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Lung Injury and Its Prognostic Significance in Acute Liver Failure

Audimoolam, Vinod K. MRCP1; McPhail, Mark J. W. MBBS, MRCP, PhD1,2; Wendon, Julia A. FRCP, FFICM, FICM1; Willars, Chris FRCA, FFICM, FICM1; Bernal, William MD, FRCP1; Desai, Sujal R. MD, FRCP, FRCR3; Auzinger, Georg MD, AFICM, EDIC1

doi: 10.1097/01.ccm.0000435666.15070.d5
Clinical Investigations

Objective: Hypoxemia is a feared complication of acute liver failure, and high oxygen requirements will frequently lead to removal of patients from the transplant list. As data regarding the prevalence and outcome of acute respiratory distress syndrome in acute liver failure are scant and hypoxemia being a commonly encountered systemic complication, we analyzed radiological, gas exchange, and ventilator data in consecutive patients admitted with acute liver failure.

Patients: Acute liver failure patients receiving mechanical ventilation admitted between January 2007 and February 2011 were included.

Interventions: Patients were categorized according to the Berlin definition as: no acute respiratory distress syndrome, acute respiratory distress syndrome (PaO2/FIO2 < 300 mm Hg), and subdivisions of mild, moderate, and severe acute respiratory distress syndrome (200–300 mm Hg, 100–200 mm Hg, and < 100 mm Hg, respectively). Chest radiographs were independently assessed by two observers for the presence or absence of acute respiratory distress syndrome. Absence of left atrial pressure elevation was based on combined hemodynamic and echocardiographic assessment.

Measurements and Main Results: Two hundred acute liver failure patients were admitted during the study period of whom 148, median age 39 years (16–74 yr), were included. Thirty-one (21%) had acute respiratory distress syndrome (17 mild acute respiratory distress syndrome [12%], 9 moderate acute respiratory distress syndrome [12%], and 5 severe acute respiratory distress syndrome) within the first 72 hours following admission. Acute respiratory distress syndrome patients required higher positive end-expiratory pressure (7 vs 6 vs 10 vs 15 cm H2O for no, mild, moderate, or severe acute respiratory distress syndrome, p = 0.014), had reduced respiratory system compliance (34 vs 29 vs 30 vs 23 L/cm H2O, p = 0.028), and an increased number of ventilator days (no acute respiratory distress syndrome, 10 d; mild acute respiratory distress syndrome acute lung injury, 12 d; moderate acute respiratory distress syndrome, 23 d; severe acute respiratory distress syndrome, 22 d; p = 0.097). Duration of liver intensive therapy unit stay (p = 0.175), survival (p = 0.877), inotrope requirements (p = 0.495), need for extracorporeal renal support (p = 0.565), and severity of organ failure scores were not affected. Extravascular lung water index had a moderate sensitivity of 65% and specificity of 77% for the prediction of acute respiratory distress syndrome.

Conclusion: The prevalence of lung injury is relatively low in acute liver failure, where 21% fulfilled acute respiratory distress syndrome criteria. Overall presence of acute respiratory distress syndrome appeared to have a limited impact on outcome.

1Institute of Liver Studies, Kings College Hospital, London, United Kingdom.

2Liver & Antiviral Centre, Imperial College London, St Mary’s Hospital Campus, London, United Kingdom.

3Department of Radiology, Kings College Hospital, London, United Kingdom.

Dr. Audimoolam contributed to analysis and interpretation of the data and drafting the article. Dr Auzinger contributed to drafting and revising of the article. Dr. McPhail contributed to statistical analysis and article revision. Prof. Wendon, Mr. Willars, and Dr. Bernal contributed to correction of the article for important intellectual content. Drs. Desai and Auzinger contributed to radiology interpretation and correction of the article for important intellectual content.

Dr. McPhail received grant support from Wellcome Trust. Prof. Wendon is a member of the Pulsion advisory board. Dr. Auzinger is on the advisory board for Liver Transplant and Fungal Disease for Gilead and has lectured for Pfizer. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins