Roy T.M. Sprooten

Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study

Introduction The effectiveness of non-invasive positive pressure ventilation (NIV) in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure (ARF) remains unclear. We investigated if nocturnal NIV in these patients prolongs the time to readmission for respiratory causes or death (primary endpoint) in the following 12 months. Methods 201 COPD patients admitted to hospital with ARF and prolonged hypercapnia >48 h after termination of ventilatory support were randomised to NIV or standard treatment. Secondary outcomes were daytime arterial blood gasses, transcutaneous PCO2 during the night, lung function, health-related quality-of-life (HRQL), mood state, daily activities and dyspnoea. Results 1 year after discharge, 65% versus 64% of patients (NIV vs standard treatment) were readmitted to hospital for respiratory causes or had died; time to event was not different (p=0.85). Daytime PaCO2 was significantly improved in NIV versus standard treatment (PaCO2 0.5 kPa (95% CI 0.04 to 0.90, p=0.03)) as was transcutaneous PCO2 during the night. HRQL showed a trend (p=0.054, Severe Respiratory Insufficiency questionnaire) in favour of NIV. Number of exacerbations, lung function, mood state, daily activity levels or dyspnoea was not significantly different. Discussions We could not demonstrate an improvement in time to readmission or death by adding NIV for 1 year in patients with prolonged hypercapnia after an episode of NIV for ARF. There is no reason to believe the NIV was not effective since daytime PaCO2 and night-time PCO2 improved. The trend for improvement in HRQL favouring NIV we believe nevertheless should be explored further. Trial registration number NTR1100.

The Severe Respiratory Insufficiency Questionnaire scored best in the assessment of health-related quality of life in chronic obstructive pulmonary disease

OBJECTIVE There are limited data on health-related quality of life (HRQL) in chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure during an admission requiring ventilatory support. The aim was to assess and compare the reliability and validity of the Clinical COPD Questionnaire (CCQ), Chronic Respiratory Questionnaire (CRQ), Maugeri Respiratory Failure-28 (MRF-28) Questionnaire, and Severe Respiratory Insufficiency (SRI) Questionnaire in patients with very severe COPD. STUDY DESIGN AND SETTING One hundred eighty hospitalized patients filled out the CCQ, CRQ, MRF-28, SRI, Groningen Activity Restriction Scale (GARS), Hospital Anxiety and Depression Scale (HADS), and the Medical Research Council Dyspnea Scale (MRC). Reliability was examined by assessing distribution of total scores, floor and ceiling effects, and internal consistency (using Cronbach α coefficient). Construct validity between questionnaires and also the other measurements were tested with Spearman ρ. RESULTS All four questionnaires were feasible in this setting and had reasonable characteristics for distribution of total scores, floor and ceiling effects, internal consistency, and construct validity. On balance, the SRI scored best. Additionally, the SRI had a remarkable high explained variance by HADS, GARS, and MRC (73%). CONCLUSION The SRI performed slightly better than the CCQ, CRQ, and MRF-28, which renders it the preferred questionnaire for scoring HRQL in patients with very severe COPD.

An adolescent with chest pain

An 18-year-old, otherwise healthy, young male reporting a 1-week history of muscular pain, a sore throat and a non-productive cough presented to the emergency room with acute chest pain and pain of the left shoulder. He also experienced some dizziness, without collapse, nausea or vomiting. He reported fever, but this was not objectively confirmed. There was no history of haemoptysis, wheezing, allergic reactions or weight loss. There was no significant family history of similar or other illnesses. ### Task 1 What can cause acute chest pain in an otherwise healthy young adult? ### Answer 1 In this case you would suspect an infectious cause like a pneumonia or viral pleurisy/pericarditis. A pulmonary embolus could also give some fever and a cough. In the case of a young male you should always consider the possibility of a pneumothorax. Less obvious are cardiac ischaemia, myocarditis or pericarditis, myalgia or orthopaedic causes (table 1). Aortic dissection is also a possible differential diagnosis (particularly in patients with Marfan’s syndrome. View this table: Table 1 Causes of chest pain On examination he had normal vital signs with a systolic/diastolic blood pressure of 135/65 mmHg, a heart rate of 80 beats·min−1, a regular respiratory rate of 15 breaths·min−1, a temperature of 37°C, normal cardiac examination, normal breath sounds, normal chest percussion and no signs of a deep vein thrombosis (DVT). Ear, nose and throat examination revealed a right-sided submandibular enlarged lymph node, but no enlarged or exudative tonsils. His shoulder examination showed some tenderness in the region of the left deltoid muscle, but no signs of fracture or dislocation. The laboratory data showed elevated white blood counts with a marked leftward shift, a high C-reactive protein (CRP) and elevated D-dimers (table 2). White blood cell counts were 15.2×109·L−1, with 77% segmented granulocytes, 13% band cells (or stab cells); d-dimers were 1011 ng·mL …

Long term survival after admission for COPD exacerbation: A comparison with the general population

BACKGROUND AND OBJECTIVE Life expectancy data of COPD patients in comparison to the general population are primarily based upon long-term population cohort studies. These studies are limited by a poor definition of clinically significant COPD. The key element in the course of COPD is a clinical exacerbation. Therefore, this study investigated 15-year survival following hospitalization for an exacerbation of COPD in comparison to the general population. METHODS A number of 4229 subjects was studied, including 845 hospitalized COPD patients and 3384 age and sex matched controls. Mortality risks were assessed using Kaplan-Meier survival curves, and hazard rate ratios for death were estimated using Cox proportional hazards regression models, for each Gold Class separately. RESULTS Overall 15-year survival was 7.3% in the COPD group and 40.6% in the general population. Survival was 24%, 11.1%, 5.3% and 0% for COPD GOLD I-IV. The mean life expectancy following hospitalization was 9.7, 7.1, 6.1 and 3.4 years for stage GOLD I-IV and 10.2 years for the general population. Overall, negative prognostic factors were age, male gender, low FEV1, low TLCO, respiratory insufficiency, Charlson comorbidity class, ICU-admission and exacerbation frequency. Factors differed among GOLD stages. CONCLUSIONS The 15-year survival for hospitalized COPD patients is reduced by 82% in comparison to the general population. This indicates a more deleterious course of clinically significant COPD in comparison to population cohorts. As such, every possible effort should be taken to reduce exacerbations in a personalized way.