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.

Application of the Rome severity classification of COPD exacerbations in a real-world cohort of hospitalised patients.

Background: Recently, the Rome classification was proposed in which objective and readily measurable variables were integrated to mark exacerbations of COPD (ECOPD) severity. The aim of this study is to investigate the distribution of a real-world patient population with hospitalised ECOPD according to the current classification across the newly proposed severity classification. We assume that a significant proportion of hospitalised patients will have a mild or moderate event. Methods: The Rome classification was applied to a cohort of 364 COPD patients hospitalised at the Department of Respiratory Medicine of Maastricht University Medical Center (MUMC) with a severe ECOPD. Differences in in-hospital, 30- and 90-day mortality were compared between mild, moderate and severe ECOPD according to the new classification. Moreover, data were stratified by the different severity classes and compared regarding general disease characteristics and clinical parameters. Results: According to the Rome proposal, 52 (14.3%) patients had a mild ECOPD, 204 (56.0%) a moderate and 108 (29.7%) a severe ECOPD. In-hospital mortality in mild, moderate and severe events was 3.8%, 6.9% and 13.9%, respectively. Most clinical parameters indicated a significantly worse condition in patients classified in the severe group, compared to those in mild or moderate groups. Conclusion: Most of the events, traditionally all classified as severe because of the hospitalisation, were classified as moderate, while almost 15% were mild. The results of this study provide insight into the heterogeneity of hospitalised ECOPD and show that the newly proposed Rome criteria can differentiate between events with different short-term mortality rates.

Predictors for long-term mortality in COPD patients requiring non-invasive positive pressure ventilation for the treatment of acute respiratory failure.

INTRODUCTION: The effectiveness of non-invasive mechanical ventilation (NIV) in the management of COPD patients suffering from acute respiratory failure (ARF) as a consequence of exacerbation of the disease, is well established. However, data on long-term outcomes and their predictors, including the individual response to NIV, are scarce. OBJECTIVES: To investigate predictors for short- and long-term mortality in this study population. METHODS: A retrospective cohort study was performed including all patients admitted to the Medium Respiratory Care Unit of Maastricht University Medical Center in Maastricht, the Netherlands, with hospitalized exacerbation of COPD (H-ECOPD) with ARF requiring NIV for the first time between January 2009 and December 2011. An extensive number of potential predictors of outcomes, including the response to NIV, were determined on admission and during hospitalization. Univariate and multivariate logistic regression was used for statistical analysis. RESULTS: Seventy-eight consecutive patients with moderate to severe COPD (mean age 71.0 ± 10.7 years; 48.7% males) were included; In-hospital, 1-year and 2-year mortality rates were 14.1%, 43.6% and 56.4%, respectively. Independent risk factors for 2-year mortality were: advanced age (odds ratio(OR) 1.025; confidence interval (CI) 1.002-1.049; P = 0.037), prolonged NIV use more than 8 days (OR:1.054;CI:1.006-1.104; P = 0.027) and no successful response to NIV (OR:2.392;CI:1.297-4.413; P = 0.005). CONCLUSION: Patients with an H-ECOPD requiring NIV for the first time, constitute a severely ill patient group with high in-hospital and 2-year mortality. This study identified advanced age, NIV use more than 8 days and unsuccessful response to NIV as clinical important independent predictors for long-term mortality.

Mechanical ventilation variability due to tracheal compression in a patient with a mycotic descending aortic aneurysm: an inverse correlation with blood pressure.

Mycotic aortic aneurysms carry significant morbidity and mortality. In the current report, we present a case of a patient with a mycotic descending aortic aneurysm with contained rupture causing variable compression of the trachea, influenced by a variability in blood pressure. In these patients, blood pressure management is paramount as relative hypertensive periods do not only increase the risk of rupture but can also warrant high ventilation pressures or can potentially result in airway occlusion.

Risk stratification for short-term mortality at hospital admission for acute exacerbations of COPD.

