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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 47  |  Issue : 2  |  Page : 87-94

Comparative study between different scores predicting outcome in mechanically ventilated patients


1 Department of Chest, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta, Egypt
3 Department of Anaesthesia & Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission01-Apr-2017
Date of Acceptance01-Oct-2017
Date of Web Publication18-May-2020

Correspondence Address:
Eman M.A Abedo
MSc of Chest Diseases, Algalaa Street, Kotour, Tanta
Egypt
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DOI: 10.4103/tmj.tmj_40_17

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  Abstract 


Background The use of severity scoring systems was considered as a predictor of mortality in mechanically ventilated patients with respiratory failure due to respiratory and nonrespiratory causes.
Aim To compare some new and simplified scores with traditional scores as predictors of outcome of mechanically ventilated patients with acute respiratory failure due to respiratory and nonrespiratory causes.
Patients and methods The present study was carried out on 30 patients with respiratory failure due to respiratory and nonrespiratory causes who were mechanically ventilated and classified into three groups with respect to the cause of respiratory failure: group І included 10 mechanically ventilated patients due to chronic obstructive pulmonary disease exacerbation, group ІІ included 10 mechanically ventilated patients due to pneumonia, and group ІІІ included 10 mechanically ventilated patients due to nonrespiratory cause. Clinical and demographic data and routine investigations were done for all patients and then acute physiology and chronic health evaluation score (APACHE ІІІ) score was measured within 24 h of admission. Moreover, other scores including oxygenation index (OI), integrative weaning index (IWI), alveolar–arterial gradient (A–aO2), arterial oxygen tension (PaO2)/fraction of inspired oxygen (FiO2) ratio, and PaO2 were measured after 4 h, 24 h and after 3 days of ventilation.
Results Nonsurvivors had significantly longer duration of ventilation, higher APACHE ІІІ score with cutoff value more than 57, higher OI mostly after 3 days of ventilation, significantly lower PaO2/FiO2 ratio as compared with survivors, IWI was significantly lower in nonsurvivors only in group І, pA–aO2 was significantly higher in nonsurvivors, and PaO2 had insignificant relation with mortality.
Conclusion APACHE ІІІ score, PaO2/FiO2 ratio, A–aO2, and OI after 3 days of ventilation were the parameters that independently predicted mortality of mechanically ventilated patients, and also IWI predicted mortality only in group І and PaO2 did not predict mortality in all groups.

Keywords: acute physiology and chronic health evaluation score ІІІ score, ICU outcome predictors, simplified scores


How to cite this article:
Abedo EM, El-Emery FA, El-Shafey BI, Ameen SM, Hantera MS, Eldib AS. Comparative study between different scores predicting outcome in mechanically ventilated patients. Tanta Med J 2019;47:87-94

How to cite this URL:
Abedo EM, El-Emery FA, El-Shafey BI, Ameen SM, Hantera MS, Eldib AS. Comparative study between different scores predicting outcome in mechanically ventilated patients. Tanta Med J [serial online] 2019 [cited 2020 Sep 23];47:87-94. Available from: http://www.tdj.eg.net/text.asp?2019/47/2/87/284497




  Introduction Top


Mechanical ventilation is an essential life support to many patients in ICU [1]. Mechanical ventilation is indicated when spontaneous ventilation is inadequate to maintain life of patients. It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs [2].

Common medical indications for mechanical ventilation include the following: acute lung injury (ALI), including acute respiratory distress syndrome (ARDS) and trauma; apnea with respiratory arrest; acute severe asthma requiring intubation; chronic obstructive pulmonary disease (COPD); acute respiratory acidosis; hypoxemia; severe pneumonia; hypotension including sepsis; shock; congestive heart failure; neurological diseases, such as muscular dystrophy; myasthenia gravis; spinal cord injury; or the effect of anesthetic and muscle relaxant, drugs, and trauma including head, neck, and chest trauma [3].

The severity scores and mortality prediction in ICU patients are important for facilitating the management of hospital resources [4], evaluating the quality of care [5],[6],[7], and most importantly evaluating therapeutic interventions [8].

