Co-morbidities and Hyperinflation Are Independent Risk Factors of All-cause Mortality in Very Severe COPD

Background: COPD is a multi-component disease that is not sufficiently reflected by FEV₁ alone. We studied in patients with very severe COPD, which dimensions of the disease, including co-morbidities, dominate prognosis. Methods: In patients with FEV₁ < 30% predicted, anthropometric, laboratory, spirometric and body plethysmographic data, smoking status, alcohol consumption, the level of dyspnoea and exercise performance were assessed. Co-morbidities were categorized by the Charlson-index and the COPD-specific co-morbidity test (COTE). The prognostic value of multiple dimensions was explored using uni- and multivariate survival analyses regarding death from any or respiratory cause. Results: Among 209 patients included (58/151 female/male; FEV₁ 25.0 (22.0–26.9)%predicted), arterial hypertension (54.1%), hyperlipidemia (38.3%) and diabetes (19.6%) were most common, 57.9% showing a COTE-index of ≥1 point. During follow-up (28 (14–45) months), 121 patients had died, mostly (56.2%) due to respiratory causes. Age, BMI, the ratio of residual volume to total lung capacity (RV/TLC), co-morbidities in terms of the COTE- and Charlson-index, but not FEV₁, were significantly associated with all-cause and respiratory mortality. The association of the median values of the Charlson- (HR 1.911 [95%-CI 1.338–2.730]) and COTE-index (HR 1.852 [95%-CI 1.297–2.644], p < 0.001 each) with mortality was similar and stronger when combined with age. In multivariate analyses, only RV/TLC and co-morbidities were independent risk factors of all-cause mortality (p < 0.05 each). Conclusion: In very severe COPD, resting hyperinflation and co-morbidities provide the major prognostic information, whereas the association of the recently introduced COTE-index with mortality was similar to that of the established Charlson-index and even stronger when including age.     

Factors Discriminating Spontaneous Pursed-Lips Breathing Use in Patients with COPD

ABSTRACT

Pursed-lips breathing (PLB) is often spontaneously performed by chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to evaluate spontaneous PLB prevalence and to identify factors discriminating its use. Fifty-seven patients with COPD (FEV₁ = 44.3 ± 17.4%pred) underwent pulmonary function testing and two incremental bicycle exercise tests. Peak workload (Wpeak), oxygen uptake (VO₂peak), breathing pattern, and dyspnea (Borg scale) were measured in the first exercise test and spontaneous PLB performance in the second. Six patients spontaneously performed pursed-lips breathing during rest (PLBrest), exercise and recovery, 18 during exercise and recovery (PLBex), 7 during recovery only (PLBrec), 20 not at all (PLBno), and 6 performed other expiratory resistive maneuvers. PLBrest and PLBex patients exhibited a lower Wpeak, O₂ uptake, and minute ventilation (V_E), greater expiratory flow limitation and higher slopes relating dyspnea to V_E or W (%predicted). PLBrest patients were more hypercapnic, had a lower exercise tolerance and diffusion capacity, and greater flow limitation and hyperinflation. PLBrec and PLBno patients were indistinguishable with regard to pulmonary function, dyspnea, and exercise performance. The most significant independent predictors of spontaneous PLB use during exercise were FEV₁/FVC and the slope relating dyspnea to V_E. Spontaneous PLB is most often performed by COPD subjects when ventilation is stimulated by exercise, and during recovery from exercise. Severity of airflow obstruction and the dyspnea experienced during exercise play an important role in determining whether or not PLB is spontaneously performed by COPD patients.     

