European Journal of Cardiovascular Medicine

 Chronic obstructive pulmonary disease (COPD) significantly contributes to morbidity (MB) & mortality (MT) related to pulmonary conditions globally, leading to a considerable and increasing social and economic burden. [1] This disease is expected to surpass tobacco as the third leading cause of MT globally by 2025, thereby increasing its significance within public health discussions. [2] The American Lung Association defines an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is "an acute worsening of respiratory symptoms (particularly dyspnea) that results in additional therapy requiring a change in medical treatment and/or hospitalization, which may be life-threatening based on the severity of the insult." [3] A variety of supplementary scoring systems (SS) have been developed for AECOPD, including DECAF (to predict inpatient MT, in patients treated with acute or recurring illness aggravation. Its acceptance is relatively high)[4,5] , CURB-65 [(Confusion, Urea, Respiratory Rate(RR), Blood pressure(BP), Age > 65) assess & direct antibiotic therapy, best predictive instrument [6]] , BAP-65[B is Blood Urea Nitrogen(BUN) (it is positive if the level is above 25 mg/dL), A is Altered Mental Status (it is counted positive when the initial GCS is 14 or less, or when the physician has designated that the patient was disoriented, stuporous or in a coma) P is Pulse (positive when the initial pulse is above 109beats/min) 65 (if the patient was above 65 of age) (published in 2011, to predict need mechanical ventilation(MV) & risk of MT)[7]  and CAPS [(chronic obstructive pulmonary disease and asthma physiology score) this named was given by Wildman et al., [8] for exacerbations of the obstructive airways disease. This score comprises 8 indices (HR, mean arterial BP, pH, sodium, urea, creatinine, albumin & WBC)], (originally designed for pneumonia), as well as general intensive care unit SS such as APACHE II(Acute

Physiology and Chronic Health Evaluation) to predict death.

Hence the goal of our study was to compare & assess the performance of 5 risk scores(R/S) DECAF, BAP-65, CURB-65, CAPS and APACHE II in AECOPD and find the best to predicts

Hospital (H) MT& MV.

The current study was conducted in the Department of Medicine at Jawahar Lal Nehru Hospital, Ajmer. Starting from January 2023 and ending in December 2023, after we received approval from the ethical committee and patient informed consent with total of 150 patients.

Study Design: Hospital based observational study

Inclusion Criteria:

1. FEV1 (forced expiratory volume in 1 sec) & FVC (forced vital capacity < 0.7) presence.
2. Age greater than or equal to 40 years.
3. Dust
4. Smoke Exposure

Exclusion Criteria:

1. Other primary cause of admission like Myocardial Infarction (MI), Chronic Kidney Disease (CKD), Acute Kidney Injury (AKI) & Malignancy.
2. Patient diagnosed with conditions like Bronchial Asthma, Bronchiectasis, Pneumonia Malignancy, Tuberculosis, Pregnant & Lactating Ladies.
3. Those on Domiciliary Ventilation.
4. Comorbidity expected to limit survival to <12 month.
5. Kyphoscoliosis

Methodology

In our study, we have taken detailed history which includes age, sex, smoking habit, assessement of stable state dyspnoea grade based on eMRCD (Extended Medical Research Council Dyspnoea score), clinical examination [mental state conscious level & signs of severity of exacerbation (cyanosis, use of Accessory inspiratory muscles, paradoxical abdominal movement, asterixis, neurological impairment, lower limb edema)], chest examination, ECG, arterial blood gases, BUN,DECAF score and BAP65, CAPS, APACHEII, were compared CBC, severity scores for AECOPD were calculated for each patient and the individual parameters were recorded. Further, based on the outcome after hospital stay, the patients were derived into two group’s i.e.group1 (non-survived/expired)-Those who died during hospital stay and group2 (survived) - Those who survived during hospital stay. Relationship between individual parameters & MT was analysed with chi square test.

TABLE 1: AGE DISTRIBUTION

Table 1 shows that, most patients were 38.67% in the age group of 71–80 years, followed by 29.33% in the age group of 61–70 years, and the least were 41–50 years of age. Thus, the mean age was 68.12±10.729years.

TABLE 2: GENDER DISTRIBUTION

Table 2 shows that, male preponderance as Males were 65.33% while female were 34.67% respectively.

