Long-term Survival in Patients With Severe Acute Respiratory Distress Syndrome and Rescue Therapies for Refractory Hypoxemia

Abstract

Objective: To assess survival up to 5 years in patients who develop severe acute respiratory distress syndrome (ARDS) and evaluate differences in characteristics and outcomes for patients selected for treatment with a rescue therapy (inhaled nitric oxide, inhaled epoprostenol or prone position ventilation) versus conventional treatment. Design and Setting:Retrospective cohort study of patients admitted to the intensive care unit (ICU) at a 413-bed Level 1 trauma university hospital. Methods: Data were abstracted from the electronic medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs.We compared patients placed on inhaled nitric oxide, inhaled epoprostenol or ventilated in the prone position with patients treated conventionally. To determine survival beyond hospital discharge, patient-level data were linked to the Washington State Death Registry. Kaplan-Meir survival analysis methods were used to assess survival. Cox's proportional hazards models were used to compare differences in outcomes between patients treated with a rescue therapy and those treated conventionally. Costs were analyzed using the Lin method to estimate mean total costs in the presence of censoring.Main Results: 428 patients meeting the inclusion criteria were identified, of whom 62 (14%) were placed on a rescue therapy. Five-year survival for all patients was 54.9% (95% CI: 50.2%, 60.1%). For patients who were discharged from the hospital alive, 5-year survival was 84.5% (95% CI: 79.8%, 89.4%). Mean hospital cost was $701 K (95% CI: $97K, $846 K). Admission PaO 2 /FIO 2 ratios were similar between patients treated with a rescue therapy and those treated conventionally. However, prior to initiation of rescue therapy, patients treated with a rescue therapy had substantially lower PaO 2 /FIO 2 ratios by 72 hours (54 mm Hg ± 17 versus 69 mm Hg ± 17; p=<.01). The hazard ratio of death up to 5 years following their ICU admission was not different between patients with and without rescue therapy (HR: 1.31, 95% CI: 0.89, 1.94; p = 0.17).Conclusions: Severe ARDS patients surviving to hospital discharge have relatively good longterm survival. Patients with worsening hypoxemia are selected to receive a rescue therapy.Future prospective studies should investigate the impact of the timing of initiation of a rescue therapy prior to the development of life-threatening critical hypoxemia on long-term outcomes.Introduction:

Mortality and Resource Utilization After Critical Care Transport of Patients With Hypoxemic Respiratory Failure

“…Additionally, patients with moderate ARDS, with a Pa o 2 /Fi o 2 ratio of 100 to ≤200 mm Hg, when treated with best practices including low tidal volume ventilation, have a mortality rate of 32% (95% CI: 29-34). 27,28 Our mortality rate was similar, despite the severity of disease in this group, reinforcing the premise that transfer for optimal respiratory and tertiary care can offer patients the lowest possible mortality rate.…”

What's Next After ARDS: Long-Term Outcomes

“…A 3-y survival probability post-hospital discharge of 85% was also found by Khandelwal et al 39 It was comparable between subjects treated with rescue therapies (prone position ventilation or inhalation of nitric oxide) and with standard treatment, although the former had higher inhospital mortality, 47% versus 32%.…”

“…Hospital mortality was significantly lower (24%) than 1-y mortality after hospital discharge (41%) regardless of the etiology of ARDS. 28 Both the severity and the presence of ARDS did not increase the risk of mortality during a median follow-up time of 2 y in sepsis or trauma subjects with ARDS compared with equally ill subjects without ARDS (sepsis-ARDS subjects 39 Survival 3 y Survival of patients treated with rescue therapies was 65% at 3 y after H discharge, comparable with survival of conventionally treated subjects Wilcox (2013) 40 Pulmonary function [13%]). 15 Age and comorbidities, in addition to the sepsis, strongly influenced the late mortality.…”

Characteristics and provision of care of patients with the acute respiratory distress syndrome: descriptive findings from the DACAPO cohort baseline and comparison with international findings

“…Additionally, the length of stay at ICU until death or discharge, the occurrence of critical events [hypoxemia (SpO 2 <85% for at least 5 min), hypoglycemia (defined as blood glucose measurement <70 mg/dL), accidental extubation, re-intubation] was assessed. In the clinical intensive care setting, an arterial SpO 2 <85%, corresponding to a PaO 2 ≤50 mmHg with a time span of a few minutes, is accepted as a valuable marker for hypoxemia (16,17). The advocated measures in these situations are the control of artificial airways and ventilator function/modes/settings, the suction of endotracheal secretions, the acute use of open lung approaches, and/or acute imaging diagnostics (Chest X-ray, ultrasound).…”