Serial Measurements of Arterial Oxygen Tension are Associated with Mortality in COPD

Background: Knowledge on factors associated with mortality can help identify patients with COPD that might benefit from close monitoring and intervention. Arterial blood gases (ABGs) are related to mortality, but both arterial tension of oxygen (PaO₂) and arterial tension of carbon dioxide (PaCO₂) vary over time. The aim of our study was to investigate the association between repeatedly measured ABGs and mortality in men and women with COPD. Methods: A cohort of 419 Norwegian subjects with COPD, GOLD stage II-IV, aged 40–75, was followed up with up to seven ABGs, measured during stable phase for three years. Cox proportional hazard models were used to quantify the relationship between both single and repeatedly measured ABGs and all-cause mortality after five years, adjusting for age, sex, and the updated BODE index. Results: A total of 64 subjects died during follow-up. Mean initial arterial oxygen tension (standard deviation) was significantly higher in survivors compared to deceased, with PaO₂ (in kPa) 9.4 (1.1) versus 8.8 (1.2), p<0.001. Corresponding numbers for PaCO₂ were 5.3 (0.5) and 5.5 (0.7), p < 0.001. In analyses adjusting for age, sex, and the updated BODE index hazard ratios – HR(95% confidence intervals) - for all-cause mortality were 0.73 (0.55, 0.97) and 1.58 (0.90, 2.76) for repeated measures of PaO₂ and PaCO₂, respectively. Conclusion: Both arterial oxygen and carbon dioxide tension were related to mortality in this study, and arterial oxygen tension added prognostic information to the updated BODE index in COPD.     

Mortality in Patients Admitted for Concurrent COPD Exacerbation and Pneumonia

It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Further, it is unknown how this interaction changes over time. We explored the effect of pneumonia and COPD on inpatient, 30-day and overall mortality. We used a Veterans Health Affairs database to compare patients who were hospitalized for a COPD exacerbation without pneumonia (AECOPD), patients hospitalized for pneumonia without COPD (PNA) and patients hospitalized for pneumonia who had a concurrent diagnosis of COPD (PCOPD). We studied records of 15,065 patients with the following primary discharge diagnoses: (a) AECOPD cohort (7,154 individuals); (b) PNA cohort (4,433 individuals); and (c) PCOPD (3,478 individuals), comparing inpatient, 30-day and overall mortality in the three study cohorts. We observed a stepwise increase in inpatient mortality for AECOPD, PNA and PCOPD (4.8%, 9.5% and 13.2%, respectively). These differences persisted at 30 days post-discharge (AECOPD = 6.7%, PNA = 12.4% and PCOPD = 14.6%; p < 0.0001), but not throughout the study period (median follow-up: 37 months). With time, the death rate rose disproportionally in patients who had been admitted for AECOPD (AECOPD = 64.5%; PNA = 57.4% and PCOPD 66.2%; p < 0.001). In multivariate analysis, PCOPD predicted the greatest inpatient mortality (p < 0.001). The data showed a progression in inpatient and 30-day mortality from AECOPD to PNA to PCOPD. Pneumonia and COPD differentially affected inpatient, 30-day and overall mortality with pneumonia affecting predominantly inpatient and 30-day mortality while COPD affecting the overall mortality.     

Mortality in COPD: Causes,Risk Factors,and Prevention

ABSTRACT

Chronic obstructive pulmonary disease (COPD) is a leading and increasing cause of death, the extent of which is underestimated as a consequence of underdiagnosis and underreporting on death certificates. Data from large trials, such as the Lung Health Study, Towards a Revolution in COPD Health (TORCH), Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT), European Respiratory Society Study on Chronic Obstructive Pulmonary Disease (EUROSCOP), and Inhaled Steroids in Obstructive Lung Disease (ISOLDE), have shown that the causes of death in patients with mild COPD are predominantly cancer and cardiovascular disease, but as COPD severity increases, deaths due to non-malignant respiratory disease are increasingly common. In practice, mortality of patients with COPD can be predicted by a variety of measures including: forced expiratory volume in one second (FEV₁), the ratio of inspiratory and total lung capacities, exercise capacity, dyspnea scores, and composite indices such as the body-mass index (B), degree of airflow obstruction (O), degree of functional dyspnea (D), and exercise capacity (E) (BODE) index. Smoking cessation improves survival in COPD patients, and in select patients with advanced disease, oxygen therapy, lung volume reduction surgery, or lung transplantation may also improve survival.     

