Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 16895

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : OC18 - OC21 Full Version

Neutrophil-Lymphocyte Ratio as a Predictor of COPD Exacerbations: A Cross-sectional Study

Published: January 1, 2023 | DOI:
Karan Sharma, Kranti Garg, Jawahar Lal Joshi, Vishal Chopra, Ramesh Kumar Kundal

1. Senior Resident, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. 2. Associate Professor, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. 3. Associate Professor, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. 4. Professor and Head, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. 5. Professor and Head, Department of Pathology, Government Medical College, Patiala, Punjab, India.

Correspondence Address :
Dr. Kranti Garg,
Associate Professor, Department of Pulmonary Medicine,
Government Medical College, Patiala, Punjab, India.


Introduction: Chronic Obstructive Pulmonary Disease (COPD) is characterised by a modified inflammatory response to chronic irritants which is often associated with some degree of systemic inflammation. Exacerbations in COPD are characterized by exaggeration of the ongoing inflammation. A number of inflammatory mediators are found to be raised in COPD exacerbations but most of them are expensive and not readily available. The Neutrophil-lymphocyte Ratio (NLR) is a rapid, easy and cheap biomarker that has been shown to be raised in patients of COPD.

Aim: To evaluate the role of NLR in patients of stable and acute exacerbation of COPD.

Materials and Methods: This cross-sectional observational study was conducted in Department of Pulmonary Medicine at Government Medical College, Patiala, Punjab, India. Study included 150 patients of stable COPD, 150 patients of Acute Exacerbation COPD (AECOPD) and 100 subjects as controls. NLR was calculated from a peripheral blood sample of the study participants. Continuous variables were summarised as mean with standard deviation and compared between groups using Unpaired t-test. A p-value <0.05 was considered statistically significant.

Results: The mean age in AECOPD group was 61.7±10.4 years, in stable COPD group was 63.1±8.9 years and 63.2±7.8 years in controls. Mean NLR was found to be highest in AECOPD group (4.0±1.7) followed by stable COPD (2.9±0.8) and then control (1.8±0.4).NLR showed good predictive value for predicting exacerbations in stable COPD patients with sensitivity and specificity of 75.3% and 70.7% respectively (cut-off 3.4 and AUC=0.806).

Conclusion: NLR is an easily available biomarker of inflammation and can be used as a predictor of exacerbation in patients of COPD.


Biomarker, Chronic obstructive pulmonary disease, Inflammation

Chronic Obstructive Pulmonary Disease (COPD) is characterized by a modified inflammatory response to chronic irritants. There is an increase in the number of macrophages, activated neutrophils, and lymphocytes in peripheral airways, lung parenchyma, and vessels (1). The role of the neutrophils in the pathogenesis of COPD is only partially known. The imbalance between proteases and their inhibitors cause parenchymal destruction and emphysematous changes, while the production of cytokines, enzymes, adhesion molecules, and growth factors from activated neutrophils promote infiltration of the airways by inflammatory cells and further production of proinflammatory factors, creating a vicious circle which maintains and enhances the local and systemic effects of the disease (2),(3).

Along with pulmonary inflammation, some degree of systemic inflammation is also seen in COPD, although the mechanism of this systemic inflammation remains unclear. Several pathways have been suggested that may lead to systemic inflammation in COPD, these include; overflow of inflammatory mediators from pulmonary compartment; proinflammatory reaction to bacterial products; inflammatory reaction to tissue hypoxia, and inflammation induced due to smoking (4).

During exacerbations of COPD, pulmonary as well as systemic inflammation is accentuated characterized by cellular activation, cytokine production and tissue injury. The infective (bacterial or viral (5)) and non infective triggers of exacerbations accentuate the ongoing inflammation in patients of COPD (6).

