0
Clinical Investigations: COPD |

Mortality and Mortality-Related Factors After Hospitalization for Acute Exacerbation of COPD* FREE TO VIEW

Karin H. Groenewegen; Annemie M.W.J. Schols; Emiel F.M. Wouters
Author and Funding Information

*From the Department of Pulmonology, University Hospital Maastricht, Maastricht, the Netherlands.

Correspondence to: Karin H. Groenewegen, MD, Department of Pulmonology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, the Netherlands; e-mail:ewo@slon.azm.nl



Chest. 2003;124(2):459-467. doi:10.1378/chest.124.2.459
Text Size: A A A
Published online

Background: Acute exacerbations form a major component of the socioeconomic burden of COPD. As yet, little information is available about the long-term outcome of patients who have been hospitalized with acute exacerbations, although high mortality rates have been reported.

Study objective: The aim of this study was to investigate prospectively the outcome for all patients admitted to the hospital with acute exacerbations of COPD during hospital admission and after 1-year of follow-up. Furthermore, patient characteristics related to increased mortality rate were analyzed.

Design: We investigated prospectively the 1-year mortality rate and potential determinants of mortality for all patients admitted to the hospital with an acute exacerbation between January 1 and December 31, 1999.

Results: A total of 171 patients were included in the study. The mortality rate during hospital stay was 8%, increasing to 23% after 1 year of follow-up. Despite a comparable in-hospital mortality rate (6%), the 1-year mortality rate was significantly higher for patients admitted to the ICU for respiratory failure (35%). The multivariate Cox proportional hazards model was used to determine independent predictors of survival. Variables included in the regression model were age, sex, FEV1, Pao2, Paco2, body mass index, long-term use of oral corticosteroids, comorbidity index, and hospital readmissions. The maintenance use of oral glucocorticosteroids (relative risk [RR], 5.07; 95% confidence interval [CI], 2.03 to 12.64), Paco2 (RR, 1.17; 95% CI, 1.01 to 1.38), and age (RR, 1.07; 95% CI, 1.01 to 1.12) were independently related to mortality.

Conclusion: We conclude that the prognosis for patients who have been admitted to the hospital for acute exacerbation of COPD is poor. Long-term use of oral corticosteroids, higher Paco2, and older age could be identified as risk factors associated with higher mortality.

Figures in this Article

COPD is a major cause of morbidity and mortality, and is an important health economic problem. Since 1960, there has been an increase in mortality associated with COPD, especially in men. In recent years, mortality from COPD, especially among women, has increased further.1 Worldwide, COPD is the only leading cause of death that still has a rising mortality rate, and it has been estimated that by the year 2020 COPD will be fifth among the conditions with a high burden to society.2 Hospitalization for acute exacerbations represents a major component of the socioeconomic burden related to COPD.3

Despite the high number of COPD-related hospitalizations, relatively little is known about the mortality rate and related determinants of patients hospitalized for this acute deterioration in the clinical course of COPD. The most important and largest study on survival after hospital admission for acute exacerbations was performed by Connors et al.4 They reported high mortality rates (in-hospital mortality rate, 11%; 1-year mortality rate, 43%; 2-year mortality rate, 49%).

Among COPD patients requiring mechanical ventilation for respiratory failure, the mortality rate is even higher, as demonstrated by Seneff et al5 that reported an in-hospital mortality rate of 24% for all patients and 30% for patients ≥ 65 years, with mortality rates after hospital discharge increasing to 59% after 1 year.

Several studies have investigated predictive factors related to an increased COPD-related mortality risk. Patient characteristics that have been reported to influence survival in stable COPD patients include FEV1,68 age,78 Paco2,,6 cardiac factors,67 diffusion capacity,6 and body mass index (BMI).912

Other studies have investigated more specifically factors related to mortality after acute exacerbations of COPD. Factors that have been reported as risk factors for mortality after exacerbations are Paco2, oxygen saturation and resting oxygen uptake13 , low BMI,4,9 older age,4,1415 cardiac factors,4,1415 other comorbidities,15 and severity of illness, serum albumin level, functional status, and Pao2.,4

The present study was designed to assess prospectively the mortality rates and potential determinants of mortality for patients admitted to the hospital for acute exacerbations of COPD during hospital stay and after 1 year of follow-up. Patient characteristics related to an increased mortality rate were analyzed. Furthermore, the frequency and determinants of hospital readmissions were assessed.

We prospectively included in the study all patients who had been admitted for an acute exacerbation of COPD to the pulmonology ward of the University Hospital Maastricht between January 1 and December 31, 1999. Besides its academic function, the University Hospital of Maastricht has an important function as a regional hospital, therefore this patient population is representative of general pulmonary practices.