Predictors of All-Cause Mortality in Patients with Stable COPD: Medical Co-morbid Conditions or High Depressive Symptoms

Co-morbid conditions are frequently found in patients with COPD. We evaluate the association of co-morbidities with mortality, in stable COPD. 224 patients, mean age 61.2 (±10.00), 48.2% female, mean FEV₁ 1.1 (±0.5) liters, median follow-up time 4.2 years, participated. Medical co-morbidities were scored according to the Charlson Co-morbidity Index (CCI). Depressive symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS) and Symptom Checklist-90 (SCL-90). The Cox proportional hazard model was used for survival analyses. In our sample, 70% of all patients have a co-morbid medical condition or high depressive symptoms. During follow-up 51% of all patients died, and those with heart failure have the highest mortality rate (75%). Age, fat-free mass and exercise capacity were predictive factors, contrary to CCI-scores and high depressive symptoms. An unadjusted association between heart failure and survival was found. Although the presence of co-morbidities, using the CCI-score, is not related to survival, heart failure seems to have a detrimental effect on survival. Higher age and lower exercise capacity or fat-free mass predict mortality.     

Predictors of Mortality in Patients with Stable COPD

OBJECTIVES  To determine which easily available clinical factors are associated with mortality in patients with stable COPD and if health-related quality of life (HRQoL) provides additional information. DESIGN  Five-year prospective cohort study. SETTING  Five outpatient clinics of a teaching hospital. PARTICIPANTS  Six hundred stable COPD patients recruited consecutively. MEASUREMENTS  The variables were age, FEV_1%, dyspnea, previous hospital admissions and emergency department visits for COPD, pack-years of smoking, comorbidities, body mass index, and HRQoL measured by Saint George’s Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Short-Form 36 (SF-36). Logistic and Cox regression models were used to assess the influence of these variables on mortality and survival. RESULTS  FEV_1%(OR: 0.62, 95% CI 0.5 to 0.75), dyspnea (OR 1.92, 95% CI 1.2 to 3), age (OR 2.41, 95% CI 1.6 to 3.6), previous hospitalization due to COPD exacerbations (OR 1.53, 1.2 to 2) and lifetime pack-years (OR 1.15, 95% CI 1.1 to 1.2) were independently related to respiratory mortality. Similarly, these factors were independently related to all-cause mortality with dyspnea having the strongest association (OR 1.54, 95% CI 1.1 to 2.2). HRQoL was an independent predictor of respiratory and all-cause mortality only when dyspnea was excluded from the models, except scores on the SGRQ were associated with all-cause mortality with dyspnea in the model. CONCLUSIONS  Among patients with stable COPD, FEV_1% was the main predictor of respiratory mortality and dyspnea of all-cause mortality. In general, HRQoL was not related to mortality when dyspnea was taken into account, and CRQ and SGRQ behaved in similar ways regarding mortality. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Sources of support: Grant no. 97/0326 from the Fondo de Investigación Sanitaria. Research Committee of Galdakao-Usansolo Hospital.     

高血压伴胸痛患者运动耐量相关因素分析

目的探讨高血压伴胸痛患者平板运动试验运动耐量的影响因素。方法纳入因胸痛行平板运动试验检查的高血压患者136例,进行症状限制性平板运动试验,将所达到的运动耐量与按年龄预测的最大运动耐量进行比较,分为两组:Ⅰ组(实际运动耐量≥预测运动耐量)、Ⅱ组(实际运动耐量预测运动耐量);比较两组患者年龄、性别、体质指数(BMI)、血脂、空腹血糖(FPG)、空腹胰岛素(FINS)、胰岛素抵抗指数(HOMA-IR)等指标,采用多元线性回归分析影响运动耐量的影响因素。结果Ⅱ组患者静息心率、BMI、FINS、HOMA-IR显著高于Ⅰ组患者,分别为[(78.3±5.4)次/min vs.(72.1±6.0)次/min,P0.001],[(26.4±2.8)kg/m2 vs.(24.1±2.6)kg/m2,P0.001],[(12.9±4.8)μIU/ml vs.(8.6±2.6)μIU/ml,P0.001],[(3.82±1.66)vs.(2.21±1.23),P0.001]。多元线性逐步回归分析显示,性别(女性)、年龄、静息心率、胰岛素抵抗指数与运动耐量呈负相关(标准回归系数β分别为:-0.547,-0.396,-0.336,-0.438;P均0.05)。结论高血压伴胸痛患者女性、年龄增长、静息心率增快及胰岛素抵抗指数增加是其运动耐量减低的重要影响因素。     