Increased inflammation in lungs is associated with raised inflammatory markers in circulation leading to an increase in systemic inflammation as well (4). Several biomarkers of inflammation which are found to be raised in COPD are C-Reactive Protein (CRP), Interleukin-8 (IL-8), Tumour Necrosis Factor (TNF-α), leptin, endothelin-1, fibrinogen, IL-6, Leukotriene (LT) B4 and E4 (7). Although some of these novel biomarkers can identify the severity of disease and acute exacerbation in COPD, most of them are time-consuming, expensive, and not readily available (8). The Neutrophil-Lymphocyte Ratio (NLR) is a rapid, easy and cheap biomarker that is calculated from Complete Blood Count (CBC). Blood NLR has been demonstrated to be an indicator of inflammatory states and is utilised for risk stratification of several disorders, including acute coronary syndrome (9), pancreatitis (10), sepsis, and infectious conditions (11). NLR is also been used as a prognostic indicator in several diseases like breast cancer (12), sepsis (13), and most recently in Coronavirus Disease 2019 (COVID-19) (14).

There has been extensive research on the role of NLR in COPD. Multiple studies have corroborated that NLR increases during exacerbations of COPD (8),(15),(16),(17),(18),(19),(20),(21),(22),(23),(24) and other studies have explored its role as a predictor of exacerbations (8),(15),(16),(18),(25),(26) and mortality (17),(24),(25),(27),(28),(29),(30). However, data in the Indian population is scarce. Prasannan G et al., and Sharma K et al., found that NLR was raised in COPD exacerbations when compared to stable patients (21),(22). Prasannan G et al., also found that NLR has a positive correlation with mMRC and BODE score of the patients (21). While Arya V et al., found no correlation between NLR and severity of COPD exacerbation (31). Hence, the present study was conducted to evaluate the role of NLR in patients of COPD specially as a predictor of exacerbations.

Material and Methods

This cross-sectional observational study was conducted from June 2019 to November 2020, in Department of Pulmonary Medicine at Government Medical College, Patiala, Punjab, India. Institutional Ethical Committee approval was obtained for the study (BFUHS/2K19p-TH/2073).

Inclusion criteria: All patients attending the study institute with diagnosis of COPD {as per GOLD 2018 report criteria (1)} were included in the study.

Exclusion criteria: Pregnant and lactating females, and patients with bronchiectasis, active tuberculosis, malignancy, or other inflammatory diseases such as arthritis, inflammatory bowel diseases, or connective tissue disorders were excluded from the study.

Patients of COPD were divided into two groups of 150 patients each.

COPD group (n=150): One group was of stable patients of COPD, defined as those with no significant change in symptoms and no need for additional therapy for the past three months (32).

AECOPD group (n=150): All patients with Acute Exacerbation of COPD (AECOPD) which was defined as an acute worsening of symptoms in COPD patient that requires additional therapy (1).

Controls (n=100): Healthy subjects with no history of smoking or biomass exposure, no co-morbidities, and no clinical symptoms.

Data collection: Baseline demographic data and clinical history was noted. Blood samples were collected from participants and subjected to total and differential leucocyte count, absolute eosinophil and neutrophil counts. Neutrophil-lymphocyte ratio was calculated by dividing neutrophil count with lymphocyte counts.

Statistical Analysis

Categorical variables were summarised as proportions. Continuous variables were summarised as mean with Standard Deviation (SD) and compared between groups using Unpaired t-test. A p-value <0.05 was considered statistically significant. Data was analysed using R software version 4.0.1.


The mean age in AECOPD group was 61.7±10.4 years, in stable COPD group was 63.1±8.9 years and 63.2±7.8 years in controls. Male predominance was seen in all three groups studied. The mean BMI of participants was significantly lower in stable COPD patients as compared to AECOPD and controls. Only 82% patients of AECOPD and 77.3% of stable COPD patients were smokers, biomass fuel exposure was present in 23.3% and 26.7% of patients of AECOPD and stable COPD respectively. Current smokers were significantly higher in AECOPD group as compared to stable COPD group (Table/Fig 1).

When comparing hematological parameters between AECOPD and stable COPD groups, total leucocyte count, neutrophil percentage, absolute neutrophil count, and absolute eosinophil count were significantly higher in the AECOPD group compared to stable COPD group. Mean NLR was significantly higher in AECOPD group (4.0±1.7) compared to stable COPD group (2.9±0.8). However, there was no significant difference in haemoglobin levels or eosinophil percentage between the two groups.

