The Changing Face of Organ Failure in ARDS: Discussion

Fewer total nonpulmonary organ failures were noted in 1994-to-1999 patients (Fig 3, with more patients having no and one organ failure, and fewer patients having two and three organ failures in 1994 to 1999 (p < 0.05). Cardiovascular and CNS failure, and sepsis were significantly lower prior to ARDS onset (Fig 4) and after ARDS onset (Fig 5) among 1994-to-1999 patients. Hepatic failure was lower in the 1994-to-1999 patients only after ARDS onset (Fig 5). Patients with higher arterial oxygenation efficiency (P/F, > 105) and those with lower arterial oxygenation efficiency (P/F, < 105) in the 1994-to-1999 group had similar total nonpulmonary organ failure at ARDS onset (Fig 6) and similar distributions of organ failures both prior to ARDS onset (Fig 7) and after ARDS onset (Fig 8). In contrast, the 1987-to-1990 patients had a lower incidence of hepatic failure after ARDS onset, as ARDS evolved.
We found an inverse association between higher initial arterial oxygenation efficiency (ie, P/F) and lower mortality (Fig 2, Table 3). This association of mortality with P/F was notably absent in the report of Zilberberg and Epstein.2 Their reported mortality rate was 58% both for patients with ALI and those with ARDS. However, their overall patient numbers were small, and they did not investigate mortality as a function of arterial oxygenation efficiency within the ARDS patient group. In addition, they studied only medical ICU patients, whereas we studied both medical and surgical patients. http://birthcontroltab.com/

We found an association between higher initial arterial oxygenation efficiency (ie, P/F) and specific organ failure before and after ARDS onset (Figs 3-5, Table 3). The association of a greater incidence of organ failure in ARDS patients with a higher mortality is well-described and was observed in our 1994-to-1999 patients. However, the change in organ failure distribution that we observed has not been reported previously. A review of the literature (Table 4) demonstrated the paucity of reports of specific organ failures at or after the onset of ARDS. Bell et al reported that increased organ failure occurring during ARDS was associated with increased mortality. They found CNS, GI, renal, endocrine, and coagulation failure to be associated adversely with survival. Subsequent publications rarely have reported specific organ failures. Zilberberg and Epstein2 and the ARDS Network reported specific organ failures or the relation of mortality to specific organ failures. The evolution of organ failure following ARDS onset, and as a function of year of onset of ARDS, has not been reported systematically. In particular, longitudinal studies are lacking.
Fig3
Figure 3. Nonpulmonary organ failure for a P/F of < 105 at ARDS onset for 1987-to-1990 and 1994-to-1999 patients. The horizontal axis represents the number of nonpulmonary organ failures. The numbers on the bar graphs are the total number of patients for that group.
Fig4
Figure 4. Organ failure distribution for a P/F of < 105 at ARDS onset for 1987-to-1990 and 1994-to-1999 patients. CV = cardiovascular; Coag = coagulation. Numbers on the bar graphs are the total number of patients for that group.
Fig5
Figure 5. Organ failure distribution for a P/F of < 105 after ARDS onset for 1987-to-1990 and 1994-to-1999 patients. See the legend of Figure 4 for abbreviations not used in the text. Numbers on the bar graphs are the total number of patients for that group.
Fig6
Figure 6. Nonpulmonary organ failure at ARDS onset for 1994-to-1999 Patients vs P/F. The horizontal axis represents the number of nonpulmonary organ failures, and the numbers on the bar graphs are the total number of patients for that group.
Fig7
Figure 7. Organ failure distribution at ARDS onset for 1994-to-1999 patients vs P/F. See the legend of Figure 4 for abbreviations not used in the text. Numbers on the bar graphs are the total number of patients for that group.
Fig8
Figure 8. Organ failure distribution after ARDS onset for 1994 to 1999 patients vs P/F. See the legend of Figure 4 for abbreviations not used in the text. Numbers on the bar graphs are the total number of patients for that group.

Table 4 —Previous ARDS Reports With Organ Failure

Study/Year Patients,No. ICUType APACHE II Score Organ Failure Reported Organ Failure Distribution Reported
Before ARDS Onset After ARDS Onset
Bell/1983 141 Mixed NA Yes Yes Yes
Montgomery/1985 207 Mixed NA No No Cause of death
Millberg/1995 918 Mixed NA No No No
Doyle/1995 57 Mixed NA No Multiple linear regression No
Stewart/1998 120 Mixed 22 Yes No No
Zilberberg and Epstein2/1998 81 Med 19 Yes No Yes
Abel/1998 129 Mixed 14 Yes No No
ARDS Network/2000 1832 Mixed 811 No Yes Yes
ARDS Network/2000 861 Mixed 821 No Yes No
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