Patients were included if the following criteria were met: diagnosis of COPD, according to the criteria of the American Thoracic Society (ATS)16 (ie, all patients had FEV1 < 70% of predicted and reversibility of < 11%); and symptoms indicating an acute exacerbation of COPD. An exacerbation was defined by the presence of an increase in at least two of the three following symptoms: dyspnea; cough; and sputum purulence severe enough to warrant hospital admission. Each patient was included only once in the study, even if the patient had been hospitalized more than once. During hospital admission, patients were treated with a standard protocol consisting of the IV administration of corticosteroids (in a standardized dosage of 0.5 mg/kg), theophylline, and nebulized salbutamol and ipratropium bromide as bronchodilating agents. O2 was titrated according to the results of blood gas analyses.

Clinical Data

For all included patients, the following data were assessed: medical history, lung function measurements, blood gas levels, BMI, duration of hospital stay, treatment prior to hospital admission, and use of oral corticosteroids. Medical history, previous treatment, use of oral corticosteroids, and comorbid conditions were recorded on standardized forms from patient charts. The use of and duration of use of oral corticosteroids were verified from outpatient records. Long-term use of corticosteroids was defined as the daily use of oral corticosteroids for at least 1 year in a dosage of at least 5 mg prednisolone or equivalent.

Comorbidity was quantified according to the index of Charlson et al.17 This index has been developed to predict the mortality of patients with chronic diseases. It assigns to each disease a score that is proportional to the disease-related risk of death. A score of 1 is allocated to myocardial infarct, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, COPD, connective tissue disease, ulcer disease, mild liver disease, and diabetes. A score of 2 is allocated to diabetes with end-organ damage, hemiplegia, renal disease, and malignancies, including leukemia and lymphoma. A score of 3 is attributed to moderate or severe liver disease, while AIDS and metastatic malignancies are attributed a score of 6.

Measurements

On hospital admission, arterial blood gas levels at rest were assessed by a puncture of the radial artery during room air breathing. On the first day after hospital admission, while patients were in a fasting state, body weight without clothes was measured in kilograms. Body height was measured in centimeters with the patient standing barefoot. BMI was measured in kilograms per square meter.

On hospital admission and after recovery (immediately before hospital discharge) lung function was determined with a portable pneumotachograph (Jaeger Instruments; Würzburg, Germany). FEV1 values measured immediately before hospital discharge were used in the analyses. FEV1 values were expressed as a percentage of the reference values.

Outcomes

During their hospital stays, patients were monitored and outcomes were determined (ie, length of hospital stay, mortality, and need for intubation or noninvasive ventilation). The decision to transfer a patient to the ICU for mechanical or noninvasive ventilation was made on clinical grounds in case of a worsening of respiratory failure.

After hospital discharge, patients were observed prospectively for at least 1 year. The following parameters were determined: survival time; need for hospital readmission; and number of hospital readmissions. Only hospital readmissions because of an acute exacerbation of COPD were counted. Survival was determined in several ways. If patients died during a hospital stay, their date of death was recorded and verified by hospital records. If patients died after hospital discharge, their date of death was verified from hospital records, general practitioners records, or the death records of the city in which they lived. The status of all patients was confirmed in this way.

Mortality rates were determined for the hospital admission period and during the follow-up period, until at least 1 year after hospital discharge. Unfortunately, mortality registration in the Netherlands does not allow access to actual records to determine the cause of death, so only for patients who died during their hospital stay was the cause of death known.

Statistical Analysis

Patients were categorized for FEV1 according to ATS criteria.16 All data were expressed as the mean ± SD. All statistical analyses were performed using a statistical software package (SPSS for Windows, version 9.0; SPSS Inc; Chicago, IL). Nominal variables were compared using the χ2 test. Comparisons between groups were performed using analysis of variance. Comparisons of individual predictor variables were performed using Cox regression analysis. To determine independent predictors of mortality, all predictor variables were included in a Cox proportional hazards model. Age, number of hospital admission days, FEV1, BMI, resting arterial blood gas levels (ie, Pao2 and Paco2), and comorbidity index were included as continuous variables in the model, and the long-term use of oral corticosteroids (0, no; 1, yes), gender (0, men; 1, women), and need for hospital readmission (0, no; 1, yes) were included as categoric variables. Crude and adjusted relative risks (RRs) with and without adjustment for interaction among the various risk factors are shown in Table 3 . The RR corresponding to a risk factor in this model is the exponential of the regression coefficient. Baseline comparisons were performed by unpaired Student t test with Bonferroni correction for multiple comparisons. A two-sided p value of < 0.05 was considered to be statistically significant. Survival plots for the influence of oral corticosteroid use vs no steroids were drawn and analyzed using the Kaplan-Meier method.

Patient Characteristics

Between January 1, 1999, and January 1, 2000, 171 patients were admitted to the pulmonology ward of the University Hospital Maastricht with an acute exacerbation of COPD. Patient characteristics are listed in Table 1 .

