# 141 Prognosis in End-Stage COPD

FAST FACTS AND CONCEPTS #141 PDF


Author(s): Julie Wilson Childers MD, Robert Arnold MD, and J Randall Curtis MD

Background   Prognostic variables in COPD patients are not well described, thus decision making regarding when to move away from aggressive life-sustaining treatments is challenging. This Fast Fact will review prognostication in patients with advanced COPD.

Ambulatory   COPD Patients The forced expiratory volume in one second (FEV1) has traditionally been used to assess COPD severity. A FEV1 of less than 35% of the predicted value represents severe disease; 25% of these patients will die within two years and 55% by four years. A number of other studies have shown that age, low body mass index (BMI), and low PaO2 were independent predictors that correlated to reduced survival time. The BODE scale, consisting of BMI, exercise capacity, and subjective estimates of dyspnea, has been shown to help predict survival over 1-3 years (Celli 2004):

Variable
Points on BODE Index
 
0
1
2
3
FEV1 (% predicted)
≥65
50-64
36-49
≤35
Distance walked in 6 min (meters)
>350
250-349
150-249
≤149
MMRC dyspnea scale*
0-1
2
3
4
Body-mass index (BMI)
>21
≤21
 
 

 

BODE Index Score
One year mortality
Two year mortality
52 month mortality

           0-2

2%
6%
19%

           3-4

2%
8%
32%

           4-6

2%
14%
40%

          7-10

5%
31%
80%


Note: these variables do not appear to help predict prognosis within six months of death.

Hospitalized COPD Patients   Mortality statistics vary for patients admitted with COPD exacerbations depending on age, functional status, co-morbidities, and physiological variables such as hypoxia and hypercarbia. Roughly 10% of patients admitted with a PaCO2 >50 mmHg will die during the index hospitalization, 33% will die within six months, and 43% die within one-year (Connors 1996). Patients with less severe COPD have lower in-hospital mortality rates (Patil 2003). COPD patients who require mechanical ventilation have an-hospital mortality of ~25% (Seneff 1995, Nevins 2001). Poor prognostic factors include: co-morbid illnesses, severity of illness (APACHE II score), low serum albumin, and/or low hemoglobin. Previous mechanical ventilation, failed extubation, or intubation for greater than 72 hours all increase mortality (Nevins 2001). In one study, patients ventilated more than 48 hours had a 50% one year survival; functional status and severity of illness were associated with short term mortality while age and co-morbidities were associated with one year mortality (Celli 2004).

National Hospice and Palliative Care Organization Criteria   NHPCO guidelines for hospice admission in COPD include factors such as cor pulmonale and pO2 <55 mmHg while on oxygen, albumin < 2.5 gm/dl, weight loss of > 10%, progression of disease, and poor functional status. However, a study showed when using these factors, 50% of the patients were still alive at six months, implying that the NHPCO criteria have a limited role in predicting six month mortality and thus should be used with caution in determining hospice eligibility under the Medicare Hospice Benefit (Fox 1999).

Summary   COPD is a heterogeneous disease without a simple prognostic trajectory. For ambulatory patients, age, degree of dyspnea, weight loss (BMI), functional status and FEV1 are relevant prognostic factors for predicting 1-3 year survival. For hospitalized patients, the same factors are relevant. In addition, the need for prolonged or recurrent mechanical ventilation is predictive of shorter prognosis.

References

  1. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Eng J Med. 2004; 350(10):1005-12.
  2. Connors AF Jr, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med. 1996; 154:959-967.
  3. Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA. 1999; 282(17):1638-45.
  4. Nevins ML, Epstein SK. Predictors of outcome for patients with COPD requiring invasive mechanical ventilation. Chest. 2001; 119:1840-9.
  5. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000; 355:1931-35.
  6. Seneff MG, Wagner DP, Wagner RP, et al. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA. 1995; 274:1852-57.

Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in August 2005. Current version re-copy-edited in April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Childers JW, Arnold R, Curtis JR. Prognosis in End-Stage COPD. Fast Facts and Concepts. August 2005; 141. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_141.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Medical Knowledge, Patient Care, Systems-Based Practice

Keyword(s): Prognosis