Journal of General Internal Medicine

, Volume 24, Issue 9, pp 1043–1048 | Cite as

Predictors of Outcome After Exacerbation of Chronic Obstructive Pulmonary Disease

  • Angeliki M. TsimogianniEmail author
  • Spyros A. Papiris
  • Georgios T. Stathopoulos
  • Effrosyni D. Manali
  • Charis Roussos
  • Anastasia Kotanidou
Original Article



The outcome after hospitalization for an exacerbation of chronic obstructive pulmonary disease (COPD) is unfavorable and uncertainty exists about factors predicting short and long-term prognosis.


To identify clinical predictors of length of hospital stay (LOS) and three-year mortality after COPD exacerbations requiring hospitalization.


Retrospective analysis of prospectively collected data.


All consecutive patients hospitalized with COPD exacerbation were enrolled. Disease severity was estimated by FEV1, body mass index (BMI), Medical Research Council (MRC) chronic dyspnoea scale, previous hospitalizations, need for long-term oxygen treatment (LTOT), arterial oxygen and carbon dioxide partial pressures (PaO2 and PaCO2), pH and respiratory rate. Outcome was assessed by LOS and three-year mortality.


Out of 81 patients enrolled, three-year mortality data were available for 61. LOS was related to BMI, MRC scale and respiratory rate. Three-year mortality was related to FEV1, BMI, MRC scale, LTOT, and PaCO2. Multiple logistic regression analysis demonstrated that MRC scale was the only independent determinant of LOS, [p = 0.001, odds ratio (OR) 7.67 (95% CI 2.50–23.41)], whereas MRC scale and BMI predicted three-year mortality, [p = 0.001, OR 8.28 (95% CI 2.25–30.47) and p = 0.006, OR 6.91 (95% CI 1.74–27.48), respectively]. Cox regression analysis demonstrated identical results. Using receiver-operator-optimized thresholds for these variables (MRC > 2 and BMI < 25 kg/m2), we propose a prediction model that accurately determines three-year mortality risk.


In this study, MRC scale and BMI predicted outcome after COPD hospitalization. Pending further validation, this predictive model may contribute to identify patients with poor outcome even when spirometric data are unavailable.


body mass index chronic obstructive pulmonary disease dyspnoea length of hospital stay mortality 



The authors wish to thank the following Chest Physicians for helping with the evaluation of patients: Dr. Spyros Tzannes, Dr. Alexandra Klitsa, Dr. Ioanna Kostara, Dr. Dimitra Haimala, and the Nursing Staff of Emergency and Pulmonary Department of “Sotiria", Chest Diseases Hospital. The statistician Christina Sotiropoulou had a major contribution in the statistical analysis and revision of the paper.

This work was supported by the Thorax Foundation, Athens, Greece.

Conflict of Interest

None disclosed.


