European Journal of Cardiovascular Medicine

“Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction”.(1) A high fatality rate is associated with severe exacerbations of COPD, which are harmful to quality of life. They raise the strain on the healthcare system and are associated with cardiovascular problems. (2) In the world, COPD ranked fourth (5.1%) in 2004 and is expected to rise to third (8.6%) by 2030. One of the main reasons for persistent morbidity is COPD.By 2030, it is expected to climb to sixth place. According to a countrywide survey using questionnaires, 3.49% of Indians are thought to have COPD. (3) Severe exacerbations of chronic obstructive pulmonary disease are frequently associated with life-threatening acute respiratory failure, or ARF. (4) In patients with chronic conditions, hypoalbuminemia is the result of poor protein and calorie intake mixed with the effects of inflammation. (4,5)

Outcome of the disease is also poor when patients develop ARF during the episode of acute exacerbation. (4)

This investigation seeks to ascertain if hypoalbuminemia in COPD patients is a risk factor for developing ARF.

Objectives Of the Study

• To study the serum levels of albumin in COPD patients with acute exacerbation.
• To study the association between hypoalbuminemia and developing acute respiratory failure (type II) in patients with acute exacerbation of COPD, admitted in K R hospital, Mysuru.

medicine department of K R Hospital, MMCRI, Mysuru. It was an in-hospital study conducted in Mysore Medical College and Research Institute, Mysuru. Institutional ethics committee granted ethical clearance and permission, and patients who fulfilled the study's inclusion criteria were incorporated upon getting written informed consent.

The history was taken in detail and a clinical examination was performed.  Data was collected using a case record form and Relevant investigations were entered.

Patients were diagnosed to have Acute Exacerbation of COPD based on clinical evaluation.After baseline evaluation, patients having PCO2 of >45mmhg in ABG was considered to be in  acute respiratory failure (type II) and serum albumin levels less than 3.2g/dl was considered as hypoalbuminemia. Based on these values, the relationship between hypoalbuminemia with acute respiratory failure (type II) was studied.

Source of data

Primary sources: COPD Subjects with acute exacerbations admitted in K R hospital, Mysuru.

Secondary source: Information including published articles, journals, books and related websites

Methods of Collection of Data

The current retrospective cross sectional observational study was conducted on 73 subjects in K. R. Hospital, MMCRI, Mysuru from October 2022 to September 2023.

73 cases with acute exacerbation of COPD will be studied (based on previous years statistics in our institute) 

S = Z 2 pq/d 2

S = 1.96 X 1.96 X 0.05 X 0.95/0.05 X 0.05

S = 73

Z = 1.96 Confidence interval=0.05

p = Proportion of prevalence =5 %=0.05

q = 1-p = 0.95

d = Margin of Error (5%) = 0.05

Inclusion Criteria & Exclusion Criteria   

COPD Subjects with acute exacerbation age >18 years admitted in K R Hospital, Mysuru were Included in this study and Subjects with chronic liver disease and nephrotic syndrome were excluded.

Statistical analysis

Serum albumin levels and PCO2 were compared between patients with and without respiratory failure using an independent sample t test. The mean and standard deviation of the results were displayed. The association between hypoalbuminemia and acute respiratory failure was studied using Chi Squared test.A p value of less than 0.05 was used to determine a statistically significant result. Software called SPSS (version 27) was used for analyzing the data.

experienced acute respiratory failure (type II). The prevalence of acute respiratory failure in COPD patients was 67.12% (95% confidence interval [55% 77%]). The average age of COPD patients with acute respiratory failure was 75.49 years (SD = 10.29), while those without acute respiratory failure had an average age of 66.96 years (SD = 7.56). This difference was noteworthy.

The mean (standard deviation) of PCO2 and serum albumin levels among COPD patients were 63.37 (22.62) and 2.85 (0.7) respectively. These parameters among the patients with and without acute respiratory failure were compared and a difference was noted. Among patients with acute respiratory failure the PCO2 levels were higher whereas the serum albumin levels were lower. The difference in these parameters were statistically significant. (p value<0.0001) (Table 1).

Hypoalbuminemia and acute respiratory failure (type II) were statistically significantly associated (p < 0.001). The prevalence of acute respiratory failure was 98% among patients with hypoalbuminemia and 0% among patients without hypoalbuminemia (Table 2).

In this study the analysis of pCO2 and serum albumin levels revealed significant differences between patients with and without acute respiratory failure (type II). The mean pCO2 level was 77.24 (SD = 12.66) in patients with acute respiratory failure, compared to 35.04 (SD = 4.44) in those without. Conversely, the mean serum albumin level was significantly lower in patients with acute respiratory failure (2.46, SD = 0.41) than in those without (3.67, SD = 0.4). Both differences were statistically significant. It was also shown that there was a considerable correlation between hypoalbuminemia and type II acute respiratory failure. Reduced serum albumin levels and elevated pCO2 may act as indicators of the likelihood of acute respiratory failure, allowing for early intervention which may lead to better patient outcomes.

