|Year : 2020 | Volume
| Issue : 3 | Page : 171-175
A study of modified DECAF score in predicting hospital outcomes in patients of acute exacerbation of chronic obstructive pulmonary disease at SMS Medical College, Jaipur
Sushant Sharma, Kalim Khan, Gulab Singh Yadav, Suresh Koolwal
Department of Respiratory Medicine, SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||05-May-2020|
|Date of Decision||25-May-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||22-Sep-2020|
Department of Respiratory Medicine, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: The value of Modified DECAF Score as a clinical prediction tool that can accurately risk stratify all patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) is needed to be assessed. Aim: The aim of this study is to evaluate the prognostic effect of the Modified DECAF score in predicting outcomes in AECOPD. Materials and Methods: A hospital-based descriptive type of observational study done on 160 patients admitted with AECOPD at the Institute of Respiratory Diseases, SMS Medical College, Jaipur. Modified DECAF score was calculated for each patient, and the individual parameters used in calculating the score were recorded. Modified DECAF score has five variables (baseline dyspnoea extended Medical Research Council Dyspnea Grade 5a or 5b, Eosinopenia (<50 cells/mm3), Consolidation, Acidemia (pH < 7.30), frequency of hospitalisations in last 1 year (2 or more), a maximum score of 6.Results: Patients could be stratified according to mortality rates observed with Modified DECAF scores into low risk (scores 0–2), intermediate risk (score 3) and high risk (scores 4–6) groups. Mortality was close to 70% in the high-risk group; it was about 7% in the intermediate risk group, whereas no deaths were recorded in the low-risk group. Conclusion: We concluded that the Modified DECAF score is sensitive and specific in predicting in-hospital mortality in AECOPD patients. Further research is required to quantify its impact on clinical practice, for example, in the identification of patients for palliative care or early supported discharge services or for escalation of therapy.
Keywords: Acidemia, Acute Exacerbation Chronic Obstructive Pulmonary Disease, consolidation, eosinopenia, modified DECAF score, mortality
|How to cite this article:|
Sharma S, Khan K, Yadav GS, Koolwal S. A study of modified DECAF score in predicting hospital outcomes in patients of acute exacerbation of chronic obstructive pulmonary disease at SMS Medical College, Jaipur. Adv Hum Biol 2020;10:171-5
|How to cite this URL:|
Sharma S, Khan K, Yadav GS, Koolwal S. A study of modified DECAF score in predicting hospital outcomes in patients of acute exacerbation of chronic obstructive pulmonary disease at SMS Medical College, Jaipur. Adv Hum Biol [serial online] 2020 [cited 2021 Apr 17];10:171-5. Available from: https://www.aihbonline.com/text.asp?2020/10/3/171/295828
| Introduction|| |
Chronic obstructive pulmonary disease (COPD) is characterised by persistent airflow limitation, which is usually progressive and associated with enhanced chronic inflammatory response in the airways and lung to noxious particles or gases.
Acute exacerbation of COPD (AECOPD) is an acute event characterised by worsening of patient's symptoms that is beyond normal day-to-day variations and leads to a change in medication. Exacerbations accelerate the rate of decline of lung function and are associated with significantly high mortality.
Prognostic research in exacerbations needing hospitalisation has been limited. There seems to be considerable difference in the prognostic factors in acute exacerbation and stable COPD. In a large prospective cohort study of unselected admissions, Steer et al. found that eMRC Dyspnea scores, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF scores) were the independent predictors of hospital mortality in patients with AECOPD. A robust clinical prediction tool could assist decisions regarding: Location of care, early escalation of care, appropriateness for end-of-life care, and suitability for early supported hospital discharge and therefore could help to reduce morbidity and mortality and direct the most efficient use of resources.
Zidan et al. found that most of the parameters in the DECAF score showed a statistically significant value to the mortality, however the frequency of admissions was found to be the more linked factor to mortality as compared to atrial fibrillation and devised the Modified DECAF score. Its value as a clinical prediction tool that can accurately risk stratify all patients with AECOPD is needed to be assessed.
| Materials and Methods|| |
This is a hospital-based descriptive type of observational study done on 160 patients admitted with AECOPD at Institute of Respiratory Diseases, SMS Medical College, Jaipur, during a 1-year period. Necessary permission was taken from the Ethical Committee and Research Review Board of SMS Medical College, Jaipur. Patients with a primary diagnosis of AECOPD as per the GOLD guidelines were included in the study after taking an informed consent. Patients with primary reason for admission other than AECOPD, those presenting with myocardial infarction, unstable angina, unstable cardiovascular status, septic shock, past or present history of tuberculosis and patients with a coexisting malignancy were excluded from the study.
