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

Surviving Critical Care: A Follow-Up Study Assessing Pulmonary Function, Cardiopulmonary Exercise Testing, and Quality of Life in COVID-19-Affected Patients

INTRODUCTION

Survivors of severe COVID-19 face complex challenges and a high degree of pulmonary sequelae. Therefore, we aim to describe their ongoing health burden.

METHODS

In this single-center prospective cohort study, COVID-19 ICU survivors were invited 3 and 6 months after ICU discharge. We examined pulmonary function with pulmonary function tests (PFT) and cardiopulmonary exercise testing (CPET), and we established health-related quality of life (HRQL) and health status (HS) with the EuroQol five-dimension five-level (EQ-5D-5L), the short-form health survey 12 (SF-12), and the modified British Medical Research Council dyspnea scale (mMRC) questionnaires.

RESULTS

Out of the 53 individuals screened, 23 participated in this study. Throughout both assessment points, participants maintained PFT results within range, apart from a decline in the transfer factor of the lung for carbon monoxide (TLCO). CPET showed improved fitness but persistent ventilatory deficiencies, indicated by altered dead space ventilation (VD/VT) and elevated arterial-alveoli gradient for oxygen (AaDO2). HRQL and HS remained compromised, with both physical (PCS) and mental component summary (MCS) scores significantly lower than the standardized norm population scores. Also, there was a rise in the prevalence of issues related to mobility, pain/discomfort, and anxiety/depression, and an increase in reported dyspnea.

CONCLUSION

These results enhance our comprehension of the complex difficulties faced by COVID-19 ICU survivors. Six months post-discharge, CPET revealed the presence of ventilatory insufficiencies. Additionally, there was a decline in HRQL and HS, notably affected by mental health concerns and an increase in the level of dyspnea.

Long-term assessment of functional capacity, muscle function, lung function, and quality of life in survivors of ventilator-associated pneumonia

Background and objective

The many patients who develop ventilator-associated pneumonia (VAP) have generated numerous VAP survivors who are not followed up in the long term. This study aimed, primarily, to evaluate the long-term functional capacity, as measured using the Glittre-ADL test (TGlittre), of VAP survivors and, secondarily, to calculate the correlations of TGlittre with muscle and lung function.

Methods

This cross-sectional study evaluated 30 VAP survivors 10 months after discharge from the intensive care unit. The participants underwent the following assessments: TGlittre; respiratory muscle strength; handgrip strength (HGS); spirometry; Functional Assessment of Chronic Therapy (FACIT-F); and Short Form-36 (SF-36).

Results

The median TGlittre time was 95 (81-130)% of predicted, and 30 % of the participants performed poorly on TGlittre. One-third of the participants had abnormal spirometry results. TGlittre time was correlated with weight (rs = -0.412, P = 0.023), body index mass (BMI, rs = -0.400, P = 0.029), forced vital capacity (FVC, rs = -0.401, P = 0.030), HGS (rs = -0.571, P = 0.0009), FACIT-F score (rs = -0.405, P = 0.026), and different SF-36 domain scores. Participants who returned to work had a shorter TGlittre time than those who did not (89 (69-104) vs. 129 (102-183)% predicted). Multiple linear regression indicated that FVC and BMI explained 39 % of TGlittre variability.

Conclusion

VAP survivors had suboptimal functional capacity, low lung function, and general fatigue 10 months after discharge. The longer the TGlittre time was, the worse the lung function, muscle function, general fatigue, and quality of life were and the less likely the patient was to have returned to work.

Trajectories of quality of life, return to work, psychopathology, and disability in survivors of the acute respiratory distress syndrome (ARDS): A three-year prospective cohort study (DACAPO)

PURPOSE

Describe the long-term development of outcomes for survivors of the Acute Respiratory Distress Syndrome (ARDS).

MATERIAL AND METHODS

A cohort study with N = 877 ARDS survivors was conducted. Health related quality of life (HRQoL, Physical and Mental Component Scale: PCS, MCS of the SF-12), return to work (RtW), panic disorder, depressive symptoms (PHQD), and post-traumatic-stress-disorder (PTSD, PTSS-14) were assessed at 3, 6, 12, 24, and 36 months after discharge from ICU.

