Riacutizzazione di BPCO

Celli B. ERJ 2004

Standards for the diagnosis andtreatment of patients with COPD: a summary of the ATS/ERS position paper

Riacutizzazioni: definizione

La riacutizzazione della BPCO è un evento, che si verifica nel corso della storia naturale della malattia, caratterizzato da un cambiamento rispetto al basale di dispnea e/o dell’espettorato, che eccede la variabilità quotidiana ed è tale da richiedere modifiche del trattamento

Sethi S, File TM. Curr Med Res Opin. 2004;20:1511-21

Costi delle AECB In generale, solo una minima parte della

spesa sanitaria pro capite è generata da pazienti con BPCO lieve o moderata

La malattia grave e molto grave, di competenza prevalentemente specialistica, spiega l’elevatissimo consumo di risorse sanitarie

Poiché la bronchite cronica è responsabile dell’85% dei casi di BPCO, una rilevante porzione della spesa sanitaria pro capite per questi pazienti è generata dalle riacutizzazioni, indipendentemente dalla gravità della malattia di base

Definition

EXACERBATIONDefined as an increase

in the baseline symptoms of the

disease in the absence of an identifiable cause.

ATS/ERS Statement ERJ 2004; 23:932-946

Cause di RIACUTIZZAZIONI

Infezioni Batteriche

Virali Allergie

InquinamentoAnidride solforosa Polveri industriali

ClimaInverno

RIACUTIZZAZIONE

Ball P. Chest. 1995;108:43S-52S. Gump DW, et al. Am Rev Respir Dis. 1976;113:465-74.

0

10

20

30

40

O N D J F M A M J J A S

Y1

Y3

Y5

ALL EXACERBATIONS BY MONTH OF STUDY: from East London COPD cohort

Modifiable risk factors in patients with COPD exacerbation (EFRAM study)

García Aymerich J et al. ERJ 2000; 16: 1037-1042

No influenza vaccination: 28 %

No rehabilitation program: 86 %

No home O2 in pts with PaO2 < 55 mm Hg: 28 %

Failed in inhaler maneuvers: 43 %

Current smokers: 26 %

AECB ETIOLOGY

BACTERIA25%

VIRUS+BACT 25%

VIRUS 24%

NO ISOLATION 21%

VIRUS VIRUS+BACTERIA BACTERIA NO ISOLATION

Papi A et al. AJRCCM 2006

CoinfectionCoronavirus

Chlamydia Pneumoniae

RSV Serology

Adenovirus

Parainfluenza

Influenza B

Influenza A

Rhinovirus

RESPIRATORY VIRUSES AND EXACERBATIONS

Seemungal et al Am J Respir Crit Care Med 2001

RSV (PCR) IN STABLE COPD AND AT EXACERBATION


EXACERBATIONS

•RSV found in 26% of exacerbations

•Detection of RSV not related to exacerbation parameters

STABLE

•RSV found in 24% of stable samples

http://www.phototakeusa.com/results.asp?Image=046402C000303-01

CHANGES IN BACTERIAL LOADn=57

7.4

7.5

7.6

7.7

7.8

7.9

8

8.1

STABLE EXACERBATION

*p=0.0001

Bacterial LoadLog cfu/ml

0

10

20

30

40

50

60

70

27

5564

4,2

2,2

5,5

Healthysubjects

StableCOPD

Exacerb.COPD

Bacterial index

Culture +

Bacterial infection and COPD

Rosell et al. Arch Intern Med 2005; 165: 891-897

The “fall & rise” of bacterial AECB

Modifying factors

Bacte

rial

load

(C

FU

/ml)

Time (days)

Clinicalthreshold

AB1

AB2

AB3

AE AB Cure Cure Cure Stop AB

Time to relapse

Miravitlles et al. Eur Respir J 2002: 20 (Suppl 36): 9s-19s

The usual suspects

AECB Etiology

Chlamydia pneumoniae

RELATIVE RISK OF EXACERBATION AND BACTERIAL STRAIN CHANGE

0

5

10

15

20

25

30

35

New strain No new

• 33% of exacerbation visits were assoaciated with a new strain, compared to 15% of visits when no new strain was found

P<0.001

• For H Influenzae,

S pneumoniae, M Catarrhalis

Sethi et al NEJM 2002

Exacerbation visits %

INTERACTION OF BACTERIAL AND VIRAL INFECTIONWilkinson et al Chest 2006; 129:317-324

