Chronic Obstructive Pulmonary Disease (COPD) is an increasingly important cause of morbidity and mortality in all countries of the world. According to the World Health Organization (WHO), COPD ranks 4th among the causes of death in the world and is expected to rise to the 3rd rank due to the increase in smoking (1). According to the Ministry of Health’s “National Burden of Disease (UHY)” study published in 2004, COPD is the 3rd cause of death in Turkey. Comorbidity describes one or more comorbid diseases, whether or not they are directly related to COPD. Comorbidities are common in COPD and may have important implications for prognosis . Because of the increasing prevalence of COPD and comorbid diseases and the societal burden they cause, these diseases require a different approach. COPD and comorbid diseases should be addressed with a multidisciplinary approach. In this way, worsening of COPD due to comorbid diseases will be prevented, it will be possible to ensure that COPD patients are diagnosed at an early stage, and awareness will be raised in related disciplines. In this study, we aimed to examine the characteristics of COPD patients with comorbidity and the effect of comorbidity on frequent hospital admissions and hospitalizations in COPD patients.
MATERIALS AND METHODS
The files of the patients who were admitted to the hospital with the diagnosis of COPD between August 2011 and February 2012 in the Chest Diseases Clinic and who were followed up in our 2011 clinic were retrospectively analyzed. Age, gender, smoking history, body mass index, sputum culture, CRP value, The treatments they received [the inhaler treatment method they used, long-term oxygen therapy (LTOT) and noninvasive ventilation therapy (NIMV)], the frequency of hospital admissions and hospitalizations, and comorbid diseases were recorded. The cases were divided into two groups as those without comorbid disease (Group 1) and with comorbid disease (Group 2), and the recorded findings were evaluated by comparing within the groups and between both groups. Statistical evaluation was compared using SPSS version 15.0.
Of the 100 patients included in our study, 84 (84%) were male and 16 (16%) was female. There were 64 (64%) patients with comorbidity and 36 (36%) patients without comorbidity. When 64 cases were analyzed in terms of comorbidities, cardiac disease in 58 (58%) patients, diabetes mellitus (DM) in 16 (1%) patients, malignancy in 12 (12%) patients, and deep vein thrombosis (DVT) and pulmonary disease in 8 (8%) patients. embolism (PE) was detected.
The mean age of all our patients was 69.5 ± 9.18 years. There was no difference between the two groups in terms of mean age, but the number of male cases was higher in group 2 patients. 14 (14%) of the cases were still smoking. The mean age of smoking onset was 16 ± 3.6 years, and the smoking history was 45.4 ± 35.8 pack years (p-years). There was no difference between the two groups in terms of smoking habits. Growth was detected in 18 (18%) of 74 (74%) cases in which sputum culture was performed. The mean of CRP was 54.6 ± 6.2 mg/L. There was no difference between the two groups in terms of infection parameters. When the treatment modalities and adherence to treatment were examined, it was found that 76 (76%) of them applied their treatment regularly and 16 (16%) of them irregularly, while 8 (8%) of them could not get information about treatment compliance. 57 (57%) cases were using LTOT treatment and 16 (16%) cases were using NIMV. The treatment compliance of the two groups was similar.
The mean number of hospital admissions of the cases was 22.7 ± 21.6 in all patients, 17.3 ± 13.2 in group 1, and 25.8 ± 24.7 in group 2. The mean number of emergency admissions was 7.7 ± 10.7 in all patients, 5.1 ± 4.6 in group 1, and 9.1 ± 12.7 in group 2. The mean number of hospitalizations was 4.7±4.2 in all patients, 3.7±3.17 in group 1, and 5.2±4.6 in group 2. Fifteen of 25 (25%) patients with a history of intensive care unit (ICU) hospitalization consisted of patients with comorbidities. When the hospital admissions were examined, the total number of hospital and emergency admissions was found to be significantly higher in the group with comorbidity compared to the group without. There was no significant difference between the groups in terms of the number of ICU and service hospitalizations. Although hospital and emergency visits were higher in patients with malignancy, no significant difference was found compared to other comorbidities. Comparison of the characteristics of all cases and Group 1 and Group 2 cases are shown in Table 2 and Graph 1.
