Assessment of prognosis in patients with community-acquired pneumonia who require mechanical ventilation.

Abstract

STUDY OBJECTIVES: Knowing that mortality is high in patients who require mechanical ventilation patients with community-acquired pneumonia (CAP), we hypothesized that the severity of acute lung injury could be used along with nonpulmonary factors to identify patients with the highest risk of death. We formulated a prediction model to quantitate the risk of hospital mortality in this population of patients. DESIGN: Historical prospective study using data collected over the first 24 h of mechanical ventilation. We utilized a hypoxemia index-(1 - lowest [PaO(2)/PAO(2)]) x (minimum fraction of inspired oxygen to maintain PaO(2) at > 60 mm Hg) x 100], where PAO(2) is the alveolar partial pressure of oxygen-to grade the severity of acute lung injury on a scale from 0 to 100. SETTING: Tertiary care university hospital ICU. PATIENTS: One hundred forty-four adult patients mechanically ventilated for respiratory failure caused by CAP. MEASUREMENTS AND RESULTS: Hospital mortality was 46% (n = 66). Multivariate logistic regression analysis revealed five independent predictors of hospital mortality: (1) the extent of lung injury assessed by the hypoxemia index; (2) the number of nonpulmonary organs that failed; (3) immunosuppression; (4) age > 80 years; and (5) medical comorbidity with a prognosis for survival < 5 years. At a 50% mortality threshold, the prediction model correctly classified outcome in 88% of cases. All patients with > 95% predicted probability of death died in hospital. CONCLUSIONS: Based on clinical parameters measured over the first 24 h of mechanical ventilation, this model accurately identified critically ill, mechanically ventilated patients with CAP for whom prolonged intensive care may not be of benefit.