The Relation between acute asthma wxacerbation and neutophils/lymptocytes ratio

doi:10.21203/rs.3.rs-3649221/v1

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The Relation between acute asthma wxacerbation and neutophils/lymptocytes ratio

https://doi.org/10.21203/rs.3.rs-3649221/v1

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Background: Bronchial asthma is one of the most common chronic diseases in different age groups, and the neutrophil-on-lymphocyte ratio (NLR) can be an important indicator for the inflammation process However, studies that investigate the relationship between asthma and NLR are very few, and here comes the importance of our study

Methods and tools: Our study is a cross-sectional study that examines the relationship between the NLR and the increase in the intensity of an asthmatic attack. In our study , we rely on reviewing the files of asthmatic patients and those who visits the emergency in Damascus Hospital. We collected those files and uploaded them to our own questionnaire. That was between 1/1/ 2023 and 9/1/2023. The sample size was 87 patients of both sexes and different ages.

Results: The results of our studies concluded that the heart rate respiratory rate and the shortness of breath increase with the increasing of the NL ratio (P-value=0.001). This was in agreement with other international studies. A specific statistical relationship was also found between oxygenation drop and the increase of NL rate (P-value=0.001), as well as there was more need for admission in the intensive care unit and mechanical ventilation with the increasing of NL ratio (P-value=0.001).

Conclusion: It can be said from the results we obtained in our study and in comparison, with other studies that an increase in the NL ratio is a strong indicator of an increase in the severity of the symptoms of the acute exacerbation of asthmatic attack.

Internal Medicine

asthma

Syria

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness and cough, that vary over time and in intensity, together with variable expiratory airflow limitation.

This definition was reached by consensus, based on consideration of the characteristics that are typical of asthma before ICS- containing treatment is commenced, and that distinguish it from other respiratory conditions. however, airflow limitation may become persistent later (1).

Bronchial asthma is one of the most common chronic diseases in different age groups, and the neutrophil-on-lymphocyte ratio (NLR) can be an important indicator for the inflammation process. However, studies that investigate the relationship between asthma and NLR are very few, and here comes the importance of our study

In our research, we relied on reviewing the medical records of patients documented by the medical staff at Damascus Hospital and extracting information from them for our research tool or questionnaire, which is a cross-sectional exploratory study. This includes some demographic information about the patient, in addition to the variables we aim to compare.

We calculated the NL ratio based on the initial emergency tests taken from the patient, and for research and statistical purposes, the results were divided into four quarters, which are:

Q1: 0.7–2.2, Q2: 4.5–0.9, Q3: 8.0-4.2, Q4: 8.2–21.2.

This was done after obtaining approval and permission from the presidency of the Syrian Private University, the dean of the Faculty of Medicine, and the management of Damascus Hospital, and the work was completed between (01.01.2023-.01.06.2023).

Sample and Population:

Patients who presented to the emergency department of Damascus Hospital with an acute asthma attack of different ages. The required sample size was calculated using the OpenEpi program for a study power of 95% and a margin of error not exceeding 2.2%, which was 72 patients. Therefore, our sample size was 87 patients of different ages and both genders.

Inclusion criteria:

Patients of all ages and both genders, Patients with a confirmed diagnosis of asthma, and the main reason for emergency department presentation is acute exacerbation of asthma.

Exclusion criteria:

Patients previously undiagnosed with asthma, and Patients with bronchial asthma admitted in deferent wards.

Statistical analysis:

Data analysis was conducted using version 25 of the Statistical Package for the Social Sciences (SPSS). P < 0.25 was considered statistically significant.

The sample was divided into quarters according to the distribution of the age groups, with the largest sample being in the age group between 1–21 years, at a rate of 35.6%.

As for gender, the majority of the sample were females, with a total of 62, accounting for 71.3%.

Regarding smoking, the vast majority of the sample were non-smokers, with a total of 76 non-smokers, accounting for 87.4%.

We also calculated the number of patients with some chronic diseases such as type 2 diabetes and hypertension. The number of patients with type 2 diabetes was 14, accounting for 16.1%, while the number of patients with hypertension was also 14, accounting for 16.1%.

