Predictors of one-year mortality after hospitalization for an exacerbation of COPD.

BACKGROUND: Hospitalization for a severe exacerbation of COPD (eCOPD) is an important event in the natural history of COPD. Identifying factors related to mortality 1 year after hospitalization could help determine interventions to reduce mortality. METHODS: In a prospective, observational, multicentre study, we evaluated data from two cohorts: the Spanish audit of hospital COPD exacerbation care (our derivation sample) and the Spanish cohort of the European audit of COPD exacerbation care (our validation sample). The endpoint was all-cause mortality. Mortality was determined by local research managers of the participating hospitals and matched the official national index records in Spain. RESULTS: In the multivariate analysis, factors independently related to an increase in mortality were older age, cardio-cerebro-vascular and/or dementia comorbidities, PaCO2 > 55 mmHg measured at emergency department arrival, hospitalizations for COPD exacerbations in the previous year, and hospital characteristics. The area under the receiver-operating curve for this model was 0.75 in the derivation cohort and 0.76 in the validation cohort. CONCLUSION: One-year mortality following the index hospitalization for an exacerbation of COPD was related to clinical characteristics of the patient and of the index event, previous events of similar severity, and characteristics of the hospital where the patient was treated.

Multi-level differential network analysis of COPD exacerbations.

Patients with chronic obstructive pulmonary disease (COPD) often suffer episodes of exacerbation (ECOPD) that impact negatively the course of their disease. ECOPD are heterogeneous events of unclear pathobiology and non-specific diagnosis. Network analysis is a novel research approach that can help unravelling complex biological systems. We hypothesised that the comparison of multi-level (i.e., clinical, physiological, biological, imaging and microbiological) correlation networks determined during ECOPD and convalescence can yield novel patho-biologic information.In this proof-of-concept study we included 86 patients hospitalised because of ECOPD in a multicentre study in Spain. Patients were extensively characterised both during the first 72 h of hospitalisation and during clinical stability, at least 3 months after hospital discharge.We found that 1) episodes of ECOPD are characterised by disruption of the network correlation observed during convalescence; and 2) a panel of biomarkers that include increased levels of dyspnoea, circulating neutrophils and C-reactive protein (CRP) has a high predictive value for ECOPD diagnosis (AUC 0.97).We conclude that ECOPD 1) are characterised by disruption of network homeokinesis that exists during convalescence; and 2) can be identified objectively by using a panel of three biomarkers (dyspnoea, circulating neutrophils and CRP levels) frequently determined in clinical practice.

Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit.

Studies report high in-hospital and post-discharge mortality of chronic obstructive pulmonary disease (COPD) exacerbations varying depending upon patient characteristics, hospital resources and treatment standards. This study aimed to investigate the patient, resource and organisational factors associated with in-hospital and 90-day post-discharge mortality and readmission of COPD exacerbations within the European COPD Audit. The audit collected data of COPD exacerbation admissions from 13 European countries.On admission, only 49.7% of COPD patients had spirometry results available and only 81.6% had blood gases taken. Using logistic regression analysis, the risk associated with in-hospital and post-discharge mortality was higher age, presence of acidotic respiratory failure, subsequent need for ventilatory support and presence of comorbidity. In addition, the 90-day risk of COPD readmission was associated with previous admissions. Only the number of respiratory specialists per 1000 beds, a variable related to hospital resources, decreased the risk of post-discharge mortality.The European COPD Audit identifies risk factors associated with in-hospital and post-discharge mortality and COPD readmission. Addressing the deficiencies in acute COPD care such as making spirometry available and measuring blood gases and providing noninvasive ventilation more regularly would provide opportunities to improve COPD outcomes.

Molecular and clinical diseasome of comorbidities in exacerbated COPD patients.

