Neutrophil-to-Lymphocyte Ratio Predicts Clinical Outcome of Severe Acute Exacerbation of COPD in Frequent Exacerbators

Use of the Serum Level of Cholinesterase as a Prognostic Marker of Nonfatal Clinical Outcomes in Patients Hospitalized with Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Introduction

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) contributes to a poor prognosis. Reliable biomarkers to predict adverse outcomes during hospitalization are important.

Aim

To investigate the relationship between the serum cholinesterase (ChE) level and adverse clinical outcomes, including hypoxemia severity, hypercapnia, duration of hospital stay (DoHS), and noninvasive ventilation (NIV) requirement, in patients with AECOPD.

Methods

Patients hospitalized with AECOPD in the Wuhu Hospital of Traditional Chinese Medicine between January 2017 and December 2021 were included.

Results

A total of 429 patients were enrolled. The serum ChE level was significantly lower in patients with hypercapnia, who required NIV during hospitalization and who had a DoHS of >10 days, with an oxygenation index < 300. The ChE level was correlated negatively with the C-reactive protein level and neutrophil-to-lymphocyte ratio and correlated positively with the serum albumin level. Multivariate logistic regression analysis indicated that a serum ChE level of ≤4116 U/L (OR = 2.857, 95% CI = 1.46-5.58, p = 0.002) was associated significantly with NIV requirement.

Conclusions

The serum ChE level was correlated significantly with complicating severe hypoxemia, hypercapnia, prolonged DoHS, and the need for NIV in patients hospitalized with AECOPD. The serum ChE level is a clinically important risk-stratification biomarker in patients hospitalized with AECOPD.

Predictive role of neutrophil-percentage-to-albumin, neutrophil-to-lymphocyte and eosinophil-to-lymphocyte ratios for mortality in patients with COPD: Evidence from NHANES 2011-2018

BACKGROUND AND OBJECTIVE

This study evaluated the predictive roles of hematologic inflammatory biomarkers including neutrophil-percentage-to-albumin ratio (NPAR), neutrophil-to-lymphocyte ratio (NLR) and eosinophil-to-lymphocyte ratio (ELR) for mortality in community-dwelling individuals with chronic obstructive pulmonary disease (COPD).

METHODS

This longitudinal study extracted data of adults 40-79 years who had physician-diagnosed COPD from the United States (US) National Health and Nutrition Examination Survey (NHANES) 1999-2018. Cox regressions determined the associations between NPAR, NLR, ELR and their components, with all-cause mortality, cardiovascular disease (CVD) mortality and mortality from chronic lower respiratory disease (CLRD). Receiver operating characteristic (ROC) curve analysis estimated the predictive performances of these biomarkers for 5-year all-cause mortality.

RESULTS

Data of 1158 subjects were analysed. After adjustment, higher NPAR was significantly associated with increased all-cause and CVD mortality, and mortality from CLRD (adjusted hazard ratio [aHR] = 1.14, 1.15 and 1.16). Higher NLR was associated with an increased all-cause and CVD mortality (aHR = 1.16 and 1.29). Higher neutrophil was associated with increased all-cause mortality and mortality from CLRD (aHR = 1.13 and 1.34). Albumin was associated with decreased all-cause and CVD mortality (aHR = 0.91 and 0.86). ELR, eosinophil or lymphocyte was not significantly associated with either mortality outcomes. Adjusted AUC of NPAR and NLR in predicting 5-year all-cause mortality were 0.808 (95% CI: 0.722-0.845) and 0.799 (95% CI: 0.763-0.835), respectively.

CONCLUSION

In community-dwelling US adults with COPD, increased NPAR and NLR are associated with mortality risks. NPAR outperforms the other hematologic inflammatory biomarkers in predicting 5-year all-cause mortality.

Analysis of sputum microbial flora in chronic obstructive pulmonary disease patients with different phenotypes during acute exacerbations

BACKGROUND

Increasing studies have shown that the imbalance of the respiratory microbial flora is related to the occurrence of COPD, the severity and frequency of exacerbations and mortality.However, it remains unclear how the sputum microbial flora differs during exacerbations in COPD patients manifesting emphysema phenotype, chronic bronchitis with emphysema phenotype and asthma-COPD overlap phenotype.