Regarding the length of hospital stay required by the patients, it was distributed as follows: the number of patients who were discharged on the same day was 12, accounting for 13.8%, those who required hospitalization for two days were 21, accounting for 24.1%, and those who required three days were 22, accounting for 25.3%.

We also surveyed the number of patients who required admission to the intensive care unit and found that there were 9 patients out of the sample, accounting for 10.3%. As for the patients who required mechanical ventilation, their number was 8 out of the sample, accounting for 9.1%.

We also measured the oxygen levels of the patients upon admission using an oximeter and statistically divided the patients into four groups based on the results we obtained. The largest group had oxygen levels above 91%, accounting for 43.6%.

We also divided the patients according to the degree of respiratory distress they were experiencing, with the largest group falling under degree three, with a total of 48 patients, accounting for 55.1%.

Additionally, we divided the patients according to their heart rate upon admission into four categories based on the results we obtained. The largest category fell under a heart rate of 85–100 beats per minute, accounting for 36.7%.

We also divided the patients according to their respiratory rate into four categories based on the results we obtained. The largest group of patients fell under the category of 21–30 breaths per minute, accounting for 39%.

Finally, we distributed the individuals in the sample according to the quarters we divided based on the NLR ratio results we obtained. The largest number of patients fell under the first quarter Q1, accounting for 27.5%.

We conducted a statistical study to investigate the relationship between age and NLR, and through the appropriate statistical test, there was no statistically significant relationship indicating an association between age and NLR, where the P-value was 0.624.

We also conducted a statistical study to investigate the relationship between gender and NLR, and through the appropriate statistical test, there was no statistically significant relationship indicating an association between gender and NLR, where the P-value was 0.493.

Furthermore, we conducted a statistical study to investigate the relationship between smoking and NLR, and through the appropriate statistical test, there was no statistically significant relationship indicating an association between smoking and NLR, where the P-value was 0.106.

Additionally, we conducted a statistical study to investigate the relationship between type 2 diabetes and NLR, and through the appropriate statistical test, there was no statistically significant relationship indicating an association between type 2 diabetes and NLR, where the P-value was 0.423.

We also conducted a statistical study to investigate the relationship between hypertension and NLR, and through the appropriate statistical test, there was no statistically significant relationship indicating an association between hypertension and NLR, where the P-value was 0.212.

Moreover, we conducted a statistical study to investigate the relationship between the degree of respiratory distress and NLR, and through the appropriate statistical test, we found a statistically significant positive relationship indicating an association between the degree of respiratory distress and NLR, where the P-value was 0.04, meaning that respiratory distress increases with an increase in NLR.

Additionally, we conducted a statistical study to investigate the relationship between heart rate and NLR, and through the appropriate statistical test, we found a statistically significant positive relationship indicating an association between heart rate and NLR, where the P-value was 0.001, meaning that heart rate increases with an increase in NLR.

We also conducted a statistical study to investigate the relationship between respiratory rate and NLR, and through the appropriate statistical test, we found a statistically significant positive relationship indicating an association between respiratory rate and NLR, where the P-value was 0.001, meaning that respiratory rate increases with an increase in NLR.

Furthermore, we conducted a statistical study to investigate the relationship between length of hospital stay and NLR, and through the appropriate statistical test, we did not find a statistically significant relationship indicating an association between length of hospital stay and NLR, where the P-value was 0.116.

Moreover, we conducted a statistical study to investigate the relationship between admission to the intensive care unit and NLR, and through the appropriate statistical test, we found a statistically significant positive relationship indicating an association between admission to the intensive care unit and NLR, where the P-value was 0.001, meaning that the likelihood of admission to the intensive care unit increases with an increase in NLR.

Lastly, we conducted a statistical study to investigate the relationship between the need for mechanical ventilation and NLR, and through the appropriate statistical test, we found a statistically significant positive relationship indicating an association between the need for mechanical ventilation and NLR, where the P-value was 0.001, meaning that the need for mechanical ventilation increases with an increase in NLR.

