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Clinical Investigations in Critical Care |

The Epidemiology of Acute Respiratory Failure in Critically Ill Patients* FREE TO VIEW

Jean-Louis Vincent, MD, PhD, FCCP; Serdar Akça, MD; Arnaldo de Mendonça, MD; Philip Haji-Michael, MD; Charles Sprung, MD, FCCP; Rui Moreno, MD; Massimo Antonelli, MD; Peter M. Suter, MD, FCCP; on behalf of the SOFA Working Group
Author and Funding Information

Affiliations: *From the Department of Intensive Care (Drs. Vincent, Akça, de Mendonça, and Haji-Michael), Erasme Hospital, Free University of Brussels, Brussels, Belgium; Department of Anesthesiology and Critical Care Medicine (Dr. Sprung), Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Intensive Care (Dr. Moreno), S. Antonio Capuchos Hospital, Lisbon, Portugal; Department of Anesthesiology and Intensive Care (Dr. Antonelli), Catholic University, Rome, Italy; and Division of Surgical Intensive Care (Dr. Suter), Cantonal University Hospital, Geneva, Switzerland.,  See Appendix for a list of participating centers.

Correspondence to: Jean-Louis Vincent, MD, PhD, FCCP, Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, B-1070 Brussels, Belgium; e-mail: jlvincen@ulb.ac.be


Affiliations: *From the Department of Intensive Care (Drs. Vincent, Akça, de Mendonça, and Haji-Michael), Erasme Hospital, Free University of Brussels, Brussels, Belgium; Department of Anesthesiology and Critical Care Medicine (Dr. Sprung), Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Intensive Care (Dr. Moreno), S. Antonio Capuchos Hospital, Lisbon, Portugal; Department of Anesthesiology and Intensive Care (Dr. Antonelli), Catholic University, Rome, Italy; and Division of Surgical Intensive Care (Dr. Suter), Cantonal University Hospital, Geneva, Switzerland.,  See Appendix for a list of participating centers.


Chest. 2002;121(5):1602-1609. doi:10.1378/chest.121.5.1602
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Study objectives: To describe the risk factors for the development of and mortality resulting from acute respiratory failure (ARF) in a large patient population.

Design: A substudy of a prospective, multicenter, observational cohort study, which was designed to validate the sequential organ failure assessment score.

Setting: Forty ICUs in 16 countries.

Patients: All critically ill patients who were admitted to one of the participating ICUs during a 1-month period were observed until the end of their hospital course.

Measurements and results: Of the 1,449 patients who were enrolled into the study, 458 (32%) were admitted to an ICU with ARF, as defined by a Pao2/fraction of inspired oxygen ratio of < 200 mm Hg and the need for respiratory support. Patients who presented with ARF were older than the other patients (63 vs 57 years, respectively; p < 0.001) and more commonly had an infection (47% vs 20%, respectively; p < 0.001). The length of ICU stay was longer (6 vs 4 days, respectively; p < 0.001) and the ICU mortality rate was more than double (34% vs 16%, respectively; p < 0.001) in ARF patients compared to non-ARF patients. Of the 991 patients who were admitted to an ICU without ARF, 352 (35%) developed ARF later during the ICU stay. The independent risk factors for the development of ARF were infection developing in the ICU (odds ratio [OR], 7.59; 95% confidence interval [CI], 5.08 to 11.33) or present on ICU admission (OR, 2.3; 95% CI, 1.68 to 3.16), the presence of neurologic failure on ICU admission (OR, 2.73; 95% CI, 1.90 to 3.91), and older age (OR, 1.70; 95% CI, 1.30 to 2.22). Of all 810 patients with ARF, 253 (31%) died. The independent risk factors for death were multiple organ failure following ICU admission, history of hematologic malignancy, chronic renal failure or liver cirrhosis, the presence of circulatory shock on ICU admission, the presence of infection, and older age.

Conclusions: The present study stresses that ARF is common in the ICU (56% of all patients) and that a number of extrapulmonary factors are related to the risk of development of ARF and to mortality rate in these patients.

Figures in this Article

Despite apparent improvements in the sophistication of respiratory support, and some suggestions that survival in patients with ARDS may have improved over the years,13 acute respiratory failure (ARF) in critically ill patients is still associated with mortality rates of between 40% and 65%.1,415 Most of the published literature has focused on the severest form of ARF, namely, ARDS, and few studies have evaluated either the incidence of or mortality rate of ARF in general among critically ill patients. We, therefore, used a large, prospective database of a population of medical-surgical ICU patients to describe the risk factors for the development of and mortality from ARF.