BACKGROUND AND OBJECTIVE: Exacerbations of chronic obstructive pulmonary disease (ECOPD) are associated with increased in-hospital and short-term mortality. Developing an easy-to-use model to predict adverse outcomes will be useful in daily clinical practice and will facilitate management decisions. We aimed to assess mortality rates and potential predictors for short-term mortality after severe ECOPD. Classification and Regression Tree (CART) model was used to identify predictors of adverse outcome. METHODS: A retrospective observational cohort study, including all patients admitted to Maastricht University Medical Center with ECOPD between June 2011 and December 2014 was performed. The last admission was taken into account, and its demographic, clinical and biochemical data were recorded. RESULTS: A total of 364 hospitalized patients were enrolled. Mean (SD) age was 70.5 (10.2) years, 54.4% were male and mean FEV1 45.2% (17.7) of predicted. The in-hospital and 90-day mortality were, respectively, 8.5 and 16.2%. Independent risk factors for 90-day mortality were: PaC02 (odds ratio (OR): 1.31; 95% confidence interval (CI): 1.00-0.35), age (OR: 1.09; CI: 0.06-0.11), body mass index (BMI) < 18.5 kg/m2 (OR: 2.72; 95% CI: 0.53-1.47) and previous admission for ECOPD in last 2 years (OR: 1.29; 95% CI: -0.14, -0.65). The CART model selected PaCO2 ≥ 9.1 kPa, age > 80 years, BMI < 18.5 kg/m2 and previous admission for ECOPD as the most discriminatory factors. CONCLUSION: According CART analysis, high PaCO2 and age, low BMI and previous admission for ECOPD in last 2 years were the strongest predictors of 90-day mortality in patients with severe ECOPD. In absence of any of these factors, no patients died, suggesting that this model indeed enables risk stratification.

Surgical treatment of bronchial rupture in blunt chest trauma: a review of literature.

Bronchial rupture by blunt chest trauma is rare. We present a case of bronchial injury after blunt chest trauma that was repaired surgically by primary reconstruction. We performed a review of literature to verify if primary reconstruction is suitable for the treatment of adult patients with blunt bronchial injury. A systematic search was conducted to identify cohort studies of bronchial rupture after blunt chest trauma in adult patients between 1985 and 2016 (n=215 articles). Studies were included concerning four or more patients and in case patient data could be extracted. This resulted in 19 articles for final review, consisting of 155 patients. Mean age of 155 patients was 28 (range, 18-60) years. The main bronchus was mostly injured (81%), in 5% including an injury of the trachea and in 14% lobar bronchi injury. Surgical repair was performed in 95% of patients: primary anastomosis in 72%, pneumonectomy in 15%, lobectomy or sleeve resection in 12% and other in 1%. Perioperative mortality rate was 10%. Other complications occurred in 17% (empyema, rebleeding, stenosis and fistula, among others). Data concerning the occurrence of long-term complications or long-term follow-up was not found. Statistical evaluation could not be performed due to lack of consistent patient data. No strong recommendations regarding type and timing of surgery can be made based on the available literature. Based on our multidisciplinary opinion we would advocate primary anastomosis in case of stable vital signs with the goal to preserve healthy lung parenchyma. Moreover, it may be considered transferring these rare cases to an experienced thoracic and trauma surgery center.

Phrenic neuropathy and diaphragm dysfunction in neuralgic amyotrophy.

OBJECTIVE: To describe the clinical phenotype and recovery of diaphragm dysfunction caused by neuralgic amyotrophy in a large cohort of patients, to improve accurate awareness of this entity, and to encourage adoption of a standardized approach for diagnosis and treatment. METHODS: This observational cohort study recruited adult patients with neuralgic amyotrophy and symptoms of idiopathic phrenic neuropathy from the database of the Dutch expert center for neuralgic amyotrophy and the Dutch centers for home mechanical ventilation. Demographic and clinical information on diagnosis, symptoms, and recovery was obtained from chart review. We attempted to contact all patients for a follow-up interview. RESULTS: Phrenic neuropathy occurs in 7.6% of patients with neuralgic amyotrophy. Unilateral diaphragmatic dysfunction and bilateral diaphragmatic dysfunction are frequently symptomatic, causing exertional dyspnea, orthopnea, disturbed sleep, and excessive fatigue. Diagnostic practices varied widely and were often not optimally targeted. The majority of patients experienced at least moderate recovery within 2 years. CONCLUSION: We recommend screening every patient with neuralgic amyotrophy for diaphragm dysfunction by asking about orthopnea and by performing upright and supine vital capacity screening and diaphragm ultrasound in cases of suspected phrenic neuropathy to optimize diagnosis and care.

