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Anemia and performance status as prognostic markers in acute hypercapnic respiratory failure due to chronic obstructive pulmonary disease.

In patients with acute hypercapnic respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with respiratory acidosis due to COPD.

METHODS: COPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV1), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded.

RESULTS: In total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS ≥ 3, long-term oxygen therapy, anemia, diastolic blood pressure < 70 mmHg, Early Warning Score ≥ 3, severe acidosis (pH < 7.20), and serum albumin < 35 g/L. On multivariate analysis, only anemia and WHO-PS ≥ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%.

CONCLUSION: WHO-PS ≥ 3 and anemia are prognostic factors in AHRF with respiratory acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.

Hypophosphatemia as a prognostic value in acute exacerbation of COPD.

Phosphorus (P) is an essential element in all living cells, it is extremely important in the process of production of ATP, main element in the structure of nucleic acids. Low levels of phosphorus in blood is very rare, however it may be caused by unbalance between components participating in phosphorus cycle and affect performances of several systems. A low level of phosphorus in the blood increases the exacerbation and the severity of chronic obstructive pulmonary disease (COPD), and requires prolonged ventilation process.

AIM: Examining the prognostic effects of hypophosphatemia in COPD patients, and evaluating the correlation between phosphorus levels and severity, recurrences of attacks, ventilation duration and successful of weaning process.

METHODS: 255 patients who were admitted due to worsening in COPD, from October 2010- April 2011, were examined. A comparison was made between the group with normal blood phosphorus (2.5 - 4.5 mg %), group of patients with low phosphorus (2 - 2.5 mg %) and group with very low phosphorous values (<2.0 mg%) . RESULTS: 95% of all admissions had normal blood phosphorus levels, 3.3% had low phosphorus levels, and only 1.7% of all admissions had very low phosphorus levels. 2.4% of patients had both low levels of phosphorus and potassium. All patients (100%) with very low phosphorus needed mechanical ventilation, compared to 62.5% of patients with low phosphorus and 16.9% of patients with normal phosphorus levels. In addition 16 ventilated patients (33% of all ventilated patients) had low potassium values.

SUMMARY: Low blood phosphorus levels contribute to an increase in: COPD flare-up, need for ventilation, duration of hospitalization, days in intensive care units and finally increased rate of mortality. Accordingly, close monitoring and careful adjustment of disorders correlated to electrolyte such as phosphorus, are crucial and may improve prognosis and also increase the survival rate of patients with COPD.

The insertion/deletion polymorphism in the ACE gene and chronic obstructive pulmonary disease.

An insertion/deletion (I/D) polymorphism was identified in intron 16 of the gene encoding the human angiotensin I-converting enzyme (ACE), a candidate gene for chronic obstructive pulmonary disease (COPD).

We investigated the relationship between this polymorphism in the ACE gene and the risk of developing COPD. Sixty-six COPD in-patients and 40 non-smoking control individuals were recruited for this study.

The distribution of ACE genotypes in these individuals was studied. The frequencies of ACE genotypes were found to be 47.0% for DD, 30.3% for ID, and 22.7% for II in the COPD group and 32.5% for DD, 47.5% for ID, and 20.0% for II in the control group. The allele frequencies were found to be 0.62% for the D allele and 0.38% for the I allele in the COPD group and 0.56% for the D allele and 0.44% for the I allele in the control group. A significant difference was found between I and D allele frequencies (P < 0.05) of the study and control groups.

Our results suggest that this ACE polymorphism may be associated with the development of COPD.

Clinical Stability versus Clinical Failure in Patients with Community-Acquired Pneumonia

Once antibiotics have been started in patients with community-acquired pneumonia (CAP), the evaluation of clinical outcomes represents one of the essential steps in patient care. Among CAP patients who improve, recognition of clinical stability should be based on both subjective and objective parameters that are locally available in the everyday clinical practice.

Different steps in the management of the pneumonia depend on this early outcome, including the switch from intravenous to oral antibiotics, patients' discharge from the hospital, and outcomes after hospitalization. When deterioration occurs in CAP patients, a “treatment failure” or a “clinical failure” should be identified. It is crucial to understand ...

Assessing Severity of Patients with Community-Acquired Pneumonia

Despite all advances in its management, community-acquired pneumonia (CAP) is still an important cause of morbidity and mortality requiring a great consumption of health, social, and economic resources. An early and adequate severity assessment is of paramount importance to provide optimized care to these patients.

In the last 2 decades, this issue has been the subject of extensive research. Based on 30 day mortality, several prediction rules have been proposed to aid clinicians in deciding on the appropriate site of care. In spite of being well validated, their sensitivity and specificity vary, which limits their widespread use. The utility of biomarkers to overcome this problem has been investigated. At this moment, t...

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