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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 92-95

Acute exacerbation of chronic obstructive pulmonary disease in rural area: Why, how, and what next?


Department of Respiratory Medicine, Pramukh Swami Medical College, Anand, Gujarat, India

Date of Submission13-Feb-2019
Date of Decision09-Apr-2019
Date of Acceptance14-Apr-2019
Date of Web Publication1-Jul-2019

Correspondence Address:
Dr. Rajiv P Paliwal
Department of Respiratory Medicine, Pramukh Swami Medical College, Anand - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrc.ijrc_4_19

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  Abstract 


Background: Acute exacerbation of chronic obstructive pulmonary disease(AECOPD) leads to fall in lung function, quality of life, and ultimately disease progression. The present study is an effort to study in detail about COPD exacerbation in a rural tertiary hospital. Aim: To study demographic, clinical, and laboratory profile of hospitalized patients of AECOPD. Methodology: Retrospective data of 170 consecutive patients of AECOPD were collected from records, were divided into two groups based on severity, and were analyzed: Group1 for admission in the wards and Group2 for intensive care unit(ICU) admissions. Results: A total of 141(82.9%) patients were hospitalized in the wards, whereas 29(17.1%) were admitted in the ICU. The mean age was 62.36years in the wards and 64.89years in the ICU. Nearly 89.4% of patients were smokers. Dyspnea(100%) was the most common symptom followed by cough(99%) and expectoration(98%). The mean respiratory rate at the time of presentation was 26/min in the wards and 31.56/min in the ICU. The mean oxygen saturation was 93% in the wards and 88.62% in the ICU. The mean post forced expiratory volume in 1 s(FEV1) was 43.98% in ward patients and 29.28% among ICU patients. Arterial blood gas revealed mean PaCO2 of 44.25mmHg in the wards and 63.24 mmHg in the ICU. The mean pH in the ward was 7.48 compared to 7.34 in the ICU. The mean pulmonary arterial pressure(PAP) was higher in the ICU(53.74mmHg) than in the ward(38.87mmHg). Conclusion: The ratio of hospitalization in ICU to ward was 1:5. The site of treatment depends on respiratory rate, oxygen saturation, post-FEV1%, PAP, pH, and PaCO2.

Keywords: Chronic obstructive pulmonary disease, exacerbation of chronic obstructive pulmonary disease, inhaler therapy, nonpharmacological measures


How to cite this article:
Kshatriya RM, Paliwal RP, Khara NV, Patel SN. Acute exacerbation of chronic obstructive pulmonary disease in rural area: Why, how, and what next?. Indian J Respir Care 2019;8:92-5

How to cite this URL:
Kshatriya RM, Paliwal RP, Khara NV, Patel SN. Acute exacerbation of chronic obstructive pulmonary disease in rural area: Why, how, and what next?. Indian J Respir Care [serial online] 2019 [cited 2019 Nov 15];8:92-5. Available from: http://www.ijrconline.org/text.asp?2019/8/2/92/261901




  Introduction Top


Chronic obstructive pulmonary disease(COPD) is a common, preventable, and treatable inflammatory respiratory disease. It is characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.[1] Smoking is the leading cause of COPD worldwide. Other common causes are biomass fuel consumption, indoor and outdoor pollution, poorly treated and controlled asthma, and postinfective sequel. Reduction of risk factors such as smoking cessation and oxygen therapy can modify the disease outcome by reducing decline in lung function. Other management strategies such as pharmacotherapy, immunization, and pulmonary rehabilitation are supportive and improve the quality of life and prevent exacerbations.[1],[2],[3] However, they are not potentially implemented in every case of COPD due to various factors which leads to severe-to-very severe exacerbations.[2],[3]

