Quality of life in acute respiratory distress syndrome survivors may be no worst than in other ICU survivors

Prospective single-center study of health-related quality of life after COVID-19 in ICU and non-ICU patients

Long-term sequelae in hospitalized Coronavirus Disease 2019 (COVID-19) patients may result in limited quality of life. The current study aimed to determine health-related quality of life (HRQoL) after COVID-19 hospitalization in non-intensive care unit (ICU) and ICU patients. This is a single-center study at the University Hospital of Wuerzburg, Germany. Patients eligible were hospitalized with COVID-19 between March 2020 and December 2020. Patients were interviewed 3 and 12 months after hospital discharge. Questionnaires included the European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L), patient health questionnaire-9 (PHQ-9), the generalized anxiety disorder 7 scale (GAD-7), FACIT fatigue scale, perceived stress scale (PSS-10) and posttraumatic symptom scale 10 (PTSS-10). 85 patients were included in the study. The EQ5D-5L-Index significantly differed between non-ICU (0.78 ± 0.33 and 0.84 ± 0.23) and ICU (0.71 ± 0.27; 0.74 ± 0.2) patients after 3- and 12-months. Of non-ICU 87% and 80% of ICU survivors lived at home without support after 12 months. One-third of ICU and half of the non-ICU patients returned to work. A higher percentage of ICU patients was limited in their activities of daily living compared to non-ICU patients. Depression and fatigue were present in one fifth of the ICU patients. Stress levels remained high with only 24% of non-ICU and 3% of ICU patients (p = 0.0186) having low perceived stress. Posttraumatic symptoms were present in 5% of non-ICU and 10% of ICU patients. HRQoL is limited in COVID-19 ICU patients 3- and 12-months post COVID-19 hospitalization, with significantly less improvement at 12-months compared to non-ICU patients. Mental disorders were common highlighting the complexity of post-COVID-19 symptoms as well as the necessity to educate patients and primary care providers about monitoring mental well-being post COVID-19.

Does mechanical threshold inspiratory muscle training promote recovery and improve outcomes in patients who are ventilator-dependent in the intensive care unit? The IMPROVE randomised trial

BACKGROUND

In patients who are ventilator-dependent in the intensive care unit, inspiratory muscle training may improve inspiratory muscle strength and accelerate liberation from the ventilator, but optimal training parameters are yet to be established, and little is known about the impact of inspiratory muscle training on quality of life or dyspnoea. Thus, we sought to ascertain whether inspiratory muscle training, commenced while ventilator-dependent, would improve outcomes for patients invasively ventilated for 7 days or longer.

METHODS

In this randomised trial with assessor blinding and intention-to-treat analysis, 70 participants (mechanically ventilated ≥7 days) were randomised to receive once-daily supervised high-intensity inspiratory muscle training with a mechanical threshold device in addition to usual care or to receive usual care (control). Primary outcomes were inspiratory muscle strength (maximum inspiratory pressure % predicted) and endurance (fatigue resistance index) at ventilator liberation and 1 week later. Secondary outcomes included quality of life (SF-36v2, EQ-5D), dyspnoea, physical function, duration of ventilation, and in-hospital mortality.

RESULTS

Thirty-three participants were randomly allocated to the training group, and 37 to the control group. There were no statistically significant differences in strength (maximum inspiratory pressure) (95% confidence interval [CI]: -7.4 to 14.0) or endurance (fatigue resistance index) (95% CI: -0.003 to 0.436). Quality of life improved significantly more in the training group than in the control group (EQ-5D: 17.2; 95% CI: 1.3-33.0) (SF-36-PCS: 6.97; 95% CI: 1.96-12.00). Only the training group demonstrated significant reductions in dyspnoea (-1.5 at rest, -1.9 during exercise). There were no between-group differences in duration of ventilation or other measures. In-hospital mortality was higher in the control group than in the training group (9 vs 4, 24% vs 12%, p = 0.23).

CONCLUSIONS

In patients who are ventilator-dependent, mechanical threshold loading inspiratory muscle training improves quality of life and dyspnoea, even in the absence of strength improvements or acceleration of ventilator liberation.

Potential Interaction Between Sepsis and Acute Respiratory Distress Syndrome and Effect on the 6-Month Clinical Outcomes: A Preliminary Secondary Analysis of a Prospective Observational Study

BACKGROUND

This study aimed to investigate the effect of the potential interaction between sepsis and acute respiratory distress syndrome (ARDS) on the 6-month clinical outcomes.

METHODS

This secondary analysis of a prospective multicenter observational study included patients who were expected to receive mechanical ventilation for more than 48 h. Patients were stratified based on the incidence of sepsis and further subdivided according to the presence of ARDS. The primary endpoints for patients whose follow-up information was available included mortality (n = 162) and the occurrence of PICS (n = 96) at six months. The diagnosis of PICS was based on any of the following criteria: (1) decrease ≥ 10 points in the physical component score of the 36-item Short Form (SF36) questionnaire; (2) decrease ≥ 10 points in the mental component score of the SF-36; or (3) decline in the Short Memory Questionnaire (SMQ) score and SMQ score < 40 at six months after ICU admission. We conducted multivariate logistic regression analyses to assess the effect of the potential interaction between ARDS and sepsis on the 6-month clinical outcomes.

