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ORIGINAL ARTICLE Table of Contents  
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Comparison of dyspnea, acidosis, consolidation, acidaemia, and atrial fibrillation score and BAP-65 score as tools for prediction of mortality and morbidity in acute exacerbations of chronic obstructive pulmonary disease at a tertiary care hospital


 Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

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Date of Submission27-Sep-2021
Date of Decision17-Oct-2021
Date of Acceptance24-Oct-2021
Date of Web Publication10-Jun-2022
 

  Abstract 


Background: According to the Global Burden of Disease 2018, chronic obstructive pulmonary disease (COPD) is the third-leading cause of death worldwide and in India COPD is the second leading cause of death among noncommunicable diseases. Tools to predict mortality in stable COPD are widely in use but there has been lack of research into exacerbations and finding an appropriate clinical tool could help to reduce morbidity and mortality in these cases. Aims: 1. To assess dyspnea, acidosis, consolidation, acidaemia, and atrial fibrillation (DECAF) score and Blood Urea Nitrogen, altered mental status, pulse > 109 beats/min, age > 65 years (BAP- 65) score in acute exacerbations of COPD. 2. To compare the DECAF score and BAP-65 score as predictors of in-hospital morbidity and mortality. Subjects and Methods: The study was a prospective observational study carried out on 80 patients with acute exacerbation of COPD admitted to Bangalore Medical College and Research Institute from November 2018 to May 2020. Detailed history, physical examination, and standard laboratory tests were done on admission. Patients were assessed by the DECAF and BAP-65 (blood urea nitrogen, altered mental status, pulse, age ≥65 years) scores. The outcomes in terms of mortality and need for mechanical ventilation were studied and comparisons were drawn between the two scores. Results: From 80 AECOPD patients, 8 patients died and 72 survived. Significant difference was found in dyspnea grade eMRCD 5b (P = 0.038), eosinopenia (P = 0.036), pH <7.3 (P < 0.001), and consolidation (P = 0.027) between survivors and patients who died. With the rise in total DECAF score mortality rose (P < 0.001). When the individual components of the BAP-65 score were compared there was no statistically significant difference. With rise in the total BAP-65 score, there was no significant difference in mortality (P = 0.09). Sensitivity for prediction of mortality for DECAF score and BAP-65 score was 88.9% and 81.7%, respectively, and specificity was 55.4% and 63.4% respectively. Sensitivity for prediction of need for mechanical ventilation for DECAF score and BAP-65 score was 83.3% and 83.8%, respectively, and specificity was 66.7% and 66.2%, respectively. Conclusions: In our study, we found the DECAF score to be a better predictor of mortality and need for mechanical ventilation than the BAP-65 score as it is a composite score taking into account various parameters such as acidosis, consolidation on imaging, and eosinopenia each of which are individually strong predictors of mortality.

Keywords: Acidaemia and atrial fibrillation score, acidosis, chronic obstructive pulmonary disease, consolidation, dyspnea, exacerbation, mortality


How to cite this URL:
Nagaraja B S, Menon A, Chandrashekar AP. Comparison of dyspnea, acidosis, consolidation, acidaemia, and atrial fibrillation score and BAP-65 score as tools for prediction of mortality and morbidity in acute exacerbations of chronic obstructive pulmonary disease at a tertiary care hospital. APIK J Int Med [Epub ahead of print] [cited 2022 Sep 25]. Available from: https://www.ajim.in/preprintarticle.asp?id=347192





  Introduction Top


The Global Burden of Disease (GBD) 2018 states that chronic obstructive pulmonary disease (COPD) is currently the third-leading cause of death worldwide. The India GBD Collaborators in October 2018 showed that COPD and asthma make the second-largest contribution to the total mortality burden of India at 10.9%.[1],[2]

Acute exacerbations are not seen in the early stages of COPD and indicate more advanced disease.