COPD exacerbation manifests as a change in patient's baseline symptoms such as worsening breathlessness and increase in cough along with increase in sputum amount and purulence.[1],[3] Lower respiratory tract infections are the most common cause of exacerbations, while the remaining causes are exposure to indoor or outdoor air pollutants, changes in weather, and several host factors including prior compliance to therapy.[2],[3] Various independent risk factors contribute to COPD exacerbations.[3],[4],[5],[6],[7] Very few studies are available from India on risk factors for exacerbations of COPD, more so from rural area.[4] Though adequate COPD control measures and guidelines are mentioned worldwide in the medical field, patients still experience episodes of exacerbations frequently with a huge impact on the overall health condition, both physically and mentally. Moreover, COPD exacerbation incurs a huge cost and can cause significant dent in pulmonary function and the quality of life.[1],[3] COPD is often described and discussed with a focus on definition, etiology, treatment, and outcomes. Less focus is aimed at the clinical assessment and presentation of the patient with an acute exacerbation, probably because this is seen as one of every clinician's basic medical skills. Demographic profile, addiction history, etiology of acute exacerbation of COPD(AECOPD), presentation of acute exacerbation, use of inhaler bronchodilators, and implementation of nonpharmacological measures can vary in different populations, whether rural or urban.

The objective of this study was to examine the demographic, clinical, and laboratory profile of patients admitted with AECOPD. The study also aimed to compare patients' profile between mild-to-moderate exacerbations requiring admissions in low-dependency area(ward) and severe-to-very severe exacerbations requiring care in high-dependency area(intensive care unit[ICU]).


  Methodology Top


Approval of institutional ethical committee was taken prior to the study. Retrospective data of 170patients with AECOPD hospitalized for 12months were analyzed. The patients were divided into two groups: “Group1” with mild-to-moderate exacerbations requiring treatment in low-dependency areas(wards) and “Group2” with severe exacerbations requiring treatment in high-dependency areas(ICUs). The following data were collected:

  • Demographic data, addiction history, occupation, and body mass index(BMI)
  • Presenting symptoms such as breathlessness, cough with purulent sputum, fever, chest pain, altered sensorium, previous history of diseases including COPD, and other comorbid conditions(hypertension, diabetes, ischemic heart disease, and tuberculosis)
  • Spirometry parameters such as postbronchodilator forced expiratory volume in 1 s(post FEV1% predicted) and forced vital capacity(predicted)
  • Arterial blood gas analysis reports at the time of admission.


Blood reports, specifically white blood cell count with neutrophilic response to check infection; echocardiography reports for pulmonary arterial pressure(PAP); and other relevant history were recorded and analyzed.

History of usage of oral and inhaler bronchodilators; type of pharmacological group of bronchodilators; and type of inhaler devices such as dry powder inhaler(DPI), metered dose inhaler(MDI), and nebulizer were studied.

Comparisons between the two groups were done among various parameters. Statistical analysis was carried out with STATA (Statistics/Data analysis) software 14 version of StataCorp. Texas, USA with the use of appropriate statistical tests.


  Results Top


Out of 170patients, 141(82.9%) were admitted in the wards(Group1) and 29(17.05%) were admitted in the ICU(Group2). Atotal of 155(91%) patients were male. The mean age of ward patients was 62.36years and that of ICU patients was 64.89years.

A total of 152(89.4%) patients were smokers: 123patients were current smokers, whereas 29patients were ex-smokers. In the smoking history 36.61 smoke pack years was average in the patients admitted in ward wheres as in the patients admitted in ICU it was 34.93 smoke pack years. In nonsmokers, 8.8% of patients had COPD due to exposure to biomass fuel. The most common occupation was farming(58/170, 34.11%). There was a seasonal pattern for exacerbation, with maximum number of exacerbations from August to March and least numbers in the remaining months[Figure1].
Figure1: Seasonal pattern

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Dyspnea was the most common presenting symptom (170patients, 100%) followed by cough(168patients, 99%) with expectoration(167patients, 98%). Fifty-four(31.67%) patients had fever and 11(6.47%) had altered sensorium.

A majority of patients had Grade2 and Grade3 dyspnea as per the Modified Medical Research Council grading.

Fifty-three patients(31.18%) had a past history of tuberculosis, 16patients(9.41%) had ischemic heart disease, 12patients(7%) had diabetes, and 34(20%) patients had hypertension, whereas 115patients(67.65%) had no comorbid conditions.

