Myriam Aburto

Predictors of Mortality in Patients with Stable COPD

OBJECTIVESTo determine which easily available clinical factors are associated with mortality in patients with stable COPD and if health-related quality of life (HRQoL) provides additional information.DESIGNFive-year prospective cohort study.SETTINGFive outpatient clinics of a teaching hospital.PARTICIPANTSSix hundred stable COPD patients recruited consecutively.MEASUREMENTSThe variables were age, FEV1%, dyspnea, previous hospital admissions and emergency department visits for COPD, pack-years of smoking, comorbidities, body mass index, and HRQoL measured by Saint George’s Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Short-Form 36 (SF-36). Logistic and Cox regression models were used to assess the influence of these variables on mortality and survival.RESULTSFEV1%(OR: 0.62, 95% CI 0.5 to 0.75), dyspnea (OR 1.92, 95% CI 1.2 to 3), age (OR 2.41, 95% CI 1.6 to 3.6), previous hospitalization due to COPD exacerbations (OR 1.53, 1.2 to 2) and lifetime pack-years (OR 1.15, 95% CI 1.1 to 1.2) were independently related to respiratory mortality. Similarly, these factors were independently related to all-cause mortality with dyspnea having the strongest association (OR 1.54, 95% CI 1.1 to 2.2). HRQoL was an independent predictor of respiratory and all-cause mortality only when dyspnea was excluded from the models, except scores on the SGRQ were associated with all-cause mortality with dyspnea in the model.CONCLUSIONSAmong patients with stable COPD, FEV1% was the main predictor of respiratory mortality and dyspnea of all-cause mortality. In general, HRQoL was not related to mortality when dyspnea was taken into account, and CRQ and SGRQ behaved in similar ways regarding mortality.

Influence of changes in physical activity on frequency of hospitalization in chronic obstructive pulmonary disease

To evaluate whether changes in regular physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) affect the rate of hospitalizations for COPD exacerbation (eCOPD).

Impact of hospitalisations for exacerbations of COPD on health-related quality of life

Exacerbations of chronic obstructive pulmonary disease (COPD) impair health-related quality of life (HRQoL). It is unknown whether exacerbations requiring hospitalisation have an impact on HRQoL. 611 ambulatory COPD patients were prospectively identified. The average age (SD) was 65.5 (8.6), FEV(1) (SD) was 52% (14%) of the predicted value. All patients completed the Saint Georges Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study Short Form (SF-36) questionnaire at the beginning of the study. After five years of follow-up, the 391 survivors again completed these HRQoL instruments. No changes in HRQoL were observed among patients not hospitalised for COPD exacerbations. Those hospitalised during follow-up experienced significant declines in HRQoL. The largest changes were observed among patients with >or=3 hospitalisations, with a 13.6 unit increase in the total SGRQ and a 10.5 unit decrease in the physical component summary scale of the SF-36. Similar changes were observed among patients with FEV(1)>or=50% at baseline. In the multivariate analysis, after adjustment by FEV(1%), age, comorbidities, and HRQoL in the respective HRQoL domain at baseline, hospitalisations were an independent predictor of the change in HRQoL. Hospitalisations for exacerbations of COPD have an independent and negative impact on the evolution of HRQoL, regardless of COPD severity.

BODE-Index vs HADO-Score in Chronic Obstructive Pulmonary Disease: Which one to use in general practice?

BackgroundForced expiratory volume in one second (FEV1) is used to diagnose and establish a prognosis in chronic obstructive pulmonary disease (COPD). Using multi-dimensional scores improves this predictive capacity.Two instruments, the BODE-index (Body mass index, Obstruction, Dyspnea, Exercise capacity) and the HADO-score (Health, Activity, Dyspnea, Obstruction), were compared in the prediction of mortality among COPD patients.MethodsThis is a prospective longitudinal study. During one year (2003 to 2004), 543 consecutively COPD patients were recruited in five outpatient clinics and followed for three years. The endpoints were all-causes and respiratory mortality.ResultsIn the multivariate analysis of patients with FEV1 < 50%, no significant differences were observed in all-cause or respiratory mortality across HADO categories, while significant differences were observed between patients with a lower BODE (less severe disease) and those with a higher BODE (greater severity). Among patients with FEV1 ≥ 50%, statistically significant differences were observed across HADO categories for all-cause and respiratory mortality, while differences were observed across BODE categories only in all-cause mortality.ConclusionsHADO-score and BODE-index were good predictors of all-cause and respiratory mortality in the entire cohort. In patients with severe COPD (FEV1 < 50%) the BODE index was a better predictor of mortality whereas in patients with mild or moderate COPD (FEV1 ≥ 50%), the HADO-score was as good a predictor of respiratory mortality as the BODE-index. These differences suggest that the HADO-score and BODE-index could be used for different patient populations and at different healthcare levels, but can be used complementarily.

