COPD ICU MORTALITY

iPhoneIcon_BigIn intensive care, we are often called to deal with marginal or crashing COPD patients. Often, we end up intubating them. Then, in the morning rounds there always seems to be at least one passive-aggressive (†) colleague in the back, shaking their heads in disgust, not saying (you see, they’re passive-aggressive) we shouldn’t have done that, because the patient won’t survive anyway. Still, the passive-aggressive dudes are often right. Patients hospitalised for a COPD exacerbation have a 2 year life expectancy and those who end up on mechanical ventilation should do a whole lot worse. A study in Thorax helps me understand what can be expected of these patients.

The study
The paper is a retrospective cohort look at patients with COPD in respiratory failure that are intubated  and admitted to an ICU for mechanical ventilation. The study includes COPD patients who are on long term oxygen therapy (LTOT). This will obviously bias the outcomes but the authors reason that LTOT is a useful surrogate marker for severe COPD. Main outcomes were in-hospital mortality, one year mortality and hospital re-admission.

Results
4791 COPD patients with LTOT defined the cohort.
Mean age was 74,3 years.
23,3% died in-hospital.
45,2% died within one year after discharge.
31,5% of the total cohort was alive after one year.
Of the 3677 survivors, 67,1% were readmitted within one year.
Of the 3677 survivors, 26,8% were discharged to a nursing home.

Take home message
Patients with severe COPD who are intubated and put on mechanical ventilation have an in- hospital mortality of 25%. Two thirds will be dead within a year.  Similar numbers have been published before. Breen et al reported a 48,6% 12-month mortality in another retrospective cohort study of from 2002. That cohort was not limited to intubated patients.

Im not sure these outcomes are better or worse than what I expected. At least they do a lot better than what my passive-aggressive colleagues seem to think.

† – General observation from all places I’ve had the pleasure of working in. Passive-agressiveness is in no way particular to my current work-place.

Paper lives here:

Thorax. 2014 May 14. What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow-up study. Hajizadeh N1, Goldfeld K2, Crothers K3.

 EDIT: This post has been edited after it was prematurely published by accident…

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One Response to COPD ICU MORTALITY

  1. Kristian Strand says:

    Decisions to withhold therapy at nights is so complicated that junior doctors should be met with understanding if they decide to admit the patient to the ICU. Predicting outcome in COPD patients is notoriously diffucult and objective measures do not enable us to make real informed decisions. Worst case scenario would be withholding therapy in a patient that only would need a few days on the ventilator and retur home with reasonable quality of life. I am a firm believer in offering ICU treatment to these patients regardless of spirometry if their quality of life is acceptable by their own accounts, but setting limits on treatment by day 3 based on clinical status and further information obtained. Having them awake, with an endotracheal tube, from day 1-2, and extubating early directly to non-invasive ventilation seems to be a good strategy as opposed to early trachestomi and weeks of traditional weaning.

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