Radiological parameters revealed that 83(49%) patients had emphysematous changes, 51(30%) had prominent bronchovascular markings, 11(6.47%) patients had infiltrations, 9(5.29%) patients had bronchiectasis, and 8(4.70%) patients had lobar consolidation. Six(3.53%) patients had fibrocavitary lung and two patients(1.18%) had pneumothorax.

Sputum Gram staining revealed isolated Gram-negative bacilli(GNB) in 19patients(11.18%), Gram-positive cocci(GPC) in 17patients(10%), and both GPC and GNB in 6patients. One patient had Gram-positive coccobacilli in his sputum. In 126 sputum samples of patients gram staining did not revealed any organism.

Culture from sputum revealed Pseudomonas aeruginosa in 12patients,  Escherichia More Details coli in 5patients, Klebsiella pneumoniae in 1patient, Acinetobacter baumanni in 1patient, Citrobacter freundii in 1patient, Staphylococcusaureus in 1patient, Streptococcus pneumoniae in 3patients, and Branhamella catarrhalis in 2patients. No organism was isolated in 143patients.

Comparison of various parameters between the two groups is summarized in [Table1].
Table 1: Comparison of various parameters between patients with acute exacerbation of chronic obstructive pulmonary disease admitted to the ward and intensive care unit

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Regarding treatment, DPI was the most common inhaler(60/170, 35.29%) used by patients in routine management followed by nebulizer(30/170, 17.65%) and MDI(6/170, 3.5%). Beta-2 agonists were used by 96% of patients overall, inhaled corticosteroids by 52.9%, and anticholinergics were used by 32.35% of patients. Use of oral bronchodilators was significantly higher(93%), whereas use of inhaler medicines was noted only in 54.7% of patients. Immunization was done for influenza only in 21(12.35%) patients. Only 95 of 170(55.9%) patients underwent pulmonary rehabilitation.


  Discussion Top


Smoking was the leading cause of COPD in this study, similar to that mentioned in GOLD study.[1] No significant association was observed between age, sex, severity of exacerbation, and level of care. Similar results were found in a study conducted by Mohapatra and Janmeja.[4] The maximum number of exacerbations was seen between August and March, possibly due to high humidity, cold weather, increased possibility of mold contamination, or viral exacerbations. Various studies including the present study showed seasonal pattern of exacerbation, with the maximum being in winter season.[8]

Out of the 170 admissions of exacerbation of COPD, for every five admissions in the ward(low-dependency area), there is one admission in high-dependency area or ICU. It is really a cause of concern as every admission in ICU can lead to significant morbidity, mortality, and economic burden to patient and health-care system in developing countries. Admission to wards or high-dependency area does not depend on smoking history, BMI, duration of COPD history, and frequency of previous hospitalizations. Parameters such as respiratory rate, oxygen saturation, raised white blood cell counts with neutrophilia, post-bronchodilator FEV1 done in stable stage, pulmonary artery pressure, blood pH, and level of PaCO2 in blood are more relevant. According to Garcia-Gutierrez et al., predictors of appropriate hospitalization were severity of current COPD exacerbation, response to previous treatment, and expected adherence to treatment.[9]

ICU admission can lead to significant financial burden with increased morbidity and increased duration of hospital stay with possible nosocomial infections as narrated by Oostenbrink and Rutten-van Mölken.[10] Underweight, history of concomitant diseases, and increased dyspnea are factors that are likely to identify patients who are at increased risk for generating high costs due to hospitalization. Hospitalization accounted for 90% of the total costs of exacerbations. The cost of care in high-dependency area with severe exacerbation was five to six times higher Than that in the ward in the present study.

The best predictor of having frequent exacerbations(two or more per year) was a history of previously treated events as mentioned in the GOLD guidelines, but history of frequent exacerbations did not signify the severity or determine the level of care after hospitalization in this study.[1] Patients with reduced lung function have severe exacerbation requiring admissions in high-dependency ward or ICU, similar to that suggested in the GOLD guidelines.[1]

Infective exacerbations are more common and severe. Viral infections are most common followed by bacterial infections. Bacterial etiology in AECOPD varies, but infections with GNB are more common in COPD due to prior colonization.[3],[11],[12] In the present study, GNB were more often isolated from the sputum of patients admitted with COPD exacerbation.