The Global Initiative for Chronic Obstructive Lung Disease (Executive and Science Committees) defines an exacerbation of COPD as an acute event characterized by sustained worsening of any of the patient's symptoms (cough, sputum quantity and/or character, dyspnea) that exceeds normal day-to-day variation and prompts a change in medication.[3]

Patients presenting in type 2 respiratory failure have in-hospital mortality of about 10%. Patients needing mechanical ventilation have a mortality of about 40%.[4]

Stable COPD has been thoroughly researched and prognostic markers of the disease process are well established. However, accurate prognostication of exacerbations of COPD needing hospitalization is lacking.

A bedside tool which can be administered on admission can help triage patients and decide on early life-saving measures such as mechanical ventilation and curb mortality.

Kumaraguru and Ramakrishnan, in an observational study in 2015, found that patients with a BAP 65 score of 3 and above were at a higher need for mechanical ventilation and risk of mortality and would benefit from an early intervention like noninvasive ventilation.[5]

Rabbani and P. Brammer, in a study on 159 patients in 2012, showed that high dyspnea, acidosis, consolidation, acidaemia, and atrial fibrillation (DECAF) score is a strong predictor of inpatient and 30-day mortality in patients admitted with COPD exacerbation.[6]

Bastidas et al. in 2018 concluded that DECAF is a better predictor of mortality, mechanical ventilation, and admission to ICU than BAP-65 and CURB-65.[7]

In the present study, we compared the DECAF score (Dyspnea, Eosinopenia, Consolidation, Acidemia, and Atrial fibrillation score) and the BAP-65 for the prediction of mortality and need for mechanical ventilation in patients with an exacerbation.


  Subjects and Methods Top


Study design

Prospective observational study.

Study period

November 2018 to May 2020.

Place of study

Bangalore Medical College and Research Institute and hospitals attached to it.

Sample Size

80 patients.

Inclusion criteria

  1. Patients who are above 18 years of age
  2. Patient or the legally authorized relatives giving informed consent
  3. Patients with primary diagnosis of COPD exacerbation with spirometry showing airflow obstruction (FEV1/FVC <0.70) when clinically stable
  4. Patients not having a baseline spirometry report, on discharge, spirometry done showing airflow obstruction (FEV1/FVC <0.70).


Exclusion criteria

  1. Patient or the legally authorized relatives not willing to give informed consent
  2. Patient with age <18 years
  3. Patient on domiciliary oxygen therapy
  4. Comorbidity expected to limit survival to <12 months.


Ethical clearance has been obtained from the Institutional Ethics Committee of Bangalore Medical College and Research Institute, Bangalore and the procedures followed were in accordance with the ethical standards of the Committee and with the Helsinki Declaration of 1975 (as revised in 2000). Patients with primary diagnosis of COPD supported by spirometric evidence of airflow obstruction (FEV1/FVC <0.70) when clinically stable were chosen. For those patients not having a baseline spirometry report, on discharge, spirometry will be done to establish the diagnosis of COPD.

An exacerbation was defined by an increase in at least one of the following three symptoms: Dyspnea, cough, sputum amount, and/or purulence severe enough to warrant hospital admission.

After the initial evaluation consisting of medical history, physical examination, 12-lead electrocardiogram, arterial blood gas analysis, and standard laboratory tests, all patients underwent stable state dyspnea scoring using extended Medical Research Council Dyspnoea score, DECAF score, and BAP 65 score. The presence of new consolidation on the chest radiograph was recorded.

Based on outcome after hospital stay, patients were divided into two groups:

Group 1 (Non-survived or Expired) – This group includes those patients who died during the hospital stay. Group 2 (Survived) – This group includes all those patients who survived during the hospital stay. All demographic, clinical, laboratory parameters, DECAF, and BAP65 score were compared between these two groups.

Assessment tools

1. DECAF Score [Table 1]
Table 1: DECAF Score (Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial fibrillation)

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  • In-hospital mortality
  • DECAF Score 0–1 (low risk)-1%–1.4%,
  • DECAF score 2 (intermediate risk)-5.4%–8.4%
  • DECAF score 3+ (high risk) – 21.4%–34.7%.