ARGUMENT
Today, awareness of COPD is increasing in developed and developing countries. COPD is a disease with pulmonary and extrapulmonary effects. The inflammation caused by the disease affects both the lungs and the system. Systemic inflammation brings together many comorbidities that also affect the prognosis of the disease. Comorbidities include cardiovascular diseases, anxiety and depression, anemia, metabolic syndrome, diabetes mellitus, cachexia, malignancy, sleep apnea syndrome. Since the development of COPD is often associated with the chronic outcome of smoking, which is the major risk factor for the disease, it greatly affects the middle and older age groups. Cardiovascular, metabolic and other systemic diseases are frequently seen in patients in this age group. In a study conducted by Mannino et al. (6), 20000 patients with COPD were examined and cardiovascular disease was found in 20% of them. The issue of whether the coexistence of COPD and cardiovascular diseases develops from systemic inflammation in COPD or from common etiological factors has not been clarified yet, but cardiovascular diseases are one of the most common comorbidities. In our study, 58 (91%) of 64 patients with comorbidity were found to have cardiovascular disease. Tracheobronchial infections are responsible for 50–80% of severe COPD exacerbations that cause hospital admissions. Bacteria are responsible for 40-50% of the attacks caused by infection, viruses for 30%, and atypical factors for about 5%. In the literature, it is seen that the isolation of agents is provided in sputum cultures up to 40-60%. In our study, agent isolation was achieved in 18 (21.4%) of the cases, which is lower than the literature data. It was thought that this situation was due to insufficient material intake. When the case groups with and without additional disease were compared, no statistical difference was found in terms of reproduction in sputum cultures. Although the pathophysiology of the association of COPD and DM has not been clarified, it is thought that systemic inflammation has an effect. In our study, DM was detected in 16 patients. Although there was no significant difference in CRP and sputum culture results between patients with or without DM in our study, some studies have shown that the presence of DM in COPD increases the incidence of infection, exacerbation and mortality(8). Pulmonary embolism (PE) is one of the non-infectious causes of COPD attack. Immobility of the patients and increased pulmonary arterial pressure values in advanced stage COPD cases disrupt the stability of the cases. In addition, it is known that additional diseases such as underlying congestive heart failure, chronic renal failure and especially malignancy cause a tendency to thrombosis. In some studies, it has been shown that pulmonary embolism is detected in 18-50% of the patients hospitalized with COPD attack (9). In the study of Hoşgün et al.(10), it was reported that PE was detected in 23% of the patients presenting with acute attack. In our study, DVT and PE were detected in 8% of the patients. The rate of lung cancer development in COPD smokers is 3-4 times higher than in smokers without COPD. This is explained by the excessive amount of systemic inflammation and oxidative stress that develops in COPD. The coexistence of COPD and malignancy increases the frequency of hospitalization and mortality. In our study, malignancy was detected in 12 of the patients. In a study conducted with COPD patients who died during hospitalization, the most common comorbid conditions were cardiovascular diseases and DM; it has been shown that the most common causes of death in these cases are pneumonia and lung cancer (13). In another study, it was shown that hypertension is the most common comorbidity in COPD patients hospitalized with an acute attack. It has been stated that the most common comorbidities following hypertension are chronic renal failure, DM, and cardiovascular diseases. It has been shown that the risk of mortality is higher in patients with advanced age, current smoking, ischemic heart disease and lung cancer. Prevention and treatment of comorbidities are essential for better care in patients with COPD(14). The prolongation of life expectancy, together with the increase in chronic diseases, causes the emergence of more than one disease in the same individual. In the study of Lin et al. (15), it was found that 24% of COPD cases were accompanied by more than one disease, and accordingly, health expenditures increased by 33%. It is thought that the causes of hospital admission and death in COPD patients are related to comorbid conditions rather than respiratory problems. CONCLUSION Reducing frequent hospital admissions and hospitalizations in COPD patients depends on effective primary treatment of COPD, infection control and prophylaxis, treatment of chronic respiratory failure, nutritional support as well as controlling additional diseases with a multidisciplinary approach. There is a need for more comprehensive and multidisciplinary studies on the subject in order to reduce the frequent hospital admissions and hospitalizations in COPD cases with frequent hospital admissions, which is an important morbidity problem in its current state.