Most patients were elderly, and comorbid illnesses were common. About 30% of the patients even had two or more comorbid conditions. Hypoxia was a common condition on hospital admission as well as hypercapnia (Pao2 ≤ 8.7 kPa, 85% of patients; Paco2 ≥ 5.9 kPa, 55% of patients). According to ATS criteria for COPD severity, 51% of the patients were in stage III (ie, FEV1 < 35% of predicted), 35% were in stage II (ie, FEV1 35 to 49% of predicted), and 14% were in stage I (ie, FEV1 ≥ 50% of predicted), based on lung function measurements before hospital discharge. Twelve patients were not able to perform spirometry during their hospital stay. Ten of these patients were followed up to establish a diagnosis of severe COPD at our outpatient department, and their conditions during hospital admission did not tolerate lung function tests. In the remaining two patients, the diagnosis of COPD was established on clinical grounds, and both patients had a history of COPD that was documented by their general practitioner.

Seventeen patients (10%) received oral corticosteroids daily for at least 1 year in a median dosage of 7.5 mg. Seventeen patients had to be transferred to the ICU after hospital admission because of progressive respiratory failure. In 15 patients, referral to the ICU was necessary on the first day (11 patients) or the second day (4 patients) after hospital admission because of the failure of conservative treatment. The remaining two patients experienced a deterioration in their clinical condition after initial improvement.

Ten patients had to be intubated for mechanical ventilation, and 4 patients received noninvasive bilevel pressure ventilation, and in 3 patients ventilatory support could be avoided by intensive conservative treatment. When the characteristics of ICU patients and non-ICU patients were compared, ICU patients had higher Pco2 and lower pH values (Table 2 ). Crude and adjusted RRs for mortality are shown in Table 3 .

Outcomes
In-Hospital Mortality:

The median length of hospital stay was 10 days. The median length of hospital stay was longer for patients after ICU admission (16.9 days) than for those in the conservatively treated group (9.5 days) [p = 0.005].

Thirteen patients (8%) died during their hospital stay. One of these patients had been admitted to the ICU. The other 12 patients were not admitted to ICU because the decision not to intubate them in case of respiratory failure had been made on medical grounds (in case of terminal COPD) or according to the patient’s own wish.

In all in-hospital cases of mortality, progressive respiratory failure was the primary cause of death. Nine patients had COPD alone, while three patients experienced respiratory failure as a consequence of COPD and congestive heart failure. In 1 patient COPD treatment was complicated with treatment-refractory gastrointestinal bleeding.

Of the surviving patients, most were discharged to home (147 patients; 93%). Six patients (4%) were transferred to another hospital or to another ward, three patients (2%) were discharged to a nursing home, and two patients (1%) were discharged to a senior citizens home.

Mortality During Follow-up:

The mean follow-up time after hospital discharge was 571 days (range, 365 to 725 days). No patients were lost to follow-up. The Kaplan-Meier survival plot for the entire study population is shown in Figure 1 .

In the first 3 months after hospital discharge, 13 additional patients (8%) died. The overall mortality rate at 3 months was 16%. Three more patients (2%) died within 6 months after initial hospital admission. The mortality rate at 6 months was 18%. In the period between 6 months and 1 year after study entry, eight other patients (5%) died. The mortality rate after 1 year was 23%.

Overall, mortality was higher in patients requiring ICU admission for respiratory failure (6 of 17 patients; 35%) than for patients not requiring ICU admission (31 of 154 patients; 23%) [p = 0.045]. Separate mortality rates for ICU and non-ICU patients are shown in Figure 2 .

Factors Related to Survival

Table 3 shows the results of the bivariate analyses for the influence of risk factors on survival (ie, crude RR). High values for age, number of hospital admission days, and comorbidity index, and low values for FEV1, Paco2, and use of oral corticosteroids were significantly associated with increased mortality. Table 3 also shows the results of the Cox regression analysis adjusting for the above-mentioned parameters (ie, adjusted RR).

The long-term use of oral corticosteroids, blood gas values on hospital admission, and older age had an independent adverse effect on survival after an acute exacerbation of COPD, after adjusting for the influence of all other variables. Duration of hospital stay, gender, lung function (ie, FEV1 percent predicted), Pao2, and the presence of comorbidity were not independently associated with mortality. BMI reached borderline significance as an independent factor associated with mortality.

A subgroup of 17 patients were receiving maintenance corticosteroid treatment, of whom 9 patients died during the 1-year follow-up period (died during hospital admission, 3 patients; died within the first 6 months after hospital discharge, 4 patients; and died within 1 year after hospital discharge, 2 patients). The Kaplan-Meier plot for influence of long-term corticosteroid use on survival is shown in Figure 1 . Comparisons between patients with and without oral corticosteroids are shown in Table 4 .

