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Outcomes up to 5 Years After Severe, Acute Respiratory Failure^*

Allan Garland, MD, FCCP; Neal V. Dawson, MD; Irene Altmann, MD; Charles L. Thomas, AB; Russell S. Phillips, MD; Joel Tsevat, MD, MPH; Norman A. Desbiens, MD; Paul E. Bellamy, MD; William A. Knaus, MD and Alfred F. Connors, Jr, MD, FCCP; for the SUPPORT Investigators

^* From the Case Western Reserve University School of Medicine (Drs. Garland, Dawson, and Connors, and Mr. Thomas), Cleveland, OH; The Everett Clinic (Dr. Altmann), Everett, WA; the Harvard Medical School (Dr. Phillips), Boston, MA; the University of Cincinnati Medical Center (Dr. Tsevat), Cincinnati, OH; the University of Tennessee College of Medicine (Dr. Desbiens), Chattanooga, TN; Kaiser Permanente (Dr. Bellamy), Woodland Hills, CA; and the University of Virginia Health Sciences System (Dr. Knaus), Charlottesville, VA. The research was performed at the following institutions: MetroHealth Medical Center, Cleveland, OH; Duke University Medical Center, Durham, NC; Beth Israel Hospital, Boston, MA; UCLA Medical Center, Los Angeles, CA; and Marshfield Clinic, Marshfield, WI.

Correspondence to: Allan Garland, MD, FCCP, Division of Pulmonary and Critical Care Medicine, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109; e-mail: agarland{at}metrohealth.org

Study objective: To use an existing database from a large cohort study with follow-up as long as 5.5 years to assess the extended prognosis of patients who survived their hospitalizations for severe acute respiratory failure (ARF).

Design, setting, and patients: Secondary analysis of an inception cohort of 1,722 patients with ARF requiring mechanical ventilation from five major medical centers who were entered into the prospective Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. The 1,075 patients (62.4%) who survived hospitalization had systematic follow-up of vital status for a median time of 662 days (interquartile range, 327 to 1,049 days; range, 2 to 2,014 days). Interviews performed a median of 5 months after hospital discharge assessed functional capacity and quality of life (QOL). The main outcome measure was survival after hospital discharge. Secondary measures were functional status and QOL. Cox proportional hazard regression identified factors influencing posthospital survival.

Results: The median survival time after hospital discharge for ARF was > 5.3 years. The posthospital survival time was shorter for those with older age, male gender, several preexisting comorbid conditions, worse prehospital functional status, greater acute physiologic derangement, and a do-not-resuscitate order while in the hospital, and for those discharged to a location other than home. Five months after hospital discharge, 48% of survivors needed help with at least one activity of daily living, and 27% rated their QOL as poor or fair. However, most of these impairments were present before respiratory failure occurred.

Conclusions: Extended survival is common among patients with ARF who require mechanical ventilation and who survive hospitalization. Among these patients, only a small fraction of the impairment in activity and QOL can be considered to be a sequela of the respiratory failure or its therapy. These findings are relevant to the care decisions for such critically ill patients.

Key Words: activities of daily living • acute lung injury • outcome assessment • quality of life • survival analysis

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