TABLE 3: COMPARISON of MT (GENDER)

Table 3 shows that, majority of patients in the study were male (65.33%). Males had a slightly higher percentage of deaths (70.59%) compared to their representation in the total sample, while females had a lower percentage of deaths (29.41%) relative to their total count (34.67%). Therefore, despite these differences, difference was non- significant as the p value was 0.598.

TABLE 4: COMPARISON of MT (AGE)

Table 4 shows that, age group 71-75 has the highest number of deaths (10) with total of 37 patients in this group, followed by those aged >80 (7 deaths) with total of 13 patients and 76-80 (6 deaths). The highest survival rates are observed in the age groups 71-75 (27 survivors) and 66-70 (22 survivors). Mortality seems to increase with age, especially in the groups over 70.

TABLE 5: NEED for MV

Table 5 shows that, no MV was present in 30.66% cases while present in 69.33% cases out of 104 cases. Here, 65 cases were on BIPAP and rest 39% cases were on Endotracheal Intubation.

TABLE 6: SMOKING HOSTORY

          Table 6 shows that, non- smokers in our study was around 21 patients (14.09%).    

TABLE 7: VARIOUS PARAMETERS BASED ON OUTCOME

Table 7 shows that, eosinopenia, acidemia, atrial fibrillation, exacerbations (more than two per year), altered mentation, tachycardia, RR >30/min, hypotension, hyponatremia, MAP, WBC, baseline dyspnea and lower mean arterial pressure showed stastistically significantly association, as the p-value was <0.001 each and 0.005 respectively . Whereas, the presence of lung consolidation, BUN, Age over 65 years, hypoalbuminemia did not significantly affect outcomes as the p value was 0.654, 0.43,0.415,0.07 respectively.

TABLE 8: COMPARISON OF PARAMETERS

Table 8 shows that, hematocrit, temperature and PO2 however, showed no significant difference, as the p-value was  0.94,0.91 and 0.87 respectively, suggesting it may not be as predictive of outcomes in this context. While this analysis highlights that, the SS (DECAF, BAP-65, CAPS, APACHE II, and CURB-65) and respiratory parameters (PCO2) are important predictors of mortalityas the p value was <0.001 and <0.01 respectively.

TABLE 9: EXACERBATION

Table 9 shows that, MT increases with the number of exacerbations, especially after 2 exacerbations, there was a sharp rise in death rates.Intubation is significantly linked with increased mortality, while BIPAP is associated with lower mortality rates, especially for patients with 2 & 3 exacerbations.

TABLE 10: DECAF SCORE (MT & MV)

Table 10 shows that, scores of 5 and 6 show particularly high MT rates, with the majority of patients dying, especially those intubated. Intubation was linked to a higher mortality rate, especially in patients with DECAF scores of 4 and above. BIPAP appears to be associated with better outcomes at lower DECAF scores (1-4), while higher scores (5-6) show significantly increased MT.

TABLE 11: OUTCOME OF BAP-65 SCORE

Table 11 shows that, score 4 predicted the highest mortality, with 100% of intubated patients dying. BIPAP shows better outcomes at lower BAP-65 scores, with a significant portion of patients discharged in scores 2 and 3. Intubation is associated with higher MT rates in scores 3 and 4, while patients with BAP-65 scores of 0-2 show no deaths and higher discharge rates without the need for invasive MV.

TABLE 12: APACHE II SCORE (MT & MV)

Table 12 shows that, the highest MT rates were observed in scores 41-50, among intubated patients. Scores 0-10 show favorable outcomes, with no deaths but high discharge rates (HDR) without the need for intensive interventions. Intubation is associated with 90% MT across scores 11-50, indicating that patients in these ranges are at significant risk if intubated. Thus, the DR indicating better outcomes & higher scores reflecting poorer prognoses.

TABLE 13: CAPS score (MT & MV)

Table 13 shows that, MT rates were 100% for all intubated patients across CAPS scores of 40 and above, indicating a strong correlation between higher CAPS scores and mortality risk. While, 0-10 shows favourable outcomes with no deaths & HDR (66 total patients), indicating lower risk and better prognosis. Therefore, patients with lower CAPS scores have better outcomes, while higher scores correspond to increased mortality and decreased DR.

TABLE 14: CURB-65 (MT & MV)

Table 14 shows that, 0-3 show no deaths, with HDR & favourable outcomes for patients.While score 5 showed the highest MT 100% rate than score 4 indicating a more severe disease course and worse prognosis. Therefore, patients with lower CURB-65 scores have better outcomes, while higher scores are associated with increased mortality and lower chances of discharge.

