association between air pollution and AECOPD hospitalizations in the Yangtze River delta (YRD) economic and industrial region. Jinhua city is located in the YRD region of East China, in the middle of Zhejiang province. For the first time, 1563 AECOPD hospitalization cases in Jinhua during 2019 were enrolled in our analysis. The spatial distribution of six pollutants (SO₂, CO, PM10, PM2.5, O₃, NO₂) and the population temporal-spatial specific air pollutant exposure levels were estimated using the ordinary Kriging model through geographic information system (GIS). Global Moran's I was used to explore the spatial association between ambient air pollutants and AECOPD hospitalizations. The Z-scores of residential SO₂, CO, PM10, PM2.5, O₃, and NO₂ levels were 31.88, 42.95, 45.90, 32.29, 52.18, and 34.59, respectively. The concentrations of six monitored pollutants and AECOPD hospitalizations showed statistically significant spatial clustering. A generalized linear model (GLM) using a Poisson distribution with the log-link function was used to construct a core model. After adjusting for potential confounders in the model, residential SO₂, NO₂ and O₃ concentrations were significantly associated with increased AECOPD hospitalizations.

Effect of High-Flow Oxygen on Exercise Performance in COPD Patients. Randomized Trial

Background: High-flow oxygen therapy (HFOT) provides oxygen-enriched, humidified, and heated air at high flow rates via nasal cannula. It could be an alternative to low-flow oxygen therapy (LFOT) which is commonly used by patients with chronic obstructive pulmonary disease (COPD) during exercise training.

Research Question: We evaluated the hypothesis that HFOT improves exercise endurance in COPD patients compared to LFOT.

Methods: Patients with stable COPD, FEV₁ 40–80% predicted, resting pulse oximetry (SpO₂) ≥92%, performed two constant-load cycling exercise tests to exhaustion at 75% of maximal work rate on two different days, using LFOT (3 L/min) and HFOT (60 L/min, FiO₂ 0.45) in randomized order according to a crossover design. Primary outcome was exercise endurance time, further outcomes were SpO₂, breath rate and dyspnea.

Results: In 79 randomized patients, mean ± SD age 58 ± 9 y, FEV₁ 63 ± 9% predicted, GOLD grades 2-3, resting PaO₂ 9.4 ± 1.0 kPa, intention-to-treat analysis revealed an endurance time of 688 ± 463 s with LFOT and 773 ± 471 s with HFOT, mean difference 85 s (95% CI: 7 to 164, P = 0.034), relative increase of 13% (95% CI: 1 to 28). At isotime, patients had lower respiratory rate and higher SpO₂ with HFOT. At end-exercise, SpO₂ was higher by 2% (95% CI: 2 to 2), and Borg CR10 dyspnea scores were lower by 0.8 points (95% CI: 0.3 to 1.2) compared to LFOT.

Interpretation: In mildly hypoxemic patients with COPD, HFOT improved endurance time in association with higher arterial oxygen saturation, reduced respiratory rate and less dyspnea compared to LFOT. Therefore, HFOT is promising for enhancing exercise performance in COPD.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03955770.

Evidence for role of acid-sensing ion channel 1a in chronic rhinosinusitis with nasal polyps

PURPOSE

A variety of inflammatory cells are infiltrated histologically in sinonasal mucosa of chronic rhinosinusitis with nasal polyps (CRSwNP), especially CRSwNP with asthma. Acid-sensing ion channel 1a (ASIC1a) is essential in the process of sensing acidification and triggering inflammation. Whereas, its role and mechanism in CRSwNP remain uncertain. The present study aimed to explore the roles and mechanism of ASIC1a in the pathogenesis of CRSwNP.

METHODS

Nasal secretions from control subjects, patients with CRSwNP with or without asthma were collected for measuring pH values. Western blotting, real-time PCR and immunohistochemistry (IHC) were employed to assess ASIC1a expression in nasal tissue samples from included subjects. The co-localization of ASIC1a with inflammatory cells was evaluated by immunofluorescence staining. Then, dispersed nasal polyp cells (DNPCs) were cultured under acidified condition (pH 6.0), with or without ASIC1a inhibitor amiloride. Western blotting, real-time PCR, LDH activity kit, and ELISA were performed to assess the effects and mechanisms of stimulators on the cells.

RESULTS

The pH values were significantly lower in the nasal secretions from patients with CRSwNP with asthma. Significant upregulation of ASIC1a protein, mRNA levels, and positive cells was found in CRSwNP with asthma. ASIC1a was detected in a variety of inflammatory cells. In cultured DNPCs, significant alterations of ASIC1a levels, LDH activity, HIF-1α levels, and inflammatory cytokines were found under acidified condition (pH 6.0), but were prevented by amiloride.

