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Description of Hospital Admissions for Acute Exacerbation of COPD | OMICS International
ISSN: 2161-105X
Journal of Pulmonary & Respiratory Medicine

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Description of Hospital Admissions for Acute Exacerbation of COPD

García-Sanz María-Teresa1*, Cánive-Gómez Juan Carlos2, Alonso Acuña Sara3, Barreiro García Alejandra3, López Val Eva3, Senín Rial Laura3, Temes Enrique4, Álvarez Dobaño José Manuel5, Valdés Luis5 and González-Barcala Francisco-Javier5

1Emergency Department. Salnés County Hospital. Vilagarcía de Arousa, Spain

2Family and Community Medicine, Pontevedra, Spain

3Nurse- Hospital Complex of Santiago de Compostela, Spain

4Pneumology Service – Hospital Complex of Pontevedra, Spain

5Pneumology Service – Hospital Complex of Santiago de Compostela, Spain

*Corresponding Author:
García Sanz MT
Servicio de Urxencias, Hospital do Salnés
Ande-Rubiáns s/n, Vilagarcía de Arousa (Pontevedra), Spain
Tel: +34-619-315-281
E-mail: [email protected]

Received date: July 04, 2014; Accepted date: September 23, 2014; Published date: September 26, 2014

Citation: María-Teresa GS, Carlos CGJ, Sara AA, Alejandra BG, Eva LV, et al. (2014) Description of Hospital Admissions for Acute Exacerbation of COPD. J Pulm Respir Med 4:200. doi:10.4172/2161-105X.1000200

Copyright: © 2014 García Sanz MT, et al. 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.

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Abstract

Background: Chronic obstructive pulmonary disease (COPD) affects 9.1% of the population aged 40-69 in Spain, with wide geographic variation. Acute exacerbations of COPD (AECOPD) are a frequent cause of hospital admission, significantly increasing healthcare costs and affecting the quality of life of patients. Patient characteristics and treatment procedures differ across geographic areas, even across hospitals in the same country.

Objective: To analyze epidemiological and clinical factors associated with hospital admissions for AECOPD in our health area.

Methods: Retrospective study reviewing the medical records of all patients admitted for AECOPD in the Hospital Complex of Santiago de Compostela, between 2007 and 2008. Data are expressed as mean (±standard deviation) or median (interquartile range) values for continuous variables and as frequencies or percentages for categorical variables. Chi-square was used to compare proportions, and Student’s t-test for mean values (Mann-Whitney’s U-test for variables on non-normal distributions).Data analysis was performed with SPSS 15.

Results: We registered 1403 admissions for AECOPD of 757 patients, predominantly male (77% of cases), elderly (60% aged above 75), with moderate to severe forms of the disease, as 56.4% of patients were either in GOLD stage II or III. Smoking history was included in the records of 475 patients (63%), 30% of patients which were active smokers. Charlson index was above 2 in 64% of cases. The most common symptom was dyspnea. Hospital admissions were more common in the winter season. The average stay in the period under study was 12.3 days. 3.6% required admission to the ICU. 6% of patients were readmitted early and 4.8% died during hospitalization. As for baseline therapy, it notably included anticholinergics for 62% and inhaled corticosteroids (ICS) for 60% of patients. 26% followed home oxygen therapy. Smoking cessation care provision took place in 7.9% of cases.

Conclusions: AECOPD patients in our health area are mainly elderly males. Their overall health is not good, with significant comorbidity. The average stay is long. 4.8% die during hospitalization. 5.8% are readmitted within 15 days. 26% follow home oxygen therapy, but this indication is questionable in one in four cases. Smoking cessation care provision during hospitalization should be significantly improved.

Abstract

Background: Chronic obstructive pulmonary disease (COPD) affects 9.1% of the population aged 40-69 in Spain, with wide geographic variation. Acute exacerbations of COPD (AECOPD) are a frequent cause of hospital admission, significantly increasing healthcare costs and affecting the quality of life of patients. Patient characteristics and treatment procedures differ across geographic areas, even across hospitals in the same country.