This report is the result of a substudy from the multicenter sequential organ failure assessment (SOFA) study,16 which was designed to validate the daily assessment of organ dysfunction in critically ill patients and was initiated by a working group of the European Society of Intensive Care Medicine. Each member of the working group was invited to participate in the data collection, and data thus were collected from a population of medical-surgical ICU patients.

The 40 participating centers in 16 countries (see the “Appendix” for a list of participating countries and centers) enrolled all patients who were ≥ 12 years of age and had been admitted to an ICU during the month of May 1995, and they observed those patients until the end of their hospital course. Those who stayed in the ICU for < 48 h after uncomplicated surgery were excluded. ICU admission data relating to demography, previous health status, and the presence of infection were obtained. A daily evaluation of organ function that was based on a set of clinical and laboratory parameters according to the SOFA score1617 was performed, with the most abnormal value for each of six organ systems (ie, respiratory, renal, cardiovascular, hepatic, coagulation, and neurologic) being collected and scored on ICU admission and every 24 h thereafter. For a single missing value, a replacement was calculated using the mean value of the results on either side of the absent result. When more than one consecutive result was missing, it was considered to be a missing value in the analysis. The mortality rate was assessed at ICU discharge.

ARF was defined based on a Pao2/fraction of inspired oxygen (Fio2) ratio of < 200 mm Hg and the need for mechanical respiratory support, including all methods of artificial ventilation with or without the presence of an artificial airway. Simple oxygen supplementation was not accepted as the presence of respiratory support. Previous health status was obtained on ICU admission from the medical history of each patient. Chronic heart failure (CHF) was defined by the presence of clinical signs and symptoms compatible with class III or IV of the New York Heart Association classification. Standard definitions were used to determine the presence of AIDS, cancer, cirrhosis, COPD, and diabetes mellitus. Infection on ICU admission and/or during the ICU stay were assessed by the physician according to clinical, laboratory, and microbiological parameters. Organ failure was defined as a SOFA score of ≥ 3 points for any system.17 Multiple organ failure (MOF) was defined as the simultaneous presence of two or more failing organs. Patients were separated into two groups according to the presence or absence of ARF on admission to the ICU. We also determined, a posteriori, the independent risk factors for the development of ARF in patients without ARF on ICU admission and the risk factors related to death during the ICU stay for ARF patients (Fig 1 ).

Data were analyzed using appropriate software (SPSS, version 5.0.1 for Windows; SPSS Inc; Chicago, IL). Categoric data were expressed in proportion, and subgroups were analyzed by a χ2 statistic (with Yates correction where applicable). Continuous data were expressed as medians, and subgroups were evaluated by a nonparametric rank test (Mann-Whitney U test). Risk factors were evaluated by univariate analysis. Of all categoric variables, only those with a p value < 0.10 after univariate analysis were included in the multivariate analysis by a multiple logistic stepwise regression procedure. Odds ratios (ORs) were estimated from the β-coefficients obtained, and respective 95% confidence intervals (CIs) were calculated. The discrimination capability of multilogistic models was evaluated by the area under the receiver operating characteristic (ROC) curve. A p value < 0.05 was considered to be significant in all procedures.

Of a total of 1,449 patients, 458 (32%) were admitted to an ICU with ARF. Demographic characteristics are shown in Table 1 . Patients who presented with ARF were older (63 vs 57 years, respectively; p < 0.001), were more likely to be admitted to the ICU from a hospital ward or for nonsurgical reasons, and more commonly had an infection (47% vs 20%, respectively; p < 0.001) than non-ARF patients. The length of ICU stay was longer (6 vs 4 days, respectively; p < 0.001) and the ICU mortality rate was more than double (34% vs 16%, respectively; p < 0.001) in ARF patients compared to non-ARF patients.

Of the 991 patients who were admitted to an ICU without ARF, 352 developed ARF during their stay in the ICU. The patients who developed ARF had a longer length of stay (8 vs 3 days, respectively; p < 0.001) and had a mortality rate that was three times greater than patients who did not develop ARF (27% vs 9%, respectively; p < 0.001) [Table 2] . We studied the risk factors for a patient developing ARF while in the ICU, and the categoric variables studied and the results of univariate and multivariate analyses are shown in Table 3 . From the multivariate analysis, independent risk factors for development of ARF were the following: infection in the ICU; the presence of neurologic failure on ICU admission; the presence of infection on ICU admission; and an age of ≥ 65 years. The discriminative capability of this model was 0.77 ± 0.01 (p < 0.001), as assessed by the area under the ROC curve.