Comparative evaluation of haematological parameters between stable COPD patients and controls showed that the total leucocyte count, neutrophil and eosinophil percentage, and absolute eosinophil and neutrophil counts were significantly lower in control group compared to stable COPD group. The mean NLR was significantly higher in stable COPD group compared to control group. Comparison of hematological parameters between AECOPD and controls revealed that the total leucocyte count, neutrophil and eosinophil percentage, absolute eosinophil count, and absolute neutrophil count were significantly higher in the AECOPD patients compared to controls group. NLR was significantly higher in AECOPD group compared to control group (Table/Fig 2).

Receiver-Operating Characteristic (ROC) analysis revealed a good predictive value of NLR for predicting an exacerbation of COPD. At a cut-off of 3.4, the sensitivity, specificity and area under curve (AUC) were 75.3%, 70.7% and 0.806 respectively (Table/Fig 3).

Study participants were characterised based on blood eosinophil percentage into two groups i.e., blood eosinophils <2% and ≥2%. In patients of AECOPD, NLR was found to be significantly higher in non eosinophilic group (blood eosinophils <2%) an in those with blood eosinophils ≥2%. NLR was similar in two groups in patients of stable COPD and controls (Table/Fig 4).


In the present study, the Total Leucocyte Counts (TLC) in patients of stable COPD were significantly higher than controls, a finding that was present consistently in previous studies (8),(15),(19),(20),(24). COPD is characterised by an altered inflammatory response to airway irritants leading to parenchymal and airway destruction which further causes persistent symptoms and airflow limitation. Apart from airway inflammation, an abnormal systemic inflammation is also seen in COPD, which in turn is responsible for most of the systemic manifestations of the disease. Several mechanisms have been proposed in order to explain systemic inflammation in COPD, like systemic spread of inflammatory mediators from pulmonary compartment, an inflammatory response to tissue hypoxia or bacterial components, smoking induced inflammation, pulmonary hyperinflation (4). Furthermore, exacerbation of COPD is characterised by increased inflammation as a result of infective aetiology in most cases and hence leads to higher TLC which is seen inthe present study as well as in previous literature (8),(15),(19),(20),(24), when compared to controls or stable COPD patients.

In the present study, it was found that NLR was significantly higher in stable COPD when compared to controls and even higher in AECOPD when compared to stable COPD and controls. Similar findings have been reported by a number of studies (Table/Fig 4). NLR is an established marker of inflammation and has been shown to increase in several inflammatory conditions (9),(10),(11),(12),(13),(14). Exacerbations in COPD are characterized by flaring of the chronic inflammatory process of COPD at pulmonary and systemic level. Bacterial, viral as well as non infectious causes of exacerbations lead to increased inflammation in airways and release of proinflammatory cytokines and chemokines (6). These markers of inflammations are often increased in AECOPD and lead to heightened systemic inflammation in form of neutrophil recruitment and activation. These result in a higher NLR in AECOPD when compared to stable COPD and controls.

Since, NLR is significantly higher in AECOPD, it could be used as a biomarker of exacerbation in patients of COPD. In the present study a cut-off value of 3.4 showed a sensitivity and specificity of 75.3%, and 70.7% for predicting an exacerbation. Several previous studies have also found a good predictive value of NLR in predicting an exacerbation of COPD (Table/Fig 5) (8),(15),(17),(18),(20),(21),(22),(23),(24),(26).

A significantly higher NLR was found in patients of AECOPD with blood eosinophil percentage <2% when compared to those with eosinophils ≥2% but no significant difference was found when categorising controls and stable COPD patients into these categories. Moreover, the number of AECOPD patients showing this trend was very less, hence no conclusion could be drawn from this finding.


NLR was not evaluated with respect to other variables like severity of underlying COPD, severity of exacerbations, frequency of previous exacerbations. Since, it was a cross-sectional study and no follow-up was done, prognostic role of NLR was not studied.


Frequent and severe exacerbations of COPD adversely affect the health status of the patient and also contribute to progression of disease and mortality (1). Predicting exacerbations early can help in early detection and management. Current study shows that NLR is an inflammatory biomarker that raises significantly during COPD exacerbations and can be used to predict COPD exacerbations, and help in detecting exacerbations early.


