Evaluating Arterial Blood Gas Modifications Before and After Corticosteroid Intervention in Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Background: Chronic Obstructive Pulmonary Disease (COPD), a prevalent and progressive respiratory disorder characterized by airflow limitation and chronic inflammation from prolonged exposure to harmful particles and gases, significantly affects patients' quality of life. Objective: This study examines the impact of corticosteroid therapy on arterial blood gas (ABG) parameters in patients with acute exacerbations of COPD (AECOPD), evaluating ABG values before and after treatment to determine therapeutic effectiveness. Methods: Conducted at Bahawal Victoria Hospital's Pulmonology Department from August 15, 2022, to January 15, 2023, this quasi-experimental study included 170 COPD patients meeting exacerbation criteria. Exclusions included severe systemic illness, unconsciousness, inability to clear airways, arterial blood pH < 7.35, hemodynamic instability, or cor-pulmonale. Patients consented to a 2-day regimen of nebulized corticosteroid (beclomethasone), with ABG parameters like PaO2 and pH measured before and after treatment. Data analysis was performed using SPSS Version 24. Results: Initially, 202 patients with AECOPD were enrolled, and nebulized beclomethasone was administered. However, 32 patients who did not respond and required IV steroids were excluded. Among the remaining 170 patients, post-treatment mean PaO2 levels significantly increased from 58.74 mmHg to 69.51 mmHg (p < 0.000). Stratified analyses across different age groups and genders confirmed the therapy's effectiveness in enhancing arterial oxygenation. Conclusion: Nebulized corticosteroid therapy have valuable role in the treatment of AECOPD patients with mild hypoxemia and significantly improves in Arterial oxygen.


Introduction
C hronic Obstructive Pulmonary Disease (COPD)   is a globally prevalent and gradually progressive respiratory disorder of small airways.COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of airways (bronchitis, bronchiolitis) and alveoli(emphysema) that cause persistent, Patients of Acute exacerbations of COPD (AECOPD) presents with worsening symptoms which includes cough, breathlessness and sputum production beyond daily variations, are critical events triggered by factors such as respiratory infections and environmental pollutants, often requiring immediate medical intervention and medication adjustments to manage the acute dete-6-7 rioration.
Patient's outcome is influenced by these exacerbations.They lead to rapidly decline in lung functions, physical activity level, quality of life and exacerbate symptoms.Additionally exacerbations are significantly associated with faster disease progression and reduction in life Corticosteroids play a vital role in the management of AECOPD.These medications, known for their potent anti-inflammatory properties, are proven to accelerate 10 recovery from exacerbations.They effectively enhance lung function, particularly the Forced Expiratory Volume in one second (FEV1), and ameliorate arterial hypoxemia (PaO2).Risks like early relapse, treatment failure, and the length of hospital stay are significantly reduced.The optimization of corticosteroid therapy, in terms of both dosage and duration, is therefore crucial in the 11 management of AECOPD.

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routes for the treatment of AECOPD.However, emerging studies have begun to explore the efficacy of nebulized corticosteroids.These studies suggest that nebulized administration may provide similar benefits in improving lung function and reducing inflammation, with potentially fewer systemic side effects.This mode of administration is particularly advantageous for patients who have difficulty with oral medications or those who require rapid relief of symptoms.
ABGs plays a very important role for the diagnosis of 13 respiratory failure and management of AECOPD.This diagnostic test, essential in emergency and intensive care settings, provides crucial information about the patient's respiratory status.For these reasons AECOPD patients need repeated analyses of their arterial blood 14 for pH, PCO2, 8 HCO3 and PO2 measurements.Its importance extends beyond immediate clinical care, as it is also utilized in the ongoing evaluation of lung diseases and in monitoring the effectiveness of various 15 treatments, including corticosteroids.
There are number of studies internationally which elaborate the effects of corticosteroids in improving Arterial Blood Gases in AECOPD but there are not much studies about this in Pakistan.This study aims to identify the effect of nebulized corticosteroids in AECOPD with mild hypoxemia taking change PO2 in arterial blood as primary end point.This will help us to identify a better treatment approach and outcome.Elaborating change in arterial blood gases will help in tailoring the use of Nebulised steroids in local circumstances as well as promoting ABGs as a predictive tool in patient's improvement.

