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The Egyptian Journal of Bronchology
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A prospective observational study on acute exacerbation of chronic obstructive pulmonary disease in pulmonology department of tertiary care hospital

The Egyptian Journal of Bronchology volume 14, Article number: 46 (2020) Cite this article

Abstract

Background

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gasses. An acute exacerbation of COPD refers to a flare up or episode where a person breathing becomes worse than normal. An acute exacerbation of COPD refers to a flare up or episode where a person breathing becomes worse than normal. Acute exacerbation in COPD (AECOPD) is frequent in the course of the illness and is the most common reason for medical visits, hospital admissions, and mortality among these patients. Exacerbations of COPD are associated with increased morbidity and mortality. To assess the exposure and severity of acute exacerbations of COPD with COPD Assessment Test (CAT Scale) and mMRC (modified Medical Research Council) Dyspnea scale. Study design was a hospital-based prospective observational study. Study site was conducted at Pulmonology Department of Government General Hospital, Vijayawada.

Results

The total patients were 197. Out of which, 119 were from In-patient Department (IPD) and 78 were from Out-patient Department (OPD). In this study, males were 167 (85%), among which, IPD were 97 (49%), OPD were 70 (36%), and females were 30 (15%), among which, IPD were 22 (11%), OPD were 8 (4%).

Conclusion

The morbidity and mortality of COPD have been increased in recent years. This study concludes that there is a relation between risk of acute exacerbations in COPD with habitual history and occupational history. Increase in exposure to occupational hazards, smoking habit leads to an increase in risk of acute exacerbations in COPD patients. The level of severity was more in smokers and the patients who had biomass, organic dust, and mineral exposure. When severity was observed, group D severity is more observed in population according to CAT scale and mMRC dyspnea scale.

Background

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gasses. An acute exacerbation of COPD refers to a flare up or episode where a person breathing becomes worse than normal [1]. Acute exacerbation in COPD (AECOPD) is frequent in the course of the illness and is the most common reason for medical visits, hospital admissions, and mortality among these patients. Exacerbations of COPD are associated with increased morbidity and mortality [2].

The prevalence of COPD disease about 251 million cases in 2016 and the deaths estimated were 3.17 million in 2015 globally and the percentage is about 5% deaths in a year were estimated globally [3]. The incidence rates were higher in men than in women above the age of 60 years people [4, 5]. As of 2016, COPD is the second biggest cause of death in India [6, 7]. The prevalence ranged between 2 and 22% among the men and 1.2 to 19% among women in different population-based studies across India [8].

Cigarette smoking is the most common cause of COPD that accounts for about 85 to 90% of cases. The other causes for COPD include exposure to environmental smoke, passive smoke, occupational exposure, and genetic predisposition [9,10,11]. The common symptoms of COPD are shortness of breath, cough (with or without expectoration), fever, chest tightness, and hemoptysis [12,13,14].

The main goals involved in the treatment of COPD are to provide symptomatic relief and reduce the risk of future prevention of exacerbation, reduce disease progression, and reduce mortality [2]. The primary goals of pharmacotherapy are to decrease the severity of symptoms, improve the overall health status and reduce the disease frequency, complications, and severity of the exacerbations [15, 16]. Based on Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) Guidelines (2019), drug classes like short-acting beta 2 agonists (SABA), long-acting beta 2 agonists (LABA), short-acting anti-cholinergic/muscarinic agonists (SAMA), long-acting anti-cholinergic/muscarinic agonists (LAMA), inhaled or systemic corticosteroids. Hospitalized patients with COPD should be provided with antibiotic therapy, appropriate supportive care, and monitoring of oxygen status [17,18,19,20]. Therapeutic options for acute exacerbations of COPD include oxygen therapy, antibiotics, corticosteroids, bronchodilators, non-invasive mechanical ventilation [21,22,23]. The main objectives of the study are to collect and document the patient data and previous medication use, to assess the etiology for exacerbations and stages of COPD with CAT (COPD Assessment Test) and MMRC (Modified Medical Research Council) dyspnea scale, to assess the drug therapy and to identify any drug for inappropriate use, undertaking clinical interventions, documenting suspected drug reactions for future references, follow-up to assess the outcomes of the drug therapy and management, to assess adherence toward therapy every week for a period of 6 months [24,25,26,27].