RESULTS

The mortality in the ARDS sub-group was higher than that in the non-ARDS subgroup [47% (7/15) versus 21% (18/85)] in the non-sepsis group. However, the mortality in the ARDS and non-ARDS subgroups was similar in the sepsis group. Multivariate logistic regression analyses revealed that ARDS was significantly associated with mortality in the non-sepsis group (adjusted OR: 5.25; 95% CI: 1.45-19.09; p = .012), but not in the sepsis group (P for interaction = .087). Multivariate logistic regression analyses showed ARDS was not associated with PICS occurrence in the non-sepsis and sepsis groups (P-value for the interaction = .039).

CONCLUSIONS

This hypothesis-generating study suggested that the effect of ARDS on the 6-month outcomes depended on the presence or absence of sepsis.

TRIAL REGISTRATION

Not applicable.

One-year patient outcomes based on lung morphology in acute respiratory distress syndrome: secondary analysis of LIVE trial

Background

Acute respiratory distress syndrome (ARDS) has different phenotypes and distinct short-term outcomes. Patients with non-focal ARDS have a higher short-term mortality than focal ones. The aim of this study was to assess the impact of the morphological phenotypes of ARDS on long-term outcomes.

Methods

This was a secondary analysis of the LIVE study, a prospective, randomised control trial, assessing the usefulness of a personalised ventilator setting according to lung morphology in moderate-to-severe ARDS. ARDS was classified as focal (consolidations only in the infero-posterior part of the lungs) or non-focal. Outcomes were assessed using mortality and functional scores for quality of life at the 1-year follow-up.

Results

A total of 124 focal ARDS and 236 non-focal ARDS cases were included. The 1-year mortality was higher for non-focal ARDS than for focal ARDS (37% vs. 24%, p = 0.012). Non-focal ARDS (hazard ratio, 3.44; 95% confidence interval, 1.80–6.59; p < 0.001), age, McCabe score, haematological cancers, SAPS II, and renal replacement therapy were independently associated with 1-year mortality. This difference was driven by mortality during the first 90 days (28 vs. 16%, p = 0.010) but not between 90 days and 1 year (7 vs. 6%, p = 0.591), at which point only the McCabe score was independently associated with mortality. Morphological phenotypes had no impact on patient-reported outcomes.

Conclusion

Lung morphologies reflect the acute phase of ARDS and its short-term impact but not long-term outcomes, which seem only influenced by comorbidities.

Trial registration: NCT 02149589; May 29, 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04036-7.

The complications of opioid use during and post-intensive care admission: A narrative review

Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.

Quality of life and mortality among survivors of acute respiratory distress syndrome in South Korea: a nationwide cohort study

Purpose

Worsening quality of life (QOL) is an important health issue in acute respiratory distress syndrome (ARDS) survivors. We aimed to investigate the prevalence of worsening QOL among ARDS survivors and their association with mortality.

Methods

South Korean National Health Insurance database information for all adults admitted to intensive care units for ARDS from January 1, 2010 to December 31, 2018 who survived ≥ 365 days were included in this study.

Results

A total of 4452 ARDS survivors were included in the final analysis. Total QOL had worsened in 1667 (37.4%) of the survivors at the follow-up 1 year after being diagnosed with the syndrome. Specifically, 1298 patients (29.2%) experienced decreased income, 334 (7.5%) lost their jobs, and 327 (7.3%) had newly acquired disabilities. In the multivariable Cox regression analysis, worsening QOL was not associated with 2-year all-cause mortality among survivors (P = 0.140). However, newly acquired disability was associated with 1.74-fold (hazard ratio [HR]: 1.74, 95% confidence interval [CI] 1.31–2.33; P < 0.001) higher 2-year all-cause mortality, while decreased income (P = 0.571) and unemployment (P = 0.952) were not associated with it. In addition, newly acquired respiratory disability was associated with a 6.61-fold higher risk of 2-year respiratory mortality (HR: 6.61, 95% CI 3.14–13.90; P < 0.001).

Conclusions

At the 1-year follow-up period, one-third of ARDS survivors experienced worsening QOL in South Korea. Specifically, newly acquired disability was associated with a higher risk of 2-year all-cause and respiratory mortality among patients who survived ARDS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-022-03036-9.

Health-related quality of life in ICU survivors-10 years later

Many Intensive Care (ICU) survivors experience long lasting impairments in physical and psychological health as well as social functioning. The objective of our study was to evaluate these effects up to 10 years after ICU discharge. We performed a long-term prospective cohort study in patients admitted for longer than 48 h in a medical-surgical ICU. We evaluated health-related quality of life (HRQOL) before ICU admission using the Short-form-36 (SF-36), at ICU discharge, at hospital discharge and at 1, 2, 5 and 10 years follow up (all by patients). Changes in HRQOL were assessed based on linear mixed modeling. We included a total of 749 patients (from 2000 to 2008). During 10 years 475 (63.4%) patients had died, 125 (16.7%) patients were lost to follow up and 149 (19.9%) patients could be evaluated. The mean scores of four HRQOL dimensions (i.e., physical functioning (p < 0.001; mean 54, SD 32, effect size 0.77, 95% CI [0.54-1.0]), role-physical (p < 0.001; mean 44, SD 47, effect size 0.65, 95% CI [0.41-0.68] general health (p < 0.001; mean 52, SD 27, effect size 0.48; 95% CI 0.25-0.71) and social functioning (p < 0.001; mean 72, SD 32, effect size 0.41, 95% CI [0.19-0.64]) were still lower 10 years after ICU discharge compared with pre-admission levels (n = 149) and with an age reference population. Almost all SF-36 dimensions changed significantly over time from ICU discharge up to 10 years after ICU discharge. Over the 10 year follow up physical functioning of medical-surgical ICU survivors remains impaired compared with their pre-admission values and an age reference population. However, effect sizes showed no significant differences suggesting that surviving patients largely regained their age-specific HRQOL at 10 years.

