Fuente: BMJ ;g Management and prevention of exacerbations of COPD. Desarrollo 2. Referencias Referencias. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease.
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Exacerbations of chronic obstructive pulmonary disease COPD carry significant consequences for patients and are responsible for considerable health-care costs—particularly if hospitalization is required. Despite the importance of hospitalized exacerbations, relatively little is known about their determinants.
This study aimed to analyze predictors of hospitalized exacerbations and mortality in COPD patients. This was a retrospective population-based cohort study. We defined moderate exacerbations as events that led a care provider to prescribe antibiotics or corticosteroids and severe exacerbations as exacerbations requiring hospital admission.
We observed exacerbation frequency over the previous year and following year We estimated the odds ratios ORs by logistic regression, adjusting for age, sex, smoking status, COPD severity, and frequent exacerbator phenotype the previous year. Of the patients, A history of at least two prior severe exacerbations was positively associated with new severe exacerbations adjusted OR, 6.
Older age and several comorbidities, such as heart failure and diabetes, were similarly associated. Hospitalized exacerbations occurred with all grades of airflow limitation. A history of severe exacerbations was associated with new hospitalized exacerbations and mortality.
Editor: Talitha L. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be made publicly available in order to protect patient privacy. Juan Luis Garcia-Rivero jgarcia separ. Funding: Dr. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: Dr. The rest of authors declare no competing interests. Chronic obstructive pulmonary disease COPD is one of the most prevalent lung diseases observed in clinical practice and the third-leading cause of death in the world [ 1 ].
The association of COPD with smoking is well established. However, an increasing number of studies have reported a considerable prevalence of COPD among nonsmokers [ 2 , 3 , 4 ]. Exacerbations of COPD are characterized by episodes of symptom worsening. If case definition is made according to health-care utilization criteria, exacerbations are defined as events that lead a care provider to prescribe antibiotics, corticosteroids, or both moderate exacerbations or that result in hospitalization severe exacerbations [ 5 , 6 ].
Exacerbations of COPD carry significant consequences for patients [ 7 , 8 ]; they are responsible for a large proportion of the health-care costs attributable to this prevalent condition [ 9 ]—particularly if they require hospitalization [ 10 ]. Consequently, preventing exacerbations is a key component of COPD-management strategies [ 11 , 12 ]. Despite the importance of exacerbations, relatively little is known about their determinants; this is probably because the heterogeneity of COPD exacerbations reflects their dependence on a complex spectrum of multiple risk factors [ 6 , 13 ].
Recently, new large observational cohort studies, such as the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints ECLIPSE study [ 14 ], have shown that the most consistent predictor of exacerbations appears to be a previous history of exacerbations; this potentially indicates a definable phenotype of exacerbation susceptibility. Epidemiology and determinants specifically associated with exacerbations that require hospital admission have been less extensively described [ 15 , 16 , 17 , 18 ].
The ECLIPSE study has shown that exacerbations requiring hospital admission occur across all grades of airflow limitation and are a significant prognostic factor of overall mortality.
The main predictor of exacerbations requiring hospital admission was a past history of similar events exacerbations requiring hospital admission the previous year. The severity of the underlying COPD has also been shown to be an independent predictor of higher risk of exacerbations requiring hospital admission and reduced survival [ 18 ]. It also did not include confirmed COPD patients with no history of tobacco consumption. We obtained approval of the research protocol from the Clinical Research Ethics Committee of Cantabria before data acquisition.
Prior to analysis, patient records and information were anonymized and de-identified. We identified them from electronic clinical databases in the province of Cantabria northern Spain on December 31, The recruitment criteria included no restrictions regarding history of tobacco consumption or degree of forced expiratory volume in 1 second FEV1 impairment.
Of the total population of , people registered in Cantabria, we identified 9, potential COPD patients. We obtained a sample of patients by simple random sampling. We carefully examined the spirometric data for each of these patients. We confirmed the diagnosis of COPD in patients We restricted our final analysis to confirmed COPD patients. We obtained the data for each patient from computerized clinical databases of primary health-care centers and hospital records.
The clinical and demographic characteristics of all the patients were recorded, including age, years since diagnosis of COPD, treatments and vaccinations, smoking status, alcohol consumption, and comorbidities.
We used the same the case definition of exacerbation as that in the ECLIPSE cohort study [ 14 ] according to health-care utilization criteria [ 5 , 6 ]. Thus, moderate exacerbations were defined as events that led a care provider to prescribe antibiotics, corticosteroids, or both; severe exacerbations were defined as those requiring hospital admission. We observed the exacerbation frequency over the previous year and following year We defined frequent exacerbations frequent exacerbator phenotype as two or more exacerbations in a year, including both moderate and severe exacerbations; we did so because this definition coincides with current health-care utilization criteria for frequent exacerbations [ 6 , 14 ].
We also categorized patients according to the severity of their level of airflow limitation GOLD grades 1—4 [ 11 ]. We expressed categorical and discrete variables as counts percentage and continuous variables as mean and standard deviation [SD].
We treated severe exacerbation frequency for the following year as a dichotomous dependent variable in the regression models: no severe exacerbations versus one or more severe exacerbations during We computed overall mortality for all causes during , and we treated it as a dichotomous dependent variable in the regression models, classifying patients into survivors and non-survivors. As an association measure, we used the odds ratio.
Odds is a frequency measure; the odds of some event reflect the likelihood that the event will occur. The relative odds or odds ratio OR in a cohort study is simply the odds of the event in the exposed group divided by the odds of event in the unexposed group.
We calculated tests for OR trends for the ordinal independent variables using logistic models that included categorical terms as continuous variables. For these trend tests, we used the likelihood ratio test.
