title: [Quality of results of therapy of acute respiratory failure : changes over a period of two decades].
abstract: Progress in intensive care (ICU) treatment of acute respiratory distress syndrome (ARDS) over the last 20 years includes the introduction of extracorporeal membrane oxygenation (ECMO) for CO2 removal and the widespread use of evidence-based lung-protective ventilatory strategies. Little is known, however, about whether these changes have resulted in improvements in short-term and long-term outcome of acute respiratory distress syndrome (ARDS) within the two decades after introduction. In a retrospective study 167 long-term survivors of severe ARDS who were transferred to the clinic for anesthesiology of the University of Munich, Campus Großhadern by means of specialized intensive care unit (ICU) transport teams and treated over a period of 20 years (1985-2005) were evaluated to investigate whether significant improvements in outcome as a consequence of the above mentioned progress in ARDS therapy have occurred. The ARDS patient cohort studied was characterized with regard to demographic variables, initial acute physiology and chronic health evaluation (APACHE) II score, duration of ICU treatment, the duration of mechanical ventilation and mortality. Data on long-term outcome were collected in a subcohort (n = 125) of patients who responded to mailed questionnaires and included health-related quality of life (HRQL, SF-36 questionnaire), symptoms of post-traumatic stress disorder (PTSD), traumatic memories from ICU treatment (PTSS-10 instrument) and current state of employment. During the observation period no significant changes regarding patient age (39 ± 16 years, mean ± SD), disease severity on admission to the ICU (APACHE II scores 22 ± 5), duration of ICU treatment (47 ± 39 days) or duration of mechanical ventilation (39 ± 38 days) were found. Overall ICU mortality during the two decades was 37.3 % (range 25.0 %-38.1 %) between 1995 and 2001 and a non-significant increase in values between 36.8 % and 58.3 % during the time interval from 2002 und 2005. The paO2/FIO2-ratio on ICU admittance improved significantly between 1990 and 2000 (69 ± 5 between 1990 and 1994 versus 101 ± 12 between 1995 and 2000, p < 0.01) and remained nearly unchanged thereafter. Long-term outcome was evaluated on average 5.0 ± 3.1 years after discharge from the ICU. During the time period between 1985 and 1994 survivors of ARDS showed significant impairments in all 8 categories of the SF-36 HRQL instrument when compared to an age and sex-matched normal population with maximal differences regarding physical function (z = -1.01), general health perception (z = -1.17) and mental health (z = -1.3). Patients who were treated from 1995 to 2005 were still impaired in 7 out of 8 categories of HRQL but reported significantly better mental health (49.6 ± 16.5 vs. 68.6 ± 17.8, p < 0,01) and better physical function than individuals from the previous decade (49.6 ± 16.5 vs. 73.4 ± 27.5, p = 0,03). The difference of mental health was no longer significant when compared to a healthy age and sex matched control group (p = 0.14) but the difference in physical function still was (z = -0.48, p < 0.01). The incidence of severe post-traumatic stress defined as a PTSS-10 score ≥ 35 was 20.4 % and remained unchanged throughout the 2 decades of observation. The PTSS-10 scores correlated with the number of traumatic memories present (r = 0.43, p < 0.01, n = 125). More than 50 % of long-term survivors were able to return to full time work with no significant changes during the 2 decades of observation. The introduction of new modalities of ARDS treatment were associated with higher paO2/FIO2-ratios on ICU admittance but had no effect on short-term outcomes including duration of ICU therapy, mechanical ventilation or mortality. The ARDS patients are still at risk for post-traumatic stress and persistent impairments in HRQL. Apart from some improvements in HRQL, the outcome of ARDS therapy remained largely unchanged during two decades.