Inspiratory muscle training for recovered COVID-19 patients after weaning from mechanical ventilation: A pilot control clinical study

BACKGROUND

To the best of our knowledge, no studies have evaluated the effects of inspiratory muscle training (IMT) on recovered COVID-19 patients after weaning from mechanical ventilation. Therefore, this study assessed the efficacy of IMT on recovered COVID-19 patients following mechanical ventilation.

METHODS

Forty-two recovered COVID-19 patients (33 men and 9 women) weaned from mechanical ventilation with a mean age of 48.05 ± 8.85 years were enrolled in this pilot control clinical study. Twenty-one patients were equipped to 2-week IMT (IMT group) and 21 matched peers were recruited as a control (control group). Forced vital capacity (FVC%), forced expiratory volume in 1 second (FEV1%), dyspnea severity index (DSI), quality of life (QOL), and six-minute walk test (6-MWT) were assessed initially before starting the study intervention and immediately after intervention.

RESULTS

Significant interaction effects were observed in the IMT when compared to control group, FVC% (F = 5.31, P = .041, ηP2 = 0.13), FEV1% (F = 4.91, P = .043, ηP2 = 0.12), DSI (F = 4.56, P = .032, ηP2 = 0.15), QOL (F = 6.14, P = .021, ηP2 = 0.17), and 6-MWT (F = 9.34, P = .028, ηP2 = 0.16). Within-group analysis showed a significant improvement in the IMT group (FVC%, P = .047, FEV1%, P = .039, DSI, P = .001, QOL, P < .001, and 6-MWT, P < .001), whereas the control group displayed nonsignificant changes (P > .05).

CONCLUSIONS

A 2-week IMT improves pulmonary functions, dyspnea, functional performance, and QOL in recovered intensive care unit (ICU) COVID-19 patients after consecutive weaning from mechanical ventilation. IMT program should be encouraged in the COVID-19 management protocol, specifically with ICU patients.

Acute respiratory distress syndrome: how do patients fare after the intensive care unit?

Patients with acute respiratory distress syndrome require ventilation strategies that have been shown to be important for reducing short-term mortality, such as protective ventilation and prone position ventilation. However, patients who survive have a prolonged stay in both the intensive care unit and the hospital, and they experience a reduction in overall satisfaction with life (independence, acceptance and positive outlook) as well as decreased mental health (including anxiety, depression and posttraumatic stress disorder symptoms), physical health (impaired physical state and activities of daily living; fatigue and muscle weakness), social health and the ability to participate in social activities (including relationships with friends and family, hobbies and social gatherings).

Post-intensive care outpatient clinic: is it feasible and effective? A literature review

The follow-up of patients who are discharged from intensive care units follows distinct flows in different parts of the world. Outpatient clinics or post-intensive care clinics represent one of the forms of follow-up, with more than 20 years of experience in some countries. Qualitative studies that followed up patients in these outpatient clinics suggest more encouraging results than quantitative studies, demonstrating improvements in intermediate outcomes, such as patient and family satisfaction. More important results, such as mortality and improvement in the quality of life of patients and their families, have not yet been demonstrated. In addition, which patients should be indicated for these outpatient clinics? How long should they be followed up? Can we expect an improvement of clinical outcomes in these followed-up patients? Are outpatient clinics cost-effective? These are only some of the questions that arise from this form of follow-up of the survivors of intensive care units. This article aims to review all aspects relating to the organization and performance of post-intensive care outpatient clinics and to provide an overview of studies that evaluated clinical outcomes related to this practice.

Long-Term Quality of Life After Extracorporeal Membrane Oxygenation in ARDS Survivors: Systematic Review and Meta-Analysis

PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an increasingly prevalent treatment for acute respiratory failure (ARF). To evaluate the impact of ECMO support on long-term outcomes for critically ill adults with ARF.

METHODS

We searched electronic databases 1948 through to November 30 2016; selected controlled trials or observational studies of critically ill adults with acute respiratory distress syndrome, examining long-term morbidity specifically health-related quality of life (HRQL); 2 authors independently selected studies, extracted data, and assessed methodological quality.

ANALYSIS

Of the 633 citations, 1 randomized controlled trial and 5 observational studies met the selection criteria. Overall quality of observational studies was moderate to high (mean score on Newcastle-Ottawa scale, 7.2/9; range, 6-8). In 3 studies (n = 245), greater decrements in HRQL were seen for survivors of ECMO when compared to survivors of conventional mechanical ventilation (CMV) as measured by the Short Form 36 (SF-36) scores ([ECMO-CMV]: 5.40 [95% confidence interval, CI, 4.11 to 6.68]). As compared to CMV survivors, those who received ECMO experienced significantly less psychological morbidity (2 studies; n = 217 [ECMO-CMV]: mean weighted difference [MWD], -1.31 [95% CI, -1.98 to -0.64] for depression and MWD, -1.60 [95% CI, -1.80 to -1.39] for anxiety).

