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Frequency of Respiratory Failure in patients with

Acute Exacerbation of Chronic Obstructive
Pulmonary Disease.

Article · September 2015

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 ORIGINAL ARTICLE

FREQUENCY OF RESPIRATORY FAILURE IN PATIENTS WITH

ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Shahid Iqbal**, Zafar Iqbal*, Hussain Ahmad*, Mustafa Kamal*,
Muhammad Yousaf Khan*, Arshad Javaid*

* Department of Pulmonology, ABSTRACT

Lady Reading Hospital,
Peshawar, Pakistan Background: Acute exacerbations of chronic obstructive pulmonary
**District Headquarter disease is a major health burden. There is accompanying hypoxia,
Hospital, Taja zai, Lakki hypercapnia and acidosis leading to deterioration of vital body functions.
Marwat, Pakistan
Objective: To determine the frequency of respiratory failure in patients
Address for correspodence: admitted with acute exacerbation of chronic obstructive pulmonary disease.
Dr. Shahid Iqbal
District Chest Specialist, Study Design: Cross sectional descriptive study.
District Headquarter Hospital,
Taja zai, Lakki Marwat, Setting: Department of Pulmonology, Lady Reading Hospital, Peshawar.
Pakistan
E-mail: Duration: 6 months from 19th April, 2010 to 19th October, 2010.
shahidiqbal332@yahoo.com
Subjects and Methods: The total number of patients included in the study
was 383 presenting with acute exacerbation of COPD. Arterial blood sample
was collected immediately at the time of presentation, analyzed for partial
pressures of carbon dioxide, oxygen, PH and HCO3 using arterial blood gas
analyzer and analyzed by using Statistical Package for Social Sciences version
10.0.
Results: The total number of patients was 383 including 257 (67.10%) males
and 126 (32.90%) females. The mean age was 59.3 years + 10.76SD.
Respiratory failure in acute exacerbation of COPD was observed in 136
(35.51%) patients including 90 males (23.50%) and 46 females (12.01%).
Maximum number with respiratory failure was in 51 to 60 years age group
which was 67 (17.49%) and minimum number was recorded 15 (3.91%) in the
age group of 71 to 80 years.
Conclusion: Respiratory failure is very common in patients presenting with
acute exacerbation of chronic obstructive pulmonary disease and Tertiary care
hospitals must be well equipped for management of these patients.
Key words: Chronic obstructive pulmonary disease; Acute exacerbation of
chronic obstructive pulmonary disease; Respiratory failure

This article may be cited as: Iqbal S, Iqbal Z, Ahmad H, Kamal M, Khan MY, Javed A. Frequency of Respiratory
failure in patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Pak J Chest Med 2015;
21(3): 109-13

INTRODUCTION increased morbidity, mortality and health care costs

associated with the condition. 5,6 Exacerbation of

C
hronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) is
is a slowly progressive disorder characterized characterized by a change in patient's base line
by fixed or partially reversible airflow obstruc- dyspnea, cough and/or sputum, that is beyond normal
tion FEV1 /FVC (forced vital capacity) ratio less than day-to-day variations.7,8 Clinical consequences of
70%.1,2 Worldwide prevalence of COPD is about 9- exacerbation of COPD range from a self limited illness
10% in adults over the age of 40 years. 3,4 to progressive respiratory failure.9 Arterial blood gas
analysis revealed respiratory failure in 46.5% patients
Acute exacerbations of chronic obstructive pulmo-
hospitalized with acute exacerbation of COPD in a
nary disease (COPD) contribute considerably to the

