The quality of acute intensive care and the incidence of critical events have an impact on health-related quality of life in survivors of the acute respiratory distress syndrome - a nationwide prospective multicenter observational study

Abstract

Background: Initial treatment (ventilator settings, rescue therapy, supportive measures), and prevention of critical events improve survival in ARDS patients, but little data exists on its effect on health-related quality of life (HRQOL) and return to work (RtW) in survivors. We analyzed the association of the intensity of treatment at ARDS onset and the incidence of critical events on HRQOL and RtW a year after ICU discharge. Methods: In a prospective multi-centre cohort study, the intensity of treatment and the incidence of critical events were determined at 61 ICUs in Germany. At 3, 6, and 12 months, 396 survivors reported their HRQOL (Short-Form 12) and RtW. The parameters of the intensity of acute management (lung protective ventilation, prone position, hemodynamic stabilization, neuromuscular blocking agents), and critical events (hypoxemia, hypoglycemia, hypotension) were associated with HRQOL and RtW. Results: Patients ventilated at ARDS onset with a low tidal volume (VT≤7 ml/kg) had higher arterial carbon dioxide levels (PaCO₂=57.5±17 mmHg) compared to patients ventilated with VT>7ml/kg (45.7±12, p=0.001). In a multivariate adjusted dichotomized analysis, a better mental 3-month SF-12 was observed in the higher VT-group (mean 43.1±12) compared to the lower VT-group (39.5±9, p=0.042), while a dichotomized analysis for driving pressures (≤14 mbar vs >14 mbar) did not show any difference neither in PaCO₂ levels nor in HRQOL parameters. A decrease in the mental (6-month: 40.0±11 vs 44.8±13, p=0.038) and physical SF-12 (12-month: 38.3±11 vs 43.0±13, p=0.015) was reported from patients with hypoglycemia (blood glucose <70 mg/dl) compared to those without hypoglycemic episodes. More frequent vasopressor use with mean arterial pressure ≥65 mmHg was associated with an impaired physical SF-12 (6-month: 38.8±10) compared to less vasopressor use (43.0±11, p=0.019). Conclusions: In acute management of ARDS, a lower VT strategy associated with hypercapnia, as well as the frequent usage of catecholamines and the management of blood glucose may influence short-term HRQOL of survivors. The awareness of these findings is of clinical importance for the acute and post-ICU care.

Keywords: acute respiratory distress syndrome; critical events; health-related quality of life; quality of care; return to work.

Table 1. General characteristics of 12-month respondents

Table 2. Characteristics of acute management of the 12-month respondents

Table 3. Association of acute care and critical events with 1-year health-related quality of life (SF-12); multiple analysis adjusted for SOFA (without Glasgow Coma Scale), body mass index, age and sex

Table 4. Effect of acute care management and critical events on return to work after 12 months: Multiple regression analysis (*adjusted for SOFA without Glasgow Coma Scale, body mass index, age and sex)

Figure 1. Patient flow. For all follow-up patients, survival/death was assessed via local municipial population registries.

Figure 2. HRQOL in ARDS survivors after 3, 6 and 12 months for the physical and mental component of the SF-12 score in regard to tidal volume ≥7 ml/kg pBw (A and B), driving pressure <14 cm H₂O (C and D), desaturation <85% for more than 5 minutes (E and F) and prone positioning (G and H). The mean score of the population is 50, whereas one standard deviation is marked in grey.

Figure 3. HRQOL in ARDS survivors after 3, 6 and 12 months for the physical and mental component of the SF-12 score in regard to mean arterial pressure <65 mmHg (A and B), glucose <70 mg/dl (C and D), neuromuscular blocking agent for more than 3 hours (E and F). The mean score of the population is 50, whereas one standard deviation is marked in grey.