CONCLUSIONS

Further studies are required to confirm findings and determine prognostic factors associated with more favorable outcomes in survivors of ECMO.

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes

OBJECTIVE

The purpose of this scoping review is to identify evidence describing benefits of interventions provided in intensive care unit (ICU) survivor follow-up clinics.

BACKGROUND

Advances in ICU treatments have increased the number of survivors who require specialized care for ICU-related sequelae. Intensive care unit survivor follow-up clinics exist, yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken.

METHOD

Ten databases were searched yielding 111 relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding nonrelated publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes.

RESULTS

Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms, whereas evidence to support implementation of other interventions was weak.

CONCLUSIONS

Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored.

IMPLICATIONS

Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

Inspiratory muscle training to enhance recovery from mechanical ventilation: a randomised trial

Background

In patients who have been mechanically ventilated, inspiratory muscles remain weak and fatigable following ventilatory weaning, which may contribute to dyspnoea and limited functional recovery. Inspiratory muscle training may improve inspiratory muscle strength and endurance following weaning, potentially improving dyspnoea and quality of life in this patient group.

Methods

We conducted a randomised trial with assessor-blinding and intention-to-treat analysis. Following 48 hours of successful weaning, 70 participants (mechanically ventilated ≥7 days) were randomised to receive inspiratory muscle training once daily 5 days/week for 2 weeks in addition to usual care, or usual care (control). Primary endpoints were inspiratory muscle strength and fatigue resistance index (FRI) 2 weeks following enrolment. Secondary endpoints included dyspnoea, physical function and quality of life, post-intensive care length of stay and in-hospital mortality.

Results

34 participants were randomly allocated to the training group and 36 to control. The training group demonstrated greater improvements in inspiratory strength (training: 17%, control: 6%, mean difference: 11%, p=0.02). There were no statistically significant differences in FRI (0.03 vs 0.02, p=0.81), physical function (0.25 vs 0.25, p=0.97) or dyspnoea (−0.5 vs 0.2, p=0.22). Improvement in quality of life was greater in the training group (14% vs 2%, mean difference 12%, p=0.03). In-hospital mortality was higher in the training group (4 vs 0, 12% vs 0%, p=0.051).

Conclusions

Inspiratory muscle training following successful weaning increases inspiratory muscle strength and quality of life, but we cannot confidently rule out an associated increased risk of in-hospital mortality.

Trial registration number

ACTRN12610001089022, results.

Six-month quality-of-life and functional status of acute respiratory distress syndrome survivors compared to patients at risk: a population-based study

Introduction

The long-term attributable burden related to acute respiratory distress syndrome (ARDS) is not fully investigated. The aim of this study is to evaluate the quality of life (QOL) and functional status at 6 months after hospitalization in patients at risk for ARDS who did and did not develop the syndrome.

Method

This is a population-based prospective cohort study of adult patients from Olmsted County, Minnesota, with or at risk for ARDS hospitalized from October 2008 to July 2011. The primary outcomes were changes in QOL and functional status, measured through 12-Item Short Form Survey (SF-12) and Barthel Index (BI) respectively, from baseline to 6 months, compared between survivors who did and did not develop ARDS.

Results

Of 410 patients with or at risk for ARDS, 98 had baseline surveys collected and 67 responded to a 6-month survey (26 ARDS, 41 non-ARDS). Both ARDS and non-ARDS groups had lower physical component of SF-12 at baseline compared to general population (P < 0.001 for both). ARDS patients had poorer baseline functional status compared to non-ARDS (mean BI 80 ± 25 vs. 88 ± 22, P = 0.03). No significant differences were observed for the change between 6 months and baseline BI (delta 2.3 for ARDS vs. 2.0 for non-ARDS, P = 0.5), or mental (delta 2.7 vs. 2.4, P = 0.9) or physical (delta –3 vs. –3.3, P = 0.9) component of SF-12 between survivors with and without ARDS.

Conclusion

In this population-based study, decreased QOL and functional status 6 months after hospitalization were largely explained by baseline condition, with similar recovery in survivors who did and did not develop ARDS.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1062-y) contains supplementary material, which is available to authorized users.

Long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study

OBJECTIVE

Frailty is a multidimensional syndrome characterized by loss of physiologic reserve that gives rise to vulnerability to poor outcomes. We aimed to examine the association between frailty and long-term health-related quality of life among survivors of critical illness.

DESIGN

Prospective multicenter observational cohort study.

SETTING

ICUs in six hospitals from across Alberta, Canada.