PJCM 2015; 21 (3) 109

 FREQUENCY OF RESPIRATORY FAILURE IN PATIENTS WITH ACUTE EXACERBATION OF COP DISEASE

study conducted in China.10 arterial carbon dioxide tension more than 45 mmHg
which is measured by analyzing arterial blood sample
Respiratory failure is defined by an arterial oxygen using blood gas analyzer machine available in
tension (PaO2) of less than 60 mmHg and/or an arterial hospital. All patients both males and females above 40
carbon dioxide tension (PaCO2) greater than 45 years of age diagnosed as having COPD presenting
mmHg.11 Hospital management of respiratory failure with acute exacerbation to pulmonology department
includes controlled oxygen therapy, bronchodilator Lady Reading Hospital, Peshawar were included in
therapy, glucocorticosteroids, antibiotics and/or the study. Exclusion criteria adopted were Patients
ventilation support including non invasive or invasive having COPD with acute severe asthma,
ventilation12-15 Non-invasive ventilation is an effective bronchogenic carcinoma, cardiac arrhythmia, left
treatment for respiratory failure in patients with ventricular failure with pulmonary edema and
exacerbation of COPD with good results.16 pneumothorax; or Patients presenting with respira-
tory failure associated with severe pneumonia,
Outcome of respiratory failure depends on underlying
pulmonary embolism, acute respiratory distress
factors and the facilities available for its treatment.
syndrome, kyphoscoliosis.
Appropriate facilities including non-invasive ventila-
tion are available in limited centers in Pakistan, which Approval was taken from hospital ethical committee.
must be arranged in hospitals admitting acutely ill Patients were admitted via emergency or OPD to the
patients, if reduction of high mortality (28%) associ- Pulmonlogy department Lady Reading Hospital,
ated with the condition is desired.17 Data is available Peshawar. Informed written consent about the
regarding the frequency of respiratory failure at potential risk and benefit was taken from all the
international level,18 but no data is available at local set patients. After documentation of clinical history and
up or Peshawar. physical examination, Demographic characteristics
were recorded. A 3ml blood sample was collected
We did this study with the objective of to determine
from radial artery using aseptic technique, immedi-
the frequency of respiratory failure in patients
ately at the time of presentation. A sterile 5ml dispos-
admitted with acute exacerbation of chronic obstruc-
able syringe heparinized with 0.5ml heparin was used
tive pulmonary disease in our setup. Results of this
to prevent blood coagulation. The sample was
study will help to know the magnitude of the problem
immediately analyzed for partial pressures of carbon
which will guide us to set recommendations regarding
dioxide and oxygen using arterial blood gas analyzer
required health facilities for management of these
(AVL Compact 2 Radiometer, Denmark). Confounding
serious patients, according to the magnitude of the
variables were controlled by strictly following the
problem in our hospital.
exclusion criteria. The sample was analyzed within 10
MATERIALS AND METHODS minutes of collection at room temperature. Care was
taken to avoid venous blood sample by using stan-
This descriptive, cross sectional study was carried out dard technique. Blood sample was taken before
at Pulmonology department, Lady Reading Hospital, starting oxygen to the patient. Study variables include
Peshawar during 6 months from 19th April, 2010 to 19th age, sex, respiratory failure, partial pressure of oxygen
October, 2010 recruiting 383 patients presenting with (PaO2), Partial pressure of carbon dioxide (PaCO2),
acute exacerbation of COPD by consecutive (non- arterial blood PH and bicarbonate level. Data was
probability sampling). Acute Exacerbation of Chronic analyzed by using Statistical Package for Social
Obstructive Pulmonary Disease was defined as; Sciences (SPSS) version 10.0.
patients with diagnosis of COPD as shown by
previous record of spirometry (FEV1 less than 80% RESULTS
predicted and FEV1/FVC ratio less than 70%), who
The total number of patients was 383 presenting with
present with dyspnea at rest (having more than 25
acute exacerbation of COPD. There were 257
breaths per minute measured by counting the number
(67.10%) males and 126 (32.90%) females. The male
of breaths in one minute using stopwatch), increase in
to female ratio was 2.03:1. The mean age of male
amount of sputum (more than 30 ml per 12 hours
patients was 57.3 years ± 10.3SD and female was 62.1
measured by collecting the sputum and measured in
years ± 11.2SD with an overall mean age of 59.3 years
graduated glass beaker performed in ward) and
± 10.76SD.
sputum purulence (more than 25 pus cells per low-
power field of sputum measured by sputum micros- The number of patients presenting with respiratory
copy performed in medical laboratory using micro- failure in acute exacerbation of COPD was 136
scope) at least for the last two days. While patients (35.51%) including 90 (23.50%) males and 46 (12.01%)
with Respiratory Failure were labeled as by an arterial females. Maximum number of patients with respira-
oxygen tension (PaO2) of less than 60 mmHg and/or an tory failure was in 51 to 60 years age group which was