CONCLUSION

Upregulation of ASIC1a might be essential in the process of sensing acidification and triggering inflammatory response via enhancing HIF-1α expression and LDH activity to activate inflammatory cells in the pathogenesis of CRSwNP, especially in CRSwNP with asthma.

Effect of chronic obstructive pulmonary disease combined with ventilator-associated pneumonia on patient outcomes: A systematic review and meta-analysis

The purpose of the present systematic review and meta-analysis was to uncover whether chronic obstructive pulmonary disease (COPD) as a co-morbidity influences outcomes of patients with ventilator-associated pneumonia (VAP) compared to VAP alone and whether the development of VAP in patients with COPD is associated with poor outcome in comparison to COPD alone. An electronic search of the PubMed, Embase, Scopus, BioMed Central, CENTRAL and Google scholar databases for all types of studies assessing the influence of COPD on outcomes of patients with VAP and vice versa was performed. A total of 7 studies were included. Of these, 3 studies assessed the impact of COPD on outcomes of patients with VAP. Meta-analysis indicated that the presence of COPD significantly increased the mortality of patients with VAP [risk ratio (RR): 1.37, 95% CI: 1.14-1.65, I²=3%, P=0.007]. The analysis failed to demonstrate any significant effect of COPD on the duration of mechanical ventilation in patients with VAP [mean difference (MD): 2.37, 95% CI: -5.77 to 10.50, I²=38%, P=0.57]. However, the duration of the intensive care unit (ICU) stay was significantly longer in patients with COPD and VAP as compared with that of patients with VAP without COPD (MD: 5.53, 95% CI: 0.73-10.33, I²=0%, P=0.02). A total of 4 studies assessed the impact of VAP on outcomes of patients with COPD. Meta-analysis indicated that the presence of VAP significantly increased mortality of patients with COPD (RR: 1.52, 95% CI: 1.08-2.12, I²=71%, P=0.02). Pooled analysis indicated that the presence of VAP in patients with COPD significantly increased the duration of mechanical ventilation (MD: 13.73, 95% CI: 7.86-19.61, I²=92%, P<0.00001) and the duration of the ICU stay as compared to patients with COPD but without VAP (MD: 17.36, 95% CI: 9.55-25.17, I²=90%, P<0.0001). To conclude, within the limitations of the study, the present results indicated that the combination of COPD and VAP significantly increased patient mortality and the duration of ICU stay. The development of VAP in patients with COPD also significantly increased the duration of mechanical ventilation. Further case-matched studies are required to assess the influence of the severity of COPD in combination with VAP on patient outcomes.

Predictors for long-term mortality in COPD patients requiring non-invasive positive pressure ventilation for the treatment of acute respiratory failure

INTRODUCTION

The effectiveness of non-invasive mechanical ventilation (NIV) in the management of COPD patients suffering from acute respiratory failure (ARF) as a consequence of exacerbation of the disease, is well established. However, data on long-term outcomes and their predictors, including the individual response to NIV, are scarce.

OBJECTIVES

To investigate predictors for short- and long-term mortality in this study population.

METHODS

A retrospective cohort study was performed including all patients admitted to the Medium Respiratory Care Unit of Maastricht University Medical Center in Maastricht, the Netherlands, with hospitalized exacerbation of COPD (H-ECOPD) with ARF requiring NIV for the first time between January 2009 and December 2011. An extensive number of potential predictors of outcomes, including the response to NIV, were determined on admission and during hospitalization. Univariate and multivariate logistic regression was used for statistical analysis.

RESULTS

Seventy-eight consecutive patients with moderate to severe COPD (mean age 71.0 ± 10.7 years; 48.7% males) were included; In-hospital, 1-year and 2-year mortality rates were 14.1%, 43.6% and 56.4%, respectively. Independent risk factors for 2-year mortality were: advanced age (odds ratio(OR) 1.025; confidence interval (CI) 1.002-1.049; P = 0.037), prolonged NIV use more than 8 days (OR:1.054;CI:1.006-1.104; P = 0.027) and no successful response to NIV (OR:2.392;CI:1.297-4.413; P = 0.005).

CONCLUSION

Patients with an H-ECOPD requiring NIV for the first time, constitute a severely ill patient group with high in-hospital and 2-year mortality. This study identified advanced age, NIV use more than 8 days and unsuccessful response to NIV as clinical important independent predictors for long-term mortality.

Blood eosinophil count predicts treatment failure and hospital readmission for COPD

We examined associations between blood eosinophil counts (BEC) and risk of treatment failure or hospital readmission following acute oral corticosteroid (OCS)-treated COPD exacerbations. We conducted studies from the Optimum Patient Care Research Database (OPCRD) (www.optimumpatientcare.org/opcrd) and Clinical Practice Research Datalink (CPRD) (www.cprd.com/home/), validated databases for medical research, with linked Hospital Episode Statistics (HES) data for ∼20 000 COPD patients aged ≥40 years. For patients with OCS-treated COPD exacerbations treated in primary care, with BECs recorded on first day of OCS treatment (Cohort 1), we assessed treatment failure (COPD-related hospitalisations and OCS prescriptions beyond index OCS course). For patients hospitalised for COPD exacerbations, with BEC measured over an exacerbation-free period during the year prior to admission (Cohort 2), we assessed readmission rate. Cox proportional hazards regression analysis was adjusted for confounders to estimate the association between BEC and treatment outcomes. Of patients treated with OCS for COPD exacerbations in primary care (Cohort 1), 44% experienced treatment failure following single OCS courses, and 10% (255/2482) were hospitalised for ≤6 weeks. Greater BEC was associated with reduced hospital-admission risk (hazard ratio [HR]=0.26; 95% CI: 0.12-0.56, per 100 cells·µL-1 increase). BEC increases of ≥200 cells·µL-1 from exacerbation-free periods to exacerbations were associated with least hospitalisation risk (HR=0.32; 95% CI: 0.15-0.71) versus no BEC change. For patients hospitalised for COPD exacerbations (Cohort 2), 4-week hospital readmission was 12% (1189/10 245). BEC increases during an exacerbation-free period within the past year were associated with reduced risk of short-term readmission (HR=0.78; 95% CI: 0.63-0.96). Greater BEC predicted better outcomes for patients with OCS-treated COPD exacerbations, whether community or hospital managed. Eosinopenia predicted worse outcomes.

Effects of Human Umbilical Cord-Derived Mesenchymal Stem Cells on the Acute Cigarette Smoke-Induced Pulmonary Inflammation Model

Cigarette smoke (CS) has been reported to induce oxidative stress and inflammatory process in the lungs. However, the role of human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) in the regulation of pulmonary inflammation remains unclear. The objective of this study is to investigate the effects of hUC-MSCs on lung inflammation in the acute CS-induced pulmonary inflammation animal model. Eight-week-old male C57BL/6 mice were intravenously administered 3 × 10⁶, 1 × 10⁷, and 3 × 10⁷ cells/kg of hUC-MSCs as well as normal saline alone (control) after 3 days of CS exposure. Mice exposed to high-efficiency particulate air (HEPA)-filtered room air served as the CS control group. High-dose (3 × 10⁷ cells/kg) hUC-MSC administration significantly decreased tumor necrosis factor (TNF)-α in the bronchoalveolar lavage fluid (BALF) of CS-exposed mice (p < 0.05). The chemokine (CXC motif) ligand 1/keratinocyte chemoattractant (CXCL1/KC) in BALF were significantly reduced by low-dose (3 × 10⁶ cells/kg) and high-dose (3 × 10⁷ cells/kg) hUC-MSC (p < 0.05). Medium-dose hUC-MSC administration decreased interleukin (IL)-1β in lung of mice, and TNF-α and caspase-3 were decreased in the lung of CS-exposed mice by medium- and high-dose MSC (p < 0.05). Low-dose hUC-MSCs significantly elevated serum CXCL1/KC and IL-1β in CS-exposed mice (p < 0.05). Our results suggest that high-dose hUC-MSCs reduced pulmonary inflammation and had antiapoptotic effects in acute pulmonary inflammation.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) impose a significant burden on patients and the emergency health care system. Patients with COPD who present to the emergency department (ED) often have comorbidities that can complicate their management.

OBJECTIVE

To discuss strategies for the management of acute exacerbations in the ED, from initial assessment through disposition, to enable effective patient care and minimize the risk of treatment failure and prevent hospital readmissions.

DISCUSSION

Establishing a correct diagnosis early on is critical; therefore, initial evaluations should be aimed at differentiating COPD exacerbations from other life-threatening conditions. Disposition decisions are based on the intensity of symptoms, presence of comorbidities, severity of the disease, and response to therapy. Patients who are appropriate for discharge from the ED should be prescribed evidence-based treatments and smoking cessation to prevent disease progression. A patient-centric discharge care plan should include medication reconciliation; bedside "teach-back," wherein patients demonstrate proper inhaler usage; and prompt follow-up.