2. BAP 65 Score [Table 2] and [Table 3]:
Table 2: BAP-65 Score (Blood Urea Nitrogen, altered mental status, pulse > 109 beats/min, age > 65 years)

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Table 3: BAP- 65 Classes

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Outcome measures

Efficacy parameters (clinical outcome parameters)

  1. Mortality rates-out of the 80 patients studied the percentage of deaths during the period of hospitalization
  2. Ventilator requirements-percentage of patients that developed respiratory failure necessitating ventilator requirement.


Statistical analysis

SPSS (Statistical Package for the Social Sciences) version 20. (IBM SPSS statistics [IBM corp. Armonk, NY, USA released 2011]) was used to perform the statistical analysis.

The data collected were analyzed systematically using descriptive statistics namely mean, standard deviation, percentage wherever applicable.

Appropriate parametric and nonparametric tests were used.


  Results Top


Out of 80 patients included in the study, 72 patients were discharged and 8 patients died. Patients who were discharged and patients who died in the hospital were compared as follows:

Demographic details

Out of the 80 patients included in the study, 67 (83.8%) were male. 42 (52.5%) out of 80 patients were of the ages of 61–75 years and 78.8% were smokers [Figure 1].
Figure 1: Distribution of the subjects based on age

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Demographic differences of variables such as age and sex did not have any bearing on the study outcomes, no statistical difference was found between the patients who were discharged or who died (P > 0.05). There was a statistically significant difference between the presence of comorbidities in the patients who were discharged or who died (P = 0.049). 6 out of the eight patients who died had comorbidities [Table 4].
Table 4: Clinical characteristics and investigations of patients who survived and died

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Clinical characteristics

There was a statistically significant difference between patients who were discharged and who died in relation to the grade of dyspnea (P = 0.038).

The mean pulse rate was 103.25 ± 17.558 bpm. We did not find any statistically significant difference between the two groups in terms of blood pressure and respiratory rate. No statistically significant difference was found between general physical examination and systemic examination of patients who were discharged and those who died in our study [Table 4].

Investigations

In the present study, statistically significant difference was found in the eosinophil counts, pH on ABG, and the presence of consolidation on chest radiography. Forty-four out of 80 patients (55%) had eosinopenia. Seven out of the 8 patients (87.5%) who died had eosinopenia. Eosinopenia was seen in a significantly larger number of people who died (P = 0.036). 33.75% (27/80) of patients had radiographic evidence of consolidation. Consolidation on chest radiograph was seen in 6 out of 8 patients (75%) who died (P = 0.027). 53.75% (43/80) of patients had Type II respiratory failure, and 12 out of these were intubated and 10 were managed with noninvasive ventilation. Eighty-five percent (68/80) of the patients studied had hypoxemia. All patients who died had hypoxemia and pH <7.3 (P < 0.001) and 6 out of the 8 patients who died had hypercapnia. Four patients presented with atrial fibrillation out of which one patient died and the others were discharged [Table 4].

Ventilation requirement

Out of all the discharged patients, 5.5%, 13.8%, and 80.5% required invasive, noninvasive and no ventilation for management of the exacerbation. Eight out of twelve (66.7%) intubated cases died. All patients who died had been intubated and mechanically ventilated (P < 0.001). All ten patients on noninvasive ventilation survived to discharge [Table 5].
Table 5: Ventilation requirement

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Dyspnea, acidosis, consolidation, acidaemia, and atrial fibrillation score and outcome

On DECAF scoring, significantly higher number of people who died had Grade 5b eMRCD score (P = 0.038), eosinopenia (P = 0.036), consolidation of lung (P = 0.027), and acidosis (P < 0.001). A higher value of DECAF score was found among patients who died (P < 0.001). Five out of 8 patients (62.5%) who died had a DECAF score of 5 [Table 6].
Table 6: Cross-tabulation of dyspnea, acidosis, consolidation, acidaemia, and atrial fibrillation and outcome