PJCM 2015; 21 (3) 110

 FREQUENCY OF RESPIRATORY FAILURE IN PATIENTS WITH ACUTE EXACERBATION OF COP DISEASE

67 (17.49%) and minimum number of patients was and female patients was 7.3 + 2.1SD and 7.3 + 2.7SD
recorded 15 (3.91%) in the age group of 71 to 80 years with an overall mean pH value of 7.3 + 2.5SD. The
(Table 1). mean PaCO2 and PaO2 were 55.0 mmHg + 7.4SD and
60.8 mmHg + 6.8SD respectively. The mean HCO3 level
On arterial blood gas analysis, the mean pH in male
was recorded as 28.4 mmol/L + 1.4SD (Table 2).

Table 1: Age and Gender wise distribution of patients with and without Respiratory
failure in Acute Exacerbation of COPD

Respiratory failure
Ages (years) Yes No
Male Female Male Female

40-50 15(3.92%) 13(3.40%) 24(6.27%) 20(5.22%)

51-60 45(11.75%) 22(5.74%) 103(26.89%) 36(9.39%)

61-70 20(5.22%) 6(1.57%) 15(3.91%) 16(4.18%)

71-80 10(2.61%) 5(1.30%) 25(6.53%) 8(2.10%)

Total 90(23.50%) 46(12.01%) 167(43.60%) 80(20.89%)

Grand Total 136 (35.51%) 247 (64.49%)

Table 2: Arterial blood gas Analysis of patients with Acute Exacerbation of COPD

Mean ± Standard deviation

Sex
pH PaCO2 (mmHg) PaO2 (mmHg) HCO3 (mmol/L)

Male 7.3 ± 2.1 54.1 ± 7.6 59.9 ± 6.0 28.4 ± 1.3

Female 7.3 ± 2.7 56.2 ± 7.4 62.0 ± 8.0 28.4 ± 1.6

Total 7.3 ± 2.5 55.0 ± 7.4 60.8 ± 6.8 28.4 ± 1.4

Table 3: Stratification of the total study population and percentages of each age group