Objective: To analyze epidemiological and clinical factors associated with hospital admissions for AECOPD in our health area.

Methods: Retrospective study reviewing the medical records of all patients admitted for AECOPD in the Hospital Complex of Santiago de Compostela, between 2007 and 2008.

Data are expressed as mean (±standard deviation) or median (interquartile range) values for continuous variables and as frequencies or percentages for categorical variables. Chi-square was used to compare proportions, and Student’s t-test for mean values (Mann-Whitney’s U-test for variables on non-normal distributions).Data analysis was performed with SPSS 15.

Results: We registered 1403 admissions for AECOPD of 757 patients, predominantly male (77% of cases), elderly (60% aged above 75), with moderate to severe forms of the disease, as 56.4% of patients were either in GOLD stage II or III. Smoking history was included in the records of 475 patients (63%), 30% of patients which were active smokers. Charlson index was above 2 in 64% of cases. The most common symptom was dyspnea. Hospital admissions were more common in the winter season. The average stay in the period under study was 12.3 days. 3.6% required admission to the ICU. 6% of patients were readmitted early and 4.8% died during hospitalization. As for baseline therapy, it notably included anticholinergics for 62% and inhaled corticosteroids (ICS) for 60% of patients. 26% followed home oxygen therapy. Smoking cessation care provision took place in 7.9% of cases.

Conclusions: AECOPD patients in our health area are mainly elderly males. Their overall health is not good, with significant comorbidity. The average stay is long. 4.8% die during hospitalization. 5.8% are readmitted within 15 days. 26% follow home oxygen therapy, but this indication is questionable in one in four cases. Smoking cessation care provision during hospitalization should be significantly improved.

Keywords

COPD; Exacerbation; Hospital admissions

Introduction

A chronic disease with high prevalence and healthcare resource consumption, COPD affects 9.1% of the population aged 40-69 in Spain, predominantly males, with wide geographic variation [1]. Acute exacerbations of COPD (AECOPD) are a frequent cause of hospital admission, significantly increasing healthcare costs and affecting the quality of life of patients [2-4]. Patient characteristics and treatment procedures differ across geographic areas, even across hospitals in the same country [5]. Our objective was to analyze epidemiological and clinical factors associated with hospital admissions for AECOPD in our health area.

Methods

We conducted a retrospective study reviewing the medical records of all patients admitted for AECOPD between 2007 and 2008. The data were provided by the Admissions and Clinical Documentation Department in the Hospital Complex of Santiago de Compostela, Spain. The study included patients admitted to the Internal Medicine, Pneumology and/or Intensive Care (ICU) Units. Baseline disease severity was defined following the criteria in the GOLD guide [6]. Baseline dyspnea was rated from the Medical Research Council (MRC) scale, in five levels, ranging from 0 (no dyspnea) to 4 (dyspnea at rest) [7]. Comorbidity was assessed with the Charlson Index [8]. Early readmission was defined as that occurring within 15 days of discharge for the same reason [9]. Severity of acute exacerbation was defined as Type 1 for patients who met all three Anthonisen’s criteria, as Type 2 for those with two out of three symptoms, and Type 3 for those with only one [10].

Vital signs were obtained from the first examination in the Emergency Department (ED). Blood chemistry and complete blood count data were taken from the first analysis performed at the time of hospital admission. Arterial blood gas (ABG) values were obtained from the first ABG analysis available following the arrival to the ED. Oxygen saturation measured by pulse oximetry was included for those patients without ABG analysis. The data obtained are expressed as mean (± standard deviation) or median (interquartile range) values for continuous variables and as frequencies or percentages for categorical variables. Chi-square was used to compare proportions, and Student’s t-test for mean values (Mann-Whitney’s U-test for variables on non-normal distributions). Data analysis was performed with SPSS 15.

Results

In the period under study, we registered 1403 admissions for AECOPD of 757 patients, predominantly male (77% of cases), elderly (60% aged above 75), with moderate to severe forms of the disease, as 56.4% of patients were either in GOLD stage II or III. Notably, smoking history was included in the records of 475 patients (63%) only, 30% of which were active smokers. Spirometry was included in the records of 202 patients (26.68%). Comorbidity was common, as the Charlson index was above 2 in 64% of cases. 30% of patients had been admitted the previous year due to AECOPD (Table 1).