On hospital admission, there was no difference in age, FEV1, Pao2, Paco2, BMI, or comorbidity index between patients with and without corticosteroid use. Patients with long-term oral corticosteroid use, however, had a higher number of hospital readmissions in the follow-up period (p = 0.0026).

Hospital Readmissions

Readmissions to the hospital frequently occurred during the follow-up period. Eighty-six patients (55%) had one or more hospital readmissions in the first year after hospital discharge. The total number of hospital readmissions was 216 in this group. The total of days spent in the hospital because of hospital readmission was 2,052 days. The median number of hospital readmissions was one per patient.

Twenty-seven patients (16%) had one hospital readmission, 29 patients (17%) had two hospital readmissions, 15 patients (9%) had three hospital readmissions, and 15 patients (9%) had even more than three hospital readmissions. Since this is the only hospital in the region, it is highly unlikely that any of the patients was readmitted into another hospital.

In the first month after hospital discharge, 24 patients (14%) had to be readmitted to the hospital because of acute exacerbation, 12 more patients (7%) were readmitted for the first time within 3 months after hospital discharge, 15 patients (9%) were readmitted within 6 months, and 34 patients (20%) had their first hospital readmission within 1 year of hospital discharge.

Patients who were readmitted one or more times were younger than patients without hospital readmission and had received more long-term corticosteroid treatment, but there were no differences in FEV1, Pao2, Paco2, pH, BMI, or comorbidity index. There was no difference in survival rates between those patients who had been readmitted and those who had not been readmitted. The social status of patients (whether they were living alone or not) did not influence hospital readmission. These results are shown in Table 5 .

The present study confirms previous data about mortality after acute exacerbations of COPD. Mortality during hospital admission for an acute exacerbation of COPD was high and continued to increase after hospital discharge.

For patients requiring ICU admission during their hospital stay, mortality was even higher. Besides Paco2 and age, which were previously established as predictors of mortality, the long-term use of oral corticosteroids was found to be an important independent risk factor for mortality.

Most patients were discharged to home. In the study follow-up period, readmissions to the hospital because of acute exacerbations were common. Patients requiring one or more hospital readmissions because of acute exacerbations were younger and used more long-term corticosteroid medication.

The high mortality rates that we found following hospital admission for an exacerbation of COPD are in line with those of other reports. In a cohort of 1,016 patients, Connors et al4 reported an in-hospital mortality of 11%, increasing to 33% after 6 months, and to 43% after 1 year. Fuso et al14 reported an in-hospital mortality rate of 14.4%. In a study5 among patients who required mechanical ventilation for respiratory failure, an in-hospital mortality rate of 24% was reported.

In our study population, age, Paco2, and use of oral corticosteroids were determining factors for mortality after an acute exacerbation. Sex, duration of hospital stay, FEV1, BMI, comorbidity index, and number of hospital readmissions had no influence on mortality.

In the past, several factors have been implied as risk factors for increased mortality in COPD after an acute exacerbation of the disease. In a study among COPD patients comparable to our patient population, Connors et al4 reported severity of illness, BMI, age, prior functional status, Pao2/fraction of inspired oxygen ratio, congestive heart failure, serum albumin level, and the presence of cor pulmonale to be independently related to survival following acute exacerbation.

Although age and Paco2 have been recognized in previous studies to be predictors for survival, the long-term use of oral corticosteroids as a risk factor for mortality is a new finding. This may have important implications for therapy. A possible explanation for higher mortality among patients using oral corticosteroids could be the side effects of this medication.

Prolonged treatment with oral corticosteroids has significant side effects,18 of which the following are the most important: suppression of the hypothalamic-adrenal axis; infectious complications; myopathy; diabetes; osteoporosis; and GI effects such as peptic ulcers, hypertension, and cataract. One study19 reported a significant increase in fractures and other adverse effects in patients with lung disease who were receiving therapy with oral corticosteroids, a finding that was strongly related to the cumulative dose taken. Several studies have demonstrated a relation between respiratory and peripheral muscle strength and steroid treatment in COPD patients2021 as negatively influencing functional status in COPD patients.2223

The relation between oral corticosteroid therapy and mortality has not been studied extensively. In studies among patients receiving long-term oxygen therapy, oral corticosteroid treatment was related to increased mortality in women.2425 Previously, we have demonstrated26 a dose-dependent increased mortality risk in COPD patients who were receiving maintenance treatment with oral corticosteroids. This observation is important to consider since positive effects are not well-established and the discontinuation of long-term systemic corticosteroid treatment in steroid-dependent COPD patients does not cause a significant increase in COPD exacerbations.27

Maintenance treatment with oral corticosteroids has been estimated to offer a clinically significant improvement in only 10% of patients.28 Therapy with systemic oral corticosteroids is often prescribed for exacerbations, but, according to a recent trial,29 the effect is limited to the first 2 weeks of treatment.