Finally, we conducted a statistical study to investigate the relationship between oxygen levels upon admission and NLR, and through the appropriate statistical test, we found a statistically significant positive relationship indicating an association between oxygen levels and NLR, where the P-value was 0.001, meaning that oxygen levels decrease

Cornerstone in asthma control is regular updating in asthma managing strategy. Both ACT and measurement of NLR as an inflammatory marker are used to evaluate and follow up management in asthmatics patients (2). Neutrophils contribute to inflammation of airways and are triggered in inflammatory pulmonary diseases like asthma (3). NLR is expected to be a biomarker for systemic and airways inflammation (4), and it may be altered in asthmatics and healthy adults. three studies showed that NLR was significantly differ between control subjects and asthmatics patients (5, 6, 7). In contrast, other two studies revealed no significant difference between asthma and healthy controls (1, 8)

In our study, the focus was mainly on examining the relationship between NLR and all the other researched variables, including those that indicate the severity of an asthmatic attack. Most of these relationships were found to be positive in the results, as it was observed that the heart rate increased in patients with a high NL ratio (0.001 = P-value), which is consistent with a study by Arwas, N et al (9). It was also found a positive relationship indicating an increase in respiratory rate with an increase in NL ratio (P-value = 0.001), and an increase in ICU admission and the likelihood of needing mechanical ventilation with an increase in NL ratio (P-value = 0.001). The oxygen saturation ratio decreased as the NL ratio increased (P-value = 0.001), all of which are in line with other studies such as the study by Arwas, N et al.

The degree of respiratory distress also increased with an increase in NL ratio (P-value = 0.001), which, along with the previous results, indicates that an increase in the severity of asthma is associated with an increase in NL ratio.

It is worth mentioning that the statistical relationship was negative with regards to the length of hospital stay and the NL ratio, which does not consent with the study by Arwas, N, and in my opinion, this is attributed to the fact that other medical variables and the patient's age, physical and social condition, or patients who were discharged to continue intensive care elsewhere, were not taken into consideration, or at least not to the extent that could indicate a convincing result.

In our study, we did not find a statistically significant relationship indicating an association between the NL ratio and smoking, age, or gender, which in some cases contradicts another study by Meena Abdul-Sattar et al.(15), which showed an association between the NL ratio and age and gender. In the study by Meena Abdul-Sattar et al., the NL ratio was found to increase with age, and the median ratio in females was higher than the median ratio in males.

It was reported higher NLRs could be associated with Asthma severity, inflammation, long hospitalization, and mortality (10)-(11). Increased cytokines levels usually accompanied with increased neutrophils (12). Pro-inflammatory mediators like tumor necrosis factors and interleukin-6 are increased in asthma and subsequently increases immune cells as natural killer cells and neutrophils (12). Additionally, Chinese Liu et al (13) research concluded that NLR level is clearly increased in severe asthma. New Japanese research by Mochimaru et al (14) recorded that NLR level is raised in acute exacerbations of asthma in adults.

Like other studies, our study had several limitations, including poor archiving. There was a significant lack of information about the patients that could have been used as additional evidence of the relationship between the NL ratio and the severity of asthma. Additionally, the severity of the disease was not assessed using spirometry, which is a cornerstone in evaluating the severity of asthma, and the asthma control in patients was not taken into consideration.

We recommend that this study be the core for larger and more comprehensive research and studies in terms of capabilities and number of patients, and to benefit from the results we have reached, which undoubtedly provide good and easy-to-handle evidence in evaluating and approaching asthma patients suffering from an acute exacerbation.

In conclusion, the NLR is an objective tool that may have a role in assessing pediatric asthma exacerbation severity and the need for hospitalization. It is a feasible and safe measure, suited for the pediatric ED setting. NLR could potentially supply an additional decision tool that could assist the clinician in the identification of severe asthma cases that require admission and further inpatient care. However, further studies are warranted for its implementation in the clinical setting.

Ethical approval:

Ethical approval was obtained from the Institutional Review Board (IRB), Faculty of Medicine, Syrian Private University.

Funding statement:

No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Availability of supporting data:

The data that support the findings of this study are available from the Corresponding author, upon reasonable request.

Competing interests:

The authors declare that they have no competing interests.

Acknowledgments:

Not applicable.

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Version 1

posted

You are reading this latest preprint version

The Relation between acute asthma wxacerbation and neutophils/lymptocytes ratio

Status:

Version 1

Abstract

Introduction

Methods

Sample and Population:

Inclusion criteria:

Exclusion criteria:

Statistical analysis:

Results

Discussion

Conclusion

Declarations

References

Status:

Version 1