Traditionally scores were developed in the ICU for detecting outcome and prognosis of mechanically ventilated patients, such as acute physiology and chronic health evaluation score (APACHE III score), which is more sophisticated and measured 6 h after intubation; the APACHE III score range from 0 to 299 [9].

New scores evaluating respiratory elements have been developed to predict outcome of mechanically ventilated patients with respiratory failure, such as the oxygenation index (OI) [OI=fraction of inspired oxygen (FiO2)/arterial oxygen tension (PaO2)×mean air way pressure (mPaw), which is a calculation used in the ICU to measure the FiO2 and its usage within the body] [10].

Another score is integrative weaning index (IWI) which is calculated from other works [11],[12],[13]:



Other parameters that are easily calculated include, for example, alveolar–arterial gradient (pA–aO2), which measures the difference between the alveolar concentration (A) of oxygen and the arterial (a) concentration of oxygen.

The equation that calculate the A–aO2 is from Logan and Rice and Maya et al [14],[15]:



Other parameters include PaO2/FiO2 and PaO2 alone.


  Patients and methods Top


This study was carried out on 30 patients with acute respiratory failure due to respiratory and nonrespiratory causes in Chest Department and Anesthesia Department, in Tanta University Hospitals. The duration of study was from June 2015 to February 2016. Informed consent was taken from patients relatives, and the study was approved from the research ethics committee, Quality Assurance Unit (Faculty of Medicine, Tanta University).

Our study was a prospective and randomized trial.

The patients were classified into three groups:
  1. Group I, which included 10 mechanically ventilated patients with acute respiratory failure due to COPD exacerbation.
  2. Group II, which included 10 mechanically ventilated patients with acute respiratory failure due to severe pneumonia.
  3. Group III, which included 10 mechanically ventilated patients with acute respiratory failure due to nonrespiratory causes.


Inclusion criteria

All patients were mechanically ventilated patients due to acute respiratory failure which is defined as type І respiratory failure in which a PaO2 of less than 60 mmHg with a normal or low PaCO2, and type II respiratory failure, which is defined as a PaO2 of less than 60 mmHg and a PaCO2 of more than 45 mmHg [16].
  1. Patients with COPD exacerbation are diagnosed as follows: sudden worsening of COPD symptoms (increase in dyspnea and increase in amount or color of sputum that lasts for several days) [17].
  2. Patients with severe pneumonia are diagnosed as acute respiratory illnesses such as cough or difficulty of breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness [18]. In addition, chest radiograph consistent with pneumonia shows bilateral infiltrates.
  3. Patients of group III with respiratory failure due to nonrespiratory causes as cerebrovascular accidents.


Exclusion criteria

The following were the exclusion criteria:
  1. Massive pulmonary embolism.
  2. Malignancy.
  3. Cardiac patients, renal patients, and hepatic patients.
  4. Patients mechanically ventilated outside Tanta University Hospital.


Method

The following was done for all patients:
  1. All patients were initially intubated and put on invasive mechanical ventilation (inspiration R ventilator system, SN:2013, 5i, 21268; eVent Medical Ltd, SAn Clemente, CA, United States, and Inspiration TM LS ventilator system, SN: 2007 w030259; eVent medical Ltd, Galway, Ireland).
  2. Full history taking from the patients relatives with stress on age, sex, smoking, and other comorbidities.
  3. Complete clinical examination.
  4. Routine investigations, such as complete blood count, liver function tests, blood sugar, blood urea, serum creatinine, and serum electrolytes.
  5. Portable chest radiography.
  6. Arterial blood gas analysis was done three times after 4 h of ventilation then after 24 h and 3 days of ventilation.


Outcome of the patients were assessed by measuring different scores and indices such as follows:
  1. APACHE III score that was measured within the first 24 h after admission. The total score is from 0 to 299, and a score more than 57 detects poor outcome.
  2. OI: it was measured at 4 h, 24 h, and 3 days after mechanical ventilation.
  3. IWI: it was measured after 4 h, 24 h, and 3 days of ventilation.
  4. A–aO2: it measures the difference between alveolar and arterial concentration of oxygen. It was measured at 4 h, 24 h, and 3 days of ventilation.
  5. PaO2/FiO2 ratio: it was measured after 4 h, 24 h, and 3 days after ventilation.
  6. PaO2: partial pressure of oxygen in arterial blood was measured after 4 h, 24 h, and 3 days after ventilation.


Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0.

The statistical methods used for comparison were mean, median, SD, Student t test, Mann–Whitney test, and logistic regression analysis.


  Results Top


This study was carried out on 30 mechanically ventilated patients having respiratory failure, comprising 19 males and 11 females. Their mean age was 60.0±7.85 years in group I, 62.3±15.59 years in group II, and 49.60±15.3 years in group III. The outcomes of the patients were 15 survivors (four patients in group I, five patients in group II, and six patients in group III) and 15 nonsurvivors from mechanical ventilation (six patients in group I, five patients in group II, and four patients in group III).

While comparing the different parameters in the three studied groups after 4 h of mechanical ventilation, there was a significant increase in APACHE III score and pA–aO2 in nonsurvivors as compared with survivors, but IWI and PaO2/FiO2 had significant decrease in nonsurvivors in comparison with survivors, with P value less than 0.05 for all patients in the three studied groups (30 patients) after 4 h of ventilation, but there was no significant difference in OI and PaO2 between survivors and nonsurvivors for all patients in the three studied groups (30 patients) after 4 h of ventilation ([Table 1]).
Table 1 Statistical comparison between survivors and nonsurvivors regarding different parameters for all patients in the three studied groups after 4 h of ventilation

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While comparing the different parameters in the three studied groups after 24 h of mechanical ventilation, there was a significant increase in APACHE III score, OI, and pA–aO2 in nonsurvivors as compared with survivors, and there was a significant decrease in IWI and PaO2/FiO2 in nonsurvivors in comparison with survivors for all patients in the three studied groups (30 patients) after 24 h of ventilation, but there was insignificant difference in PaO2 between survivors and nonsurvivors for all patients in the three studied groups (30 patients) after 24 h of ventilation ([Table 2]).
Table 2 Statistical comparison between survivors and nonsurvivors regarding different parameters for all patients in the three studied groups after 24 h of ventilation

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While comparing the different parameters in the three studied groups after 3 days of mechanical ventilation, there was a significant increase in APACHE III score, OI, and pA–aO2 in nonsurvivors in comparison with survivors for all patients in the three studied groups (30 patients) after 3 days of ventilation, but there was a significant decrease in PaO2/FiO2 in nonsurvivors as compared with survivors, with P value less than 0.05, and there was no significant difference in IWI and PaO2 between survivors and nonsurvivors for all patients in the three studied groups (30 patients) after 3 days of ventilation ([Table 3]).
Table 3 Statistical comparison between survivors and nonsurvivors as regards different parameters for all patients in the three studied groups after 3 days of ventilation

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Logistic regression was assessed after 3 days of ventilation to elucidate parameters that had relation to mortality and found that APACHE III score was the parameter most closely related to mortality (P<0.001) followed by OI and PaO2/FiO2 (P<0.001) and then pA–aO2 (P=0.003), whereas IWI and PaO2 had no significant relation to mortality ([Table 4]).
Table 4 Logistic regression for parameters that affecting mortality for all patients in the three studied groups after 3 days of ventilation

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  Discussion Top


Respiratory failure in patients admitted to critical care unit is a major cause of morbidity and mortality. Patients can get into critical care unit because of respiratory failure secondary to pulmonary pathology like pneumonia and COPD exacerbation: in many other patients, respiratory failure is secondary to sepsis, cardiac failure, or neurological disorders. Obviously, respiratory failure involves diverse pathology [19].

Mechanical ventilation is probably the most frequently life-saving procedure used in the management of critically ill patients with severe respiratory failure. However, it is associated with multiple complications [20], primarily increased risk of nosocomial pneumonia with a high mortality rate. [21].