The risk factors for death are shown in Table 4 . From the multivariate analysis, the independent risk factors for death in patients with ARF were the following: MOF in the ICU; a history of hematologic malignancy, chronic renal failure, or liver cirrhosis; the presence of circulatory shock on ICU admission; the presence of infection on ICU admission; and an age ≥ 65 years. Interestingly, infection in the ICU was not a risk factor in this model. The discriminative capability of this model was 0.80 ± 0.01 (p < 0.001), as assessed by the area under the ROC curve (Fig 2 ).

The nonsurviving patients with ARF had a higher number of failing organs than did the survivors (Fig 3 ). A total of 184 of the 253 nonsurvivors (73%) had MOF. Isolated organ failure in all patients at any time in the ICU and mortality rates are shown in Figure 4 . Of the 810 ARF patients, 275 never met any other organ failure criteria, and the mortality rate in this group was 7%. The most common associated organ failure was renal failure (n = 93), followed by neurologic failure (n = 45). The mortality rate was significantly higher only in patients with neurologic failure (20%).

The presence of ARF severe enough to necessitate mechanical ventilatory support is seen by some as crucial to the development of intensive care medicine as a specialty in its own right.18 Today, ARF remains a common reason for admission to the ICU, with our data showing ARF to be present in 32% of patients on ICU admission, with a further 24% of patients developing ARF during the ICU stay. Thus, in this multicenter study, a total of 56% of all ICU admissions for a length of > 48 h (excluding patients admitted to the ICU for routine postoperative surveillance) had ARF at some point during their stay. While this figure is derived from data from multiple ICUs, which likely had varying admission criteria, and while extrapolation to any individual ICU should be made with caution, it still provides some indication of the frequency of occurrence of ARF in our ICUs. Such a high incidence is confirmed by one epidemiologic study5 reporting that ARF accounted for 69% of all ICU bed usage in an urban, European population, although other groups have reported lower rates of ARF. Roupie et al13 reported that just 22% of patients admitted to an ICU had ARF, although their study also included patients who had been admitted to the ICU for routine postsurgical monitoring, which could account for the lower incidence. Such estimates are obviously very dependent on the definition of respiratory failure that is used. We chose to use the Pao2/Fio2 ratio because it is quite reproducible and is little affected by local differences in management.,19The degree of hypoxemia necessary for inclusion in this study was as severe as that used for the current definition of ARDS,20 although patients may not have fulfilled the other criteria. Our study population would, therefore, have included patients with less severe forms of ARF as well as those with ARDS.

The development of ARF in our study population was related by multivariate analysis to the presence of infection before and subsequent to ICU admission, as well as to the age of the patient and to the presence of neurologic failure on ICU admission. An explanation of the importance of neurologic failure as a risk factor in the development of ARF may be the increased risk of inhalation of gastric contents, the presence of an endotracheal tube predisposing the patient to nosocomial pneumonia, and associated multiple trauma requiring volume resuscitation and blood transfusion.

ARDS is considered to be the most severe form of respiratory failure, with high mortality rates.1,415 The overall mortality rate of 34% was slightly lower in our nonselected patients with ARF than in selected ARDS populations. However, our rate is similar to those quoted in other epidemiologic studies with nonselected ARF patients, for instance, 43% in a German study,5 41% (at 90 days) in a Scandinavian study,15 and 41% in a French study.13

Much of the current research into novel therapies and treatments for respiratory failure tends to focus solely on improving gas exchange in patients with ARDS.21The implicit assumption of such work is that the severity of respiratory failure is indicative of the severity of the disease process and of both the risk for and cause of death. Perhaps in the past, death in ARF patients was frequently due to persistent hypoxia, respiratory acidosis, or a complication of mechanical ventilation,22 but improvements in respiratory support and medical treatment over the past 30 years may have changed this pattern. Respiratory failure, while it may be a good marker of the severity of the underlying pathology, is rarely the actual cause of death in ARF patients.7,23In our study, the degree of respiratory system failure was not an independent predictor of outcome. These data confirm those of Jimenez et al24 who noted that the number of associated complications on ICU admission was a key determinant of outcome but that the degree of hypoxemia and related parameters was not. Roupie et al13 also reported that oxygenation indexes were not significantly associated with mortality rate. In a study by Luhr et al,15 a Pao2/Fio2 ratio of < 200 mm Hg was not significantly associated with mortality in patients with ARF, but a Pao2/Fio2 ratio of < 100 mm Hg was associated with mortality in patients with ARDS. In patients with ARDS, Bone et al,25 showed that although the Pao2/Fio2 ratio at diagnosis was not predictive of mortality, a subsequent improvement in the ratio was associated with survival.

