Chest

Chest

Volume 71, Issue 4, April 1977, Pages 456-462
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Prospective Study of Controlled Oxygen Therapy: Poor Prognosis of Patients with Asynchronous Breathing

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Thirty-two patiente were evaluated within 24 hours of admission for 36 episodes of acute respiratory faliure (arterial oxygen pressure = 50 mm Hg). Clinical data, spirometric determinations, blood gas analysis, and synchronization of chest (rib cage) and abdominal (diaphragmatic) breathing movements were studied. All patiente were initially treated with controlled oxygen therapy. In 25 episodes the patients recovered without intubation (successes). In nine episodes the patients required intubation and assisted ventilation; two of these patients died. Two patients died without intubation. The 25 successful episodes were compared with the 11 requiring intubation or associated with death (failures). The breathing pattern proved to be the best single factor for predicting success or failure (77 percent correct prediction). The breathing pattern plus the arterial carbon dioxide tension on admission was the best two-factor guide (86 percent correct prediction). Patients with asynchronous breathing and severe hypercapnia are so unlikely to do well with a program of controlled oxygen therapy that preparations for intubation and assisted ventilation should be made on admission and such measures should be instituted at the first sign of deterioration.

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MATERIALS AND METHODS

Thirty-two patients with chronic obstructive airway disease were studied during 36 episodes of acute respiratory failure. The diagnosis of chronic obstructive airway disease was based on the usual clinical and spirographic features. Most of the patients were previously known to the investigators, and no patient was included in whom there was doubt about the primary diagnosis. None of the patients had bronchial asthma.

Acute respiratory failure was diagnosed as a worsening of previous dyspnea,

RESULTS

The results are summarized in Table 1. In 25 of the 36 episodes of respiratory failure, the patient recovered without the need for intubation and assisted ventilation. Nine patients were intubated; two of these died, and the other seven recovered after a prolonged period of assisted ventilation. Two patients who were not intubated died. Both of these patients had far advanced disease, and a decision had been made not to intubate, even in the face of deterioration (a similar decision was made in

DISCUSSION

We cannot state with absolute certainty that all patients in the failure group required intubation and assisted ventilation for survival. The only way to assess this would have been to intubate no one; the success group would then consist of the survivors and the failure group of those who died. Obviously, such an approach cannot be justified. Our rate of intubation (25 percent) is higher than that of many series,1, 9, 10 although not as high as the 50 percent rate reported by Asmundsson and

ACKNOWLEDGMENTS

We gratefully acknowledge the technical assistance of Mrs. Lynn LaTraelle and Miss Sharon Bleb.

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Supported by a grant from the Parker B. Francis Foundation and Pulmonary Disease Training Grant 05954 from the National Heart and Lung Institute.

Manuscript received June 14; revision accepted August 4.

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Copyright © 1977 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.