Scoring systems have been developed and applied to evaluate the effectiveness of treatment practices. The outcome of intensive care patients depends on several factors present on the first day in the ICU and subsequently on the patient’s course in ICU. For such populations, many scoring systems have been developed but few are used. Several of these systems are known simply by their acronym [22].

The aim of this study was to compare some new and simplified scores with traditional scores as predictors of outcome of mechanically ventilated patients with acute respiratory failure due to respiratory and nonrespiratory causes.

Regarding APACHE III score, the results of our current study showed that the mean APACHE III score was 46.87±8.69 and 78.07±10.91 for survivors and nonsurvivors, respectively, with a statistically significant correlation (P<0.05). In accordance with our results, Saleh et al. [23] reported that the four studied ICU predictive scoring systems (APACHE II, APACHE III, simplified acute physiologic score, and sequential organ failure assessment score) were significantly different severity scores and mortality predictors in survivors compared with nonsurvivors among ICU patients with ARDS. However, their accuracy in predicting the actual mortality was limited, and the performance of the APACHE II/III scoring systems was superior to that of the other systems in mortality prediction, and applying a combination of scoring systems improved their performance. Zhang et al. [24] in their study in validating the discrimination of APACHE III in patients with sepsis-associated ALI, Bakr et al. [25] showed that the mean APACHE III score was 45.2±12.62 and 80.9±15.82 for survivors and nonsurvivors, respectively, with a statistically significant correlation (P<0.05) in patients admitted with acute exacerbation of COPD, and Paul and Bailey [26] found that APACHE III score in patients admitted with respiratory disorders have close relation with mortality.

In disagreement with our results, Sudarsanam et al. [27] found that APACHE II score had significant relation with mortality than APACHE III score.

Regarding the IWI, the present work showed marked decrease in IWI in nonsurvivors as compared with survivors, with a statistical significant correlation (P value less than 0.05) only in group І in serial measurements after 4 h, 24 h, and 3 days of mechanical ventilation, and there was no statistical significance difference between survivors and nonsurvivors in group II and group III. IWI more than 25 was associated with successful weaning and good outcome. In agreement with our results, the study by El-Baradey et al. [28] found that IWI had better predictive value for weaning patients from mechanical ventilation, with IWI more than 25 in patients who succeeded weaning and less than 25 who failed weaning. This shows IWI had high sensitivity (0.97), specificity (0.78), and positive and negative predictive values (0.92 and 0.93, respectively). Boniatti et al. [29] concluded that the modified IWI, similar to other extubation predictors, does not accurately predict extubation failure. Moreover, Madani et al. [30] assessed validity of IWI for discontinuation from mechanical ventilation in Iranian ICUs, one limitation of IWI is the difficulty in measuring static compliance of the respiratory system in the spontaneously breathing patient.

Regarding OI, our study reported highly significant relation with outcome after 24 h and on third day of ventilation, with sensitivity and specificity of 86.67 and 93.33, respectively. When multivariate logistic regression analysis was implemented, third day OI was found to be an independent risk factor for hospital mortality. In accordance with our results, El-Shafey and El-Bedewy [31] and Kao et al. [32] reported that there was a significant increase in OI in nonsurvivors as compared with survivors after 3 days of ventilation. Moreover, Tseng et al. [33] found that high OI was a strong predictor of ventilator dependence. Seeley et al. [34] found that OI was the best bedside pulmonary predictor of mortality, and its predictive ability was sustained in multivariate analysis. In disagreement with our results, Estenssoro et al. [35] could not confirm a predictive power of OI in predicting outcome of patients with respiratory failure. These results were concomitant with our results in group І.

Regarding A–aO2, the present study found that there was a significant increase in pA–aO2 in nonsurvivors as compared with survivors after serial measurements with statistically significance correlation, and it was considered as a strong parameter in predicting mortality in logistic regression analysis after 24 h and 3 days of mechanical ventilation.

