Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic pulmonary disease. JAMA 274: 1852-1857
To describe outcomes and identify variables associated with hospital and 1-year survival for patients admitted to an intensive care unit (ICU) with an acute exacerbation of chronic obstructive pulmonary disease (COPD).
Prospective, multicenter, inception cohort study.
Forty-two ICUs at 40 US hospitals.
A total of 362 admissions for COPD exacerbation selected from the Acute Physiology and Chronic Health Evaluation (APACHE) III database of 17,440 ICU admissions.
Hospital mortality for the 362 admissions was 24%. For the 167 patients aged 65 years or older, mortality was 30% at hospital discharge, 41% at 90 days, 47% at 180 days, and 59% at 1 year. Median survival for all patients was 224 days, and median survival for the patients who died within 1 year was 30.5 days. On multiple regression analysis, variables associated with hospital mortality included age, severity of respiratory and nonrespiratory organ system dysfunction, and hospital length of stay before ICU admission. Development of nonrespiratory organ system dysfunction was the major predictor of hospital mortality (60% of total explanatory power) and 180-day outcomes (54% of explanatory power). Respiratory physiological variables (respiratory rate, serum pH, PaCO2, PaO2, and alveolar-arterial difference in partial pressure of oxygen [PAO2-PaO2]) indicative of advanced dysfunction were more strongly associated with 180-day mortality rates (22% of explanatory power) than hospital death rates (4% of explanatory power). After controlling for severity of illness, mechanical ventilation at ICU admission was not associated with either hospital mortality or subsequent survival.
Patients with COPD admitted to an ICU for an acute exacerbation have a substantial hospital mortality (24%). For patients aged 65 years or older, mortality doubles in 1 year from 30% to 59%. Hospital and longer-term mortality is closely associated with development of nonrespiratory organ system dysfunction; severity of the underlying respiratory function substantially influences mortality following hospital discharge. The need for mechanical ventilation at ICU admission did not influence either short- or long-term outcomes. Physicians should be aware of these relationships when making treatment decisions or evaluating new therapies.
Available from: Nathalie Lund
- "In patients with COPD and acute dyspnea, a high pressure of carbon dioxide in arterial blood is a well-established predictor of poor prognosis and motivates a high level of care and treatment intensity  . However, in the general setting of patients with acute dyspnea at the ED, arterial blood gas analysis is usually not performed. "
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ABSTRACT: Patients with acute dyspnea are a large heterogeneous patient group where initial management is important for outcome.
The objective of the study is to investigate if venous blood gas parameters predict 1-year risk of readmission or death in patients admitted to the emergency department due to acute dyspnea.
We studied 283 patients with acute dyspnea and followed them up for 1 year regarding incidence of readmission or death.
In venous blood obtained immediately upon admission levels of total carbon dioxide (TCO2), base excess (BE), potential hydrogen (pH), and partial pressure of carbon dioxide (pCO2) were measured. In Cox proportional hazards models, patients belonging to top and bottom quartiles of TCO2, BE, pH, and pCO2 were compared to patients belonging to the 2 central quartiles and assessed for end point. After adjustment, top (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.08-2.04; P = .016) and bottom (HR, 1.54; 95% CI, 1.08-2.18; P = .017) quartiles of BE were associated with increased risk of readmission or death. The strongest predictor was top quartile of TCO2 (HR, 1.68; 95% CI, 1.21-2.35; P = .002). In the combined analysis, top quartile of TCO2 remained significantly related to the end point (HR, 1.59; 95% CI, 1.03-2.45; P = .035), whereas BE became nonsignificant. Comorbidities, for example, prevalent chronic obstructive pulmonary disease, did not explain the association. Neither pCO2 nor pH predicted the end point.
A high value of TCO2 appears to be an easily accessible marker for 1-year readmission or death in patients with acute dyspnea and may thus add clinically important information for risk stratification and follow-up strategies.
Copyright © 2015. Published by Elsevier Inc.
Available from: sciencedirect.com
- "All the cases that showed failure with NIPPV had comorbidities as diabetes, hypertension, pneumonia and congestive heart failure. This was in agreement with many studies, which stated that NIPPV failure was greater in patients with medical comorbidities either acute or chronic   , especially cardiovascular diseases  and pneumonia . This may be due to the associated refractory hypoxemia and hypoxemic respiratory failure . "
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ABSTRACT: 27 patients diagnosed as chronic obstructive pulmonary disease (COPD) came with acute hypercapnic respiratory failure due to COPD and met the inclusion and exclusion criteria. They were managed by non invasive positive pressure ventilation (NIPPV). 21 cases showed success and 6 cases showed failure and were put on invasive mechanical ventilation within the first 24 h. It was shown that before initiation of NIPPV, the failed cases had significantly higher Body Mass Index (BMI) 34.7 compared to 28.1 in successful cases and significantly lower pH 7.20 ± 0.05 compared with 7.27 ± 0.04. After 1 h of initiation of NIPPV, the successful group showed improvement regarding pH and PaCO2, while the failed group showed worsening of the same parameters, with a significant difference (p value <0.001, 0.005), respectively. After 4 h, there was improvement in both groups regarding pH which reached normalization in the successful group, PaCO2, and PO2, with no statistical significant difference. There were significant differences in the respiratory rate (p value < 0.001), and the expiratory positive airway pressure (EPAP) (p value 0.024) between the two groups. Thus we can conclude that the use of NIPPV in such patients can be successful in around 78% of cases, however failure can be predicted by high BMI, initial lower pH and higher PaCO2, insignificant response to NIPPV after 1 h. They also show increased respiratory rate and need for higher expiratory positive airway pressure.
Available from: Vijay Hadda
- "These results also explain that why many of the preventive strategies such as use of topical antibiotics/antiseptics, subglottic secretion drainage, chest physiotherapy, and so on successfully reduce the incidence of VAP but not the mortality caused by this. Our study showed higher mortality rate (51%) than reported in the literature (2.5-30%). There are various factors such as severity of the disease, presence of type-2 respiratory failure, high acute physiology and chronic health evaluation (APACHE) score, presence of hypoxemia or cor pulmonale, and so on which may affect the mortality among these patients. "
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ABSTRACT: There are sparse data regarding the impact of ventilator-associated pneumonia (VAP) on outcome among patients with chronic obstructive pulmonary disease (COPD) exacerbation.
This retrospective study included patients with COPD exacerbation requiring endotracheal intubation for more than 48 h admitted in a single respiratory unit from January 2008 to December 2009. Records of these patients were checked for the occurrence of VAP.
One hundred and fifty-three patients required endotracheal intubation for COPD exacerbation during this period. The mean age of this cohort was 61.46 ± 11.3 years. The median duration of COPD was 6 years (range: 1-40). A total of 35 (22.8%) patients developed VAP (early: 9 and late: 26). The risk of mortality was comparable between two groups, that is, patients with and without VAP [odd's ratio (OR)-1.125; 95% confidence interval (CI), 0.622-2.035]. The duration of mechanical ventilation and hospital stay (median ± standard error, 95% CI) was 32 ± 10 (95% CI, 13-51) versus 10 ± 2 (95% CI, 6-14) days; P ≤ 0.001 and 53 ± 26 (95% CI, 3-103) versus 18 ± 7 (95% CI, 5-31) days; P = 0.031, respectively was higher among patients with VAP.
Our study has shown that VAP leads to increased duration of mechanical ventilation and hospital stay; however, the mortality is not affected.
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