Ages in Years Respiratory Failure Patients Percentages

40-50 28 7.32%

51-60 67 17.49%

61-70 26 6.79%

71-80 15 3.91%

Total 136 35.51%

PJCM 2015; 21 (3) 111

 FREQUENCY OF RESPIRATORY FAILURE IN PATIENTS WITH ACUTE EXACERBATION OF COP DISEASE

DISCUSSION On arterial blood gas analysis, the mean pH value was

7.3 ± 2.5SD in our study. Ventilatory support (Non-
Exacerbation of chronic obstructive pulmonary invasive) should be considered in patients with severe
disease leads to clinically significant consequences acidosis (pH <7.26) and/or a rising Partial pressure of
especially respiratory failure and major health care arterial CO2 level, who fail to respond to supportive
resource utilization.19 COPD is a leading cause of treatment and controlled oxygen therapy. A pH of
death worldwide with a continued rising mortality rate more than 7.26 is a better predictor of survival during
due to complications like respiratory failure, and is a an acute episode.25
major socioeconomic burden. The natural course of
COPD is characterized by progressive decline in lung Due to lack of health facilities, most of COPD patients
function and recurrent exacerbations. Respiratory remain undiagnosed in the peripheral areas of our
failure may develop, requiring admission to the ICU for province and are diagnosed in advanced stages of
assisted ventilation.20 COPD. Lady Reading Hospital is a tertiary care
hospital and patients are referred from far areas of the
Our study is the first to determine the frequency of province where health facilities are deficient. Most of
respiratory failure in patients admitted with acute the patients with acute exacerbation are not managed
exacerbation of chronic obstructive pulmonary properly in periphery, leading to deterioration of the
disease in our country. In our study, frequency of condition. This is the main reason of high frequency of
respiratory failure in patients presented with acute respiratory failure in our study.
exacerbation was 35.51% on arterial blood gas
analysis. Frequency of respiratory failure in our study Respiratory failure was not classified into acute and
is comparable to international literature. In an Indian chronic respiratory failure in our study, which was a
study, the laboratory abnormalities at presentation on major limitation in our study. As this is one centered
arterial blood gas analysis revealed respiratory failure study, so the results may not be generalized but still
in 33.8% patients.21 A multicentre retrospective study there is good evidence that respiratory failure is very
conducted in four hospitals of China, 46.5% patients common in patients with acute exacerbation of COPD
had respiratory failure during acute exacerbation of in our setup. Large multi-centered studies should be
chronic obstructive pulmonary disease on arterial carried out to confirm these findings.
blood gas analysis.22 Other studies in the literature
CONCLUSION
have reported the frequency of respiratory failure
ranging from 16% to 35% with overall mortality 35% to This study showed that respiratory failure is very
43%.23 Corrado et al has reported that 12.5% patients common in patients presenting with acute exacerba-
with acute exacerbation of chronic obstructive tion of chronic obstructive pulmonary disease. This
pulmonary disease have acute on chronic respiratory finding points towards very important health problem
failure.24 20% patients with COPD exacerbation were and is a significant complication of acute exacerba-
having chronic type 2 respiratory failure in elderly tion of chronic obstructive pulmonary disease.
hospitalized patients in China.20
Given the high prevalence of COPD in our country, the
In our study, there was male dominancy i.e. 67.10% consequences in terms of morbidity and mortality are
with male to female ratio of 2.03:1. Similar male significant. It also indicates that steps must be taken
dominancy has been shown by other studies in the to arrange facilities required for the management of
international literature. In the Indian study, there were such patients. Tertiary care hospitals receiving such a
80.7% male.20 In another study, there were 87.9% male heavy number of patients with respiratory failure must
patients with acute exacerbation of COPD.21 The be well equipped with facilities like controlled oxygen
reason for male dominancy in our study is related to therapy, NIPPV, mechanical ventilation and respira-
prevalence of smoking in our population. Smoking is tory ICU with specialized staff trained in the manage-
more common in males with resultant higher COPD ment of these patients. This will help to reduce the
prevalence than females, which are why more male morbidity and mortality associated with the condition.
patients presented with acute exacerbation of COPD.
Keeping in mind the impact of COPD on health care
In our study, the mean age of patients was 59.3 years ± resources, it is essential to develop effective strate-
10.76SD while in literature; the mean age of patients gies for prevention of COPD exacerbations and
has been reported as 70 years ± 8.0SD years20 and smoking cessation.
62.1 years ± 9.8SD.21 In the study conducted in China,
REFERENCES
the mean age reported is 73.4 years.9 Advanced age is
a prognostic factor for in-hospital mortality as 1. Pakistan Chest Society; Guidelines for the
described by some authers.20 management of COPD, 2005 April.

PJCM 2015; 21 (3) 112

 FREQUENCY OF RESPIRATORY FAILURE IN PATIENTS WITH ACUTE EXACERBATION OF COP DISEASE

2. Buist AS, McBurnie MA, Vollmer WM, Gillespie S, morbidity and mortality, and disease heterogene-
Burney P, , et al. International variation in the ity. Chest 2002 May;121(5 Suppl):121S-6S.
prevalence of COPD (the BOLD Study): a popula-
tion-based prevalence study. Lancet 2007 Sep 14. Britton M. The burden of COPD in the U.K.: results
1;370(9589):741-50. from the confronting COPD survey. Respir Med
2003 Mar;97(Suppl C):S71-9.
3. Halbert R, Natoli J, Gano A, Badamgarav E, Buist
A, Mannino D. Global burden of COPD.systematic 15. Seamark DA, Seamark CJ, Halpin DMJ. Palliative
review and meta-analysis. Eur Respir J care in chronic obstructive pulmonary disease: a
2006;28:523-32. review for clinicians. J R Soc Med 2007
May;100(5):225–33]
4. Russell R, Anzueto A, Weisman I. Optimizing
management of chronic obstructive pulmonary 16. Elliott MW. Noninvasive ventilation in acute
disease in the upcoming decade. Int J Chron exacerbations of COPD. Eur Respir Rev
Obstruct Pulmon Dis 2011 Jan 10;6:47-61. 2005;14:39-42.

