Hospitalization For Acute Exacerbation Of COPD Research Articles

Association between long-term ozone exposure and readmission for chronic obstructive pulmonary disease exacerbation

The relationship between long-term ozone (O₃) exposure and readmission for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) remains elusive. In this study, we collected individual-level information on AECOPD hospitalizations from a standardized electronic database in Guangzhou from January 1, 2014, to December 31, 2015. We calculated the annual mean O₃ concentration prior to the dates of the index hospitalization for AECOPD using patients’ residential addresses. Employing Cox proportional hazards models, we assessed the association between long-term O₃ concentration and the risk of AECOPD readmission across several time frames (30 days, 90 days, 180 days, and 365 days). We estimated the disease and economic burden of AECOPD readmissions attributable to O₃ using a counterfactual approach. Of the 4574 patients included in the study, 1398 (30.6%) were readmitted during the study period, with 262 (5.7%) readmitted within 30 days. The annual mean O₃ concentration was 90.3 μg/m3 (standard deviation [SD] = 8.2 μg/m3). A 10-μg/m3 increase in long-term O₃ concentration resulted in a hazard ratio (HR) for AECOPD readmission within 30 days of 1.28 (95% confidence interval [CI], 1.09 to 1.49), with similar results for readmission within 90, 180, and 365 days. Older patients (aged 75 years or above) and males were more susceptible (HR, 1.33; 95% CI, 1.10–1.61 and HR, 1.29; 95% CI, 1.09–1.53, respectively). The population attributable fraction for 30-day readmission due to O₃ exposure was 29.0% (95% CI, 28.4%–30.0%), and the attributable mean cost per participant was 362.3 USD (354.5–370.2). Long-term exposure to elevated O₃ concentrations is associated with an increased risk of AECOPD readmission, contributing to a significant disease and economic burden.

Comprehensive Nomograms Using Routine Biomarkers Beyond Eosinophil Levels: Enhancing Predictability of Corticosteroid Treatment Outcomes in AECOPD.

Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) exhibit heterogeneous responses to corticosteroid treatment. We aimed to determine whether combining eosinophil levels with other routine clinical indicators can enhance the predictability of corticosteroid treatment outcomes and to come up with a scoring system. Consecutive patients admitted with AECOPD receiving corticosteroid treatment between July 2013 and March 2022 at Beijing Chao-Yang Hospital were retrospectively analyzed. Data on patients' demographics, smoking status, hospitalization for AECOPD in the previous year, comorbidities, blood laboratory tests, in-hospital treatment and clinical outcomes were collected. Least absolute shrinkage and selection operator (LASSO) regression and backward logistic regression were used for predictor selection, and predictive nomograms were developed. The discrimination and calibration of the nomograms were assessed using the area under the receiver operating curve (AUC) and calibration plots. Internal validation was performed using the 500-bootstrap method, and clinical utility was evaluated using decision curve analysis (DCA). Among the 3254 patients included, 804 (24.7%) had treatment failure. A nomogram of eosinophils, platelets, C-reactive protein (CRP), low density lipoprotein cholesterol, prognostic nutritional index (PNI), hospitalization for AECOPD in the previous year, ischemic heart diseases and chronic hepatic disease was developed to predict treatment failure for patients with a smoking history. For patients without a smoking history, a nomogram of CRP, PNI, ischemic heart diseases and chronic hepatic disease was developed. Although the AUCs of these two nomograms were only 0.644 and 0.647 respectively, they were significantly superior to predictions based solely on blood eosinophil levels. We developed easy-to-use comprehensive nomograms utilizing readily available clinical biomarkers related to inflammation, nutrition and immunity, offering modestly enhanced predictive value for treatment outcomes in corticosteroid-treated patients with AECOPD. Further investigations into novel biomarkers and additional patient data are imperative to optimize the predictive performance.

Risk of Death and Cardiovascular Events Following an Exacerbation of COPD: The EXACOS-CV US Study.

This study estimated the magnitude and duration of risk of cardiovascular events and mortality following acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and whether risks varied by number and severity of exacerbation in a commercially insured population in the United States. This was a retrospective cohort study of newly diagnosed COPD patients ≥40 years old in the Healthcare Integrated Research Database from 2012 to 2019. Patients experiencing exacerbations comprised the "exacerbation cohort". Moderate exacerbations were outpatient visits with contemporaneous antibiotic or glucocorticoid administration; severe exacerbations were emergency department visits or hospitalizations for AECOPD. Follow-up started on the exacerbation date. Distribution of time between diagnosis and first exacerbation was used to assign index dates to the "unexposed" cohort. Cox proportional hazards models estimated risks of a cardiovascular event or death following an exacerbation adjusted for medical and prescription history and stratified by follow-up time, type of cardiovascular event, exacerbation severity, and rank of exacerbation (first, second, or third). Among 435,925 patients, 170,236 experienced ≥1 exacerbation. Risk of death was increased for 2 years following an exacerbation and was highest during the first 30 days (any exacerbation hazard ratio (HR)=1.79, 95% CI=1.58-2.04; moderate HR=1.22, 95% CI=1.04-1.43; severe HR=5.09, 95% CI=4.30-6.03). Risks of cardiovascular events were increased for 1 year following an AECOPD and highest in the first 30-days (any exacerbation HR=1.34, 95% CI=1.23-1.46; moderate HR=1.23 (95% CI 1.12-1.35); severe HR=1.93 (95% CI=1.67-2.22)). Each subsequent AECOPD was associated with incrementally higher rates of both death and cardiovascular events. Risk of death and cardiovascular events was greatest in the first 30 days and rose with subsequent exacerbations. Risks were elevated for 1-2 years following moderate and severe exacerbations, highlighting a sustained increased cardiopulmonary risk associated with exacerbations.

