Severity of acidosis affects long-term survival in COPD patients with hypoxemia after intensive care unit discharge

The Long-Term Impact of Frailty After an Intensive Care Unit Admission Due to Chronic Obstructive Pulmonary Disease

Rationale

Frailty is an increasingly recognized aspect of chronic obstructive pulmonary disease (COPD). The impact of frailty on long-term survival after admission to an intensive care unit (ICU) due to an exacerbation of COPD has not been described.

Objective

The objective was to quantify the impact of frailty on time to death up to 4 years after admission to the ICU in Australia and New Zealand for an exacerbation of COPD.

Methods

We performed a multicenter retrospective cohort study of adult patients admitted to 179 ICUs with a primary diagnosis of an exacerbation of COPD using the Australian and New Zealand Intensive Care Society Adult Patient Database from January 1, 2018, through December 31, 2020, in New Zealand, and March 31, 2022, in Australia. Frailty was measured using the clinical frailty scale (CFS). The primary outcome was survival up to 4 years after ICU admission. The secondary outcome was readmission to the ICU due to an exacerbation of COPD.

Measurements and Main Results

We examined 7126 patients of which 3859 (54.1%) were frail (CFS scores of 5-8). Mortality in not-frail individuals versus frail individuals at 1 and 4 years was 19.8% versus 40.4%, and 56.8% versus 77.3% respectively (both p<0.001). Frailty was independently associated with a shorter time to death (adjusted hazard ratio 1.66; 95% confidence interval 1.54-1.80).There was no difference in the proportion of survivors with or without frailty who were readmitted to the ICU during a subsequent hospitalization.

Conclusions

Frailty was independently associated with poorer long-term survival in patients admitted to the ICU with an exacerbation of COPD.

Evaluation of Potential Effects of Increased Outdoor Temperatures Due to Global Warming on Cerebral Blood Flow Rate and Respiratory Function in Chronic Obstructive Disease and Anemia

Global warming due to increased outdoor carbon dioxide (CO2) levels may cause several health problems such as headaches, cognitive impairment, or kidney dysfunction. It is predicted that further increases in CO2 levels will increase the morbidity and mortality of patients affected by a variety of diseases. For instance, patients with Chronic Obstructive Pulmonary Disease (COPD) may suffer cognitive impairments or intracranial bleeding due to an increased cerebral blood flow rate. Predicting the harmful effects of global warming on human health will help to take measures for potential problems. Therefore, the quantification of physiological parameters is an essential step to investigate the effects of global warming on human health. In this study, the effects of increased outdoor temperatures due to climate change on cerebral blood flow rate and respiratory function in healthy subjects and COPD patients with anemia and respiratory acidosis are evaluated utilizing numerical simulations. The numerical model simulates cardiac function and blood circulation in systemic, pulmonary and cerebral circulations, cerebral autoregulatory functions, respiratory function, alveolar gas exchange, oxygen (O2) and CO2 contents, and hemoglobin levels in the blood. The simulation results show that although the cardiovascular function is not significantly altered, the respiratory function and cerebral blood flow rates are altered remarkably.

An audit of patients admitted to hospital in Nepal for COPD exacerbation

Objectives:

Chronic obstructive pulmonary disease is a large and increasing problem in low- and middle-income countries; Nepal is no exception. We aimed to obtain information on patient characteristics and the level of care provided to patients admitted for acute exacerbation of chronic obstructive pulmonary disease in two Nepalese hospitals and to compare the given care with the Global Initiative for Chronic Obstructive Lung Disease guidelines.

Methods:

This was a cross-sectional, observational, descriptive study. All patients admitted to two Nepalese hospitals due to acute exacerbation of chronic obstructive pulmonary disease between 18 February and 5 April 2019 were asked to participate.

Results:

In total, 108 patients with a median age of 70 years participated. Fifty-three (42.7%) were male, 80 (74.8%) were former smokers, and 46 (45.1%) were farmers. Using the Global Initiative for Chronic Obstructive Lung Disease A-D classification, 97 (90.6%) of the patients were classified in group D. All the patients received supplementary oxygen treatment and 103 (95.4%) were treated with short-acting beta2 agonists. A total of 105 (97.2%) patients received antibiotics, and 80 (74.5%) received systemic corticosteroids. The majority was discharged with triple therapy including long-acting muscarinic antagonist, long-acting beta2 agonist, and inhaled corticosteroids, and 72 (75.8%) were discharged with long-term oxygen treatment.

Conclusion:

All elements of the Global Initiative for Chronic Obstructive Lung Disease guidelines were applied. However, due to a lack of information, it cannot be concluded whether the treatment was provided on the correct indications. The average patient received almost all the treatment alternatives available. This might indicate a very sick population or over-treatment.