Rate of Change in Renal Function and Mortality in Elderly Treated Hypertensive Patients

Background and objectives

Evidence relating the rate of change in renal function, measured as eGFR, after antihypertensive treatment in elderly patients to clinical outcome is sparse. This study characterized the rate of change in eGFR after commencement of antihypertensive treatment in an elderly population, the factors associated with eGFR rate change, and the rate’s association with all-cause and cardiovascular mortality.

Design, setting, participants, & measurements

Data from the Second Australian National Blood Pressure study were used, where 6083 hypertensive participants aged ≥65 years were enrolled during 1995–1997 and followed for a median of 4.1 years (in-trial). Following the Second Australian National Blood Pressure study, participants were followed-up for a further median 6.9 years (post-trial). The annual rate of change in the eGFR was calculated in 4940 participants using creatinine measurements during the in-trial period and classified into quintiles (Q) on the basis of the following eGFR changes: rapid decline (Q1), decline (Q2), stable (Q3), increase (Q4), and rapid increase (Q5).

Results

A rapid decline in eGFR in comparison with those with stable eGFRs during the in-trial period was associated with older age, living in a rural area, wider pulse pressure at baseline, receiving diuretic-based therapy, taking multiple antihypertensive drugs, and having blood pressure <140/90 mmHg during the study. However, a rapid increase in eGFR was observed in younger women and those with a higher cholesterol level. After adjustment for baseline and in-trial covariates, Cox-proportional hazard models showed a significantly greater risk for both all-cause (hazard ratio, 1.28; 95% confidence interval, 1.09 to 1.52; P=0.003) and cardiovascular (hazard ratio, 1.40; 95% confidence interval, 1.11 to 1.76; P=0.004) mortality in the rapid decline group compared with the stable group over a median of 7.2 years after the last eGFR measure. No significant association with mortality was observed for a rapid increase in eGFR.

Conclusions

In elderly persons with treated hypertension, a rapid decline in eGFR is associated with a higher risk of mortality.     

Validation of the i-BODE Index as a Predictor of hospitalization and Mortality in Patients with COPD Participating in Pulmonary Rehabilitation

The aim of this study was to examine the value of the i-BODE index to predict hospital admission and to confirm its usefulness to predict mortality in a Danish population. The incremental shuttle walking test (ISWT) is widely used in the UK and Europe and previous work has examined the replacement of the 6MWT with the ISWT within the BODE index for predicting the prognosis of COPD (i-BODE). The 674 patients included in the analysis participated in a 7-week pulmonary rehabilitation program from 2002 to 2011. The National Health Services Central Register ascertained vital status and provided information on all hospital admissions. The mean follow-up period was 66 months (range 11–118 months). Cox proportional hazards model was used to identify factors that significantly predicted mortality and time to first hospital admission.

The i-BODE index as well as body mass index, MRC dyspnea grade, and exercise capacity (ISWT) were significantly associated with all-cause mortality. The adjusted hazard ratio for death per one point increase in the i-BODE score was 1.28 (95% confidence interval 1.20 to 1.37). The i-BODE index was also a significant predictor of hospitalization, both for all causes and COPD exacerbation. Patients in the highest i-BODE quartile had a median time to first hospitalization of 17 months compared to 51 months for patients in the lowest quartile. The i-BODE index is a significant predictor of hospital admission and thus health care utilization, and also mortality.     

