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Prognosis of Patients With Advanced Idiopathic Pulmonary Fibrosis Requiring Mechanical Ventilation for Acute Respiratory Failure: ARF

The baseline characteristics of these 23 patients are given in Table 1. We recorded the most recent results of pulmonary function tests performed before the current hospitalization when the patient was considered to be in a stable condition. At admission to the ICU, 16 patients were potential candidates for LTx: 5 patients were already on the waiting list for LTx (mean ± SD waiting time, 18.6 ± 12 days); 3 patients who had completed the preoperative evaluation and who were not yet on the waiting list were enrolled 2.3 ± 3 days after ICU admission; and 8 patients were in the preoperative evaluation phase. The remaining seven patients did not fulfill the selection criteria for LTx program. Patients considered for LTx had a longer history of IPF, received more immunosuppressive therapy (corticosteroids and/or cytotoxic agents), required more oxygen, and had a longer duration of oxygen therapy than patients who were not suitable for LTx. Additionally, patient candidates for a LTx had worse baseline respiratory function (as assessed by vital capacity [VC] and total lung capacity [TLC]) than those who were not. In 15 of the 23 patients (65%), the diagnosis of IPF was confirmed by histologic examination (by open lung biopsy specimen before admission to the ICU [n = 9], by autopsy [n = 5], or by examination of the explanted lung in the case of LTx [n = 1]). In 14 of these 15 patients, an attempt at classification was made according to the published criteria: usual interstitial pneumonia (n = 8), nonspecific interstitial pneumonia (n = 1), or classification considered impossible (n = 5). In 1 of the 15 patients, open lung biopsy was performed in another country and histologic data were not available. canadian family pharmacy online

The decision of initiating MV depended on the attending physician. This decision was based on the presence of at least one of the two following criteria of respiratory failure: severe dyspnea with marked deterioration of oxygen saturation, or oxygen saturation < 80% despite a high oxygen flow rate using a high-concentration facial mask (Rusch Medical; Le Paget, France), or acute alteration of consciousness with or without marked hyper-capnia.
The patients were receiving mechanical ventilation using Cesar (Taema; Paris, France), Erica (Engstrom; Bromma, Sweden), or Evita 2 (Drager Medical; Lubeck, Germany) ventilators. The initial settings of the ventilator were adjusted in order to minimize peak airway pressure and to maintain adequate ventilation. To accomplish the goal of limiting peak airway pressure, Paco2 was permitted to rise. The fraction of inspired oxygen (Fio2) was 100% at the time of intubation and was then progressively decreased to the lowest level compatible with arterial oxygen hemoglobin saturation > 90%. Thereafter, these settings were adjusted by the attending physician. After intubation, there were no decisions of withdrawal of support or of “do not resuscitate.”
Assessment of the Cause of ARF
The precipitating cause of ARF leading to MV was investigated retrospectively by analyzing the medical records of patients. The final diagnosis of the cause of ARF was made after reviewing the clinical, radiologic, ultrasound, microbiological, hemodynamic, and pathologic records of each patient when available. The diagnosis of pneumonia was considered if the patient met the following criteria: appearance of a new pulmonary infiltrate on chest radiograph and documented pulmonary pathogen, ie, culture of BAL yielding > 104 cfu/mL or culture of Wimberley brush catheter with > 103 cfu/mL.
Table 1—Baseline Characteristics of Patients Admitted to the ICU

Characteristics All Patients Patients Candidates for LTx (n = 16) Patients Not Candidates for LTx (n = 7) p Value
Mean age, yr (range) 53 (21-82) 45 (21-62) 71 (56-82) < 0.001
Male/female gender, No. 19/4 12/4 7/0 0.23
Onset of IPF, mo 31 (2-180) 51 (6-98) 4(2-180) 0.03
Oxygen flow rate, L/min 3.8 ± 2.7 4.2 ± 2.3 2.7 ± 3.5 0.2
Duration of oxygen therapy, 3(0-62) 5.5 (1-62) 0.5 (0-4) 0.002
mo
Immunosuppressive therapy 21 (91) 16 (100) 5(71) 0.08
for IPF, No. (%)
Pao2 at rest, room air, mm Hg 57 ± 10 56 ± 8 61 ± 13 0.3
Paco2 at rest, room air, 41 ± 4 41 ± 4 39 ± 4 0.3
mm Hg
VC (% predicted)! 41 ± 15 36 ± 12 61 ± 2 0.001
TLC (% predicted)! 48 ± 13 43.5 ± 8 70 ± 8 < 0.001
Dlco (% predicted)! 30 ± 13 NP