Hospitalization For Chronic Obstructive Pulmonary Disease Exacerbation Research Articles

Nasal Cannula Dislodgement During Sleep in Veterans Receiving Long-term Oxygen Therapy for Hypoxemic Chronic Respiratory Failure.

Chronic obstructive pulmonary disease (COPD) is highly prevalent in male veterans. Long-term oxygen therapy (LTOT) can effectively reduce all-cause mortality in these patients, but the effects of nasal cannula dislodgement (NCD) during sleep have not been well studied. This study sought to determine whether veterans receiving LTOT for hypoxemic chronic respiratory failure (CRF) due to COPD reported NCD while they slept and, if so, its impact on hospitalizations for COPD exacerbations. Electronic health records were reviewed of veterans with hypoxemic CRF due to COPD who received LTOT and were followed in the pulmonary clinic at the Jesse Brown Veterans Affairs Medical Center between February 1, 2022, and December 31, 2022. Overall hospital cost was calculated for each hospitalized veteran with diagnosed COPD exacerbation. Veterans reported whether they experienced NCD during sleep and, if so, its frequency. Interviews were conducted with 66 veterans with a mean age of 71 years. Twenty-two veterans (33%) reported NCD ≥ 1 weekly (median, 4). There were no statistically significant differences in demographics, supplemental oxygen flow rate, duration of LTOT, and pulmonary function tests between patients with and without NCD. Ten patients (45%) with NCD and 9 patients (20%) without NCD were hospitalized for ≥ 1 COPD exacerbation (P = .045). Three patients (14%) with NCD were admitted to the medical intensive care unit. Overall hospital costs were 25% higher in the NCD group compared with the no NCD group. Veterans receiving LTOT for hypoxemic CRF due to COPD who report frequent NCD during sleep have higher hospitalization rates for COPD exacerbation and higher hospital costs.

Does the 2017 global initiative for chronic obstructive lung disease revision really improve the assessment of Chinese chronic obstructive pulmonary disease patients? A multicenter prospective study for more than 5 years.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 proposed a new classification that reclassified many chronic obstructive pulmonary disease (COPD) patients from group D to B. However, there is a paucity of data related to the comparison between reclassified and non-reclassified COPD patients in terms of long-term prognosis. This study aimed to investigate long-term outcomes of them and determine whether the GOLD 2017 revision improved the assessment of COPD patients. This observational, multicenter, prospective study recruited outpatients at 12 tertiary hospitals in China from November 2016 to February 2018 and followed them up until February 2022. All enrolled patients were classified into groups A to D based on GOLD 2017, and the subjects in group B included patients reclassified from group D to B (group DB) and those remaining in group B (group BB). Incidence rates and hazard ratios (HRs) were calculated for the exacerbation of COPD and hospitalization in each group. We included and followed up 845 patients. During the first year of follow-up, the GOLD 2017 classification had a better discrimination ability for different risks of COPD exacerbation and hospitalization than GOLD 2013. Group DB was associated with a higher risk of moderate-to-severe exacerbation (HR = 1.88, 95% confidence interval [CI] = 1.37-2.59, P < 0.001) and hospitalization for COPD exacerbation (HR = 2.23, 95% CI = 1.29-3.85, P = 0.004) than group BB. However, during the last year of follow-up, the differences in the risks of frequent exacerbations and hospitalizations between group DB and BB were not statistically significant (frequent exacerbations: HR = 1.02, 95% CI = 0.51-2.03, P = 0.955; frequent hospitalizations: HR = 1.66, 95% CI = 0.58-4.78, P = 0.348). The mortality rates of the two groups were both approximately 9.0% during the entire follow-up period. The long-term prognosis of patients reclassified into group B and of those remaining in group B was similar, although patients reclassified from group D to group B had worse short-term outcomes. The GOLD 2017 revision could improve the assessment of Chinese COPD patients in terms of long-term prognosis.