Detailed history, including age, sex, smoking status and assessment of stable state dyspnoea grade over the preceding 3 months based on the extended Medical Research Council Dyspnea Score (eMRCD), clinical examination including assessment of mental state conscious level and signs of severity of exacerbation (cyanosis, use of accessory inspiratory muscles, paradoxical abdominal movement, asterixis, neurological impairment and lower limb edema), chest radiological examination, ECG, arterial blood gas analysis and complete blood count were done for all patients in the study.
Severity scores for AECOPD were calculated for each patient, and the individual parameters used in calculating the scores were recorded. Modified DECAF score has five variables (Baseline dyspnoea eMRCD 5a or 5b, Eosinopenia (<50 cells mm3), Consolidation, Acidemia (pH < 7.3), frequency of hospitalisation in the last 1 year, with a maximum score of 6 [Table 1].
|Table 1: Modified dyspnea scores, eosinopenia, consolidation, acidemia, and atrial fibrillation score|
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Hospital outcomes were evaluated in terms of mortality, length of hospital stay, number of days of non-invasive (NIV) and invasive ventilation used and evaluated in relation to Modified DECAF score.
| Results|| |
Distribution of cases according to demographic data
A total of 160 patients were studied. There were 94 (58.75%) patients in the age group above 60 years, followed by 63 (39.37%) patients in 41–60 years' age group. There were only three cases in the age group 21–40 years. Overall, the mean age of patients was 64.27 ± 9.768 years. There was a predominance of males as compared to females, 137 patients were male and 23 were female. Smoking history was elicited, 142 patients were smokers and only 18 were non-smokers.
Distribution of cases according to modified DECAF score
There were 92 cases presenting with eMRCD Grades 0–4 with score 0, 42 cases presented with eMRCD Grade 5a with score 1 and 26 cases presented with eMRCD Grade 5b with score 2 [Table 2].
|Table 2: Relationship between mortality and modified dyspnea scores, eosinopenia, consolidation, acidemia, and atrial fibrillation score variables|
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There were 139 cases with total eosinophil count ≥50 cells/mm3, with score 0. For 21 cases their total eosinophil count was <50 cells/mm3, their score was 1 [Table 2].
There were 118 cases whose X-ray did not show consolidation, their score was 0. In 42 cases X-ray showed consolidation, they were given a score of 1 [Table 2].
There were 50 cases whose ABG showed Acidemia (pH < 7.30), they were assigned a score 1. The remaining 110 cases had normal pH with a score of 0 [Table 2].
Frequency of hospitalisations in the previous one year
There were 81 cases without history of previous hospital admission in the previous year, whereas there were 34 cases with a history of one admission in the previous year. All these patients were given a score of 0. The remaining 45 cases had a history of two or more hospital admissions in the previous year, their score was 1 [Table 3].
|Table 3: Relation between mortality and frequent admission in the last year|
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Mortality and demographic data
Out of the 160 patients, 141 (88.12%) patients survived and 19 (11.88%) patients died in the hospital. It was seen that 12 patients died in the age group above 60 years out of the total 94 patients in that group as compared to seven patients who died in the age group of 41–60 years out of the total 63 patients in that age group. There were no deaths in the age group between 21 and 40 years. It was seen that 15 male patients died out of total 137 males, as compared to 4 females who died out of total 23 females. In our study, a positive smoking history could be elicited in 142 patients, out of which 16 patients expired. Out of the total 18 non-smoker patients, 3 had expired. The relationship of mortality with both gender and smoking history was statistically not significant, however increasing mortalities were seen more frequently with advancing age of patients presenting with COPD exacerbation.
Mortality and dyspnoea
We found that 8 patients of the 42 patients with eMRCD Grade 5a expired, and 11 patients out of the 26 patients with eMRCD Grade 5b expired. No mortality was seen in eMRCD Grades 1–4 [Table 2]. There was a statistically significant relation between grade of dyspnea in the modified DECAF score and in-hospital mortality of AECOPD (P < 0.0001).
