Severe Hypoxemic Respiratory Failure

Raoof, Suhail; Goulet, Keith; Esan, Adebayo; Hess, Dean; Sessler, Curtis N.

doi:10.1378/chest.09-2415

Cited by 139 publications

(31 citation statements)

References 108 publications

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“…In clinical practice, as an effort to improve oxygenation in these patients, several different “rescue therapies” are often advocated, including inhaled nitric oxide, inhaled epoprostenol and prone position ventilation (3, 11-13). However, randomized controlled trials conducted to date utilized rescue therapies as an adjunctive modality to treat ARDS, rather than a “last resort” intervention for treatment of critical hypoxemia in rapidly deteriorating patients.…”

Section: Introductionmentioning

confidence: 99%

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

Hough

Bansal

Veenstra

2014

Critical Care Medicine

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Objective To describe long-term survival in patients with severe acute respiratory distress syndrome (ARDS) and assess differences in patient characteristics and outcomes among those who receive rescue therapies (prone position ventilation, inhaled nitric oxide, or inhaled epoprostenol) versus conventional treatment. Design and Setting Cohort study of patients with severe hypoxemia at a University-affiliated Level 1 trauma center. Patients Patients diagnosed with severe ARDS within 72 hours of ICU admission between 1/1/2008 and 12/31/2011. Methods Data were abstracted from the medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. Patient-level data were linked to the Washington State Death Registry. Kaplan-Meier methods and Cox's proportional hazards models were used to estimate survival and hazard ratios. Main Results 428 patients meeting study inclusion criteria were identified; 62 (14%) were initiated on a rescue therapy. PaO2/FIO2 ratios were comparable at admission between patients treated with a rescue therapy and those treated conventionally, but were substantially lower by 72 hours in those who received rescue therapies (54 ± 17 versus 69 ± 17 mmHg; p<.01). For the entire cohort, estimated survival probability at three years was 55% (95% CI: 51%, 61%). Among 280 hospital survivors (65%), three-year survival was 85% (95% CI: 80%, 89%). The relative hazard of in-hospital mortality was 68% higher among patients who received rescue therapy compared to patients treated conventionally (95% CI: 8%, 162%; p=0.02). For long-term survival, the hazard ratio of death following ICU admission was 1.56 (95% CI: 1.02, 2.37; p=0.04), comparing rescue versus conventional treatment. Conclusions Despite high hospital mortality, severe ARDS patients surviving to hospital discharge have relatively good long-term survival. Worsening hypoxemia was associated with initiation of rescue therapy. Patients on rescue therapy had higher in-hospital mortality; however, survivors to hospital discharge had long-term survival that was comparable to other ARDS survivors.

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Section: Introductionmentioning

confidence: 99%

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

Hough

Bansal

Veenstra

2014

Critical Care Medicine

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“…A recruitment maneuver is a transient increase of trans-pulmonary pressure intended to promote reopening of collapsed alveoli [29]. Techniques described for recruitment maneuvers include sustained high-pressure inflation and increased PEEP, with concurrent reduction of tidal volume [30], but it is not clear if any maneuver is superior to others.…”

Section: Treatmentmentioning

confidence: 99%

Acute Respiratory Distress Syndrome: Pathophysiology and Therapeutic Options

et al. 2012

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Acute Respiratory Distress Syndrome (ARDS) is a common entity in critical care. ARDS is associated with many diagnoses, including trauma and sepsis, can lead to multiple organ failure and has high mortality. The present article is a narrative review of the literature on ARDS, including ARDS pathophysiology and therapeutic options currently being evaluated or in use in clinical practice. The literature review covers relevant publications until January 2011. Recent developments in the therapeutic approach to ARDS include refinements of mechanical ventilatory support with emphasis on protective lung ventilation using low tidal volumes, increased PEEP with use of recruitment maneuvers to promote reopening of collapsed lung alveoli, prone position as rescue therapy for severe hypoxemia, and high frequency ventilation. Supportive measures in the management of ARDS include attention to fluid balance, restrictive transfusion strategies, and minimization of sedatives and neuromuscular blocking agents. Inhaled bronchodilators such as inhaled nitric oxide and prostaglandins confer short term improvement without proven effect on survival, but are currently used in many centers. Use of corticosteroids is also important, and appropriate timely use may reduce mortality. Finally, extra corporeal oxygenation methods are very useful as rescue therapy in patients with intractable hypoxemia, even though a survival benefit has not, to this date been demonstrated. Despite intense ongoing research on the pathophysiology and treatment of ARDS, mortality remains high. Many pharmacologic and supportive strategies have shown promising results, but data from large randomized clinical trials are needed to fully evaluate the true effectiveness of these therapies.KeywordsARDS; Pathophysiology; Treatment

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“…Despite various treatment options, such as high positive end-expiratory pressure, corticosteroids, recruitment maneuvers, conservative fluid management, and rescue maneuvers, including prone ventilation, nitric oxide, and high frequency oscillation ventilation, severe ARDS has a mortality ranging from 40% to 60% [2,3]. Only low tidal volume ventilation and extracorporeal membrane oxygenation have been shown to decrease mortality in patients with ARDS [4,5]. …”

Section: Commentarymentioning

confidence: 99%