RESULTS

PCS, MCS, and RtW increased during the first 12 months [e.g. PCS: Md = 36 (IQR 31-43) at 3 months, Md = 42 (IQR 34-52) at 12 months; MCS: Md = 44 (IQR 32-54) at 3 months, Md = 47 (IQR 33-57) at 12 months, RtW = 23.2% at 3 months, 54.5% at 12 months], and remained relatively stable afterwards. Proportion of major depressive syndrome decreased from 3 (14.2%) to 36 months (8.9%). Proportions of panic disorder (5.3% to 7.4%) and PTSD (27.1% to 32.6%) varied only slightly.

CONCLUSIONS

Most of recovery in HRQoL and RtW occur during the first 12 months, after which a plateau is reached, indicating a chronification for many patients. Contrary to this, however, psychopathological symptoms remain stable, except for depressive symptoms. [200 words].

Impact of COVID infection on lung function test and quality of life

Post-COVID-19 pulmonary sequalae are well-recognized early in the pandemic. Survivorship clinics are crucial for managing at-risk patients. However, it is unclear who requires pulmonary function test (PFT) and when PFTs should be performed. We aim to investigate for whom and how these interval PFTs should be performed. We performed a single-centre, prospective cohort study on COVID-19 survivors between 1st May 2020 and 31st April 2022. These patients were followed up at 6, 9 and 12 months with interval PFT and Short Form-36 (SF-36) Health Survey. Those with PFT defects were offered a computed tomography scan of the thorax. Of the 46 patients recruited, 17 (37%) had severe/critical illness. Compared to those with mild/moderate disease, these patients were more likely to experience DLCO defects (59% versus 17%, p = 0.005) and had lower SF-36 scores (mean physical component summary score of 45 ± 12 versus 52 ± 8, p = 0.046). These differences were most notable at 6 months, compared to the 9- and 12-months intervals. DLCO defects were also associated with older age, raised inflammatory markers and extensive CXR infiltrates. Besides interstitial-like abnormalities, obesity and undiagnosed lung conditions accounted for 39% of the PFT abnormalities. Interval PFTs can be performed earliest 6 months post-COVID-19. Patients with normal tests were unlikely to develop new abnormalities and would not require repeat PFTs. Abnormal PFTs can be followed-up with repeat PFTs 6 monthly until resolution. Non-COVID-19 differentials should be considered for persistent PFT abnormalities.

One-Year Mental and Physical Health Assessment in Survivors after Extracorporeal Membrane Oxygenation for COVID-19-related Acute Respiratory Distress Syndrome

Rationale: Long-term outcomes of patients with coronavirus disease (COVID-19)-related acute respiratory distress syndrome treated with extracorporeal membrane oxygenation (ECMO) are unknown. Objectives: To assess physical examination, pulmonary function tests, anxiety, depression, post-traumatic stress disorder and quality of life at 6 and 12 months after ECMO onset. Methods: Multicenter, prospective study in patients who received ECMO for COVID-19 acute respiratory distress syndrome from March to June 2020 and survived hospital discharge. Measurements and Main Results: Of 80 eligible patients, 62 were enrolled in seven French ICUs. ECMO and invasive mechanical ventilation duration were 18 (11-25) and 36 (27-62) days, respectively. All were alive, but only 19/50 (38%) returned to work and 13/42 (31%) had recovered a normal sex drive at 1 year. Pulmonary function tests were almost normal at 6 months, except for Dl_CO, which was still impaired at 12 months. Mental health, role-emotional, and role-physical were the most impaired domain compared with patients receiving ECMO who did not have COVID-19. One year after ICU admission, 19/43 (44%) patients had significant anxiety, 18/43 (42%) had depression symptoms, and 21/50 (42%) were at risk for post-traumatic stress disorders. Conclusions: Despite the partial recovery of the lung function tests at 1 year, the physical and psychological function of this population remains impaired. Based on the comparison with long-term follow-up of patients receiving ECMO who did not have COVID-19, poor mental and physical health may be more related to COVID-19 than to ECMO in itself, although this needs confirmation.

Incidence of death or disability at 6 months after extracorporeal membrane oxygenation in Australia: a prospective, multicentre, registry-embedded cohort study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment.

METHODS

This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov, NCT03793257.

FINDINGS

Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] -32% [95% CI -49 to -15]; p<0·001) but not VA-ECMO (VA-ECMO vs eCPR -8% [-22 to 6]; p=0·27).

