Introduction:

Chronic obstructive pulmonary disease (COPD) is a complex illness, associated with many comorbidities, it is usually misdiagnosed and underrated. Extra than 3 million individuals international die yearly from COPD, that make this illness a major problems in community, the main cause of COPD is cigarette smoking, (15-20%) of smokers have COPD and while other patients have genetic problems like (alfa1-antitrypsin insufficiency) and other patients have not genetic problem like (air pollution)¹. Chronic and permanent obstruction of airflow are the main features of disease². Chronic inflammation, oxidative stress and protease-antiprotease inequality are the main pathological mechanisms occur in COPD, so the symptoms of COPD occur either locally (pulmonary) or systemically³. Management of COPD include short-acting β2-agonist or short-acting muscarinic antagonists, this make forced expiratory volume in one second (FEV1) get better and symptoms also get better, but long-acting β2- agonists and long-acting muscarinic antagonists make lung function improve¹. Systemic inflammation documented as a risk factors in patients with COPD, these risk factors increase hospitalization and increase mortality⁴. In COPD patients when comparing with normal person there is increase in white blood cells (WBC), C-reactive protein (CRP), fibrinogen (Fbg) and decrease in count of lymphocyte^4-7. Current studies stated that neutrophil-lymphocyte ratio (NLR) could use as indicator of inflammation especially in COPD and coronary artery illness⁸. NLR is low-cost and possible indicator in evaluating the malignancy severity and in appendicitis like bacteremia^9,10. The aim of study is to improve that NLR could use as indicator of inflammation especially in COPD.

Method:

The data collection was conducted between 1 December 2019 and 1 March 2020 among patients with approved diagnosis of AECOPD and attendees to emergency unit and respiratory outpatient clinic or admitted to general word and intensive care unit of Marjan medical city/ Iraq. A consecutive sample of patients with approved diagnosis of AECOPD by based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines¹¹, during the period of data collection was adopted. The attendees to emergency unit and respiratory outpatient clinic or admitted to general word and intensive care unit were asked to participate in this study and sample size of 79 patients were included. Other 79 healthy volunteers it in the same age and gender and who be present emergency unit as relative to patients were selected as the control group.

Laboratory test: Both groups (case and control) age and gender were required than sent for CBC. All laboratory measurements were made at morning between 08:00–12:00 am, using standardized methods at the Marjan medical city laboratory. collected (5cc) of venous blood by venipuncture from patients and normal individuals, put this sample in a plane tube and not add anticoagulant, post centrifugation for 10 minutes and examined the serum was arranged. An electronic hematology analyzer (Siemens ADVIA® 2120i System, Siemens Healthcare Diagnostics and Japan) determined hematological parameters as complete blood count. The CBC parameters: total lymphocyte count, neutrophil count, mean corpuscular hemoglobin concentration (MCHC), hematocrit (HCT), mean corpuscular volume (MCV), platelet count and mean platelet volume (MPV), red cell distribution width (RDW) were assessed.

Spirometry test: Spirometry performed according to the recommendations of the American Thoracic Society guidelines ^[12]. Statistical analysis done by used SPSS22, frequency and percentage for categorical variables and mean ± SD for continuous variables. Fischer exact test for show association of categorical variables and t-test for difference of means of continues variables, ROC curve for sensitivity and specificity cut-off point of N/L ratio. P-value less than 0.05 considered significant.

Results:

Comparative cross sectional study of 79 patients with COPD and 79 patients normal, mean ± SD of age (66±10) years old and N/L ratio (5.9±4.8), according to fig 1; (45.57%) of patients with COPD have sever FEV1 and (30.38%) of patients have moderate FEV1. In addition, fig 2 show 73% of patients in current study are males and 27% are females with 71% are old age (more than 60 years old).

Fig 1:
FEV1 distribution of patients with COPD.

Fig 2:
gender distribution of patients with COPD.

Fig 3:
age distribution of patients with COPD.

According to table 1, there is significant difference between N/L ratio of patients with COPD and normal patients, the ratio increase in patients with COPD.

According to fig 4 very sensitive and specific cutoff point of N/L ration is (2.7), so more than it considered high ratio.

Fig 4:
Roc curve for sensitivity and specificity cutoff point of N/L ratio.
Area Under the Curve 0.76, N/L ratio (2.7) with sensitivity 76% and specificity 66%

Discussion:

Parameters that simply assessable and noninvasive which might mirror general inflammation has been studied. WBC, neutrophil counts and CRP are still the utmost regularly maker of infection in everyday clinical practice. In spite of numerous cytokines, endothelin-1 besides copeptin appear hopeful outcomes in evaluation of risk of infection but these parameters have disadvantaged by confirmation, price, and availability. In numerous stressful actions, there is increase in neutrophil count and low count of lymphocyte. Demargination, late apoptosis of neutrophils lead to neutrophilia. Lymphocytes margination, rearrangement and faster apoptosis are the chief reasons of lymphocytopenia in communicable illness¹³. Lymphocytopenia has revealed encouraged consequence in the bacteremia valuation in communicable disease¹⁴. Newly, NLR discovered as hopeful and simple indicator in numerous clinical conditions^15,16. NRL is low-cost and freely obtainable indicator providing an extra benefit in expecting period of hospitalization and mortality rate. Current study show that NLR is simple and accruable marker in evaluation and diagnosis of bacteremia and COPD, also another study stated that NLR is highly sensitive in the diagnosis patient5s with community-acquired pneumonia^17,18. In current study, there is significant difference between patients with COPD and normal patients in NLR, it is increase in COPD patients, (2.7) and more considered high NLR, this is similar to other study state that cut-off values determined 3.2 for NLR^19,20, this is like to other study revealed that NLR more than (3.4) would be a better predictor of inflammation. NLR may be a beneficial inflammation predictor in COPD patients²¹.

Conclusion:

NLR may beneficial inflammation predictor in COPD and acute exacerbation of COPD.

No conflict of Interest Disclosure.

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