The frequent occurrence of comorbidities in patients with chronic obstructive pulmonary disease (COPD) suggests that they may share pathobiological processes and/or risk factors.To explore these possibilities we compared the clinical diseasome and the molecular diseasome of 5447 COPD patients hospitalised because of an exacerbation of the disease. The clinical diseasome is a network representation of the relationships between diseases, in which diseases are connected if they co-occur more than expected at random; in the molecular diseasome, diseases are linked if they share associated genes or interaction between proteins.The results showed that about half of the disease pairs identified in the clinical diseasome had a biological counterpart in the molecular diseasome, particularly those related to inflammation and vascular tone regulation. Interestingly, the clinical diseasome of these patients appears independent of age, cumulative smoking exposure or severity of airflow limitation.These results support the existence of shared molecular mechanisms among comorbidities in COPD.

Variability of hospital resources for acute care of COPD patients: the European COPD Audit.

Studies have suggested that larger hospitals have better resources and provide better care than smaller ones. This study aimed to explore the relationship between hospital size, resources, organisation of care and adherence to guidelines. The European COPD Audit was designed as a pilot study of clinical care and a survey of resources and organisation of care. Data were entered by clinicians to a multilingual web tool and analysed centrally. Participating hospitals were divided into tertiles on the basis of bed numbers and comparisons made of the resources, organisation of care and adherence to guidelines across the three size groups. 13 national societies provided data on 425 hospitals. The mean number of beds per tertile was 220 (lower), 479 (middle), and 989 (upper). Large hospitals were more likely to have resources and increased numbers of staff; hospital performance measures were related in a minority of indicators only. Adherence to guidelines also varied with hospital size, but the differences were small and inconsistent. There is a wide variation in the size, resources and organisation of care across Europe for hospitals providing chronic obstructive pulmonary disease care. While larger hospitals have more resources, this does not always equate to better accessibility or quality of care for patients.

European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions.

Understanding how European care of chronic obstructive pulmonary disease (COPD) admissions vary against guideline standards provides an opportunity to target appropriate quality improvement interventions. In 2010-2011 an audit of care against the 2010 'Global initiative for chronic Obstructive Lung Disease' (GOLD) standards was performed in 16 018 patients from 384 hospitals in 13 countries. Clinicians prospectively identified consecutive COPD admissions over a period of 8 weeks, recording clinical care measures on a web-based data tool. Data were analysed comparing adherence to 10 key management recommendations. Adherence varied between hospitals and across countries. The lack of available spirometry results and variable use of oxygen and non-invasive ventilation (NIV) are high impact areas identified for improvement.

European COPD Audit: design, organisation of work and methodology.

Clinical audit has an important role as an indicator of the clinical practice in a given community. The European Respiratory Society (ERS) chronic obstructive pulmonary disease (COPD) audit was designed as a pilot study to evaluate clinical practice variability as well as clinical and organisational factors related to outcomes for COPD hospital admissions across Europe. The study was designed as a prospective observational noninterventional cohort trial, in which 422 hospitals from 13 European countries participated. There were two databases: one for hospital's resources and organisation and one for clinical information. The study was comprised of an initial 8-week phase during which all consecutive cases admitted to hospital due to an exacerbation of COPD were identified and information on clinical practice was gathered. During the 90-day second phase, mortality and readmissions were recorded. Patient data were anonymised and encrypted through a multi-lingual web-tool. As there is no pan-European Ethics Committee for audits, all partners accepted the general ethical rules of the ERS and ensured compliance with their own national ethical requirements. This paper describes the methodological issues encountered in organising and delivering a multi-national European audit, highlighting goals, barriers and achievements, and provides valuable information for those interested in developing clinical audits.

Persistent respiratory symptoms in clean-up workers 5 years after the Prestige oil spill.