Rapporti tra infiammazione e infezione nei pazienti con BPCO

BACTERIAL ERADICATION AND INFLAMMATIONWhite et al Thorax 2003

ALTERAZIONI STRUTTURALIVIE AEREE-PARENCHIMA

COLONIZZAZIONEBATTERICA

RIACUTIZZAZIONIOSTRUZIONE BRONCHIALEINSUFFLAZIONE

DISPNEALIMITAZIONE SFORZO

PEGGIORAMENTO Q of L

Circolo vizioso del declino funzionale nei pazienti con BPCO

Upper lobes 43.6%

Middle lobe/lingula 46.2%

Lower lobes 76.9%

39 (72.2%) of patients had bronchiectasis on HRCT

Median score was 3/24 (range 1-14)Patel et al AJRCCM2004

NATURAL HISTORY OF COPDL

un

g F

un

cti

on

Time (Years)

Exacerbation

Exacerbation

Exacerbation

Never smoked

Smoker

Fletcher C. BMJ 1977;1:1645-1648.

Rodriguez-Roisin, R. Chest 2000;117:398S-401S

Day-to-day variability of a patient with COPD

Normal variation of clinical state Exacerbation threshold

Time

Fun

ctio

n

Relationship between lung function and

exacerbations

Exacerbations increase as lung function declines.

Lung function shows a small decline in the days immediately preceding an exacerbation

Pauwels et al. Am J Respir Crit Care Med 2003; 167(7): A949

-14 14Day

0

210

220

230

240

250

270

Mean P

EF

(L/m

in)

-12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12

FSC 50/500mcg bdSalmeterol 50mcg bd

Fluticasone propionate 500mcg bdPlacebo

Onset of exacerbation

260

INTERACTION OF BACTERIAL AND VIRAL INFECTIONWilkinson et al, Chest 2006; 129:317-324

Seemungal TAR et al, AJRCCM 2000; 161: 1608

101 patients - F/up 2.5 years

FEV1 41.9% Pred

Daily Symptoms and PEFR FEV1 (34)

Time Course and Recovery of COPD Exacerbations

Recovery 75.2%

No recovery 7.1% (90 d.)

Impatto delle infezioni delle basse vie respiratorie sul declino annuale del FEV1 (ml/anno)

0

10

20

30

40

50

60

70

0-0.24 0.25-0.49 0.50-0.99 1.00-1.49 >1.50

Ex fumatori

Fumatori intermittenti

Fumatori

Kanner RE et al. AJRCCM 2001 indice

-80

-60

-40

-20

0

0 1 2 >2

Number of exacerbations/year

Ch

an

ge

in

FE

V1

Decline in FEV1 Over 12 Months in Patients with COPD

Pauwels et al. AJRCCM 2001;163:A770

Variazione percentualedel FEV1 in 4 anni

0,75

0,8

0,85

0,9

0,95

0 1 2 3 4

Infrequente

Frequente

Anni

Donaldson GC et al. Thorax 2002;57:847-852 indice

The risk of an exacerbation increases as lung function declines

Hauber et al. Am J Respir Crit Care Med 2002; 165(8): A271.

0

60

100

Perc

enta

ge o

f pati

ents

re

main

ing

80

400

Mild

Exacerbation-free time (days)

3002001000

40

20Moderate

Severe

ATS stage

Exacerbation Rate by FEV1

Donaldson & Wedzicha Thorax 2006;61:164

Relationship between symptoms and exacerbations

Symptoms worsen before and during an exacerbation, prompting presentation to a physician, but their resolution is not sufficient for recovery.

Breathlessness increases during an exacerbation

Pauwels et al. Am J Respir Crit Care Med 2003; 167(7): A949.

-14-14 1414

DaysDays

00

1.41.4

1.61.6

1.81.8

2.02.0

2.22.2

2.42.4

Mean b

reath

less

ness

sco

re

-12-12 -10-10 -8-8 -6-6 -4-4 -2-2 00 22 44 66 88 1010 1212

FSC 50/500mcg bd

Salmeterol 50mcg bd

Fluticasone propionateFluticasone propionate500mcg bd500mcg bd

Placebo

Onset of exacerbation

Symptoms worsen during the 2 days preceding an exacerbation

Pauwels et al. Am J Respir Crit Care Med 2003; 167(7): A949

% patients with worsening of one or two symptoms

Breathlessness score

Cough score

Sputum colour

Sputum production

Breathlessness score

25% 11% 11% 12%

Cough score 30% 17% 20%

Sputum colour 34% 19%

Sputum production

28%

INTERACTION OF BACTERIAL AND VIRAL INFECTIONWilkinson et al Chest 2006; 129:317-324

Relationship between exacerbations and health

statusExacerbations have a pronounced detrimental impact on health status, while low health status is linked with increased probability of exacerbations

Recovery of health status after an exacerbation is Recovery of health status after an exacerbation is prolonged, particularly if another exacerbation occurs prolonged, particularly if another exacerbation occurs

during the recovery periodduring the recovery period

Spencer & Jones. Thorax 2003; 58: 589-93.