METHODS

Sputum samples were obtained from 29 COPD patients experiencing acute exacerbations who had not received antibiotics or systemic corticosteroids within the past four weeks.Patients were divided into three groups;emphysema phenotype(E);chronic bronchitis with emphysema phenotype(B+E) and asthma-COPD overlap phenotype(ACO).We utilized metagenomic Next Generation Sequencing (mNGS) technology to analyze the sputum microbial flora in COPD patients with different phenotypes during exacerbations.

RESULTS

There was no significant difference in alpha diversity and beta diversity among three groups.The microbial flora composition was similar in all three groups during exacerbations except for a significant increase in Streptococcus mitis in ACO.Through network analysis,we found Candidatus Saccharibacteria oral taxon TM7x and Fusobacterium necrophorum were the core nodes of the co-occurrence network in ACO and E respectively.They were positively correlated with some species and play a synergistic role.In B+E,Haemophilus pittmaniae and Klebsiella pneumoniae had a synergistic effect.Besides,some species among the three groups play a synergistic or antagonistic role.Through Spearman analysis,we found the relative abundance of Streptococcus mitis was negatively correlated with the number of hospitalizations in the past year(r = -0.410,P = 0.027).We also observed that the relative abundance of Prevotella and Prevotella melaninogenica was negatively correlated with age(r = -0.534,P = 0.003;r = -0.567,P = 0.001),while the relative abundance of Streptococcus oralis and Actinomyces odontolyticus was positively correlated with age(r = 0.570,P = 0.001;r = 0.480,P = 0.008).In addition,the relative abundance of Prevotella melaninogenica was negatively correlated with peripheral blood neutrophil ratio and neutrophil to lymphocyte ratio(r = -0.479,P = 0.009;r = -0.555,P = 0.002),while the relative abundance of Streptococcus sanguinis was positively correlated with peripheral blood neutrophil ratio and neutrophil to lymphocyte ratio (r = 0.450,P = 0.014;r = 0.501,P = 0.006).There was also a significant positive correlation between Oribacterium and blood eosinophil counts(r = 0.491,P = 0.007).

CONCLUSION

Overall,we analyzed the sputum microbiota of COPD patients with different phenotypes and its relationship with clinical indicators, and explored the relationships between microbiota and inflammation in COPD.We hope to alter the prognosis of patients by inhibiting specific bacterial taxa related to inflammation and using guide individualized treatment in the future research.

Association of Blood Inflammatory Biomarkers with Clinical Outcomes in Patients with AECOPD: An 8-Year Retrospective Study in Beijing

Purpose

To discover potential inflammatory biomarkers, which can compare favorably with traditional biomarkers, and their best cut-offs at first admission to predict clinical outcomes (short-term and long-term) and the risk of readmission among acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients.

Patients and Methods

Novel inflammatory biomarkers (such as the neutrophil-lymphocyte ratio [NLR], platelet-lymphocyte ratio [PLR], etc.) were compared with traditional biomarkers by Pearson's correlation test. Logistic regression analysis and receiver operating characteristic (ROC) curves were applied to judge the accuracy of these novel biomarkers to predict in-hospital mortality.

Results

Surviving AECOPD patients had lower NLR, PLR, and lymphocyte-to-monocyte ratios than non-survival patients (all P < 0.001). According to Pearson's correlation test, there was a linear correlation between novel and traditional biomarkers (all P < 0.05). In terms of a single biomarker, the AUC value of NLR was the largest, which was not inferior to C-reactive protein (Z-P = 0.064), and superior to erythrocyte sedimentation rate (Z-P = 0.002) and other novel single inflammatory biomarkers (all Z-P < 0.05). The mortality of patients with NLR ≥ 4.43 was 2.308-fold higher than that of patients with NLR < 4.43. After dividing patients into a higher or lower NLR group, pooled results showed that patients with NLR ≥ 4.43 had a higher rate of treatment failure, intensive care unit admission, longer hospital length of stay, one-year mortality after the index hospitalization, and overall mortality than patients with NLR < 4.43 (all P < 0.001). Patients with NLR ≥ 4.43 were associated with higher and earlier first readmission due to AECOPD than patients with lower NLR.