For ARF patients, death is more frequently the result of associated sepsis and MOF. Our findings confirmed this. Although the exact cause of death was not defined here in all patients with ARF, mortality was strongly related to MOF and infection. Several groups have reported sepsis to be an important risk factor for mortality in ARF patients,4,1213,26 and most of the effect of infection on outcome can be explained by resultant MOF. Squara and colleagues10 found that the presence of MOF was an important negative prognostic indicator, and, as noted in our study, Kraus et al27 and Suchyta et al26 reported that mortality rates rose significantly with the associated failure of other organs. Doyle et al4 also stressed the importance of the development of nonpulmonary organ system failure during the ICU stay on outcomes in patients with ARF.

Preexisting disease states can be associated with increased mortality rates due to ARF. We identified a history of hematologic malignancy, or chronic renal or liver failure as independent risk factors for death. Other groups have identified the association of various underlying pathologies with increased mortality rates in ARF patients. Zilberberg and Epstein12 identified organ transplantation, HIV infection, cirrhosis, active malignancy, and sepsis as independent risk factors for hospital mortality in their study of ALI patients. Luhr et al15 reported that immunosuppression was associated with mortality in ARF patients, and that the presence of chronic liver disease was associated with mortality in ARDS patients. Monchi et al11 reported that the length of mechanical ventilation prior to ARDS, cirrhosis, and the occurrence of right ventricular dysfunction were all independently associated with an elevated risk of death. Doyle et al4 also reported an association between the presence of chronic liver disease and increased mortality rate.

An older age was identified as an independent risk factor for mortality in our ARF patients, a finding that was common to several other studies.2,5,910,12,15,26 Suchyta et al8 reported a mortality rate of 64% for ARDS patients > 55 years of age compared with 45% for younger patients (p = 0.002).

In conclusion, ARF patients form a large percentage of all ICU admissions. We acknowledge that the use of data obtained in just 1 month of the year (May 1995) places some limitations on their interpretation, as higher incidences may perhaps be expected during the winter months and the underlying etiology of the ARF may vary with season, potentially influencing the associated risk factors. However, we believe that this study still provides valuable information regarding the epidemiology of ARF, an area in which published data are scarce. With the high incidence, any improvement in the outcome of such a population is likely to have a marked effect on intensive care resource allocation. The risk of dying following the development of ARF is crucially linked to the presence of infection and the development of MOF. This knowledge alone may serve to improve outcome in this high-risk group of patients.