30

SG

RQ

tota

l sc

ore

Time after presentation with an exacerbation (weeks)

0 4 26

Experiencing an exacerbation during the follow-up period

Experiencing no further exacerbation

12

n =133

35

40

45

50

55

60

Impro

ved h

ealt

h s

tatu

s

n =133 n =116 n =115

n =299

n =280

n =233n =221

Exacerbations and quality of life

0

10

20

30

40

50

60

70

0 - 2

Exacerbations/year

SGRQ Score

3 - 8

Seemungal TAR et al, AJRCCM 1998; 157: 1418

P < 0.0005

A higher frequency of exacerbations is related to greater impairment of health status

Seemungal et al. Am J Respir Crit Care Med 1998; 157: 1418-22

Mean S

GR

Q s

core

Total Activity Impacts Symptoms

p<0.0005

3-8 exacerbations per year (n=38)

0-2 exacerbations per year (n=32)

p=0.002

p=0.001

p<0.0005

Impro

ved h

ealt

h s

tatu

s

48,9

67,7

36,3

53,2

64,1

80,9

50,4

77,0

0

20

40

60

80

100

Exacerbation category

0

1.0

2.0

3.0

Nonein 3 years

Infrequent<1.65/year

Frequent>1.65/year

* p<0.0001S

GR

Q s

lop

e (u

nit

s/y

ear)

(Worse)

Spencer S et al. Eur Respir J. 2004;23:698-702

COPD exacerbations: Health status

235

613 mod. to severe COPD pts. followed for a maximum of 3 yrs

# p<0.004

*

#

285

91

Relationship between exacerbations and mortality

Exacerbations increase the risk of death in patients with COPD.

Outcome delle AECBMortalità

Seneff MG, et al. JAMA. 1995;274:852-1857; Connors et al. Am J Respir Crit Care Med. 1996 Oct;154(4 Pt 1):959-67. Murata GM, et al. Ann Emerg Med. 1991 Feb;20(2):125-9; Adams SG, et al. Chest. 2000;117:1345-1352

Mortalità ospedaliera 24%

Mortalità ospedaliera 11-49%Pazienti ospedalizzati

Pazienti in UTI

indice

Sopravvivenzaassociata a AECB grave

0

20

40

60

80

100

0 100 300 350

Connors et al. Am J Respir Crit Care Med 1996;154:959

Giorni

Sop

ravviv

en

za (

%)

indice

Hospital stay

60 days 180 days 1 year 2 years

Mo

rta

lity

(%)

60

50

40

30

20

10

0

COPD Exacerbations : Mortality

11%

20%

33%

43%

49%

Connors AF Jr et al. Am J Respir Crit Care Med. 1996;154:959-67

1016 pts with severe COPD exacerbation

(PaCO2 > 50 mm Hg)

Soler-Cataluña JJ et al. Thorax. 2005;64:925-31

COPD exacerbations: Survival

0.0

0.2

0.4

0.6

0.8

1.0

0 10 20 30 40 50 60

Time (months)

Pro

bab

ility

of

su

rviv

ing

p<0.0001

p<0.001

p=0.073–4 exacerbations

1–2 exacerbations

No exacerbation

COPD exacerbations: Survival

Soler-Cataluña JJ et al. Thorax. 2005;64:925-31

0.0

0.2

0.4

0.6

0.8

1.0

0 10 20 30 40 50 60Time (months)

Pro

bab

ility

of

su

rviv

ing

p<0.0001p<0.01

p<0.0001

NS

NS

No exacerbation

1 hospitalization

ER visits

Readmission

Sethi et al Chest 2000

Airway inflammation and aetiologyof COPD exacerbations

SPUTUM IL-8 AT EXACERBATION AND MORAXELLA CATTARHALIS

Powrie et al ERS 2005

Moraxella at Exacerbation

1.00.00

Exa

ce

rba

tio

n s

pu

tum

IL

8 p

g/m

l

14000

12000

10000

8000

6000

4000

2000

0

P=0.018

EFFECT OF CHLAMYDIA INFECTIONON INDUCED SPUTUM IL-6Seemungal et al Thorax 2002

0

5

10

15

20

25

30

2180 patients, 777 isolates of 673 patients

%Inclusion criteria:age > 40 years 3 exacerb./year 3 comorbiditiestreatment failureorhigh prevalence ofresistant pathogens

