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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 68  |  Issue : 2  |  Page : 170-174

Serum procalcitonin level as a predictor of NIPPV and mortality in patients with COPD at Zagazig University Hospitals


1 Department of Chest Diseases, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Biochemistry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission15-Sep-2018
Date of Acceptance09-Jan-2019
Date of Web Publication17-May-2019

Correspondence Address:
Niveen E Zayed
Lecturer of Chest Diseases, Chest Department, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejcdt.ejcdt_136_18

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  Abstract 


Background Several reports showed the diagnostic value of procalcitonin (PCT) level in the serum to predict a bacterial cause of acute exacerbations in cases of chronic obstructive pulmonary disease (COPD); however, measurement of PCT for detection of prognosis in case of severe COPD exacerbation has been less studied.
Aim The aim was to assess the value of using measured PCT in the serum to predict the severity, the progression, and the need of noninvasive positive pressure ventilation (NIPPV) in patients with COPD with acute exacerbation.
Patients and methods This study was done at Chest Department, Zagazig University Hospital, during the period from January 2017 to July 2018. It included 100 patients with COPD who were admitted to chest ICU. They are classified into group A, which included 59 patients who needed NIPPV, and group B, which included 41 patients who did not need NIPPV. Serum PCT level was measured three times.
Results PCT level was higher in group A than group B especially second (0.9±0.4 vs. 0.5±0.2) and third samples (2±1.9 vs. 0.6±0.9), which showed high statistical significance (P<0.001), with high death rate among group A patients (45.80%). Increasing PCT second sample was associated with progressive global initiative for chronic obstructive lung disease stage.
Conclusion Serum PCT level is a good predictor of severity of progression and the need of NIPPV in patients with acute exacerbation of COPD.

Keywords: acute exacerbations of chronic obstructive pulmonary disease, noninvasive positive pressure ventilation, procalcitonin


How to cite this article:
Lotfy SM, Zayed NE, Moghawri MW, Fouad RA. Serum procalcitonin level as a predictor of NIPPV and mortality in patients with COPD at Zagazig University Hospitals. Egypt J Chest Dis Tuberc 2019;68:170-4

How to cite this URL:
Lotfy SM, Zayed NE, Moghawri MW, Fouad RA. Serum procalcitonin level as a predictor of NIPPV and mortality in patients with COPD at Zagazig University Hospitals. Egypt J Chest Dis Tuberc [serial online] 2019 [cited 2020 May 27];68:170-4. Available from: http://www.ejcdt.eg.net/text.asp?2019/68/2/170/258437




  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity, disability, and mortality [1]. Acute exacerbations of chronic obstructive pulmonary disease (AeCOPD) are characterized by dyspnea and increase in the purulence and production of sputum [2]. These AeCOPD speed up disease progression, impair the health status of the patients, increase the health care costs, and if respiratory failure develops, it may cause death. Sometimes, AeCOPD are mild, and treatment can be done at home; some of them need hospitalization even in ICU, so the severity of the exacerbation should be determined before treatment [3].

In 50–60% of AeCOPD cases, infection is the main cause, and approximately half of the exacerbations are because of bacterial infection, 30% of them owing to viral infection, and 5–10% of them owing to atypical bacterial infection [4].

The severity and frequency of exacerbation both are determining factors for prognosis of the disease [5].

Procalcitonin (PCT) is a polypeptide of 116 amino acids that is widely used as a marker of bacterial etiology [6],[7]. Level of PCT in the serum increases markedly in bacterial infections as a specialty; it does not change in viral infections or autoimmune inflammations [8],[9].

Although several studies highlighted the role of PCT in differentiating type of infection in cases with chronic obstructive pulmonary disease exacerbations (COPDE), the use of PCT as a marker for prognosis in severe exacerbation has not been studied well.


  Aim Top


The aim was to evaluating the usefulness of using serum procalcitonin level to predict the severity, the progression, and the need of noninvasive positive pressure ventilation (NIPPV) in patients with AeCOPD.


  Patients and methods Top


This is a prospective, observational, follow-up study. It was done at Chest ICU, Zagazig University Hospital, from January 2017 to July 2018.