Erasme University Hospital, Brussels, Belgium (J.L. Vincent); Universitá La Sapienza, Rome, Italy (M. Antonelli); Hospital Santa Maria delle Grazie, Naples, Italy (E. de Blazio); Universitätsklinik für Chirurgie, Vienna, Austria (M. Rogy); Klinik Friedrich-Schiller University, Jena, Germany (K. Reinhardt); Charing Cross Hospital, London, United Kingdom (M. Palazzo); Hospital Geral Santo António, Porto, Portugal (A. Marinho); C.H.U. Vaudois, Lausanne, Switzerland (M. Glauser); University Catholique del Sacro Cuore, Rome, Italy (G. Sganga); University Hospital, Ghent, Belgium (F. Colardyn); University Hospital, Milan, Italy (A. Pesenti); H.G.U. Vall d’Hebron, Barcelona, Spain (A. Salgado); Hôpital St Joseph, Paris, France (J. Carlet); University Hospital, Kuopio, Finland (J. Takala); Ospedale Maggiore di Milano, Milan, Italy (M. Langer); Hadassah Hebrew University Medical Center, Jerusalem, Israel (C. Sprung); Free University Hospital, Amsterdam, the Netherlands (L.G. Thijs); Cattinara Hospital, Trieste, Italy (G. Berlot); UCIP Guimarães, Guimarães, Portugal (E. Lafuente); Academisch Ziekenhuis, Nijmegen, the Netherlands (J. Goris); Academic Hospital Dijkzigt, Rotterdam, the Netherlands (H. Bruining); Complexo Hospitalar Santa Casa, Porto Alegre, Brazil (G. Friedman); Hôpital Boucicaut, Paris, France (J. Labrousse); Western General Hospital, Edinburgh, United Kingdom (I. Grant); Hospital de Santo António dos Capuchos, Lisboa, Portugal (R. Moreno); Bristol Royal Infirmary, Bristol, United Kingdom (S. Willatts); KAT General Hospital, Athens, Greece (H. Ioanidou); C.H.U. de Nantes, Nantes, France (D. Villers); Casa de Saúde Santa Marcelina, São Paulo, Brazil (S. Blecher); Guy’s Hospital, London, United Kingdom (R. Beale); UCIP Santo António, Porto, Portugal (A. Carneiro); St Elizabeth Ziekenhuis, Tilburg, the Netherlands (L. Leenen); University Hospital, Manchester, United Kingdom (P. Nightingale); Royal Prince Alfred Hospital, Sydney, Australia (S. Smith); C.H.U. de Liège, Liège, Belgium (P. Damas); C.H.R.U. de Marseille, Marseille, France (C. Martin); Hospital Israelita Albert Einstein, São Paulo, Brazil (E. Knobel); The Toronto Hospital, Toronto, Canada (J.C. Marshall); Hospital General de Castellon, Castellon, Spain (A. Abizanda); and C.H.U. Cochin Port Royal, Paris, France (J.F. Dhainaut).

Abbreviations: ARF = acute respiratory failure; CHF = chronic heart failure; CI = confidence interval; Fio2 = fraction of inspired oxygen; MOF = multiple organ failure; OR = odds ratio; ROC = receiver operating characteristic; SOFA = sequential organ failure assessment

Figure Jump LinkFigure 1. Flow chart of the study and the different subgroups. 1 = description of the differences between ARF and non-ARF patients on ICU admission; 2 = study of the risk factors for the development of ARF in the ICU; and 3 = study of the risk factors for death in the ARF patients; * = outcome was undefined in four ARF patients and in one non-ARF patient.Grahic Jump Location
Table Graphic Jump Location
Table 1. Demographic Characteristics of the Study Population on ICU Admission*
* 

Values given as median (range) or No. (%), unless otherwise indicated. NS = not significant.

Table Graphic Jump Location
Table 2. Demographic Characteristics of the Study Population Subgroups*
* 

Values given as median (range) or No. (%), unless otherwise indicated.

 

p < 0.05 between survivors and nonsurvivors within the same group.

Table Graphic Jump Location
Table 3. Results of Univariate and Multivariate Analysis of Categoric Variables of Risk Factors to Development of ARF in Patients Admitted to ICUs Without ARF*
* 

Values given as No. (%), unless otherwise indicated. CRH = cirrhosis or end-stage renal failure or hematologic malignancy. See Table 1 for abbreviations not used in text.

 

Value for univariate analysis.

 

Value for multivariate analysis.

Table Graphic Jump Location
Table 4. Results of Univariate and Multivariate Analysis of Categorical Variables of Risk Factors of Death in ARF Patients*
* 

Values given as No. (%), unless otherwise indicated. See Tables 1 and 3 for abbreviations not used in text.

 

Value for univariate analysis.

 

Value for multivariate analysis.

Figure Jump LinkFigure 2. ROC curve for risk of death in ARF patients.Grahic Jump Location
Figure Jump LinkFigure 3. Percentage of survivors (white columns) and nonsurvivors (black columns) according to the number of organ failures (other than the lung) for patients with ARF.Grahic Jump Location
Figure Jump LinkFigure 4. Relationship between isolated organ failure and mortality rate. CNS = neurologic; CVS = cardiovascular; * = p < 0.05 (between CNS and other organ failures).Grahic Jump Location
Milberg, JA, Davis, DR, Steinberg, KP, et al (1995) Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983–1993.JAMA273,306-309. [PubMed] [CrossRef]
 
Abel, SJ, Finney, SJ, Brett, SJ, et al Reduced mortality in association with the acute respiratory distress syndrome (ARDS).Thorax1998;53,292-294. [PubMed]
 