Extracorporeal carbon dioxide removal for treatment of exacerbated chronic obstructive pulmonary disease (ORION): study protocol for a randomised controlled trial

Background

Hypercapnic exacerbations are severe complications of chronic obstructive pulmonary disease (COPD), characterized by negative impact on prognosis, quality of life and healthcare costs. The present standard of care for acute exacerbations of COPD is non-invasive ventilation; when it fails, the use of invasive mechanical ventilation is inevitable, but is associated with extremely poor prognosis. Extracorporeal circuits designed to remove CO₂ (ECCO₂R) may enhance the efficacy of NIV to remove CO₂ and avoid the worsening of respiratory acidosis, which inevitably leads to failure of non-invasive ventilation. Although the use of ECCO₂R for acute exacerbations of COPD is steadily increasing, solid evidence on its efficacy and safety is scarce, thus the need for a randomized controlled trial.

Methods

multicenter randomized controlled unblinded clinical trial including 284 (142 per arm) patients with acute hypercapnic respiratory failure caused by exacerbation of COPD, requiring respiratory support with NIV. The primary outcome is event free survival at 28 days, a composite outcome defined by survival in absence of prolonged mechanical ventilation, severe hypoxemia, septic shock and second episode of COPD exacerbation. Secondary outcomes are incidence of endotracheal intubation and tracheostomy, intensive care and hospital length-of-stay and 90-day mortality.

Discussion

Acute exacerbations of COPD represent a significant burden in terms of prognosis, quality of life and healthcare costs. Lack definite evidence despite increasing use of ECCO₂R justifies a randomized trial to evaluate whether patients with acute hypercapnic acidosis not responsive to NIV should undergo invasive mechanical ventilation (with all serious related risks) or be treated with ECCO₂R to avoid invasive ventilation but be exposed to possible adverse events of ECCO₂R. Owing to its pragmatic nature, sample size and composite primary outcome, this trial aims at providing valuable answers to relevant questions for clinical treatment of acute exacerbations of COPD.

Trial registration

ClinicalTrials.gov, NCT04582799. Registered 12 October 2020, .

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05692-w.

Prognostic Value of Oxygenated Hemoglobin Assessed during Acute Exacerbations of Chronic Pulmonary Disease

BACKGROUND

Oxygenated hemoglobin(OxyHem) is a simple-to-measure marker of oxygen content capable of predicting all-cause mortality in stable chronic obstructive pulmonary disease (COPD).

OBJECTIVES

We aimed to analyze its predictive value during acute exacerbations of COPD (AECOPD).

METHODS

In this retrospective study, data from 227 patients discharged after severe AECOPD at RoMed Clinical Center Rosenheim, Germany, between January 2012 and March 2018, was analyzed. OxyHem (hemoglobin concentration [Hb] × fractional SpO2, g/dL) was calculated from oxygen saturation measured by pulse oximetry and hemoglobin assessed within 24 h after admission. The follow-up (1.7 ± 1.5 years) covered all-cause mortality, including readmissions for severe AECOPD.

RESULTS

During the follow-up period, 127 patients died, 56 due to AECOPD and 71 due to other reasons. Survivors and non-survivors showed differences in age, FVC % predicted, C-reactive protein, hemoglobin, Cr, Charlson Comorbidity Index (CCI), and OxyHem (p < 0.05 each). Significant independent predictors of survival were BMI, Cr or CCI, FEV1 % predicted or FVC % predicted, Hb, or OxyHem. The predictive value of OxyHem (p = 0.006) was superior to that of Hb or SpO2 and independent of oxygen supply during blood gas analysis. OxyHem was also predictive when using a cutoff value of 12.1 g/dL identified via receiver operating characteristic curves in analyses including either the CCI (hazard ratio 1.85; 95% CI 1.20, 2.84; p = 0.005) or Cr (2.04; 95% CI 1.35, 3.10; p = 0.001) as covariates.

CONCLUSION

The concentration of OxyHem provides independent, easy-to-assess information on long-term mortality risk in COPD, even if measured during acute exacerbations. It therefore seems worth to be considered for broader clinical use.

Impact of Hyponatremia on COPD Exacerbation Prognosis

The most common electrolyte disorder among hospitalized patients, hyponatremia is a predictor of poor prognosis in various diseases. The aim of this study was to establish the prevalence of hyponatremia in patients admitted for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), as well as its association with poor clinical progress. Prospective observational study carried out from 1 October 2016 to 1 October 2018 in the following hospitals: Salnés in Vilagarcía de Arousa, Arquitecto Marcide in Ferrol, and the University Hospital Complex of Santiago de Compostela, Galicia, Spain, on patients admitted for AECOPD. Patient baseline treatment was identified, including hyponatremia-inducing drugs. Poor progress was defined as follows: prolonged stay, death during hospitalization, or readmission within one month after the index episode discharge. 602 patients were enrolled, 65 cases of hyponatremia (10.8%) were recorded, all of a mild nature (mean 131.6; SD 2.67). Of all the patients, 362 (60%) showed poor progress: 18 (3%) died at admission; 327 (54.3%) had a prolonged stay; and 91 (15.1%) were readmitted within one month after discharge. Patients with hyponatremia had a more frequent history of atrial fibrillation (AF) (p 0.005), pleural effusion (p 0.01), and prolonged stay (p 0.01). The factors independently associated with poor progress were hyponatremia, pneumonia, and not receiving home O₂ treatment prior to admission. Hyponatremia is relatively frequent in patients admitted for AECOPD, and it has important prognostic implications, even when mild in nature.