The current knowledge on various aspects of COPD is to be studied further. Further studies should be done on the impact of risk factors and triggers such as smoking, severe airflow limitations, bacterial and viral infections, bronchiectasis, and comorbidities. Severe exacerbations indicate the worsening of survival outcome [28]. The present study is to assess the prescribing patterns and evaluate the clinical interventions associated with exacerbations in COPD. Previous medication use and suspected adverse drug reactions in the drug therapy for COPD is documented. This study also identify the etiology for exacerbations based on various criteria and stages of COPD with COPD Assessment Test (CAT), Modified Medical Research Council (MMRC) dyspnea scale, and drug therapy to identify any drug for inappropriate use, medication adherence and to provide patient education to reduce the exacerbations in COPD [29].

Methods

Source of data

Data was collected from prescriptions of the patients in the Pulmonology Department of IP and OP of the hospital.

Evaluation of patient medication charts in follow-up cases.

Study site

This study was conducted at the Pulmonology Department of Government General Hospital, Vijayawada. Study design—a hospital-based prospective observational study.

Sample size

A total of 197 patients who fulfilled the inclusion and exclusion criteria were selected for the study. Out of which 119 patients are from the in-patient department (IPD) and 78 patients are from out-patient department (OPD).

Study duration

The study is conducted over a period of 6 months from August 2019 to January 2020.

Study criteria

The study is carried out considering the following criteria.

Inclusion criteria

Patients who are suffering with COPD.

Exclusion criteria

Patients with no COPD.

Patients from other departments.

Data analysis

All the collected data were analyzed to assess the etiology and severity of acute exacerbations of COPD occurred in the tertiary care hospital. The predisposing factors like age and gender were determined through the analysis. Most common reasons for developing acute exacerbations were determined.

All patients were monitored from the day of admission to the day of discharge. The patient data was collected and documented in the prepared IP and OP data collection forms.

Statistical analysis

Standard statistics were used to describe patient demographics. Mean and standard deviation were calculated for age, onset of symptoms, past years of disease. The statistical significance was tested using chi-square test manually and two-way ANOVA test using the Microsoft Excel 2011.

Results

The present prospective observational study was done at the General Medicine Department, Government General Hospital, Vijayawada, over a period of 6 months since July 2019 to December 2019. A total number of 197 cases were collected from the Pulmonology Department of Government General Hospital, Vijayawada.

Distribution of gender

Clinical profile

Distribution of number of exacerbations

Distribution of age with gender

Distribution of symptoms

Distribution of dyspnea grades

Distribution of habitual exposure with exacerbations

Distribution of occupational exposure with exacerbations

Distribution of habitual exposure with gender

Distribution of occupational exposure with gender

Distribution of habitual exposure with severity

Statistical significance of habitual exposure & severity by 2-way ANOVA

Distribution of occupational exposure with severity

Statistical significance of occupational exposure, severity by 2-way ANOVA

Discussion

Gender distribution has been presented in Table 1 and Fig. 1. The total patients were 197. Out of which 119 were from In-patient Department (IPD) and 78 were from Out-patient Department (OPD). In this study, males were 167 (85%), among which, IPD were 97 (49%), OPD were 70 (36%), and females were 30 (15%), among which, IPD were 22 (11%), OPD were 8 (4%). Clinical profile of the patients has been presented in Table 2. The parameters included are mean age of 58.24 ± 5.79 years, mean age at onset of symptoms is 56.3 years, mean years of disease in past is 3.5 years. No. of exacerbation distributed among the gender has been presented in Table 3 and Fig. 2. Number of exacerbations was categorized as ≤ 1 and ≥ 2. Males and female with ≤ 1 exacerbation were 62 (31.5%) and 10 (5.1%) respectively. Males and females with ≥ 2 exacerbations were 105 (53.3%) and 20 (10.1%) respectively. Distribution of age with gender has been presented in Table 4 and Fig. 3. Age with gender was distributed and more number of patients were observed in 41-60 years of about 94 patients followed by 61-80 years of about 92 patients, 21-40 years of about 8 patients, < 20 years of about 2 patients and > 80 years of about 1 patient. Complaints based distribution has been presented in Table 5 and Fig. 4. Based on complaints more number of patients were observed in shortness of breath of about 182 patients followed by cough of about 161 patients, chest pain of about 67 patients, fever of about 60 patients, and least was observed in hemoptysis of about 6 patients. Dyspnea grade distribution has been presented in Table 6 and Fig. 5. More number of patients were observed in grade IV of about 87patients followed by grade III of about 54 patients, grade II of about 37 patients, and least was observed in grade I of about 9 patients. Habitual exposure with number of exacerbations distribution has been presented in Table 7 and Fig. 6. More number of exacerbations was observed in smokers of about 89 patients followed by ex-smokers more than 6 months of about 67 patients, nonsmokers of about 13 patients, and least was observed in ex-smokers less than 6 months of about 13 patients.

