Marie-Kathrin Breyer

Incidence and outcome of weaning from mechanical ventilation according to new categories

Weaning from mechanical ventilation was categorised as simple, difficult or prolonged by an international task force of the American Thoracic Society/European Respiratory Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine/Sociéte de Réanimation de Langue Française in 2007. This new classification has not been tested in clinical practice. The objective of the present study was to determine the incidence and outcome of weaning according to the new categories. We included medical and surgical patients who required mechanical ventilation in a prospective, multicentre, 6-month cohort study. From an initial cohort of 510 patients, 257 intubated patients started weaning. Of these patients, the cumulative incidences of simple, difficult, and prolonged weaning were 152 (59%), 68 (26%) and 37 (14%), respectively. Hospital mortality was increased in patients with prolonged (32%) but not difficult (9%) weaning in comparison with those with simple weaning (13%), overall p = 0.0205. In a multivariate logistic regression model, prolonged but not difficult weaning was associated with an increased risk of death. Ventilator-free days and intensive care unit (ICU)-free days were decreased in both difficult and prolonged weaning. In conclusion, the new weaning category prolonged weaning is associated with increased mortality and morbidity in the ICU. The new category difficult to wean was associated with increased morbidity, but not mortality.

Comparison of daily physical activity between COPD patients from Central Europe and South America

BACKGROUND In healthy elderly and adults, lower physical activity level in daily life has been associated with lower socio-economic level and non-Caucasian race. The objective of this study was to determine if this is also applicable in chronic obstructive pulmonary disease (COPD) by comparing physical activity levels in daily life in stable patients from two countries (Austria and Brazil) with different socio-economic and ethnic characteristics. METHODS Physical activity in daily life was objectively assessed in 40 Austrian and 40 Brazilian COPD patients. Groups were matched for age, gender, body mass index, disease severity, smoking history, presence of concomitant heart disease, lung function, dyspnea and functional exercise capacity. In addition, climatic conditions were similar during the period of data collection in the two groups. RESULTS In comparison to Brazilian patients, Austrian patients had a significantly lower walking time (p=0.04), higher sitting time (p=0.02) and lower movement intensity (p=0.0001). The proportion of patients who did not reach an average of 30min of walking per day was 48% in the Austrian group and 23% in the Brazilian group. CONCLUSIONS Austrian patients with COPD showed a significantly lower daily physical activity level in comparison to matched Brazilian patients. Socio-economic and ethnic factors appear to influence stable COPD patients differently than described in previous studies including healthy subjects.

Long-term non-invasive ventilation in COPD after acute-on-chronic respiratory failure *

BACKGROUND COPD patients who remain hypercapnic after acute respiratory failure requiring mechanical ventilation have a poor prognosis. Long-term nocturnal non-invasive ventilation (NIV) may be beneficial for these patients. We hypothesized that stable patients on long-term NIV would experience clinical worsening after withdrawal of NIV. METHODS We included 26 consecutive COPD patients (63 ± 6 years, 58% male, FEV(1) 31 ± 14% predicted) who remained hypercapnic after acute respiratory failure requiring mechanical ventilation. After a six month run-in period, during which all patients received NIV, they were randomised to either continue (ventilation group, n = 13) or to stop NIV (withdrawal group, n = 13). The primary endpoint was time to clinical worsening defined as an escalation of mechanical ventilation. RESULTS All patients remained stable during the run-in period. After randomisation the withdrawal group had a higher probability of clinical worsening compared to the ventilation group (p = 0.0018). After 12 months, ten patients (77%) in the withdrawal group, but only two patients (15%) in the ventilation group, experienced clinical worsening (p = 0.0048). Six-minute walking distance increased in the ventilation group. CONCLUSION COPD patients who remain hypercapnic after acute respiratory failure requiring mechanical ventilation may benefit from long-term NIV.

Highly elevated C-reactive protein levels in obese patients with COPD: A fat chance?

BACKGROUND & AIMS Chronic obstructive pulmonary disease (COPD) has been recognized as a multi component disease. Currently, limited data are available about determining factors of systemic inflammation in COPD, in particular C-reactive protein (CRP). The aim was to determine whether and to what extent COPD patients with a low, high or obese body mass index (BMI) are more likely to have elevated CRP levels compared to normal-weight COPD patients. Furthermore, we aimed to explore the effects of clinically relevant covariates on the likelihood of having elevated CRP levels. METHODS In 628 elderly patients with moderate to severe COPD (61% male), lung function and BMI were assessed before entering pulmonary rehabilitation. In addition, blood was collected in the fasted state. High-sensitive C-reactive protein (CRP) was classified into: normal, < or =3; elevated, >3-5 and highly elevated, >5mg/l. RESULTS Obese COPD patients (BMI> or =30 kg/m(2)) were 3.3 times more likely (95% CI, 1.5-7.0, p=0.002) to have highly elevated CRP levels compared to normal weight (BMI 21-24.9 kg/m(2)) COPD patients after taking clinically relevant confounders into account. In contrast, COPD patients with a low BMI (<21 kg/m(2)) were 2 times less likely (OR, 0.5; 95% CI, 0.3-0.9, p=0.022) to have highly elevated CRP levels compared to normal-weight peers. CONCLUSION Obese BMI is associated with highly elevated CRP levels in patients with COPD. These findings are suggestive for an adipocyte-induced systemic inflammation in COPD.

Gender differences in the adipose secretome system in chronic obstructive pulmonary disease (COPD): A pivotal role of leptin

BACKGROUND COPD is characterized by a multi-component character involving a state of low-grade systemic inflammation and an increased prevalence of cardiovascular co-morbidity. The role of circulating leptin and other adipokines in the involvement of the systemic inflammation in COPD is only studied scarcely. OBJECTIVE To investigate gender related differences in the adipokine metabolism in relation to systemic inflammatory biomarkers in clinically stable subjects with COPD. METHODS In total, 91 clinically stable COPD patients and 35 healthy control subjects, matched for body mass index (BMI) with the COPD subjects, were included. Lung function measurement and body composition were performed in patients with COPD. In the total group, plasma concentration of the adipokines (leptin, adiponectin and resistin) and systemic inflammatory biomarkers C-reactive protein (CRP), interleukin 6 (IL-6), tumor necrosis factor α (TNFα), and its soluble receptors 55 and 75 (sTNFα-R55, R75) were analyzed. RESULTS The COPD group was characterized by increased levels of CRP, IL-6 and leptin. Plasma adiponectin and resistin concentrations were not different between the COPD and the control group. Within the COPD group, there was a significant interaction between gender and BMI on the leptin/fat mass ratio. In COPD women, a significant correlation between leptin and CRP was present. CONCLUSIONS In men with clinically stable COPD, leptin, adiponectin and resistin appear to be physiologically regulated, while in women, leptin metabolism is altered. Leptin secretion is increased in COPD women when compared to healthy women and compared to COPD men, and to a greater extent in overweight women with COPD.

Dysregulated adipokine metabolism in chronic obstructive pulmonary disease

Eur J Clin Invest 2012; 42 (9): 983–991