5. Perera WR, Hurst JR, Wilkinson TMA, Sapsford 17. Hussain SF, Irfan M, Naqi YS, Islam M, Akhtar W.
RJ, Mullerova H, Donaldson GC, et al . Acute respiratory failure in Pakistani patients: risk
Inflammatory changes, recovery and recurrence factors associated with mortality. J Coll
at COPD exacerbation. Eur Respir J 2007;29:527- Physicians Surg Pak 2006;16:287-90.
34. 18. Fremault A, Janssens W, Beaucage F, Celis G,
6. Jolley CJ, Luo YM, Steier J, Reilly C, Seymour J, Pérez-Bogerd S, Decramer M. Modification of
Lunt A, et al. Neural respiratory drive in healthy COPD presentation during the last 25 years.
subjects and in COPD. Eur Respir J 2009 COPD 2010 Oct;7(5):345-51.
Feb;33(2):289-97. 19. Rodriguez-Roisin R. impacting patient centered
7. Guidelines for the Diagnosis, Management and outcomes in COPD: exacerbations and hospital-
Prevention of COPD, Global Initiative for Chronic izations. Eur respir Rev 2006;15(99):47-50.
Obstructive Lung Disease (GOLD), 2006. 20. Ai-Ping C, Lee KH, Lim TK. In hospital and 5-year
8. Pitsiou G, Kyriazis G, Hatzizisi O, Argyropoulou P, mortality of patients treated in the ICU for acute
Mavrofridis E, Patakas D. Tumor necrosis factor- exacerbation of COPD; a retrospective study.
alpha serum levels, weight loss and tissue Chest 2005;128;518-24.
oxygenation in chronic obstructive pulmonary 21. Mohan A, Premanand R, Reddy LN, Rao MH,
disease. Respir Med 2002 Aug;96(8):594-8. Sharma SK, Kamity R, et al. Clinical presentation
9. Maclntyre N, Huang YC. Acute exacerbations and and predictors of outcome in patients with severe
Respiratory failure in Chronic Obstructive acute exacerbation of chronic obstructive
Pulmonary Disease. Proc Am Thorac Soc pulmonary disease requiring admission to
2008;5:530-5. intensive care unit. BMC Pulm Med 2006;6:27.

10. Hong CY, Zhen YW, Qiang CB, Hong W, Mei DX, Li 22. Hong CY, Zhen YW, Qiang CB, Hong W, Mei DX, Li
GH, et al. Economic analysis in admitted patients GH, et al. Economic analysis in admitted patients
with acute exacerbation of chronic obstructive with acute exacerbation of chronic obstructive
pulmonary disease. Chin Med J 2008;121:587-91. pulmonary disease. Chin Med J 2008;121:587-91.

11. Budweiser S, Jorres RA, Pfeifer M. Treatment of 23. Khilnani GC, Saikia N, Banga A, Sharma SK. Non-
respiratory failure in COPD. Int J chron Obstruct invasive ventilation for acute exacerbation of
Pulmon Dis, 2008;3:605-18. COPD with very high PaCO2; a randomized
controlled trial. Lung India 2010;27(3):125-30.
12. Márquez-Martín E, Ramos PC, López-Campos
JL, Gotarredona MPS, Herrero SN, Aguilar RT. 24. Corrado A, Ginanni R, Villella G, Gorini M,
Components of physical capacity in patients with Augustynen A, Messori DT, et al.Iron lung versus
chronic obstructive pulmonary disease: relation- conventional mechanical ventilation in acute
ship with phenotypic expression. Int J Chron exacerbation of COPD. Eur Respir J 2004;23:419-
Obstruct Pulmon Dis 2011;6:105–12. 24.

13. Mannino DM. COPD: epidemiology, prevalence, 25. MacNee W. Acute exacerbations of COPD. Swiss
Med Wkly 2003;133:247-57.

PJCM 2015; 21 (3) 113

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