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BAP-65 score and outcome

On BAP-65 scoring, the individual components taken separately were not found to have a statistical significance to mortality. The total BAP-65 score did not show a statistically significant bearing on mortality (P = 0.09) [Table 7]. For 19 out of 80 patients (28% of patients) the DECAF and BAP 65 scores coincide [Table 6] and [Table 7].
Table 7: Cross-tabulation of BAP-65 and outcome

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DECAF and BAP 65 scores had a significant correlation with the outcomes of these patients. Among the parameters included by these two scores, pulse rate has a significant bearing on the outcome (P = 0.056) [Table 8].
Table 8: Comparison of parameters between patients who survived and died

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Indicator of mortality

The area under the receiver operating characteristics (AUROC) for prediction of mortality for DECAF score was 0.911 (95% confidence interval [CI] = 0.835–0.987) and for BAP-65 score was 0.67 (95% CI = 0.492–0.848). Sensitivity for prediction of mortality for DECAF was 88.9% and for BAP-65 score was 81.7%. Specificity for prediction of mortality was 55.4% for DECAF score and 63.4% for BAP-65 score, while P value for DECAF score was significant (P = 0.001) and that of BAP-65 score was 0.09 [Table 9] and [Figure 2].
Table 9: Mortality

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Figure 2: Receiver operator characteristic curve for mortality

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Indicator of the need for mechanical ventilation

The AUROC for need for mechanical ventilation for DECAF score was 0.876 (95% CI = 0.782–0.97) and for BAP-65 score was 0.712 (95% CI = 0.56–0.85). Sensitivity for prediction of need for mechanical ventilation was 83.3% for DECAF and 83.8% for BAP-65 score. Specificity was 66.7% for DECAF score and 66.2% for BAP-65 score while P value for DECAF score was P = 0.001 and that of BAP-65 score was P = 0.02 [Table 10] and [Figure 3].
Table 10: Invasive ventilation

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Figure 3: Receiver operator characteristic curve for need for mechanical ventilation

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  Discussion Top


A total of 80 patients with AECOPD were analyzed. Seventy-two patients were discharged while eight patients (10%) died during the hospital stay. In the study by Steer et al.[8] and Shorr et al., mortality in AECOPD was 10.4% and 4%, respectively.

eMRCD score was used to grade the dyspnea of all the patients. Out of the total 80 patients, 35 patients had an eMRCD score of 5b. The 8 patients who died had an eMRCD score of 5b. There was a significant difference in the dyspnea scores of the patients who survived to discharge and those who died (P = 0.38). Our results are similar to the study by Steer et al.

In our study, when each component of DECAF score was compared between survivors and patients who died, statistically significant difference was found in dyspnea grade eMRCD 5b (40.2% vs. 100%, P = 0.038), eosinopenia <0.05 × 109/L (52.7% vs. 87.5%, P = 0.036), pH <7.3 (22.2% vs. 100%, P < 0.001), consolidation (29.2% vs. 75%, P = 0.027). When the total DECAF score was considered, with the rise in DECAF score, there was rise in mortality (P < 0.001). Steer et al.[8] in their study found that every individual component of the DECAF score was a predictor of mortality, however, in our study atrial fibrillation was not found to be a strong predictor. This is probably due to the smaller sample size of our study and is a limitation of our study.

The area under DECAF score (ROC curve) for the prediction of mortality was 0.911 (95% CI = 0.835–0.987), showing good validity. In the present study, the area under the DECAF score (ROC curve) for the prediction of need for invasive ventilation was 0.876 (0.782–0.97), showing good validity. The sensitivity, specificity, and P-value in the prediction of mortality by DECAF score were 88.9%, 55.4%, and <0.001 respectively.