In-hospital antibiotic use for severe chronic obstructive pulmonary disease exacerbations: a retrospective observational study

BackgroundThe use of antibiotics in mild to severe acute exacerbations of chronic obstructive pulmonary disease (COPD) remains controversial.AimTo explore in-hospital antibiotic use in severe acute exacerbations of COPD (AECOPD), to analyze determinants of in-hospital antibiotic use, and to investigate its association with hospital length of stay (LOS) and in-hospital mortality.MethodsA retrospective, observational study was conducted in Ghent University Hospital. Severe AECOPD were defined as hospitalizations for AECOPD (ICD-10 J44.0 and J44.1) discharged between 2016 and 2021. Patients with a concomitant diagnosis of pneumonia or ‘pure’ asthma were excluded. An alluvial plot was used to describe antibiotic treatment patterns. Logistic regression analyses identified determinants of in-hospital antibiotic use. Cox proportional hazards regression analyses were used to compare time to discharge alive and time to in-hospital death between antibiotic-treated and non-antibiotic-treated AECOPD patients.ResultsIn total, 431 AECOPD patients (mean age 70 years, 63% males) were included. More than two-thirds (68%) of patients were treated with antibiotics, mainly amoxicillin-clavulanic acid. In multivariable analysis, several patient-related variables (age, body mass index (BMI), cancer), treatment-related variables (maintenance azithromycin, theophylline), clinical variables (sputum volume and body temperature) and laboratory results (C-reactive protein (CRP) levels) were associated with in-hospital antibiotic use independent of sputum purulence, neutrophil counts, inhaled corticosteroids and intensive care unit of which CRP level was the strongest determinant. The median hospital LOS was significantly longer in antibiotic-treated patients (6 days [4–10]) compared to non-antibiotic-treated patients (4 days [2–7]) (p < 0.001, Log rank test). This was indicated by a reduced probability of hospital discharge even after adjustment for age, sputum purulence, BMI, in-hospital systemic corticosteroid use and forced expiratory volume in one second (FEV1) (adjusted hazard ratio 0.60; 95% CI 0.43; 0.84). In-hospital antibiotic use was not significantly associated with in-hospital mortality.ConclusionsIn this observational study in a Belgian tertiary hospital, in-hospital antibiotic use among patients with severe AECOPD was determined by the symptom severity of the exacerbation and the underlying COPD severity as recommended by the guidelines, but also by patient-related variables. Moreover, in-hospital antibiotic use was associated with a longer hospital stay, which may be linked to their disease severity, slower response to treatment or 'harm' due to antibiotics.Trial registrationNumber: B670201939030; date of registration: March 5, 2019.

The Influence of Air Pollution on Non-Infectious Hospitalizations for Severe Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Time-Series from Serbia

The available data on the impact of air pollution on acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are inconsistent. We investigated the influence of air pollution on the number of severe AECOPD hospitalizations of non-infectious etiology in patients residing in Novi Sad, Serbia. In this time-series, we used a quasi-Poisson generalized linear model in conjunction with distributed lag non-linear models, after controlling for lag days, seasonal and long-term trends, and meteorological factors (air temperature and humidity), to estimate the relative risk (RR) of AECOPD hospitalization for each increase of 10 μg/m3 in the air pollutant concentration. A total of 552 AECOPD hospitalizations were registered during 2017–2022. With each 10 μg/m3 increase in the selected air pollutants’ concentration, the cumulative RR (lags0–7) in single-predictor models for AECOPD admission were 1.52 (95% CI 0.98–2.35) for PM10, 1.44 (95% CI 0.93–2.25) for PM2.5, 1.13 (95% CI 0.87–1.47) for SO2, and 0.99 (95% CI 0.69–1.42) for NO2. Similar results were found in multi-predictor models as well as in group analyses between smokers and non-smokers. In conclusion, no significant associations between exposure to air pollutants and the daily AECOPD admissions were found. There is an obvious need for additional research on the topic.

Malnutrition associated with readmission in elderly patients with chronic obstructive pulmonary disease.