It is remarkable that in our population the patients who were receiving maintenance treatment with oral corticosteroids were not different in clinical characteristics like age, lung function parameters, blood gas levels, BMI, and presence of comorbidity. Therefore, the reason for prescribing maintenance treatment with oral corticosteroids is unclear. Possibly, the continuation of oral corticosteroid treatment is related to the frequency of exacerbations, as the long-term steroid users have more frequent hospital readmissions. On the other hand, these hospital readmissions also could have been the result of the mentioned side effects, creating a vicious circle for these patients.

In the present study, age was also an independent predictor of mortality. In a large number of other studies,4,78,15,30 age has been demonstrated to be an important determinant of survival in COPD patients. Age also has been associated with an accelerated decline in lung function.31 It seems important to discover and treat the symptoms of COPD at an earlier stage to try to prevent this decline.

A high Paco2 also was found to be a risk factor for mortality in our population. This is in line with other reports.5,9,13,32 The level of hypercapnia, suggestive of chronic alveolar hypoventilation, reflects the severity of the underlying respiratory condition, and patients with chronic hypercapnia, who comprised the majority of our study population, have a worse prognosis than patients with normoventilation.

In our study, we did not find any influence of BMI on survival, contrary to other reports.4,9 This may be because BMI was relatively well-preserved in our study population (mean BMI, 24). Another explanation could be that BMI was measured on hospital admission, while some patients may have had fluid retention at that point because of concomitant right heart failure or because of decreased renal flow as a result of respiratory failure. As a consequence, BMI may have been overestimated in the analyses. Nevertheless, there was a trend to a higher mortality risk for patients with lower BMI (p = 0.0596).

In the present study, there was also no influence of comorbidity on survival in contrast to a report by Incalzi et al,15 which specifically investigated this factor, and other studies4,14 that have demonstrated the influence of specific cardiac diseases on survival. A possible explanation could be that we measured comorbidity by the Charlson index, which also lacked predictive ability in the study by Incalzi et al.15 It was hypothesized that only selected diseases like cardiac failure or cor pulmonale can influence the prognosis in severe COPD patients. We have not specifically measured cardiac factors in this study, and echocardiographs were not performed, unless indicated by a cardiologist.

An important problem in the treatment of acute exacerbations of COPD is the need for hospital readmission. In the present study, the number of hospital readmissions was high, with 55% of patients having had one or more hospital readmissions because of an acute exacerbation during the follow-up period.

As for mortality, the determining factors for hospital readmission in the present study were age and the use of oral corticosteroids. Remarkably, patients who were readmitted one or more times were younger than other patients. It is difficult to find an explanation for this finding.

Also, patients who were readmitted to the hospital received maintenance therapy with oral corticosteroids more frequently. The reason for the observed relationship between corticosteroid use and hospital readmission is not clear, but it could be due to the side effects of corticosteroid use that were mentioned earlier.

The need for hospital readmission was not associated with mortality in this population. This is in contrast to the findings of Connors et al,4 who found that patients who had to be readmitted to the hospital one or more times had a higher mortality rate. However, in the latter study medication was not taken into account.

Our results demonstrate that the mortality rate after acute exacerbation is high, especially for older patients with chronic respiratory failure. This is important to realize in order to be able to offer the patient better supportive care. In one study,33 patients with severe COPD with at least one hospital admission for hypercapnic respiratory failure were compared to patients who had been treated for unresectable non-small cell lung cancer. The results of this study showed that COPD patients had significantly less ability to perform the activities of daily life, physical, and lower social and emotional functioning than did patients with non-small cell lung cancer. This study confirms that COPD patients do not receive the necessary palliative care that is appropriate in their situation.

The present study emphasizes the need for adequate care facilities for patients who are treated for acute exacerbations. The care needs of these patients should be considered as being comparable to patients with lung cancer.

The present study demonstrates clearly that mortality in patients with acute exacerbations of COPD is high and that the risk factors for mortality are older age, higher Paco2, and long-term use of oral corticosteroids. These results should be taken into account when making clinical decisions in patients who have been admitted to the hospital with acute exacerbations, especially when prescribing corticosteroid treatment.

Abbreviations: ATS = American Thoracic Society; BMI = body mass index; RR = relative risk

This study was supported by a research grant from Astra-Zeneca BV, the Netherlands.

Table Graphic Jump Location
Table 3. Multivariate Cox Proportional Hazards Model for Factors Associated With Mortality*
* 

CI = confidence interval.

Table Graphic Jump Location
Table 1. Characteristics of 171 Patients With Acute Exacerbation of COPD*
* 

Values given as mean ± SD, unless otherwise indicated.

