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      COPD exacerbations admitted to intensive care unit. Organization, mortality, and noninvasive or invasive mechanical ventilation strategies: are they sufficiently well known?

      International Journal of Chronic Obstructive Pulmonary Disease

      Dove Medical Press

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          Abstract

          Dear editor We read with interest the survival analysis of chronic obstructive pulmonary disease (COPD) patients who are admitted to critical care units with exacerbation, conducted in Saudi Arabia by Alaithan et al.1 This study makes an important contribution on the real practice of intensive care units (ICUs). The authors, in the overall results, provided some great information similar in some aspects to previous epidemiologic surveys where a low level of consciousness on admission, need for endotracheal intubation (ETI), being a current smoker, cardiopulmonary arrest, tracheostomy, and development of acute renal failure are associated with higher ICU and hospital mortality. Although, study design showed some limitations with respect to interpretation predictors of mortality, there are aspects that differ compared to previous studies in this area that could be taken into account for clinical and practical implications. First, there are no references regarding protocols of noninvasive mechanical (NIV) or invasive mechanical ventilation (IMV) implementation to ICU admissions, for example, where and how these mechanical ventilation options were performed at first line in the emergency departments. Additionally, there were not clearly defined criteria of applications, places or severity of exacerbation of COPD among participating ICUs. After endotracheal intubation (ETI) and IMV, the rate of successful weaning, prolonged mechanical ventilation, or tracheostomy practices are lacking. These are well known predictive factors associated with COPD in ICU and hospital mortality.2,3 Interestingly, Alaithan et al did not consider COPD as a comorbidity associated with other indications of NIV or IMV.4,5 Second, a relevant aspect that could influence hospital practices and COPD outcomes in this study1 was that only 55% of COPD exacerbations received NIV as initial first line treatment and assumed that the remaining patients received oxygen therapy alone. These data may have health care implications for ICUs, because it could be refecting three potential scenarios: (1) delayed NIV applications, (2) staff training and skills, or (3) limited access to the NIV therapy (the availability of beds in ICU ward). These factors are related to COPD exacerbation and mortality and escape NIV international recommendations during exacerbations of COPD, an important epidemiological factor in this study.6 Third, the low rate of COPD hospital mortality (11%) and ICU mortality (6%) is lower than other studies and may be influenced by these aforementioned factors. However, there are other factors with recognized influence that were not analyzed, such as body mass index (BMI),7 lower health status, nutritional status, or nonrespiratory organ system dys-function.2,3,8 Alaithan et al1 considered that ICU mortality was associated with a longer duration of mechanical ventilation and lower Acute Physiology and Chronic Health Evaluation II (APACHE II)2,3 score, but this is a controversial aspect by other epidemiological published studies.2,3 Additionally, COPD readmissions,7,8 existence of do not-ETI orders, and NIV palliative in severe exacerbation of COPD, were not taken into account.9 The study highlights the complexity of the epidemiological aspects that may affect attendance, prognosis, and mortality in different health systems.8,9 Revealing the diversity of factors that affect NIV and IMV possibilities. Further studies are required to determine sensitive factors that could be modifiable that influence ICU admission criteria, prognosis, and mortality.

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          Most cited references 9

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          Mortality in COPD: Role of comorbidities.

          Chronic obstructive pulmonary disease (COPD) represents an increasing burden throughout the world. COPD-related mortality is probably underestimated because of the difficulties associated with identifying the precise cause of death. Respiratory failure is considered the major cause of death in advanced COPD. Comorbidities such as cardiovascular disease and lung cancer are also major causes and, in mild-to-moderate COPD, are the leading causes of mortality. The links between COPD and these conditions are not fully understood. However, a link through the inflammation pathway has been suggested, as persistent low-grade pulmonary and systemic inflammation, both known risk factors for cardiovascular disease and cancer, are present in COPD independent of cigarette smoking. Lung-specific measurements, such as forced expiratory volume in one second (FEV(1)), predict mortality in COPD and in the general population. However, composite tools, such as health-status measurements (e.g. St George's Respiratory Questionnaire) and the BODE index, which incorporates Body mass index, lung function (airflow Obstruction), Dyspnoea and Exercise capacity, predict mortality better than FEV(1) alone. These multidimensional tools may be more valuable because, unlike predictive approaches based on single parameters, they can reflect the range of comorbidities and the complexity of underlying mechanisms associated with COPD. The current paper reviews the role of comorbidities in chronic obstructive pulmonary disease mortality, the putative underlying pathogenic link between chronic obstructive pulmonary disease and comorbid conditions (i.e. inflammation), and the tools used to predict chronic obstructive pulmonary disease mortality.
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            Nutritional status and long-term mortality in hospitalised patients with chronic obstructive pulmonary disease (COPD).

