Incidence and Outcome among COPD Patients Attending the Emergency Department of the King Abdul-Aziz Medical City Hospital, Riyadh, Saudi Arabia

Background: Chronic Obstructive Pulmonary Disease (COPD) is a common chronic lung disease. Objectives: The aim of this study is to determine the incidence and outcome among the patients attending the emergency department of the King Abdul-Aziz Medical City (KAMC) Hospital, Riyadh and receiving a discharge diagnosis of COPD. Methods: We reviewed all the charts of subjects attending the Emergency Department of the KAMC (King Abdul-Aziz Medical City) hospital in the period, from 1 June to 31 September 2016. We analyzed the chart of all subjects receiving a diagnosis of COPD. They formed the subjects of this retrospective study. Results: Two hundred and ten subjects accessed the emergency department into the study period . We selected 140 subjects with mean (±SD) age of 71.9 (  9.84) years; males 54, 38.6 %) with a discharge diagnosis of COPD. The incidence of COPD was 1.9%. The outcome of COPD management indicated that the majority of the subjects discharged with home ventilation were 85 (60.7%), 30(21.4%) subjects were shifted to different wards, whereas 22 (15.7%) were discharged in stable condition, while 3 (2.2%) died. Conclusion: The study revealed a high pervasiveness of COPD (66.66%) among the Saudi patients. The outcome of COPD ranged from living with home ventilation to


INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow limitation. Currently, this disease is the fourth highest cause of death in the world. Patients with COPD are frequently exposed to Human Rhinovirus, Respiratory Syncytial and Influenza Virus, as well as to Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis. These infectious agents are sometimes responsible for exacerbations increasing morbidity and mortality in COPD patients [1]. Pulmonary emphysema is a pathologic condition characterized by permanently enlarged airspaces distal to the terminal bronchiole with destruction of the alveolar walls. Functional information of the lungs is important to understand the pathophysiology of emphysema and that of COPD [2].
Smoking, asthma, and genetic problems (deficiency in alpha-1-antitrypsin) are the etiological bases of developing COPD. Smoking cessation is the most effective strategy for slowing down the progression of COPD and reducing mortality in the approximately 50% of patients with diagnosed COPD [3]. The results of various studies among nonsmokers show that some occupations are associated with an increased risk of developing COPD. The newly identified occupations with high COPD prevalence include machine operators, construction trades, financial record processing, cotton workers, farm machinery workers, construction workers, and bus drivers. To reduce the prevalence of COPD in the workplace, etiologic research and preventive interventions should focus on occupations at risk for occupational exposures [4]. Variants in FAM13A have been found in genome-wide association studies to associate with lung function in the general population as well as in several common chronic lung diseases such as COPD, asthma, as well as in idiopathic interstitial pneumonias. The redundancy of its genetic contribution in chronic lung diseases suggests a major function of this gene both in lung physiology and chronic lung disease [5].
COPD can be diagnosed according to symptoms, signs, and chest X-ray or pulmonary function test (PFT) which are strong indicators for COPD diagnosis. Symptoms involve productive cough, wheezing, and dyspnea on exertion. Signs include tachypnea, respiratory distress, usage of accessory muscles, elevated jugular venous pulse, cyanosis, edema fromcorpulmonale, change in mental state due to hypercapnia and hypoxia, physiological distress and limitation on daily activity [6]. Measurements of lung function, including spirometry and body plethesmography, are easy to perform and are the current clinical standard for assessing disease severity. However, these lung functional techniques do not adequately explain the observed variability in clinical manifestations of disease and offer little insight into the relationship of lung structure and function [7]. In a study based on a combination of multi-detector computed tomography scanning of an intact specimen with microcomputed tomography and histological analysis of lung tissue samples, Hogg [8] reported that the number of terminal bronchioles were reduced from approximately 44,500/lung pair in control (donor) lungs to approximately 4800/lung pair in lungs donated by individuals with very severe chronic obstructive lung disease stage 4 COPD treated by lung transplantation. High-resolution chest computed tomography is one of the most useful techniques available to verify destruction of airspace, attenuated vasculatures and hyper-lucent as well as hyper-inflated lungs [9].
Treatment recommendations can be divided into four elementary steps: the first step is the removal of all risk factors, the second is the standard therapy including inhaled bronchodilators, pulmonary rehabilitation and treatment of severe co morbidities, the third is the targeted therapy centered on clinical phenotypes of COPD. The fourth step is the treatment of respiratory insufficiency and palliative care of the terminal COPD [10]. Biomarkers (quantitative cell counts in sputum, fraction of nitric oxide in exhaled breath, various metabolites in exhaled breath) with a particular emphasis on how eosinophil and neutrophil counts in sputum are used to manage asthma and COPD [11]. Besides, these cost effective treatments, the pressurized metered dose inhalers and dry powder inhalers are the most widely used devices for inhalation therapy in asthma and COPD [12].
Notwithstanding the symptomatic and treatments for insidious conditions, the obstructive lung disorders are responsible for functional limitations and the deaths of millions of Americans and COPD is said to be the top 5 leading causes of death and the incidence is increasing [13]. The Breath Study Group [14] conducted a survey of COPD in eleven countries, namely; Algeria, Egypt, Jordan, Lebanon, Morocco, Pakistan, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates. They screened a total 62,086 subjects and identified 2,187 subjects were diagnosed with COPD.
COPD is one of the major health problem leading to death in the world, however; little is known about pervasiveness, occurrence and consequences of COPD among Saudi Population in Riyadh. This might lead to a delay in diagnosing patients and might result in a high risk for mortality and morbidity [15]. "The World Health Organization has estimated that approximately 44 million people -mainly mensuffer from COPD. By 2030, the number of cases will increase by 65% and COPD will become the fourth leading cause of death. In Europe, COPD affects up to 8%-10% of population above 30 years of age" [16].
The aim of the Study is to estimate the pervasiveness, occurrences and consequences of COPD patients attending KAMC which represents Saudi population.

