Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease

PURPOSE

To identify factors affecting the short-term prognosis of patients with acutely exacerbated chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

The 590 patients having COPD as primary disease who were hospitalized in the pneumology unit of a university hospital from 1981 to 1990 were studied. A standardized protocol for the treatment of acutely exacerbated COPD was adopted for all the patients. The patient records were retrospectively analyzed by two observers, and 23 clinical and laboratory variables defining the patient status on admission were collected. Age and arterial gas data were also taken into account, and the outcome mortality was recorded. Interobserver reproducibility was tested by computing the kappa coefficient and Spearman's rho for dichotomous and continuous variables, respectively. The relationship of clinical and laboratory factors to the outcome was assessed first by univariate analysis and then by a logistic regression analysis assessing the independent predictive role of variables previously shown to be univariately correlated with mortality.

RESULTS

The mortality rate was 14.4%. The logistic regression analysis identified four independent predictors of death: age (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.04 to 1.11), alveolar-arterial oxygen gradient greater than 41 mm Hg (OR 2.33; 95% CI 1.39 to 3.90), ventricular arrhythmias (OR 1.91; 95% CI 1.10 to 3.31), and atrial fibrillation (OR 2.27; 95% CI 1.14 to 4.51).

CONCLUSIONS

Patients with acutely exacerbated COPD having a high risk of death can be identified at the time of admission. Variables reflecting heart dysfunction are important determinants of this risk. Among pulmonary function data, only alveolar-arterial oxygen gradient contributes to the predictive model.

The cardiopulmonary response to incremental exercise test: the effect of aging

The aims of the present study were to define the respective roles of the cardiac and respiratory response to exercise as determinants of the age-related physiological decrease in exercise performance, and to assess the relationship between aging and interindividual variability in the response to effort. We studied 91 normal subjects recruited in three age-groups: Group A (42 children, aged 10 +/- 2 years); Group B (29 young adults, aged 27 +/- 5 years); Group C (20 elderly, aged 74 +/- 9 years). All the subjects underwent an incremental cycle ergometer exercise test with a work load increase of 15 W every 2 minutes in groups A and C, and 25 W every 2 minutes in group B, until they achieved 80% of the predicted maximal heart rate. Ventilatory equivalent changes during exercise were significantly lower in group A than in the other two groups, and in group B compared to group C. Exercise-induced changes in oxygen pulse were significantly higher in group A, but no difference was found between groups B and C. Thus, gas-exchange function and overall exercise performance decrease with advancing age, whereas cardiovascular performance is well maintained in normal elderly subjects. Discriminant analysis showed that the exercise response conformed to the group-specific model in 74% and 79% of subjects in groups A and B, but only in 50% of the group C subjects; 5% and 45% of the elderly subjects were functionally classified in groups A and B, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchial asthma: still an inadequately assessed and improperly treated disease

In this paper we present data on the assessment and treatment of asthma in a large sample (13,899 subjects) representative of the population of young males living in four districts of the Tuscany region (Italy). In this group, 404 asthmatics (2.9%) were identified and 365 of the eligible patients were included in the study. A total of 323 asthmatics (88.5%) reported respiratory symptoms during the preceding year. A total of 162 asthmatics (44%) had previously had lung function tests to assess asthma, whereas in 89% of the patients the atopic component of asthma had been previously evaluated by prick tests. Fifty-seven percent of the patients in whom bronchial obstruction was observed and 38% of the asthmatics with severe bronchial hyperresponsiveness (BH) were receiving either no medication or treatment with only one drug. The drugs prescribed most frequently during the preceding year were beta agonists (56%) as opposed to sodium cromoglycate (22%) and inhaled steroids (17%); the latter two drugs were included in the therapy of 143 asthmatics (39%) and represented the treatment of choice in 16% of the subjects with bronchial obstruction and in 38% of the subjects with severe BH. We conclude that in our sample of young asthmatics the pulmonary function tests and the inhaled anti-inflammatory drugs were insufficiently utilized.

The relationship between sporting activity and smoking habits in young adults

The authors investigated the relationship between sporting activity and smoking habits in young Italian men. One thousand, one hundred fifty-three men, age 20 years, completed a self-administered questionnaire on their smoking habits and sporting activity patterns. Five hundred sixty subjects (53%) were found to be smokers, with a high prevalence of heavy smokers (33.6%). Four hundred sixty-four (44%) of the examined subjects were sportsmen. In the group of young men not engaged in sports, the rate of smokers was significantly higher. Non-sportsmen started smoking earlier than sportsmen, and the prevalence of heavy smokers was significantly higher in the non-sportsmen group than in the sportsmen group. Finally, the young men not engaged in sports were more likely to be habitual smoke inhalers than sportsmen. These results suggest that sporting activity may indirectly influence smoking habits.