Pulmonary rehabilitation after severe exacerbation of COPD: a nationwide population study

BackgroundAcute exacerbations of chronic obstructive pulmonary disease (COPD) lead to a significant reduction in quality of life and an increased mortality risk. Current guidelines strongly recommend pulmonary rehabilitation (PR) after a severe exacerbation. Studies reporting referral for PR are scarce, with no report to date in Europe. Therefore, we assessed the proportion of French patients receiving PR after hospitalization for COPD exacerbation and factors associated with referral.MethodsThis was a national retrospective study based on the French health insurance database. Patients hospitalized in 2017 with COPD exacerbation were identified from the exhaustive French medico-administrative database of hospitalizations. In France, referral to PR has required as a stay in a specialized PR center or unit accredited to provide multidisciplinary care (exercise training, education, etc.) and admission within 90 days after discharge was assessed. Multivariate logistic regression was used to assess the association between patients’ characteristics, comorbidities according to the Charlson index, treatment, and PR uptake.ResultsAmong 48,638 patients aged ≥ 40 years admitted for a COPD exacerbation, 4,182 (8.6%) received PR within 90 days after discharge. General practitioner’s (GP) density (number of GPs for the population at regional level) and PR center facilities (number of beds for the population at regional level) were significantly correlated with PR uptake (respectively r = 0.64 and r = 0.71). In multivariate analysis, variables independently associated with PR uptake were female gender (aOR 1.36 [1.28–1.45], p < 0.0001), age (p < 0.0001), comorbidities (p = 0.0013), use of non-invasive ventilation and/or oxygen therapy (aOR 1.52 [1.41–1.64], p < 0.0001) and administration of long-acting bronchodilators (p = 0.0038).ConclusionThis study using the French nationally exhaustive health insurance database shows that PR uptake after a severe COPD exacerbation is dramatically low and must become a high-priority management strategy.

Predictors of poor clinical outcomes including in-hospital death and low ability to perform activities of daily living at discharge in hospitalized patients with chronic obstructive pulmonary disease exacerbation.

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity worldwide. Many patients with COPD experience exacerbations that require hospitalization, which is associated with an increased risk of in-hospital death and impaired ability to perform activities of daily living (ADL). Declining ability to perform ADL is a critical issue for these patients. To identify predictors of poor clinical outcomes, including in-hospital death and low ability to perform ADL at discharge, in patients who are hospitalized with exacerbation of COPD. This retrospective study involved a cohort of patients with exacerbation of COPD who were admitted to Iwata City Hospital in Japan between July 2015 and October 2019. We collected clinical data, measured the cross-sectional area of the erector spinae muscles (ESMCSA) on computed tomography (CT) scans at admission, and investigated the associations of poor clinical outcomes (in-hospital death and severe dependence when performing ADL, defined as a Barthel Index (BI) of ⩽40 at discharge) with clinical parameters. Overall, 207 patients were hospitalized for exacerbation of COPD during the study period. The incidence of poor clinical outcomes was 21.3%, and the in-hospital mortality rate was 6.3%. Multivariate logistic regression analyses showed that older age, long-term oxygen therapy, an elevated D-dimer concentration, and a reduced ESMCSA on chest CT at admission were significantly associated with poor clinical outcomes (in-hospital death and a BI of ⩽40). Hospitalization for exacerbation of COPD was associated with high rates of in-hospital mortality and a BI of ⩽40 at discharge, which may be predicted by assessment of ESMCSA.

Health System Approach to Improve Chronic Obstructive Pulmonary Disease Care after Hospital Discharge: Stepped-Wedge Clinical Trial.

Rationale: Patients discharged from the hospital for chronic obstructive pulmonary disease (COPD) exacerbation have impaired quality of life and frequent readmission and death. Clinical trials to reduce readmission demonstrate inconsistent results, including some demonstrating potential harms. Objectives: We tested whether a pragmatic proactive interdisciplinary and virtual review of patients discharged after hospitalization for COPD exacerbation would improve quality of life, using the Clinical COPD Questionnaire, and reduce all-cause 180-day readmission and/or mortality. Methods: We performed a stepped-wedge clinical trial. We enrolled primary care providers and their patients after hospital discharge for COPD at two Department of Veterans Affairs medical centers and 10 outpatient clinics. A multidisciplinary team reviewed health records and developed treatment recommendations delivered to primary care providers via E-consult. We facilitated uptake by entering recommendations as unsigned orders that could be accepted, modified, or canceled. Providers and patients made all final treatment decisions. Measurements and Main Results: We enrolled 365 primary care providers. Over a 30-month period, 352 patients met eligibility criteria, with 191 (54.3%) patients participating in the control and 161 (45.7%) in the intervention. The intervention led to clinically significant better Clinical COPD Questionnaire scores (-0.47; 95% confidence interval [CI], -0.85 to -0.09; 52.6% missing) but did not reduce 180-day readmission and/or mortality (adjusted odds ratio, 0.83; 95% CI, 0.49 to 1.38), in part because of wide CIs. Among the 161 patients in the intervention group, we entered 519 recommendations as unsigned orders, of which 401 (77.3%) were endorsed. Conclusions: A pragmatic health system-level intervention that delivered proactive specialty supported care improved quality of life but did not reduce 180-day readmission or death. Clinical trial registered with www.clinicaltrials.gov (NCT02021955).

