Engel Brigitte, Schindler Christian, Leuppi Jörg D, Rutishauser Jonas
Department of Medicine, Fricktal Health Centre, Laufenburg, Switzerland.
Swiss Tropical and Public Health Institute, University of Basel, Switzerland.
Swiss Med Wkly. 2017 May 11;147:w14439. doi: 10.4414/smw.2017.14439. eCollection 2017.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) compromise physical activity and quality of life and contribute significantly to health care costs. Systemic glucocorticoids benefit clinical outcome in AECOPD, and the REDUCE trial demonstrated noninferiority of a 5-day treatment course with prednisone compared with 14 days therapy regarding clinical outcome over 6 months of follow-up. Unexpectedly, we found an inverse correlation between circulating cortisol levels and exacerbation risk during a 6-month follow-up period.
To evaluate whether additional predictors of COPD re-exacerbation can be identified after the index exacerbation in the REDUCE cohort.
Of 314 patients with AECOPD randomised to 5 or 14 days of prednisone treatment, 311 were included in the analysis. Parameters tested as predictors of re-exacerbation were sex, age, smoking status, forced expiratory volume in one second (FEV1), dyspnoea as assessed with the Medical Research Council (MRC) dyspnoea scale, home oxygen therapy, pretreatment with systemic glucocorticoids, pretreatment with antibiotics, duration of hospitalisation, blood pressure, oxygen saturation, admission to the Intensive Care Unit (ICU) and relevant infections in follow-up. The risks for re-exacerbation were estimated by means of logistic regression and Cox proportional hazard models and expressed as odds ratios and hazard ratios, respectively.
After multivariate adjustment, significant predictors at hospital discharge for COPD re-exacerbation during follow-up were: duration of hospital stay >8 days (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.03-2.28); FEV1 <30% predicted (HR 1.76, 95% CI 1.06-2.91); hypertension (HR 2.39, 95% CI 1.04-5.48) and MRC dyspnoea scale (HR 1.61, 95% CI 1.30-2.01, per unit increment). Present cigarette smoking (HR 0.60, 95% CI 0.38-0.92) was negatively associated with re-exacerbation.
In addition to biochemical suppression of the adrenal glands, other standard clinical parameters predict re-exacerbation in patients admitted to the emergency department with AECOPD. (REDUCE trial registration: ISRCTN29646069).
慢性阻塞性肺疾病急性加重（AECOPD）会损害身体活动能力和生活质量，并显著增加医疗费用。全身用糖皮质激素可改善AECOPD的临床结局，REDUCE试验表明，在6个月的随访期内，泼尼松5天疗程与14天疗程在临床结局方面非劣效。出乎意料的是，我们发现在6个月的随访期内，循环皮质醇水平与加重风险呈负相关。
评估在REDUCE队列中，能否在首次加重后识别出慢性阻塞性肺疾病再次加重的其他预测因素。
314例随机接受5天或14天泼尼松治疗的AECOPD患者中，311例纳入分析。作为再次加重预测因素进行检测的参数包括性别、年龄、吸烟状况、一秒用力呼气容积（FEV1）、用医学研究委员会（MRC）呼吸困难量表评估的呼吸困难程度、家庭氧疗、全身用糖皮质激素预处理、抗生素预处理、住院时间、血压、血氧饱和度、入住重症监护病房（ICU）以及随访期间的相关感染。通过逻辑回归和Cox比例风险模型估计再次加重的风险，分别表示为比值比和风险比。
多因素调整后，随访期间慢性阻塞性肺疾病再次加重的出院时显著预测因素为：住院时间>8天（风险比[HR]1.54，95%置信区间[CI]1.03 - 2.28）；FEV1<预计值的30%（HR 1.76，95% CI 1.06 - 2.91）；高血压（HR 2.39，95% CI 1.04 - 5.48）以及MRC呼吸困难量表（HR 1.61，95% CI 1.30 - .01，每单位增量）。当前吸烟（HR 0.60，95% CI .38 - 0.92）与再次加重呈负相关。
除肾上腺的生化抑制外，其他标准临床参数可预测因AECOPD入住急诊科患者的再次加重情况。（REDUCE试验注册号：ISRCTN29646069）