To the Editor: Compared with non-readmission chronic obstructive pulmonary disease (COPD) patients, the mortality rate of readmission patients is significantly higher (2.3% vs. 13.4%),[1] which undoubtedly causes socio-economic pressures on rehabilitation care and medical resources. The potential factors affecting the risk of readmission are required to be identified. The incidence of malnutrition, occurring frequently in elderly COPD patients, varies from 20% to 45% depending on the screening tools used. As a practical, economical and effective scoring system, the Mini Nutrition Assessment (MNA) is of great value to assessing nutritional status in the elderly. Malnutrition is a state of vulnerability in elder populations and is associated with a poor long-term prognosis. This study aimed to research the impact of nutritional status related risk factors on readmission and assess the value of MNA scoring system and updated sarcopenia diagnostic criteria in predicting readmission risk for elderly COPD patients. This observational prospective study protocol was approved by the Human Research Ethics Committee of Huadong Hospital, Fudan University (No. 2019K125) and has been registered and approved by Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx, chiCTR1900022576). The written informed consent was obtained from each participant. This study was conducted at the Department of Pulmonary and Critical Care Medicine, Huadong Hospital, between November 2018 and December 2019. Inclusion criteria were: (1) COPD patients diagnosed by the Global Initiative for Chronic Obstructive Lung Disease guideline[2]; (2) patients were admitted to hospital due to acute exacerbation of COPD (AECOPD); (3) age ≥65 years; and (4) patients who met the criteria of discharge with stable condition. The exclusion criteria were: (1) patients who were unable to stand steadily or finish the walk test; (2) patients had a history of pacemaker implantation; (3) severe cognitive impairment; (4) clinically visible edema; and (5) patients who declined to participate. All the candidates, who were admitted to hospital for AECOPD, received the first interview in person to obtain baseline data within 48 h before discharge. Follow-up assessments were offered to all the participants by experienced physicians (TZ and JYC) up to 180 days after discharge, and the follow-up information was obtained from digital medical records or telephone calls with permission. At the first interview, the information on demographic characteristics, mid-arm circumference, calf circumference (CC), Charlson Comorbidity Index (CCI), drug usage, and laboratory results such as the level of serum albumin was collected. And the smoking information as well as chronic cough history during childhood was also collected. Additionally, pulmonary function tests were performed according to the American Thoracic Society/European Respiratory Society criteria using standardized equipment (Master Screen PFT System, Jager, Germany) at the time of baseline data collection. Besides, dyspnea and the quality of life were evaluated with the modified scale of the Medical Research Council (mMRC) and the COPD assessment test (CAT) questionnaire, respectively. The mMRC score ranges from 0 to 4, and higher score indicates worse dyspnea. The CAT score ranges from 0 to 40, and a score more than 31.0 points indicates a very serious impact on the quality of life. At the time of monthly follow-up, information on readmission events was recorded. MNA [Supplementary files, https://links.lww.com/CM9/B324] scores were measured to assess nutritional status at baseline. A score <17.0 points was considered as malnutrition, a score between 17.0 points and 23.5 points was considered to be at risk of malnutrition, and well-nourished patients had a MNA score >23.5 points. All participants have completed the assessments within 48 h before discharge. Sarcopenia was defined following the updated Asian Working Group for Sarcopenia (AWGS): 2019 Consensus.[3] Body composition was measured by bioelectrical impedance analysis (InBody 570, InBody Co., Seoul, Korea) using a standard hand-to-foot tetra-polar technique. The skeletal muscle mass index (SMI) was calculated using the appendicular skeletal muscle mass divided by the square of body height in meters. Low muscle mass was defined as SMI <7.0 kg/m2 in men and SMI <5.7 kg/m2 in women. Muscle strength was assessed by digital handgrip strength using a JAMAR Dynamometer (JAMAR Co., Ltd., DuLuth, Minnesota, USA) in a standard posture. Low muscle strength was defined as handgrip strength <28 kg in men and <18 kg in women. Physical performance was measured by gait speed (GS): a 4-m walking test was performed to measure the usual GS. A score of <0.8 m/s was used to identify low GS. Statistical differences between groups were assessed with the chi-squared tests, Fisher's exact tests, Mann-Whitney U tests, or one-way analysis of variance tests as appropriate. We used multivariable logistic regression analysis to measure the independent risk factors of sarcopenia. A Cox regression analysis, was performed to investigate risk factors for readmission. The variables with P values <0.10 in univariable analysis were included in multivariable analysis. We created Kaplan–Meier curve of cumulative risk of readmission with log-rank test. Statistical analyses were performed with IBM SPSS Statistics 25.0 (IBM SPSS Inc., Chicago, IL, USA). A two-sided P-value of <0.05 was considered statistically significant. Also, we had conducted collinearity diagnostics by calculating the variance inflation factor (VIF) between MNA scores and sarcopenia. The results showed that VIF is 1.032, lower than 10, indicating no significant multicollinearity between two variables. Totally 302 COPD patients, including 55.0% (166/302) of male, were enrolled in this study. A total of 54 (17.9%) patients had readmission within 6 months after discharge from hospital. The average age of all patients was 77.0 ± 7.6 years and the mean body mass index (BMI) was 24.3 ± 3.4 kg/m2. Patients with readmission events were significantly elder (79.7 ± 7.9 years vs. 76.4 ± 7.4 years, t = 2.99, P = 0.003), and had lower BMI (23.0 ± 3.2 kg/m2vs. 24.6 ± 3.4 kg/m2, t = −3.14, P = 0.002), skeletal muscle mass index (5.9 ± 1.3 kg/m2vs. 7.2 ± 1.0 kg/m2, in males, t = −6.21, P < 0.001, and 5.4 ± 1.0 kg/m2vs. 5.8 ± 1.3 kg/m2, in females, t = −2.36, P = 0.020) and handgrip strength (22.0 [15.3–31.2] kg vs. 27.0 [22.0–33.2] kg, Z = −3.41, P < 0.001) than those without readmission within 6 months. Higher CAT scores (18.0 [11.8–22.0] vs. 15.0 [10.0–22.0], Z = −1.36, P = 0.001) and lower forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio (57.0 ± 10.4% vs. 61.3 ± 9.1%, t = −2.90, P = 0.004) were also found among patients with readmission events, when compared with patients without readmission within six months. While the levels of serum albumin as well as drug usage were similar between patients with and without readmission. Thirty-one (10.3%) and 84 (27.8%) of all patients were malnourished and at risk of malnutrition according to the MNA score, respectively. Compared with non-readmission group, the CCI was significantly higher in patients with readmission events (3 [2–4) vs. 2 [1–3], Z = −3.74, P < 0.001]. Higher percentages of cerebrovascular diseases (22.2% [12/54] vs. 11.3% [28/248], χ2 = 4.61, P = 0.033), diabetes (25.9% [14/54] vs. 12.9% [32/248], χ2 = 5.82, P = 0.017), and rheumatologic diseases (5.6% [3/54] vs. 0 [0/248], P = 0.005) were found in patients with readmission than those without readmission [Supplementary Table 1, https://links.lww.com/CM9/B324]. Our findings showed that the average time to readmission was 151.2 ± 46.8 days, 157.5 ± 43.3 days, and 171.6 ± 30.1 days among malnourished, risk of malnutrition, and normal nutrition groups, respectively. Also, the mean time from discharge to readmission in sarcopenia patients was significantly shorter than that in non-sarcopenia patients (152.3 ± 49.2 days vs. 172.7 ± 25.6 days; P < 0.001). Moreover, among all readmitted patients, 16.7% (9/54) of patients were hospitalized for no less than twice within 6 months. No statistical significance was found in readmission frequency among different nutritional status groups. A total of 107 (35.4%) participants were diagnosed as sarcopenia according to the 2019 AWGS criteria. The univariate analysis showed that factors such as BMI, FEV1/FVC ratio, FEV1 of predicted, CAT, and malnutritional status were related to sarcopenia. Multivariate logistic regression analyses revealed that malnutrition (odds ratio [OR] = 2.88, 95% confidence interval [CI]: 1.14–7.23, P = 0.025), BMI (OR = 0.90, 95% CI: 0.83–0.98, P = 0.025), and FEV1/FVC ratio (OR = 0.95, 95% CI: 0.92–0.98, P = 0.003) were more likely to be associated with sarcopenia. Our findings showed that 32.3% (10/31) of malnourished patients were readmitted to hospital after discharge, which occurred in 28.6% (24/84) of patients at risk of malnutrition and 10.7% (20/187) of well-nourished patients. Cox regression analysis suggested that poor nutritional status, sarcopenia, and current smoking were associated with risk of readmission. Patients with malnutrition had a 2.97-fold (95% CI: 1.18–7.47, P = 0.021) of readmission risk compared to those who were well-nourished. Current smokers had a 2.82-fold (95% CI: 1.02–7.80, P = 0.046) of readmission risk compared to those who never smoked. By the end of 6 months follow-up, the incidences of readmission were 22% and 18% higher in patients with malnutrition and at risk of malnutrition than well-nourished patients. The incidence of readmission was 24% in patients with sarcopenia, higher than that in non-sarcopenia patients, as shown in Figure 1.Figure 1: Kaplan–Meier curves of the cumulative incidence of non-readmission within 180 days among COPD patients with different nutritional status (A) and with or without sarcopenia (B).Among all the 54 patients, who suffered readmission within 6 months after discharge, 66.7% (36/54) were due to the AECOPD, and 33.3% (18/54) were readmitted for other causes, including cardiovascular disease, disturbance of consciousness, lung cancer, pleural effusion, pulmonary embolism, etc. Among patients admitted due to AECOPD, 69.4% (25/36) were at worse nutritional status (malnutrition or at risk of malnutrition), and 16.7% (6/36) were current smokers. In our study, malnutrition accounted for 10.3% of AECOPD hospitalized patients, besides, 27.8% AECOPD hospitalized patients were at risk of malnutrition. The prevalence of at risk of malnutrition was similar to the study of Min Fang Hsu et al.[4] With the threshold of a score <17 as malnutrition, our study revealed that it occurred in 18.7% (20/107) of patients with sarcopenia, and malnutrition was also an independent risk factor for the presence of sarcopenia. Existing evidence suggested that poor nutritional status among elderly COPD patients, even at risk of malnutrition, would be accompanied with the elevated resting energy consumption, the increased systemic protein turnover and higher levels of adenosine triphosphate consumption during muscle contraction. The disease-related increases in daily metabolism and the energy imbalance of intake and consumption played a role in muscle atrophy and functional decline. Given that skeletal muscle function (muscle strength and endurance), was closely related to muscle mass, COPD patients with either poor nutritional status or sarcopenia may be more vulnerable to weakness as well as the next exacerbation of disease. Existing evidence has demonstrated that sarcopenia is a risk factor for all-cause mortality,[5] and in hospitalized patients with AECOPD, the group with muscle loss had higher in-hospital mortality, longer average hospital stay and higher hospitalization cost. In our study, the mean time to readmission was significantly shorter in patients with sarcopenia, suggesting that sarcopenia, diagnosed by updated sarcopenia diagnostic criteria, can be used as an indicator to predict poor prognosis of COPD patients as well as to offer practical interventions, including dietary modification and rehabilitation strategies to improve nutritional status against sarcopenia. However, the study has some limitations. First, our study was conducted in a single center, with the limited participants focusing on elderly hospitalized patients in a tertiary hospital. Second, the proportion of female participant in this study is relatively higher. Thirdly, the measurements of body composition, muscle strength, and serum sample tests were only performed at baseline due to the limited funds and labor resources. In summary, our findings suggested that worse nutritional status identified by MNA score system as well as sarcopenia which was diagnosed with the updated criteria were supposed to be reliable predictors for readmission of COPD patients, which help to better understand the value of screening for nutritional status and sarcopenia in elderly COPD individuals as well as to provide supporting evidence on the necessity of taking nutritional precautions for preventing readmission of COPD patients. Funding This work was supported by grants from the National Natural Science Foundation of China (Nos. 81900072 and 82170092). Conflicts of interest None