TABLE 15: DIFFERENT PARAMETER COMPARISON (MV)

Table 15 shows that, all the parameters showed significant diffrence as the p value was <0.001 respectively. Because they were so sensitive and had a high negative predictive value, DECAF, BAP-65, and APACHE-II were very good at finding patients who needed mechanical ventilation. On the other hand, CAPS is better at ruling out the need for mechanical ventilation, as shown by its high specificity and positive predictive value, even though it is less sensitive. CURB-65 exhibits moderate performance, though it is less specific compared to the other SS.

  FIGURE 1: MECHANICAL VENTILATOR (MV)

Figure1 shows that, DECAF has very high sensitivity(SN), however, its specificity(SP) is moderate, BAP-65 same SN & SP values (DECAF), APACHE-II showed high SN, but with slightly lower SP compared to DECAF & BAP-65, CAPS showed high SP and low SN, CURB-65 showed high SN but lower SP compared to other scores respectively.

       FIGURE 2 : MORTALITY(MT)

Figure 2 shows that, DECAF was 0.844 with SN 88.2% & SP 80.9% , BAP 65 was 0.868 with SN 88.2% & SP 79.1%,  APACHE-II was 0.926 with SN 85.3% & SP 89.6%, CAPS was 0.742 with SN 55.9% & SP 83.5% and CURB-65 was 0.646 with SN 42.6% & SP of 58.8% respectively.

According to the current research, the age group of 71–80 years old had the highest concentration of patients (36.67%), followed by the age group of 61–70 years with 29.33%, and the age group of 41–50 years had the lowest concentration of patients. From the 1940s through the 1980s, the occurrence takes place throughout the course of eight decades. Around 68.12±10.729 years was the average age. Based on this distribution, it seems that AECOPD mostly impacts persons in their latter years, especially those who are 60 and above. In the study conducted by Tabet et al. (2016), the mean age of the patients was reported to be 68 ±9.5, with a male predominance observed in 67.6% of the cases.[9] Sweed R A et al. (2019) reported that the study group had a mean age of 61.1 ± 10.7 years.[10] In the study conducted by Saad et al. in 2019, a total of 101 patients were included. The mean age of the participants was 60 ± 8.52, and their ages ranged from 44 to 85 years.[11] Ahmed N. et al. (2020), 114 patients diagnosed with AECOPD, 50% were aged between 61 and 70 years, 36% were in the 51–60 years age group, and 14% were in the 35–50 years age group. The findings consistently indicate that AECOPD predominantly impact older populations, particularly individuals aged 60 years and older.[12] There is a significant male bias in the occurrence of acute exacerbations of chronic obstructive pulmonary disease (AECOPD), with 65.33% of the patient population being male and 34.67% being female, according to this study. In our study, the comparison of MT rates(R) by age revealed that the age group 71-75 exhibited the highest number of deaths, totaling 10. Individuals over 80 accounted for 7 deaths, while those in the 76-80 age range accounted for 6 deaths. The age groups 71-75 exhibit the highest survival rates, with 27 individuals surviving, followed closely by the 66-70 age group, which has 22 survivors. MT appears to rise with advancing age, particularly among individuals aged 70 and older. Another study concluded that, COPD patients who were hospitalized, revealing that, MTR exhibit a significant increase in individuals aged over 70 years. In the cohort analyzed, individuals aged over 70 represented the predominant proportion of fatalities, consistent with our findings, which indicated that MTR escalated with increasing age, especially beyond the age of 70.[13] The findings from our study suggest that, older patients exhibit poorer outcomes due to the presence of multiple comorbid conditions and reduced physiological reserves. MV was not utilized in 30.66% of the cases, while it was employed in 69.33% of the 104 cases analyzed. 65 patients received non-invasive ventilation, while the remaining thirty-nine percent underwent endotracheal intubation (ET-I). Our study observed a prevalence of nonsmokers at 14.09%. In the analysis of the prevalence of non-smokers diagnosed with AECOPD over the past 5 years, it is evident that, although smoking is a significant risk factor, a considerable percentage of patients are non-smokers. Thus, there was high in WBC, changed mental status, frequent exacerbations, tachycardia, acidemia, AF, hypotension, hyponatremia, and eosinopenia were all significantly linked to greater MT. On the other hand, the relationship between age and elevated BUN levels does not demonstrate a significant correlation with MTR. A study looked at people with AECOPD and found Grade 2 dyspnea in 47% of cases, which is a little less than the 54% reported in the previous study.[10] The current study found a slightly higher proportion of patients with milder symptoms, with grade 1 dyspnoea accounting for 53% of cases. A study found that 56% of their AECOPD patients had Grade 2 dyspnea, which is very close to the 54% seen in our study. 44% of patients had grade 1 dyspnea, showing good agreement with the 46% in the current study.[11]