Table Graphic Jump Location
Table 2. Characteristics of Patients Transferred to ICU*
* 

Values given as mean ± SD, unless otherwise indicated. NS = not significant.

Figure Jump LinkFigure 1. Influence of long-term corticosteroid use on survival.Grahic Jump Location
Figure Jump LinkFigure 2. Mortality for ICU and non-ICU patients.Grahic Jump Location
Table Graphic Jump Location
Table 4. Characteristics of Patients Receiving and Not Receiving Oral Corticosteroids*
* 

Values given as mean ± SD, unless otherwise indicated. See Table 2 for abbreviation not used in the text.

Table Graphic Jump Location
Table 5. Characteristics of Patients Who Were and Were Not Readmitted to the Hospital*
* 

Values given as mean ± SD, unless otherwise indicated. See Table 2 for abbreviation not used in the text.

Lacasse, Y, Brooks, D, Goldstein, RS (1999) Trends in the epidemiology of COPD in Canada, 1980 to 1995: COPD and Rehabilitation Committee of the Canadian Thoracic Society.Chest116,306-313. [PubMed] [CrossRef]
 
Hurd, S The impact of COPD on lung health worldwide: epidemiology and incidence.Chest2000;117,1S-4S. [PubMed]
 
Rutten van Molken, MP, Postma, MJ, Joore, MA, et al Current and future medical costs of asthma and chronic obstructive pulmonary disease in The Netherlands.Respir Med1999;93,779-787. [PubMed]
 
Connors, AF, Jr, Dawson, NV, Thomas, C, et al Outcomes following acute exacerbation of severe chronic obstructive lung disease: the SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) [erratum published in Am J Respir Crit Care Med 1997; 155:386]Am J Respir Crit Care Med1996;154,959-967. [PubMed]
 
Seneff, MG, Wagner, DP, Wagner, RP, et al Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease.JAMA1995;274,1852-1857. [PubMed]
 
Burrows, B, Earle, RH Prediction of survival in patients with chronic airway obstruction.Am Rev Respir Dis1969;99,865-871. [PubMed]
 
Traver, GA, Cline, MG, Burrows, B Predictors of mortality in chronic obstructive pulmonary disease: a 15-year follow-up study.Am Rev Respir Dis1979;119,895-902. [PubMed]
 
Anthonisen, NR, Wright, EC, Hodgkin, JE Prognosis in chronic obstructive pulmonary disease.Am Rev Respir Dis1986;133,14-20. [PubMed]
 
Gray Donald, K, Gibbons, L, Shapiro, SH, et al Nutritional status and mortality in chronic obstructive pulmonary disease.Am J Respir Crit Care Med1996;153,961-966. [PubMed]
 
Hospers, JJ, Schouten, JP, Weiss, ST, et al Asthma attacks with eosinophilia predict mortality from chronic obstructive pulmonary disease in a general population sample.Am J Respir Crit Care Med1999;160,1869-1874. [PubMed]
 
Landbo, C, Prescott, E, Lange, P, et al Prognostic value of nutritional status in chronic obstructive pulmonary disease.Am J Respir Crit Care Med1999;160,1856-1861. [PubMed]
 
Schols, A, Slangen, J, Volovics, L, et al Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease.Am J Respir Crit Care Med1998;157,1791-1797. [PubMed]
 
Sukumalchantra, Y, Dinakara, P, Williams, MH, Jr Prognosis of patients with chronic obstructive pulmonary disease after hospitalization for acute ventilatory failure: a three-year follow-up study.Am Rev Respir Dis1966;93,215-222. [PubMed]
 
Fuso, L, Incalzi, RA, Pistelli, R, et al Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease.Am J Med1995;98,272-277. [PubMed]
 
Incalzi, RA, Fuso, L, DeRosa, M, et al Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease.Eur Respir J1997;10,2794-2800. [PubMed]
 
American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma: this official statement of the American Thoracic Society was adopted by the ATS Board of Directors, November 1986.Am Rev Respir Dis1987;136,225-244. [PubMed]
 
Charlson, ME, Pompei, P, Ales, KL, et al A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis1987;40,373-383. [PubMed]
 
McEvoy, CE, Niewoehner, DE Adverse effects of corticosteroid therapy for COPD: a critical review.Chest1997;111,732-743. [PubMed]
 
Walsh, LJ, Wong, CA, Oborne, J, et al Adverse effects of oral corticosteroids in relation to dose in patients with lung disease.Thorax2001;56,279-284. [PubMed]
 
Decramer, M, Stas, KJ Corticosteroid-induced myopathy involving respiratory muscles in patients with chronic obstructive pulmonary disease or asthma.Am Rev Respir Dis1992;146,800-802. [PubMed]
 
Decramer, M, Lacquet, LM, Fagard, R, et al Corticosteroids contribute to muscle weakness in chronic airflow obstruction.Am J Respir Crit Care Med1994;150,11-16. [PubMed]
 
