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Clinical Investigations in Critical Care |

Assessment of Prognosis in Patients With Community-Acquired Pneumonia Who Require Mechanical Ventilation*

Fred E. Pascual, MD; Michael A. Matthay, MD, FCCP; Peter Bacchetti, PhD; Robert M. Wachter, MD
Author and Funding Information

*From the Cardiovascular Research Institute (Dr. Matthay), the Department of Epidemiology and Biostatistics (Dr. Bacchetti), and the Department of Medicine (Drs. Pascual and Wachter), University of California, San Francisco, San Francisco CA; and Pulmonary & Critical Care Medicine (Dr. Pascual), Harborview Medical Center, Seattle, WA. Supported by the UCSF Department of Medicine and NIH grant HL51856.

Correspondence to: Fred E. Pascual, MD, Harborview Medical Center, Pulmonary & Critical Care Medicine, 325 9th Ave, Box 359762, Seattle, WA 98104; e-mail: feppccm@usa.net



Chest. 2000;117(2):503-512. doi:10.1378/chest.117.2.503
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Study objectives: Knowing that mortality is high in patients who require mechanical ventilation patients with community-acquired pneumonia (CAP), we hypothesized that the severity of acute lung injury could be used along with nonpulmonary factors to identify patients with the highest risk of death. We formulated a prediction model to quantitate the risk of hospital mortality in this population of patients.

Design: Historical prospective study using data collected over the first 24 h of mechanical ventilation. We utilized a hypoxemia index—(1 − lowest[ Pao2/PAo2]) × (minimum fraction of inspired oxygen to maintain Pao2 at> 60 mm Hg) × 100], where PAo2 is the alveolar partial pressure of oxygen—to grade the severity of acute lung injury on a scale from 0 to 100.

Setting: Tertiary care university hospital ICU.

Patients: One hundred forty-four adult patients mechanically ventilated for respiratory failure caused by CAP.

Measurements and results: Hospital mortality was 46% (n = 66). Multivariate logistic regression analysis revealed five independent predictors of hospital mortality: (1) the extent of lung injury assessed by the hypoxemia index; (2) the number of nonpulmonary organs that failed; (3) immunosuppression; (4) age > 80 years; and (5) medical comorbidity with a prognosis for survival < 5 years. At a 50% mortality threshold, the prediction model correctly classified outcome in 88% of cases. All patients with > 95% predicted probability of death died in hospital.

Conclusions: Based on clinical parameters measured over the first 24 h of mechanical ventilation, this model accurately identified critically ill, mechanically ventilated patients with CAP for whom prolonged intensive care may not be of benefit.

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