INTERPRETATION

In our study, only a third of patients were alive without moderate-to-severe disability at 6 months after initiation of ECMO. The finding that disability was common across all areas of functioning points to the need for long-term, multidisciplinary care and support for surviving patients who have had ECMO. Further studies are needed to understand the 180-day and longer-term prognosis of patients with different diagnoses receiving different modes of ECMO, which could have important implications for the selection of patients for ECMO and management strategies in the ICU.

FUNDING

The National Health and Medical Research Council of Australia.

Pulmonary Aspects of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus that gains entry via angiotensin-converting enzyme 2 (ACE2) within airway epithelium. Patients exhibit a spectrum of respiratory symptoms from asymptomatic to respiratory failure. Patient factors including obesity, tobacco use, and black race are all associated with increased ACE2 expression and may contribute to increased complications. Consolidation and ground-glass opacities on chest imaging are typical but not specific for coronavirus disease 2019 (COVID-19). Venous thromboembolism occurs infrequently when prophylactic anticoagulation is provided. However, capillary microthrombosis is nearly ubiquitous, suggesting that it contributes to hypoxemia. Remdesivir and glucocorticoids may benefit some hospitalized patients. Many of those afflicted remain symptomatic two weeks following diagnosis and continue to require health care. Total lung capacity, diffusion capacity, and maximal oxygen consumption may be reduced for months in some survivors. Lung transplant offers chronically critically ill patients new hope, and this option may have increasing potential for outpatients with COVID-19-associated fibrosis.

Quality of life and functional status of patients treated with venovenous extracorporeal membrane oxygenation at 6 months

PURPOSE

Quality of life (QoL) outcomes of patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) have been conflicting. This study reports on QoL outcomes for a broad group of ARDS patients managed with up-to-date treatment modalities.

METHODS

We prospectively recruited patients at a quaternary hospital in the United Kingdom from 2013 to 2015 who were treated with ECMO for ARDS. We evaluated their pulmonary function and QoL at 6-months after admission using three QoL instruments: EuroQoL 5D (EQ-5), HADS, and PTSS-14.

RESULTS

Forty-three patients included in the analysis had near-normal pulmonary function at 6 months. HADS showed moderate-to-severe anxiety and depression in 32% and 11% of patients, respectively. PTSS-14 showed 29% had signs of post-traumatic stress disorder. EQ-5D showed that 67% of patients had difficulty returning to usual activities, 74% suffered some pain, none reported severe problems and 77% were able to return to work. No clinical or demographic variables were associated with poor 6-month QoL.

CONCLUSIONS

Patients with ARDS treated with ECMO generally had good QoL outcomes, similar to outcomes reported for patients managed without ECMO. With respect to QoL, VV-EMCO represents a valid treatment modality for patients with refractory ARDS.

Long-Term Impact of COVID-19: A Systematic Review of the Literature and Meta-Analysis

Background: The long-term impact of COVID-19 is still unknown. This study aimed to explore post COVID-19 effects on patients chest computed tomography (CT), lung function, respiratory symptoms, fatigue, functional capacity, health-related quality of life (HRQoL), and the ability to return to work beyond 3 months post infection. Methods: A systematic search was performed on PubMed, Web of Science, and Ovid MEDLINE on 22 May 2021, to identify studies that reported persistent effects of COVID-19 beyond 3 months follow-up. Data on the proportion of patients who had the outcome were collected and analyzed using a one-group meta-analysis. Results: Data were extracted from 24 articles that presented information on a total of 5323 adults, post-infection, between 3 to 6 months after symptom onset or hospital discharge. The pooled prevalence of CT abnormalities was 59% (95% CI 44–73, I² = 96%), abnormal lung function was 39% (95% CI 24–55, I² = 94%), fatigue was 38% (95% CI 27–49, I² = 98%), dyspnea was 32% (95% CI 24–40, I² = 98%), chest paint/tightness was 16% (95% CI 12–21, I² = 94%), and cough was 13%, (95% CI 9–17, I² = 94%). Decreased functional capacity and HRQoL were found in 36% (95% CI 22–49, I² = 97%) and 52% (95% CI 33–71, I² = 94%), respectively. On average, 8 out of 10 of the patients had returned to work or reported no work impairment. Conclusion: Post-COVID-19 patients may experience persistent respiratory symptoms, fatigue, decreased functional capacity and decreased quality of life up to 6 months after infection. Further studies are needed to establish the extent to which post-COVID-19 effects continue beyond 6 months, how they interact with each other, and to clarify their causes and their effective management.