Gosselink, R, Troosters, T, Decramer, M Peripheral muscle weakness contributes to exercise limitation in COPD.Am J Respir Crit Care Med1996;153,976-980. [PubMed]
 
Bernard, S, LeBlanc, P, Whittom, F, et al Peripheral muscle weakness in patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med1998;158,629-634. [PubMed]
 
Strom, K Survival of patients with chronic obstructive pulmonary disease receiving long-term domiciliary oxygen therapy.Am Rev Respir Dis1993;147,585-591. [PubMed]
 
Strom, K Oral corticosteroid treatment during long-term oxygen therapy in chronic obstructive pulmonary disease: a risk factor for hospitalization and mortality in women.Respir Med1998;92,50-56. [PubMed]
 
Schols, AM, Wesseling, G, Kester, AD, et al Dose dependent increased mortality risk in COPD patients treated with oral glucocorticoids.Eur Respir J2001;17,337-342. [PubMed]
 
Rice, KL, Rubins, JB, Lebahn, F, et al Withdrawal of chronic systemic corticosteroids in patients with COPD: a randomized trial.Am J Respir Crit Care Med2000;162,174-178. [PubMed]
 
Callahan, CM, Dittus, RS, Katz, BP Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease: a meta-analysis.Ann Intern Med1991;114,216-223. [PubMed]
 
Niewoehner, DE, Erbland, ML, Deupree, RH, et al Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease.N Engl J Med1999;340,1941-1947. [PubMed]
 
Hansen, EF, Phanareth, K, Laursen, LC, et al Reversible and irreversible airflow obstruction as predictor of overall mortality in asthma and chronic obstructive pulmonary disease.Am J Respir Crit Care Med1999;159,1267-1271. [PubMed]
 
Kerstjens, HA, Brand, PL, Postma, DS Risk factors for accelerated decline among patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med1996;154,S266-S272. [PubMed]
 
Menzies, R, Gibbons, W, Goldberg, P Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure.Chest1989;95,398-405. [PubMed]
 
Gore, JM, Brophy, CJ, Greenstone, MA How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer.Thorax2000;55,1000-1006. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Influence of long-term corticosteroid use on survival.Grahic Jump Location
Figure Jump LinkFigure 2. Mortality for ICU and non-ICU patients.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 3. Multivariate Cox Proportional Hazards Model for Factors Associated With Mortality*
* 

CI = confidence interval.

Table Graphic Jump Location
Table 1. Characteristics of 171 Patients With Acute Exacerbation of COPD*
* 

Values given as mean ± SD, unless otherwise indicated.

Table Graphic Jump Location
Table 2. Characteristics of Patients Transferred to ICU*
* 

Values given as mean ± SD, unless otherwise indicated. NS = not significant.

Table Graphic Jump Location
Table 4. Characteristics of Patients Receiving and Not Receiving Oral Corticosteroids*
* 

Values given as mean ± SD, unless otherwise indicated. See Table 2 for abbreviation not used in the text.

Table Graphic Jump Location
Table 5. Characteristics of Patients Who Were and Were Not Readmitted to the Hospital*
* 

Values given as mean ± SD, unless otherwise indicated. See Table 2 for abbreviation not used in the text.

References

Lacasse, Y, Brooks, D, Goldstein, RS (1999) Trends in the epidemiology of COPD in Canada, 1980 to 1995: COPD and Rehabilitation Committee of the Canadian Thoracic Society.Chest116,306-313. [PubMed] [CrossRef]
 
Hurd, S The impact of COPD on lung health worldwide: epidemiology and incidence.Chest2000;117,1S-4S. [PubMed]
 
Rutten van Molken, MP, Postma, MJ, Joore, MA, et al Current and future medical costs of asthma and chronic obstructive pulmonary disease in The Netherlands.Respir Med1999;93,779-787. [PubMed]
 
Connors, AF, Jr, Dawson, NV, Thomas, C, et al Outcomes following acute exacerbation of severe chronic obstructive lung disease: the SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) [erratum published in Am J Respir Crit Care Med 1997; 155:386]Am J Respir Crit Care Med1996;154,959-967. [PubMed]
 
Seneff, MG, Wagner, DP, Wagner, RP, et al Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease.JAMA1995;274,1852-1857. [PubMed]
 
Burrows, B, Earle, RH Prediction of survival in patients with chronic airway obstruction.Am Rev Respir Dis1969;99,865-871. [PubMed]
 
Traver, GA, Cline, MG, Burrows, B Predictors of mortality in chronic obstructive pulmonary disease: a 15-year follow-up study.Am Rev Respir Dis1979;119,895-902. [PubMed]
 
