Chest
Volume 104, Issue 3, September 1993, Pages 854-860
Journal home page for Chest

Clinical Investigations
Severe COPD and Acute Respiratory Failure: Correlates for Survival at the Time of Tracheal Intubation

https://doi.org/10.1378/chest.104.3.854Get rights and content

The recognition of a reversible cause for acute respiratory failure (ARF) is frequently difficult in patients with severe chronic obstructive pulmonary disease (COPD). We sought to identify clinical findings present at the time of tracheal intubation that were associated with successful weaning and short-term survival among a population of male veterans with severe COPD. Over a 5-year period (1987 to 1991), 39 episodes of ARF requiring mechanical ventilation (MV) were identified in 33 men with severe COPD. All the patients had a baseline FEV1 <1 L. Univariate analysis suggested a higher serum albumin level and absence of pulmonary infiltrates on chest radiography distinguished survivors (weaned from MV for 72 h) from nonsurvivors (died while undergoing MV or within 72 h of weaning). Multivariate analysis revealed the absence of pulmonary infiltrates on initial chest radiography was the strongest correlate for survival. To examine the significance of these correlates in ARF complicating milder COPD, 19 patients with lesser degrees of chronic airways obstruction and ARF were also studied. Unlike patients with severe COPD, the presence or absence of pulmonary infiltrates on chest radiography was not correlated with survival in patients with milder chronic airways obstruction. Analyzing all COPD patients with ARF, the mortality risk associated with the presence of pulmonary infiltrates on chest radiography increased dramatically with declining baseline lung function. Mortality risk ratio analysis revealed the greatest likelihood for survival was predicted by a higher baseline FEV1 and the absence of pulmonary infiltrates on chest radiography. The extent of baseline airways obstruction alone was not correlated with short-term survival in either group. These observations suggest that in the subset of patients with severe COPD and ARF, the presence of pulmonary infiltrates on chest radiography at the time of tracheal intubation may be associated with less likelihood for survival. An exacerbation of COPD may infrequently he the terminal illness in these patients.

Section snippets

Patient Selection

During the period Jan 1, 1987 to Jan 31, 1992, data were recorded prospectively on all Jackson Veterans Affairs Medical Center MICU patients with suspected COPD and ARF requiring MV. Severe COPD was defined as a baseline FEV1 less than 1 L among patients with compatible history and physical findings of COPD. Criteria for inclusion in the study cohorts included prior spirometric confirmation of fixed airways obstruction during a period of clinical stability and the development of ARF requiring

Battent Characteristics

During the study period, 73 episodes of ARF requiring tracheal intubation and MV occurred among patients with suspected COPD. Fifteen (21 percent) of these episodes involved patients who had not been followed in clinics or who lacked prior pulmonary function testing. The 39 episodes of ARF complicating severe COPD, occurring among 33 patients, were studied in detail. Four patients were treated for two episodes of ARF, and one patient was treated for three episodes of ARF. These episodes were

Discussion

The natural history of COPD has been studied extensively over the past 30 years. Several variables have been correlated with survival. These positive correlates include a slow decline of lung function as assessed by forced expiration maneuvers, younger age, higher baseline FEV1 (especially postbronchodilator), active functional status, and the absence of cor pulmonale.11, 16, 17 Less data have accumulated regarding the clinical course of the subset of patients with severe COPD. Long-term

Appendix

The outcome modeling formulas for patients with severe COPD were produced via stepwise logistic regression analysis and incorporate the numeric serum albumin level (g/dl) and the presence (1) or absence (0) of pulmonary infiltrates on chest radiography (CXR). The probability of ARF survival or nonsurvival is as follows: P(survival)=11+exp[3.6947+5.9265(CXR)-2.2211(albumin)] P(nonsurvival)=exp[3.6947+5.9265(CXR)-2.2211(albumin)]1+exp[3.6947+5.9265(CXR)-2.2211(albumin)]

The outcome

References (28)

  • RA Pearlman

    Variability in physician estimates of survival for acute respiratory failure in chronic obstructive pulmonary disease

    Chest

    (1987)
  • PN Lanken et al.

    Withholding and withdrawing life-sustaining therapy

    Am Rev Respir Dis

    (1991)
  • JP Derenne et al.

    Acute respiratory failure of chronic obstructive pulmonary disease

    Am Rev Respir Dis

    (1988)
  • NR Anthonisen et al.

    Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease

    Ann Intern Med

    (1987)
  • Cited by (0)

    View full text