Severity of respiratory failure identifies intermediate-risk patients with acute pulmonary embolism at increased risk for death
C Becattini, L A Cimini, G Bassanelli, M A Clementi, M C Leone, I Lobascio, S Dorigoni, M Sacco, M Correale, A Fabbri, R Di Paola, G Petrelli, A P Maggioni, M M Gulizia, G AgnelliAbstract
Background
For hemodynamically stable patients with acute pulmonary embolism (PE) who are at an increased risk of death based on clinical criteria (i.e. intermediate-risk patients), there is a debate about whether respiratory failure should drive clinical management. We aimed at assessing the prognostic role of respiratory failure, in intermediate-risk patients with acute, symptomatic PE from a prospective, multicentre study (COPE).
Methods
Respiratory failure was classified according to global definition of acute respiratory distress syndrome (ARDS) based on the oxygen saturation-to-inspired oxygen flow (SpO2:FiO2) into absent (SpO2:FiO2 >315), mild (235< SpO2:FiO2 ≤315), moderate (148< SpO2:FiO2 ≤235) and severe (SpO2:FiO2 ≤148). The primary outcome for this analysis was time to death due to PE at 30 days. In-hospital death and in-hospital death or clinical deterioration were also reported.
Results
Among 5,213 patients with acute, symptomatic PE included in the COPE study, 3,874 intermediate-risk patients were included in this analysis. At admission, respiratory failure was absent in 3233 (82.9%), mild in 326 (8.4%), moderate in 292 (7.5%) and severe in 33 (0.8%).
Death due to PE occurred in 1.2%, 1.2%, 3.4% and 6.0% of patients with absent, mild, moderate or severe respiratory failure, respectively; in-hospital death in 2.7%, 4.9%, 5.1% and 12.1% of patients with absent, mild, moderate or severe respiratory failure, respectively.
The severity of respiratory failure was associated with the risk for death due to PE and for in-hospital death independently with respect to the intermediate risk category (no right ventricle dysfunction [RVD], normal troponin; RVD or increased troponin; RVD and increased troponin).
Conclusions
In patients with acute PE at intermediate risk for death, severity of respiratory failure defined according to global definition by classes of SpO2:FiO2 is associated with the risk for death. Whether different treatment strategies should be adopted based on severity of respiratory failure should be defined.