Anthonisen, NR, Wright, EC, Hodgkin, JE Prognosis in chronic obstructive pulmonary disease.Am Rev Respir Dis1986;133,14-20. [PubMed]
 
Gray Donald, K, Gibbons, L, Shapiro, SH, et al Nutritional status and mortality in chronic obstructive pulmonary disease.Am J Respir Crit Care Med1996;153,961-966. [PubMed]
 
Hospers, JJ, Schouten, JP, Weiss, ST, et al Asthma attacks with eosinophilia predict mortality from chronic obstructive pulmonary disease in a general population sample.Am J Respir Crit Care Med1999;160,1869-1874. [PubMed]
 
Landbo, C, Prescott, E, Lange, P, et al Prognostic value of nutritional status in chronic obstructive pulmonary disease.Am J Respir Crit Care Med1999;160,1856-1861. [PubMed]
 
Schols, A, Slangen, J, Volovics, L, et al Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease.Am J Respir Crit Care Med1998;157,1791-1797. [PubMed]
 
Sukumalchantra, Y, Dinakara, P, Williams, MH, Jr Prognosis of patients with chronic obstructive pulmonary disease after hospitalization for acute ventilatory failure: a three-year follow-up study.Am Rev Respir Dis1966;93,215-222. [PubMed]
 
Fuso, L, Incalzi, RA, Pistelli, R, et al Predicting mortality of patients hospitalized for acutely exacerbated chronic obstructive pulmonary disease.Am J Med1995;98,272-277. [PubMed]
 
Incalzi, RA, Fuso, L, DeRosa, M, et al Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease.Eur Respir J1997;10,2794-2800. [PubMed]
 
American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma: this official statement of the American Thoracic Society was adopted by the ATS Board of Directors, November 1986.Am Rev Respir Dis1987;136,225-244. [PubMed]
 
Charlson, ME, Pompei, P, Ales, KL, et al A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis1987;40,373-383. [PubMed]
 
McEvoy, CE, Niewoehner, DE Adverse effects of corticosteroid therapy for COPD: a critical review.Chest1997;111,732-743. [PubMed]
 
Walsh, LJ, Wong, CA, Oborne, J, et al Adverse effects of oral corticosteroids in relation to dose in patients with lung disease.Thorax2001;56,279-284. [PubMed]
 
Decramer, M, Stas, KJ Corticosteroid-induced myopathy involving respiratory muscles in patients with chronic obstructive pulmonary disease or asthma.Am Rev Respir Dis1992;146,800-802. [PubMed]
 
Decramer, M, Lacquet, LM, Fagard, R, et al Corticosteroids contribute to muscle weakness in chronic airflow obstruction.Am J Respir Crit Care Med1994;150,11-16. [PubMed]
 
Gosselink, R, Troosters, T, Decramer, M Peripheral muscle weakness contributes to exercise limitation in COPD.Am J Respir Crit Care Med1996;153,976-980. [PubMed]
 
Bernard, S, LeBlanc, P, Whittom, F, et al Peripheral muscle weakness in patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med1998;158,629-634. [PubMed]
 
Strom, K Survival of patients with chronic obstructive pulmonary disease receiving long-term domiciliary oxygen therapy.Am Rev Respir Dis1993;147,585-591. [PubMed]
 
Strom, K Oral corticosteroid treatment during long-term oxygen therapy in chronic obstructive pulmonary disease: a risk factor for hospitalization and mortality in women.Respir Med1998;92,50-56. [PubMed]
 
Schols, AM, Wesseling, G, Kester, AD, et al Dose dependent increased mortality risk in COPD patients treated with oral glucocorticoids.Eur Respir J2001;17,337-342. [PubMed]
 
Rice, KL, Rubins, JB, Lebahn, F, et al Withdrawal of chronic systemic corticosteroids in patients with COPD: a randomized trial.Am J Respir Crit Care Med2000;162,174-178. [PubMed]
 
Callahan, CM, Dittus, RS, Katz, BP Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease: a meta-analysis.Ann Intern Med1991;114,216-223. [PubMed]
 
Niewoehner, DE, Erbland, ML, Deupree, RH, et al Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease.N Engl J Med1999;340,1941-1947. [PubMed]
 
Hansen, EF, Phanareth, K, Laursen, LC, et al Reversible and irreversible airflow obstruction as predictor of overall mortality in asthma and chronic obstructive pulmonary disease.Am J Respir Crit Care Med1999;159,1267-1271. [PubMed]
 
Kerstjens, HA, Brand, PL, Postma, DS Risk factors for accelerated decline among patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med1996;154,S266-S272. [PubMed]
 
Menzies, R, Gibbons, W, Goldberg, P Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure.Chest1989;95,398-405. [PubMed]
 
Gore, JM, Brophy, CJ, Greenstone, MA How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer.Thorax2000;55,1000-1006. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543