Background     Prognostic variables in chronic obstructive pulmonary disease (COPD) patients are not well described and available prognostic models in COPD have methodologic flaws, thus decision making regarding when to move away from aggressive life-sustaining treatments is challenging.  This Fast Fact will review prognostication in patients with advanced COPD.

Outpatients with COPD    The forced expiratory volume in one second (FEV1) has traditionally been used to assess COPD severity.  A FEV1 of less than 35% of the predicted value represents severe disease; 25% of these patients will die within two years and 55% by four years. Other studies have shown that age, low body mass index (BMI), elevated serum inflammatory biomarkers (C-reactive protein, IL-6, fibrinogen), multiple hospital admissions in the previous year, cor pulmonale, and low PaO2 were independent predictors of reduced survival time.  The BODE scale, consisting of BMI, exercise capacity, and subjective estimates of dyspnea, has been shown to help predict survival over 1-3 years (2). 

Note: these variables do not appear to help predict prognosis within six months of death.

Hospitalized patients    Mortality statistics vary for patients admitted with COPD exacerbations depending on age, functional status, co-morbidities, and physiological variables such as hypoxia and hypercarbia.  Roughly 10% of patients admitted with a PaCO2 >50 mmHg will die during the index hospitalization, 33% will die within six months, and 43% die within one-year (3).  Patients with less severe COPD have lower in-hospital mortality rates (4). Patients who require mechanical ventilation have an-hospital mortality of ~25% (5,6).  Poor prognostic factors include co-morbid illnesses, severity of illness (APACHE II score), low serum albumin, and/or low hemoglobin.  Previous mechanical ventilation, failed extubation, or intubation for greater than 72 hours all increase mortality (5). Patients ventilated more than 48 hours had a 50% one-year survival; functional status and severity of illness were associated with short term mortality while age and co-morbidities were associated with one year mortality (2).

National Hospice and Palliative Care Organization (NHPCO) guidelines for hospice admission in COPD include three major characteristics: 

• Dyspnea at rest or with minimal exertion.
• Dyspnea that is poorly responsive to bronchodilator therapy.
• Progression of chronic pulmonary disease as evidenced by frequent use of medical services (e.g., frequent hospitalizations, ED visits), frequent episodes of bronchitis or pneumonia, unintentional weight loss of 10% body weight in the previous 6 months, or progressive inability to perform activities of daily living (ADLs). 

NHPCO also encourages clinicians to consider these factors when determining hospice eligibility for COPD: continuous oxygen therapy, resting heart rate >100, cyanosis, systemic corticosteroid dependence, FEV1 ≤ 30%, O2 saturation ≤ 88% on room air, and signs of right heart dysfunction (cor pulmonale).  However, studies show that about 50% of the patients who met hospice criteria for COPD were still alive at six months, implying that the NHPCO criteria have a limited role in predicting six-month mortality and thus should be used with caution in determining hospice eligibility (7).

Summary     COPD is a heterogeneous disease without a simple prognostic trajectory.  While there is no specific sign or symptom which clearly portends a prognosis of 6 months or less in COPD, age, degree of dyspnea, weight loss (BMI), functional status, FEV1, and recent need for mechanical ventilation are relevant prognostic factors for predicting 1–3-year survival. In the absence of clear hospice criteria, clinician gestalt will be necessary when determining the prognostic appropriateness of hospice.

References 

1. Celli BR, Locantore N, et al.  Inflammatory biomarkers improve clinical prediction of mortality in chronic obstructive pulmonary disease.  American Journal of Respiratory and Critical Care Medicine. 2012; 185:1065-72.
2. Celli BR, Cote CG, Marin JM, et al.  The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease.  N Eng J Med. 2004; 350(10):1005-12.
3. Connors AF Jr, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med. 1996; 154:959-967.
4. Patil SP, Kirshnan JA, et al. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Intern Med. 2003; 163:1180-1186.
5. Nevins ML, Epstein SK. Predictors of outcome for patients with COPD requiring invasive mechanical ventilation. Chest. 2001; 119:1840-9.
6. Seneff MG, Wagner DP, Wagner RP, et al. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease.  JAMA. 1995; 274:1852-57.
7. Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J.  Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA. 1999; 282(17):1638-45.
8. Bellou V, Belvasis L, Konstantinidis AK, et al.  Prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease: systematic review and critical appraisal.  BMJ 2019; 367:153-58.
9. Leach RM. Oxford Textbook of Palliative Medicine 4th Edition: 12.3 Palliative care in non-malignant end-stage respiratory disease. 2010, Oxford University Press.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in August 2005; 2nd Edition April 2009; 3rd Edition in July 2015 by Sean Marks MD; 4th Edition in February 2025.