Conclusion

NLR was the best to forecast the clinical prognosis and readmission risk among AECOPD patients, which was not inferior to CRP, and the best cut-off value of NLR was 4.43.

Hematological Parameters for Predicting Mortality in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

(1) Introduction: COPD is a common and serious condition affecting a significant proportion of the population globally. Patients often suffer from exacerbations which lead to the worsening of their health status and respiratory function, and can often lead to death. Quick and cheap investigations are required that are capable of predicting mortality in patients with acute exacerbations that can be applied in low resource settings. (2) Materials and methods: This was a retrospective study carried out using hospital records of patients admitted for AECOPD from 1 January 2017 to 30 November 2022. Chi-square test (for sex) and Student's t-test were used to look for significant associations. Receiver Operating Characteristics (ROC) curves were plotted and Area Under Curve (AUC) values were calculated for various hematological parameters. Youden's J was used to identify the ideal cut-off with optimal sensitivity and specificity. Multivariate Cox regression was used to identify independent hematological predictors of mortality. Kaplan-Meir survival plots for neutrophil lymphocyte ratio (NLR) with the optimal cut-off were plotted. (3) Results: Amongst the 500 patients, 42 died while 458 survived, giving a mortality rate of 8.4%. NLR had the strongest association with mortality. The cut-off for various parameters were: NLR 14.83 (AUC 0.73), total leukocyte count (TLC) 13,640 cells/mm³ (AUC 0.60), absolute neutrophil count (ANC) 12,556 cells/mm³ (AUC 0.62), derived NLR (dNLR) 9.989 (AUC 0.73), hemoglobin 11.8 mg/dL (AUC 0.59), packed cell volume (PCV) 36.6% (AUC 0.60), and platelet lymphocyte ratio (PLR) 451.32 (AUC 0.55). (4) Conclusions: In patients with acute exacerbation of COPD, NLR was strongly associated with mortality, followed by dNLR. Cox regression identified NLR as an independent predictor of mortality.

Identification of frequent acute exacerbations phenotype in COPD patients based on imaging and clinical characteristics

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common disease with high morbidity, with acute exacerbations manifesting as a worsening of respiratory symptoms. This study aimed to identify the frequent acute exacerbation phenotype in patients with COPD based on imaging and clinical characteristics.

METHODS

Patients with COPD (n = 201) were monitored for acute exacerbations one year after their initial hospital admission and further divided into frequent and non-frequent exacerbation groups according to the frequency and severity of acute exacerbations. All patients underwent high resolution CT scans and low attenuation area less than -950Hu (LAA-950) in the whole lung was measured. Differences in visual subtypes, LAA-950, and clinical basic characteristics were compared between groups. The clinical factors influencing frequent exacerbation were determined using binary logistic regression. Finally, based on imaging and clinical factors, the receiver operating characteristic curve was used to identify the phenotype of COPD with frequent acute exacerbations.

RESULTS

Patients with frequent exacerbations had a larger LAA-950 than those non-frequent exacerbations patients (p＜0.001). Frequent acute exacerbations were associated with worsening visual subtypes. Multivariate binary logistic regression illustrated that age, smoking status, BMI, FEV1 pred, and LAA-950 were associated with frequent exacerbations of COPD. The area under the receiver operating characteristic curve for predicting frequent exacerbations based on age, smoking status, BMI, FEV1 pred, and LAA-950 was 0.907 (p＜0.001).

CONCLUSION

The combination of imaging and clinical characteristics reached high diagnostic efficacy in the identification of frequent acute exacerbations in patients with COPD.