MATERIALS AND METHODS
The period of the study was 6 months starting from 01 June to 31 September 2016 including the collection and analysis of data and computing of results. The materials and methods used in order to achieve the objectives of the study are elaborated as follows:

Study Area/Setting
The proposed study was conducted by using the data of patients with respiratory diseases from the Information database of Ministry of National Guard Health Affairs. The electronic medical record contained data on patient demographics, descriptions, patient reported signs and symptoms, diagnoses, treatment modalities, clinical and biochemical and microbiological assessments. The study was approved by the Institutional Review Board (IRB), King Abdullah Institutional Medical Research Center (KAIMRC).

Study Subjects
All registered patients of NGHA who visited the hospital, with history of respiratory diseases and newly diagnosed as COPD formed the subjects for the study. The inclusion criteria was for the patients of both genders (age ≥ 40 years), registered in NGHA for respiratory diseases for one year prior to the study.

Study Design, Sample size and Sampling Technique
Design of the proposed study was chart review. According to the data from NGHA, 210 patients (on an average) visited the Emergency Department with respiratory disorders per quarter of a year. The sample size was fixed to be 140 with 95% confidence level and 5% margin of error. Random sampling was used to select the subjects. The calculation of incidence and prevalence was done by the following formulae.

Data Collection Methods, Instruments Used, Measurements
All registered patients with a history of respiratory diseases were assessed with Global Initiative for Chronic Obstructive Lung Disease guidelines. Those who were confirmed COPD before the start of the study were screened out to assess the pervasiveness of COPD. Those who were diagnosed newly with COPD as per PFT (<0.70) were also selected for their data with respect to demographic characters along with past clinical history of selected patients and data with respect to descriptions, reported signs and symptoms, diagnoses, treatment modalities, clinical, biochemical and microbiological assessments were taken for the study.