Anzueto et al., Clin Ther, 1998

Microbial patterns in outpatients with COPD exacerbations and risk factors for a complicated

course

Germi Variabile dipendente Rapporto di probabilità

LC 95%

H. influenzaevs fumatori

Non- ed ex-fumatori

FEV1 > 50% vs <50%

8,16

6,85

1,9-43,0

1,6-52,6

P. aeruginosa FEV1 > 50% vs <50% 6,62 1,21-123,6

S. pneumoniae Mesi dall’ultimariacutizzazione

<2 vs >2

5,02 1,12-35,7

M. catarrhalis ------ ------ ------

Miravilles et al, 1999

Fattori associati indipendentemente con l’isolamento dei più comuni patogeni

Predictors of pathogens in hospitalized patients

with COPD exacerbations

%

0

10

20

30

40

50

60

70

Mild Moderate Severe

G+cocci H.influenzae/M.catarrhalis GNEB/Pseudomonas spp.

Eller et al., Chest 1998

05

101520253035404550

Fagon et al., 1989AJRCCM

Ewig et al., 1999 CCM

CEP GNEB PDRM others viruses non-PPMs

%

Predictors of pathogens in patients with COPD exacerbations treated in the ICU

Heterogeneity of COPD exacerbations

The cause of an exacerbation can include acute viral bronchitis, environmental pollutants, and allergic responses as well as bacterial infections.

Patients with similar degree of airflow limitation may have different rates of exacerbations, with a minority of the patients presenting with more than two exacerbations per year (frequent exacerbators).

• Le manifestazioni cliniche non permettono di identificare le cause della riacutizzazione, perché virus e atipici sono associati con gli stessi sintomi e grado di risposta infiammatoria.

• Solo la presenza di escreato purulento è stata associata ad elevata carica batterica nelle secrezioni respiratorie durante le riacutizzazioni

Esacerbazioni Sintomi cardinaliTipo I • Tutti:

Aumento dispneaAumento volume escreatoAumento escreato purulento

Tipo II • Due dei sintomi sopra citati

Tipo III • Uno dei sintomi del Tipo I + uno tra i seguenti:

Infezione delle vie respiratorie superiori nei 5 giorni precedentiFebbre senza altre causeIncremento del “wheezing”Incremento della tosseIncremento della frequenza respiratoria o cardiaca Anthonisen 1987

CLASSIFICAZIONE DELLE RIACUTIZZAZIONI DELLA BRONCHITE CRONICA BASATA SUI SINTOMI

Possibile classificazione della severità delle riacutizzazioni di BPCO

Severità Stato di fondo Definizione dellariacutizzazione

Stadio 1 Sempliceipersecrezionemucosa

Tracheobronchite acutain pazienteprecedentemente sano

Stadio 2 BC semplice(2-3 anni di storia ditosse edespettorato per 2-3mesi/anno

Aumento acuto di(a) dispnea(b) volume

dell'espettorato(c) purulenza

dell'espettoratoStadio 3 BC complicata Come nello stasio 2 più

(a) <4 EBC nell'annoprecedente

(b) co-morbilità(c) >10 anni di storia di

BC

Operational Classification of Severity of Exacerbations

• The Operational Classification of Severity is as follows: ambulatory (Level I), requiring hospitalisation (Level II) and acute respiratory failure (Level III).

Level I Level II Level IIIClinical history

Co-morbid conditionsHistory of frequent exacerbationsSeverity of COPD

++

Mild/moderate

++++++

Moderate/severe

++++++

Severe

Physical findingsHaemodynamic evaluationUse accessory respiratory muscles, tachypnoeaPersistent symptoms after initial therapy

StableNot present

No

Stable++++

Stable/unstable++++++

Diagnostic proceduresOxygen saturationArterial blood gasesChest radiographBlood testsSerum drug concentrationsSputum gram stain and cultureElectrocardiogram

YesNoNoNo

If applicableNoNo

YesYesYesYes

If applicableYes Yes

YesYesYesYes

If applicableYesYes

+: unlikely to be present; ++: likely to be present; +++: very likely to be present