For COPD patients, a healthy diet can help avoid acute exacerbations and abrupt respiratory failure. Since preventing acute respiratory failure and exacerbation are the main goals of COPD maintenance therapy, Serum albumin is used as a test to assess malnutrition in patients with the illness, which is linked to a higher risk of both morbidity and death. Nevertheless, more prospective research is needed to confirm if nutritional assistance or albumin supplementation lowers the risk of abrupt respiratory failure in COPD patients.

A nationwide cohort study in Taiwan from 1997 to 2011 by Char-Wen Chen, Yih-Yuan Chen, Chin-Li Lu, Solomon Chih-Cheng Chen, Yi-Jen Chen, Ming-Shian Lin, and Wei Chen found that being elderly was the most powerful independent risk factor for ARF, followed by hypoalbuminemia. The study emphasized severe hypoalbuminemia as a strong independent risk factor for acute respiratory failure in COPD. (4)

Blood biomarkers associated with acute type II respiratory failure in COPD: A meta-analysis was published in China in 2021. The study's findings revealed that low levels of albumin and uric acid were risk factors for type II respiratory failure in patients experiencing an acute exacerbation of their COPD. (6)

In a study conducted by Jean-Pierre Laaban M.D., Basile Kouchakji M.D., Marie-France Dore Ph.D., Elizabeth Orvoen-Frija M.D., Jacques Rochemaure M.D., F.C.C.P, Patrick David Ph.D. on Nutritional Status of Patients with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure in Paris, France concluded that Patients who needed MV had higher rates of malnutrition than those who did not. In 68% of patients, there was a decrease in subcutaneous fat storage (triceps skinfold thickness [TSF] <80% pred). The measurements of lean body mass, namely the creatinine height index (CHI) and the mid-arm muscle circumference (MAMC), were reduced.There was a marked drop in the serum concentrations of albumin (<20 g/L), retinol-binding protein (<20 mg/L), and prealbumin (<100 mg/L).(7)

At the All-India Institute of Medical Sciences in New Delhi, India, Gopi C. Khilnani, MD, Sushil Kumar, MD, Amit Banga, MD, and S K. Sharma, PhD performed research on the determinants of mortality in patients with acute respiratory failure (ARF) related to COPD in a tertiary care hospital. The nonsurvivor group had significantly lower blood albumin levels, longer hospital stays, and artificial ventilation. (8)

Hypoalbuminemia is a potent independent risk factor for acute respiratory failure (type II), Taken together, it is important to keep an eye on pCO2 and serum albumin levels in patients with COPD.  and hence it is possible to predict that patients with COPD with hypoalbuminemia will have respiratory failure.

1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis management and prevention of Chronic Obstructive Pulmonary disease. Updated 2022. Global Initiative for Chronic Obstructive Lung Disease, 2022.
2. Halpin DM, Miravitlles M, Metzdorf N, Celli B. Impact and prevention of severe exacerbations of COPD: a review of the evidence. International journal of chronic obstructive pulmonary disease. 2017; 12:2891.
3. Rajkumar P, Pattabi K, Vadivoo S, Bhome A, Brashier B, Bhattacharya P,Mehendale SM. A cross-sectional study on prevalence of chronic obstructive pulmonary disease (COPD) in India: rationale and methods. BMJ open. 2017 May 1;7(5): e015211.
4. Chen CW, Chen YY, Lu CL, Chen SC, Chen YJ, Lin MS, Chen W. Severe hypoalbuminemia is a strong independent risk factor for acute respiratory failure in COPD: a nationwide cohort study. International journal of chronic obstructive pulmonary disease. 2015 Jun 17:1147-54.
5. Sheinenzon A, Shehadeh M, Michelis R, Shaoul E, Ronen O. Serum albumin levels and inflammation. International journal of biological macromolecules. 2021 Aug 1; 184:857-62.
6. Shi T, Feng L. Blood biomarkers associated with acute type II respiratory failure in COPD: A meta‐analysis. The Clinical Respiratory Journal. 2022 Feb;16(2):75-83.
7. Laaban JP, Kouchakji B, Dore MF, Orvoen-Frija E, Rochemaure J, David P. Nutritional status of patients with chronic obstructive pulmonary disease and acute respiratory failure. Chest. 1993 May 1;103(5):1362-8.
8. Khilnani GC, Kumar S, Banga A, Sharma SK. Predictors of mortality in patients with acute respiratory failure (ARF) secondary to COPD in a tertiary care hospital in india: a prospective study. Chest. 2010 Oct 1;138(4):765A.