In agreement with our results, Bakr et al. [25] showed a significant difference between the mean value of pA–aO2 for survivors and nonsurvivors with a statistically significant correlation (P<0.05). Moreover, Park and Koh [36] found significant differences between survivors and nonsurvivors regarding pA–aO2 although with different figures. Their mean pA–aO2 was 36.1±29.9 and 47.9±36.1 mmHg for survivors and nonsurvivors, respectively, in mechanically ventilated patients with COPD with septic shock. Sudarsanam et al. [27] reported that by logistic regression analysis, pA–aO2 had prognostic significance on outcome, and these data coincided with our current results. In disagreement with our results, Steer et al. [37] and Trachsel et al. [38] reported that increased pA–aO2 was not a predictor for hospital mortality.

Regarding PaO2/FiO2 ratio, the present study showed that there was a significant decrease in nonsurvivors than survivors with a statistically significant correlation (P<0.05), and also on logistic regression analysis for factors predicting mortality, we found that PaO2/FiO2 ratio is the second independent parameter affecting mortality with statistically higher significance mainly after 3 days of ventilation.

In agreement with our results, El-Shafey and El-Bedewy [31] found that there was a significant decrease in PaO2/FiO2 in nonsurvivors as compared with survivors, and by linear regression analysis, it was reported that P/f ratio was the third parameter having a close relation to the mortality. Bakr et al. [25] showed a significant difference between the mean value of PaO2/FiO2, which was 280±45 and 180±60, for both survivors and nonsurvivors, respectively, with a statistically significant correlation (P<0.05). Moreover, Park and Koh [36] found significant difference regarding PaO2/FiO2, but with different figures in mechanically ventilated patients with COPD with septic shock.In disagreement with our study, Seeley et al. [34] reported that PaO2/FiO2 had significant relation with mortality in bivariate analysis but insignificant in multivariate analysis and reported that the value of PaO2/FiO2 as an early predictor of death in ALI/ARDS is uncertain. Moreover, Sudarsanam et al. [27] reported that PaO2/FiO2 was independently affecting mortality in their study on 200 patients requiring mechanical ventilation in a medical ICU. Ware et al. [44] found that PaO2/FiO2 at the onset of ALI/ARDS did not predict clinical outcome, but a persistently low PaO2/FiO2 was associated with worse outcomes and may be a marker of failure to respond to conventional therapy. Casadoa et al. [39] confirmed that on adding positive end-expiratory pressure (PEEP) to the PaO2/FiO2 model, using PaFip: Ln[(PaO2/FiO2)/(PEEP+12)], it is able to improve the model considerably, with a better goodness of fit, bringing it closer to the routine clinical setting and introducing a parameter as important as PEEP in an easy manner.

Regarding arterial oxygen tension (PaO2) in mmHg, our study reported that there was no significant difference between survivors and nonsurvivors after serial measurements at 4 h, 24 h, and 3 days of mechanical ventilation, and by logistic regression for parameters that affecting mortality, we found that PaO2 did not affect mortality.

In accordance with our results, Khalil et al. [40] found that there was an insignificant difference between survivors and nonsurvivors in PaO2, and it had no significant relation with outcome. Mohan et al. [41] reported no significance relation between PaO2 and outcome in mechanically ventilated patients.

In disagreement with our results, Bakr et al. [25] showed an increase in mortality with derangement of all ABG items. Moreover, Yıldız and Gundogus [42] and Gunen et al. [43] showed significant difference regarding PaO2 between both survivors and nonsurvivors.

The discrepancies between the results of this work and the result of the other studies may be attributed to differences in case selection criteria of patients and the smaller sample size in this study.


  Conclusion Top


APACHE III score was the parameter most closely related to mortality in all patients in the three studied groups, and PaO2/FiO2 ratio, OI, and A–aO2 were considered the most significant parameters in predicting mortality, correspondingly, in all patients in the three studied groups, but OI is considered to be a late predictor of mortality (after 3 days of ventilation).

Recommendations

Future studies including larger number of patients and long-term follow-up of patients on their course of stay in ICU are needed. This study also recommended that PaO2/FiO2 ratio was a simple and easy predictor of mortality in patients with respiratory failure on mechanical ventilation. Moreover, it was nearly equal to the more complicated one, APACHE III score.

It was recommended not to use PaO2 as a predictor of mortality in patients with respiratory failure.

Acknowledgements

The authors thank all participants who helped during this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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