Stability of Blood Eosinophils in COPD with Multiple Acute Exacerbations Within 1 Year and Its Relationship with Prognosis.

The relationship between increased blood eosinophils (EOS) and the prognosis of patients with chronic obstructive pulmonary disease (COPD) remains controversial. We aimed to explore the stability of blood eosinophils in patients with multiple hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) over a 1-year period and its relationship with readmission rates and mortality. Prospectively include patients with at least 2 hospitalizations for AECOPD in 1 year between June 2019 and December 2021. Using 150 cells/ul as the cut-off value, the study population was divided into EOS, non-EOS, and fluctuating groups based on the longitudinal stability of blood EOS. The relationship between blood EOS and readmission rate and mortality was analyzed according to the 6-month follow-up after hospital discharge. A total of 202 patients were included. 48, 108, and 46 patients were in the EOS, non-EOS, and fluctuating groups, respectively. The stability of blood EOS at 1 year was 77.2%. The risk of death was lower in the EOS group compared to the non-EOS group (HR=0.323, 95% CI 0.113-0.930, P =0.036). The risk of readmission was lower in both the EOS group (HR=0.486, 95% CI 0.256-0.923, P =0.027) and the non-EOS group (HR=0.575, 95% CI 0.347-0.954, P = 0.032) than in the fluctuating group. The blood EOS of COPD patients is relatively stable over 1 year. Patients with consistently high blood EOS had a lower risk of all-cause mortality after discharge; patients with fluctuating blood EOS had a higher risk of readmission.