Association Between Neutrophil-Lymphocyte Ratio and All-Cause Mortality in Critically Ill Patients with Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study

BACKGROUND Neutrophil-lymphocyte ratio (NLR) is related to increased mortality risk in many diseases. However, there is limited research on critically ill patients with chronic obstructive pulmonary disease (COPD). A retrospective cohort study was performed to investigate whether NLR can be used as a biomarker to predict the mortality of critically ill COPD patients. MATERIAL AND METHODS In the research, the data were gathered from the database of the Medical Information Mart for Intensive Care-IV. The 28-day mortality was defined as the primary outcome, while the secondary outcomes were in-hospital and 90-day mortality. Through the application of the Kaplan-Meier curves and the multivariate Cox regression analysis, the potential association between NLR and mortality for critically ill patients with COPD was evaluated. For subgroup analysis, age, sex, ethnicity, mean blood pressure, and comorbidities were considered. RESULTS We extracted data on 2650 patients, of which 53.7% were male. A higher level of NLR was correlated with higher 28-day mortality risk. Compared to the lower quartile (NLR<4.56), HR (95% CI) of the upper quartile (NLR>16.86) was 1.75 (1.21-2.52) in the multivariate Cox regression model when adjusted for confounders (P=0.003). A similar tendency was found in the 90-day mortality (HR=1.59, 95% CI=1.16-2.19, P=0.004) and the in-hospital mortality (HR=1.71, 95% CI=1.22-2.42, P=0.002). Subgroup analyses showed that the correlation between NLR and 28-day mortality was stable. CONCLUSIONS The higher level of NLR is likely to be correlated with the increase of the all-cause mortality risk in critically ill patients with COPD, but this needs to be validated in future prospective research.

Sarcopenia index as a predictor of clinical outcomes among older adult patients with acute exacerbation of chronic obstructive pulmonary disease: a cross-sectional study

BACKGROUND

Sarcopenia is a geriatric syndrome with progressive loss of skeletal muscle mass and function and has a negative impact on clinical outcomes associated with chronic obstructive pulmonary disease (COPD). Recently, the sarcopenia index (SI) was developed as a surrogate marker of sarcopenia based upon the serum creatinine to cystatin C ratio. We aimed to assess the value of SI for predicting clinically important outcomes among elderly patients with acute exacerbation of COPD (AECOPD).

METHODS

This cross-sectional study included elderly patients with AECOPD in China from 2017 to 2021. Clinical data were collected from medical records, and serum creatinine and cystatin C were measured. Outcomes included respiratory failure, heart failure, severe pneumonia, invasive mechanical ventilation, and mortality. Binary logistic regression was used to analyze the association between SI and clinical outcomes.

RESULTS

A total of 306 patients (260 men, 46 women, age range 60-88 years) were enrolled in this study. Among the total patients, the incidence of respiratory failure and severe pneumonia was negatively associated with SI values. After adjusting for potential confounding factors, binary logistic regression analyses showed that a higher SI was still independently associated with a lower risk of respiratory failure (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.13-0.56, P < 0.05). In subgroup analysis, the incidence of respiratory failure was negatively associated with SI values in groups with both frequent exacerbation and non-frequent exacerbation. After adjustment for potential confounders, binary logistic regression analyses showed that a higher SI was also independently associated with a lower risk of respiratory failure in both groups (OR: 0.19, 95% CI: 0.06-0.64 and OR: 0.31, 95% CI: 0.11-0.85). However, there were no significant differences in the correlations between SI and the risk of heart failure, invasive mechanical ventilation, and mortality in all groups.

CONCLUSION

The SI based on serum creatinine and cystatin C can predict respiratory failure in patients with AECOPD and either frequent or infrequent exacerbations. This indicator provides a convenient tool for clinicians when managing patients with AECOPD in daily clinical practice.

Clinical significance of the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in acute exacerbations of COPD: present and future

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a leading cause of hospitalisation and death in COPD patients. In addition to the identification of better strategies to prevent AECOPD, there is an intense focus on discovering novel markers of disease severity that enhance risk stratification on hospital admission for the targeted institution of aggressiveversussupportive treatments. In the quest for such biomarkers, an increasing body of evidence suggests that specific indexes derived from routine complete blood counts,i.e.the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR), can significantly predict adverse outcomes in AECOPD. This narrative review discusses the current evidence regarding the association between the NLR and the PLR on admission and several clinical end-points (need for invasive ventilation, noninvasive mechanical ventilation failure, admission to an intensive care unit, pulmonary hypertension, length of hospitalisation, and mortality) in AECOPD. Future research directions and potential clinical applications of these haematological indexes in this patient group are also discussed.

