- Email: [email protected]
Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD
Egyptian Journal of Chest Diseases and Tuberculosis (2017) xxx, xxx–xxx
H O S T E D BY
The Egyptian Society of Chest Diseases and Tuberculosis
Egyptian Journal of Chest Diseases and Tuberculosis www.elsevier.com/locate/ejcdt www.sciencedirect.com
ORIGINAL ARTICLE
Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD Amal A. Abd-Elaziz a, Rabab A. Alwahsh a, Gehan A. Abd-Elaal a, Ahmed A.M. Tameem b,* a b
Department of Chest, Menoufia University, Shebin Elkom, Egypt El Mahalla El Kobra Chest Hospital, El Mahalla El Kobra, Egypt
Received 10 June 2015; accepted 24 August 2015
KEYWORDS COPD; Exacerbation; CAT; CRP; Plasma fibrinogen
Abstract The Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) is an eight-item questionnaire designed to assess and quantify the impact of COPD symptoms on health status. COPD exacerbations impair quality of life and are characterized by worsening respiratory symptoms from the stable state. We hypothesized that CAT scores at exacerbation relate to exacerbation severity as measured by lung function impairment, we measured CRP and plasma fibrinogen to quantify their importance in assessing exacerbation severity. Aim of the work: To assess the correlation between CAT score & both systemic inflammatory markers as CRP and Fibrinogen and spirometry in patients with acute exacerbation of COPD. Methods: Fifty-two COPD patients at acute exacerbation had PFTs, completed the CAT score, then CRP and plasma fibrinogen levels were measured in the same day the patient completed the test. Results: There was a statistically significant negative correlation between CAT score results and BMI, FEV1, FEV1/FVC, PEF and FEF50 (p = 0.032, <0.001, 0.000, 0.009 and 0.000 respectively) and there was a statistically significant positive correlation between CAT score and smoking index (p = 0.000) and there was no statistically significant correlation between CAT score results and CRP or plasma fibrinogen (p = 0.18, 0.249 respectively). Conclusions: CAT score provides a reliable score of exacerbation severity as determined by lung functions but CRP and plasma fibrinogen are nonspecific markers for assessment of exacerbation severity. Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
* Corresponding author. E-mail addresses: [email protected] (G.A. Abd-Elaal), [email protected] (A.A.M. Tameem). Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. http://dx.doi.org/10.1016/j.ejcdt.2015.08.013 0422-7638 Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
2
A.A. Abd-Elaziz et al.
Introduction COPD exacerbations are characterized by a worsening of respiratory symptoms from the usual stable state especially dyspnea, increased sputum volume and purulence. Changes in exacerbation symptoms relate to exacerbation recovery time which is an index of exacerbation severity. In addition to exacerbation length, exacerbation severity influences acute treatment and drives hospital admission and mortality [1]. The COPD Assessment Test (CAT) is a validated eightitem questionnaire designed to assess and quantify the impact of COPD symptoms on the patient health status. It has excellent measurement properties and is short and simple for patients to complete, providing a score out of 40 to indicate disease impact without the need for complex calculation [2]. Initial studies have shown that the CAT correlates closely with health-related quality of life as measured by the St. George’s Respiratory Questionnaire (SGRQ) when patients are stable and it is responsive to pulmonary rehabilitation [4]. Although COPD affects the lungs, it also produces significant systemic consequences. These consequences can be detected clinically and appear to be associated with the presence of systemic inflammatory markers such as C – reactive protein and fibrinogen [3]. CAT scores were significantly related to contemporaneous spirometry as measured by FEV1 at exacerbation where spirometry was performed on the same day. Rises in the CAT recorded at exacerbation were significantly associated with falls in FEV1 at exacerbation [5,6]. Patients and methods This study was carried out on 52 patients diagnosed as COPD during acute exacerbation admitted to El-Mahalla Chest Hospital. All cases were subjected to the following 1- Full history taking. 2- Clinical examination, general and local chest examination. 3- Radiological studies in the form of chest X ray postro anterior and lateral views. 4- Laboratory investigations including: A. Routine lab. investigations as CBC, ESR, liver and kidney function tests. . . etc.