CONCLUSIONS

An effective assessment, accurate diagnosis, and appropriate discharge plan for patients with AECOPD could improve treatment outcomes, reduce hospitalization, and decrease unplanned repeat visits to the ED.

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.

Physical Therapy and Rehabilitation in Chronic Obstructive Pulmonary Disease Patients Admitted to the Intensive Care Unit

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition that affects a person's ability to exercise and undertake normal physical function due to breathlessness, poor physical fitness, and muscle fatigue. Patients with COPD often experience exacerbations due to pulmonary infections, which result in worsening of their symptoms, more loss of function, and often require hospital treatment or in severe cases admission to intensive care units. Recovery from such exacerbations is often slow, and some patients never fully return to their previous level of activity. This can lead to permanent disability and premature death.Physical therapists play a key role in the respiratory management and rehabilitation of patients admitted to intensive care following acute exacerbation of COPD. This article discusses the key considerations for respiratory management of patients requiring invasive mechanical ventilation, providing an evidence-based summary of commonly used interventions. It will also explore the evidence to support the introduction of early and structured programs of rehabilitation to support recovery in both the short and the long term, as well as active mobilization, which includes strategies to minimize or prevent physical loss through early retraining of both peripheral and respiratory muscles.

Perceptions of Home Telemonitoring Use Among Patients With Chronic Obstructive Pulmonary Disease: Qualitative Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major health problem and an economic burden globally. There is growing interest in how electronic health (eHealth) can be used to provide efficient health care. Telemonitoring, where the patient's health-related data is transmitted to a health care provider, can be used to detect early signs of exacerbations. A successful implementation of telemonitoring systems into clinical practice requires in-depth knowledge of the users' preferences.

OBJECTIVE

The aim of this study was to explore perceptions of the use of a home telemonitoring system among patients with COPD.

METHODS

Semistructured individual interviews were carried out with 8 women and 5 men who were participants in a project aimed at developing and evaluating a telemonitoring system. The web-based telemonitoring system measured pulmonary function, subjective symptoms, and oxygen saturation. Participants were interviewed after having used the system for 2-4 months. Interview transcripts were analyzed with qualitative content analysis.

RESULTS

The analysis resulted in the theme A transition toward increased control and security and four categories: using with (in)security, affecting technical concern or confidence, providing easy access to health care, and increasing control over the disease. The participants reported various perceptions of using the telemonitoring system. They expressed initial feelings of insecurity, both in terms of operating the system and in terms of their disease. However, the practical management of the telemonitoring system became easier with time; the participants gradually gained confidence and improved their self-management. New technology was perceived as an important complement to existing health care, but the importance of maintaining a human contact in real life or through the telemonitoring system was emphasized.

CONCLUSIONS

This study captured a transition among the participants from being insecure and experiencing technical concerns to acquiring technical confidence and improving disease management. Telemonitoring can be a valuable complement to health care, leading to increased self-knowledge, a sense of security, and improved self-management. Suggestions to improve the further development and implementation of telemonitoring systems include better patient education and the involvement of end users in the technical development process. Additional research is needed, particularly in the design of user-friendly systems, as well as in developing tools to predict which patients are most likely to find the equipment useful, as this may result in increased empowerment, improved quality of life, reduced costs, and a contribution to equity in health.

Effect of high-flow nasal therapy during early pulmonary rehabilitation in patients with severe AECOPD: a randomized controlled study

Background

Chronic obstructive pulmonary disease (COPD) is airway inflammation characterized and low daily physical activity. Most pulmonary rehabilitation (PR) programs are often provided to stable patients, but fewer training programs are specific for hospitalized patients with acute exacerbation (AE). Patients with AECOPD experience increased dyspnea sensations and systemic inflammation during exercise training. High-flow nasal therapy (HFNT) reduces the minute volume, lowers the respiratory rate, and decreases the work of breathing. However, it is not clear whether HFNT is efficient during exercise training. In this study, we investigated the effects of HFNT during exercise training in an early PR program among hospitalized patients with severe AECOPD.

Methods

We enrolled COPD patients hospitalized due to AE. They were randomized into two groups according to their status into HFNT PR and non-HFNT PR groups. This study collected basic data, and also assessed a pulmonary function test, 6-min walking test, blood inflammatory biomarkers, and arterial gas analysis at the baseline, and at 4 and 12 weeks of the intervention. Data were analyzed using SPSS statistical software.