Hospital admissions and mortality for acute exacerbations of COPD during the COVID-19 pandemic: A nationwide study in France.

BackgroundA global reduction in hospital admissions for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) was observed during the first months of the COVID-19 pandemic. Large-scale studies covering the entire pandemic period are lacking. We investigated hospitalizations for AECOPD and the associated in-hospital mortality at the national level in France during the first 2 years of the pandemic.MethodsWe used the French National Hospital Database to analyse the time trends in (1) monthly incidences of hospitalizations for AECOPD, considering intensive care unit (ICU) admission and COVID-19 diagnoses, and (2) the related in-hospital mortality, from January 2016 to November 2021. Pandemic years were compared with the pre-pandemic years using Poisson regressions.ResultsThe database included 565,890 hospitalizations for AECOPD during the study period. The median age at admission was 74 years (interquartile range 65–83), and 37% of the stays concerned women. We found: (1) a dramatic and sustainable decline in hospitalizations for AECOPD over the pandemic period (from 8,899 to 6,032 monthly admissions, relative risk (RR) 0.65, 95% confidence interval (CI) 0.65–0.66), and (2) a concomitant increase in in-hospital mortality for AECOPD stays (from 6.2 to 7.6% per month, RR 1.24, 95% CI 1.21–1.27). The proportion of stays yielding ICU admission was similar in the pre-pandemic and pandemic years, 21.5 and 21.3%, respectively. In-hospital mortality increased to a greater extent for stays without ICU admission (RR 1.39, 95% CI 1.35–1.43) than for those with ICU admission (RR 1.09, 95% CI 1.05–1.13). Since January 2020, only 1.5% of stays were associated with a diagnosis of COVID-19, and their mortality rate was nearly three-times higher than those without COVID-19 (RR 2.66, 95% CI 2.41–2.93).ConclusionThe decline in admissions for AECOPD during the pandemic could be attributed to a decrease in the incidence of exacerbations for COPD patients and/or to a possible shift from hospital to community care. The rise in in-hospital mortality is partially explained by COVID-19, and could be related to restricted access to ICUs for some patients and/or to greater proportions of severe cases among the patients hospitalized during the pandemic.

Effectiveness of influenza and pneumococcal vaccines on chronic obstructive pulmonary disease exacerbations.

Single-study evidence of separate and combined effectiveness of influenza and pneumococcal vaccination in patients with chronic obstructive pulmonary disease (COPD) is limited. To fill this gap, we studied the effectiveness of trivalent seasonal influenza vaccine (TIV) and 23-valent pneumococcal polysaccharide vaccine (PPSV23), separately and together, at preventing adverse COPD outcomes. Our study used a self-controlled, before-and-after cohort design to assess the effectiveness of TIV and PPSV23 in COPD patients. Patients were recruited from hospitals in Tangshan City, Hebei Province, China. Subjects self-selected into one of the three vaccination schedules: TIV group, PPSV23 group and TIV&PPSV23 group. We used a physician-completed, medical record-verified questionnaire to obtain data on acute exacerbations of COPD (AECOPD), pneumonia and related hospitalization. Vaccine effectiveness was determined by comparing COPD outcomes before and after vaccination, controlling for potential confounding using Cox regression. We recruited 474 COPD patients, of whom 109 received TIV, 69 received PPSV23 and 296 received TIV and PPSV23. Overall effectiveness for preventing AECOPD, pneumonia and related hospitalization were respectively 70%, 59% and 58% in the TIV group; 54%, 53% and 46% in the PPSV23 group; and 72%, 73% and 69% in the TIV&PPSV23 group. The vaccine effectiveness without COVID-19 non-pharmaceutical intervention period were 84%, 77% and 88% in the TIV group; 63%, 74% and 66% in the PPSV23 group; and 82%, 83% and 91% in the TIV&PPSV23 group. Influenza vaccination and PPSV23 vaccination, separately and together, can effectively reduce the risk of AECOPD, pneumonia and related hospitalization. Effectiveness for preventing AECOPD was the greatest.

Evaluating temporally decomposed associations between PM2.5 and hospitalisation risks of AECOPD: A case study in Beijing from 2010 to 2019

Few studies investigated relative contributions of PM2.5 concentration at multiple time-scales (short-term, seasonal and long-term periods) on the hospitalisation risk for acute exacerbation of COPD (AECOPD). In this study, we specified and discriminated the short-term, seasonal and long-term trend effects of PM2.5 concentration on the hospitalisation for AECOPD in Beijing between 2010 and 2019. Daily PM2.5 observations from US Beijing Embassy from Jan 1, 2010, to Dec 31, 2019 (3652 days) were decomposed to short-term, seasonal and long-term trend components by using the robust Kolmogorov-Zurbenko filter. During the study period, daily counts of AECOPD hospitalisation were obtained from a database compiled by Beijing Public Health Information Center. Two separate generalized additive models were built to assess effects of raw PM2.5 concentrations and the three decomposed components of time-scales on hospitalisation of AECOPD in Beijing. We found raw PM2.5 concentrations were associated with AECOPD in Beijing with a 10 μg/m3 increase corresponding to 0.46% (95% CI: 0.40%–0.52%) increase in hospitalisation. In the model of decomposed PM2.5 time-series, both the short-term and long-term components exhibited statistically significant positive association with AECOPD, which, respectively, was associated to 0.42% (95% CI: 0.36%–0.48%) and 6.91% (95% CI: 6.08%–7.74%) increase in AECOPD hospitalisation per 10 μg/m3 increase. The seasonal trend had an insignificant U-shaped relationship with AECOPD. Our study simultaneously confirmed that a statistically significant positive association between the raw PM2.5 concentrations, the decomposed short-term and long-term trend of PM2.5 concentrations and increased risk for AECOPD hospitalisation. Strong long-term effects in this study indicated that stringent emission control measures would bring strong public health benefits concerning AECOPD.