The alpha error was set at 0. The baseline characteristics of the patients appear in Table 1. Among the patients with confirmed COPD, The overall mean age was Of the confirmed COPD patients, Of the mild GOLD grade 1 patients, 9.
The incidence of at least one hospitalized exacerbation increased in our study with increasing disease severity: The most prevalent comorbidity was high blood pressure, which affected Table 2 shows the association between a history of exacerbations and the risk of hospitalized exacerbations and mortality the following year.
Independent of COPD severity, a history of at least two hospitalized exacerbations the previous year was also associated with overall mortality: adjusted OR, 7.
Table 3 shows the association according to COPD severity for the risk of hospitalized exacerbations and mortality the following year. More severe airflow limitation was associated with a higher odds of new hospitalized exacerbations the following year, and it showed a statistically significant dose-response trend: adjusted OR GOLD grade 4, 6.
With respect to the sociodemographic age, sex and lifestyle tobacco, body mass index variables, only age was statistically significantly associated with a higher odd of hospitalized exacerbations and mortality the following year in the multivariable models Table 4.
Regarding comorbidities, heart failure, atrial fibrillation, any severe heart disease, diabetes, and lung cancer were statistically significantly associated with both hospitalized exacerbations and mortality the following year Table 5. S2 Table presents an analysis of the existence of future severe exacerbations with the regression results of all the main associated variables in the full model. The associations and statistically significance were maintained. Regarding sociodemographic and lifestyle factors, older age was associated with new hospitalized exacerbations and mortality the following year.
Our results for the risk of hospitalized exacerbations OR, 1. With respect to mortality, most published studies also show similar results [ 22 , 23 , 24 , 25 , 26 ]. A prior history of hospitalized exacerbations of COPD was associated with new hospitalized exacerbations and showed a statistically significant dose-response pattern.
This effect was independent of COPD severity and the main confounders identified in the present study. In the latter study, at least one hospitalized exacerbation the previous year was the main predictor of at least one hospitalized exacerbation over the following 2 years with a hazard ratio of 2. Independent of the severity of airflow limitation, a history of hospitalized exacerbations the previous year was associated with reduced survival in the present study.
In our sample, These results present an original clinical perspective, supporting the hypothesis that even with milder forms of COPD, there may be some susceptibility to severe exacerbations.
In the present study, as in the ECLIPSE cohort study, the incidence of exacerbations requiring hospital admission increased according to disease severity; it was Thus, COPD severity was also associated with exacerbations requiring hospitalization in our crude and adjusted models, which supports the findings of previous studies [ 15 , 18 , 25 , 31 , 32 ]. When we added the frequent exacerbator phenotype to the multivariable model, the adjusted p trend and associations remained statistically significant.
This suggests that the effect of COPD severity is independent of the frequent exacerbator phenotype. This could explain the associations related to hospitalization.
Regarding mortality, the independent predictive accuracy for COPD severity according to our results was lower than the association between COPD severity and hospitalization; it only appeared to be clinically important for the most advanced severity grade very severe GOLD grade 4. This lower predictive accuracy has been described in other studies [ 22 , 24 , 34 , 35 , 36 ]. In the present study, several comorbidities, such as heart failure and diabetes, were found to be associated with both hospitalized exacerbations and mortality.
On the one hand, it is plausible that with greater number and severity of the comorbidities, more interactions will increasingly result in poor health. Worsening of the general health status or comorbidities could, for example, occur as a consequence of COPD exacerbation treatment side effects systemic steroids inducing hyperglycemia or muscle weakness [ 37 , 38 ]. Anyway, the importance of comorbidities in the role of hospitalized exacerbations and mortality has grown in recent years [ 11 , 26 , 33 , 39 , 40 ].
As a main limitation of the present study, it is necessary to note the retrospective design based on secondary information through clinical databases that were not specifically designed for research objectives. In retrospective studies based on secondary information records , a main limitation could be the low quality of that information; this could be due either to insufficient completion of medical records or lack of agreement among different records.
To minimize bias in the study protocol, we chose only the variables that had been more homogeneously, systematically, and objectively collected in the records. Where possible, we obtained agreement by making a comparison between the primary-care and hospital records. We specifically studied the performance of these missing values; we did so by treating missing values as a separate category and comparing the association between the missing values and risk of hospitalized exacerbations and overall mortality.
Exacerbaciones de la EPOC
Exacerbations of chronic obstructive pulmonary disease COPD carry significant consequences for patients and are responsible for considerable health-care costs—particularly if hospitalization is required. Despite the importance of hospitalized exacerbations, relatively little is known about their determinants. This study aimed to analyze predictors of hospitalized exacerbations and mortality in COPD patients. This was a retrospective population-based cohort study.
Optimizing antibiotic selection in treating COPD exacerbations
The data collected included the following: main patient characteristics, diagnostic tests, applied treatments, response times, discharge destination, need for hospital admission, and re-admissions and deaths at 90 days. Comparisons were made according to sex and need for hospitalization. The overall quality of care provided to AECOPD patients was satisfactory and consistent with current clinical guidelines. Nevertheless, improving the quality of care at the HED requires establishing protocols that ensure that the necessary diagnostic tests are performed, optimize response times and guarantee that all relevant information is collected. Chronic obstructive pulmonary disease COPD is a progressive and debilitating respiratory condition that leads to significant burden in terms of hospital resources, generating more than 50, admissions per year with an average stay of 8. The need for hospital admissions has been of increasing concern. Similarly, the efficient use of alternative routes to conventional hospitalization, such as home hospitalization programs HH , has demonstrated a significant impact on hospital dynamics bed availability and costs associated with AECOPD while maintaining high patient care and satisfaction standards.