Methods
The quasi-experimental study was conducted at the Department of Pulmonology, Bahawal Victoria Hospital,

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Bahawalpur from 15 August 2022 to 15 January 2023.Total 202 with COPD were selected by using non-probability consecutive sampling technique.Inclusion criteria was: all the patients who met the criteria for exacerbation, both male or female patients aged between 40 to 70 years.Acute Exacerbation of COPD (AECOPD) is defined as: A known case of COPD presenting with acute worsening of respiratory symptoms including shortness of breath, cough, sputum with an Oxygen saturation (SpO2) 88% .
Patients were excluded if they suffered from severe systemic illnesses (such as sepsis, malignancy, or trauma), were unconscious, unable to spontaneously clear the airways, required immediate tracheal intubation, had an arterial blood pH less than 7.35 on admission, were hemodynamically unstable and SpO2 less than 88%.Employing a 95% confidence level and an 80% power for the test, the required sample size was established 16 to be 169 participants.

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Study was approved by the ethical committee of the hospital (approval date is 1/8/22 and letter number is 2331) and written informed consent was taken from every patient.Demographic data of the patients was recorded on a predesigned proforma.On day 0, about 2 ml of blood was drawn from the radial artery of patients using a disposable pre-heparinized system.The samples were stored on ice and processed within 15

Results
The study initially included 202 patients with acute exacerbations of COPD who were administered nebulized corticosteroid (beclomethasone) aimed at improving PaO2 levels.However, 32 patients did not respond to the nebulized corticosteroid therapy and were subsequently managed with IV steroids, leading to their exclusion from the study.The analysis continued with the remaining 170 patients, who had a mean age of 57.04 years (SD = 6.90).
A paired sample t-test was conducted to compare the mean arterial oxygen partial pressure (PaO2) levels before and after corticosteroid therapy in these patients.indicating a statistically significant improvement (pvalue 0.000).(Table 2)

Discussion
Our research focused on evaluating the impact of nebulized corticosteroid therapy on arterial blood gas parameters in patients with acute exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) with mild hypoxemia.This evaluation is crucial in understanding the efficacy and safety of corticosteroid therapies, a cornerstone in the management of AECOPD.
Our findings have to be contextualized within the broader spectrum of current research and clinical practices, as demonstrated by several high-quality studies.
In management like COPD.
While this study provides valuable insights, has several limitations that should be considered.First, the exclusion of patients who failed to respond to nebulized corticosteroids and required IV steroid., as well as those with worsening hypoxemia/respiratory failure requiring supplemental oxygen or those whose saturation PO2 dropped below 88% post-treatment were excluded and managed with systemic therapy.This selection could potentially limit the applicability of our findings to all patients with AECOPD.
Another limitation relates to the study design and timing of interventions.
In addition, the study's findings are based on observational data from a single demographic or geographical area, which might not be representative of COPD patient populations.
To overcome these limitations randomized controlled trials (RCTs) involving IV steroids are required to validate the efficacy and effectiveness of nebulized corticosteroids compared to systemic therapy Such studies should include a more diverse patient populations and explore different time frames and settings for measuring respiratory parameters.

Conclusion
This study highlights the potential benefits of nebulized -March 2024 | Volume 30 | Issue 01 | Page 59

Table 1 :
The mean PaO2 level before the therapy was 58.74 mmHg (SD = 4.53), and the mean PaO2 level after the therapy was 69.51 mmHg (SD = 3.92).The matched example t-test uncovered a critical improvement in PaO2 levels post-treatment (p-esteem < 0.000).(Table1)Comparisons of Mean PaO2 Values Before and After Therapy January -March 2024 | Volume 30 | Issue 01 | Page 60

Table 2 :
Comparisons of Mean PaO2 Values Before and After Therapy for Age Groups and Gender study comparative of Hu HS et al, nebulized and systemic corticosteroids, demonstrate a comparable Page 61 corticosteroid therapy, specifically beclomethasone, in improving arterial oxygen partial pressure (PaO2) in patients with acute exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD).The significant increase of PaO2 following treatment with nebulized corticosteroids highlights that this is a viable and effective alternative to systemic steroid therapy for managing AECOPD with mild hypoxemia.However, the findings need to be further studied through randomized controlled clinical trials to fully determine the comparative efficacy and safety of nebulized versus systemic corticosteroids, in COPD patients.Ethical Approval: The Institutional Ethical Review Board, Quaid-e-Azam Medical College, Bahawalpur approved the study vide letter No. 2331/DMI/QAMC Bahawalpur.