Data Management and Analysis Plan
The collected data was recorded into Microsoft Excel before importing the same to SPSS (Version 22) for statistical analysis. The Wilcoxon signed-rank test was used. Data is presented as tables and figures. Frequencies and percentages were used for categorical variables. Continuous variables represented as mean and standard deviation. Population who are at risk of getting COPD during the study period, global clinic outcomes were used to assess the acute exacerbations by using indexes which are Saint George's Respiratory Questionnaire (SGRQ) and Chronic Respiratory Questionnaire (CRQ) [17,18]. SGRQ contains the symptoms, activity, and impacts, it also has a range from 0 (Normal) to 100 (Very ill patient). Whereas, CRQ contains dyspnea, fatigue, emotional function, and mastery, it has a score of seven (which is a good health) as when it becomes lower meant that the condition of the patient is worsening [19]. Miscellaneous outcomes are radiological examination to detect the abnormalities of lungs with COPD patient by using CXR and CT. Anxiety is an outcome which has to be considered among COPD patient in order to know how psychological functioning is associated with outcomes of this disease [20].

Ethical Consideration
Privacy and confidentiality were completely protected; no identifiers or personal information, including participant's name, IDs and others were leaked.

RESULTS
The results of the present study are detailed as follows:

Demography of the Subjects
The results of our study show that majority 61(43.6%) of the subjects belong to the age group of 70-80 years. The female patients constituted 86(61.4%).Hundred and five (75%) patients were married. Furthermore 135 (96.4%) of the subjects were unemployed. Among the patients 22(15.7%) were smokers, while 118(84.3%) were nonsmokers.

Pervasiveness and Occurrence of COPD
Among the 140 cases of COPD studied, the pervasiveness was calculated to be 66.66%. The calculated rate of occurrence of COPD was identified as 1.9 % (Table 1).

Diagnostic Parameters at the Time of Hospital Admission
The major diagnostic parameters at the time of hospital admission are provided in Table 2.
As indicated in Table 2, parameters related to ABG such as pH and PO 2 were found decreased. The mean pH of the subjects was 7.31± 0. 34

Biomedical Parameters at the Time of Hospital Admission
The main biomedical parameters at the time of hospital admission are provided in

Microbiological Analysis at Admission
Microbiological results at the time of hospital admission are given in Table 4. Ten patients (7%) positively had Pseudomonas aeruginosa. It was observed that majority (139, 99.3%) of the subjects indicated negative microbiological results and some of the subjects were infected with more than one microbe.

Management of COPD in Hospital
At the hospital, COPD patients were managed either by pharmacological, non-pharmacological or through pulmonary rehabilitation measures. The management of the COPD patients is provided in Table 5.
As detailed in the Table 5, pharmacologic management indicated that the majority (133, 95%) were prescribed with bronchodilators and 118(84.3%) with steroids. One hundred and thirty three (95%) of the subjects were on oxygen therapy through non pharmacologic management where as 120(85.7%) received non-invasive ventilation. COPD management by intubation was on 22(15.7%) patients and 9(6.4%) were managed with tracheostomy. The subjects who were under pulmonary rehabilitation were 26 (18.6%).

Pre-and Post-managerial Changes in Diagnostic Parameters
The major pre-and post-managerial changes in diagnostic parameters are listed in Table 6.
In comparison with pre-medical management, post-managerial parameters showed the following changes: With post-medical management: pH mean declined to 7.37 (±0.08), which appear to be within normal range. HCO 3 mean increased to 33.22 (±7.75), yet it is considered to be above the normal range. PO 2 mean increased to 66.32 (±18.37) which is below the normal range. On the other hand, PCO 2 showed a decrease in the mean 59.24 (±13.46) which is not within the normal range. Wilcoxon sign rank test indicated that the medical management in the hospital influenced the different ABG variables such as pH (z = -5.71; p=0.001), PCO 2 (z= -3.95; p=0.001) and PO 2 (z= -3.29; 0.001) which was statistically significant with a p value <0.05. The Vital Signs displayed the following changes after the medical management: HR, RR, Systolic blood pressure, Diastolic blood pressure, and Temperature found to decrease and within the normal ranges. HR mean 88. 26