PATIENTS

Four hundred twenty-one critically ill patients who were 50 years or older.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Frailty was operationalized by a score of more than 4 on the Clinical Frailty Scale. Health-related quality of life was measured by the EuroQol Health Questionnaire and Short-Form 12 Physical and Mental Component Scores at 6 and 12 months. Multiple logistic and linear regression with generalized estimating equations was used to explore the association between frailty and health-related quality of life. In total, frailty was diagnosed in 33% (95% CI, 28-38). Frail patients were older, had more comorbidities, and higher illness severity. EuroQol-visual analogue scale scores were lower for frail compared with not frail patients at 6 months (52.2 ± 22.5 vs 64.6 ± 19.4; p < 0.001) and 12 months (54.4 ± 23.1 vs 68.0 ± 17.8; p < 0.001). Frail patients reported greater problems with mobility (71% vs 45%; odds ratio, 3.1 [1.6-6.1]; p = 0.001), self-care (49% vs 15%; odds ratio, 5.8 [2.9-11.7]; p < 0.001), usual activities (80% vs 52%; odds ratio, 3.9 [1.8-8.2]; p < 0.001), pain/discomfort (68% vs 47%; odds ratio, 2.0 [1.1-3.8]; p = 0.03), and anxiety/depression (51% vs 27%; odds ratio, 2.8 [1.5-5.3]; p = 0.001) compared with not frail patients. Frail patients described lower health-related quality of life on both physical component score (34.7 ± 7.8 vs 37.8 ± 6.7; p = 0.012) and mental component score (33.8 ± 7.0 vs 38.6 ± 7.7; p < 0.001) at 12 months.

CONCLUSIONS

Frail survivors of critical illness experienced greater impairment in health-related quality of life, functional dependence, and disability compared with those not frail. The systematic assessment of frailty may assist in better informing patients and families on the complexities of survivorship and recovery.

Outcome of ICU survivors: a comprehensive review. The role of patient-reported outcome studies

Problems survivors face after intensive care unit (ICU) discharge begin while they are still in the ward, where many of their specific problems may run unrecognized, but they assume a heavy weight when they arrive at their homes and face several kind of limitations, from being unable to climb stairs because of weight loss, asthenia, dyspnea or joint stiffness to anxiety, depression or post-traumatic stress disorder. Follow-up consultations have given us a better understanding of these specific problems, and the information gained has been used to improve intensive care itself and promote a quality service for patients and relatives. The aim of this article is to provide an overview on adult ICU outcome studies and discuss how they have influenced and improved the delivery of intensive care. We will explain how we went from real patients to outcome studies and what we have learned concerning the consequences of critical illness and critical care. Development of outcome studies, what we have learned through them and our own experience will be outlined focusing mainly in four topics: mortality, physical disability, neuropsychological disability and health-related quality of life. Interventions to improve outcome on these main topics will be presented, and we will explain how we went from outcome studies to clinical interventions, focusing on the most recent proposals of intervention to improve outcome.

Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions

RATIONALE

Survivors of critical illness suffer significant limitations and disabilities.

OBJECTIVES

Ascertain whether severe sepsis is associated with increased risk of so-called geriatric conditions (injurious falls, low body mass index [BMI], incontinence, vision loss, hearing loss, and chronic pain) and whether this association is measured consistently across three different study designs.

METHODS

Patients with severe sepsis were identified in the Health and Retirement Study, a nationally representative cohort interviewed every 2 years, 1998 to 2006, and in linked Medicare claims. Three comparators were used to assess an association of severe sepsis with geriatric conditions in survivors: the prevalence in the United States population aged 65 years and older, survivors' own pre-sepsis levels assessed before hospitalization, or survivors' own pre-sepsis trajectory.

MEASUREMENTS AND MAIN RESULTS

Six hundred twenty-three severe sepsis hospitalizations were followed a median of 0.92 years. When compared with the 65 years and older population, surviving severe sepsis was associated with increased rates of low BMI, injurious falls, incontinence, and vision loss. Results were similar when comparing survivors to their own pre-sepsis levels. The association of low BMI and severe sepsis persisted when controlling for patients' pre-sepsis trajectories, but there was no association of severe sepsis with injurious falls, incontinence, vision loss, hearing loss, and chronic pain after such controls.

CONCLUSIONS

Geriatric conditions are common after severe sepsis. However, severe sepsis is associated with increased rates of only a subset of geriatric conditions, not all. In studying outcomes after acute illness, failing to measure and control for both preillness levels and trajectories may result in erroneous conclusions.

Protocol: inspiratory muscle training for promoting recovery and outcomes in ventilated patients (IMPROVe): a randomised controlled trial

INTRODUCTION

Inspiratory muscle weakness is a known consequence of mechanical ventilation and a potential contributor to difficulty in weaning from ventilatory support. Inspiratory muscle training (IMT) reduces the weaning period and increases the likelihood of successful weaning in some patients. However, it is not known how this training affects the residual inspiratory muscle fatigability following successful weaning nor patients' quality of life or functional outcomes.

METHODS AND ANALYSIS

This dual centre study includes two concurrent randomised controlled trials of IMT in adult patients who are either currently ventilator-dependent (>7 days) (n=70) or have been recently weaned from mechanical ventilation (>7 days) in the past week (n=70). Subjects will be stable, alert and able to actively participate and provide consent. There will be concealed allocation to either treatment (IMT) or usual physiotherapy (including deep breathing exercises without a resistance device). Primary outcomes are inspiratory muscle fatigue resistance and maximum inspiratory pressures. Secondary outcomes are quality of life (Short Form-36v2, EQ-5D), functional status (Acute Care Index of Function), rate of perceived exertion (Borg Scale), intensive care length of stay (days), post intensive care length of stay (days), rate of reintubation (%) and duration of ventilation (days).

ETHICS AND DISSEMINATION

Ethics approval has been obtained from relevant institutions, and results will be published with a view to influencing physiotherapy practice in the management of long-term ventilator-dependent patients to accelerate weaning and optimise rehabilitation outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12610001089022.

