Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients.

Background: Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design. Methods: A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement. Results: Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event. Conclusions: This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

Predictive factors for high-flow nasal cannula failure in acute hypoxemic respiratory failure in an intensive care unit.

BACKGROUND AND OBJECTIVE: High-flow nasal cannula (HFNC), a relatively new technique in acute hypoxemic respiratory failure (AHRF), is gaining popularity in intensive care units (ICUs). Our study aims to identify the predictive factors for failure of HFNC. MATERIALS AND METHODS: This is a 5-year retrospective cohort study in patients with AHRF using HFNC in an ICU of a regional hospital in Hong Kong. The primary outcome is to identify the predictive factors for failure of HFNC which is defined as escalation of treatment to noninvasive ventilation, mechanical ventilation, extracorporeal membrane oxygenation, or death. RESULTS: Of the 124 ICU patients with AHRF, 69 (55.65%) failed in the use of HFNC. The patients failing HFNC had higher Acute physiology and Chronic Health Evaluation IV scores, lower Glasgow Coma Scale scores, lower platelet counts and serum sodium levels upon ICU admission, and higher pH on day of HFNC commencement. They had higher respiratory rates before HFNC and higher heart rates before and 1 h after HFNC. The respiratory rate-oxygenation (ROX) index which is defined as a ratio of SpO2/FiO2 to respiratory rate was significantly lower in the failure group 1 h and 12 h after HFNC. By multivariate binary logistic regression, failure of HFNC is associated with lower ROX index at 12 h after HFNC. CONCLUSION: ROX index at 12 h serves as a valuable tool to monitor the responsiveness to HFNC treatment. Close monitoring is required to identify patient failing using HFNC.

A territory-wide study on the factors associated with recurrent asthma exacerbations requiring hospitalization in Hong Kong.

BACKGROUND: The real-world relationships between the demographic and clinical characteristics of asthma patients, their prehospitalization management and the frequency of hospitalization due to asthma exacerbation is poorly established. OBJECTIVE: To determine the risk factors of recurrent asthma exacerbations requiring hospitalizations and evaluate the standard of baseline asthma care. METHODS: A territory-wide, multicentre retrospective study in Hong Kong was performed. Medical records of patients aged ≥18 years admitted to 11 acute general hospitals from January 1 to December 31, 2016 for asthma exacerbations were reviewed. RESULTS: There were 2280 patients with 3154 admissions (36.7% male, median age 66.0 [interquartile range: 48.0-81.0] years, 519 had ≥2 admissions). Among them, 1830 (80.3%) had at least one asthma-associated comorbidity, 1060 (46.5%) and 885 (38.9%) of patients had Accident and Emergency Department (AED) attendance and hospitalization in the preceding year, respectively. Patients with advancing age (incidence rate ratio [IRR]: 1.003 for every year increment), a history of AED visits or hospitalization (IRR: 1.018 and 1.070 for every additional episode, respectively) for asthma exacerbation in the preceding year, the presence of neuropsychiatric (IRR: 1.142) and gastrointestinal (IRR: 1.154) comorbidities were risk factors for an increasing number of admissions for asthma exacerbation. For patients with ≥2 admissions, 17.1% were not prescribed inhaled corticosteroid and only 44.6% had spirometry checked before the index admission. Asthma phenotyping was often incomplete, as assessment of atopy (total serum immunoglobulin E level and senitization to aeroallergens) was only performed in 30 (5.8%) patients with ≥2 admissions. CONCLUSIONS AND CLINICAL RELEVANCE: Improving asthma care, especially in elderly patients with a prior history of urgent healthcare utilization and comorbidities, may help reduce healthcare burden. Suboptimal management before the index admission was common in patients hospitalized for asthma exacerbations. Early identification of patients at risk and enhancement of baseline asthma management may help to prevent recurrent asthma exacerbation and subsequent hospitalization.

The aquarium in the right heart.

We presented a case with massive hepatic portovenous gas (HPVG) and gastric emphysema, probably due to increased intraluminal pressure in the stomach after bagging and noninvasive ventilation. There are multiple microbubbles in the inferior vena cava, right atrium and right ventricle. There has been only one case report ever published showing the similar features of the "aquarium sign" in the right heart in a patient with intussusception. We believe our case is a good illustration of this extremely rare entity in echocardiography.

Differences in baseline factors and survival between normocapnia, compensated respiratory acidosis and decompensated respiratory acidosis in COPD exacerbation: A pilot study.

BACKGROUND AND OBJECTIVE: Patients with chronic obstructive pulmonary disease (COPD) experiencing acute exacerbation (AE-COPD) with decompensated respiratory acidosis are known to have poor outcomes in terms of recurrent respiratory failure and death. However, the outcomes of AE-COPD patients with compensated respiratory acidosis are not known. METHODS: We performed a 1-year prospective, single-centre, cohort study in patients surviving the index admission for AE-COPD to compare baseline factors between groups with normocapnia, compensated respiratory acidosis and decompensated respiratory acidosis. Survival analysis was done to examine time to readmissions, life-threatening events and death. RESULTS: A total of 250 patients fulfilling the inclusion and exclusion criteria were recruited and 245 patients were analysed. Compared with normocapnia, both compensated and decompensated respiratory acidosis are associated with lower FEV1 % (P < 0.001), higher GOLD stage (P = 0.003, <0.001) and higher BODE index (P = 0.038, 0.001) and a shorter time to life-threatening events (P < 0.001). Comparing compensated and decompensated respiratory acidosis, there was no difference in FEV1 (% predicted) (P = 0.15), GOLD stage (P = 0.091), BODE index (P = 0.158) or time to life-threatening events (P = 0.301). High PaCO2 level (P = 0.002) and previous use of non-invasive ventilation (NIV) in acute setting (P < 0.001) are predictive factors of future life-threatening events by multivariate analysis. CONCLUSIONS: Compared with normocapnia, both compensated and decompensated respiratory acidosis are associated with poorer lung function and higher risk of future life-threatening events. High PaCO2 level and past history of NIV use in acute settings were predictive factors for future life-threatening events. Compensated respiratory acidosis warrants special attention and optimization of medical therapy as it poses risk of life-threatening events.

A pilot randomized study comparing two methods of non-invasive ventilation withdrawal after acute respiratory failure in chronic obstructive pulmonary disease.

BACKGROUND AND OBJECTIVE: Patients with chronic obstructive pulmonary disease (COPD) presenting with acute hypercapnic respiratory failure (AHcRF) benefit from non-invasive ventilation (NIV). The best way to withdraw NIV is not known, and we conducted a pilot study comparing stepwise versus immediate withdrawal of NIV in these patients. METHODS: This was a prospective, single-centre, open-labelled randomized study comparing stepwise versus immediate withdrawal of NIV in patients with COPD exacerbation recovering from AHcRF. The primary end-point was the success rate of NIV withdrawal, defined as no restarting of NIV from randomization to 48 h after complete withdrawal of NIV. RESULTS: Sixty patients were randomized, 35 patients to stepwise withdrawal and 25 patients to immediate withdrawal. The two study arms were clinically comparable. There was no statistically significant difference in the success rate, with NIV successfully stopped in 74.3% and 56% in the stepwise and immediate withdrawal groups, respectively (P = 0.139). CONCLUSIONS: We could not show any benefits for either strategy to withdraw NIV. The study may have been underpowered to detect differences, and larger prospective studies are required.