Table 1
B. Serum C-Reactive protein and fibrinogen during acute exacerbation of COPD. 5- Standard spirometric measures (pre and post bronchodilator test). 6- Arterial blood gases. 7- CAT score questionnaire was filled by each patient in the same day of measuring the systemic inflammatory markers. Adminstration of CAT score questionnaire The questionnaire was completed in a quiet area. The mean completion time for answering was about 15 min, not including the time required for scoring. The aim of the work was explained to the subjects. They completed the questionnaire themselves without any aid and there were no right or wrong answers. How the CAT was performed? The patient wrote his name and the date of the test then he saw the solved example. He began to place a mark (X) in the box that best describes him currently. Then we calculate the total score for his response. Scoring Calculation of CAT score is very important in assessment of severity or future risk of exacerbations If CAT score 610 it indicates low risk. CAT score >10 it indicates high risk. Results 1. All participants (n = 52) in the study were men, their age ranged from 51 to 79 years with a mean ± SD (62.058 ± 6.830) years, the smoking index ranged from 100 to 900 with a mean ± SD (377.500 ± 214.418) and the body mass index ranged from 17 to34 with a mean ± SD (21.700 ± 2.813). 2. Patients with CAT score >10 had a significantly lower BMI (p = 0.016) and a significantly higher smoking index than patients with CAT score <10 (p = 0.001) but there
Statistical comparison between patients with different CAT score results as regards age, BMI and smoking index. CAT score
T-Test
CAT < 10
CAT > 10
t
p-value
AGE (years)
Range Mean ± SD
53–75 60.375 ± 8.651
51–79 62.364 ± 6.52
0.754
0.454
BMI (kg/m2)
Range Mean ± SD
17–24 22.750 ± 2.375
17.5–24 20.852 ± 1.584
2.876
0.006*
Smoking index
Range Mean ± SD
100–200 146.25 ± 39.256
120–900 419.545 ± 206.203
3.707
0.001*
*
p < 0.05.
Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
CAT in COPD exacerbation Table 2
3
Statistical comparison between patients with different CAT score results as regards some spirometric data. CAT score
T-Test
CAT < 10
CAT > 10
t
p-value
FVC% (L)
Range Mean ± SD
90.1–134.4 102.8 ± 16.111
80.5–146.5 92.868 ± 12.828
1.938
0.058
FEV1% PRED (L)
Range Mean ± SD
70.4–82.6 74.763 ± 4.356
31.99–80 60.902 ± 10.988
3.494
0.001*
FEV1/FVC
Range Mean ± SD
48.26–66.12 59.504 ± 7.281
31.44–68.06 53.299 ± 10.042
1.664
0.102
PEF% (L/min)
Range Mean ± SD
29–92.7 57.413 ± 23.857
10.4–87.5 43.523 ± 18.786
1.846
0.071
FEF50% (L/min)
Range Mean ± SD
30.4–52.6 40.363 ± 9.554
13.7–59.5 31.059 ± 10.724
2.290
0.026*
Plasma Fibrinogen (mg/dl)
Range Mean ± SD
84–341 221.300 ± 114.310
30–350 235.818 ± 100.591
0.368
0.714
CRP (mg/L)
Range Mean ± SD
12–96 47.857 ± 35.779
6–96 34.514 ± 26.477
1.148
0.258
*
p < 0.05.
was no statistically significant difference between patients with different CAT score results as regards age (p = 0.454) (in Table 1). 3. Patients with CAT score >10 had a significantly lower FEV1% and FEF50% (p = 0.001, 0.026 respectively) than patients with CAT score <10, also there was no statistically significant difference between patient with different CAT scores regarding CRP and plasma fibrinogen (in Table 2). 4. There was a statistically significant negative correlation between CAT score results and BMI, FEV1, FEV1/FVC, PEF and FEF50 (p = 0.032, <0.001, 0.000, 0.009 and Table 3 Correlation between CAT score results and some demographic and spirometric data. CAT score r AGE (years) BMI (kg/m2) Smoking index CRP (mg/L) Plasma fibrinogen (mg/dl) FVC% (L) FEV1% pred (L) FEV1/FVC PEF% (L/min) FEF50% (L/min) *
p-value 0.045 0.286 0.64 0.211 0.163 0.162 0.758 0.595 0.358 0.554
0.752 0.040* 0.000* 0.18 0.249 0.25 0.000* 0.000* 0.009* 0.000*
p < 0.05.