            Patients with chronic obstructive pulmonary disease (COPD) often have difficulties with keeping their weight. The aim of this investigation was to study nutritional status in hospitalised Nordic COPD patients and to investigate the association between nutritional status and long-term mortality in this patient group. In a multicentre study conducted at four university hospitals (Reykjavik, Uppsala, Tampere and Copenhagen) hospitalised patients with COPD were investigated. Patient height, weight and lung function was recorded. Health status was assessed with St. George's Hospital Respiratory Questionnaire. After 2 years, mortality data was obtained from the national registers in each country. Of the 261 patients in the study 19% where underweight (BMI <20), 41% were of normal weight (BMI 20-25), 26% were overweight (BMI 25-30) and 14% were obese. FEV(1) was lowest in the underweight and highest in the overweight group (p=0.001) whereas the prevalence of diabetes and cardio-vascular co-morbidity went the opposite direction. Of the 261 patients 49 (19%) had died within 2 years. The lowest mortality was found among the overweight patients, whereas underweight was related to increased overall mortality. The association between underweight in COPD-patients, and mortality remained significant after adjusting for possible confounders such as FEV(1) (hazard risk ratio (95% CI) 2.6 (1.3-5.2)). We conclude that COPD patients that are underweight at admission to hospital have a higher risk of dying within the next 2 years. Further studies are needed in order to show whether identifying and treating weight loss and depletion of fat-free mass (FFM) is a way forward in improving the prognosis for hospitalised COPD patients.
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              Non-invasive ventilation in exacerbations of COPD

              Randomized controlled trials have confirmed the evidence and helped to define when and where non invasive mechanical ventilation (NIV) should be the first line treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Noninvasive ventilation has its best indication in moderate-to-severe respiratory acidosis in patients with AECOPD. For this indication, studies conducted in ICU, in wards and in accident and emergency departments confirmed its effectiveness in preventing endotracheal intubation and reducing mortality. The skill of the health care team promotes proper NIV utilization and improves the patient outcome. Patients with severe acidosis or with altered levels of consciousness due to hypercapnic acute respiratory failure are exposed to high risk of NIV failure. In these patients a NIV trial may be attempted in closely monitored clinical settings where prompt endotracheal intubation may be assured.
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                Author and article information

                Journal
                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
                1176-9106
                1178-2005
                2013
                2013
                29 July 2013
                : 8
                : 365-367
                Affiliations
                Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain
                [1 ]Department of Medicine, King Abdulaziz Hospital, Al-Hasa, Saudi Arabia
                [2 ]Department of emergency Medicine, King Abdulaziz Hospital, Al-Hasa, Saudi Arabia
                [3 ]King Abdullah International Medical research Center – eastern region (KAIMrC-er), Al-Hasa, Saudi Arabia
                Author notes
                Correspondence: Antonio M esquinas, Avenida Marques Velez s/n, Murcia, 30.008, Spaink, Tel +30 609 32 1966, Fax +34 968 23 2484, Email antmesquinas@ 123456gmail.com
                Correspondence: Abdulsalam Alaithan, Pulmonary, Critical Care,and Sleep Medicine, Adult Intensive Care Unit Division, Internal Medicine Department, King Abdulaziz Hospital, Al-Hasa National Guard Health Affairs, PO Box 2477 Al-Hasa 31982, Saudi Arabia, Tel +966 3591 0000 ext 33445, Email alaithan@ 123456gmail.com
                Article
                copd-8-365
                10.2147/COPD.S44602
                3760470
                24015058
                © 2013 Esquinas. This work is published by Dove Medical Press Ltd, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License.

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed.

                Categories
                Letter

                Respiratory medicine

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