The DECAF (dyspnoea, eosinopenia, consolidation, acidaemia, atrial fibrillation) score is a risk stratification instrument designed for assessment at admission, effectively forecasting mortality risk.[14] It may be readily computed at the bedside to inform treatment decisions, such as home hospitalization for low-risk patients.[15] Another reported that the AUC for the DECAF score was 0.777 (0.673-0).[12] Shorr et al.19 say that, BAP-65 looks at things like age, mental state, pulse, and BUN levels to figure out how likely someone is to MT & MV.[7] They also found an AUROC value of 0.77. [7]  APACHE II uses routine physiological variables to assess illness severity and predict MTR. Another study found that the AUROC for MT prediction was 0.982, the highest recorded.[10] The CURB-65 score estimates MTR using clinical criteria in our study. Another study reported an AUROC of 0.87 in a subgroup with consolidation.[16] A study reported an AUROC of 0.715.[12] A study found that AUROC was 0.83, which outperformed CURB-65 (AUROC = 0.65) and APACHE II (AUROC = 0.68).[16] Other investigations reported no significant difference when compared to CURB-65 and APACHE II. [12,16] An investigation showed that the DECAF score is about as good as the BAP-65, CURB-65, CAPS, and APACHE II risk scores at predicting hospital death in people with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).[17] The BAP65 score demonstrated the highest area under the receiver operating characteristic (AUROC) curve (0.861) in comparison to DECAF, modified DECAF (2008), and BAP65 scores for predicting mortality, as reported in another study.[5, 18] An analysis done in the past study showed that, CURB-65 was more accurate than DECAF at predicting death outcomes (93.4% vs. 75.7%). [18] Before the year 2020, a study showed that, the DECAF score was more specific than the CURB-65 score, with values of 86.25% and 68.75%, respectively. However, the sensitivity levels for both scoring systems were nearly equivalent, recorded at 67.65% for DECAF and 64.71% for CURB-65.[12] In our study , ROC curve for MV showed that, DECAF, BAP-65, and APACHE-II are the most effective in identifying patients who will need MV because of their high SN & NPV. CAPS, on the other hand, has a high SP & PPV, making it ideal for ruling out cases that do not require MV. CURB-65 performed averagely, ranking in the center of the pack in terms of SN & SP but scoring lower in precision. While for MT our study showed that, the APACHE-II, DECAF, and BAP-65 scores were the best at predicting MT in AECOPD patients, with APACHE-II having the most predictive power. When it comes to verifying non-MT, the CAPS score showed greater specificity, but when it comes to identifying patients at risk, its lower SN restricts its utility. On the other hand, this group did not benefit from the CURB-65 score.

The study found that various scoring systems, particularly APACHE II, effectively predicted the need for mechanical ventilation and mortality in patients. APACHE II had the highest sensitivity, while CAPS was the most specific for ventilation prediction. For mortality, BAP-65 and DECAF were most sensitive, while APACHE II and CAPS were most specific. Additionally, clinical factors like exacerbations, confusion, tachycardia, and laboratory markers such as eosinopenia and acidemia were strong mortality indicators. The study suggests that while scoring systems are useful, individual parameters may offer a simpler and effective approach, advocating for further research and routine use in patient triage.