Lung function and quality of life in survivors of the acute respiratory distress syndrome (ARDS)

Recent studies have begun to describe the long-term outcomes of acute respiratory distress syndrome (ARDS) survivors. These patients experience a number of physical, mental and psychological morbidities that significantly impair their health-related quality of life (HRQL). The trajectory of pulmonary recovery in survivors of ARDS, as it relates to lung function, structure and health-related quality of life (HRQL), is predictable and often persists years after hospital discharge. True pulmonary parenchymal morbidity is uncommon and when present, persistent restrictive disease is likely related to diaphragmatic weakness with a mild reduction in diffusion capacity (DLCO). Future research should focus on identifying patients at risk for long-term functional limitations and the design of rehabilitation interventions tailored to individual patient needs.

Challenges and possible solutions for long-term follow-up of patients surviving critical illness

INTRODUCTION

Surviving critical illness can be life-changing and present new healthcare challenges for patients after discharge from hospital. Optimisation of recovery, rather than mere survival, is an important goal of intensive care. Observational studies have identified decreased quality of life and increased healthcare needs for survivors but loss to follow-up can be high with possible selection bias. Patients in need of support may therefore not be included in study results or allocated appropriate follow up support.

AIM

To examine the frequency and reasons patients admitted to general ICUs who survive critical illness are excluded from study participation or lost to follow-up and consider the possible implications and solutions.

METHOD

The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies (2006-2010) were included if they described follow-up of survivors from general ICUs.

RESULTS

Ten studies were reviewed. Of the 3269 eligible patients, 14% died after hospital discharge, 27% declined, and 22% were lost to follow-up. Reasons for loss to follow-up included no response, inability to contact the patient, too ill or admitted to another facility.

CONCLUSION

The most appropriate method of care follow-up has yet to be established but is likely to involve an eclectic model that tailors service provision to support individual patient needs. Identifying methods to minimise loss to follow-up may enhance interpretation of patients' recovery, lead to improvements in clinical practice and inform healthcare service decisions and policy.

Small airway remodeling in acute respiratory distress syndrome: a study in autopsy lung tissue

INTRODUCTION

Airway dysfunction in patients with the Acute Respiratory Distress Syndrome (ARDS) is evidenced by expiratory flow limitation and dynamic hyperinflation. These functional alterations have been attributed to closure/obstruction of small airways. Airway morphological changes have been reported in experimental models of acute lung injury, characterized by epithelial necrosis and denudation in distal airways. To date, however, no study has focused on the morphological airway changes in lungs from human subjects with ARDS. The aim of this study is to evaluate structural and inflammatory changes in distal airways in ARDS patients.

METHODS

We retrospectively studied autopsy lung tissue from subjects who died with ARDS and from control subjects who died of non pulmonary causes. Using image analysis, we quantified the extension of epithelial changes (normal, abnormal and denudated epithelium expressed as percentages of the total epithelium length), bronchiolar inflammation, airway wall thickness, and extracellular matrix (ECM) protein content in distal airways. The Student's t-test or the Mann-Whitney test was used to compare data between the ARDS and control groups. Bonferroni adjustments were used for multiple tests. The association between morphological and clinical data was analyzed by Pearson rank test.

RESULTS

Thirty-one ARDS patients (A: PaO2/FiO2 ≤200, 45 ± 14 years, 16 males) and 11 controls (C: 52 ± 16 years, 7 males) were included in the study. ARDS airways showed a shorter extension of normal epithelium (A:32.9 ± 27.2%, C:76.7 ± 32.7%, P < 0.001), a larger extension of epithelium denudation (A:52.6 ± 35.2%, C:21.8 ± 32.1%, P < 0.01), increased airway inflammation (A:1(3), C:0(1), P = 0.03), higher airway wall thickness (A:138.7 ± 54.3 μm, C:86.4 ± 33.3 μm, P < 0.01), and higher airway content of collagen I, fibronectin, versican and matrix metalloproteinase-9 (MMP-9) compared to controls (P ≤0.03). The extension of normal epithelium showed a positive correlation with PaO2/FiO2 (r2 = 0.34; P = 0.02) and a negative correlation with plateau pressure (r2 = 0.27; P = 0.04). The extension of denuded epithelium showed a negative correlation with PaO2/FiO2 (r2 = 0.27; P = 0.04).

CONCLUSIONS

Structural changes in small airways of patients with ARDS were characterized by epithelial denudation, inflammation and airway wall thickening with ECM remodeling. These changes are likely to contribute to functional airway changes in patients with ARDS.

Long-term effect of the ICU-diary concept on quality of life after critical illness

BACKGROUND

Critically ill patients often spend time in the intensive care unit (ICU) either unconscious or sedated. On recovery, they are often in a state of confusion with memory loss that may be associated with a longstanding reduction in health-related quality of life (QoL). We hypothesised that the ICU-diary concept could improve their QoL by filling in their memory gaps.

METHODS

A non-randomised, prospective study in a non-academic eight-bedded general ICU. A group of patients (n=38) were selected to receive the ICU-diary concept (keeping a diary with photos while on the ICU plus a follow-up meeting) when a long and complicated course was expected. Health-related QoL at 6, 12, 24 and 36 months was compared with a group that did not receive the ICU-diary (n=224). The Medical Outcomes Study 36-Item Short-Form (SF-36) was used to measure health-related QoL. Multiple regression models adjusted for age, sex, illness severity, pre-existing disease and diagnostic category was used to analyse the effects of the ICU-diary concept at 6 months, and changes over time were analysed using repeated measures MANOVA.