The health, activity, dyspnea, obstruction, age, and hospitalization: Prognostic score for stable COPD patients

UNLABELLED Multidimensional instruments for determining the severity and prognosis of chronic obstructive pulmonary disease (COPD) must be used in daily clinical practice. OBJECTIVE To develop and validate a new COPD severity score using variables readily obtained in clinical practice and to compare its predictive capacity with that of other multidimensional indexes. Data collected from a prospective cohort of 611 stable COPD patients were used to derive a clinical prediction rule that was later validated in a separate prospective cohort of 348 patients. In the multivariate analyses, six independent predictive factors were correlated with overall and respiratory mortality: health status, physical activity, dyspnea, airway obstruction (FEV(1)), age, and hospitalizations for COPD exacerbations in the previous two years. These create the HADO-AH score. Based on the β parameter obtained in the multivariate model, a score was assigned to each predictive variable. The area under the curve for 5-year mortality was 0.79 (95% CI, 0.74-0.83) in the derivation cohort and 0.76 (95% CI, 0.71-0.81) in the validation cohort. The HADO-AH score was a significantly better predictor of mortality than the HADO-score and the Body-mass index, Obstruction, Dyspnea, Exercise-index were statistically significant (p < 0.0004 and p = 0.021, respectively), but was similar to the Age, Dyspnea, and Obstruction-index (p = 0.345). The HADO-AH score provides estimates of all-cause and respiratory mortality that are equal to, or better than, those of other multidimensional instruments. Because it uses only easily accessible measures, it could be useful at all levels of care.

Development of a decision tree to assess the severity and prognosis of stable COPD

The aim of this study was to develop and validate a new method: a classification and regression tree (CART) based on easily accessible measures to predict mortality in patients with stable chronic obstructive pulmonary disease (COPD). This was a prospective study of two independent prospective cohorts: a derivation cohort with 611 recruited patients and a validation cohort with 348 patients, all followed for 5 yrs. CART analysis was used to predict 5-yr mortality risk using the following covariates from the derivation cohort: age, % predicted forced expiratory volume in 1 s (FEV1), dyspnoea, physical activity, general health and number of hospital admissions for COPD exacerbations in the previous 2 yrs. Age (≥75 or <75 yrs) provided the first branch of the COPD-CART. The highest mortality risk (0.74) was seen in patients >75 yrs of age with higher levels of dyspnoea and FEV1 <50% pred. Patients with the lowest risk of 5-yr mortality (0.04) were <55 yrs of age with FEV1 >35% pred and one or no recent hospitalisations for COPD exacerbations. A simple decision tree that uses variables commonly gathered by physicians can provide a quick assessment of the severity of the disease, as measured by the risk of 5-yr mortality.

Descripción de una muestra de pacientes con enfermedad pulmonar obstructiva crónica atendidos en las consultas del área de neumología dependientes de un hospital

Objetivo: Conocer las caracteristicas generales, la percepcion de salud y las limitaciones de los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) atendidos en las consultas de area dependientes de nuestro servicio. Metodo: El estudio se llevo a cabo en 5 consultas de area en las que, de forma consecutiva, se fue incluyendo a los pacientes. Mediante cuestionarios se recabo informacion sobre diversos aspectos sociodemograficos, percepcion de salud y limitacion en la vida habitual. Asimismo se recogio informacion sobre los tratamientos que realizaban los pacientes y las enfermedades asociadas que padecian, y se practico una espirometria. Resultados: Se estudio a 611 pacientes con una edad media de 67,2 anos; de ellos, el 97,7% eran varones. Las enfermedades asociadas mas frecuentes fueron la patologia de columna y la osteoartrosis (el 43 y el 37%, respectivamente). La media del volumen espiratorio forzado en el primer segundo (FEV1) fue del 1,37 l respecto al valor teorico, y el FEV1 medio fue del 49,7%. Los farmacos mas utilizados en relacion con la EPOC fueron los s-adrenergicos y los anticolinergicos, el 66% de los pacientes recibia tratamiento con esteroides inhalados. La mayoria de los pacientes (52,7%) referia su salud como regular y el 59,9% manifestaba presentar algun grado de limitacion en sus actividades habituales que atribuia a su enfermedad respiratoria. Se encontraron diferencias estadisticamente significativas entre el grado de limitacion y el grado de disnea (p < 0,0001), el grado de percepcion de salud (p < 0,0001) y el FEV1 (p = 0,001). Conclusiones: Los datos de nuestro estudio dibujan las caracteristicas generales de los pacientes con EPOC e indican que la disnea se relaciona intimamente con la percepcion de limitacion que presentan los pacientes.