Chronic obstructive pulmonary disease. An original model of cognitive decline

In order to characterize the neuropsychologic profile of patients with hypoxic-hypercapnic chronic obstructive pulmonary disease (COPD), the performance of 36 patients with COPD 69 +/- 10 yr of age (mean +/- SD) on 19 tests exploring eight cognitive domains was compared with those of 29 normal adults (69 +/- 7 yr of age), 20 normal elderly adults (78 +/- 2 yr of age), 26 patients with Alzheimer-type dementia (72 +/- 6 yr of age), and 28 with multi-infarct dementia (MID) (70 +/- 8 yr of age). The discriminant analysis of cognitive test scores showed that 48.5% of patients with COPD had a specific pattern of cognitive deterioration characterized by a dramatic impairment in verbal and verbal memory tasks, well-preserved visual attention, and diffuse worsening of the other functions. The remaining patients with COPD were functionally classified as normal adults (12.1%), normal elderly adults (15.2%), those with MID (12.1%), and those with Alzheimer-type dementia (12.1%) according to discriminant analysis. Cognitive impairment was significantly and positively correlated with age (p < 0.05) and duration of hypoxic-hypercapnic chronic respiratory failure (p < 0.05). Because patients with COPD were receiving oxygen therapy from the beginning of oxyhemoglobin desaturation, results suggest that continuous oxygen therapy does not prevent or only partly prevents cognitive decline in COPD. Although some analogies between age-related and COPD-related cognitive decline are evident, a distinct cognitive profile was found in a large fraction of patients with COPD and it differs in several aspects from those of both normal and demented subjects.

Effects of hospitalization on affective status of elderly patients

The effects of hospitalization on affective status were assessed by an original protocol in 214 consecutive elderly patients (mean age = 78.3 +/-5.0 years, range = 70-92 years). Psychological decompensation was significantly related to length of stay (p less than 0.01) and drug use (p less than 0.05) and unaffected by sex, marital status, prior living place, diagnostic category. Affective status and functional status were directly correlated (p less than 0.0001), although in 51% of medical patients the affective status worsened or remained unchanged despite improved physical function. Improvement in affective status occurred more frequently in surgical patients (p less than 0.001) due to psychological improvement following surgery. Physicians providing medical and surgical care for geriatric patients must remain aware of the patients' emotional response to hospitalization and illness, given the accompanying risk for psychological decompensation.

Factors affecting variations in pulmonary diffusing capacity resulting from postural changes

The relation of postural changes to the diffusing capacity of the lung for carbon monoxide (DLCO) was investigated in 12 normal nonsmokers in order to evaluate the influence of body position on several components of lung resistance to gas diffusion. The well-known increase in CO diffusing capacity in the supine position was obtained only for data corrected for alveolar volume (KCO: 6.18 +/- 0.75 vs. 5.45 +/- 0.67 ml/min/mm Hg/l; p less than 0.005). Moreover, only the membrane component (Dm) increased significantly in supine subjects (KDm = 2.81 +/- 1.32 vs. 1.82 +/- 0.54 ml/min/mm Hg/l; p less than 0.05), the increase in capillary blood volume (Vc) being not significant (KVc = 12.54 +/- 4.22 vs. 11.17 +/- 3.79 ml/l; NS). These data could be interpreted as a demonstration of a more homogeneously distributed ventilation with respect to diffusion surface in healthy young people in a supine position. The amount of surface available for diffusion seems therefore to be a limiting factor to gas flow across the lungs in these subjects. Thus a straightforward attribution of posturally influenced changes in CO diffusing capacity exclusively to factors affecting Vc is not recommended, particularly in pathological conditions, if information about variation in distribution of ventilation is unavailable.

Comparison of the performance of two mini peak flow meters

Two mini peak flow meters commonly used to monitorize the peak expiratory flow rate (PEFR) are compared to assess their agreement, precision and, with respect to a standard pneumotachygraph, accuracy. Precision of the mini-Wright peak flow meter is greater, possibly as result of a systematic overestimation of PEFR values. The Assess peak-flow meter is more accurate, but its ability to reproduce the actual well-known PEFR variability is dependent from the absolute level of air flow. The agreement between two instruments is very poor, both in asthmatics and in normals, so that it is mandatory to use always the same mini peak flow meter in population studies and during the follow-up of asthmatic patients.

Pulmonary involvement in progressive systemic sclerosis: a multidisciplinary approach

In an attempt to define the early features and the natural evolution of lung involvement in progressive systemic sclerosis (PSS), we planned a multidisciplinary study of these patients using radiological, scintigraphic and functional methods. As yet we have studied 21 subjects, all affected by PSS according to the American Rheumatism Association criteria. A well-defined restrictive functional pattern was present only in 10 patients out of 21; an increased elastic recoil may be present before a significant decrease of the transfer test for carbon monoxide; an increased alveolar-capillary permeability assessed by the 99mTc-diethylene-triamine-pentacetic acid (99mTc-DTPA) clearance rate has been detected in almost all the patients (13 out of 14) in at least one lung field; no significant correlation has been found between the radiological lung involvement and the 99mTc-DTPA clearance rate. We think that these preliminary results are consistent with an alveolar and interstitial inflammation rather than with a vasculitic process.