A decision tree to assess short-term mortality after an emergency department visit for an exacerbation of COPD: a cohort study

Abstract

BackgroundCreating an easy-to-use instrument to identify predictors of short-term (30/60-day) mortality after an exacerbation of chronic obstructive pulmonary disease (eCOPD) could help clinicians choose specific measures of medical care to decrease mortality in these patients. The objective of this study was to develop and validate a classification and regression tree (CART) to predict short term mortality among patients evaluated in an emergency department (ED) for an eCOPD.MethodsWe conducted a prospective cohort study including participants from 16 hospitals in Spain. COPD patients with an exacerbation attending the emergency department (ED) of any of the hospitals between June 2008 and September 2010 were recruited. Patients were randomly divided into derivation (50 %) and validation samples (50 %). A CART based on a recursive partitioning algorithm was created in the derivation sample and applied to the validation sample.ResultsTwo thousand four hundred eighty-seven patients, 1252 patients in the derivation sample and 1235 in the validation sample, were enrolled in the study. Based on the results of the univariate analysis, five variables (baseline dyspnea, cardiac disease, the presence of paradoxical breathing or use of accessory inspiratory muscles, age, and Glasgow Coma Scale score) were used to build the CART. Mortality rates 30 days after discharge ranged from 0 % to 55 % in the five CART classes. The lowest mortality rate was for the branch composed of low baseline dyspnea and lack of cardiac disease. The highest mortality rate was in the branch with the highest baseline dyspnea level, use of accessory inspiratory muscles or paradoxical breathing upon ED arrival, and Glasgow score <15. The area under the receiver-operating curve (AUC) in the derivation sample was 0.835 (95 % CI: 0.783, 0.888) and 0.794 (95 % CI: 0.723, 0.865) in the validation sample. CART was improved to predict 60-days mortality risk by adding the Charlson Comorbidity Index, reaching an AUC in the derivation sample of 0.817 (95 % CI: 0.776, 0.859) and 0.770 (95 % CI: 0.716, 0.823) in the validation sample.ConclusionsWe identified several easy-to-determine variables that allow clinicians to classify eCOPD patients by short term mortality risk, which can provide useful information for establishing appropriate clinical care.Trial registrationNCT02434536.Electronic supplementary materialThe online version of this article (doi:10.1186/s12931-015-0313-4) contains supplementary material, which is available to authorized users.

The feasibility of early pulmonary rehabilitation and activity after COPD exacerbations: external pilot randomised controlled trial, qualitative case study and exploratory economic evaluation

“…The small numbers in the pilot trial do not allow us to draw inferences from the data and the focus was on safety data, especially in light of recent evidence. 58 No deaths were recorded in any of the intervention arms during the 90-day follow-up period, which, given the severity of illness of the patients recruited (see Chapter 3, Baseline data, and previous studies 32,58,156,157 ), is perhaps surprising. Attendance at group PR (usual care) was poor for the participants in our trial at the 90-day follow-up period.…”

Development of a nomogram for predicting in-hospital mortality of patients with exacerbation of chronic obstructive pulmonary disease

“…Some tools for predicting in-hospital mortality in patients hospitalized with COPD exacerbations have already been developed 10,11. One of them was the “DECAF” score, which comprises five predictors (stable state dyspnea, eosinopenia, consolidation, acidemia, and atrial fibrillation) 10.…”

Clinical Factors Associated with an Increased Risk of Death at and During Hospitalization for an Acute Exacerbation of COPD (AECOPD) and for a Short Period after Discharge

“…With regards to clinical signs of AECOPD severity, the use of accessory inspiratory [13,15,17] or expiratory muscles [13] , paradoxical breathing [15,17] , cyanosis [13] , lower limb oedema [13] , and impaired neurological status [13,17] , especially with a Glasgow score < 15 [15] were found to be important factors related to mortality of AECOPD patients at and during hospitalization. Moreover, general blood gas alterations [12,14,16,[18][19] , in particular hypercapnia [12,14,19] or hypoxaemia [18,19] , have been found to be strong predictors of mortality.…”

“…This aspect may in fact, be true especially when defining the prognosis of patients and then, adjusting levels of care and treatments, or optimizing timing of discharge and planning a followup visit. With regards to variables influencing survival and related to the general characteristics of patients, age at admission [9,[12][13][14][15][16][17] , particularly in older patients [9,13,16] , has been seen to be an important indicator of poor prognosis during hospitalization [9,[12][13][14][15][16][17] and in the post-discharge period [12,15] . Moreover, the presence of associated comorbidities to COPD [9,12,15,17] , may worsen the prognosis of AECOPD patients; in this context, cardiovascular disease plays a special role [15,16] .…”

“…Related to the severity of COPD, several factors have been defined as risk factors. In particular, is has been demonstrated that patients with chronic respiratory failure and previous need for longterm home oxygen therapy (LTOT) [16,18] or non-invasive mechanical ventilation [17] , patients with high values at admission of dyspnoea perception [13,15,17,18] , and patients with very severe airflow obstruction (forced expiratory volume in the 1st second, FEV1 ≤ 30 % of predicted) [16,18] have an increased risk of death related to AECOPD.…”