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      Prediction of severe exacerbations and mortality in COPD: the role of exacerbation history and inspiratory capacity/total lung capacity ratio

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          Severe exacerbations and mortality are major outcomes in COPD, and risk factors for these events are actively searched for. Several predictors of mortality have been identified in COPD. The inspiratory capacity/total lung capacity (IC/TLC) ratio has been shown to be a strong predictor of all cause and respiratory mortality in patients with COPD. The major objectives of this study were to analyze which clinical parameters, including lung volumes, were the best predictors of the 5-year cumulative risk of hospital admissions or death and the 5-year risk of exacerbations, in stable COPD patients.


          This study retrospectively reviewed data from 98 stable COPD patients, consecutively recruited in 2012. Forced expiratory volume in 1 s (FEV 1), modified Medical Research Council dyspnea scale, exacerbation history (ExH), Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 groups, and lung volumes were reviewed. Five years later, this population was evaluated for cumulative exacerbations, hospital admissions, and mortality. All the population, and GOLD group D separately, were analyzed.


          The cumulative 5-year combined risk of hospital admission or death was significantly predicted by the ExH and the IC/TLC ratio. Analyzing separately group D, FEV 1 was the only predictor of this outcome. The frequency of exacerbations in the previous year was the best predictor of future cumulative 5-year risk of subsequent exacerbations, both for the total population and the GOLD D group.


          ExH and IC/TLC ratio were the best predictors of the most severe outcomes in COPD (admissions or mortality), independently of COPD severity. FEV 1 was the only predictor of the cumulative 5-year combined risk of hospital admission or death in the GOLD D group. ExH was the best predictor of 5-year cumulative future risk of exacerbations. Besides FEV 1 and ExH, the IC/TLC ratio can be a useful predictor of severe outcomes in COPD.

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          Most cited references 13

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          Predictors of mortality in patients with emphysema and severe airflow obstruction.

          Limited data exist describing risk factors for mortality in patients having predominantly emphysema. A total of 609 patients with severe emphysema (ages 40-83 yr; 64.2% male) randomized to the medical therapy arm of the National Emphysema Treatment Trial formed the study group. Cox proportional hazards regression analysis was used to investigate risk factors for all-cause mortality. Risk factors examined included demographics, body mass index, physiologic data, quality of life, dyspnea, oxygen utilization, hemoglobin, smoking history, quantitative emphysema markers on computed tomography, and a modification of a recently described multifunctional index (modified BODE). Overall, high mortality was seen in this cohort (12.7 deaths per 100 person-years; 292 total deaths). In multivariate analyses, increasing age (p=0.001), oxygen utilization (p=0.04), lower total lung capacity % predicted (p=0.05), higher residual volume % predicted (p=0.04), lower maximal cardiopulmonary exercise testing workload (p=0.002), greater proportion of emphysema in the lower lung zone versus the upper lung zone (p=0.005), and lower upper-to-lower-lung perfusion ratio (p=0.007), and modified BODE (p=0.02) were predictive of mortality. FEV1 was a significant predictor of mortality in univariate analysis (p=0.005), but not in multivariate analysis (p=0.21). Although patients with advanced emphysema experience significant mortality, subgroups based on age, oxygen utilization, physiologic measures, exercise capacity, and emphysema distribution identify those at increased risk of death.
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            Impact of exacerbations on COPD.

             A Anzueto (2010)
            Exacerbations of chronic obstructive pulmonary disease (COPD) determine disease-associated morbidity, mortality, resource burden and healthcare costs. Acute exacerbation care requirements range from unscheduled primary care visits to emergency room, inpatient or intensive care, generating significant costs in COPD. Even after an exacerbation resolves, respiratory, physical, social and emotional impairment may persist for prolonged time. Frequent exacerbations, mainly in patients with severe COPD, accelerate disease progression and mortality. Thus, patients with frequent exacerbations have a more rapid decline in lung function, worse quality of life and decreased exercise performance. Management of COPD directed to reduce incidence and severity of exacerbations improves long-term health status and conserves health care resources and costs.
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              The 6-min walk distance, peak oxygen uptake, and mortality in COPD.

              In patients with COPD, the maximal oxygen uptake (Vo2) measured at peak exercise and the 6-min walk distance (6MWD) have been associated with survival; however, no study has compared the strength of the association in the same patients. In this study, we compared the association between the 6MWD and peak Vo2 and mortality in 365 patients with COPD. Patients' cardiopulmonary cycle ergometry test results and 6MWD were determined at entry, and patients were followed up for a mean period of 67 months. There were 171 deaths. Compared with survivors, nonsurvivors were older (mean [+/- SD] age, 67.9 +/- 8 vs 65.9 +/- 8 years, respectively; p = 0.008), had worse mean FEV1 (36.5 +/- 12 vs 42.6 +/- 14 L, respectively; p = 0.02), had lower mean peak Vo2 (9.8 +/- 3 vs 11.8 +/- 3.6 mL/Kg/min, respectively; p < 0.0001), lower mean 6MWD (312 +/- 104 vs 377 +/- 95 m, respectively; p < 0.0001), and lower mean exercise minute ventilation (37.4 +/- 12 vs 42.3 +/- 13 L/min, respectively; p = 0.004). Univariate analysis showed that peak Vo2 and 6MWD as well as comorbidity, FEV1, and body mass index were associated with death. Logistic regression analysis with mortality as the dependent variable revealed that 6MWD (hazard ratio [HR], 0.996; 95% confidence interval [CI], 0.993 to 0.999; p < 0.01) had a stronger association than the peak Vo2 (HR, 0.971; 95% CI, 0.959 to 1.000; p = 0.050) with mortality. This study shows the 6MWD is as good predictor of mortality as the peak Vo2 in patients with COPD.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                05 April 2018
                : 13
                : 1105-1113
                [1 ]Department of Respiratory Medicine, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal
                [2 ]Nova Medical School/ Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
                [3 ]Faculdade de Medicina, Universidade de Lisboa, Portugal
                Author notes
                Correspondence: João Cardoso, Department of Respiratory Medicine, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Rua de Santa Marta, 1169-1024 Lisboa, Portugal, Tel/fax +35 1213594268, Email joaocardoso@
                © 2018 Cardoso et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Respiratory medicine

                ic/tlc ratio, fev1, mortality, admissions, severe outcomes


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