Approach to the treatment of severe adult respiratory failure

Objectives: The purpose of this article is to evaluate outcome in adult patients with severe respiratory failure managed with an approach using (1) limitation of end inspiratory pressure, (2) inverse ratio ventilation, (3) titration of PEEP by SVO2, (4) intermittent prone positioning, (5) limitation of FiO(2), (6) diuresis, (7) transfusion, and (8) extracorporeal life support (ECLS) if patients failed to respond. Patients and Methods: This study was designed as a retrospective review in the intensive care unit of a tertian/referral hospital. One-hundred forty-one consecutive patients with hypoxic (n = 135) or hypercarbic (n = 6) respiratory failure referred for consideration of ECLS between 1990 and 1996. Overall, initial PaO2/FiO(2) (P/F) ratio was 75 +/- 5 (median = 66). Results: Lung recovery occurred in 67% of patients and 62% survived. Forty-one patients improved without ECLS (83% survived); 100 did not and were supported with ECLS (54% survived). Survival was greater in patients cannulated within 12 hours of arrival (59%) compared with those cannulated after 12 hours (400%, P<.05). Multiple logistic regression identified age, duration of mechanical ventilation before transfer, four or more dysfunctional organs, and the requirement for ECLS as independent predictors of mortality. Conclusions: An approach that emphasizes lung protection and early implementation of extracorporeal life support is associated with high rates of survival in patients with severe respiratory failure. Copyright (C) 1998 by W.B. Saunders Company.