OBJECTIVES: Fishermen who had participated in clean-up activities of the Prestige oil spill showed an excess risk of respiratory symptoms 1-2 years later, but the long-term persistence of these health effects is unclear. The aim of this study was to evaluate the persistence of these respiratory symptoms 5 years after clean-up work. METHODS: Subgroups of 501 fishermen who had been exposed to clean-up work and 177 non-exposed individuals were re-interviewed by telephone in 2008, including the same symptom questions as in the initial survey. Associations between participation in clean-up work and respiratory symptoms were assessed using log-binomial and multinomial regression analyses adjusting for sex, age and smoking. RESULTS: Information from 466 exposed (93%) and 156 non-exposed (88%) fishermen was obtained. The prevalence of lower respiratory tract symptoms (including wheeze, shortness of breath, cough and phlegm) had slightly decreased in both groups, but remained higher among the exposed (RR 1.4, 95% CI 1.1 to 1.9). The risk of having persistent respiratory symptoms (reported both at baseline and at follow-up) increased with the degree of exposure: RR ratio 1.7 (95% CI 0.9 to 3.1) and 3.3 (95% CI 1.8 to 6.2) for moderately and highly exposed, respectively, when compared with those without any symptoms. Findings for nasal symptoms and for respiratory medication usage were similar. CONCLUSIONS: Participation in clean-up activities of oil spills may result in respiratory symptoms that persist up to 5 years after exposure. Guidelines for preventive measures and a continued surveillance of clean-up workers of oil spills are necessary.

Health changes in fishermen 2 years after clean-up of the Prestige oil spill.

BACKGROUND: In 2002, the oil tanker Prestige spilled more than 67,000 tons of bunker oil, heavily contaminating the coast of northwestern Spain. OBJECTIVE: To assess respiratory effects and chromosomal damage in clean-up workers of the oil spill 2 years after the exposure. DESIGN: Cross-sectional study. SETTING: Fishermen cooperatives in coastal villages. PARTICIPANTS: Local fishermen who were highly exposed (n = 501) or not exposed (n = 177) to oil 2 years after the spill. MEASUREMENTS: Respiratory symptoms; forced spirometry; methacholine challenge; markers of oxidative stress (8-isoprostane), airway inflammation (interleukins, tumor necrosis factor-α, and interferon-γ), and growth factor activity in exhaled breath condensate; and chromosomal lesions and structural alterations in circulating lymphocytes. RESULTS: Compared with nonexposed participants, persons exposed to oil were at increased risk for lower respiratory tract symptoms (risk difference, 8.0 [95% CI, 1.1 to 14.8]). Lung function did not significantly differ between the groups. Among nonsmoking participants, exposed individuals had higher exhaled 8-isoprostane levels than nonexposed individuals (geometric mean ratio, 2.5 [CI, 1.7 to 3.7]), and exposed individuals with lower respiratory tract symptoms had higher 8-isoprostane levels than those of exposed individuals without symptoms. Exposed nonsmoking participants also had higher levels of exhaled vascular endothelial growth factor (risk difference, 44.8 [CI, 27.9 to 61.6]) and basic fibroblast growth factor (risk difference, 16.0 [CI, 3.5 to 28.6]). A higher proportion of exposed participants had structural chromosomal alterations (risk difference, 27.4 [CI, 10.0 to 44.8]), predominantly unbalanced alterations. The risk for elevated levels of exhaled 8-isoprostane, vascular endothelial growth factor, and basic fibroblast growth factor and structural chromosomal alterations seemed to increase with intensity of exposure to clean-up work. LIMITATIONS: The clinical significance of exhaled biomarkers and chromosomal findings are uncertain. The association between oil exposure and the observed changes may not be causal. The findings may not apply to spills involving other types of oil or to different populations of oil spill workers. CONCLUSION: Participation in clean-up of a major oil spill was associated with persistent respiratory symptoms, elevated markers of airway injury in breath condensate, and chromosomal damage.

Memantine in patients with Parkinson's disease dementia or dementia with Lewy bodies: a double-blind, placebo-controlled, multicentre trial.