Initiating exercise training early during the hospitalisation for an exacerbation of chronic obstructive pulmonary disease improves exercise capacity and quadriceps strength: A randomised controlled trial

BackgroundHospitalisations for an exacerbation of chronic obstructive pulmonary disease (COPD) impair exercise tolerance, muscle strength and participation in physical activity. Earlier studies of exercise training in this population often initiate training late in the admission and have not combined aerobic and resistance exercise. ObjectiveIn adults hospitalised with an exacerbation of COPD, to determine the effects of aerobic and resistance exercise, initiated within 48 h of admission, on exercise tolerance, peak quadriceps muscle force (QMFpeak), functional performance and physical activity. MethodsThirty-eight patients (mean ± SD age 64 ± 7yr; FEV1 33 ± 14%pred) were randomised to a control group (CG; n = 18) or an exercise group (EG; n = 20). Both groups received usual care (airway clearance and encouragement to mobilise). Those in the EG participated in twice daily walking and resistance exercise. Outcome measures comprised the 2-min walk distance (2MWD), QMFpeak, performance on the Sit-To-Stand-Test (STST), Timed Up and Go (TUG) and physical activity measured using wearable technology. ResultsMedian [interquartile range] length of stay in the CG and EG were 7 [6 to 8] and 8 [6 to 9] days. Compared with the CG, those in the EG demonstrated greater gains in 2MWD (mean between-group difference; 95% confidence interval 13 m; 3 to 23) and QMFpeak (2.8 kg; 0.3 to 5.3). No between-group differences were seen in performance on the STST (1 repetition; −1 to 2), TUG (−0.8s; −0.2 to 0.4) and or daily steps (1462 steps; −469 to 3393). ConclusionExercise initiated early during a hospitalisation for exacerbation of COPD optimised exercise tolerance and QMFpeak. Clinical trial registrationThis trial was prospectively registered with the Australian New Zealand Clinical Trials Registry; ACTRN12612000745842; URL: www.anzctr.org.au.

Patients with Obesity Have Better Long-Term Outcomes after Hospitalization for COPD Exacerbation

Obesity has been shown to have a paradoxical benefit in a number of conditions, but the long-term effects in obesity after chronic obstructive pulmonary disease (COPD) exacerbation is still unclear. In this study, the effects of obesity on short- and long-term outcomes after a COPD exacerbation were evaluated. This was a secondary analysis of the Rapid Empiric Treatment with Oseltamivir Study (RETOS): a prospective, randomized, unblinded clinical trial. Patients were included in the study if they were hospitalized for acute exacerbation of COPD. Obesity was noted as patients with BMI >30. Clinical outcomes of time to clinical stability, length of stay, and mortality were compared. A total of 301 patients were included in the study, 122 (41%) patients were obese. There was no significant difference in the length of stay and time to clinical stability between patients with and without obesity. Mortality for patients with and without obesity was 3% and 3% at 30 days, 7% and 18% at six months, and 8% and 28% at one year, respectively. After adjusting with multivariable regression analysis, patients with obesity had a significant reduction in odds of dying at one year (adjusted odds ratio (aOR): 0.18; 95% CI: 0.06–0.58; p = .004) and at six months (aOR: 0.28; 95% CI: 0.09–0.89; p = .031). Our study showed that obesity was associated with reduced mortality at one year and six months after a COPD exacerbation. Although patients with obesity had higher rates of comorbidities, they had reduced mortality at one year after multivariable regression analysis.

Hospitalization and mortality for acute exacerbation of chronic obstructive pulmonary disease (COPD): an Italian population-based study.

Patients with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) have a significant mortality and morbidity. Previous studies have identified a number of independent prognostic factors. However, information on hospital admission databases is limited and data regarding short-term prognosis of these patients in Italian hospitals are lacking. Thus, we performed an epidemiological study on hospital admission for COPD acute exacerbation in Italy. Patients were identified using clinical Modification (ICD-9-CM) codes. Information was collected on baseline characteristics, vital status at discharge, duration of hospitalization, and up to five secondary discharge diagnoses. Comorbidity was evaluated using the Charlson comorbidity index (CCI). During the observation period (2013-2014), 170,684 patients with COPD acute exacerbation were hospitalized. Mean length of hospitalization (LOH) was 9.95±8.69 days and mean in-hospital mortality was 5.30%. These data correspond to the 4.1% of all hospitalizations and to the 2.8% of all the days of hospitalization in Italy during the study period. In-hospital mortality and LOH varied among different regions (from 3.13 to 7.59% and from 8.22 to 11.28 days respectively). Old age, male gender, low discharge volume, previous hospitalization for COPD exacerbation and CCI resulted as significantly associated with higher in-hospital mortality. Hospitalization for COPD exacerbation is extremely frequent even in contemporary Italian population. COPD exacerbation is clinically demanding with a not negligible short-term mortality rate and a mean LOH approaching 10 days. These latter findings were quite variable in different regions but should be further analyzed to set up appropriate health-care policies on COPD patients.

"You Leave There Feeling Part of Something": A Qualitative Study of Hospitalized COPD Patients' Perceptions of Pulmonary Rehabilitation.

RationaleCurrent guidelines recommend that patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) initiate pulmonary rehabilitation (PR) shortly after discharge from the hospital. However, fewer than 2 percent of Medicare beneficiaries do so. Few studies have examined hospitalized patients’ perceptions of the barriers and facilitators to enroll in PR. The aim of this study was to develop an understanding of these factors by interviewing patients.MethodsWe conducted semi-structured interviews with patients during a hospitalization for COPD exacerbation in a large teaching hospital. Directed content analysis was used to code and analyze interview transcripts.ResultsOf the 15 patients we interviewed, 9 had participated in PR prior to their hospitalization, 10 were women; 4 were black, and 1 was Hispanic. Facilitators of enrollment included a desire to learn more about the disease, social support, and trust in the health-care provider recommending PR. Barriers to enrollment included lack of awareness, family obligations, lack of motivation, and transportation. For those who had previous experience with PR, but who did not complete the program, another barrier was not feeling well enough. Facilitators to adherence included the educational component of the program; feeling better through exercise; and a social connection with both participants and staff. For some patients. PR contributed to a renewed sense of hope or meaning. Most interviewees expressed interest in a peer coaching program.ConclusionOur results highlight the importance of increasing awareness of PR and building trust between the provider and patients to facilitate initial enrollment. Future interventions to improve enrollment and adherence should address the need for education about the benefits of PR and the value of social support.

Tolerability and Safety of High-Flow Nasal Therapy in Patients Hospitalized with an Exacerbation of COPD.

The effect of high-flow nasal therapy (HFNT) in individuals with an exacerbation of chronic obstructive pulmonary disease (COPD) and hypercapnia is not well studied. We assessed patient tolerance and impact of air-gas therapy delivered by humidified HFNT (20-35 L/min) on gas exchange in hypercapnic COPD patients during hospitalization for COPD exacerbation. We hypothesized that HFNT use would be safe and well tolerated in individuals hospitalized for COPD exacerbation regardless of the degree of hypercapnia. Patients hospitalized for a COPD exacerbation were included if they were hypercapnic (arterial partial pressure of carbon dioxide [PaCO2] > 45 mmHg), ≥ 10 pack-year history, and agreed to treatment with HFNT, along with daily arterial blood gas (ABG) samples and bedside spirometry. They were placed on a HFNT system following admission for at least 3 days with an air-gas blend to maintain a flow rate between 20-35 L/min and fraction of inspired oxygen (FiO2) titrated to keep oxygen saturation (SaO2) values > 90%. Patient tolerance of HFNT and evidence of clinical deterioration as defined by worsening hypoxia or hypercapnia was the primary endpoint. Ten consecutive patients participated in the study. The patients had frequent prior exacerbations, were hypercapnic, dyspneic, and gas trapped. Participants received an air-gas flow rate (median [interquartile range (IQR)] 25 (IQR 20-30) L/min and FiO2 of 30 (IQR 30-30) %. There was no increase in PaCO2- levels (p = 0.26) or dyspnea (Borg scale, p= 0.52) while using HFNT. No patient discontinued HFNT, had further decompensation, required non-invasive ventilation or intubation during the study period. In a pilot study, patients experiencing a severe COPD exacerbation were able to tolerate continuous HFNT safely regardless of degree of hypercapnia.