0.000 respectively) and there was a statistically significant positive correlation between CAT score and smoking index (p = 0.000) (in Table 3). 5. There was no statistically significant correlation between serum CRP and some PFTs (in Table 4). 6. There was a statistically significant negative correlation between plasma fibrinogen and FVC and positive correlation between plasma fibrinogen and FEV1/FVC (in Table 5).
Discussion Chronic obstructive pulmonary disease (COPD) is a growing cause of morbidity and mortality worldwide, and will be the third leading cause of death by 2020 [7]. The natural course of COPD is that of repeated acute exacerbations (AEs) which are defined as changes in purulence, viscosity or volume of sputum production and/or an increase in dyspnea [8], and may be associated with other symptoms such as increased cough or wheeze, for at least two consecutive days [9]. The mean frequency of AEs in patients with severe COPD is one to four per year [9]. Three to 16% require hospitalization [9] and in severe AEs, mortality is up to 10% [10]. Although increased inflammatory activity and worsened airway obstruction are found during AEs [11], infections (viral, bacterial or a combination of the two) account for up to 80% [12]. Table 5 Correlation between plasma fibrinogen marker and some PFTs.
Table 4
Correlation between CRP marker and SOME PFTs.
Plasma fibrinogen
CRP r FVC% (L) FEV1% pred (L) FEV1/FVC
r p-value
0.179 0.059 0.17
0.257 0.712 0.28
FVC% (L) FEV1% pred (L) FEV1/FVC *
p-value 0.424 0.039 0.336
0.002* 0.782 0.015*
p < 0.05.
Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
4 Our study was done to assess the relation between CAT score & both systemic inflammatory markers (CRP and Fibrinogen) and spirometry in patients with acute exacerbation of COPD and to confirm the usefulness of CAT score to evaluate the exacerbation severity in those patients. This study was conducted on 52 male patients admitted to El-mahalla El-Kobra Chest Hospital presenting with acute exacerbation of COPD and all the patients did not complain of any other chest, systemic or inflammatory diseases. In the present study, regarding demographic data, the age of the patients ranged from 51 to 79 years with a mean of 62.058 ± 6.83 years and there was no statistically significant difference regarding age between patients with different CAT score results (p = 0.454). These results were in agreement with Wiklund et al. study in 2010 that showed that the CAT scores were the same in males and females and were not influenced by age [13]. Jones et al. in 2011 showed in their study that the CAT score was independent of the age of the patients [14]. In the present study there was a statistically significant positive correlation between CAT score and smoking index as shown in Table 5 (p = 0.000). In the present study there was a statistically significant difference between patients with different CAT score results as regards FEV1% and FEF50% (p = 0.001, 0.026 respectively) as shown in Table 4 and there was a statistically significant negative correlation between CAT score results and FEV1, FEV1/FVC, PEF and FEF50 (p = 0.000, 0.000, 0.009 and 0.000 respectively). These results agreed with Jones et al. (2011) who found that rises in the CAT score recorded at exacerbation were significantly associated with falls in FEV1 at exacerbation (r = 0.20, p = 0.032) [14]. Our results also agreed with Donaldson et al. (2002) study which hypothesized that patients with frequent exacerbations had a significantly faster decline in FEV1 and peak expiratory flow (PEF) than infrequent exacerbators [15]. In the present study there was no statistically significant difference between patients with different CAT score results as regards the systemic inflammatory markers CRP and plasma fibrinogen (p = 0.258, 0.714 respectively) as shown in Table 4 also there was no statistically significant correlation between CAT score results and CRP and plasma fibrinogen (p = 0.18, 0.249 respectively) as shown in Table 5. Perera et al. study (2007) demonstrated that there was a weak relationship between CAT scores at exacerbation and systemic inflammatory markers [17]. This was explained by Calverley et al. study in 2007 who demonstrated that it was difficult for CAT score to reflect the levels of systemic inflammatory markers because of antiinflammatory therapeutic agents in COPD [16]. Conclusion The CAT provides a simple and reliable measure of overall COPD-related health status for the assessment and long-term follow-up of individual patients, CAT score is correlated well with PFTs during acute exacerbation so CAT score provides a reliable score of exacerbation severity but CRP and plasma fibrinogen are non specific markers for assessment of COPD exacerbation severity.