Mortality and eosinopenia
It was observed that 9 patients died out of the total 21 patients who had eosinopenia as compared to 10 patients who died out of the 139 patients without eosinopenia [Table 2]. The relationship between eosinopenia and in-hospital mortality was significant (P < 0.0001).
Mortality and consolidation
It was seen that only 6 out of the 118 patients with a clear chest X-ray expired as compared to 13 deaths among the 42 patients who had consolidation on chest X-ray [Table 2]. There was a statistically significant relationship between the presence of consolidation on X-ray of cases of AECOPD and in-hospital mortality (P < 0.0001).
Mortality and acidemia
It was seen that 16 patients died out of the 50 patients with acidemia in comparison to 3 deaths among 110 patients who had normal pH [Table 2]. There is a significant relationship between acidemia and in-hospital mortality rate (P < 0.0001).
Mortality and history of prior hospital admissions
In our study 45 patients had a history of two or more hospitalizations in last 1 year. This group showed 12 deaths, as compared to a total of 7 deaths among 115 patients who were admitted no more than once in the previous year [Table 3]. We found a significant relation between the increase in frequency of hospital admissions and mortality rate in-hospital due to AECOPD (P = 0.0006).
Mortality and modified DECAF score
In our study, mortality was the highest (83.33%) in cases with modified DECAF score 5, it was also significantly high (65%) in patients with score 4, hence these two scores were classified as High risk category. A mortality of 6.66% was observed among patients with Modified DECAF score 3, hence classified as intermediate risk category. Modified DECAF scores 02 did not show any mortality. They were classified as low risk group [Table 4]. It suggests that mortality was increasing progressively with increase in Modified DECAF score. The Modified DECAF score showed a statistically significant relation with the in-hospital mortality of AECOPD (P < 0.0001).
|Table 4: Modified dyspnoea scores, eosinopenia, consolidation, acidemia and atrial fibrillation score and in-hospital mortality|
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Modified DECAF score and the length of hospital stay
The length of hospital stay was 4, 6, 9, 11, 9 and 6 days on an average for modified DECAF scores 0, 1, 2, 3, 4 and 5, respectively [Table 5]. This relation between modified DECAF score and the length of hospital stay is statistically significant (P < 0.0001).
|Table 5: Modified dyspnoea scores, eosinopenia, consolidation, acidemia, and atrial fibrillation score with mean of hospital stay, non-invasive ventilation use and ventilator used|
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Modified DECAF score and the number of days of non-invasive use
NIV was used for 4, 4, 6, 6 and 4 days on an average among patients with Modified DECAF scores 1, 2, 3, 4 and 5, respectively [Table 5]. This relation between Modified DECAF score and number of days of NIV use is statistically significant (P = 0.0472).
Modified DECAF score and number of days ventilator use
Ventilator was not used in patients who had Modified DECAF score 0–2. Average length of ventilator use was 3, 2 and 3 days in Modified DECAF scores 3, 4 and 5, respectively [Table 5].
| Discussion|| |
In patients hospitalised with AECOPD, identifying upon admission those at higher risk of dying in-hospital could be useful for triaging patients to the appropriate level of care, determining aggressiveness of therapies and timing safe discharges. A simple prognostic tool incorporating clinical and laboratory information available routinely on admission, accurately predicted in-hospital mortality. The prognostic indices included in the Modified DECAF Score are objective with little potential for variable interpretation.
To ensure generalisability, all the eligible patients were included. Agewise distribution of cases show that we had more patients in older age groups than younger age groups. This is consistent with the fact that age is often listed as a risk factor for COPD. There was a predominance of male population in our study; this could be attributed to the higher prevalence of smoking among males in our society than the females. Most of the females in our study were non-smokers but had a positive history of biomass fuel exposure as well as passive smoking.
MRC dyspnoea scale is used because it is simple and allows patients to indicate the level of breathlessness. Extended Medical Research Council (eMRC) dyspnoea grading is used since it includes functional dependence as well. Grade 5 comprises of patients who are dyspnoeic even at rest. Patients with Grade 5a could manage self-care independently, whereas in Grade 5b required assistance for basic self-care like bathing and dressing. There was 42% mortality in patients admitted with eMRCD Grade 5b as compared to 19% mortality among patients with eMRCD Grade 5a. There was no mortality observed in patients with eMRCD Grades 0–4. Hence, dyspnoea grade is a potent predictor of mortality and provides important information which could aid in management decisions.