authors.affiliation: Klinik für Anaesthesiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland. Isabel.Briegel@med.uni-muenchen.de
authors.forename: I
authors.initials: I
authors.lastname: Briegel
authors.forename: M
authors.initials: M
authors.lastname: Dolch
authors.forename: M
authors.initials: M
authors.lastname: Irlbeck
authors.forename: D
authors.initials: D
authors.lastname: Hauer
authors.forename: I
authors.initials: I
authors.lastname: Kaufmann
authors.forename: G
authors.initials: G
authors.lastname: Schelling
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003422:Critical Care / Q000706:statistics & numerical data / Q000639:trends*; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008603:Mental Health; D008875:Middle Aged; D011788:Quality of Life; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D013313:Stress Disorders, Post-Traumatic / Q000150:complications / Q000453:epidemiology; D017741:Survivors; D016896:Treatment Outcome
references.citation: Curr Opin Crit Care. 2002 Aug;8(4):331-6
references.pmid: 12386494
references.citation: Crit Care Med. 1998 Apr;26(4):651-9
references.pmid: 9559601
references.citation: N Engl J Med. 2008 Jan 10;358(2):125-39
references.pmid: 18184958
references.citation: J Crit Care. 2000 Sep;15(3):91-6
references.pmid: 11011821
references.citation: Intensive Care Med. 2011 Apr;37(4):719-20
references.pmid: 21210077
references.citation: Intensive Care Med. 2004 Jan;30(1):51-61
references.pmid: 14569423
references.citation: Soc Sci Med. 1995 Nov;41(10):1359-66
references.pmid: 8560303
references.citation: N Engl J Med. 2005 Oct 20;353(16):1685-93
references.pmid: 16236739
references.citation: Crit Care. 2007;11(1):R30
references.pmid: 17319937
references.citation: Am J Psychiatry. 2004 Jan;161(1):45-52
references.pmid: 14702249
references.citation: N Engl J Med. 2012 Jul 12;367(2):124-34
references.pmid: 22738085
references.citation: Am J Respir Crit Care Med. 2006 Sep 1;174(5):538-44
references.pmid: 16763220
references.citation: Psychosom Med. 2008 May;70(4):512-9
references.pmid: 18434495
references.citation: J Clin Exp Neuropsychol. 1991 Nov;13(6):950-64
references.pmid: 1779033
references.citation: Intensive Care Med. 1999 Sep;25(9):930-5
references.pmid: 10501747
references.citation: JAMA. 1999 Jan 27;281(4):354-60
references.pmid: 9929089
references.citation: Crit Care Med. 2009 Sep;37(9):2527-34
references.pmid: 19602975
references.citation: Intensive Care Med. 1999 Jul;25(7):697-704
references.pmid: 10470573
references.citation: Crit Care Med. 2000 Nov;28(11):3626-30
references.pmid: 11098964
references.citation: Crit Care. 2010;14(5):R191
references.pmid: 21029460
references.citation: Anesthesiology. 2011 Jun;114(6):1380-8
references.pmid: 21532463
references.citation: N Engl J Med. 2011 Apr 7;364(14):1293-304
references.pmid: 21470008
references.citation: Psychosomatics. 2006 May-Jun;47(3):223-30
references.pmid: 16684939
references.citation: Am J Respir Crit Care Med. 1994 Mar;149(3 Pt 1):818-24
references.pmid: 7509706
references.citation: Arch Phys Med Rehabil. 2010 Mar;91(3):481-8
references.pmid: 20298843
references.citation: Med Care. 1992 Jun;30(6):473-83
references.pmid: 1593914
references.citation: Crit Care. 2007;11(1):R28
references.pmid: 17316452
references.citation: Chest. 2008 May;133(5):1120-7
references.pmid: 18263687
references.citation: Curr Opin Crit Care. 2012 Feb;18(1):99-104
references.pmid: 22186218
references.citation: Prog Brain Res. 2008;167:229-37
references.pmid: 18037018
references.citation: Intensive Care Med. 2010 Dec;36(12):2030-7
references.pmid: 20661726
references.citation: Crit Care Med. 2011 Apr;39(4):643-50
references.pmid: 21169818
references.citation: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003844
references.pmid: 17636739
references.citation: Am J Respir Crit Care Med. 2003 Dec 15;168(12):1457-61
references.pmid: 14525802
references.citation: N Engl J Med. 2003 Feb 20;348(8):683-93
references.pmid: 12594312