The study included 100 cases diagnosed to have COPD (57 males and 43 females). The diagnosis of COPD was confirmed by clinical symptoms, physical examination, chest radiography, and pulmonary function tests according to global initiative for chronic obstructive lung disease (GOLD) guidelines, in which forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) was less than 70 and graded according to FEV1 into mild, moderate, severe, and very severe (FEV1 ≥80%, ≥50 to <80%, ≥30 to <50%, and <30% of predicted, respectively) [10].

Patients were admitted to ICU owing to COPD exacerbation. Traditional treatments were given to all the patients and then they were divided according to the need of noninvasive ventilation (NIV) into two groups.

Exclusion criteria included all patients with diseases that may affect serum level of procalcitonin (sepsis, pulmonary, and extrapulmonary malignancies) and other disease such as bronchial asthma, pulmonary tuberculosis, bronchiectasis, and pneumonia [11].

The following were done to every participant included in our research: complete history taking, chest radiography, arterial blood gas, pulmonary function test, and C-reactive protein (CRP) were done.

Measurements of procalcitonin

For each participant included in this work, blood sample was taken and the serum was separated and stored at −80°C. PCT level was determined with automated immunochemistry method (Brahms Kryptor; Brahms Liaison, Berlin, Germany) [12].

Follow-up of the patients was done for the risk of complications, need of NIV, or death.

Statistical analyses

All data were collected by using the SPSS version 20.0 (SPSS Inc., Chicago, Illinois, USA) for Windows. Quantitative data were expressed as mean and SD and analyzed by applying Student’s t-test for comparison of two groups of normally distributed variables. All these tests were used as tests of significance at P less than 0.05.


  Results Top


The present study included 100 patients with COPD (57 males and 43 females) who were classified into group A, which included 59 patients who needed NIPPV, and group B, which included 41 patients who did not need NIPPV. Overall, 80% of group A patients were smokers, whereas 97.6% of group B patients were smokers ([Table 1]).
Table 1 Baseline characteristics

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Although pH value was higher in group A, with mean±SD of 7.27±0.06 than group B with mean±SD of 7.25±0.07, other parameters (PO2, PCO2, FEV%, and FVC%) were higher in group B ([Table 2] and [Table 3]).
Table 2 Arterial blood gas and pulmonary function tests

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Table 3 Global initiative for chronic obstructive lung disease stages, BODE index, and C-reactive protein

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Procalcitonin level was higher in group A especially second and third samples which were highly significant ([Table 4]). This was associated with higher mortality among patients of group A (45.80%) ([Figure 1]).
Table 4 Procalcitonin levels

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Figure 1 Mortality rate.

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Increasing procalcitonin second sample was associated with progressive GOLD stage and cigarette smoking, but no correlation with other parameters ([Table 5]).
Table 5 Correlation between procalcitonin levels and other parameters

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Procalcitonin second sample was the best predictor for NIV with high statistical significance, and PCO2 was the best co-predictor with procalcitonin second sample in our study ([Table 6] and [Figure 2]).
Table 6 Stepwise regression analysis to predict the need for noninvasive ventilation

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Figure 2 The receiver operating curve for the independent predictor (procalcitonin second sample) by stepwise test, with area under the curve of 0.865 with 95% confidence interval: 0.794–0.936 and P value less than 0.001. The cutoff value was calculated to be 0.65 as a best value with sensitivity and specificity 79. 9 and 71.7%, respectively.

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  Discussion Top


This study was done on 100 patients diagnosed as having acute exacerbations of COPD (AeCOPD) according to GOLD criteria. They were classified into two groups depending on the need of NIV or not. The baseline characteristics of both groups were similar, with no statistical difference according to age, sex, BMI, and smoking.

Baseline arterial blood gas measurement was done on admission, which showed that pH was lower and PaCO2 was higher on group B than group A, but with no statistical significance difference. GOLD stage, body mass index, airflow obstruction, dyspnea and exercise capacity (BODE) index, and CPR were measured for all patients, with no statistical difference between both groups.

Stolz et al. [13] did not find any significant association of age, PaO2, and PCO2 with 6-month prognosis.

Serum procalcitonin level was measured three times on the day of admission, third day of admission, and fifth day. Procalcitonin level was higher in group A, especially second (0.9±0.4 vs. 0.5±0.2) and third samples (2±1.9 vs. 0.6±0.9), which were highly significant (P<0.001).

