Treatment strategies after acute exacerbations of chronic obstructive pulmonary disease: Impact on mortality

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Abstract

Introduction

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common reason for presentation to emergency departments (ED), but the management of these episodes is often heterogeneous regardless of their potential impact on short-term adverse outcomes.

Methods

This was a longitudinal, retrospective study of all patients >40 years old admitted to the ED of two Spanish teaching hospitals for an AECOPD between January 1 ^st and May 31 ^st, 2016. All data were collected from electronic medical records. The primary outcomes were patient treatment at discharge and 90-day mortality. Logistic regression was used to model the determinants of 90-day mortality.

Results

Of the 465 included patients, 56% were prescribed a 3-drug combination at hospital discharge, 22% a 2-drug combination, 19% a single drug, and 4% other or no treatment. Approximately 8% of patients died within 90 days after an AECOPD. Multivariate logistic models revealed that having more than 2 severe exacerbations within the last 12 months (OR (95% CI): 15.12 (4.22–54.22)) and being prescribed a single drug at discharge (OR (95% CI): 7.23 (2.44–21.38)) were the main determinants of 90-day mortality after an AECOPD.

Conclusions

This study reflects the real-life heterogeneity in the pharmacological treatments prescribed after an ED admission for an AECOPD and suggests the potential impact of suboptimal inhaled treatment strategies on 90-day mortality rates.

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Most cited references 17

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Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.

W MacNee, , B Celli (2004)

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Tiotropium versus salmeterol for the prevention of exacerbations of COPD.

Claus Vogelmeier, Bettina M Hederer, Thomas Glaab … (2011)

Treatment guidelines recommend the use of inhaled long-acting bronchodilators to alleviate symptoms and reduce the risk of exacerbations in patients with moderate-to-very-severe chronic obstructive pulmonary disease (COPD) but do not specify whether a long-acting anticholinergic drug or a β(2)-agonist is the preferred agent. We investigated whether the anticholinergic drug tiotropium is superior to the β(2)-agonist salmeterol in preventing exacerbations of COPD. In a 1-year, randomized, double-blind, double-dummy, parallel-group trial, we compared the effect of treatment with 18 μg of tiotropium once daily with that of 50 μg of salmeterol twice daily on the incidence of moderate or severe exacerbations in patients with moderate-to-very-severe COPD and a history of exacerbations in the preceding year. A total of 7376 patients were randomly assigned to and treated with tiotropium (3707 patients) or salmeterol (3669 patients). Tiotropium, as compared with salmeterol, increased the time to the first exacerbation (187 days vs. 145 days), with a 17% reduction in risk (hazard ratio, 0.83; 95% confidence interval [CI], 0.77 to 0.90; P<0.001). Tiotropium also increased the time to the first severe exacerbation (hazard ratio, 0.72; 95% CI, 0.61 to 0.85; P<0.001), reduced the annual number of moderate or severe exacerbations (0.64 vs. 0.72; rate ratio, 0.89; 95% CI, 0.83 to 0.96; P=0.002), and reduced the annual number of severe exacerbations (0.09 vs. 0.13; rate ratio, 0.73; 95% CI, 0.66 to 0.82; P<0.001). Overall, the incidence of serious adverse events and of adverse events leading to the discontinuation of treatment was similar in the two study groups. There were 64 deaths (1.7%) in the tiotropium group and 78 (2.1%) in the salmeterol group. These results show that, in patients with moderate-to-very-severe COPD, tiotropium is more effective than salmeterol in preventing exacerbations. (Funded by Boehringer Ingelheim and Pfizer; ClinicalTrials.gov number, NCT00563381.).

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Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease.

