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Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome*

Kangelaris, Kirsten Neudoerffer MD, MAS1; Ware, Lorraine B. MD2; Wang, Chen Yu MD, MHA3; Janz, David R. MD, MSc4; Zhuo, Hanjing MPH5; Matthay, Michael A. MD5,6; Calfee, Carolyn S. MD, MAS5,6

doi: 10.1097/CCM.0000000000001359
Clinical Investigations
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SDC

Objective: The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized.

Design: Secondary analysis of a prospective observational cohort study.

Setting: Vanderbilt University Medical Center.

Patients: Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support.

Interventions: None.

Measurements and Main Results: Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results.

Conclusions: A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.

1Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.

2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.

3Department of Critical Care Medicine, Taichung Veteran General Hospital, Taichung, Taiwan.

4Section of Pulmonary and Critical Care Medicine, Department of Medicine, Louisiana State University School of Medicine New Orleans, LA.

5Division of Pulmonary and Critical Care, University of California, San Francisco, San Francisco, CA.

6Departments Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA.

*See also p. 246.

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Dr. Kangelaris was supported by the Society of Hospital Medicine Young Researchers Award, the National Institutes of Health (NIH) National Center for Advancing Translational Sciences through UCSF-CTSI KL2 TR000143, and National Heart, Lung, and Blood Institute (NHLBI) 1K23HL116800-01. Dr. Ware has served on a medical advisory board for Glaxo Smith Kline and as a consultant for Abbot. She was supported by NHLBI HL112656, and HL103836 and received support for article research from the NIH. Her institution received grant support from the NIH and the American Heart Association. Dr. Janz was supported by NIH T32 HL087738. Dr. Zhuo received support for article research from the NIH. Dr. Matthay has served on medical advisory boards for Cerus (ARDS consult - money paid to Dr. Matthay), GlaxoSmithKline (consultant for ARDS and grant for studies of sepsis, grant to UCSF his institution), and Roche Genentec (Chair of DSMB for Asthma trials). He was supported by NHLBI R37 HL51856. He received funding from Quark Pharmaceuticals, received support for article research from the NIH. Dr. Calfee has served on medical advisory boards for Cerus and GlaxoSmithKline. She was supported by HL110969. She received support for travel from Boehringer Ingelheim (travel for meeting related to potential research grant) and for article research from the NIH. Drs. Calfee and Matthay have also received grant support from GlaxoSmithKline. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: kirsten.kangelaris@ucsf.edu

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