Assessment of effectiveness of training of respiratory musculature in patients with chronic obstructive pulmonary disease and obesity

Aim. To assess the influence of training of respiratory musculature on the expressiveness of symptoms, tolerance to physical loads, spirometric parameters and quality of life of patients with chronic obstructive pulmonary disease (COPD) and obesity.&#x0D; Materials and Methods. The study included 52 patients with COPD (clinical group D) and obesity, of them 42 men and 10 women with the mean age 65.4±6.8 years and body mass index 33.6±2.9 kg/m2. The patients were divided to 2 groups: the main group with training of respiratory musculature (TRM) within 12 months using a respiratory exerciser, and the control group with simulation of TRM using the same exerciser, but with minimal load.&#x0D; Results. In 12 months the patients of the main group showed a reliable reduction of dyspnea on mMRC scale (Modified Medical Research Council), improvement of health related quality of life on St. George’s Respiratory Questionnaire (SGRQ), increase in forced expiration volume in 1 second and in forced vital capacity of lungs, increase in the covered distance in 6-minute walk test, reduction of the average duration of hospitalization for exacerbation of COPD.&#x0D; Conclusion. Taking into account the obtained data, TRM can be considered as an effective component of the lung rehabilitation program in patients with COPD.

Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease among Medicare Beneficiaries.

Current guidelines recommend pulmonary rehabilitation (PR) after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, but little is known about its adoption or factors associated with participation. To evaluate receipt of PR after a hospitalization for COPD exacerbation among Medicare beneficiaries and identify individual- and hospital-level predictors of PR receipt and adherence. We identified individuals hospitalized for COPD during 2012 and recorded receipt, timing, and number of PR visits. We used generalized estimating equation models to identify factors associated with initiation of PR within 6 months of discharge and examined factors associated with number of PR sessions completed. Of 223,832 individuals hospitalized for COPD, 4,225 (1.9%) received PR within 6 months of their index hospitalization, and 6,111 (2.7%) did so within 12 months. Median time from discharge until first PR session was 95 days (interquartile range, 44-190 d), and median number of sessions completed was 16 (interquartile range, 6-25). The strongest factor associated with initiating PR within 6 months was prior home oxygen use (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.39-1.59). Individuals aged 75-84 years and those aged 85 years and older (respectively, OR, 0.70; 95% CI, 0.66-0.75; and OR, 0.25; 95% CI 0.22-0.28), those living over 10 miles from a PR facility (OR, 0.42; 95% CI, 0.39-0.46), and those with lower socioeconomic status (OR, 0.42; 95% CI, 0.38-0.46) were less likely to receive PR. Two years after Medicare began providing coverage for PR, participation rates after hospitalization were extremely low. This highlights the need for strategies to increase participation.

Roflumilast in patients with advanced chronic obstructive pulmonary disease: towards a better-targeted use

ABSTRACTIntroduction: For patients with chronic obstructive pulmonary disease (COPD), one of the main goals in its management is to reduce the number of disease exacerbations. Roflumilast is an anti-inflammatory compound used in patients with advanced COPD and chronic bronchitis in order to fulfill this objective. However, this is not always easily achieved due to the heterogeneity of the population. Clinical trial data can allow more in-depth analysis in order to identify predictors for maximal efficacy in different patient populations.Areas covered: A post hoc pooled data analysis derived from two large-scale randomized controlled trials helped to better define the disease subsets in which roflumilast would exert the maximal therapeutic effect. These are represented by patients with prior hospitalizations for COPD exacerbations and by patients with higher values for eosinophil blood count. This analysis is the focus of our key paper evaluation.Expert opinion: This pooled data analysis suggests that a phenotype/endotype guided therapy has the potential to be impactful on overall survival by reducing the number of exacerbations and increase the life span of patients.

