Pedro J. Marcos

Hypocapnia and Hypercapnia Are Predictors for ICU Admission and Mortality in Hospitalized Patients With Community-Acquired Pneumonia

OBJECTIVE The purpose of our study was to examine in patients hospitalized with community acquired pneumonia (CAP) the association between abnormal Pa CO 2 and ICU admission and 30-day mortality. METHODS A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of CAP. Arterial blood gas analyses were obtained with measurement of PaCO2 on admission. Multivariate analyses were performed using 30-day mortality and ICU admission as the dependent measures. RESULTS Data were abstracted on 453 subjects with a documented arterial blood gas analysis. One hundred eighty-nine patients (41%) had normal PaCO2 (35-45 mm Hg), 194 patients (42%) had aPa CO 2 , 35 mm Hg (hypocapnic), and 70 patients (15%) had a Pa CO 2 . 45 mm Hg (hypercapnic).In the multivariate analysis, after adjusting for severity of illness, hypocapnic patients had greater 30-day mortality (OR= 2.84; 95% CI, 1.28-6.30) and a higher need for ICU admission (OR= 2.88;95% CI, 1.68-4.95) compared with patients with normal PaCO2. In addition, hypercapnic patients had a greater 30-day mortality (OR= 3.38; 95% CI, 1.38-8.30) and a higher need for ICU admission(OR =5.35; 95% CI, 2.80-10.23). When patients with COPD were excluded from the analysis,the differences persisted between groups. CONCLUSION In hospitalized patients with CAP, both hypocapnia and hypercapnia were associated with an increased need for ICU admission and higher 30-day mortality. These findings persisted after excluding patients with CAP and with COPD. Therefore, PaCO2 should be considered for inclusion in future severity stratification criteria to appropriate identified patients who will require a higher level of care and are at risk for increased mortality.

The CAT (COPD Assessment Test) questionnaire as a predictor of the evolution of severe COPD exacerbations.

INTRODUCTION Since exacerbations of chronic obstructive pulmonary disease (COPD) cause both a great impact on the progression of the disease and generate high health expenditures, there is a need to develop tools to evaluate their prognosis. METHOD Multicenter, observational, prospective study that evaluated the prognostic utility of the COPD Assessment Test (CAT) in severe exacerbations of COPD. Anthropometric and clinical variables were analyzed: smoking, history of exacerbations during the previous year, drug treatment, degree of baseline dyspnea, comorbidities; laboratory variables at admission (complete blood count, arterial blood gas and biochemistry) and CAT scores in the first 24 h of admission, on the third day, at discharge and at 3 months. RESULTS We evaluated 106 patients (91 males) with a mean age of 71.1 (SD 9.8 years), mean FEV1 45.2% (14.7%) and average CAT score at admission of 24.7 points (7.1). At three months after discharge, treatment failure was observed in 39 (36.8%) patients: 14 (13.2%) presented an exacerbation without the need for hospital admission, 22 were readmitted (20.8%) and 3 (2.8%) died during follow-up. The three factors associated with increased risk of failure were a reduction less than 4 units in the CAT at discharge compared to admission, lower hemoglobin levels and treatment with domiciliary oxygen. CONCLUSIONS A change of ≤4 points in the CAT score at discharge compared to that obtained at admission due to a severe exacerbation of COPD, helps to predict therapeutic failure such as a new exacerbation, readmission or death in the subsequent three months.

Community-acquired pneumonia team decreases length of stay in hospitalized, low-risk patients with pneumonia.

Abstract Background: Team-focused intervention to improve the care of low-risk patients with community-acquired pneumonia (CAP) is a matter of controversy. Our aim was to determine if a community-acquired pneumonia team (CAPT) would shorten hospital length of stay (LOS) and improve health care utilization in low-risk patients with CAP compared with management by a general pulmonary team (GPT). Methods: We performed a prospective cohort study of hospitalized, low-risk patients with CAP (Pneumonia Severity Index [PSI] score class I or II) at a single tertiary hospital from June 2007 to June 2008. Study patients were stratified to management by the CAPT treating group (n = 35), following the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) CAP guideline recommendations, or to management by the GPT (n = 30) following the standard of care. Primary outcome measure for comparison of the efficacy of the 2 different team-focused interventions was hospital LOS for patients with CAP. Secondary study outcome measures included patient 30- and 90-day all-cause readmission rate, rate of mortality at 30 and 90 days, antibiotic-treatment duration, time to switch patient from intravenous (IV) to oral antibiotic treatment, and time to achieve clinical stability for patients. Results: Hospitalized, low-risk patients with CAP, who were assisted by a CAPT were more likely to have a shorter hospital stay (9 days less; P < 0.001), shorter time to switch from IV to oral antibiotic therapy (8 days less; P < 0.001), and total shorter duration of antibiotic treatment (6 days less; P < 0.001), when compared with low-risk patients with CAP who were assisted by a GPT. In addition, for both groups of assisted patients, there were no differences in the time to achieve clinical stability, use of guideline-concordant antibiotic therapy, rate of mortality, or rate of readmissions at 30 and 90 days. Conclusions: Management by a dedicated CAPT reduced patient hospital LOS, time to switch from IV to oral antibiotic therapy, and duration of antibiotic treatment, without causing adverse events, compared with standard of care, in low-risk patients with CAP.