Association of Red Cell Index and Adverse Hospitalization Outcomes in Chronic Obstructive Pulmonary Disease Patients with Acute Exacerbation: A Retrospective Cohort Study

Purpose

Previous studies have shown that the red cell index (RCI) can be considered as a simple and useful method to evaluate respiratory function. However, at present its association with adverse hospitalization outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is not fully understood. Our study aimed to examine the relationship between adverse hospitalization outcomes and RCI among AECOPD patients.

Patients and Methods

We performed a retrospective analysis of consecutive patients from January 2015 to October 2021. In this study, RCI was the independent variable, measured at baseline, and adverse hospitalization outcome was the dependent variable. According to the RCI median (RCI=2.221), we divided 377 patients into two roughly equal groups (188 and 189, respectively). Next, the association between RCI and adverse hospitalization outcomes was explored using multivariable logistic regression models. To identify any non-linear relationship, a generalized additive model (GAM) was employed.

Results

With a total of 377 patients with AECOPD, we divided them into two roughly equal groups to compare the clinical factors and RCI levels. The patients in the higher RCI group showed poorer outcome incidence (18 [9.57%] vs 31 [16.40%]; p = 0.049). After accounting for potential confounders, the results showed that RCI was positively associated with adverse hospitalization outcomes (odds ratio [OR] = 1.15, 95% CI: 1.01-1.32). In addition, a non-linear relationship was detected between RCI and adverse hospitalization outcomes, which had an inflection point of 3.2. There were odds ratios and confidence intervals of 0.8 (0.7-1.0) and 1.3 (1.2-1.4) on the left and right sides of the inflection point, respectively.

Conclusion

The RCI and adverse hospitalization outcomes exhibited a non-linear relationship in the AECOPD patients. RCI is strongly positively correlated with adverse hospitalization outcomes when it was greater than 3.2.

Practical parameters that can be used for nutritional assessment in patients hospitalized in the intensive care unit with the diagnosis of chronic obstructive pulmonary disease: Prognostic nutritional index, neutrophil-to-lymphocyte, platelet-to-lymphocyte, and lymphocyte-to-monocyte ratio

Malnutrition is an important condition in patients diagnosed with chronic obstructive pulmonary disease (COPD). There is a need for practical and objective nutritional assessment methods in patients hospitalized in the intensive care unit with the diagnosis of COPD. In this study, it was aimed to determine the parameters that can practically evaluate the nutritional status of these patients. It was aimed to determine the relationship between prognostic nutritional index (PNI), and nutritional risk screening (NRS)-2002, nutrition risk in the critical ill (Nutric) Score and to determine a cut-off value for PNI, neutrophil-to-lymphocyte (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and other complete blood count parameters.Hemogram values, albumin values, NLR, PLR, LMR, NRS-2002, PNI and modified Nutric Score calculations of the patients hospitalized in the intensive care unit due to COPD were recorded. The relationship between PNI and NRS-2002 and modified Nutric Score, as well as the relationship between NLR, PLR, LMR, hemogram parameters and PNI were analyzed using statistical methods.The PNI cut-off value for nutritional assessment in patients hospitalized in the intensive care unit due to COPD was determined as 38.5 (area under curve = 0.891, sensitivity 80.8%, specificity 88.1%, positive predictive value 92.9%, negative predictive value 88%). High-risk group according to PNI compared to low-risk group, lymphocyte count (P < .001), basophil count (P = .004), red blood cell (P < .001), hemoglobin (P < .001), hematocrit (P < .001), and LMR (P = .001) were statistically significantly lower, while NLR (P < .001) and PLR (P = .001) were statistically significantly higher. Cut-off values for lymphocyte count, basophil count, NLR, PLR, and LMR were found to be 1.18, 0.035, 7.97, 291.10, and 2.606, respectively.Nutritional risk assessment can be made in a practical way by using PNI in patients hospitalized in intensive care unit due to COPD. For this, the PNI cut-off value was determined as 38.5 in our study. In addition, NLR, PLR, LMR, basophil and lymphocyte values, which can be calculated using complete blood count parameters, may also be useful in the evaluation of nutritional status in these patients. In our study, the cut-off values determined for NLR, PLR, LMR, basophil and lymphocyte were 7.97, 291.10 and 2.606, 0.035 and 1.18, respectively. We think that the results we have obtained can provide preliminary information for future research.