Long term survival after admission for COPD exacerbation: A comparison with the general population.

BACKGROUND AND OBJECTIVE: Life expectancy data of COPD patients in comparison to the general population are primarily based upon long-term population cohort studies. These studies are limited by a poor definition of clinically significant COPD. The key element in the course of COPD is a clinical exacerbation. Therefore, this study investigated 15-year survival following hospitalization for an exacerbation of COPD in comparison to the general population. METHODS: A number of 4229 subjects was studied, including 845 hospitalized COPD patients and 3384 age and sex matched controls. Mortality risks were assessed using Kaplan-Meier survival curves, and hazard rate ratios for death were estimated using Cox proportional hazards regression models, for each Gold Class separately. RESULTS: Overall 15-year survival was 7.3% in the COPD group and 40.6% in the general population. Survival was 24%, 11.1%, 5.3% and 0% for COPD GOLD I-IV. The mean life expectancy following hospitalization was 9.7, 7.1, 6.1 and 3.4 years for stage GOLD I-IV and 10.2 years for the general population. Overall, negative prognostic factors were age, male gender, low FEV1, low TLCO, respiratory insufficiency, Charlson comorbidity class, ICU-admission and exacerbation frequency. Factors differed among GOLD stages. CONCLUSIONS: The 15-year survival for hospitalized COPD patients is reduced by 82% in comparison to the general population. This indicates a more deleterious course of clinically significant COPD in comparison to population cohorts. As such, every possible effort should be taken to reduce exacerbations in a personalized way.

Increased Small Intestinal Permeability during Severe Acute Exacerbations of COPD.

BACKGROUND: Disturbances of intestinal integrity, manifested by increased gastro-intestinal (GI) permeability, have been found in chronic obstructive pulmonary disease (COPD) patients during physical activity, often associated with intermittent hypoxic periods. Evidence about extrapulmonary organ disturbances, especially of the GI tract, during hospitalised acute exacerbation of COPD (AE-COPD) with hypoxaemic respiratory failure (RF) is lacking. OBJECTIVE: The aim was to assess changes in GI permeability in patients with AE-COPD and during recovery 4 weeks later. METHODS: All patients admitted to our hospital with AE-COPD accompanied by hypoxaemia at admission (PaO2 <8.7 kPa or O2 saturation <93%) were screened between October 2013 and February 2014. Patients with a history of GI or renal disease, chronic heart failure, or use of non-steroidal anti-inflammatory drugs in the 48 h before the test were excluded. GI permeability was assessed by evaluating urinary excretion ratios of the orally ingested sugars lactulose/L-rhamnose (L/R ratio), sucrose/L-rhamnose (Su/R ratio) and sucralose/erythritol (S/E ratio). RESULTS: Seventeen patients with severe to very severe COPD completed the study. L/R ratio (×103) at admission of AE-COPD was significantly higher than in the recovery condition (40.9 [29.4-49.6] vs. 27.3 [19.5-47.7], p = 0.039), indicating increased small intestinal permeability. There were no significant differences in the individual sugar levels in urine nor in the 0- to 5-h urinary S/E and Su/R ratios between the 2 visits. CONCLUSION: This is the first study showing increased GI permeability during hospitalised AE-COPD accompanied by hypoxaemic RF. Therefore, GI integrity in COPD patients is an attractive target for future research and for the development of interventions to alleviate the consequences of AE-COPD.