Endothelial adhesion molecules and multiple organ failure in patients with severe sepsis

OBJECTIVE To determine if serum levels of endothelial adhesion molecules were associated with the development of multiple organ failure (MOF) and in-hospital mortality in adult patients with severe sepsis. DESIGN This study was a secondary data analysis of a prospective cohort study. SETTING Patients were admitted to two tertiary intensive care units in San Antonio, TX, between 2007 and 2012. PATIENTS Patients with severe sepsis at the time of intensive care unit (ICU) admission were enrolled. Inclusion criteria were consistent with previously published criteria for severe sepsis or septic shock in adults. Exclusion criteria included immunosuppressive medications or conditions. INTERVENTIONS None. MEASUREMENTS Baseline serum levels of the following endothelial cell adhesion molecules were measured within the first 72h of ICU admission: Intracellular Adhesion Molecule 1 (ICAM-1), Vascular Cell Adhesion Molecule-1 (VCAM-1), and Vascular Endothelial Growth Factor (VEGF). The primary and secondary outcomes were development of MOF (⩾2 organ dysfunction) and in-hospital mortality, respectively. MAIN RESULTS Forty-eight patients were enrolled in this study, of which 29 (60%) developed MOF. Patients that developed MOF had higher levels of VCAM-1 (p=0.01) and ICAM-1 (p=0.01), but not VEGF (p=0.70) compared with patients without MOF (single organ failure only). The area under the curve (AUC) to predict MOF according to VCAM-1, ICAM-1 and VEGF was 0.71, 0.73, and 0.54, respectively. Only increased VCAM-1 levels were associated with in-hospital mortality (p=0.03). These associations were maintained even after adjusting for APACHE and SOFA scores using logistic regression. CONCLUSIONS High levels of serum ICAM-1 was associated with the development of MOF. High levels of VCAM-1 was associated with both MOF and in-hospital mortality.

Community-Acquired Pneumonia Requiring Hospitalization.

To the Editor: With regard to the results of the Centers for Disease Control and Prevention (CDC) Etiology of Pneumonia in the Community (EPIC) study reported by Jain et al. (July 30 issue),1 two related points warrant emphasis. First, although the authors found an increased incidence of pneumonia with increasing age, this study shows that “old” is not so old. The results showed that half of all hospitalizations for communityacquired pneumonia in adults involved patients who were 57 years of age or younger. Second, as noted by the authors, concerted efforts to define a microbial cause did not reveal a pathogen of especially great concern. Responsible microbes were not detected in nearly two thirds of the patients, and no single microbe was associated with more than a small fraction of cases (<9% for every microbe). Thus, pneumonia in adults is less about the microbe and more about the host. The combination of immunemediating antimicrobial activities with homeostatic pathways limiting physiological disruption provides an integrated host defense2 that increases during childhood, in part because of adaptive immunity to respiratory infections,3 but it then becomes compromised by diverse factors during aging, with the result that the risk of pneumonia is increased.4 A person’s susceptibility to pneumonia cannot be measured. New tools are needed to diagnose, track, and counter susceptibility to pneumonia, a chronic disease of aging that has not been effectively addressed.

Actualización de GesEPOC 2014 y corticoides sistémicos en la agudización de enfermedad pulmonar obstructiva crónica (EPOC)

We have read the latest version of the Spanish guidelines on COPD (GesEPOC), published recently (January 2014) in Archivos de Bronconeumología.1 When the AUDIEPOC study was published in July 2012, we observed that there was little homogeneity in the management of COPD exacerbation at the national level.2 A more rigorous review of the published data revealed that this variability also exists in the use of systemic corticosteroids during exacerbations. In the 2014 update, GesEPOC clinical guidelines propose a change in systemic corticosteroid treatment during exacerbations. Thus, the original version recommended a short course of 7–10 days,3 while in the 2014 update, the guidelines support the use of “short 5-day courses for [. . .] exacerbations that do not require hospitalization”. We believe that this change is based essentially on data from the REDUCE clinical trial,4 which compared treatment with a short 5-day course of 40 mg of prednisone versus a 14-day course during exacerbations. The trial showed a similar reexacerbation rate, with the advantage of lower exposure to corticosteroids and very similar findings as regards outcomes (hospital stay and deaths). We agree that exacerbations can be managed with lower doses and shorter treatment times than those used in routine clinical practice. At the same time, we consider that this conclusion, currently limited by the guidelines to outpatients, could also be extended to some patients with more severe exacerbations who require hospital admission. In the REDUCE clinical trial, of the 314 patients who attended the Emergency Department (311 evaluated) and were randomized to receive a short or long corticosteroid regimen, 289 (92%) patients were admitted to hospital. The groups