Global strategy for the diagnosis, management, and prevention of Chronic Obstructive Pulmonary Disease, 2018 report. Glob Initiat Chronic Obstr Lung Dis. 2018;4. [cited 2021 Jan 15]. Available from:
Barbu C, Iordache M, Man MG. Inflammation in COPD: pathogenesis, local and systemic effects. Rom J Morphol Embryol. 2011;52:21-27.
Hoenderdos K, Condliffe A. The neutrophil in chronic obstructive pulmonary disease: Too little, too late or too much, too soon? Am J Respir Cell Mol Biol. 2013;48:531-39. [crossref] [PubMed]
Wouters E. Local and Systemic Inflammation in Chronic Obstructive Pulmonary Disease. Proc Am Thorac. Soc. 2005;2:26-33. [crossref] [PubMed]
Mallia P, Johnston SL. How viral infections cause exacerbation of airway diseases. Chest. 2006;130:1203-10. [crossref] [PubMed]
Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2007;29:1224-38. [crossref] [PubMed]
Hurst JR, Donaldson GC, Perera WR, Wilkinson TMAA, Bilello JA, Hagan GW, et al. Use of plasma biomarkers at exacerbation of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2006;174:867-74. [crossref] [PubMed]
Taylan M, Demir M, Kaya H, Selimoglu Sen H, Abakay O, Carkanat AI, et al. Alterations of the neutrophil-lymphocyte ratio during the period of stable and acute exacerbation of chronic obstructive pulmonary disease patients. Clin Respir J. 2017;11:311-17. [crossref] [PubMed]
Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association Between Admission Neutrophil to Lymphocyte Ratio and Outcomes in Patients With Acute Coronary Syndrome. Am J Cardiol. 2008;102:653-57. [crossref] [PubMed]
Azab B, Jaglall N, Atallah JP, Lamet A, Raja-Surya V, Farah B, et al. Neutrophil-lymphocyte ratio as a predictor of adverse outcomes of acute pancreatitis. Pancreatology. 2011;11:445-52. [crossref] [PubMed]
Yoon NB, Son C, Um SJ. Role of the neutrophil-lymphocyte count ratio in the differential diagnosis between pulmonary tuberculosis and bacterial community-acquired pneumonia. Ann Lab Med. 2013;33:105-10. [crossref] [PubMed]
Ethier JL, Desautels D, Templeton A, Shah PS, Amir E. Prognostic role of neutrophil-to-lymphocyte ratio in breast cancer: A systematic review and meta-analysis. Breast Cancer Res. 2017;19:2. [crossref] [PubMed]
Huang Z, Fu Z, Huang W, Huang K. Prognostic value of neutrophil-to-lymphocyte ratio in sepsis: A meta-analysis. Am J Emerg Med. 2020;38:641-47. [crossref] [PubMed]
Lagunas-Rangel FA. Neutrophil-to-lymphocyte ratio and lymphocyte-to-C-reactive protein ratio in patients with severe coronavirus disease 2019 (COVID-19): A meta-analysis. J Med Virol. 2020;92:1733-44. [crossref] [PubMed]
Yousef AM, Alkhiary W. Role of neutrophil to lymphocyte ratio in prediction of acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc. 2017;66:43-48. [crossref]
Pascual-González Y, López-Sánchez M, Dorca J, Santos S. Defining the role of neutrophil-to-lymphocyte ratio in COPD: a systematic literature review. Int J Chron Obstruct Pulmon Dis. 2018;13:3651-62. [crossref] [PubMed]
Xiong W, Xu M, Zhao Y, Wu X, Pudasaini B, Liu JM, et al. Can we predict the prognosis of COPD with a routine blood test? Int J COPD. 2017;12:615-25. [crossref] [PubMed]
Farah R, Ibrahim R, Nassar M, Najib D, Zivony Y, Eshel E, et al. The neutrophil/lymphocyte ratio is a better addition to C-reactive protein than CD64 index as a marker for infection in COPD. Panminerva Med. 2017;59:203-09. [crossref] [PubMed]