Exacerbación de EPOC: factores predictores de mortalidad en una unidad de cuidados respiratorios intermedios

OBJECTIVE The aim of our study was to investigate the mortality predictive factors after a severe exacerbations of COPD admitted to a Spanish respiratory intermediate care unit (IRCU). PATIENTS AND METHODS Prospective observational 2 years study, where we included all episodes of acute exacerbations of COPD with hypercapnic respiratory failure admitted in an IRCU. We analyzed different sociodemographic, functional and clinical variables including physical activity. RESULTS We collected data from 102 consecutive episodes admitted to IRCU (90.1% men). Mean age was 69.4±10.6. The mean APACHE II was 19.6±5.0 and 9.5% presented a failure of other non respiratory organ. Non invasive ventilation was applied in 75.3% of the episodes and this treatment failed in 11.6% of them. The duration of stay in the IRCU was 3.5±2.1 days and 8.0±5.3 days in the hospital. The hospital mortality rate was 6.9%, and another 12.7% after 90 days of discharged. In order to predict hospital mortality, multivariant statistics identified a model with AUC of 0.867, based in 3 variables: the number of previous year admission for COPD exacerbation (p=0,048), the respiratory rate after 2 hours of treatment in the IRCU (p=0.0484) and the severity of the disease established with ADO score (p=0.0241). CONCLUSIONS The number of previous year admission for COPD exacerbation, the severity of the disease established with ADO score, the respiratory rate after 2 hours of treatment, allow us to identify what patients with a COPD exacerbation admitted in a IRCU can die during this episode.

Cuidados respiratorios intermedios: un año de experiencia

BACKGROUND The aim of this study was to describe the characteristics and results of patients admitted to an intermediate respiratory care unit (IRCU). PATIENTS AND METHODS We performed a 12-month prospective observational study of all the patients admitted to our IRCU during the study period. We analyzed sociodemographic and clinical variables, the APACHE-II score, blood gas parameters, duration of stay in hospital, mortality, and readmission to hospital. RESULTS We evaluated 190 patients (64.2% men), with a mean age of 69.4 years. A score of greater than 2 on the Charlson index was recorded in 43.2% of patients. The mean APACHE-II score was 16.3 in the emergency department and 14.3 on entering the IRCU. Fifty percent of the patients were admitted to receive ventilation and, of these, only 6 (5.7%) were admitted for disconnection of the ventilator. The mean duration of stay in the IRCU was 3.7 days. The readmission rate was 12.7% Mortality was 12.6% during hospitalization and 11.6% 90 days after discharge. CONCLUSIONS The patients admitted to our IRCU were elderly, with considerable comorbidity and high mortality, both during hospitalization and 90 days after discharge from hospital. The results revealed no statistically significant differences (mean length of stay, readmission, mortality) according to the type of care administered to the patients (ventilation compared to monitoring).

Normalización de las cifras de presión en la arteria pulmonar tras tratamiento efectivo de la enfermedad de Graves

Presentamos el caso de una paciente de 48 anos de edad con diagnostico de hipertension pulmonar e hipertiroidismo (enfermedad de Graves) en la que se objetivo la normalizacion de las cifras de presion en la arteria pulmonar tras el tratamiento de su enfermedad tiroidea. Los posibles mecanismos etiopatogenicos involucrados en esta asociacion incluirian la presencia de un fallo cardiaco hiperdinamico y/o la existencia de una alteracion de la inmunidad subyacente y comun a ambos.