Table 1 Distribution based on gender
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Fig. 1
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Distribution based on gender

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Table 2 Clinical profile of the patients
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Table 3 Distribution of number of exacerbations
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Fig. 2
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Distribution of no. of exacerbations

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Table 4 Distribution of age with gender
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Fig. 3
figure 3

Distribution of age with gender

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Table 5 Distribution based on symptoms
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Fig. 4
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Distribution based on symptoms

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Table 6 Distribution based on dyspnea grades
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Fig. 5
figure 5

Distribution based on dyspnea grades

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Table 7 Distribution of habitual exposure with number of exacerbations
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Fig. 6
figure 6

Distribution of habitual exposure with no. of exacerbations

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Habitual exposure with a number of exacerbations distribution has been presented in Table 7 from this table, we observed the association between the habitual exposures with the number of exacerbations by using the chi-square test. The calculated value is 5.104 and the table value is 3.84. This proves that the habitual exposure influences the number of exacerbations. Occupational exposure with the number of exacerbations has been presented in Table 8 and Fig. 7. More number of patients was observed in mineral dust of about 88 patients followed by biomass exposure of about 46 patients, organic dust of about 43 patients, and least was observed in no exposure of about 20 patients. Statistical analysis of occupational exposure by chi-square test: Occupational exposure with number of exacerbations has been presented in Table 8; from this table, we observed the association between habitual exposure and occupational exposure with number of exacerbations by using the chi-square test. The calculated value is 7.48 and the table value is 3.84. This proves that the occupational exposure influences the number of exacerbations. Gender distribution based on habitual exposure has been presented in Table 9 and Fig. 8. About 94 patients were smokers followed by ex-smokers more than 6 months in 65 patients, non-smokers were 26 patients, and least was observed in ex-smokers less than 6 months in 12 patients. Gender-based distribution of occupational exposure has been presented in Table 10 and Fig. 9. About 88% of patients were exposed to mineral dust followed by 46% exposed to biomass, 43% exposed to organic dust and only 20% were not exposed to any type of pollution. Habitual exposure with severity has been presented in Table 11 and Fig. 10. Habitual exposure with respect to severity was distributed. More number of patients was observed in group D of about 73 patients followed by group B of about 60 patients, group A of about 37 patients, and least was observed in group C of about 27 patients. Habitual exposure with severity has been presented in Tables 11 and 12 from this, we observed that the impact of habitual exposure on severity grouping of the disease to analyze that by the ANOVA 2-way classification. The row characteristic was habitual exposure (smokers, ex-smokers < 6 months, ex-smokers > 6 months, and non-smokers), and the column characteristic was severity grouping of the disease (group A, group B, group C, and group D). We obtained the results using Excel 2011. As per habitual exposure concerned, which shows there is a significant difference in habitual exposure. There is a significant difference in the severity grouping of the disease. Occupational exposure based on severity grouping has been presented in Table 13 and Fig. 11, occupational exposure with respect to severity grouping was distributed. More number of patients were observed in group D of about 74 patients followed by group B of about 60 patients, group A of about 36 patients, and least was observed in group C of about 27 patients. Statistical significance of occupational exposure has been presented in Tables 13 and 14, we observed that the impact of occupational exposure on severity grouping of the disease to analyze that by the ANOVA 2-way classification. The row characteristic was occupational exposure (biomass exposure, mineral dust exposure, organic dust exposure, and no exposure) and the column characteristic was severity grouping of the disease (group A, group B, group C, and group D). We obtained the results using Excel 2011. As per occupational exposure concerned, which shows there is a significant difference in occupational exposure. There is no significance in severity grouping of the disease.