1. Qureshi H, Sharafkhaneh A, Hanania NA. Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic advances in chronic disease. 2014 Sep;5(5):212-27. https://doi.org/10.1177/2040622314532862.
2. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018 Nov 10;392(10159):1736-1788. https://doi.org/10.1016/s0140-6736(18)32203-7
3. Celli BR, Wedzicha JA. Update on clinical aspects of chronic obstructive pulmonary disease. New England Journal of Medicine. 2019 Sep 26;381(13):1257-66. DOI: 10.1056/NEJMra1900500
4. Thambi N, Padmanabhan KV, Manoj DK, Rajani M. Comparison of scoring systems for mortality prediction in acute exacerbation of chronic obstructive pulmonary disease. J Med Sci Clin Res. 2017;5:19125-32. https://dx.doi.org/10.18535/jmscr/v5i3.130\
5. Yousif M, El Wahsh RA. Predicting in-hospital mortality in acute exacerbation of COPD: Is there a golden score?. Egyptian Journal of Chest Diseases and Tuberculosis. 2016 Jul 1;65(3):579-84. https://doi.org/10.1016/j.ejcdt.2016.03.003
6. Singh PK, Bhatnagar M, Deore SN, Joshi M, Bhowmick S, Verma S. Pneumonia severity index and CURB-65 score as a predictor of in-hospital mortality in acute exacerbation of COPD. Int J Sci Res. 2020;9:247–53. DOI: 10.21275/SR201101122343
7. Shorr AF, Sun X, Johannes RS, Yaitanes A, Tabak YP. Validation of a novel risk score for severity of illness in acute exacerbations of COPD. Chest. 2011 Nov 1;140(5):1177-83. https://doi.org/10.1378/chest.10-3035
8. Wildman MJ, Harrison DA, Welch CA, Sanderson C. A new measure of acute physiological derangement for patients with exacerbations of obstructive airways disease: the COPD and Asthma Physiology Score. Respiratory medicine. 2007 Sep 1;101(9):1994-2002. https://doi.org/10.1016/j.rmed.2007.04.002
9. Tabet R, Ardo C, Makhlouf P, Hosry V. Application of Bap-65: a new score for risk stratification in acute exacerbation of chronic obstructive pulmonary disease. J Clin Respir Dis Care. 2016;2(1):2472-1247. https://doi.org/10.4172/2472-1247.1000110
10. Sweed, R.A., Shaheen, M.A.E.M. & El Gendy, E.A. Usefulness of different prognostic scores for AECOPD: APACHE II, BAP65, 2008, and CAPS scores. Egypt J Bronchol 13, 498–504 (2019). https://doi.org/10.4103/ejb.ejb_20_19
11. Saad E, Ata K, Hossien MT, Khalil A. Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Predictors of Outcome. Sohag Medical Journal. 2019 Jan 1;23(1):61-79. https://dx.doi.org/10.21608/smj.2019.40987
12. Ahmed N, Jawad N, Jafri S, Raja W. DECAF versus CURB-65 to foresee mortality among patients presenting with an acute exacerbation of chronic obstructive pulmonary disease. Cureus. 2020 Jan;12(1). https://doi.org/10.7759/cureus.6613
13. Echevarria C, Steer J, Heslop-Marshall K, Stenton SC, Hickey PM, Hughes R, Wijesinghe M, Harrison RN, Steen N, Simpson AJ, Gibson GJ. Validation of the DECAF score to predict hospital mortality in acute exacerbations of COPD. Thorax. 2016 Feb 1;71(2):133-40. https://doi.org/10.1136/thoraxjnl-2015-207775
14. Mathioudakis AG, Moberg M, Janner J, Alonso-Coello P, Vestbo J. Outcomes reported on the management of COPD exacerbations: a systematic survey of randomised controlled trials. ERJ open research. 2019 Apr 1;5(2). https://doi.org/10.1183/23120541.00072-2019
15. Echevarria C, Gray J, Hartley T, Steer J, Miller J, Simpson AJ, Gibson GJ, Bourke SC. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax. 2018 Aug 1;73(8):713-22. https://doi.org/10.1136/thoraxjnl-2017-211197
16. Nafae R, Embarak S, Gad DM. Value of the DECAF score in predicting hospital mortality in patients with acute exacerbation of chronic obstructive pulmonary disease admitted to Zagazig University Hospitals, Egypt. Egyptian Journal of Chest Diseases and Tuberculosis. 2015 Jan 1;64(1):35-40.https://doi.org/10.1016/j.ejcdt.2014.10.007
17. Sangwan V, Chaudhry D, Malik R. Dyspnea, eosinopenia, consolidation, acidemia and atrial fibrillation score and BAP-65 score, tools for prediction of mortality in acute exacerbations of chronic obstructive pulmonary disease: a comparative pilot study. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine. 2017 Oct;21(10):671. https://doi.org/10.4103/ijccm.IJCCM_148_17
18. Parras AM, Bautista CL, Chica GP, López ML. Evaluation of DECAF, CURB-65 and BAP-65 scales as predictor of mortality risk in acute exacerbation of COPD in a retrospective cohort. https://doi.org/10.1183/1393003.congress-2017.PA931