A.A. Abd-Elaziz et al. Conflict of interest No conflict of interest. References [1] T.A. Seemungal, G.C. Donaldson, A. Bhowmik, et al, Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease, Am. J. Respir. Crit. Care Med. 161 (2000) 1608–1613. [2] P.W. Jones, G. Harding, P. Berry, et al, Development and first validation of the COPD Assessment Test, Eur. Respir. J. 34 (2009) 648–654. [3] D.R. Taylor, Risk assessment in asthma and COPD: a potential role for biomarker?, Thorax 64 (2009) 261–264 [4] P.W. Jones, M. Tabberer, W.H. Chen, Creating scenarios of the impact of COPD and their relationship to COPD assessment test (CATTM) scores, BMC Pulm. Med. 11 (2011) 42. [5] P.W. Jones, G. Harding, I. Wiklund, et al, Improving the process and outcome of care in COPD: development of a standardized assessment tool, Prim. Care Resp. J. 18 (3) (2009) 208–215. [6] P.W. Jones, G. Harding, P. Berry, et al, Development and first validation of the COPD assessment test, Eur. Respir. J. 34 (3) (2009) 648–654. [7] J. Garcia-Aymerich, P. Lange, M. Benet, et al, Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease’ population based cohort study, Thorax 61 (2006) 772–778. [8] N.R. Anthonisen, J. Manfreda, C.P. Warren, et al, Antibiotic therapy in exacerbation of chronic obstructive pulmonary disease, Ann. Intern. Med. 106 (1987) 196–200. [9] T.A.R. Seemungal, G.C. Donaldson, A. Bhowmik, et al, Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease, Am. J. Respir. Crit. Care Med. 161 (2000) 1608–1613. [10] A. Mushlin, E. Black, C. Connolly, et al, The necessary length of hospital stay for chronic pulmonary disease, JAMA 266 (1991) 80–83. [11] A. Bhowmik, T. Seemungal, R. Sapsford, et al, Relation of sputum inflammatory markers to symptoms and lung function changes in COPD exacerbations, Thorax 55 (2000) 114–120. [12] (a) J. Sethi, C. Rochester, Smoking and chronic obstructive pulmonary disease, Clin. Chest Med. 21 (1) (2000) 67–86; (b) S. Sethi, T. Murphy, Bacterial infection in chronic obstructive pulmonary disease in 2000: a state of the art review, Clin. Microbiol. Rev. 14 (2001) 336–363. [13] I. Wiklund, P. Berry, K.X. Lu, et al, The Chinese translation of COPD Assessment TestTM (CAT) provides a valid and reliable measurement of COPD health status in Chinese COPD patients, Am. J. Respir. Crit. Care Med. 181 (2010) A3575. [14] P.W. Jones, G. Bruselle, R.W. Dal Negro, et al, Properties of the COPD assessment test in a cross-sectional European study, Eur. Respir. J. 38 (2011) 29–35. [15] G.C. Donaldson, T.A. Seemungal, A. Bhowmik, et al, Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease, Thorax 57 (2002) 847–852. [16] P.M. Calverley, F. Sanchez-Toril, A. McIvor, et al, Effect of 1year treatment with roflumilast in severe chronic obstructive pulmonary disease, Am. J. Respir. Crit. Care Med. 176 (2007) 154–161. [17] W.R. Perera, J.R. Hurst, T.M. Wilkinson, et al, Inflammatory changes, recovery and recurrence at COPD exacerbation, Eur. Respir. J. 29 (2007) 527–534.
Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
H O S T E D BY
The Egyptian Society of Chest Diseases and Tuberculosis
Egyptian Journal of Chest Diseases and Tuberculosis www.elsevier.com/locate/ejcdt www.sciencedirect.com
ORIGINAL ARTICLE
Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD Amal A. Abd-Elaziz a, Rabab A. Alwahsh a, Gehan A. Abd-Elaal a, Ahmed A.M. Tameem b,* a b
Department of Chest, Menoufia University, Shebin Elkom, Egypt El Mahalla El Kobra Chest Hospital, El Mahalla El Kobra, Egypt
Received 10 June 2015; accepted 24 August 2015
KEYWORDS COPD; Exacerbation; CAT; CRP; Plasma fibrinogen
Abstract The Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) is an eight-item questionnaire designed to assess and quantify the impact of COPD symptoms on health status. COPD exacerbations impair quality of life and are characterized by worsening respiratory symptoms from the stable state. We hypothesized that CAT scores at exacerbation relate to exacerbation severity as measured by lung function impairment, we measured CRP and plasma fibrinogen to quantify their importance in assessing exacerbation severity. Aim of the work: To assess the correlation between CAT score & both systemic inflammatory markers as CRP and Fibrinogen and spirometry in patients with acute exacerbation of COPD. Methods: Fifty-two COPD patients at acute exacerbation had PFTs, completed the CAT score, then CRP and plasma fibrinogen levels were measured in the same day the patient completed the test. Results: There was a statistically significant negative correlation between CAT score results and BMI, FEV1, FEV1/FVC, PEF and FEF50 (p = 0.032, <0.001, 0.000, 0.009 and 0.000 respectively) and there was a statistically significant positive correlation between CAT score and smoking index (p = 0.000) and there was no statistically significant correlation between CAT score results and CRP or plasma fibrinogen (p = 0.18, 0.249 respectively). Conclusions: CAT score provides a reliable score of exacerbation severity as determined by lung functions but CRP and plasma fibrinogen are nonspecific markers for assessment of exacerbation severity. Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
* Corresponding author. E-mail addresses: [email protected] (G.A. Abd-Elaal), [email protected] (A.A.M. Tameem). Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. http://dx.doi.org/10.1016/j.ejcdt.2015.08.013 0422-7638 Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
2
A.A. Abd-Elaziz et al.
Introduction COPD exacerbations are characterized by a worsening of respiratory symptoms from the usual stable state especially dyspnea, increased sputum volume and purulence. Changes in exacerbation symptoms relate to exacerbation recovery time which is an index of exacerbation severity. In addition to exacerbation length, exacerbation severity influences acute treatment and drives hospital admission and mortality [1]. The COPD Assessment Test (CAT) is a validated eightitem questionnaire designed to assess and quantify the impact of COPD symptoms on the patient health status. It has excellent measurement properties and is short and simple for patients to complete, providing a score out of 40 to indicate disease impact without the need for complex calculation [2]. Initial studies have shown that the CAT correlates closely with health-related quality of life as measured by the St. George’s Respiratory Questionnaire (SGRQ) when patients are stable and it is responsive to pulmonary rehabilitation [4]. Although COPD affects the lungs, it also produces significant systemic consequences. These consequences can be detected clinically and appear to be associated with the presence of systemic inflammatory markers such as C – reactive protein and fibrinogen [3]. CAT scores were significantly related to contemporaneous spirometry as measured by FEV1 at exacerbation where spirometry was performed on the same day. Rises in the CAT recorded at exacerbation were significantly associated with falls in FEV1 at exacerbation [5,6]. Patients and methods This study was carried out on 52 patients diagnosed as COPD during acute exacerbation admitted to El-Mahalla Chest Hospital. All cases were subjected to the following 1- Full history taking. 2- Clinical examination, general and local chest examination. 3- Radiological studies in the form of chest X ray postro anterior and lateral views. 4- Laboratory investigations including: A. Routine lab. investigations as CBC, ESR, liver and kidney function tests. . . etc.