  1. 1.
    Global strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Lung Disease (GOLD) report updated November 2008. Available at: Accessed 11th June 2009.
  2. 2.
    Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2007;29:1224–38.PubMedCrossRefGoogle Scholar
  3. 3.
    Connors AFJ, Dawson NV, Thomas C, Harrell FE, Desbiens N, Fulkerson WJ, Kussin P, Bellamy P, Goldman L, Knaus W. Outcomes following acute exacerbation of severe chronic obstructive airways disease. Am J Respir Crit Care Med. 1996;154:959–67.PubMedGoogle Scholar
  4. 4.
    Groenewegen K, Schols A, Wouters E. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD. Chest. 2003;124:459–67.PubMedCrossRefGoogle Scholar
  5. 5.
    Mushlin AI, Black ER, Connolly CA, Buonaccorso KM, Eberly SW. The necessary length of hospital stay for chronic pulmonary disease. JAMA. 1991;266(1):80–3.PubMedCrossRefGoogle Scholar
  6. 6.
    Villalta J, Sequeira E, Cereijo AC, Sisó A, de la Sierra A. Factors predicting a short length of stay for acute exacerbations of chronic obstructive pulmonary disease. Med Clin (Barc). 2005;124(17):648–50.CrossRefGoogle Scholar
  7. 7.
    Gunen H, Hacievliyagil SS, Kosar F, Mutlu LC, Gulbas G, Pehlivan E, Sahin I, Kizkin O. Factors affecting survival of hospitalised patients with COPD. Eur Respir J. 2005;26(2):234–41.PubMedCrossRefGoogle Scholar
  8. 8.
    Soler-Cataluna JJ, Martinez-Garcia MA, Roman Sanchez P, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005;60:925–31.PubMedCrossRefGoogle Scholar
  9. 9.
    Yohannes AM, Baldwin RC, Connolly MJ. Predictors of 1-year mortality in patients discharged from hospital following acute exacerbation of chronic obstructive pulmonary disease. Age Ageing. 2005;34(5):491–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Menzies R, Gibbons W, Goldberg P. Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure. Chest. 1995;398–405.Google Scholar
  11. 11.
    Burge S, Wedzicha JA. COPD exacerbations: definitions and classifications. Eur Respir J. 2003;21(Suppl 41):46s–53s.CrossRefGoogle Scholar
  12. 12.
    Nishimura K, Izumi T, Tsukino M, Oga T. Dyspnea is a better predictor of 5- year survival than airway obstruction in patients with COPD. Chest. 2002;121:1434–40.PubMedCrossRefGoogle Scholar
  13. 13.
    Calverley P, Anderson J, Celli B, Ferguson GT, Jenkins Ch, Jones PW, Yates JC, Vestbo J. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356:775–89.PubMedCrossRefGoogle Scholar
  14. 14.
    Tsimogianni AM, Papiris SA, Kanavaki S, Stathopoulos GT, Sotiropoulou C, Manali ED, Michalopoulou P, Roussos C, Kotanidou A. Predictors of positive sputum cultures in exacerbations of chronic obstructive pulmonary disease. Respirology, in pressGoogle Scholar
  15. 15.
    American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med. 1995;152:1107–36.Google Scholar
  16. 16.
    Agustí AG, Noguera A, Sauleda J, Sala E, Pons J, Busquets X. Systemic effects of chronic obstructive pulmonary disease. Eur Respir J. 2003;21:347–60.PubMedCrossRefGoogle Scholar
  17. 17.
    Celli B, Cote C, Mario J, Casanova C, Montes de Oca M, Mendez RA, Plata VP, Cabral HJ. The body-mass index, airflow obstruction, dyspnea and exercise capacity index in Chronic Obstructive Pulmonary Disease. N Engl J Med. 2004;350:1005–12.PubMedCrossRefGoogle Scholar
  18. 18.
    Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54:581–6.PubMedGoogle Scholar
  19. 19.
    Kim S, Clark S, Camargo CA Jr. Mortality after an emergency department visit for exacerbation of chronic obstructive pulmonary disease. COPD. 2006;3(2):75–81.PubMedCrossRefGoogle Scholar
  20. 20.
    Budweiser S, Jörres RA, Riedl T, Heinemann F, Hitzl AP, Windisch W, Pfeifer M. Predictors of survival in COPD patients with chronic hypercapnic respiratory failure receiving noninvasive home ventilation. Chest. 2007;131(6):1650–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Ai-Ping C, Lee KH, Lim TK. In-hospital mortality and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD. A retrospective study. Chest. 2005;128:518–24.PubMedCrossRefGoogle Scholar
  22. 22.
    Sethi S, Muscarella K, Evans N, Klingman KL, Grant BJ, Murphy TF. Airway inflammation and etiology of acute exacerbation of chronic bronchitits. Chest. 2000;118(6):1557–65.PubMedCrossRefGoogle Scholar
  23. 23.
    Van der Valk P, Monninkhof E, Van der Palen J, Zielhuis G, van Herwaarden C, Hendrix R. Clinical predictors of bacterial involvement in exacerbations of chronic obstructive pulmonary disease. Clin Infect Dis. 2004;39(7):980–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Panagiotakos DB, Pitsavos C, Chrysohoou C, Risvas G, Kontogianni MD, Zampelas A, Stefanadis C. Epidemiology of overweight and obesity in Greek adult population: the ATTICA Study. Obes Res. 2004;12(12):1914–20.PubMedCrossRefGoogle Scholar
  25. 25.
    Hajiro T, Nishimura K, Tsukino M, Ikeda A, Oga T, Izumi T. A comparison of the level of dyspnea vs disease severity in indicating the health-related quality of life of patients with COPD. Chest. 1999;116:1632–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Donaldson GC, Seemungal TAR, Blowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 2002;57:847–52.PubMedCrossRefGoogle Scholar
  27. 27.
    Almagro P, Calbo E, Ochoea de Echaguen A, Barreiro B, Quintana S, Heredia JL, Garau J. Mortality after hospitalisation for COPD. Chest. 2002;121:1441–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Garcia-Aymeric J, Farrero E, Felez MA, Izquierdo J, Marrades RM, Anto JM. Risk factors for readmission to hospital for a COPD exacerbation: a prospective study. Thorax. 2003;58:100–5.CrossRefGoogle Scholar
  29. 29.
    Pitta F, Troosters Th, Probst V, Spruit MA, Decramer M, Gosselink R. Physical activity and Hospitalization for Exacerbation of COPD. Chest. 2006;129:536–44.PubMedCrossRefGoogle Scholar
  30. 30.
    Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD: role of comorbidities. Eur Respir J. 2006;28:1245–57.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Angeliki M. Tsimogianni
    • 1
    Email author
  • Spyros A. Papiris
    • 2
  • Georgios T. Stathopoulos
    • 1
  • Effrosyni D. Manali
    • 2
  • Charis Roussos
    • 1
  • Anastasia Kotanidou
    • 1
  1. 1.Department of Critical Care and Pulmonary Services, General Hospital “Evangelismos”, School of MedicineNational and Kapodistrian University of AthensAthensGreece
  2. 2.2nd Pulmonary Department, “Attikon” University Hospital, School of MedicineNational and Kapodistrian University of AthensAthensGreece

Personalised recommendations