Jardin, F, Fellahi, JL, Beauchet, A, et al Improved prognosis of acute respiratory distress syndrome 15 years on.Intensive Care Med1999;25,936-941. [PubMed]
 
Doyle, LA, Szaflarski, N, Modin, GW, et al Identification of patients with acute lung injury: predictors of mortality.Am J Respir Crit Care Med1995;152,1818-1824. [PubMed]
 
Lewandowski, K, Metz, J, Deutschmann, C, et al Incidence, severity, and mortality of acute respiratory failure in Berlin, Germany.Am J Respir Crit Care Med1995;151,1121-1125. [PubMed]
 
Vasilyev, S, Schaap, RN, Mortensen, JD Hospital survival rates of patients with acute respiratory failure in modern respiratory intensive care units. An international, multicenter, prospective survey.Chest1995;107,1083-1088. [PubMed]
 
Ferring, M, Vincent, JL Is outcome from ARDS related to the severity of respiratory failure?Eur Respir J1997;10,1297-1300. [PubMed]
 
Suchyta, MR, Clemmer, TP, Elliott, CG, et al Increased mortality of older patients with acute respiratory distress syndrome.Chest1997;111,1334-1339. [PubMed]
 
Nolan, S, Burgess, K, Hopper, L, et al Acute respiratory distress syndrome in a community hospital ICU.Intensive Care Med1997;23,530-538. [PubMed]
 
Squara, P, Dhainaut, JF, Artigas, A, et al Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study.Intensive Care Med1998;24,1018-1028. [PubMed]
 
Monchi, M, Bellenfant, F, Cariou, A, et al Early predictive factors of survival in the acute respiratory distress syndrome.Am J Respir Crit Care Med1998;158,1076-1081. [PubMed]
 
Zilberberg, MD, Epstein, SK Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome.Am J Respir Crit Care Med1998;157,1159-1164. [PubMed]
 
Roupie, E, Lepage, E, Wysocki, M, et al Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients.Intensive Care Med1999;25,920-929. [PubMed]
 
Villar, J, Perez-Mendez, L, Kacmarek, RM Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome.Intensive Care Med1999;25,930-935. [PubMed]
 
Luhr, OR, Antonsen, K, Karlsson, M, et al Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland: The ARF Study Group.Am J Respir Crit Care Med1999;159,1849-1861. [PubMed]
 
Vincent, JL, de Mendonça, A, Cantraine, F, et al Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicentric, prospective study.Crit Care Med1998;26,1793-1800. [PubMed]
 
Vincent, JL, Moreno, R, Takala, J, et al The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure.Intensive Care Med1996;22,707-710. [PubMed]
 
Vincent, JL, Thijs, L, Cerny, V Critical care in Europe.Crit Care Clin1997;13,245-254. [PubMed]
 
Gowda, MS, Klocke, RA Variability of indices of hypoxemia in adult respiratory distress syndrome.Crit Care Med1997;25,41-45. [PubMed]
 
Bernard, GR, Artigas, A, Brigham, KL, et al The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination.Am J Respir Crit Care Med1994;149,818-824. [PubMed]
 
Dellinger, RP, Zimmerman, JL, Taylor, RW, et al Effects of inhaled nitric oxide in patients with acute respiratory distress syndrome: results of a randomized phase II trial; Inhaled Nitric Oxide in ARDS Study Group.Crit Care Med1998;26,15-23. [PubMed]
 
Rogers, RM, Weiler, C, Ruppenthal, B Impact of respiratory intensive care unit on survival of patients with acute respiratory failure.Chest1972;62,94-97. [PubMed]
 
Montgomery, BA, Stager, MA, Carrico, J, et al Causes of mortality in patients with the adult respiratory distress syndrome.Am Rev Respir Dis1985;132,485-491. [PubMed]
 
Jimenez, P, Torres, A, Roca, J, et al Arterial oxygenation does not predict the outcome of patients with acute respiratory failure needing mechanical ventilation.Eur Respir J1994;7,730-735. [PubMed]
 
Bone, RC, Maunder, R, Slotman, G, et al An early test of survival in patients with the adult respiratory distress syndrome. The PaO2/FlO2 ratio and its differential response to conventional therapy.Chest1989;96,849-851. [PubMed]
 
Suchyta, MR, Clemmer, TP, Elliot, CG, et al The adult respiratory distress syndrome. A report of survival and modifying factors.Chest1992;101,1074-1079. [PubMed]
 