Detection of exacerbactions of chronic obstructive lung disease in the ambulatory practice

The article presents the results of a retrospective study aimed at identifying exacerbations in outpatients with chronic obstructive pulmonary disease (COPD) during the previous 12 months. А telephone interview was conducted with 20 patients with COPD from the departments of general medical practice of three polyclinics in the Kalininsky district of St. Petersburg. The obtained data were compared with records in outpatient cards to determine the presence of registered cases of appeals to the polyclinic for exacerbation of the disease.7 patients (35%) were identified retrospectively using the questionnaire, which can be attributed to the phenotype of COPD with frequent exacerbations. Among them, five people were hospitalized in a hospital for exacerbation of COPD, and two patients had 2 or more exacerbations in an outpatient card that did not lead to hospitalization. In 5 patients (33%), among those who were not in hospital for an exacerbation of COPD for the previous 12 months, indirect signs of low self-esteem were revealed, indicating that it is necessary to raise awareness of the exacerbation of COPD and the education patients self-management skills. (For citation: Maliavko NS, Shatyi NO, Alagova EV, et al. Detection of exacerbactions of chronic obstructive lung disease in the ambulatory practice. Russian Family Doctor. 2018;22(1):18-22. doi 10.17816/RFD2018118-22).

Outcomes after early and delayed rehabilitation for exacerbation of chronic obstructive pulmonary disease: a nationwide retrospective cohort study in Japan

BackgroundThe effectiveness of early pulmonary rehabilitation (PR) for exacerbation of chronic obstructive pulmonary disease (COPD) remains controversial. The present study aimed to compare the outcomes between early and delayed PR for exacerbation of COPD, using a national inpatient database.MethodsUsing the Japanese Diagnosis Procedure Combination database, we examined patients who were transported to hospital for exacerbation of COPD, received PR during hospitalisation, and were discharged to their home. The patients were divided into those who received early PR (defined as PR starting within 48 h of admission) and those who received delayed PR. The outcomes included 90-day readmission, length of stay (LOS), and activities of daily living (Barthel index ≥15) at discharge. Multiple imputation was used for missing data. To assess the associations between early PR and the outcomes, we used risk-adjusted treatment effects and instrumental variable methods.ResultsWe identified 12,572 eligible patients, including 8459 patients with delayed PR and 4113 with early PR. In the risk-adjusted treatment effect models, the early PR group had lower proportion of 90-day readmission (risk difference, −3.4%; 95% CI, −5.7% to −1.5%) and shorter LOS (−9.8 days; 95% CI, −10.8 days to −8.7 days) than the delayed PR group. There was no significant difference in activities of daily living at discharge between the two groups. The instrumental variable analyses showed similar results.ConclusionsIn this national database study, early PR was associated with reduced 90-day readmission and shortened LOS in patients with exacerbation of COPD.

Antibody deficiency in patients with frequent exacerbations of Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease is the third leading cause of death in the US, and is associated with periodic exacerbations, which account for the largest proportion of health care utilization, and lead to significant morbidity, mortality, and worsening lung function. A subset of patients with COPD have frequent exacerbations, occurring 2 or more times per year. Despite many interventions to reduce COPD exacerbations, there is a significant lack of knowledge in regards to their mechanisms and predisposing factors. We describe here an important observation that defines antibody deficiency as a potential risk factor for frequent COPD exacerbations. We report a case series of patients who have frequent COPD exacerbations, and who were found to have an underlying primary antibody deficiency syndrome. We also report on the outcome of COPD exacerbations following treatment in a subset with of these patients with antibody deficiency. We identified patients with COPD who had 2 or more moderate to severe exacerbations per year; immune evaluation including serum immunoglobulin levels and pneumococcal IgG titers was performed. Patients diagnosed with an antibody deficiency syndrome were treated with either immunoglobulin replacement therapy or prophylactic antibiotics, and their COPD exacerbations were monitored over time. A total of 42 patients were identified who had 2 or more moderate to severe COPD exacerbations per year. Twenty-nine patients had an underlying antibody deficiency syndrome: common variable immunodeficiency (8), specific antibody deficiency (20), and selective IgA deficiency (1). Twenty-two patients had a follow-up for at least 1 year after treatment of their antibody deficiency, which resulted in a significant reduction of COPD exacerbations, courses of oral corticosteroid use and cumulative annual dose of oral corticosteroid use, rescue antibiotic use, and hospitalizations for COPD exacerbations. This case series identifies antibody deficiency as a potentially treatable risk factor for frequent COPD exacerbations; testing for antibody deficiency should be considered in difficult to manage frequently exacerbating COPD patients. Further prospective studies are warranted to further test this hypothesis.

