Clinical Investigations

Muscle Weakness and 5-Year Survival in Acute Respiratory Distress Syndrome Survivors*

Dinglas, Victor D. MPH^1,2; Aronson Friedman, Lisa ScM^1,2; Colantuoni, Elizabeth PhD^1,3; Mendez-Tellez, Pedro A. MD^1,4; Shanholtz, Carl B. MD⁵; Ciesla, Nancy D. DPT, MS^1,2; Pronovost, Peter J. MD, PhD^1,4; Needham, Dale M. FCPA, MD, PhD^1,2,6

Author Information

¹Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD.

²Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD.

³Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.

⁴Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD.

⁵Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland, Baltimore, MD.

⁶Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD.

*See also p. 563.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by the National Institutes of Health (P050HL73994, R01HL088045, and K24HL088551), along with the Johns Hopkins Institute for Clinical and Translational Research (UL1 TR 000424-06).

Dr. Needham, Ms. Aronson Friedman, and Mr. Dinglas had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the conception and/or design of this study. Mr. Dinglas, Ms. Ciesla, Dr. Mendez-Tellez, and Dr. Needham contributed to the acquisition of data. All authors contributed to the analysis and interpretation of data. Mr. Dinglas drafted the article, and all authors critically revised it for important intellectual content and approved the final version to be submitted.

Mr. Dinglas received support for article research from the National Institutes of Health (NIH). Ms. Aronson Friedman received support for article research from the NIH. Dr. Colantuoni received support for article research from the NIH. Her institution received funding from the NIH. Dr. Mendez-Tellez received support for article research from the NIH. Dr. Shanholtz received support for article research from the NIH. His institution received funding from the NIH. Ms. Ciesla received support for article research from the NIH. Dr. Pronovost received money from Johns Hopkins University (employee), Lehigh Speakers Bureau (speaker), and Penguin Publishing (book royalties). Dr. Needham received support for article research from the NIH. His institution received funding from Agency for Healthcare Research and Quality, the Gordon & Betty Moore Foundation, and National Health and Medical Research Council (Australia).

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 45(3):p 446-453, March 2017. | DOI: 10.1097/CCM.0000000000002208

Abstract

Objectives:

To longitudinally evaluate the association of post-ICU muscle weakness and associated trajectories of weakness over time with 5-year survival.

Design:

Longitudinal prospective cohort study over 5 years of follow-up.

Setting:

Thirteen ICUs in four hospitals in Baltimore, MD.

Patients:

One hundred fifty-six acute respiratory distress syndrome survivors.

Interventions:

None.

Measurements and Main Results:

Strength was evaluated with standardized manual muscle testing using the Medical Research Council sum score (range, 0–60; higher is better), with post-ICU weakness defined as sum score less than 48. Muscle strength was assessed at hospital discharge and at 3, 6, 12, 24, 36, and 48 months after acute respiratory distress syndrome. At discharge, 38% of patients had muscle weakness. Every one point increase in sum score at discharge was associated with improved survival (hazard ratio [95% CI], 0.96 [0.94–0.98]), with similar findings longitudinally (0.95 [0.93–0.98]). Having weakness at discharge was associated with worse 5-year survival (1.75 [1.01–3.03]), but the association was attenuated (1.54 [0.82–2.89]) when evaluated longitudinally over follow-up. Persisting and resolving trajectories of muscle weakness, occurring in 50% of patients during follow-up, were associated with worse survival (3.01 [1.12-8.04]; and 3.14 [1.40-7.03], respectively) compared to a trajectory of maintaining no muscle weakness.

Conclusions:

At hospital discharge, greater than one third of acute respiratory distress syndrome survivors had muscle weakness. Greater strength at discharge and throughout follow-up was associated with improved 5-year survival. In patients with post-ICU weakness, both persisting and resolving trajectories were commonly experienced and associated with worse survival during follow-up.