Eosinopenia accompanies the response to acute infection and inflammation. Holland et al. studied eosinopenia in AECOPD cases and concluded that mortality in eosinopenia cases was significantly higher when compared to patients with normal eosinophil counts. Similarly, group with eosinopenia had significantly longer duration of hospital stay. Gil et al. found that the presence of leukocytosis along with eosinopenia was significantly associated with the occurrence of bacterial infections. In the presence of acute infection or inflammations, the leukocytes are diverted toward the formation of polymorphonuclear cells, thereby leading to a low eosinophil count. Thus eosinopenia occurs when the body responds to acute infection. In our study, significantly higher mortality rates were observed in the eosinopenia group as compared to normal eosinophil count group.
Exacerbations in COPD are frequently associated with radiographic consolidation. In this study, 26% of all the patients presented with consolidation. Patients with consolidation had a sudden onset of symptoms, higher rates of hypoxemia, ICU admissions, intubation, in-hospital death and longer duration of stay in hospital. Mortality rate was 31% in cases with consolidation as compared to just over 5% in cases without consolidation.
Respiratory acidosis in COPD is secondary to hypoventilation. It includes multiple mechanisms including decreased responsiveness to hypoxia and hypercapnia, increased ventilation-perfusion mismatch leading to increased dead space ventilation and decreased diaphragmatic function due to fatigue and hyperinflation. Respiratory acidosis is an indication for ventilator support in AECOPD. It can be provided either by non-invasive or invasive ventilation. Mechanical ventilation decreases acute respiratory acidosis. It reduces tachypnea, work of breathing, severity of dyspnea and duration of stay in hospital. Steer et al. showed in their study that arterial pH was statistically lower in patients who died in hospital compared to those who survived till discharge. In our study mortality was 32% in patients presenting with Acidemia while it was <3% in cases with normal pH.
Hurst et al. studied the susceptibility to exacerbation in COPD. The best predictor of having frequent exacerbations (2 or more exacerbations per year) is a history of previous hospitalisation. Higher mortality was observed in AECOPD patients with prior history of two or more hospitalizations in the last 1 year at 26% as compared to 6% in those with history of not more than one hospital admission in last one year due to AECOPD.
Patients could be classified according to Modified DECAF scores into low risk (scores 0–2), intermediate risk (score 3) and high risk (scores 4–6) groups. Mortality was close to 70% in the high-risk group, it was about 7% in the intermediate risk group, whereas no deaths were recorded in the low risk group. Hence, Modified DECAF score is a strong predictor of in-hospital mortality in patients admitted with AECOPD. Length of hospital stay increased with progressively increasing modified DECAF scores, so it can help to identify cases that can be safely discharged early and those who will need prolonged hospitalisation.
Modified DECAF score can also help the clinician to guide treatment; identifying which patients can be managed in general ward and which of them will need intensive care and ventilatory support. Non-invasive ventilation was required in low risk group patients for shorter durations only with the duration of use increasing progressively in intermediate and high risk groups. Invasive ventilation was not needed in patients in low risk group, whereas it was often needed in high-risk group patients. Hence, the clinician can get a faint idea of the line of treatment of the patients admitted with AECOPD at the time admission itself.
In summary, mortality from AECOPD was observed to be increasing with age and increasing Modified DECAF scores. The Modified DECAF score is a powerful indicator to predict in hospital mortality from COPD exacerbation. Clinicians are unable to accurately estimate the risk of death in patients hospitalised with AECOPD. A reliable prediction tool, which stratifies patients according to mortality risk, may help inform management This could include the selection of low-risk patients for early supported discharge (ESD), and the identification of high risk patients for early escalation or appropriate palliation.
| Conclusion|| |
We concluded that the Modified DECAF score is both sensitive and specific in predicting in-hospital mortality in AECOPD patients. Patients with lower Modified DECAF scores (0–2) are found to have better prognosis, but those who have higher Modified DECAF scores (3, 4 and 5) are associated with higher mortality rate and the need for prolonged hospital stay and NIV use. Further research is required to quantify its impact on clinical practice, for example, in the identification of patients for palliative care or ESD services or for escalation of therapy.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]