BACKGROUND: Dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) are common forms of dementia that substantially affect quality of life. Currently, the only treatment licensed for PDD is rivastigmine, and there are no licensed treatments for DLB. We aimed to test the safety and efficacy of the N-methyl D-aspartate (NMDA) receptor antagonist memantine in patients with PDD or DLB. METHODS: We did a parallel-group, 24-week, randomised controlled study of memantine (20 mg per day) versus placebo at four psychiatric and neurological outpatient clinics in Norway, Sweden, and the UK during 2005-08. Patients were included if they fulfilled the UK Parkinson's Disease Society Brain Bank clinical diagnostic criteria for Parkinson's disease (PD) and developed dementia according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM IV) criteria at least 1 year after the onset of motor symptoms (PDD) or met the revised consensus operationalised criteria for DLB. Patients were assigned to a computer-generated randomisation list. All physicians who had contact with patients were masked to treatment allocation. The primary outcome measure was clinical global impression of change (CGIC), which ranged from 1 to 7 points, and a low score means a better outcome. Analysis was by intention to treat based on the last observation carried forward. This trial is registered, number ISRCTN89624516. FINDINGS: 72 patients with PDD or DLB were randomly assigned and started treatment: 34 with memantine and 38 with placebo. 56 (78%) completed the study. All withdrawals were owing to adverse events, but the proportion of withdrawals was similar in both groups. At week 24 the patients in the memantine group had better CGIC scores than those taking placebo (mean difference 0.7, 95% CI 0.04-1.39; p=0.03). With the exception of improved speed on attentional tasks in the memantine group (a quick test of cognition [AQT] form: difference 12.4, 95% CI 6.0-30.9; p=0.004), there were no significant differences between the groups in secondary outcome measures. INTERPRETATION: Patients with DLB or PDD might benefit from treatment with memantine, which was well tolerated. Large-scale studies are now required to confirm our preliminary findings. FUNDING: The Western Norway Regional Health Authority; H Lundbeck A/S.

Loss of the mitochondrial bioenergetic capacity underlies the glucose avidity of carcinomas.

The down-regulation of the catalytic subunit of the mitochondrial H+-ATP synthase (beta-F1-ATPase) is a hallmark of most human carcinomas. This characteristic of the cancer cell provides a proteomic signature of cellular bioenergetics that can predict the prognosis of colon, lung, and breast cancer patients. Here we show that the in vivo tumor glucose uptake of lung carcinomas, as assessed by positron emission tomography in 110 patients using 2-deoxy-2-[18F]fluoro-d-glucose as probe, inversely correlates with the bioenergetic signature determined by immunohistochemical analysis in tumor surgical specimens. Further, we show that inhibition of the activity of oxidative phosphorylation by incubation of cancer cells with oligomycin triggers a rapid increase in their rates of aerobic glycolysis. Moreover, we show that the cellular expression level of the beta-F1-ATPase protein of mitochondrial oxidative phosphorylation inversely correlates (P < 0.001) with the rates of aerobic glycolysis in cancer cells. The results highlight the relevance of the alteration of the bioenergetic function of mitochondria for glucose capture and consumption by aerobic glycolysis in carcinomas.

Accuracy of helical computed tomography and [18F] fluorodeoxyglucose positron emission tomography for identifying lymph node mediastinal metastases in potentially resectable non-small-cell lung cancer.

PURPOSE: Computed tomography (CT) and [18F] Fluorodeoxyglucose positron emission tomography (FDG-PET) are considered suitable methods for the noninvasive staging of the mediastinum. Our study was intended to estimate the efficacy of contrast-enhanced helical CT (hCT) and FDG-PET, alone and combined, in the diagnosis of lymph node mediastinal metastases. METHODS: This study was a prospective and blind comparison of the efficacy of hCT and FDG-PET with two alternative reference standards, mediastinoscopy, and mediastinoscopy plus thoracotomy plus a 6-month follow-up to diagnose lymph node mediastinal metastases in 132 consecutive patients with potentially resectable non-small-cell lung cancer (NSCLC). The metastatic disease was assessed histopathologically. Further clinical information was obtained postoperatively after a median follow-up of 42 months. RESULTS: The prevalence of cN2,3 is 0.28. For hCT the sensitivity and specificity are 0.86 (95% CI, 0.70 to 0.93) and 0.67 (95% CI, 0.56 to 0.75), for PET 0.94 (95% CI, 0.81 to 0.98) and 0.59 (95% CI, 0.49 to 0.68), and for hCT and PET combined in-parallel 0.97 (95% CI, 0.84 to 0.99) and 0.44 (95% CI, 0.34 to 0.53), which translate into a negative predicted probability of 0.98 (95% CI, 0.88 to 1.00). The crude diagnostic odds ratio of PET in the total sample studied is 13.1, in the subgroup hCT+ 11.04 (3.0 to 40 0.1), and in the hCT- 3.5 (0.5 to 21.5). Similar results were obtained for hCT stratified by PET. CONCLUSION: hCT and PET perform similarly in the mediastinal staging of NSCLC, both tests are conditionally dependent and provide complementary information, and their diagnostic value mainly resides on the negative results.