A Comprehensive Systematic Review and Meta-Analysis of the Association between the Neutrophil-to-Lymphocyte Ratio and Adverse Outcomes in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

The neutrophil-to-lymphocyte ratio (NLR) predicts adverse outcomes in stable chronic obstructive pulmonary disease (COPD); however, its prognostic role in acute exacerbations (AECOPD) is less clear. We conducted a systematic review and meta-analysis of the association between the NLR on admission and adverse outcomes (mortality, need for mechanical ventilation, transfer to the intensive care unit, length of stay, pulmonary hypertension, or their combination) in AECOPD by searching PubMed, Web of Science, and Scopus from inception to April 2022. Risk of bias and certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and the Grades of Recommendation, Assessment, Development, and Evaluation, respectively. In 15 studies (n = 10,038 patients), the NLR was significantly associated with the risk of adverse outcomes (odds ratio = 1.054, 95% CI 1.016 to 1.093, p = 0.005; low certainty of evidence; standard mean difference = 0.82, 95% CI 0.57 to 1.06, p < 0.001; high certainty of evidence). Pooled sensitivity, specificity, and area under the curve were 0.71 (95% CI 0.64 to 0.77), 0.73 (95% CI 0.65 to 0.80), and 0.78 (95% CI 0.74 to 0.81), respectively. In our study, the NLR on admission was significantly associated with adverse outcomes in AECOPD patients, suggesting the potential utility of this biomarker for early risk stratification and management in this group.

Risk Factors for Length of Hospital Stay in Acute Exacerbation Chronic Obstructive Pulmonary Disease: A Multicenter Cross-Sectional Study

Background/Purpose

Patients and Methods

Results

Conclusion

Sarcopenia, systemic immune-inflammation index and all-cause mortality in middle-aged and older people with COPD and asthma: a population-based study

Background

Increasing evidence suggests that sarcopenia and a higher systemic immune-inflammation index (SII) are linked with morbidity in patients with COPD. However, whether these two conditions contribute to all-cause mortality in middle-aged and older patients with COPD or asthma is unclear. Therefore, we investigated the association between sarcopenia, SII, COPD or asthma and all-cause mortality in a large-scale population-based setting.

Methods

Between 2009 and 2014, 4482 participants (aged >55 years; 57.3% female) from the population-based Rotterdam Study were included. COPD and asthma patients were diagnosed clinically and based on spirometry. Six study groups were defined according to the presence or absence of COPD or asthma and sarcopenia. Cox regression models were used to assess all-cause mortality in the study groups, adjusted for sex, age, body mass index, SII, smoking, oral corticosteroid use and comorbidities. In addition, all participants were categorised into sex-specific quartiles of SII, and mortality in these groups was compared.

Results

Over a median follow-up of 6.1 years (interquartile range 5.0–7.2 years), 466 (10.4%) persons died. Independent of the presence of sarcopenia, participants with COPD had a higher risk of all-cause mortality (hazard ratio (HR) 2.13, 95% CI 1.46–3.12 and HR 1.70, 95% CI 1.32–2.18 for those with and without sarcopenia, respectively). Compared to lower SII levels, higher SII levels increased mortality risk even in people without sarcopenia, COPD or asthma.

Conclusion

Middle-aged and older people with COPD, higher SII levels or sarcopenia had an independently increased mortality risk. Our study suggests prognostic usefulness of routinely evaluating sarcopenia and SII in older people with COPD or asthma.

Sarcopenia and COPD increased the risk of all-cause mortality in middle-aged and older populations. Additionally, compared to lower SII levels, higher SII levels increased mortality risk in people with and without sarcopenia and COPD.https://bit.ly/3d659m2