Pre-and Post-managerial Changes in Biomedical Parameters
In comparison with Pre-hospital management, Post-hospital management biomedical parameters showed the following changes in Table 7. The Parameter which showed elevation, yet considered within normal range was Albumin. On the other hand, Creatinine clearance, Sodium and Potassium levels were decreased, but it was considered within normal range. Hematological parameters after medical management were as follows: WBC mean showed elevation and not in the normal range. Platelets mean was decreased, but it was considered to be within the normal range. Post management means were as follows: Sodium 135.24 (±7.77), Potassium 4.23 (± 0.62), Creatinine clearance levels in males 112.52 (± 55.76) and in females 101.97 (± 76.35), albumin 51.13 (± 33.75).
Wilcoxon sign rank test indicated that the medical management in the hospital influenced the biomedical and hematological parameters such as Potassium (Z=-3.17; p=0.002*), and platelets (Z=-2.09; p=0.037) which was statistically significant with p value <0.05.

COPD Patients Outcome
Hospital outcome of COPD patients are given in Table 8

DISCUSSION
The study was conducted to find the pervasiveness, occurrence and consequences of COPD among Saudi patients attending KAMC. The results of the study are discussed as follows:

Demography of the Subjects
The demographic details of the subjects indicated that majority of the patients were in advance age group, our observation is supported by earlier studies [19], which reported that adults of ≥40 years are at risk of having COPD . On a gender comparison, we found COPD is more common among females. Although various studies conclude prevalence of COPD in men is higher than women, there are studies which found the disease is markedly increased in women [21]. Although, cigarette smoking was considered one of the major etiological factors for COPD, majority (118, 84.3%) in our present

Diagnostic Parameters at the Time of Hospital Admission
The study included vital signs at the time of hospital admission to conform that patients were experiencing the symptoms of this disease such as: decrease in Spo 2 (%). These changes demonstrate the typical signs of desaturation that represent patients with COPD in various cases [24]. ABG parameters in this study showed that pH and PO 2 were found decreased. In contrast, parameters like PCO 2 and HCO 3 found elevated.
Similarly, a study conducted for COPD patients indicated that in comparison with a normal person, COPD patients will have certain changes in ABG due to the pathophysiology of the disease. The study further showed ABG parameter in COPD showed decrease in pH, PO 2 , while the PCO 2 and HCO 3 were increased, which is found similar to an earlier observation [25].

Biomedical Parameters at the Time of Hospital Admission
In this study, biomedical parameters showed that Sodium, Potassium, Creatinine clearance, and Albumin were in the normal range in both male and female patients. In contrast, a study conducted for Dyselectrolytemia in COPD patients found sodium and potassium to decrease [26]. Another study explained that COPD patients' creatinine level was usually high due to the disease pathophysiology [27]. The Hematological parameters, that include WBC showed elevation and the Platelets were in normal ranges. Fattouh and Alkady [28] in a similar study showed WBC to elevate, while Gulfidan [29] found platelets to increase in COPD patients.

Microbiological Analysis at Admission
Majority of the subjects in this study indicated negative microbiological results. Ten (7.3%) of the patients positively had Pseudomonas aeruginosa. In contrast, Hunter and King [30] showed most of the COPD exacerbation cases were caused by Streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis.

Management of COPD in Hospital
The findings of the study showed that 133 (95%) of the patients were prescribed with bronchodilators and 118 (84.3%) with steroids, this observation is supported by WHO on the pharmacological treatment of COPD. Bronchodilators and steroids are medications which relieve the abstraction of the airway and were proved to be a significantly effective treatment [31]. One hundred and thirty three (95%) patients were on oxygen therapy and 120(85.7%) of the subjects received non-invasive ventilation. Previous studies showed that noninvasive ventilation improves gas exchange and respiratory muscle use in these patients [32]. COPD management by intubation was found in 22 (15.7%) patients which is considered low in comparison to previous studies with 57.6 per cent intubated patients [33]. The reason behind low percentage in this study was the good management of COPD patients by skilled respiratory therapists: oxygen therapy, non-invasive ventilation, and pharmacological managements. Nine (6.4%) patients were managed with tracheostomy. Twenty six (18.6%) subjects were under pulmonary rehabilitation, and there were studies that supported the pulmonary rehabilitation programs to increase daily physical activate and improve the quality of life [34].