Age (years)  
Mean (SD) 74.8 (11.26)
Median (IR) 77 (69.83)
< 65 117 (15.5%)
65-74 200 (26.4%)
75-84 301 (39.8%)
≥ 85 139 (18.4%)
Males 585 (77.3%)
Tobacco use (n=475)  
Never smoker 67 (14.1%)
Smoker 144 (30.3%)
Former smoker 255 (53.7%)
Passive smoker 9 (1.9%)
Charlson  
0 4 (0.5%)
1, 2 270 (35.7%)
>2 483 (63.8%)
GOLD (n= 202)  
I 28 (13.9%)
II 58 (28.7%)
III 57 (28.2%)
IV 59 (7.8%)
FEV1% (SD) ( n=202) 51.16 (26.68%)
Admissions previous year  
None 539 (71.2%)
1 156 (19.3%)
2 or more 72 (9.5%)
Emergencies previous year  
None 460 (60.8%)
1 161 (21.3%)
2 or more 136 (18%)

Table 1: Socio-demographic and clinical characteristics (N =757)

The most common reason for consultation was dyspnea (84.8%), which was also the most common symptom (reported by 94.1% of patients), followed by coughing (74.5%). 70% of patients were admitted to the Pneumology Service. 3.6% required admission to the ICU. Hospital admissions were more common in the winter season, as 40% of them occurred between January and March. The average stay in the period under study was 12.3 days. 6% of patients were readmitted early and 4.8% died during hospitalization (Table 2). As for baseline therapy, it notably included anticholinergics for 62% and inhaled corticosteroids (ICS) for 60% of patients (Table 3). 26% followed home oxygen therapy, but this indication was questionable in one in four cases, as gas analysis following stabilization could not be verified in 22.5% of patients, and 0.5% of patients had no respiratory failure. Smoking cessation care provision took place in 7.9% of cases.

  Total (n=757) < 85 years (n=618) ≥ 85 years (n=139) P
Department of admission        
PNE 527(70%) 445(72.2%) 82(59.9%) 0.003
IM 218(29%) 163(26.5%) 55(40.1%)  
Mean stay (SD) 12.3(9.12) 12.4(9.5) 11.6(7.1) NS
ICU 27(3.6%) 26(4.2%) 1(0.7%) 0.045
Season       NS
Spring 199(26.3%) 158(25.6%) 41(29.5%)  
Summer 116(15.3%) 94(15.2%) 22(23%)  
Fall 141(18.6%) 109(17.6%) 32(23%)  
Winter 301(39.8%) 257(41.6%) 44(31.7%)  
Reason for consultation       0.015
Dyspnea 642(84.8%) 530(85.9%) 112(80.6%)  
Temperature 31(4.1%) 28(4.5%) 3(2.2%)  
Coughing 13(1.7%) 12(1.9%) 1(0.7%)  
Symptoms        
Dyspnea 712(94,1%) 585(94,7%) 127(91,4%) NS
Coughing 564(74,5%) 460(74,4%) 104(74,8%) NS
Increased sputum amount 452(59,7%) 368(59,5%) 84(60,4%) NS
Sputum purulence 261(34,5%) 215(34,8%) 46(33,1%) NS
Temperature 231(30,5%) 194(31,4%) 37(26,6%) NS
Hemoptysis 36(4,8%) 29(4,7%) 7(5%) NS
Exacerbation (Anthonisen)       NS
Type 1 245(32.4%) 200(32.4%) 45(32.4%)  
Type 2 206(27.2%) 169(27.3%) 37(26.6%)  
Type 3 278(36.7%) 230(37.2%) 48(34.5%)  
Vital signs (SD)        
T (C) 36.9(0.94) 36.9(0.96) 36.8(0.85) NS
Respiratory rate 23(6.4) 23(6.5) 20(5) 0.018
SBP (mmHg) 131(24.1) 131(24) 132(24.3) NS
DBP (mmHg) 74(13.5) 74.7(13.4) 70.7(13.2) 0.001
Laboratory data (SD)        
Hemoglobin (g/dl) 13.5(2.2) 13.6(2.2) 13.1(1.9) 0.015
Hematocrit (%) 40 (6.7) 40.2(6.8) 39.2(5.8) NS
Leukocytes (106/L) 12 160(9424.3) 11 993(9273) 12 880(10 068) NS
Platelets (106/L) 249 514(104 336) 249 243(107 745) 250 717(87 944) NS
Fibrinogen (mg/dl) 454(152.7) 450(159) 468(127) NS
Glycemia (mg/dl) 143(67.7) 142(68) 143(62) NS
Urea (mg/dl) 68.4(38) 56.5(31.2) 77.2(44.5) < 0.0001
Creatinine (mg/dl) 1.15(0.7) 1.14(0.7) 1.4(0.7) 0.001
PaO2 (mmHg) 58(19.1) 59(20.2) 55(13) 0.049
PaCO2 (mmHg) 47.7(15.3) 46.9(15.8) 45.6(12.7) NS
Early readmission 44(5.8%) 34(5.6%) 10(7.4%) NS
Hospital mortality 36(4.8%) 25(4%) 11(7.9%) 0.053