Risk Factors and Mortality in Patients with Cancer and Hemorrhage from Stress Ulcer

Hemorrhagic gastritis is the most frequent cause of upper gastrointestinal bleeding in patients with cancer. A study was undertaken to evaluate the clinical course of 87 patients, in a cancer hospital setting, with hemorrhagic gastritis associated with stress, exogenous gastric irritants and the combination of the two. The average number of blood transfusions was four times higher and the average duration of bleeding was twice as long in stress patients as in patients without stress. Fifty-four per cent of stress patients died, whereas all patients survived in the group without stress. Although there were no statistically significant differences, patients with the combination of gastric irritants and stress tended to bleed longer and have a higher mortality than patients with stress alone. Over two-thirds of the deaths were ascribed to associated stress risk factors such as sepsis, multiple organ failure and advanced cancer and not to gastrointestinal hemorrhage.     

Explained variance for blood gases in a population with COPD

Introduction: Variation of blood gas levels in chronic obstructive pulmonary disease (COPD) patients has not been extensively reported and there is limited knowledge about predictors of chronic respiratory failure in COPD patients. Objectives: The aim of this study was to identify predictors of hypoxemia, hypercapnia and increased alveolar‐arterial oxygen difference in COPD patients. We hypothesized that prediction of arterial blood gases will be improved in multivariate models including measurements of lung function, anthropometry and systemic inflammation. Methods: A cross‐sectional sample of 382 Norwegian COPD patients, age 40–76, Global Initiative for Chronic Obstructive Lung Disease stage II–IV, with a smoking history of at least 10 pack‐years, underwent extensive measurements, including medical examination, arterial blood gases, systemic inflammatory markers, spirometry, plethysmography, respiratory impedance and bioelectrical impedance. Possible predictors of arterial oxygen (PaO₂), arterial carbon dioxide (PaCO₂) and alveolar‐arterial oxygen difference (AaO₂) were analyzed with both bivariate and multiple regression methods. Results: We found that various lung function measurements were significantly associated with PaO2, PaCO₂ and AaO₂. In addition, heart rate and Fat Mass Index were predictors of PaO₂ and AaO₂, while heart failure and current smoking status were associated with PaCO₂. The explained variance (R²) in the final multivariate regression models was 0.14–0.20. Conclusions: With a wide assortment of possible clinical predictors, we could explain 14–20% of the variation in blood gas measurements in COPD patients. Please cite this paper as: Saure EW, Eagan TML, Jensen RL, Voll‐Aanerud M, Aukrust P, Bakke PS and Hardie JA. Explained variance for blood gases in a population with COPD. Clin Respir J 2012; 6: 72–80.     

Computerized Respiratory Sounds in Patients with COPD: A Systematic Review

Computerized respiratory sound analysis provides objective information about the respiratory system and may be useful to monitor patients with chronic obstructive pulmonary disease (COPD) and detect exacerbations early. For these purposes, a thorough understanding of the typical computerized respiratory sounds in patients with COPD during stable periods is essential. This review aimed to systematize the existing evidence on computerized respiratory sounds in stable COPD. A literature search in the Medline, EBSCO, Web of Knowledge and Scopus databases was performed. Seven original articles were included. The maximum frequencies of normal inspiratory sounds at the posterior chest were between 113 and 130Hz, lower than the frequency found at trachea (228 Hz). During inspiration, the frequency of normal respiratory sounds was found to be higher than expiration (130 vs. 100Hz). Crackles were predominantly inspiratory (2.9–5 vs. expiratory 0.73–2) and characterized by long durations of the variables initial deflection width (1.88–2.1 ms) and two cycle duration (7.7–11.6 ms). Expiratory wheeze rate was higher than inspiratory rate. In patients with COPD normal respiratory sounds seem to follow the pattern observed in healthy people and adventitious respiratory sounds are mainly characterized by inspiratory and coarse crackles and expiratory wheezes. Further research with larger samples and following the Computerized Respiratory Sound Analysis (CORSA) guidelines are needed.     

