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Correspondence |

Nonpulmonary Organ Dysfunction and Mortality With Acute Respiratory FailureResponse FREE TO VIEW

Philip S. Barie, MD, MBA; Lynn J. Hydo, MBA; Soumitra R. Eachempati, MD
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Affiliations: Weill Cornell Medical College, New York, NY,  Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence to: Philip S. Barie, MD, MBA, Department of Surgery, Weill Cornell Medical College, 525 East 68 St, New York, NY 10065; e-mail: pbarie@med.cornell.edu



Chest. 2008;134(2):467-468. doi:10.1378/chest.08-0879
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Aggarwal et al1 found that nonpulmonary organ dysfunction predicts mortality among patients with acute respiratory failure. We concur, and correspond to describe interactions between respiratory dysfunction and other manifestations of organ dysfunction.

Interactions between hepatic and pulmonary dysfunction have been described for nearly 2 decades. Historically, hepatic dysfunction was hypothesized to cause failure of reticuloendothelial host defenses, with resultant pulmonary microembolization and respiratory failure. We quantified this deleterious relationship2; the mortality rate was 10% for patients with neither hepatic nor pulmonary dysfunction, 20 to 23% for patients with modest degrees of either manifestation, and 58 to 93% mortality when both were present to a modest or severe degree.

Using the sequential organ dysfunction assessment (SOFA) score, Aggarwal et al1 found in a heterogeneous group of 475 patients (34% hospital mortality) that overall nonpulmonary organ dysfunction and cardiovascular and neurologic dysfunction specifically (but not hepatic dysfunction) predicted mortality following pulmonary dysfunction. Using similar methodology but studying a more homogeneous population of patients with ARDS, we reported similar results recently.3Using the multiple organ dysfunction (MOD) score of Marshall et al,4which measures dysfunction of the same six organs as the SOFA score and yields quantitatively similar results,5 nonpulmonary organ dysfunction overall and by each of the five other components (cardiovascular, coagulation, hepatic, neurologic, renal) were independent predictors of ARDS-related mortality.3 Notably, the area under the receiver operating characteristic curve for cumulative (maximum) MOD score was 0.83, which is similar to the value of 0.76 calculated by Aggarwal et al.1

It is important for clinicians and investigators to recognize that nonpulmonary organ dysfunction kills patients with acute respiratory failure. Attention to resuscitation, early and effective antibiotic therapy, and global support of organ dysfunction to minimize the proinflammatory host response are crucial to improved outcomes of acute respiratory failure.

The authors have no conflicts of interest to disclose.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Aggarwal, AN, Agarwal, B, Gupta, D, et al (2007) Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest132,829-835. [PubMed] [CrossRef]
 
Hydo, LJ, Barie, PS Patterns of mortality in the multiple organ dysfunction syndrome [abstract].Crit Care Med2005;33,a77
 
Eachempati, SR, Hydo, LJ, Shou, J, et al Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.J Trauma2007;63,344-350. [PubMed]
 
Marshall, JC, Cook, DJ, Christou, NV, et al Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.Crit Care Med1995;23,1638-1652. [PubMed]
 
Khwannimit, B A comparison of three organ dysfunction scores: MODS, SOFA and LOD for predicting ICU mortality in critically ill patients.J Med Assoc Thai2007;90,1074-1081. [PubMed]
 
To the Editor:

We thank Dr. Barie and his colleagues for their interest in our data.1It is satisfying to note that other investigators also have had a similar experience regarding the influence of nonpulmonary organ dysfunction and failure on outcome in patients with respiratory failure. Contrary to our findings, they have reported2 that hepatic dysfunction had a significant influence of patient mortality in the patients they studied. The study appears to have been conducted at a primarily surgical ICU. Unfortunately, we do not have access to the detailed methodology and results of the abstract cited by Barie et al2 in this regard. In another study3 on patients with ARDS who were managed at a surgical ICU, they found that the dysfunction of all nonpulmonary organs contributed to an adverse outcome. The difference in the quantum of contribution of individual organ dysfunction to overall mortality is perhaps, therefore, related to the variability in case mix at their ICU and ours. Additionally, we used sequential organ function assessment (or SOFA) scores, and they used multiple organ dysfunction (or MOD) scores. Some differences in findings could therefore also be explained by variations in the definitions used to describe and stratify individual organ dysfunction. Despite these minor differences, we concur with them regarding the importance of recognizing and managing nonpulmonary organ dysfunction in patients with respiratory failure.

References
Aggarwal, AN, Agarwal, R, Gupta, D, et al Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest2007;132,829-835. [PubMed] [CrossRef]
 
Barie, PS, Hydo, LJ, Eachempati, SR Nonpulmonary organ dysfunction and mortality with acute respiratory failure.Chest2008;134,467. [PubMed]
 
Eachempati, SR, Hydo, LJ, Shou, J, et al Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.J Trauma2007;63,344-350. [PubMed]
 

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References

Aggarwal, AN, Agarwal, B, Gupta, D, et al (2007) Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest132,829-835. [PubMed] [CrossRef]
 
Hydo, LJ, Barie, PS Patterns of mortality in the multiple organ dysfunction syndrome [abstract].Crit Care Med2005;33,a77
 
Eachempati, SR, Hydo, LJ, Shou, J, et al Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.J Trauma2007;63,344-350. [PubMed]
 
Marshall, JC, Cook, DJ, Christou, NV, et al Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.Crit Care Med1995;23,1638-1652. [PubMed]
 
Khwannimit, B A comparison of three organ dysfunction scores: MODS, SOFA and LOD for predicting ICU mortality in critically ill patients.J Med Assoc Thai2007;90,1074-1081. [PubMed]
 
Aggarwal, AN, Agarwal, R, Gupta, D, et al Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest2007;132,829-835. [PubMed] [CrossRef]
 
Barie, PS, Hydo, LJ, Eachempati, SR Nonpulmonary organ dysfunction and mortality with acute respiratory failure.Chest2008;134,467. [PubMed]
 
Eachempati, SR, Hydo, LJ, Shou, J, et al Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.J Trauma2007;63,344-350. [PubMed]
 
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