Pre-and Post-managerial Changes in Diagnostic Parameters
Our study compared the pre-medical management with the post managerial parameters which showed the following changes: With post-medical management, the pH mean was within normal range. The HCO 3 mean increased above the normal range. PO 2 mean increased below the normal range. On the other hand, Pco 2 showed a decrease in the mean which was not within the normal range. The Vital Signs displayed the following changes after the medical management: HR, Systolic blood pressure, Diastolic blood pressure, and Temperature were found to decrease within the normal ranges. RR mean decreased above the normal range. SPO 2 showed elevation and the mean was within normal ranges. A comparison with other studies could not be made as there is no study similar to pre-and post-managerial changes in diagnostic parameters.

Pre-and Post-managerial Changes in Biomedical Parameters
The study on the pre-and post-managerial changes in biomedical parameters showed, increase of Albumin within the normal range and decrease in the sodium, potassium and creatinine clearance levels (in males and females) which was also within the normal range. For the hematological parameters, the WBC elevated but not in the normal range, on other hand, the platelets decreased within the normal range. A comparison with other work was not possible because there has been no study similar to pre-and post-managerial changes in biomedical parameters.

COPD Patients Outcomes
The majority of the subjects required home ventilation (noninvasive ventilation provided at home) [35]. A study on Impact of noninvasive home ventilation on long-term survival in chronic hypercapnia COPD proved that noninvasive ventilation was associated with improved survival and decreased hospitalizations in patients with COPD [36]. The per cent mortality during the hospital stay was 2.2. This is very less as compared to the percentage of mortality (33.1 per cent) that occurred in another study carried out in the Osmangazi University, Medical Faculty, Department of Chest Diseases [33].
COPD patients who were discharge in a stable condition accounts for 15.7 per cent after they were managed by oxygen therapy, bronchodilators, and systemic corticosteroids which is supported by other studies as an intervention [35]. Some of the patients (21.4 per cent) were shifted to Wards in the hospital this means that COPD is required more medical care which is increase the cost for patients. It is estimated that on an average each adult with COPD paid USD 6000 more in medical care than an adult without COPD [22].

LIMITATIONS
The major limitations of the study were the small sample size and limited time allowed for collecting the data. Lack of similar studies in KSA set a constraint while discussing the findings of the study. Also, the researchers found that the patient's files did not include the contributing factors that lead to COPD which was the major constraint during the conduct of the study.

CONCLUSION
Chronic Obstructive Pulmonary Disease is described as an airway obstruction that leads to airflow limitation and accumulation of secretions resulting from loss of lung elasticity by dust exposure and inflammatory mediator's response. COPD is one of the causes of high morbidity and mortality in the world. According to GOLD, COPD can be diagnosed by pulmonary function test, which is performed by spirometry. Patients who were confirmed COPD before the start of the study were screened out to assess the pervasiveness of COPD. Patients who were diagnosed newly with COPD as per PFT (<0.70) selected and monitored for the occurrence and consequences of COPD. In this study, the pervasiveness of COPD was 66.66 per cent, while the occurrence was 1.9 per cent among Saudi population. The diagnostic parameters used in this study were PFT, ABG, and vital signs. The consequences of COPD were: 85 (60.7%) of COPD patients were requiring home ventilation, 30 (21.4%) were shifted from ICU to general ward requiring continuance medical care, 22(15.7%) were discharged from hospital in a stable condition, and 3 (2.2%) died during hospital stay. The result of the study can be used in making policies with respect to the facilities to be premeditated for COPD patients.

RECOMMENDATIONS
Activate an awareness day of COPD in Saudi Arabia, so people will have general idea about the disease and how to prevent it. Also, emphasize the important role of PFT in diagnosing COPD in early stage.

CONSENT
It is not applicable.

ETHICAL APPROVAL
As per international standard or university standard, written approval of Ethics committee has been collected and preserved by the authors.