Feasibility of Using Daily Home High-Flow Nasal Therapy in COPD Patients Following a Recent COPD Hospitalization.

High-flow nasal therapy (HFNT) has beneficial effects in patients hospitalized with acute hypoxemic respiratory failure. HFNT has not been extensively studied following hospitalization for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We explored the feasibility of conducting a multicentered trial to evaluate the use of HFNT to increase the time to next moderate/ severe exacerbation in patients recently hospitalized for a COPD exacerbation. In this pilot study we measured the hours of home daily HFNT use, maximally tolerated flow rates and temperature, and side effects for a period of 90 days. Patients were enrolled in a 90-day, open-labeled pilot study of HFNT to determine the safety and feasibility of home use for daily outpatient COPD management. Patients ≥ 40 years of age with prior hospitalization within the past 12 weeks for an AECOPD were enrolled. COPD was the primary diagnosis in all patients. Thirty patients presented for HFNT titration. Two dropped out; 1 after receiving a lung transplant and the other was lost to follow-up. The remaining 28 patients completed 90 days of HFNT. None withdrew from HFNT due to intolerance. Use of HFNT averaged 6.8 (2.1) hours daily. Daily home HFNT for up to 3 months is feasible in COPD patients following hospitalization for AECOPD. Improvements observed in disease-specific quality of life, respiratory symptoms, and 6-minute walk distance suggest the need for a prospective multicenter controlled clinical trial.

30-day Readmission After an Acute Exacerbation of Chronic Obstructive Pulmonary Disease is Associated with Cardiovascular Comorbidity.

Readmission after hospitalization for a chronic disease is a major concern of interest for health care quality. Our aim was to investigate the predictors and rates of early readmission after an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in a tertiary care hospital. Over a 3-year period, patients hospitalized in our pulmonary disease clinic with a diagnosis of chronic obstructive pulmonary disease (COPD) and who had an index hospitalization for AECOPD were included. Readmission was defined as rehospitalization within 30 days of AECOPD discharge. Demographics, comorbidities, exacerbations, prior intensive care unit (ICU) stay, and long-term oxygen therapy (LTOT), blood eosinophil count, and antibiotic and/or steroid treatment at the index AECOPD admission were recorded. Fifty-two (17.3%) readmissions occurred in 300 patients. Readmissions were due to AECOPD in 46.2%, pneumonia in 19.2%, and cardiovascular disease in 15.4% patients. Twenty-one (40%) of the readmitted patients were frequent exacerbators. After adjusting for individual and clinical predictors, the odds ratio for readmission was 2.11 (95% CI, 1.07-4.15, P = .03) for those with congestive heart failure, 3.30 (95% CI, 1.05-9.75, P = .04) for those with arrhythmia, and 1.99 (95% CI, 1.04-3.81, P = .04) for LTOT users prior to AECOPD. A significant majority of patients readmitted after an AECOPD mainly suffered from recurrent AECOPD. Associated congestive heart failure, arrhythmia, and prior LTOT were risk factors identified for early AECOPD readmissions in our study. Better recognition of readmission risk factors might help to reduce readmission rates of AECOPD.

Risk assessment and rate of readmission within 30 days of discharge after hospitalization for acute exacerbation of chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease (COPD) hospitalized for an exacerbation are at risk of early readmission for any reason within 30 days of discharge. Understanding the frequency and risk factors related to readmission can provide valuable input for the development of readmission reduction strategies. The aim of this study was to investigate the frequency, specific risk factors and the cost analysis of early readmission for any reason within 30 days after discharge of the patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In a prospective comparative case series study, 110 patients over 40 years of age who were hospitalized with AECOPD were included. The frequency of readmissions within 30 days of discharge after hospitalization for AECOPD was investigated. Those who were admitted to any hospital for any reason within 30 days after discharge were classified as the readmission group. Whereas nonhospitalized patients were defined as the nonreadmission group. Demographic, clinical, therapeutic, laboratory and financial data of the groups were evaluated. Thirty-four (30.9%) COPD patients were readmitted during the first 30 days post index hospitalization. In multivariate analysis, the best predictors of early readmission were the low forced expiratory volume in one second (FEV1) predicted % (FEV1%) (OR= 0.961, %95 CI 0.927-0.997 p= 0.034) and COPD diagnosis time (OR= 0.908, %95 CI 0.838-0.983 p= 0.017). Mean length of stay of the second hospitalization was longer than both the readmitted and nonreadmitted groups (8.3, 8.1 and 7.8 days respectively). While mean cost of second hospitalization was 1189$, mean cost of index hospitalization of the readmission group was 794$ and that of index hospitalization of nonreadmission group was 582$. The frequency of readmissions within 30 days after discharge of the patients hospitalized for AECOPD are common and costly. Low FEV1 percentage and lower diagnosis time were found to be significant predictors for readmission within 30 days of the index hospitalization.

Impact of Frailty on the Risk of Exacerbations and All-Cause Mortality in Elderly Patients with Stable Chronic Obstructive Pulmonary Disease.