RESULTS

Crude and adjusted scores for two dimensions of SF-36 (general health and vitality) and the physical component summary score were significantly higher at 6 months in the ICU-diary group (P<0.05) and some of the effects remained during the 3-year follow-up period (P<0.05).

CONCLUSION

The ICU-diary concept was associated with improved health-related QoL during the 3-year follow-up period after a critical illness. The effect of this intervention needs to be confirmed in a larger randomised study.

Long-term survival and quality of life after transfusion-associated pulmonary edema in critically ill medical patients

BACKGROUND

Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) commonly complicate transfusion in critically ill patients. Prior outcome studies of TACO and TRALI have focused on short-term morbidity and mortality, but the long-term survival and quality of life (QOL) of these patients remain unknown.

METHODS

In a nested case-control study, we compared survival and QOL between critically ill medical patients who developed pulmonary edema after transfusion (TRALI or TACO) and medical critically ill transfused controls, matched by age, gender, and admission diagnostic group. QOL in survivors was assessed with a 36-item short form health survey 1 year after initial hospitalization.

RESULTS

Hospital, 1-year, and 2-year mortality among the 74 TRALI cases and 74 matched controls were 43.2% vs 24.3% (P = .020), 63.8% vs 46.4% (P = .037) and 74.3% vs 54.3% (P = .031), whereas among the 51 TACO cases and 51 matched controls these values were 7.8% vs 11.8% (P = .727), 38.0% vs 28.0% (P = .371), and 44.9% vs 38.8% (P = .512). When adjusted for age and baseline severity of illness in a Cox proportional hazard analysis, the development of TRALI remained associated with decreased survival (hazard ratio 1.86; 95% CI, 1.19-2.93; P = .006). Both TRALI (P = .006, P = .03) and TACO (P = .03, P = .049) were associated with prolonged ICU and hospital lengths of stay.

CONCLUSIONS

In critically ill medical patients, development of TRALI, but not TACO, is independently associated with decreased long-term survival.

[Outcome for adults with acute respiratory distress syndrome]

Acute respiratory distress syndrome in adults (ARDS) is a relatively frequent disease, the mortality of which has diminished considerably in recent years. The long-term outcome of patients who have survived ARDS has been studied extensively and should in the future be taken into account in assessing new treatment modalities. The long-term respiratory sequelae are generally minimal and moderately disabling. Secondary deterioration of respiratory function is not part of the natural history of ARDS and should suggest other diagnoses. The various studies find a clear diminution in quality of life after ARDS (compared with the general population), essentially related to neuromuscular deficiencies associated with the neuromyopathies of resuscitation or to neuropsychological damage combining cognitive disorders and symptoms of posttraumatic stress. These symptoms are not at all specific to ARDS. They are found in varying degrees in patients who have survived intensive care or resuscitation. Appropriate management for these symptoms remains to be determined. Critical care units must now work at preventing the onset of these disorders, by limiting the treatments at risk when possible and by identifying these disorders before discharge to prepare for optimal subsequent management. Patients with ARDS are only a subgroup of more severe illness among all patients in critical care departments.

Neuromuscular Sequelae in Survivors of Acute Lung Injury

Pulmonary function improves rapidly in most survivors of ALI, yet most have profound and life-altering physical impairment. critical illness polyneuropathy and myopathy (CIPM) are complications that may account for most long-term disability. Short-term morbidity includes difficulty weaning from mechanical ventilation, return to assisted breathing after weaning, and delayed return home after hospital discharge. Therapies that reduce sepsis and prolonged mechanical ventilation may minimize CIPM, as in intensive insulin treatment of ICU hyperglycemia. CIPM identification is important for ALI patients' care and prognostication. Observational studies are needed to understand the epidemiology and natural history of CIPM; interventional studies with CIPM and functional outcomes as major endpoints are essential for improvement of ALI patients' health and quality of life.

Quality of life after acute respiratory distress syndrome: a meta-analysis

OBJECTIVE

To summarize long-term quality of life (QOL) and the degree of variation in QOL estimates across studies of acute respiratory distress (ARDS) survivors.

DESIGN

A systematic review of studies evaluating QOL in ARDS survivors was conducted. Medline, EMBASE, CINAHL, pre-CINAHL, and the Cochrane Library were searched, and reference lists from relevant articles were evaluated. Two authors independently selected studies reporting QOL in adult survivors of ARDS or acute lung injury at least 30 days after intensive care unit discharge and extracted data on study design, patient characteristics, methods, and results.

MEASUREMENTS AND RESULTS

Thirteen independent observational studies (557 patients) met inclusion criteria. Eight of these studies used eight different QOL instruments, allowing only qualitative synthesis of results. The five remaining studies (330 patients) measured QOL using the Medical Outcomes Study 36-Item Short Form survey (SF-36). Mean QOL scores were similar across these studies, falling within a range of 20 points for all domains. Pooled domain-specific QOL scores in ARDS survivors 6 months or later after discharge ranged from 45 (role physical) to 66 (social functioning), or 15-26 points lower than population norms, in all domains except mental health (11 points) and role physical (39 points). Corresponding confidence intervals were no wider than +/-9 points. Six studies all found stable or improved QOL over time, but only one found significant improvement beyond 6 months after discharge.

