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

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. 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%). 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 anticholinergic/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, noninvasive 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].

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.

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 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    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.
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  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    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 nonsmokers), 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 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.

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.