Kraus, PA, Lipman, J, Lee, CC, et al Acute lung injury at Baragwanath ICU. An eight-month audit and call for consensus for other organ failure in the adult respiratory distress syndrome.Chest1993;103,1832-1836. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Flow chart of the study and the different subgroups. 1 = description of the differences between ARF and non-ARF patients on ICU admission; 2 = study of the risk factors for the development of ARF in the ICU; and 3 = study of the risk factors for death in the ARF patients; * = outcome was undefined in four ARF patients and in one non-ARF patient.Grahic Jump Location
Figure Jump LinkFigure 2. ROC curve for risk of death in ARF patients.Grahic Jump Location
Figure Jump LinkFigure 3. Percentage of survivors (white columns) and nonsurvivors (black columns) according to the number of organ failures (other than the lung) for patients with ARF.Grahic Jump Location
Figure Jump LinkFigure 4. Relationship between isolated organ failure and mortality rate. CNS = neurologic; CVS = cardiovascular; * = p < 0.05 (between CNS and other organ failures).Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Demographic Characteristics of the Study Population on ICU Admission*
* 

Values given as median (range) or No. (%), unless otherwise indicated. NS = not significant.

Table Graphic Jump Location
Table 2. Demographic Characteristics of the Study Population Subgroups*
* 

Values given as median (range) or No. (%), unless otherwise indicated.

 

p < 0.05 between survivors and nonsurvivors within the same group.

Table Graphic Jump Location
Table 3. Results of Univariate and Multivariate Analysis of Categoric Variables of Risk Factors to Development of ARF in Patients Admitted to ICUs Without ARF*
* 

Values given as No. (%), unless otherwise indicated. CRH = cirrhosis or end-stage renal failure or hematologic malignancy. See Table 1 for abbreviations not used in text.

 

Value for univariate analysis.

 

Value for multivariate analysis.

Table Graphic Jump Location
Table 4. Results of Univariate and Multivariate Analysis of Categorical Variables of Risk Factors of Death in ARF Patients*
* 

Values given as No. (%), unless otherwise indicated. See Tables 1 and 3 for abbreviations not used in text.

 

Value for univariate analysis.

 

Value for multivariate analysis.

References

Milberg, JA, Davis, DR, Steinberg, KP, et al (1995) Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983–1993.JAMA273,306-309. [PubMed] [CrossRef]
 
Abel, SJ, Finney, SJ, Brett, SJ, et al Reduced mortality in association with the acute respiratory distress syndrome (ARDS).Thorax1998;53,292-294. [PubMed]
 
Jardin, F, Fellahi, JL, Beauchet, A, et al Improved prognosis of acute respiratory distress syndrome 15 years on.Intensive Care Med1999;25,936-941. [PubMed]
 
Doyle, LA, Szaflarski, N, Modin, GW, et al Identification of patients with acute lung injury: predictors of mortality.Am J Respir Crit Care Med1995;152,1818-1824. [PubMed]
 
Lewandowski, K, Metz, J, Deutschmann, C, et al Incidence, severity, and mortality of acute respiratory failure in Berlin, Germany.Am J Respir Crit Care Med1995;151,1121-1125. [PubMed]
 
Vasilyev, S, Schaap, RN, Mortensen, JD Hospital survival rates of patients with acute respiratory failure in modern respiratory intensive care units. An international, multicenter, prospective survey.Chest1995;107,1083-1088. [PubMed]
 
Ferring, M, Vincent, JL Is outcome from ARDS related to the severity of respiratory failure?Eur Respir J1997;10,1297-1300. [PubMed]
 
Suchyta, MR, Clemmer, TP, Elliott, CG, et al Increased mortality of older patients with acute respiratory distress syndrome.Chest1997;111,1334-1339. [PubMed]
 
Nolan, S, Burgess, K, Hopper, L, et al Acute respiratory distress syndrome in a community hospital ICU.Intensive Care Med1997;23,530-538. [PubMed]
 
Squara, P, Dhainaut, JF, Artigas, A, et al Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study.Intensive Care Med1998;24,1018-1028. [PubMed]
 
Monchi, M, Bellenfant, F, Cariou, A, et al Early predictive factors of survival in the acute respiratory distress syndrome.Am J Respir Crit Care Med1998;158,1076-1081. [PubMed]
 
Zilberberg, MD, Epstein, SK Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome.Am J Respir Crit Care Med1998;157,1159-1164. [PubMed]
 
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