De la exclusión a la certidumbre. El recorrido hacia el diagnóstico de la fibrosis pulmonar idiopática

Idiopathic pulmonary fibrosis (IPF) is a differentiated disease within the idiophatic interstitial pneumonias. IPF is progressive and fibrosing and is limited to the lungs. This entity generally affects persons older than 50 years old and is associated with the radiological and/or histological pattern of usual interstitial pneumonia (UIP). Clinically, IPF causes progressive exertional dyspnea and nonproductive cough. In most patients, physical examination reveals fine bibasilar inspiratory crackles and 50% of patients have digital clubbing. There are no specific laboratory alterations. Bronchoalveolar lavage and transbronchial biopsy will not establish the diagnosis of IPF but are useful to exclude other entities. Definitive diagnosis requires: a) exclusion of other, defined clinical entities or diffuse pulmonary diseases of known cause, and b) the presence of a histological pattern of UIP on analysis of pulmonary tissue from surgical biopsy, radiological evidence of the defined pattern of UIP on high-resolution computed tomography, or both.

High endocan levels are associated with the need for mechanical ventilation among patients with severe sepsis

Sepsis affects more than 750 000 Americans each year, with a mortality rate close to 30% [1]. A significant amount of resources has been put into improving our understanding of sepsis and developing new therapies. A push for early sepsis recognition and subsequent timely treatment has led to an interest in inflammatory biomarkers to identify sepsis and its severity [2]. Respiratory dysfunction occurs in up to 81% of cases and a significant proportion requires ventilatory support [1]. Studies have looked at a variety of biomarkers, from inflammatory cytokines such as interleukin (IL)-6 to endothelial proteins like intercellular adhesion molecule-1, to identify patients at greatest risk of developing respiratory compromise [3]. Endocan may have a role as a predictive biomarker for need for mechanical ventilation in patients with severe sepsis http://ow.ly/raKd30bSqTk

Risk Factors of Poor Outcomes after Admission for a COPD Exacerbation: Multivariate Logistic Predictive Models

ABSTRACT The aim of this study was to identify a multivariate model to predict poor outcomes after admission for exacerbation of chronic obstructive pulmonary disease (COPD). We performed a multicenter, observational, prospective study. Patients admitted to hospital for COPD were followed up for 3 months. Relevant clinical variables at admission were selected. For each variable, the best cut-offs for the risk of poor outcome were identified using receiver operating characteristic (ROC) curves. Finally, a stepwise logistic regression model was performed. A total of 106 patients with a mean age of 71.1 (9.8) years were included. The mean maximum expiratory volume in the first second (FEV1)(%) was 45.2%, and the mean COPD assessment test (CAT) score at admission was 24.8 (7.1). At 3 months, 39 (36.8%) patients demonstrated poor outcomes: death (2.8%), readmission (20.8%) or new exacerbation (13.2%). Variables included in the logistic model were: previous hospital admission, FEV1 < 45%, Charlson ≥ 3, hemoglobin (Hb)<13 g/L, PCO2 ≥ 46 mmHg, fibrinogen ≥ 554 g/L, C-reactive protein (CRP)≥45 mg/L, leukocyte count < 9810 × 109/L, purulent sputum, long-term oxygen therapy (LTOT) and CAT ≥ 31 at admission. The final model showed that Hb < 13 g/L (OR = 2.46, 95%CI 1.09–6.36), CRP ≥ 45 mg/L (OR = 2.91, 95%CI: 1.11–7.49) and LTOT (3.07, 95%CI: 1.07–8.82) increased the probability of poor outcome up to 82.4%. Adding a CAT ≥ 31 at admission increased the probability to 91.6% (AUC = 0.75; p = 0.001). Up to 36.8% of COPD patients had a poor outcome within 3 months after hospital discharge, with low hemoglobin and high CRP levels being the risk factors for poor outcome. A high CAT at admission increased the predictive value of the model.

Using Standardized Care Bundles in the Emergency Department to Decrease Mortality in Patients Presenting with Community-Acquired Pneumonia (CAP) and Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)

There is significant variability when managing community-acquired pneumonia (CAP) and exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency department among doctors, hospitals, and health systems. This variability could contribute to the variable outcomes related with them. The use of standardized care bundles allows clinical teams to focus their efforts on a small number of measurable strategies aimed at improving specified outcomes. This article will review the importance of clinical care bundles when managing these diseases in the emergency department and its potential to decrease mortality.