Disfuncion Pulmonar

Non pulmonary Organ Dysfunction and Its Impact on Outcome
in Patients with Acute Respiratory Failure
Chest - Volume 132, Issue 3 (September 2007) - Copyright © 2007 The American College of Chest Physicians - About This
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DOI: 10.1378/chest.06-2783

Ashutosh N. Aggarwal MD, FCCP 1 Ritesh Agarwal MD 1 Dheeraj Gupta MD, FCCP 1
Surinder K. Jindal MD, FCCP 1Purpose:This study aimed to define the prevalence, severity, and progression of
nonpulmonary organ dysfunction, and its impact on outcome in patie nts with acute
respiratory failure (ARF) at a respiratory ICU of a tertiary referral hospital in northern
India.
Methods:Daily patient data were collected on 711 adult patients with ARF to calculate
component and total nonpulmonary sequential organfailure assessment (SOFA) scores.
Hospital survival was the main outcome measure. Multiple logistic regression modeling
was conducted to assess contribution of incremental dysfunction of various nonpulmonary
organ systems to mortality. Kaplan-Meier curves were drawn to assess temporal trends in
survival, and group comparisons were based on log-rank test. Cox proportional hazard
modeling wasperformed to define hazards of earlier mortality. Discrimination was
evaluated using receiver operating characteristic (ROC) curves.
Results: Four hundred seventy-five patients (66.8%) had one or more nonpulmonary organ
dysfunctions at hospital admission. The overall hospital mortality rate was 33.9%. Hospital
survival rates and median survival declined steadily as the number of organsinvolved
increased. Admission, maximum, and ΔSOFA scores were significantly higher in
nonsurvivors. Increasing baseline cardiovascular and neurologic SOFA scores, and
corresponding ΔSOFA scores, were associated with progressively higher odds of hospital
mortality, as well as increasing hazard for ea rlier mortality after adjustment for etiology of
respiratory failure. Maximum nonpulmonary SOFAscore was the best discriminator in
predicting mortality (area under ROC curve, 0.767).
Conclusion: Baseline and new-onset nonpulmonary organ dysfunction significantly
influences hospital survival in patients with ARF.
Key words: hospital mortality, multiple organ failure, multivariate analysis, respiratory
insufficiency, severity of illness.
Abbreviations: ARF acute respiratory failure, RICUrespiratory ICU, ROC receiver
operating characteristic, SOFA sequential organ failure assessment.

The traditional outcome of critically ill patients admitted to the ICU has always remained
hospital mortality. Indeed, standard severity scoring systems such as the acute physio logy
and chronic health evaluation and the simplified acute physiology score use values obtained
within the first24 h of ICU stay to predict hospital outcome. However, these scores ignore
the many factors that influence patient outcome during ICU stay beyond the initial 24 h.
Thus, there is a need for severity indexes that monitor and quantify disease process and
organ dysfunction in a continuous and dynamic fashion.
A few scores have been developed to assess organ dysfunction/failure. [1] [2] [3] Oneof the
most widely used such scores, the sepsis-related organ failure assessment score, was
developed to evaluate organ dysfunction in patients with sepsis. [3] Later, it was renamed the
sequential organ failure assessment (SOFA) score because its utility was not restricted
merely to patients with sepsis. Although primarily developed to describe organ dysfunction,
and not predict mortalityrisk, correlation between organ dysfunction/failure and outcome
has been demonstrated in both prospective and retrospective analyses.[3] [4] [5]
We are actively involved in managing patients with acute respiratory failure (ARF) at our
specialized respiratory ICU (RICU). We have earlier shown that failure of extrapulmonary
organs was a predictor of mortality in patients of ARDS. [6] Other...