Prevalence and correlates of suicide ideation in patients with COPD: a mixed methods study

PurposeThe purpose of this study was to examine the prevalence and correlates of suicidal ideation (SI) in patients with stable moderate to very severe chronic obstructive pulmonary disease (COPD).Patients and methodsWe conducted an exploratory mixed methods analysis of data from participants in a longitudinal observational study of depression in COPD. We measured depression with the Patient Health Questionnaire-9 (PHQ-9), which includes an item on SI. We compared participants with and without SI in relation to sociodemographics, symptoms, anxiety, and healthcare resource use with independent t-tests and chi-square tests. Content analysis was performed on qualitative data gathered during a structured SI safety assessment.ResultsOf 202 participants, 121 (60%) had depressive symptoms (PHQ ≥6); 51 (25%) had a PHQ-9 ≥10, indicating a high likelihood of current major depression; and 22 (11%) reported SI. Compared to the 99 depressed participants without SI, those with SI were more likely to be female (59% vs 27%, P=0.004); had worse dyspnea (P=0.009), depression (P<0.001), and anxiety (P=0.003); and were also more likely to have received treatment for depression and/or anxiety (82% vs 40%, P<0.001) and more hospitalizations for COPD exacerbations (P=0.03) but had similar levels of airflow obstruction and functioning than participants without SI. Themes from the qualitative analysis among those with SI included current or prior adverse life situations, untreated or partially treated complex depression, loss of a key relationship, experience of illness and disability, and poor communication with providers.ConclusionOur findings suggest that current SI is common in COPD, may occur disproportionately in women, can persist despite mental health treatment, and has complex relationships with both health and life events. Adequate management of SI in COPD may therefore require tailored, comprehensive treatment approaches that integrate medical and mental health objectives.

The need to further understand who gets hospitalized for a COPD exacerbation

Chronic obstructive pulmonary disease (COPD) has significant morbidity, major impact on health care costs [1] and is the 3rd leading cause of death in the United States [2-4]. The impact becomes greater as the disease progresses, and is mainly due to the development of acute exacerbations and need for hospitalizations [5]. Preventing COPD exacerbations has been a main focus in the treatment of COPD patients. Patients admitted to the hospital for COPD exacerbation are at a higher risk of re-hospitalization and death [6-8]. COPD also increases the hospitalization rate and in-hospital mortality from other co-morbidities [9]. Several therapeutic options including the use of inhaled corticosteroids, long acting bronchodilators, phosphodiesterase inhibitors, pulmonary rehabilitation services, and prolonged antibiotic use have been showed to reduced the incidence of these events [5,10]. Identifying risk factors for hospitalizations have important health care implications, but the knowledge of these is limited. In this issue of Multidisciplinary Respiratory Medicine, Garcia-Sanz et al. [11] reported a prospective observational study conducted in their Emergency Department to determine the frequency of COPD exacerbations, and factors associated with hospitalization. These investigators reported 409 exacerbations in 239 patients (79% male, mean age 75 years); 57% of exacerbations required hospitalization. There were several differences between hospitalized and non-hospitalized patients including history of prior exacerbations, COPD disease severity, use of concomitant medications such as inhaled and systemic corticosteroids, beta-blockers and antibiotics. In the multivariate logistic regression analysis the factors associated with hospitalization were impaired oxygenation (p<0.001), increased white blood cells (p<0.01) and prescribed antibiotics (p<0.05). This study provides insight into factors associated with hospitalizations for COPD exacerbations in patients that are evaluated in an emergency room. The study was carried out in a single center and therefore the results may be difficult to generalize to other institutions. It is possible that some inherent limitations hampered the ability to find significant differences in several clinical parameters and outcomes. For example, several of the differences in variables between both groups were not significant in the multivariate logistic regression analysis. Some of the results reported in this study are consistent with large cohort publications. For example, patients with prior history of hospitalizations and more severe lung disease were more likely to required hospitalization. These data are similar to the reports by Hurst et al. [5] and Tsoumakidou M. et al. [12], and provide useful clinical data when these patients are evaluated in the emergency department. This study provides practitioners with other useful clinical data that is routinely collected in patients with a severe COPD exacerbation evaluated in the emergency department, such as oxygenation parameters (PaO2/FiO2 index), and white blood cell counts. COPD severity based on lung function (GOLD stage) was shown to also predicted the risk of hospitalization in COPD for other conditions like pneumonia [4]. Therefore, in this study, patients with a suspicious underlying infectious process, elevated white blood cell count and worsening oxygenation were prescribed antibiotics and were more likely to be hospitalized. It will be interesting if the investigators could provide additional data, such as patients co-morbid conditions, concomitant medications, radiological findings if a chest radiograph was obtained and complications developed during hospitalization. Nevertheless, the data presented by Garcia-Sanz et al. [11] will help to design prospective clinical studies and interventions related to decrease COPD exacerbations related hospitalizations. Because of the fragile condition of these patients and concomitant morbidity associated with COPD exacerbations, the identification of clinical parameters that indicate patient’s need for hospitalization will have a significant clinical impact. Providing effective clinical care by using routine clinical data represents a new perspective of the overall management of these complex patients. The current study by Garcia- Sanz et al. [11], taken together with existing data from other large observations cohorts, highlights the need to challenge commonly used clinical parameters to make a decision when to hospitalize patients with COPD exacerbations. In our opinion, further clinical studies are needed to help in the management of this critical condition and should take into consideration the results of these investigators.