Table 1
B. Serum C-Reactive protein and fibrinogen during acute exacerbation of COPD. 5- Standard spirometric measures (pre and post bronchodilator test). 6- Arterial blood gases. 7- CAT score questionnaire was filled by each patient in the same day of measuring the systemic inflammatory markers. Adminstration of CAT score questionnaire The questionnaire was completed in a quiet area. The mean completion time for answering was about 15 min, not including the time required for scoring. The aim of the work was explained to the subjects. They completed the questionnaire themselves without any aid and there were no right or wrong answers. How the CAT was performed? The patient wrote his name and the date of the test then he saw the solved example. He began to place a mark (X) in the box that best describes him currently. Then we calculate the total score for his response. Scoring Calculation of CAT score is very important in assessment of severity or future risk of exacerbations If CAT score 610 it indicates low risk. CAT score >10 it indicates high risk. Results 1. All participants (n = 52) in the study were men, their age ranged from 51 to 79 years with a mean ± SD (62.058 ± 6.830) years, the smoking index ranged from 100 to 900 with a mean ± SD (377.500 ± 214.418) and the body mass index ranged from 17 to34 with a mean ± SD (21.700 ± 2.813). 2. Patients with CAT score >10 had a significantly lower BMI (p = 0.016) and a significantly higher smoking index than patients with CAT score <10 (p = 0.001) but there
Statistical comparison between patients with different CAT score results as regards age, BMI and smoking index. CAT score
T-Test
CAT < 10
CAT > 10
t
p-value
AGE (years)
Range Mean ± SD
53–75 60.375 ± 8.651
51–79 62.364 ± 6.52
0.754
0.454
BMI (kg/m2)
Range Mean ± SD
17–24 22.750 ± 2.375
17.5–24 20.852 ± 1.584
2.876
0.006*
Smoking index
Range Mean ± SD
100–200 146.25 ± 39.256
120–900 419.545 ± 206.203
3.707
0.001*
*
p < 0.05.
Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
CAT in COPD exacerbation Table 2
3
Statistical comparison between patients with different CAT score results as regards some spirometric data. CAT score
T-Test
CAT < 10
CAT > 10
t
p-value
FVC% (L)
Range Mean ± SD
90.1–134.4 102.8 ± 16.111
80.5–146.5 92.868 ± 12.828
1.938
0.058
FEV1% PRED (L)
Range Mean ± SD
70.4–82.6 74.763 ± 4.356
31.99–80 60.902 ± 10.988
3.494
0.001*
FEV1/FVC
Range Mean ± SD
48.26–66.12 59.504 ± 7.281
31.44–68.06 53.299 ± 10.042
1.664
0.102
PEF% (L/min)
Range Mean ± SD
29–92.7 57.413 ± 23.857
10.4–87.5 43.523 ± 18.786
1.846
0.071
FEF50% (L/min)
Range Mean ± SD
30.4–52.6 40.363 ± 9.554
13.7–59.5 31.059 ± 10.724
2.290
0.026*
Plasma Fibrinogen (mg/dl)
Range Mean ± SD
84–341 221.300 ± 114.310
30–350 235.818 ± 100.591
0.368
0.714
CRP (mg/L)
Range Mean ± SD
12–96 47.857 ± 35.779
6–96 34.514 ± 26.477
1.148
0.258
*
p < 0.05.
was no statistically significant difference between patients with different CAT score results as regards age (p = 0.454) (in Table 1). 3. Patients with CAT score >10 had a significantly lower FEV1% and FEF50% (p = 0.001, 0.026 respectively) than patients with CAT score <10, also there was no statistically significant difference between patient with different CAT scores regarding CRP and plasma fibrinogen (in Table 2). 4. There was a statistically significant negative correlation between CAT score results and BMI, FEV1, FEV1/FVC, PEF and FEF50 (p = 0.032, <0.001, 0.000, 0.009 and Table 3 Correlation between CAT score results and some demographic and spirometric data. CAT score r AGE (years) BMI (kg/m2) Smoking index CRP (mg/L) Plasma fibrinogen (mg/dl) FVC% (L) FEV1% pred (L) FEV1/FVC PEF% (L/min) FEF50% (L/min) *
p-value 0.045 0.286 0.64 0.211 0.163 0.162 0.758 0.595 0.358 0.554
0.752 0.040* 0.000* 0.18 0.249 0.25 0.000* 0.000* 0.009* 0.000*
p < 0.05.
0.000 respectively) and there was a statistically significant positive correlation between CAT score and smoking index (p = 0.000) (in Table 3). 5. There was no statistically significant correlation between serum CRP and some PFTs (in Table 4). 6. There was a statistically significant negative correlation between plasma fibrinogen and FVC and positive correlation between plasma fibrinogen and FEV1/FVC (in Table 5).