In our study when the individual components of BAP-65 score were compared between survivors and those who died, we did not find any statistically significant difference between the two groups (Blood urea nitrogen >25 P = 0.81; Altered mental status P = 0.07; Pulse >109 bpm P = 0.71; Age >65 years P = 0.93). When the total BAP-65 score was considered, with rising BAP-65 score there was no significant difference in mortality (P = 0.09). The area under the BAP-65 score (ROC curve) for the prediction of mortality was 0.67 (0.492–0.848), indicating good validity. In the present study, the area under the BAP-65 score for the prediction of need for invasive ventilation was 0.712 (0.56–0.85), showing good validity. The sensitivity, specificity, and P-value in the prediction of mortality by BAP-65 score were 81.7%, 63.4%, and 0.09%, respectively. Kumaraguru and Ramakrishnan, in an observational study in 2015, found that patients with a BAP 65 score of 3 and above were at a higher need for mechanical ventilation and risk of mortality and would benefit from an early intervention like noninvasive ventilation.[5] BAP-65 score was used previously as a tool for assessing acute exacerbations of COPD due to the lack of a more specific scoring system. Our study hence shows that DECAF is a more specific and useful scoring system for predicting outcomes and for risk stratification in exacerbations of COPD than BAP-65.

On comparison of DECAF and BAP-65 scores for prediction of mortality and need for mechanical ventilation in acute exacerbations of COPD, on Pearson's correlation graph, we found a weak correlation (r = 0.19, P = 0.086). In the study by Sangwan et al.,[9] the correlation between DECAF and BAP-65 scores was found to be linear.


  Conclusions Top


From our study, we concluded that both the DECAF score and BAP-65 score can be easily calculated by the bedside of the patient with data available on admission. In our study we found the DECAF score to be a better predictor of mortality and need for mechanical ventilation than the BAP-65 score as it is a composite score taking into account various parameters such as acidosis, consolidation on imaging, and eosinopenia each of which are individually strong predictors of mortality. However, larger studies are required for validation of these two tools to use them in the triage of patients and to decide which patients would need invasive ventilator support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med 2017;5:691-706.  Back to cited text no. 1
    
2.
Salvi S, Kumar GA, Dhaliwal RS, Paulson K, Agrawal A, Koul PA, et al. The burden of chronic respiratory diseases and their heterogeneity across the states of India: The global burden of disease study 1990-2016. Lancet Glob Health 2018;6:e1363-74.  Back to cited text no. 2
    
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Singh D, Agusti A, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019. Eur Respir J. 2019 May 18;53(5):1900164.   Back to cited text no. 3
    
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Naughton MT, Tuxen DV. Acute respiratory failure in chronic obstructive pulmonary disease. Oh's Intensive Care Man 2014;354-63.e3.  Back to cited text no. 4
    
5.
Kumaraguru K, Ramakrishnan G. Utility of BAP-65 score in assessing the severity and predicting the outcome in acute exacerbation of COPD, in a tertiary care hospital in South India. Eur Respir J 2015;46:3981.  Back to cited text no. 5
    
6.
Rabbani B, Brammer P. Can the decaf score be used to guide prognosis after an acute admission for copd exacerbation? Thorax 2014;69:A139 40.  Back to cited text no. 6
    
7.
Bastidas A, Diaz H, Cardozo M. Validity CURB 65, BAP 65, DECAF for predicting outcomes in exacerbation of COPD. Am J Respir Crit Care Med 2018;197:A5039.  Back to cited text no. 7
    
8.
Steer J, Norman EM, Afolabi OA, Gibson GJ, Bourke SC. Dyspnoea severity and pneumonia as predictors of in-hospital mortality and early readmission in acute exacerbations of COPD. Thorax 2012;67:117-21.  Back to cited text no. 8
    
9.
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 J Crit Care Med. 2017;21(10):671-67.  Back to cited text no. 9
    

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Correspondence Address:
Anindita Menon,
001, Ansal Krsna 2, Hosur Road, Adugodi, Bengaluru - 560 030, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_104_21



    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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    -  Nagaraja B S
    -  Menon A
    -  Chandrashekar AP


Abstract
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Subjects and Methods
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