Paliogiannis P, Fois AG, Sotgia S, Mangoni AA, Zinellu E, Pirina P, et al. The neutrophil-to-lymphocyte ratio as a marker of chronic obstructive pulmonary disease and its exacerbations: A systematic review and meta-analysis. Eur J Clin Invest. 2018;48:0-2. [crossref] [PubMed]
S ahin F, Koşar AF, Aslan AF, Yiğitbas¸ B, Uslu B. Serum biomarkers in patients with stable and acute exacerbation of chronic obstructive pulmonary disease: A comparative study. J Med Biochem. 2019;38:503-11. [crossref] [PubMed]
Prasannan G, Muralidharan K, Premkumar VT. Neutrophil-lymphocyte ratio as a marker of disease severity and exacerbation in COPD. Indian J Appl Res. 2019;9:17-20.
Sharma K, Singh G, Singh U. To Compare Neutrophil Lymphocyte Ratio with Other Parameters in Acute Exacerbation of COPD and Stable COPD: A Hospital Based Study. Asian J Med Res. 2020;9:PM20-23. [crossref]
El-Gazzar AG, Kamel MH, Elbahnasy OKM, El-Naggar MES. Prognostic value of platelet and neutrophil to lymphocyte ratio in COPD patients. Expert Rev Respir Med. 2020;14:111-16. [crossref] [PubMed]
Mohamed-Hussein AA, Aly SS, Zahran AM, Sadek SH. Neutrophil CD64 and Neutrophil/Lymphocyte ratio as predictors of hospital outcome in acute exacerbation COPD. Int J Adv Sci Res Manag. 2017;2. [crossref]
Ye Z, Ai X, Liao Z, You C, Cheng Y. The prognostic values of neutrophil to lymphocyte ratio for outcomes in chronic obstructive pulmonary disease. Medicine (Baltimore). 2019;98:e16371. [crossref] [PubMed]
Acartürk Tunçay E, Karakurt Z, Aksoy E, Saltürk C, Gungor S, Ciftaslan N, et al. Eosinophilic and non-eosinophilic COPD patients with chronic respiratory failure: Neutrophil-to-lymphocyte ratio as an exacerbation marker. Int J COPD 2017;12:3361-70. [crossref] [PubMed]
Kumar P, Law S, Sriram KB. Evaluation of platelet lymphocyte ratio and 90-day mortality in patients with acute exacerbation of chronic obstructive pulmonary disease. J Thorac Dis. 2017;9:1509-16. [crossref] [PubMed]
Teng F, Ye H, Xue T. Predictive value of neutrophil to lymphocyte ratio in patients with acute exacerbation of chronic obstructive pulmonary disease. PLoS One. 2018;13:e0204377. [crossref] [PubMed]
Liu J, Liu J, Zou Y. Relationship between neutrophil-lymphocyte ratio and short-term prognosis in the chronic obstructive pulmonary patients with acute exacerbation. Biosci Rep. 2019;39:20190675. [crossref] [PubMed]
Emami Ardestani M, Alavi Naeini N. Evaluation of the relationship of neutrophil- to lymphocyte ratio and platelet to lymphocyte ratio with in-hospital mortality in patients with acute exacerbation of chronic obstructive pulmonary disease. Clin Respir J. 2021;15:382-8. [crossref] [PubMed]
Arya V, Gupta A, Malhotra AK. Correlation of Neutrophil lymphocyte ratio with the severity of Chronic obstructive pulmonary disease: A cross-sectional study. Int J Heal Clin Res. 2020;3:90-95.
Celli BR, MacNee W, Agusti A, Anzueto A, Berg B, Buist AS, et al. Standards for the diagnosis and treatment of patients with COPD: A summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-46. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/59293.17337

Date of Submission: Aug 26, 2022
Date of Peer Review: Oct 06, 2022
Date of Acceptance: Nov 03, 2022
Date of Publishing: Jan 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Aug 28, 2022
• Manual Googling: Oct 26, 2022
• iThenticate Software: Nov 02, 2022 (19%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)