Diagnosis of myocardial infarction following hospitalisation for exacerbation of COPD

Cardiovascular disease is common in chronic obstructive pulmonary disease (COPD) and raised troponin is common in exacerbations. However, the prevalence of myocardial infarction following hospitalisation for exacerbation of COPD is unknown. Patients aged ≥ 40 yrs hospitalised with acute exacerbation of COPD (n = 242) with ≥ 10 pack-yrs of cigarette smoking were included in a prospective case series conducted in four hospitals. Patients whose primary presenting complaint was chest pain or who had an alternative diagnosis were excluded. Chest pain histories, serial ECGs and troponin levels were obtained. The mean ± SD age was 69 ± 9 yrs; 108 (45%) patients were male and almost half were current smokers. 124 (51%; 95% CI 48-58%) patients had chest pain, which was exertional in 62 (26%). 24 (10%) had raised troponin, among whom, 20 (8.3%; 95% CI 5.1-12.5%) had chest pain and/or serial ECG changes, fulfilling the 2007 Universal Definition of Myocardial Infarction. Neither chest pain (p = 0.77) nor serial ECG changes (p = 0.39) were associated with raised troponin. Raised troponin, chest pain and serial ECG changes are common in patients admitted to hospital with exacerbation of COPD. Overall, one in 12 patients met the criteria for myocardial infarction. Whether these patients would benefit from further cardiac investigation is unknown.

Pseudomonas aeruginosa and Mortality after Hospital Admission for Chronic Obstructive Pulmonary Disease

Background:Pseudomonas aeruginosa (PA) is isolated in advanced stages of chronic obstructive pulmonary disease (COPD). Objectives: The aim of our study was to determine whether PA isolation during hospitalization for COPD exacerbation was associated with a poorer prognosis after discharge. Methods: We prospectively studied all patients with COPD exacerbation admitted between June 2003 and September 2004. A sputum culture was obtained at admission. Comorbidity, functional dependence, hospitalizations during the previous year, dyspnea, quality of life and other variables previously associated with mortality in COPD were studied. Spirometry and a 6-min walking test were performed 1 month after discharge. Mortality was evaluated 3 years after discharge. Results: A total of 181 patients were included in the study. Of these, 29 (16%) had PA in the sputum. The mean age was 72 years, and mean basal postbronchodilator forced expiratory volume in 1 s was 45.2% predicted (SD 14.4). The mean point value on the BODE index was 5.1 (SD 2.5). At 3 years, 17 of 29 patients (58.6%) in the PA group had died, compared to 53 of the 152 non-PA patients [34.9%; p < 0.004; hazard ratio (HR) 2.23, 95% confidence interval (CI) 1.29–3.86]. In the multivariate analysis, PA remained statistically related to posthospital mortality (p = 0.02; HR 2.2, 95% CI 1.2–4.2) after adjustment for age (p < 0.02; HR 1.04, 95% CI 1.007–1.07), BODE index (p < 0.02; HR 1.15, 95% CI 1.02–1.3) and comorbidity (p < 0.02; HR 1.24, 95% CI 1.03–1.5). Conclusions: PA isolation in sputum in patients hospitalized for acute exacerbation of COPD is a prognostic marker of 3-year mortality. Poor prognosis is independent of other significant predictors of mortality such as BODE index, age and comorbidity, as measured by the Charlson index.