Sequelae of Acute Respiratory Distress Syndrome: Interest of Rehabilitation

Case Presentation

This clinical case presents the history of a woman hospitalized for acute respiratory distress syndrome (ARDS). A 62-year-old woman, with regular physical activity and no history of respiratory disease or smoking, was hospitalized for moderate ARDS with bilateral pneumonitis. Fourteen days later, she was discharged from the intensive care unit and received respiratory physical therapy. One month later, she experienced exertional dyspnea. A regression of alveolar condensation with persistent sequelae at the pulmonary bases was noted. Three months later, the patient continued daily physical activity with satisfactory tolerance. A reduction in alveolar-capillary transfer, inappropriate hyperventilation upon exercise, and impairment of gas exchanges at maximal effort, suggestive of pulmonary shunt, were demonstrated. At the 6-month evaluation, the patient displayed exertional dyspnea with residual bilateral basal consolidations. Six months later, the dyspnea had ceased. The persistence of bilateral basal interstitial syndrome associated with bronchial dilatation and pleural-based consolidations was noted, as well as a stable impaired alveolar-capillary diffusing capacity.

Discussion

Upon discharge from intensive care, pulmonary follow-up should be proposed to ARDS survivors. Moreover, pulmonary function testing at rest and exercise is advised as soon as possible to evaluate the respiratory sequelae. This will help to limit the severity of complications through adapted exercise rehabilitation and then regular physical activity.

Mesenchymal stem cells with downregulated Hippo signaling attenuate lung injury in mice with lipopolysaccharide‑induced acute respiratory distress syndrome

Mesenchymal stem cell (MSC)-mediated repair of injured alveolar epithelial cells is a promising potential cure for acute respiratory distress syndrome (ARDS); however, the repairing effect of MSCs is limited by poor homing and differentiation. Our previous study revealed that the inhibition of the Hippo signaling pathway promotes the proliferation, migration and differentiation of MSCs in vitro, leading to the hypothesis that MSCs with downregulated Hippo signaling could further ameliorate lipopolysaccharide (LPS)-induced ARDS in vivo. In the current study, mouse bone marrow-derived MSCs (mMSCs) with downregulated Hippo signaling were constructed by shRNA-mediated knockdown of large tumor suppressor kinase 1 (Lats1) and were intratracheally administered to LPS-induced mouse models of ARDS. The inhibition of Hippo signaling increased the retention of mMSC in ARDS lung tissue and their differentiation toward alveolar type II epithelial cells. Furthermore, mMSCs with downregulated Hippo signaling led to a decreased lung wet weight/body weight ratio, decreased total protein and albumin concentrations in bronchoalveolar lavage fluid, decreased levels of proinflammatory factors and increased levels of anti-inflammatory factors. Finally, mMSCs with downregulated Hippo signaling improved pathological changes and decreased pulmonary fibrosis in lungs of mice with ARDS. These results suggest that the inhibition of the Hippo signaling pathway in mouse mMSCs by knockdown of Lats1 could further improve the protective effects of mMSCs against epithelial damage and the therapeutic potential of mMSCs on mice with ARDS.

Importance of carbon dioxide in the critical patient: Implications at the cellular and clinical levels

Important recent insights have emerged regarding the cellular and molecular role of carbon dioxide (CO₂) and the effects of hypercapnia. The latter may have beneficial effects in patients with acute lung injury, affording reductions in pulmonary inflammation, lessened oxidative alveolar damage, and the regulation of innate immunity and host defenses by inhibiting the expression of inflammatory cytokines. However, other studies suggest that CO₂ can have deleterious effects upon the lung, reducing alveolar wound repair in lung injury, decreasing the rate of reabsorption of alveolar fluid, and inhibiting alveolar cell proliferation. Clearly, hypercapnia has both beneficial and harmful consequences, and it is important to determine the net effect under specific conditions. The purpose of this review is to describe the immunological and physiological effects of carbon dioxide, considering their potential consequences in patients with acute respiratory failure.

Neuromuscular and neuropsychological assessments in survivors of acute respiratory distress syndrome: exploratory comparisons with an at-risk cohort

BACKGROUND

Long-term studies of survivors of acute respiratory distress syndrome (ARDS) have reported neuromuscular, quality of life, and neuropsychological impairments. This study aims to determine if development of ARDS was associated with neuromuscular weakness and depression at 6-month following hospital discharge in a population-based cohort of patients at high risk for ARDS.

