Seneff M G, Wagner D P, Wagner R P, Zimmerman J E, Knaus W A
Department of Anesthesiology, George Washington University, Washington, DC, USA.
JAMA. 1995 Dec 20;274(23):1852-7.
To describe outcomes and identify variables associated with hospital and 1-year survival for patients admitted to an intensive care unit (ICU) with an acute exacerbation of chronic obstructive pulmonary disease (COPD).
Prospective, multicenter, inception cohort study.
Forty-two ICUs at 40 US hospitals.
A total of 362 admissions for COPD exacerbation selected from the Acute Physiology and Chronic Health Evaluation (APACHE) III database of 17,440 ICU admissions.
Hospital mortality for the 362 admissions was 24%. For the 167 patients aged 65 years or older, mortality was 30% at hospital discharge, 41% at 90 days, 47% at 180 days, and 59% at 1 year. Median survival for all patients was 224 days, and median survival for the patients who died within 1 year was 30.5 days. On multiple regression analysis, variables associated with hospital mortality included age, severity of respiratory and nonrespiratory organ system dysfunction, and hospital length of stay before ICU admission. Development of nonrespiratory organ system dysfunction was the major predictor of hospital mortality (60% of total explanatory power) and 180-day outcomes (54% of explanatory power). Respiratory physiological variables (respiratory rate, serum pH, PaCO2, PaO2, and alveolar-arterial difference in partial pressure of oxygen [PAO2-PaO2]) indicative of advanced dysfunction were more strongly associated with 180-day mortality rates (22% of explanatory power) than hospital death rates (4% of explanatory power). After controlling for severity of illness, mechanical ventilation at ICU admission was not associated with either hospital mortality or subsequent survival.
Patients with COPD admitted to an ICU for an acute exacerbation have a substantial hospital mortality (24%). For patients aged 65 years or older, mortality doubles in 1 year from 30% to 59%. Hospital and longer-term mortality is closely associated with development of nonrespiratory organ system dysfunction; severity of the underlying respiratory function substantially influences mortality following hospital discharge. The need for mechanical ventilation at ICU admission did not influence either short- or long-term outcomes. Physicians should be aware of these relationships when making treatment decisions or evaluating new therapies.
描述慢性阻塞性肺疾病（COPD）急性加重入住重症监护病房（ICU）患者的预后，并确定与住院及1年生存率相关的变量。
前瞻性、多中心、起始队列研究。
美国40家医院的42个ICU。
从17440例ICU入院患者的急性生理与慢性健康状况评价（APACHE）III数据库中选取362例COPD加重患者。
362例患者的住院死亡率为24%。167例65岁及以上患者，出院时死亡率为30%，90天时为41%，180天时为47%，1年时为59%。所有患者的中位生存期为224天，1年内死亡患者的中位生存期为30.5天。多因素回归分析显示，与住院死亡率相关的变量包括年龄、呼吸和非呼吸器官系统功能障碍的严重程度以及ICU入院前的住院时间。非呼吸器官系统功能障碍的发生是住院死亡率（占总解释力的60%）和180天预后（占解释力的54%）的主要预测因素。提示严重功能障碍的呼吸生理变量（呼吸频率、血清pH值、动脉血二氧化碳分压[PaCO2]、动脉血氧分压[PaO2]和肺泡-动脉血氧分压差[PAO2-PaO2]）与180天死亡率（占解释力的22%）的相关性比与住院死亡率（占解释力的4%）更强。在控制疾病严重程度后，ICU入院时的机械通气与住院死亡率及后续生存率均无关。
因急性加重入住ICU的COPD患者住院死亡率较高（24%）。65岁及以上患者1年内死亡率从30%翻倍至59%。住院及长期死亡率与非呼吸器官系统功能障碍的发生密切相关；基础呼吸功能的严重程度对出院后的死亡率有重大影响。ICU入院时是否需要机械通气对短期或长期预后均无影响。医生在做出治疗决策或评估新疗法时应了解这些关系。