Aran Singanayagam, Stuart Schembri, James Chalmers (2013)

There is a need to identify clinically meaningful predictors of mortality following hospitalized COPD exacerbation. The aim of this study was to systematically review the literature to identify clinically important factors that predict mortality after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD). Eligible studies considered adults admitted to hospital with COPD exacerbation. Two authors independently abstracted data. Odds ratios were then calculated by comparing the prevalence of each predictor in survivors versus nonsurvivors. For continuous variables, mean differences were pooled by the inverse of their variance, using a random effects model. There were 37 studies included (189,772 study subjects) with risk of death ranging from 3.6% for studies considering short-term mortality, 31.0% for long-term mortality (up to 2 yr after hospitalization), and 29.0% for studies that considered solely intensive care unit (ICU)-admitted study subjects. Twelve prognostic factors (age, male sex, low body mass index, cardiac failure, chronic renal failure, confusion, long-term oxygen therapy, lower limb edema, Global Initiative for Chronic Lung Disease criteria stage 4, cor pulmonale, acidemia, and elevated plasma troponin level) were significantly associated with increased short-term mortality. Nine prognostic factors (age, low body mass index, cardiac failure, diabetes mellitus, ischemic heart disease, malignancy, FEV1, long-term oxygen therapy, and PaO2 on admission) were significantly associated with long-term mortality. Three factors (age, low Glasgow Coma Scale score, and pH) were significantly associated with increased risk of mortality in ICU-admitted study subjects. Different factors correlate with mortality from COPD exacerbation in the short term, long term, and after ICU admission. These parameters may be useful to develop tools for prediction of outcome in clinical practice.

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Author and article information

Contributors

Fernando Casas-Mendez: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Maria Jose Abadías: Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – review & editing

Oriol Yuguero: Role: ConceptualizationRole: Data curationRole: InvestigationRole: Project administrationRole: ValidationRole: Writing – review & editing

Ignasi Bardés: Role: ConceptualizationRole: InvestigationRole: Writing – review & editing

Ferran Barbé: Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: SupervisionRole: ValidationRole: Writing – review & editing

Jordi de Batlle:

ORCID: http://orcid.org/0000-0003-3500-6608

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Manlio Milanese: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 14 December 2018

Publication date Collection: 2018

Volume: 13

Issue: 12

Electronic Location Identifier: e0208847

Affiliations

[1 ] Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova de Lleida,IRBLleida, Universitat de Lleida, Lleida, Catalonia, Spain

[2 ] Emergency Department, Hospital Universitari Arnau de Vilanova de Lleida, Catalonia, Spain

[3 ] Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Catalonia, Spain

[4 ] Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain

Ospedale S. Corona, ITALY

Author notes

Competing Interests: The authors declare having received funds for the realization of the current project from ALLER, Menarini Spain and GSK Spain. The funders' did not have any role in the study design; collection, analysis, and interpretation of data; writing of the paper; and/or decision to submit for publication. Therefore, this does not alter our adherence to PLOS ONE policies on sharing data and materials. No other competing interests exist.

* E-mail: jordidebatlle@ 123456gmail.com

Author information

Jordi de Batlle http://orcid.org/0000-0003-3500-6608

Article

Publisher ID: PONE-D-18-21124

DOI: 10.1371/journal.pone.0208847

PMC ID: 6294427

PubMed ID: 30550602

SO-VID: 699e71e0-20de-4c22-a4bd-1c6ab273a967

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 17 July 2018

Date accepted : 24 November 2018

Page count

Figures: 0, Tables: 4, Pages: 11

Funding

Funded by: GSK Spain

Funded by: Menarini Spain

Funded by: ALLER

Funded by: funder-id http://dx.doi.org/10.13039/501100010552, Departament de Salut, Generalitat de Catalunya;

Award ID: PERIS 2016: SLT002/16/00364

Award Recipient :

ORCID: http://orcid.org/0000-0003-3500-6608

Jordi de Batlle

This research was supported by ALLER, Menarini Spain and GSK Spain. Jordi de Batlle acknowledges a research contract from Departament de Salut [PERIS 2016: SLT002/16/00364]. The funders had no role in the design, execution, analyses, interpretation of the data, or decision to submit results.

Custom metadata

Data Availability Due to the ethical constraints on the sensitive nature of the analyzed data, imposed by the ethics committee of Hospital Arnau de Vilanova, only excerpts of data will be available on request. Any request should be addressed to the corresponding author Dr Jordi de Batlle or to the abovementioned ethics committee ( cea_arnau.lleida.ics@ 123456gencat.cat ).

Treatment strategies after acute exacerbations of chronic obstructive pulmonary disease: Impact on mortality

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Abstract

Introduction

Methods

Results

Conclusions

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PLOS Climate

Most cited references 17

Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.

Tiotropium versus salmeterol for the prevention of exacerbations of COPD.

Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease.

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