METHODS

A validated lung injury prediction model prospectively identified adult patients at increased risk for ARDS admitted to Mayo Clinic between October 2008 and July 2011. Instruments for functional impairment [Overall Neuropathy Limitations Scale (ONLS)] and the presence of depressive symptoms (the Yale Single Question) were administered at baseline and at 6 months.

RESULTS

Of 107 patients enrolled in the study, 98 (92 %) underwent baseline assessment. Of these, 83 (85 %) were admitted to intensive care, 41 (42 %) developed ARDS, and 67 (68 %) completed assessment at 6 months. Patients with ARDS had longer intensive care and hospital length of stay (7.9 vs. 3.1 days, p = 0.005 and 19.5 vs. 10.6 days, p = 0.004, respectively). There was no difference in reported functional impairment at 6 months from baseline in the ARDS group compared to the non-ARDS group-mean ONLS Total Score 2.95 versus 2.07 p = 0.09 and 3.0 versus 2.1 p = 027, respectively. There was also no difference in the prevalence of depression at 6 months between the ARDS and non-ARDS group (21.9 vs. 30.7 % p = 0.41).

CONCLUSIONS

In this single-center population-based cohort study, survivors of ARDS in the community had similar reported functional impairment and depression prevalence compared to an at-risk cohort that did not develop ARDS.

High-frequency oscillatory ventilation for early acute respiratory distress syndrome in adults

PURPOSE OF REVIEW

High-frequency oscillatory ventilation (HFOV) has been considered a potentially ideal mode of lung-protective ventilation. A recent meta-analysis suggested improved oxygenation and reduced mortality in adults and children with acute respiratory distress syndrome (ARDS), but the use of outdated control strategies and small numbers of patients in many of the studies rendered these findings hypothesis-generating only.

RECENT FINDINGS

During 2013, two large randomized controlled trials comparing HFOV with a conventional lung-protective ventilation were published - the Oscillation for Acute Respiratory Distress Syndrome Treated Early (OSCILLATE) and the Oscillation in ARDS (OSCAR) trials. These trials suggested no benefit or even harm with HFOV in adults with early moderate-to-severe ARDS. In this article, the major characteristics of these two studies and the possible reasons for failure to achieve the expected theoretical benefits are reviewed. Moreover, future directions with potential new technical advances and the use of new bedside monitoring techniques are addressed.

SUMMARY

The OSCILLATE and OSCAR trials showed that the early application of HFOV in moderate-to-severe adult ARDS does not reduce mortality compared with conventional ventilation strategies. Future studies on HFOV will need to identify those patients who might benefit most from HFOV and to determine the best oscillator settings. Both goals require an improved capability of monitoring recruitment and overdistension, and oscillatory volumes.

The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

Purpose

This study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors’ health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies.

Methods

Data from 140 ECMO-treated ARDS patients admitted to three French ICUs (2008–2012) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQL, psychological and PTSD status.

Results

Main ARDS etiologies were bacterial (45 %), influenza A[H₁N₁] (26 %) and post-operative (17 %) pneumonias. Six months post-ICU discharge, 84 (60 %) patients were still alive. Based on multivariable logistic regression analysis, the PRESERVE (PRedicting dEath for SEvere ARDS on VV-ECMO) score (0–14 points) was constructed with eight pre-ECMO parameters, i.e. age, body mass index, immunocompromised status, prone positioning, days of mechanical ventilation, sepsis-related organ failure assessment, plateau pressure andpositive end-expiratory pressure. Six-month post-ECMO initiation cumulative probabilities of survival were 97, 79, 54 and 16 % for PRESERVE classes 0–2, 3–4, 5–6 and ≥7 (p < 0.001), respectively. HRQL evaluation in 80 % of the 6-month survivors revealed satisfactory mental health but persistent physical and emotional-related difficulties, with anxiety, depression or PTSD symptoms reported, by 34, 25 or 16 %, respectively.

Conclusions

The PRESERVE score might help ICU physicians select appropriate candidates for ECMO among severe ARDS patients. Future studies should also focus on physical and psychosocial rehabilitation that could lead to improved HRQL in this population.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-013-3037-2) contains supplementary material, which is available to authorized users.