CONCLUSIONS

ARDS survivors in different clinical settings experience similar decrements in QOL. The precise magnitude of these decrements helps clarify the long-term prognosis for ARDS survivors.

Studying outcomes of intensive care unit survivors: the role of the cohort study

BACKGROUND

As research focuses on long-term patient outcomes and the "real world" effectiveness of intensive care unit (ICU) therapies, the cohort study is increasingly being used in critical care research.

METHODS

Using examples of prior cohort studies in intensive care, we review the key elements of this research design and evaluate its advantages and limitations for critical care research. Furthermore, through a systematic search of the literature we summarize data from 70 prior published cohort studies of medium- and long-term outcomes in adult critical care medicine.

DISCUSSION

This research demonstrates that the prospective cohort study is a powerful research design that has not been fully leveraged to assess relationships between exposures and long-term outcomes of ICU survivors.

CONCLUSIONS

We make recommendations for the design of future cohort studies to maximize the impact of this research in improving the long-term outcomes of critically ill patients.

Patients' recollections of experiences in the intensive care unit may affect their quality of life

Introduction

We wished to obtain the experiences felt by patients during their ICU stay using an original questionnaire and to correlate the memories of those experiences with health-related quality of life (HR-QOL).

Methods

We conducted a prospective study in 10 Portuguese intensive care units (ICUs). Six months after ICU discharge, an original questionnaire on experiences of patients during their ICU stay, the recollection questionnaire, was delivered. HR-QOL was evaluated simultaneously, with the EQ-5D questionnaire. Between 1 September 2002 and 31 March 2003 1433 adult patients were admitted. ICU and hospital mortalities were 21% and 28%, respectively. Six months after ICU discharge, 464 patients completed the recollection questionnaire.

Results

Thirty-eight percent of the patients stated they did not remember any moment of their ICU stay. The ICU environment was described as friendly and calm by 93% of the patients. Sleep was described as being good and enough by 73%. The experiences reported as being more stressful were tracheal tube aspiration (81%), nose tube (75%), family worries (71%) and pain (64%). Of respondents, 51% experienced dreams and nightmares during their ICU stay; of these, 14% stated that those dreams and nightmares disturb their present daily life and they exhibit a worse HR-QOL. Forty-one percent of patients reported current sleep disturbances, 38% difficulties in concentrating in current daily activities and 36% difficulties in remembering recent events. More than half of the patients reported more fatigue than before the ICU stay. Multiple and linear regression analysis showed that older age, longer ICU stay, higher Simplified Acute Physiology Score II, non-scheduled surgery and multiple trauma diagnostic categories, present sleep disturbances, daily disturbances by dreams and nightmares, difficulties in concentrating and difficulties in remembering recent events were independent predictors of worse HR-QOL. Multicollinearity analysis showed that, with the exception of the correlation between admission diagnostic categories and length of ICU stay (0.47), all other correlations between the independent variables and coefficient estimates included in the regression models were weak (below 0.30).

Conclusion

This study suggests that neuropsychological consequences of critical illness, in particular the recollection of ICU experiences, may influence subsequent HR-QOL.

Understanding the lingering consequences of what we treat and what we do

Granja and colleagues have helped us by showing that long-term follow-up is feasible and by trying to tease out whether select intensive care unit patient populations are at particular risk of adverse outcomes. This work gives us clues for future investigations which will hopefully interrogate further the potential mechanisms of action that underlie poor long-term outcomes. In the meantime, we can hope that this quality of follow-up will move from the research arena to become a part of routine clinical care.

Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness

Introduction

The objective of the present study was to compare the health-related quality of life (HR-QoL) of survivors from severe sepsis and septic shock with HR-QoL in others who survived critical illness not involving sepsis.

Methods

From March 1997 to March 2001, adult patients in an eight-bed medical/surgical intensive care unit (ICU) of a tertiary care hospital admitted with severe sepsis or septic shock (sepsis group; n = 305) were enrolled and compared with patients admitted without sepsis (control group; n = 392). Patients younger than 18 years (n = 48) and those whose ICU stay was 1 day or less (n = 453) were excluded. In addition, patients exhibiting nonsevere sepsis on admission were excluded (n = 87). Finally, patients who developed nonsevere sepsis or severe sepsis/septic shock after admission were also excluded (n = 88).

Results

In-hospital mortality rates were 34% in the sepsis group and 26% in the control group. There were no differences in sex, age, main activity (work status), and previous health state between groups. Survivors in the sepsis group had a significantly higher Acute Physiology and Chronic Health Evaluation II score on admission (17 versus 12) and stayed significantly longer in the ICU. A follow-up appointment was held 6 months after ICU discharge, and an EQ-5D (EuroQol five-dimension) questionnaire was administered. A total of 104 sepsis survivors and 133 survivors in the control group answered the EQ-5D questionnaire. Sepsis survivors reported significantly fewer problems only in the anxiety/depression dimension. Although there were no significant differences in the other dimensions of the EQ-5D, there was a trend towards fewer problems being reported by sepsis survivors.

Conclusion

Evaluation using the EQ-5D at 6 months after ICU discharge indicated that survivors from severe sepsis and septic shock have a similar HR-QoL to that of survivors from critical illness admitted without sepsis.