急性呼吸窘迫综合征病死危险因素分析

目的 :探讨急性呼吸窘迫综合征 (ARDS)病死率居高不下因素。方法 :收集 1年 8个月中因ARDS收入ICU所有患者的临床资料 (原发病或诱发因素、APACHEⅡ评分、严重程度、机械通气治疗和PEEP水平、糖皮质激素 ) ,分析各种特定危险因素与病死率之间关系 ,χ2 检验差异显著性。结果 :4 4例中 ,年龄 5～ 84岁 (5 4 .5± 2 1.5 )岁 ;肺内组病死率 93.3% (14 /15例 ) ,肺外组 4 4 .8% (13/2 9例 ) ,肺内组高于肺外组 (P <0 .0 1) ;APACHEⅡ评分≤ 2 0分组病死率低于≥ 31分组 (P <0 .0 5 ) ;以PaO2 /FiO2 和 Qs/ QT判断严重程度 ,对预后无显著影响 (P >0 .0 5 ) ;PEEP水平 6～ 10cmH2 O组病死率低于≥ 11cmH2 O组 (P <0 .0 5 ) ;机械通气治疗组病死率明显低于未接受机械通气治疗组 ,P <0 .0 5 ;34例接受不同类型激素治疗病死率 (70 .6 % )高于未接受激素治疗组 (30 .0 % ) ,差异显著 (P <0 .0 1) ,应用时间与剂量间无显著差异 (P >0 .0 5 ) ;直接死亡原因为ARDS未得到纠正者仅占 11.1% (3/2 7例 ) ,明显低于感染性休克和MODS(P <0 .0 1)。结论 :在及时应用机械通气治疗前提下 ,肺内疾病和APACHEⅡ评分≥ 31可能是预报ARDS病死率高的指标。     

老年脑卒中患者活动情况影响因素分析

目的 探讨老年脑卒中患者活动不足和久坐行为的状况，并分析活动不足的影响因素。方法 选取2022年1月～2022年10月某三甲医院302名老年脑卒中患者，采用一般资料与疾病状况调查、国际体力活动问卷、国际跌倒效能感量表、简版老年抑郁量表、起立-行走测试对患者进行调查。根据患者是否活动不足，将患者分为2组，对比2组各指标差异。采用SPSS26.0软件进行数据分析,采用二元Logistic回归分析活动不足的独立影响因素。结果 302名老年脑卒中患者中，115例（38.1%）活动不足，225例（74.5%）有久坐行为，124例（41.10%）有跌倒恐惧，55例（18.21%）有抑郁情绪，212例（70.20%）活动能力减退。Logistic分析显示，有跌倒恐惧（OR=4.66）、久坐行为（OR=4.03）、下肢感觉异常（OR=2.23）、抑郁情绪（OR=2.21）是老年脑卒中患者活动不足的独立风险因素。结论 老年脑卒中患者普遍存在活动不足和久坐行为。在改善患者活动不足问题时，不仅要关注患者的躯体功能问题，改善患者下肢肌力，减少久坐时间，以间断轻度活动代替久坐，也要关注患者心理问题，制定多维度干预方案，改善患者活动情况，从而实现更有效的康复。     

运动训练对慢性阻塞性肺疾病缓解期患者的影响

目的分析运动训练对缓解期慢性阻塞性肺疾病患者运动耐力、呼吸功能和生活质量的影响。方法对45例临床缓解期的慢性阻塞性肺疾病患者进行系统的步行训练和呼吸体操训练治疗,并在训练前、后分别测量6分钟步行距离、Borg呼吸困难评分及圣·乔治医院呼吸问题调查问卷评分等指标。结果经过系统运动训练的缓解期慢性阻塞性肺疾病患者,运动耐力和生活质量好于未经过系统呼吸训练的COPD患者。结论系统的运动训练能够提高缓解期慢性阻塞性肺疾病患者运动耐力和健康相关生活质量。