RationaleFor the high prevalence of frail in patients with chronic obstructive pulmonary disease (COPD), further study should explore an in-depth understanding of the relationship between frailty and prognosis of COPD.ObjectiveTo determine the correlation between frailty and risk of acute exacerbation, hospitalizations, and mortality in older patients with stable COPD.Participants and MethodsConsecutive older adults (≥65) diagnosed with stable COPD from January 2018 to July 2019, with an average follow-up of 546 days (N = 309). Frailty was defined by the Fried frailty phenotype. Poisson regression was performed to assess the influence of frailty on the incidence of acute exacerbations of COPD (AECOPD) and all-cause hospitalizations in a year. Cox regression was performed to evaluate the effect of frailty on all-cause mortality in patients with stable COPD.ResultsThe prevalence of frailty was 49.8%. The most common phenotypic characteristics were weakness (99.4%) followed by slowness (92.9%). After adjustment, frailty increased the incidence of AECOPD (IRR = 1.75, 95% CI: 1.09–2.82) and all-cause hospitalizations (IRR = 1.39, 95% CI 1.04–1.87) within a year. Slowness was associated with AECOPD (IRR = 1.77, 95% CI: 1.03–3.03), and weakness was associated with increased all-cause hospitalizations (IRR = 1.53, 95% CI: 1.04–2.25). The all-cause mortality risk was more than twofold higher in frail patients (HR = 2.54, 95% CI: 1.01–6.36) than non-frail patients. Low physical activity (HR = 2.66, 95% CI: 1.17–6.05) and weight loss (HR = 2.15, 95% CI: 1.02–4.51) were significantly associated with increased all-cause mortality in patients with COPD.ConclusionFrailty increased the incidence of acute exacerbation and hospitalization, as well as increased mortality in older patients with stable COPD. This knowledge will help physicians identify high-risk groups with COPD and frailty who may benefit from targeted interventions to prevent disease progression.

Association of change in air quality with hospital admission for acute exacerbation of chronic obstructive pulmonary disease in Guangdong, China: A province-wide ecological study

AimsTo assess possible effect of air quality improvements, we investigated the temporal change in hospital admissions for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) associated with pollutant concentrations. MethodsWe collected daily concentrations of particulate matter (i.e., PM2.5, PM10 and PMcoarse), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), and admissions for AECOPD for 21 cities in Guangdong from 2013 to 2017. We examined the association of air pollution with AECOPD admissions using two-stage time-series analysis, and estimated the annual attributable fractions, numbers, and direct hospitalization costs of AECOPD admissions with principal component analysis. ResultsFrom 2013–2017, mean daily concentrations of SO2, PM10 and PM2.5 declined by nearly 40%, 30%, and 26% respectively. As the average daily 8 h O3 concentration increased considerably, the number of days exceeding WHO target (i.e.,100 μg/m³) increased from 103 in 2015–152 in 2017. For each interquartile range increase in pollutant concentration, the relative risks of AECOPD admission at lag 0–3 were 1.093 (95% CI 1.06–1.13) for PM2.5, 1.092 (95% CI 1.08–1.11) for O3, and 1.092 (95% CI 1.05–1.14) for SO2. Attributable fractions of AECOPD admission advanced by air pollution declined from 9.5% in 2013 to 4.9% in 2016, then increased to 6.0% in 2017. A similar declining trend was observed for direct AECOPD hospitalization costs. ConclusionDeclined attributable hospital admissions for AECOPD may be associated with the reduction in concentrations of PM2.5, PM10 and SO2 in Guangdong, while O3 has emerged as an important risk factor.Summarizes the main finding of the work：Reduction in PM may result in declined attributable hospitalizations for AECOPD, while O3 has emerged as an important risk factor following an intervention.

Associations between ambient air pollution and hospitalizations for acute exacerbation of chronic obstructive pulmonary disease in Jinhua, 2019

Most cities in China are experiencing severe air pollution due to rapid economic development and accelerated industrialization. Exposure to various air pollutants has been related to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, less is known about the spatial association between air pollution and AECOPD hospitalizations in the Yangtze River delta (YRD) economic and industrial region. Jinhua city is located in the YRD region of East China, in the middle of Zhejiang province. For the first time, 1563 AECOPD hospitalization cases in Jinhua during 2019 were enrolled in our analysis. The spatial distribution of six pollutants (SO2, CO, PM10, PM2.5, O3, NO2) and the population temporal-spatial specific air pollutant exposure levels were estimated using the ordinary Kriging model through geographic information system (GIS). Global Moran’s I was used to explore the spatial association between ambient air pollutants and AECOPD hospitalizations. The Z-scores of residential SO2, CO, PM10, PM2.5, O3, and NO2 levels were 31.88, 42.95, 45.90, 32.29, 52.18, and 34.59, respectively. The concentrations of six monitored pollutants and AECOPD hospitalizations showed statistically significant spatial clustering. A generalized linear model (GLM) using a Poisson distribution with the log-link function was used to construct a core model. After adjusting for potential confounders in the model, residential SO2, NO2 and O3 concentrations were significantly associated with increased AECOPD hospitalizations.

Blood Eosinophil Count and Hospital Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

PurposeThis retrospective, observational cohort study investigated the association of blood eosinophil counts within 1 week of hospitalization for acute exacerbation of COPD (AECOPD) with subsequent risk of all-cause and COPD-related readmission from a large integrated health system.Patients and MethodsElectronic medical records were extracted for index hospitalization for AECOPD at all Intermountain Healthcare hospitals. The primary outcome was the relationship of blood eosinophil count to 30-day all-cause readmission; secondary outcomes were 60-day, 90-day, and 12-month all-cause readmission, COPD-related readmission, and empiric derivation of the eosinophil count with the highest area under the curve (AUC) for predicting 30-day all-cause readmission.ResultsOf 2445 included patients, 1935 (79%) had a blood eosinophil count <300 cells/µL and 510 (21%) had a count ≥300 cells/µL. Using a 300-cells/μL threshold, there was no significant difference between high and low eosinophil groups in 30-day (odds ratio [OR]=1.05, 95% confidence interval [CI]=0.75–1.47) or 60-day (OR=1.15, 95% CI=0.88–1.51) all-cause readmissions. However, patients with greater (versus lesser) eosinophil counts had increased 90-day and 12-month all-cause readmissions (OR=1.35, 95% CI=1.06–1.72, and OR=1.32, 95% CI=1.07–1.62). COPD-related readmission rates were significantly greater for patients with greater (versus lesser) eosinophil counts at 30, 60, and 90 days and 12 months (OR range=1.52–1.97). A total of 70 cells/µL had the most discriminatory power to predict 30-day all-cause readmission (highest AUC).ConclusionEosinophil counts in patients with COPD were not associated with a difference in 30-day all-cause readmissions. However, greater eosinophil counts were associated with increased risk of all-cause readmission at 90 days and 12 months and COPD-related readmission at 30, 60, and 90 days and 12 months. Patients with eosinophils <70 cells/μL had the lowest risk for 30-day all-cause readmission. Blood eosinophils in patients hospitalized with AECOPD may be a useful biomarker for the risk of hospital readmission.