ERS-ATS COPD Guidelines

Meta-analyses of typical study demographics showed that there was significant overlap in 95% CI and study data distributions for the three exacerbation severity levels

Franciosi et al, Respir Res 2006; 7:74

Fixed Effect Meta-Analysis Results of Selected Spirometry Variables

P < 0.017 is indicated for statistical comparisons of Level I versus II (*), II versus III (†), and I versus III (#) as well as P < 0.05 for comparison of out- versus in-patient setting (*)

Fixed Effect Meta-Analysis Results of Selected Clinical Variables

P < 0.017 is indicated for statistical comparisons of Level I versus II (*), II versus III (†), and I versus III (#) as well as P < 0.05 for comparison of out- versus in-patient setting (*)

Franciosi et al, Respir Res 2006; 7:74

The current management and treatment of COPD exacerbations is primarily dependent on the evaluation of the symptoms rather than the signs related to the exacerbation event.

Arterial carbon dioxide tension and breathing rate consistently varied with the severity of COPD exacerbations and with in- versus out-patients.

Other commonly-accepted measures and suggested biomarkers for exacerbations failed to show consistent trends or lacked sufficient data to permit any meta-analysis.

PLASMA FIBRINOGEN AT EXACERBATIONWedzicha et al Thrombosis and Hemostasis 2000


3.43.53.63.73.83.9 44.14.24.3

Stable Exacerbation Convalescence

Fib

rin

og

en g

/l

Mean ± SEM

P<0.001 P<0.001

•Increased fibrinogen with colds P = 0.02

•Increased fibrinogen with sputum purulence P = 0.03

•Rise 0.56 g/l during viral Exs

•Rise in 0.27 g/l during non-viral Exs•P = 0.056

N = 120 Exacerbations

Procalcitonin-guided antibiotic therapy in acute exacerbations of COPD: a randomised trial - The ProCOLD Study: D. Stolz, M. Christ-Crain, R. Bingisser, M. Gencay, J. Leuppi, D. Miedinger, C.

Müller, P. Huber, B. Müller, M. Tamm. ERS Copenhagen, 2005

AE-COPD: Procalcitonin

Standard groupProCT guided-group

p-value

Age, male gender (%)

71 y, 48 (53%) 70 y, 48 (53%) ns

Antibiotics at admission (%)

19 (21%) 20 (22%) ns

Anthonisen Typ I (%) 43 (48%) 49 (54%) ns

Positive bacteriology 31/45 (67%) 28/57 (49%) ns

GOLD III + IV % 68% 83% 0.039

FEV1 mean (L) (%)0.99 ± 0.48 (44.9%)

0.85 ± 0.32 (38.4%)

ns

Antibiotic use (%) 62 (68.8%) 35 (38.8%) 0.0001

Antibiotic use (days) 7 ± 5 4 ± 5 0.0001

Patient & Prescriberfactors

Stockley RA, O'Brien C, Pye A, Hill SL. Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. Chest 2000; 117(6):1638-1645.

Evidence in favor: Stockley Prescriber factors

Stockley RA, O'Brien C, Pye A, Hill SL. Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. Chest 2000; 117(6):1638-1645.

Consequence: Stockley dataPrescriber factors

Bronko Test Chart

Cut-off color

Relation ofseverity of COPD and acute exacerbation

COPD

mild

moderate

severe

acute

exacerbation

mild

moderate

severe

Wilkinson TMA et al. Am J Respir Crit Care Med. 2004;169:1298-303

24

6

18

12

00 7 14

Delay between onset and treatment (days)

Sy

mp

tom

re

co

ve

ry t

ime

(da

ys)

0.42 d/d-delay(p<0.001)

COPD exacerbations: Early therapy and recovery

Bacterial Eradication vs Failure Rate

05

101520253035404550

0 20 40 60 80

y= 0.5785x + 5.7679

r=0.91

Clin

ica

l fa

ilure

ra

te (

%)

Eradication failure rate (%)

Pechere JC et al. J Antimicrob Chemo 2000;45:19-24

Criteri per decidere se trattare una riacutizzazione di BPCO a casa o in ospedale. I.

(BTS guidelines 1997)

Trattare acasa

Trattare inospedale

Capacità di far fronte alleesigenze di casa

Si No

Dispnea Lieve Grave

Condizione generale Buona Modesta,in deterioramento

Livello di attività Buono Modesto,confinato a letto

Cianosi No Si

Peggioramento dell’edemaperiferico

No Si

Criteri per decidere se trattare una riacutizzazione di BPCO a casa o in ospedale. II.