Table 2: Characteristics of the acute exacerbation

   Before admission Indication at discharge
Anticholinergics 422(61.9%) 559 (79.1%)
SABA 230(33.8%) 208 (29.5%)
LABA 393(57.8%) 521 (73.7%)
Inhaled corticosteroids 410(60.3%) 543 (76.8%)
Theophylline 36(5.3%) 22 (3.1%)
Oral corticosteroids 34(5%) 358 (50.4%)
Home oxygen therapy   196 (26%)
Anti-smoking advice   60 (7.9%)

Table 3: Baseline treatment and treatment at discharge

Discussion

Hospital admissions for AECOPD in our health area occur mainly in elderly males. The higher male rate is referred to in other studies including Spanish populations [11,12], but it is much higher than the rate reported in other countries, ranging 52-70%, probably or at least partly related to the late access of women to tobacco in our population [5,13-15]. Old age is a common feature in the various studies of patients admitted for AECOPD, as most studies report a mean age above 70 [16-20]. In those cases where data on tobacco use were recorded, we found that 86% of patients were active smokers or former smokers, as befits a disease closely associated with smoking [6], and as reported in other studies [12,16].

The majority of patients were admitted to the Pneumology Service, with a relative participation higher than that by the same specialists in other European countries, where assistance to AECOPD patients is less dependent on this specialty [13,15]. Seasonality in admissions for AECOPD—more frequent in winter, as for viral respiratory infections—confirms the trend observed in other studies [19,21,22]. The hospital stay of our patients seems long compared to that observed in other populations [18,19,21,23,24]. Hospital mortality was 4.8%, lower than that in most published studies [19,21,24-26]. The possible factors related to hospital stay and mortality have not been addressed in this study. Being complex issues, they will require a specific study [24,27-30]. The indication of bronchodilators and ICS at discharge shows a significant increase in the use of maintenance therapy for our patients. One quarter of the patients discharged were prescribed home oxygen therapy, although not always in accordance with blood gas criteria. Recent studies in other European countries show that the prescription of home oxygen therapy is inadequate for 10-15% of patients [31,32]. Notably, attention to smoking cessation care—even in COPD patients—is poor, as data on tobacco use were recorded only for 63% of patients, and anti-smoking advice at discharge was given to less than 8% of patients. As these figures are clearly better in other populations, this suggests the urgency to alert healthcare professionals on the need to increase proactivity against tobacco use [33-35].

Conclusions

AECOPD patients in our health area are mainly elderly males. Their overall health is not good, with significant comorbidity. 70% are admitted to the Pneumology Service. The average stay is long. 4.8% die during hospitalization. 5.8% are readmitted within 15 days. 26% follow home oxygen therapy, but this indication is questionable in one in four cases. Smoking cessation care provision during hospitalization should be significantly improved.

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