Slide 1

Slide 2 CLINICAL PRESENTATION AND PREDICTORS OF OUTCOME IN PATIENTS WITH SEVERE ACUTE EXACERBATION OF COPD REQUIRING ADMISSION TO ICU By Mohan et al Slide 3 Slide 4 BACKGROUND COPD is a common, costly preventable disease and is the 4 th leading cause of death globally Acute exacerbation of COPD(AE-COPD) is a common cause of ER visit Major cause of morbidity and mortality with more than half of these patients requiring re-admission in subsequent 6 months Great variability in clinical course making predictions of outcome in a given patient difficult The study was designed to prospectively study the clinical presentation and predictors of outcome in patients with AE-COPD requiring admission to ICU Slide 5 METHODS During period from June 2000 and December 2004, 914 patients diagnosed with COPD in MOPD and Chest Clinic at a Tertiary Hospital 314 of these later on presented to ER with AE-COPD After appropriate initial treatment, 116 admitted to Medical ICU, 18 discharged, 180 admitted to Acute Medical Unit and Medical Ward Basis of study is on the 116 admitted to ICU Patients with bronchiectasis, interstitial lung disease,PE, Pulmonary Oedema excluded Study was approved by Ethical Committee Slide 6 COPD diagnosed on basis of Pulmonary Function tests during MOPD visits AE-COPD diagnosed if all following present: rapid worsening dyspnoea, increase in sputum volume and purulence Only single enrolement per patient regardless of frequency of exacerbations On arrival full Hx including type of smoking habit cigarette or bidi and pack years, domestic fuel use and examination Baseline investigations including imaging Slide 7 O2 given as appropriate nasal prongs, face mask or Ventura devices Nebs of Salbutamol/Ipratropium every 15 min to 8 hourly, steroids if no improvement iv aminophylline. Empiric antibiotics given could be changed on sensitivities No standard criterion for Invasive Ventilation In study indications include, failure to respond to pharmacologic and other non-ventilatory Rx, severe dyspnoea, severe acidosis (pH 60mmHg), life threating hypoxaemia, respiratory arrest, somnolence, impaired mental status and co-morbid illness Slide 8 STATISTICAL ANALYSIS Variables following normal distribution were summarised by mean and standard deviation Association between two categorical variables was by 2 or Fishers exact test as appropriate Student t test used for quantitative variables Quantitative variables categorised and if it showed statistically significant association with outcome at p < 0.20 considered for inclusion Stepwise multivariate logistic regression performed with potential candidate variables as co-variates SYSTAT Version 7.0 used. All stat tests performed were two tailed, p Table 2 Clinical presentation in 116 patients with acute exacerbation of chronic obstructive pulmonary disease admitted to the medical intensive care unit JVP = jugular venous pulse Mohan et al. BMC Pulmonary Medicine 2006 6:27 doi:10.1186/1471-2466-6-27 Variable% Symptoms Cough100 Increased sputum volume100 Increased sputum purulence100 Recent rapid worsening of dyspnea100 Accessory muscle use60.3 Inability to complete a full sentence while talking60.3 Pedal edema19.8 Fever29.3 Altered sensorium12.9 Upper respiratory infection8.6 Gastroesophageal reflux7.8 Signs Wheezing100 Respiratory rate > 24/min94 Crepitations56 Cyanosis33.6 Heart rate > 100/min25 Elevated JVP12.9 Systolic BP < 90 mm Hg3.4 Slide 12 Table 3 Laboratory abnormalities in 116 patients with acute exacerbation of chronic obstructive pulmonary disease admitted to the medical intensive care unit ESR = erythrocyte sedimentation rate Mohan et al. BMC Pulmonary Medicine 2006 6:27 doi:10.1186/1471-2466-6-27 Variable% Polycythemia (PCV >54% in men, >49% in women)32.8 Leukocytosis [(>12 103/mm3), (>12 109/l)]64.7 Neutrophilia [(> 70%), (> 0.7)]77.6 Elevated ESR (>20 mm at the end of the first hour)64.7 Hypoalbuminemia [(< 3.5 g/dl), (< 35 g/dl)]19.0 Hyponatremia [serum sodium < 120 meq/l, (< 120 mmol/l)]16.4 Hypokalemia [serum potassium < 3.5 meq/l, (< 3.5 mmol/l)]16.4 Hyperbilirubinemia [(>1.2 mg/dl), (> 20.5 mol/l)]6.0 Elevated transaminases [>50 IU/l]22.4 Elevated blood urea [(>50 mg/dl), (>17.9 mmol/l)]45.7 Elevated serum creatinine [(>1.5 mg/dl), (> 132.6 mol/l)]19.0 Slide 13 Table 4 Predictors of outcome in 116 patients with severe acute exacerbation of chronic obstructive pulmonary disease requiring admission to the intensive care unit: univariate sensitivity analysis Mohan et al. BMC Pulmonary Medicine 2006 6:27 doi:10.1186/1471-2466-6-27 Variable2p-value Presence of co-morbid illness1.6730.0196 Altered consciousness3.6500.0560 Presence of tachycardia9.6050.0020 Peripheral edema1.9000.1680 Hypoalbuminemia4.3000.0380 Elevated transaminases4.2000.0350 Acidosis10.2570.0010 Arterial hypoxemia4.9990.0250 Hypercapnia2.1890.1390 Presence of new infiltrates on the chest radiograph5.2400.0170 Need for invasive ventilation16.1780.0001 Slide 14 Table 5 Predictors of death in 116 patients with severe acute exacerbation of chronic obstructive pulmonary disease requiring admission to the intensive care unit: stepwise multivariate logistic regression analysis Mohan et al. BMC Pulmonary Medicine 2006 6:27 doi:10.1186/1471-2466-6-27 VariableOdds ratio95% Confidence intervalsp-value Need for invasive ventilation45.809607.46 to 3.009p < 0.001 Presence of co-morbid illness0.1260.428 to 0.037p < 0.01 Hypercapnia0.1141.324 to 0.010p < 0.05 Slide 15 Slide 16 DISCUSSION Not much info on burden of AE-COPD in ER, its presentation and outcome Significant number of patients (n=53; 45.7%) had co-morbid conditions, and this was a predictor of death Accurate assessment of co-morbid conditions and institution of specific treatments should help to reduce morbidity and mortality Past PTB important cause of COPD and also of AE-COPD (p