Result

We recruited 44 AECOPD patients who completed the 12-week PR program. The HFNT PR program produced significant improvements in exercise tolerance as assessed by the 6-min walking distance (6MWD), reduced dyspnea sensations in the modified Medical Research Council (mMRC), and decreased systemic inflammation as evidenced by the a lower C-reactive protein (CRP) level. A reduction in the length of hospitalization was achieved with PR in the 1-year follow-up in the two groups. The HFNT PR group showed better trends of reduced air trapping in the delta inspiration capacity (IC) and an increased quality of life according to the COPD assessment test (CAT) than did the non-HFNT PR group.

Conclusions

HFNT during exercise training in early PR increases exercise tolerance and reduces systemic inflammation in hospitalized patients with severe AECOPD.

Interventions at presentation and discharge for patients with acute exacerbation of chronic obstructive pulmonary disease to reduce unnecessary admissions and readmissions: A scoping review protocol

Aim

This scoping review will gather existing evidence on specific interventions at presentation and discharge which aim to standardize care and/or reduce unnecessary admissions and/or readmissions to hospital for patients presenting with acute exacerbation of chronic obstructive pulmonary (airways) disease.

Design

Scoping review of relevant literature from January 2000-March 2019.

Methods

Database searches for primary evidence in peer-reviewed journals will be conducted electronically using Web of Science, EMBASE (Elsevier) and PUBMED. Eligibility criteria will include hospital-based interventions for presentations of acute exacerbation of chronic obstructive pulmonary disease with outcomes specific to standardizing care or reducing unnecessary admissions or readmissions. Abstract, full-text screening and data extraction will be completed independently by a panel of expert reviewers.

Results

We aim to identify current interventions and improvement approaches in acute exacerbation of chronic obstructive pulmonary (airways) disease care that have an impact on admission and discharge processes or readmissions. Recommendations as a result of this review will aid the design and development of future improvement intervention.

How may we improve clinical outcomes for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease? A narrative review about possible therapeutic and preventive strategies

Introduction: In a subset of chronic obstructive pulmonary disease (COPD)patients the course of the disease is complicated by a severe acute exacerbations (AECOPD) that may require hospitalization, at which time negative outcomes may occur up to 30 days after discharge. Several predictors of negative outcomes have been documented.Areas covered: We considered five negative outcomes related to patients hospitalized with AECOPD: treatment failure, noninvasive mechanical ventilation (NIMV) failure, prolonged length of hospital stay (LHS), short-term mortality (≤ 90 days from admission and including the in-hospital mortality), and early readmission (≤30 days from discharge). Possible therapeutic and preventive strategies to improve these outcomes are outlined and discussed.Expert opinion: Several strategies have been proposed to improve outcomes. Among these, steroid or antibiotic use may reduce the risks of treatment failure or of prolonged hospital stay. We note that operator-related factors may influence the outcome of NIMV. However, little has been documented about the short-term mortality or early readmission rates. In general, few interventions consistently improve negative outcomes and prognosis of AECOPD.

The association of delta neutrophil index with the prognosis of acute exacerbation of chronic obstructive pulmonary disease

Background

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is associated with infective triggers including bacterial or viral in many cases, and pneumonia is a major contributor to hospitalization for AECOPD and has a close relationship with poor outcomes. Increased delta neutrophil index (DNI) can be useful in the detection of COPD patients with pneumonia.

Methods

A retrospective cohort study was performed to investigate the mortality rate of the patients who were re-admitted within 6 months after discharge from the hospital due to AECOPD with or without CAP. We analyzed the difference of cumulative survival rate according to serum DNI level and readmission duration.

Results

Finally, 140 AECOPD patients with community-acquired pneumonia (CAP) and 174 AECOPD patients without CAP were enrolled during 6 months, respectively. The mean age was 72.2 ± 9.4 year-old, and 240 patients (76.4%) were male. When comparing the cumulative survival rate according to readmission duration (≤ 30 vs >  30 days) and DNI level (< 3.5 vs ≥ 3.5%), AECOPD patients with readmission ≤30 days and DNI ≥ 3.5% showed the lowest cumulative survival rate compared to other groups (P <  0.001). Multivariate analysis revealed readmission duration ≤30 days (HR 7.879, 95% CI 4.554–13.632, P <  0.001); and serum DNI level (HR 1.086, 95% CI 1.043–1.131, P <  0.001) were significantly associated with the mortality of AECOPD patients during 6 months. The area under the curve for readmission (≤ 30 days) + DNI level (≥ 3.5%) was 0.753 (95% CI 0.676–0.830, P <  0.001) with a sensitivity of 73.7% and a specificity of 67.3%.

Conclusion

AECOPD patients who were readmitted ≤30 days and DNI ≥ 3.5% showed higher mortality. DNI level can be used as a predictor of prognosis in AECOPD patients who were readmitted after discharge.