[Bronchioloalveolar carcinoma in Spain: a rare and different form of lung cancer]. / Carcinoma bronquioloalveolar en España. Un cáncer de pulmón infrecuente y diferente.

OBJECTIVE: To describe a series of cases of bronchioloalveolar carcinoma (BAC) treated surgically between 1993 and 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pulmonology and Thoracic Surgery (GCCB-S). PATIENTS AND METHODS: From a total of 2,944 cases of non-small cell lung cancer (NSCLC), 82 (3%) were BAC. The clinical characteristics and prognosis of patients with BAC were compared with those of the remaining 2,862 patients with NSCLC. RESULTS: The percentage of men was lower for BAC than for other types of NSCLC (64.6% compared with 93.5%; P< .001) and BAC was associated with less comorbidity (50% vs 62%; P< .05), particularly in terms of chronic obstructive pulmonary disease (33% vs 47.2%; P< .05). Other characteristics showing significant differences were the higher frequency of BAC as a chance finding and the lower likelihood of weight loss or reduced performance status at the time of diagnosis. Classification as stage cI was significantly more common in patients with BAC (87% vs 75%; P.001), and this difference between groups was more pronounced for stage pI (68.5% vs 47%; P< .01). Only taking into account patients classified as stage pI with complete resection of NSCLC and following exclusion of operative mortality, patients with BAC presented an overall 5-year survival of 65% (95% confidence interval [CI], 51%-79%), compared with a significantly lower survival of 53% (95% CI, 50%-56%; P< .05) in patients with other forms of NSCLC. CONCLUSIONS: In Spain, among cases of lung cancer treated by surgery, BAC is very rare (3%) and displays clinical characteristics that are different from other forms of NSCLC. Controlling for the most basic prognostic factors (stage pI and complete resection), survival is significantly higher for BAC.

Understanding variation in length of hospital stay for COPD exacerbation: European COPD audit.

Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4-11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries.

Persistence of Breakage in Specific Chromosome Bands 6 Years after Acute Exposure to Oil.

BACKGROUND: The identification of breakpoints involved in chromosomal damage could help to detect genes involved in genetic disorders, most notably cancer. Until now, only one published study, carried out by our group, has identified chromosome bands affected by exposure to oil from an oil spill. In that study, which was performed two years after the initial oil exposure in individuals who had participated in clean-up tasks following the wreck of the Prestige, three chromosomal bands (2q21, 3q27, 5q31) were found to be especially prone to breakage. A recent follow-up study, performed on the same individuals, revealed that the genotoxic damage had persisted six years after oil exposure. OBJECTIVES: To determine whether there exist chromosome bands which are especially prone to breakages and to know if there is some correlation with those detected in the previous study. In addition, to investigate if the DNA repair problems detected previously persist in the present study. DESIGN: Follow-up study performed six years after the Prestige oil spill. SETTING: Fishermen cooperatives in coastal villages. PARTICIPANTS: Fishermen highly exposed to oil spill who participated in previous genotoxic study six years after the oil. MEASUREMENTS: Chromosome damage in peripheral lymphocytes. For accurate identification of the breakpoints involved in chromosome damage of circulating lymphocytes, a sequential stain/G-banding technique was employed. To determine the most break-prone chromosome bands, two statistical methods, the Fragile Site Multinomial and the chi-square tests (where the bands were corrected by their length) were used. To compare the chromosome lesions, structural chromosome alterations and gaps/breaks between two groups of individuals we used the GEE test which takes into account a possible within-individual correlation. Dysfunctions in DNA repair mechanisms, expressed as chromosome damage, were assessed in cultures with aphidicolin by the GEE test. RESULTS: Cytogenetic analyses were performed in 47 exposed individuals. A total of 251 breakpoints in exposed individuals) were identified, showing a non-uniform distribution in the human ideogram. Ten chromosome bands were found to be especially prone to breakage through both statistical methods. By comparing these bands with those observed in certain exposed individuals who had already participated the previous study, it was found in both studies that four bands (2q21, 3q27, 5q31 and 17p11.2) are particularly sensitive to breakage. Additionally, the dysfunction in DNA repair mechanisms was not significantly higher in oil-exposed individuals than in non-exposed individuals. LIMITATIONS: The sample size and the possibility of some kind of selection bias should be considered. Genotoxic results cannot be extrapolated to the high number of individuals who participated occasionally in clean-up tasks. CONCLUSION: Our findings show the existence of at least four target bands (2q21, 3q27, 5q31 and 17p11.2) with a greater propensity to break over time after an acute exposure to oil. The breaks in these bands, which are commonly involved in hematological cancer, may explain the increase of cancer risk reported in chronically benzene-exposed individuals. In addition, a more efficiency of the DNA repair mechanisms has been detected six years after in fishermen who were highly exposed to the oil spill. To date, only this study, performed by our group on the previous and present genotoxic effects, has analyzed the chromosomal regions affected by breakage after an acute oil exposure.