Discussion Chronic obstructive pulmonary disease (COPD) is a growing cause of morbidity and mortality worldwide, and will be the third leading cause of death by 2020 [7]. The natural course of COPD is that of repeated acute exacerbations (AEs) which are defined as changes in purulence, viscosity or volume of sputum production and/or an increase in dyspnea [8], and may be associated with other symptoms such as increased cough or wheeze, for at least two consecutive days [9]. The mean frequency of AEs in patients with severe COPD is one to four per year [9]. Three to 16% require hospitalization [9] and in severe AEs, mortality is up to 10% [10]. Although increased inflammatory activity and worsened airway obstruction are found during AEs [11], infections (viral, bacterial or a combination of the two) account for up to 80% [12]. Table 5 Correlation between plasma fibrinogen marker and some PFTs.
Table 4
Correlation between CRP marker and SOME PFTs.
Plasma fibrinogen
CRP r FVC% (L) FEV1% pred (L) FEV1/FVC
r p-value
0.179 0.059 0.17
0.257 0.712 0.28
FVC% (L) FEV1% pred (L) FEV1/FVC *
p-value 0.424 0.039 0.336
0.002* 0.782 0.015*
p < 0.05.
Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013
4 Our study was done to assess the relation between CAT score & both systemic inflammatory markers (CRP and Fibrinogen) and spirometry in patients with acute exacerbation of COPD and to confirm the usefulness of CAT score to evaluate the exacerbation severity in those patients. This study was conducted on 52 male patients admitted to El-mahalla El-Kobra Chest Hospital presenting with acute exacerbation of COPD and all the patients did not complain of any other chest, systemic or inflammatory diseases. In the present study, regarding demographic data, the age of the patients ranged from 51 to 79 years with a mean of 62.058 ± 6.83 years and there was no statistically significant difference regarding age between patients with different CAT score results (p = 0.454). These results were in agreement with Wiklund et al. study in 2010 that showed that the CAT scores were the same in males and females and were not influenced by age [13]. Jones et al. in 2011 showed in their study that the CAT score was independent of the age of the patients [14]. In the present study there was a statistically significant positive correlation between CAT score and smoking index as shown in Table 5 (p = 0.000). In the present study there was a statistically significant difference between patients with different CAT score results as regards FEV1% and FEF50% (p = 0.001, 0.026 respectively) as shown in Table 4 and there was a statistically significant negative correlation between CAT score results and FEV1, FEV1/FVC, PEF and FEF50 (p = 0.000, 0.000, 0.009 and 0.000 respectively). These results agreed with Jones et al. (2011) who found that rises in the CAT score recorded at exacerbation were significantly associated with falls in FEV1 at exacerbation (r = 0.20, p = 0.032) [14]. Our results also agreed with Donaldson et al. (2002) study which hypothesized that patients with frequent exacerbations had a significantly faster decline in FEV1 and peak expiratory flow (PEF) than infrequent exacerbators [15]. In the present study there was no statistically significant difference between patients with different CAT score results as regards the systemic inflammatory markers CRP and plasma fibrinogen (p = 0.258, 0.714 respectively) as shown in Table 4 also there was no statistically significant correlation between CAT score results and CRP and plasma fibrinogen (p = 0.18, 0.249 respectively) as shown in Table 5. Perera et al. study (2007) demonstrated that there was a weak relationship between CAT scores at exacerbation and systemic inflammatory markers [17]. This was explained by Calverley et al. study in 2007 who demonstrated that it was difficult for CAT score to reflect the levels of systemic inflammatory markers because of antiinflammatory therapeutic agents in COPD [16]. Conclusion The CAT provides a simple and reliable measure of overall COPD-related health status for the assessment and long-term follow-up of individual patients, CAT score is correlated well with PFTs during acute exacerbation so CAT score provides a reliable score of exacerbation severity but CRP and plasma fibrinogen are non specific markers for assessment of COPD exacerbation severity.
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Please cite this article in press as: A.A. Abd-Elaziz et al., Correlation between CAT score, inflammatory markers and pulmonary function tests in patient with acute exacerbation of COPD, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2015.08.013