Trattare acasa

Trattare inospedale

Livello di coscienza Normale Alterato

In in trattamentocon ossignoterapiaa lungo termine

No Si

Circostanze sociali Buone Vive da solo/incapace di gestirsi

Confusione acuta No Si

Rapida velocità diinsorgenza

No Si

Criteri per decidere se trattare una riacutizzazione di BPCO a casa o in

ospedale. III.Da valutare con l’ausilio ospedaliero


Trattare a casa

Trattare in ospedale

Modifiche nella xgrafia del torace

No Presenti

Livelli del pH arterioso

≥7,35 <7,35

PaO2 arterioso ≥7 kPa <7 kPa

Criteria for hospitalizationATS standards of care 1995ERS / ATS guidelines 2004

ATS 1995 ERS / ATS 2004

severe dyspnea marked increase in dyspnea

worsening hypoxemia / hypercapnia

inability to eat or to sleep due to symptoms

new onset of immobility

significant, potentially unstable comorbidity

presence of high risk comorbid conditions

confusion changes in mental status

inadequate response to outpatient management

uncertain diagnosis

inadequate home care

INDICAZIONI PER L’AMMISSIONE A REPARTI SPECIALIZZATI O DI TERAPIA INTENSIVA

Presenza di gravi disfunzioni respiratorie

Ammissione nel reparto di terapia intensiva

INDICAZIONI PER RICOVERO IN ICU:

insufficienza respiratoria

presenza di altre disfunzioni di end-organ

shock

disturbi renali, epatici o neurologici

instabilità emodinamica

Criteria for ICU admissionATS standards of care 1995ERS / ATS guidelines 2004

ATS 1995 ERS / ATS 2004

severe dyspnea, not improved after 2 h impending or actual respiratory failure

respiratory acidosis (pH < 7.3) despite oxagen supplementation

signs of ventilatory fatigue

confusion presence of other end-organ dysfunction

neurological disturbance

presence of other end-organ dysfunction

hemodynamic instability

Quanto maggiore è la presenza dei succitati indicatori, tanto più

pressante è la necessità di ospedalizzare il paziente

Outcome delle AECB:insuccesso terapeutico

Pazienti ospedalizzati

Pazienti ambulatoriali

Tasso di insuccesso terapeutico

Recidiva (ripetute visite di emergenza)

19-32%

19%

Seneff MG, et al. JAMA. 1995;274:852-1857; Connors et al. Am J Respir Crit Care Med. 1996 Oct;154(4 Pt 1):959-67. Murata GM, et al. Ann Emerg Med. 1991 Feb;20(2):125-9; Adams SG, et al. Chest. 2000;117:1345-1352 indice

Predictors of outcomein outpatients with acute COPD exacerbations

Variables Odds of failure

Home oxygen and one exacerbation 0,311

Home oxygen and two exacerbations 1,008

Home oxygen and three exacerbations 3,274

Home oxygen and four exacerbations 10,627

Home oxygen and five exacerbations 34,707

Odds of failure in relation to home oxygen therapyand number of exacerbations over 24 months

Dewan NA et al., Chest 2000

Predictors of outcomein hospitalized patients with acute COPD exacerbations

1400 admissions from 38 hospitals

14 % died within 3 months

However:

variation between hospitals 0-50%

Predictors of LOS

Age > 65

Low FEV1

Poor performance status

Predictors of death

Poor performance status

Acidosis

Presence of leg edema

Predictors of readmission

Low FEV1

Previous admission

Readmission with > 4 medications Roberts CM et al., Thorax 2002

LOWER LOBE BRONCHIECTASIS AND EXACERBATION RECOVERY

Patel et al AJRCCM 2004

Patients with lower lobe score 0 or 1/8

time to recovery of symptoms = 10

days

Patients with lower lobe score >/=2/8

time to recovery of symptoms = 12

days

p = 0.001

Predictors of outcome (mortality)in hospitalized patients with acute COPD exacerbations

590 patients hospitalized in a university hospitalMortality rate 14,4 %

OR 95% CI p

Age 1,07 1,04 – 1,11 0.0001

PA-aO2 > 41 mm Hg 2,33 1,39 – 3,9 0.001

Ventricular arrhythmias

1,91 1,1 – 3,31 0.0022

Atrial fibrillation 2,27 1,14 – 4,51 0.019

Fuso L et al., Am J Med 1995

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