Pazarli et al. [11] did a cross-sectional study from 2009 to 2010. Their study included 118 patients with COPD, and 68 (58%) of them were in acute exacerbations, and they were considered as the case group. Control group included others who had stable COPD. In the case group, the mean level of erythrocyte sedimentation rate was 28.4±2.65, CRP was 44.7±5.92, white blood cell was 9.4±0.43, percentage of neutrophils was 69.9±1.22, and serum PCT level was 0.19±0.02, which were higher than the controls in a significant statistical pattern (P=0.0001).

Mean serum PCT differs significantly according to exacerbation type and severity.

In hospitalized patients needing NPPV, serum level of PCT was 0.36 ng/ml, whereas in those treated without NPPV, it was 0.15 ng/ml (P=0.0001). Cutoff value for the need of NPPV was concluded to be a PCT level of 0.10 ng/ml.

In our study, increasing procalcitonin second sample was associated with progressive GOLD stage and cigarette smoking, but there was no correlation with BMI, dyspnea scale, or FEV1%.

In contrary with our study, Pazarli et al. [11] found no significant association between serum PCT and COPD stages.

In our study, procalcitonin second sample was the best predictor for NIV, with statistical high significance, and PCO2 was the best co-predictor with procalcitonin second sample in our study. The best cutoff value for NIPPV was calculated to be 0.65 with 79.9% sensitivity and 71.7% specificity. Moreover, mortality rate was higher in group A (48.8%) than in group B (7.3%). This is consistent with the study done by Stolz et al. [13] to assess levels of CRP circulating in the blood; copeptin, the precursor of vasopressin; and serum procalcitonin as possible prognostic markers for hospitalization and long-term outcomes in acute exacerbation of COPD cases requiring hospitalization.

In the current work, there was a significant direct correlation between serum levels of PCT and the duration of hospital stay (r=0.216, P=0.002), but there was no correlation with the duration of ICU stay (P=0.916). Moreover, patients needing ICU admission had higher levels of serum procalcitonin with high significance (0.233 ng/ml; interquartile range: 0.086–0.408 ng/ml) than the cases that did not need ICU stay (0.094 ng/ml; interquartile range: 0.064–0.164; P=0.005). Longer durations of hospitalization were observed in cases with high serum PCT in comparison with patients having low serum PCT (P=0.056).

In agreement with our study, Daubin et al. [10] showed a PCT level greater than 0.25 µg/l was associated with mortality (4/10 vs. 0/25 deaths among those with a PCT <0.25 µg/l, P<0.006).

Rammaert et al. [14] did their study on patients with AeCOPD who were intubated. They found that PCT values were greater than 0.24 ng/ml in 63% of nonsurvivors; however, it was high only in 38% of survivors. In their study, the risk ratio for PCT was 1.02 [95% confidence interval (CI): 1.00–1.03] for ICU mortality.Kutz et al. [15] in their meta-analysis, with the adjusted odds ratio of 6.12 (95% CI: 2.46–15.18; P<0.001), showed a higher positive predictive value for mortality among patients who were admitted in ICU with increased PCT levels. From all these data they concluded that elevated PCT levels may be associated with increased risk of death in acute cases of COPD exacerbation.

In contrary with our study, Daubin et al. [10] assessed serum procalcitonin levels in critically ill patients with COPD. The admission of these severe cases of AeCOPD was based on the national criteria of GOLD. Thirty one (79%) patients were indicated for NIV or mechanical ventilation during their ICU stay. The mean duration of NIV, mechanical ventilation, and ICU stay without ventilation were 4.33±4.54, 2.10±5.55, and 2.13±1.89 days, respectively. Procalcitonin levels had no correlation with these findings at all.

Ergan et al. [16] did their study to determine whether the serum PCT level at admission in patients with acute exacerbations of COPD provides a prognostic marker for in-hospital death, and they found the death rate was 23.8%. The dead patients after hospitalization had higher admission serum PCT levels (0.66 vs. 0.17 ng/ml; P=0.014). So, the relation between serum PCT level and hospital mortality was significant for every 1 ng/ml elevation in PCT level, and mortality increased 1.85 times (odds ratio: 95% CI: 1.07–3.19; P=0.026).


  Conclusion Top


Serum procalcitonin level can predict well the severity of progression and the need of NIPPV in patients with exacerbation of COPD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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