Only half of the patients with AECOPD were using inhalers as a part of their routine treatment. Lower use of inhalers is a cause of concern as demonstrated in a study done by Chrystyn et al., who mentioned that better compliance for use of inhalers appears to be modestly associated with better health status and less frequent COPD exacerbations.[13] There is a greater need to promote inhaler use among patients which ultimately helps in the better management of COPD.

Nonpharmacological measures are still less utilized for holistic management of COPD in rural areas of developing countries, which again raises questions regarding the implications and effectiveness of pulmonary rehabilitation.


  Conclusion Top


Exacerbations of COPD in rural area are quite common and severe, which demands high level of health-care facility and resources. Factors determining the severity of exacerbations and level of care in the hospital are poor lung function, higher respiratory rate on presentation, blood pH, blood carbon dioxide level, and PAP. Inhaler bronchodilators are still less utilized as compared to oral bronchodilators. Interventions to promote the use of inhaler devices such as mass media coverage, subsidized rate of inhaler medicines, health education at the level of primary care physician, and discouraging the use of oral bronchodilators may be promoted. Immunization for influenza in COPD patients is very low. Pulmonary rehabilitation which is an integral part of COPD management is less implemented in rural areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
SinghD, AgustiA, AnzuetoA, BarnesPJ, BourbeauJ, CelliBR, etal. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: The GOLD science committee report 2019. Eur Respir J 2019. pii: 1900164.  Back to cited text no. 1
    
2.
Garcia-AymerichJ, Monsó E, MarradesRM, EscarrabillJ, Félez MA, SunyerJ, etal. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study. Am J Respir Crit Care Med 2001;164:1002-7.  Back to cited text no. 2
    
3.
Ghoshal AG, Dhar R, Kundu S. Treatment of acute exacerbation of COPD. Supplement To J Assoc Physicians India 2012;60:38-43.  Back to cited text no. 3
    
4.
MohapatraPR, JanmejaAK. Factors associated with hospital admission in patients with acute exacerbation of chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2010;52:203-6.  Back to cited text no. 4
    
5.
KesslerR, FallerM, FourgautG, MennecierB, WeitzenblumE. Predictive factors of hospitalization for acute exacerbation in a series of 64patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999;159:158-64.  Back to cited text no. 5
    
6.
RobertsCM, LoweD, BucknallCE, RylandI, KellyY, PearsonMG. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax 2002;57:137-41.  Back to cited text no. 6
    
7.
MohanA, PremanandR, ReddyLN, RaoMH, SharmaSK, KamityR, etal. Clinical presentation and predictors of outcome in patients with severe acute exacerbation of chronic obstructive pulmonary disease requiring admission to intensive care unit. BMC Pulm Med 2006;6:27.  Back to cited text no. 7
    
8.
DonaldsonGC, GoldringJJ, WedzichaJA. Influence of season on exacerbation characteristics in patients with COPD. Chest 2012;141:94-100.  Back to cited text no. 8
    
9.
Garcia-GutierrezS, QuintanaJM, BilbaoA, UnzurrunzagaA, EstebanC, Baré M, etal. Validity of criteria for hospital admission in exacerbations of COPD. Int J Clin Pract 2014;68:820-9.  Back to cited text no. 9
    
10.
OostenbrinkJB, Rutten-van Mölken MP. Resource use and risk factors in high-cost exacerbations of COPD. Respir Med 2004;98:883-91.  Back to cited text no. 10
    
11.
Sinha N, Christopher DJ, Prakash J, James P. Prospective study of infectious bacterial etiology of acute exacerbation of chronic obstructive pulmonary disease in India. F1000Research 2010;1.  Back to cited text no. 11
    
12.
HurstJR, DonaldsonGC, WilkinsonTM, PereraWR, WedzichaJA. Epidemiological relationships between the common cold and exacerbation frequency in COPD. Eur Respir J 2005;26:846-52.  Back to cited text no. 12
    
13.
ChrystynH, SmallM, MilliganG, HigginsV, GilEG, EstruchJ. Impact of patients' satisfaction with their inhalers on treatment compliance and health status in COPD. Respir Med 2014;108:358-65.  Back to cited text no. 13
    


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