Antibiotic Prescription for COPD Exacerbations Admitted to Hospital: European COPD Audit.

OBJECTIVE: Appropriate use of antibiotics in the management of hospitalised patients with COPD exacerbations is defined within the GOLD strategy. This paper analyses the factors associated with antibiotic prescribing in patients to better understand how prescribing may be improved. METHODS: The European COPD audit was a study of clinical care in 384 hospitals from 13 European countries between 2010 and 2011 enrolling 16018 patients. Those admitted to hospital due to a clinician-made diagnosis of exacerbation of COPD at the time of discharge were audited. We defined antibiotic prescribing compliance as consistent with the GOLD 2010 recommendations. Two different multivariate models were used to evaluate factors associated with the prescription of antibiotics and the guideline-compliant prescriptions. RESULTS: Overall 86% of admissions were given antibiotics but only 61.4% cases met the GOLD recommendations. Antibiotics were more likely to be given in hospital and at discharge if received prior to admission. Antibiotic prescription was more likely in patients who met the GOLD recommendations and in those with radiological consolidation but there was also a significant use of antibiotics in patients who did not meet either criterion. Patients cared for on a Respiratory Ward were more likely to receive GOLD compliant antibiotic management. CONCLUSIONS: The present study describes the audited in-hospital antibiotic prescription for COPD exacerbation across different European countries. In general, there is an apparent overuse of antibiotics likely to be associated with both patient and practice-related variables.

The Effect of Incidental Consolidation on Management and Outcomes in COPD Exacerbations: Data from the European COPD Audit.

OBJECTIVE: There is controversy regarding the significance of radiological consolidation in the context of COPD exacerbation (eCOPD). While some studies into eCOPD exclude these cases, consolidation is a common feature of eCOPD admissions in real practice. This study aims to address the question of whether consolidation in eCOPD is a distinct clinical phenotype with implications for management decisions and outcomes. PATIENTS AND METHODS: The European COPD Audit was carried out in 384 hospitals from 13 European countries between 2010 and 2011 to analyze guideline adherence in eCOPD. In this analysis, admissions were split according to the presence or not of consolidation on the admission chest radiograph. Groups were compared in terms of clinical and epidemiological features, existing treatment, clinical care utilized and mortality. RESULTS: 14,111 cases were included comprising 2,714 (19.2%) with consolidation and 11,397 (80.8%) without. The risk of radiographic consolidation increased with age, female gender, cardiovascular diseases, having had two or more admissions in the previous year, and sputum color change. Previous treatment with inhaled steroids was not associated. Patients with radiographic consolidation were significantly more likely to receive antibiotics, oxygen and non-invasive ventilation during the admission and had a lower survival from admission to 90-day follow-up. CONCLUSIONS: Patients admitted for COPD exacerbation who have radiological consolidation have a more severe illness course, are treated more intensively by clinicians and have a poorer prognosis. We recommend that these patients be considered a distinct subset in COPD exacerbation.