Evaluation of the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in Hospitalized Patients.

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are estimated to cost $1.5 billion annually in Canada. Previous studies have shown that barely half of all patients receive ideal care in hospitals. Deviations from guideline-defined optimal care lead to longer hospital stays, readmissions, and increased mortality. Objective: To determine the proportion of patients admitted to hospital for AECOPD who received treatment adherent to guidelines. Methods: A retrospective cohort study was conducted with ethics approval from the University of British Columbia Clinical Research Ethics Board. Patients hospitalized for ≥24 hours with an AECOPD at a tertiary care center and a community hospital were assessed. Guideline-adherent treatment was defined as appropriate use of supplemental oxygen, inhaled bronchodilators, systemic corticosteroids, antibiotics, venous thromboembolism prophylaxis, initiation/continuation of nicotine replacement therapy for current smokers, and vaccination optimization, reflecting international standards of care. Outcomes were assessed using descriptive statistics. Results: A random sample of 210 patients were selected of which 99 met inclusion criteria. Only 4% received therapy that met all recommendations. Differences in management were found between sites, specifically the appropriate use of bronchodilators, corticosteroids, antibiotics, and supplemental oxygen. Venous thromboembolism prophylaxis and smoking cessation rates were 97% and 94%, respectively, at the tertiary care center, compared with 73% and 100% at the community hospital. Additionally, less than half of all patients had their immunization history verified. Conclusion: Gaps in the inpatient management of AECOPD continue to exist. Initiatives must be targeted to optimize management and reduce the burden of the disease.

Comparison of Narrow-Versus Broad-Spectrum Antibiotics in Elderly Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Background Little evidence is available regarding the choice of empiric antibiotic therapy in elderly patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The primary objective of this study is to compare the outcomes of elderly patients receiving broad- versus narrow-spectrum antibiotics during hospitalization for AECOPD. Design A multicenter, retrospective, cohort analysis was performed. Inpatients 65 years and older with a primary discharge diagnosis of AECOPD who received ≥48 hours of antibiotic therapy were included in the study population. Patients were compared based on the spectrum of their antibiotic therapy. Narrow-spectrum antibiotics included: azithromycin, doxycycline, sulfamethoxazole/trimethoprim, or aminopenicillin. The primary outcome was a composite of mechanical ventilation 48 hours after admission, transfer to the intensive care unit 48 hours after admission, 30-day chronic obstructive pulmonary disease (COPD) readmission, and oxygen saturation less than 90% on room air or increased oxygen requirements from baseline 48 hours after admission. Results Two hundred fifty-three patients were included in this analysis; 127 patients were included in the narrow-spectrum group, and 126 patients were included in the broad-spectrum group. Patient demographics and comorbid conditions were similarly distributed in each group. The incidence of the primary composite outcome occurred in 50 (39.3%) and 60 (47.6%) of patients in the narrow- and broad-spectrum groups, respectively (P = .19). Conclusions and Relevance No difference was found in the primary outcome in inpatients aged ≥65 years with AECOPD who received empiric broad-spectrum or narrow-spectrum antibiotics.

Effects of Ambient Temperature on Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Results from a Time-Series Analysis of 143318 Hospitalizations.

PurposeTo evaluate the associations between acute exacerbations of chronic obstructive pulmonary disease (AECOPD) hospitalizations and daily mean temperature (Tmean) as well as daily apparent temperature (AT), and to explore the practical values of these two indices in policymaking and patient education.MethodsDaily AECOPD hospitalizations and Meteorological data in Beijing were obtained between 2013 and 2016. Distributed lag non-linear model was adopted to investigate the association between daily ambient temperature and AECOPD hospitalizations. The cumulative effects of cold/hot temperature were abstracted. For the extreme and moderate low-temperature effect estimates, we, respectively, computed the RR of AECOPD hospitalizations at the 1st and 10th percentiles of temperature in comparison with that at the 25th percentile of temperature. For the extreme and moderate high temperature effect estimates, we, respectively, computed the RR of AECOPD hospitalizations at the 99th and 90th percentiles of temperature in comparison with that at the 75th percentile of temperature.ResultsDuring the study period, 143, 318 AECOPD hospitalizations were collected. A reverse J-shape relationship was found between temperature and AECOPD hospitalizations. When comparing the effect of Tmean, higher RRs were associated with increases in AT on AECOPD hospitalizations but a lower value of Akaike’s Information Criterion for quasi-Poisson (Q-AIC). The RR of extremely low temperature of Tmean and AT were 1.55 (95% CI: 1.21,2.00) and 2.08 (95% CI: 1.44,3.01), respectively. Moderate low temperature also had an adverse impact on AECOPD hospitalizations. No associations were found between high temperature and AECOPD risk. We found the females and those aged <65 years to be more susceptible to temperature change.ConclusionLower temperature is associated with a higher risk for AECOPD hospitalizations. Ambient temperature is probably a better predictor in terms of quantifying risk than mean temperature when studying temperature impact on health.