Table 8 Distribution of occupational exposure with number of exacerbations
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Fig. 7
figure 7

Distribution of occupational exposure with no. of exacerbations

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Table 9 Distribution of habitual exposure with respect to gender
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Fig. 8
figure 8

Distribution of habitual exposure with gender

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Table 10 Distribution of occupational exposure with respect to gender
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Fig. 9
figure 9

Distributional occupational exposure with gender

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Table 11 Distribution of habitual exposure with severity grouping
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Fig. 10
figure 10

Distribution of habitual exposure with severity grouping

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Table 12 ANOVA Two-way classification
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Table 13 Distribution of occupational exposure with severity grouping
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Fig. 11
figure 11

Distribution of occupational exposure with severity grouping

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Table 14 ANOVA two-way classification of occupational exposure
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Conclusion

The morbidity and mortality of COPD have been increased in recent years. This study concludes that there is a relation between risk of acute exacerbations in COPD with habitual history and occupational history. Increase in exposure to occupational hazards, smoking habit leads to an increase in risk of acute exacerbations in COPD patients. The level of severity was more in smokers and the patients who had biomass, organic dust, and mineral exposure. When severity was observed, group D severity is more observed in population according to CAT scale and mMRC dyspnea scale. Males have the highest prevalence than females due to various etiological factors such as habitual history or occupational history, comorbidities, and lifestyle.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

AECOPD:

Acute exacerbation in chronic obstructive pulmonary disease

COPD:

Chronic obstructive pulmonary disease

ANOVA:

Analysis of variance

IPD:

In-patient department

OPD:

Out-patient department

CAT:

COPD assessment test

MMRC:

Modified Medical Research Council

GOLD:

Global Initiative for Chronic Obstructive Pulmonary Disease

SABA:

Short-acting beta 2 agonists

LABA:

Long-acting beta 2 agonists

SAMA:

Short-acting muscaranic agonists

LAMA:

Long-acting muscaranic agonists

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Acknowledgements

We gratefully acknowledge the Doctors of Pulmonology Department of Government General Hospital (GGH), Vijayawada, and Dr. K. Padmalatha, Principal of Vijaya Institute of Pharmaceutical Sciences for Women for support.

Funding

Nil

Author information

Authors and Affiliations

  1. Department of Pharmacology, SRM College of Pharmacy, SRMIST, Kattankulathur, Kancheepuram, Tamil Nadu, 603203, India

    Sreenu Thalla

  2. Department of Pharmacy Practice, Vijaya Institute of Pharmaceutical Sciences for Women, Enikepadu, Vijayawada, Andhra Pradesh, 521108, India

    Akhila Yerubandi, Sk. Hafeezunnisa, Sk. Jareena & Sivakshari Makkapati

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  1. Sreenu Thalla
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Contributions

ST contributed to the idea of the study and work proposal and supervision; SH and SJ collected the patient data, consent for the study, and documentation regarding COPD with acute exacerbations; and AY and SM were the contributors for analyzing, interpreting, and writing the manuscript. “All authors read and approved the manuscript.”

Corresponding author

Correspondence to Sreenu Thalla.

Ethics declarations

Ethics approval and consent to participate

Written informed consent was signed by all study participants. The study approval was taken from the Institutional Ethical Committee (IEC), Siddhartha Medical College and Government General Hospital, Vijayawada, held on 18 August 2019, with Ethical Committee number—IEC/2019/096E/SMC.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

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Thalla, S., Yerubandi, A., Hafeezunnisa, S. et al. A prospective observational study on acute exacerbation of chronic obstructive pulmonary disease in pulmonology department of tertiary care hospital. Egypt J Bronchol 14, 46 (2020). https://doi.org/10.1186/s43168-020-00047-6

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