Nonpulmonary Organ Dysfunction and Mortality With Acute Respiratory Failure

Abstract

To the Editor: Aggarwal et al1Aggarwal AN Agarwal B Gupta D et al.Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest. 2007; 132: 829-835Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar found that nonpulmonary organ dysfunction predicts mortality among patients with acute respiratory failure. We concur, and correspond to describe interactions between respiratory dysfunction and other manifestations of organ dysfunction. Interactions between hepatic and pulmonary dysfunction have been described for nearly 2 decades. Historically, hepatic dysfunction was hypothesized to cause failure of reticuloendothelial host defenses, with resultant pulmonary microembolization and respiratory failure. We quantified this deleterious relationship2Hydo LJ Barie PS Patterns of mortality in the multiple organ dysfunction syndrome [abstract].Crit Care Med. 2005; 33: a77Crossref Google Scholar; the mortality rate was 10% for patients with neither hepatic nor pulmonary dysfunction, 20 to 23% for patients with modest degrees of either manifestation, and 58 to 93% mortality when both were present to a modest or severe degree. Using the sequential organ dysfunction assessment (SOFA) score, Aggarwal et al1Aggarwal AN Agarwal B Gupta D et al.Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest. 2007; 132: 829-835Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar found in a heterogeneous group of 475 patients (34% hospital mortality) that overall nonpulmonary organ dysfunction and cardiovascular and neurologic dysfunction specifically (but not hepatic dysfunction) predicted mortality following pulmonary dysfunction. Using similar methodology but studying a more homogeneous population of patients with ARDS, we reported similar results recently.3Eachempati SR Hydo LJ Shou J et al.Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.J Trauma. 2007; 63: 344-350Crossref PubMed Scopus (47) Google Scholar Using the multiple organ dysfunction (MOD) score of Marshall et al,4Marshall JC Cook DJ Christou NV et al.Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.Crit Care Med. 1995; 23: 1638-1652Crossref PubMed Scopus (2032) Google Scholar which measures dysfunction of the same six organs as the SOFA score and yields quantitatively similar results,5Khwannimit B A comparison of three organ dysfunction scores: MODS, SOFA and LOD for predicting ICU mortality in critically ill patients.J Med Assoc Thai. 2007; 90: 1074-1081PubMed Google Scholar nonpulmonary organ dysfunction overall and by each of the five other components (cardiovascular, coagulation, hepatic, neurologic, renal) were independent predictors of ARDS-related mortality.3Eachempati SR Hydo LJ Shou J et al.Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.J Trauma. 2007; 63: 344-350Crossref PubMed Scopus (47) Google Scholar Notably, the area under the receiver operating characteristic curve for cumulative (maximum) MOD score was 0.83, which is similar to the value of 0.76 calculated by Aggarwal et al.1Aggarwal AN Agarwal B Gupta D et al.Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.Chest. 2007; 132: 829-835Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar It is important for clinicians and investigators to recognize that nonpulmonary organ dysfunction kills patients with acute respiratory failure. Attention to resuscitation, early and effective antibiotic therapy, and global support of organ dysfunction to minimize the proinflammatory host response are crucial to improved outcomes of acute respiratory failure.