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Recovery Rate and Prognosis in Older Persons Who Develop Acute Lung Injury and the Acute Respiratory Distress Syndrome

E. Wesley Ely, MD, MPH; Arthur P. Wheeler, MD; B. Taylor Thompson, MD; Marek Ancukiewicz, PhD; Kenneth P. Steinberg, MD; Gordon R. Bernard, MD, Acute Respiratory Distress Syndrome Network
[+] Article and Author Information

From Vanderbilt University School of Medicine and the Veterans Affairs Tennessee Valley Healthcare Research and Clinical Education Center, Nashville, Tennessee; Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington.


Presented in part at the International Conference of the American Lung Association and the American Thoracic Society on 8 May 2000 in Toronto, Ontario, Canada.

Acknowledgment: The authors thank Dr. William Hazzard, one of the nation's premier leaders in geriatric medicine, for raising our awareness of the importance of age-related issues in the decision making and care of critically ill older persons.

Grant Support: By contracts (NO1-HR 46054-46064) with the U.S. National Heart, Lung, and Blood Institute. Dr. Ely is a recipient of an American Federation for Aging Research Pharmacology in Aging Grant and the Paul Beeson Faculty Scholar Award from the Alliance for Aging Research. He is a recipient of a K23 from the National Institutes of Health (#AG01023-01A1) and is a Geriatric Research and Education Clinical Center investigator.

Requests for Single Reprints: E. Wesley Ely, MD, MPH, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, 6th Floor, #6109 Medical Center East, Vanderbilt University Medical Center, Nashville, TN 37232-8300; e-mail, wes.ely@mcmail.vanderbilt.edu.

Current Author Addresses: Dr. Ely: Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, 6th Floor, #6109 Medical Center East, Vanderbilt University Medical Center, Nashville, TN 37232-8300.

Dr. Wheeler: Vanderbilt Medical Center, T-1217 Medical Center North, Nashville, TN 37232-2650.

Dr. Thompson: Massachusetts General Hospital, Bulfinch 148, 55 Fruit Street, Boston MA 02114.

Dr. Ancukiewicz: Radiation-Oncology Department, Harvard University, 55 Fruit Street, Boston, MA 02114.

Dr. Steinberg: Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104.

Dr. Bernard: Vanderbilt Medical Center, T-1208 Medical Center North, Nashville, TN 37232-2650.

Author Contributions: Conception and design: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, K.P. Steinberg, and G.R. Bernard.

Analysis and interpretation of the data: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, K.P. Steinberg, and G.R. Bernard.

Drafting of the article: E.W. Ely, A.P. Wheeler, M. Ancukiewicz.

Critical revision of the article for important intellectual content: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, K.P. Steinberg, and G.R. Bernard.

Final approval of the article: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, K.P. Steinberg, and G.R. Bernard.

Provision of study materials or patients: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, K.P. Steinberg, and G.R. Bernard.

Statistical expertise: E.W. Ely.

Obtaining of funding: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, and G.R. Bernard.

Administrative, technical, or logistic support: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, and G.R. Bernard.

Collection and assembly of data: E.W. Ely, A.P. Wheeler, B.T. Thompson, M. Ancukiewicz, and G.R. Bernard.


Ann Intern Med. 2002;136(1):25-36. doi:10.7326/0003-4819-136-1-200201010-00004
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More than half of all days spent in an intensive care unit are incurred by patients older than 65 years of age, and the number of days per year spent in the intensive care unit (per 1000 person-years) is sevenfold higher for persons older than 75 years compared with persons younger than 65 years (1). The population of older persons and their respective proportion of health care expenditures are expected to double by 2030 (2), and some have suggested that we ration the care provided to older patients (35). Indeed, physicians in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) withheld mechanical ventilation at higher rates in older patients, especially in patients 70 years of age or older (68). However, previous reports of older patients with respiratory failure from various causes have indicated that recovery and overall prognosis in this age group do not justify using age alone to determine treatment decisions (911). Instead, the decision to place older persons with acute lung injury on mechanical ventilation should incorporate several factors, including comorbid illnesses (12), patient preference or previously stated wishes, physician gestalt, and bedside judgment.

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Figures

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Figure 1.
Histogram of 28-day survival by decade of age.P

Depicted is the decrease in survival seen in patients with acute lung injury by decade of age (Spearman rho = 0.25; < 0.001 for comparison across all groups). The number of patients enrolled in each age group is listed above the bars; the bars represent the percentage of survivors at 28 days for each age group.

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Figure 2.
Histogram of patient outcomes—time on ventilator and death.white barsgray barsfar leftPcenterfar right

This plot compares the percentage of patients younger than 70 years of age ( ) with the percentage of patients at least 70 years of age ( ) who were alive on the ventilator, alive off the ventilator, or dead at weekly intervals. At each time point, the percentages of younger and older patients who were alive and receiving mechanical ventilation ( ) were nearly identical ( = 1.0), but the older patients were less often alive off the ventilator ( ) and more often dead ( ).

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Figure 3.
Histogram of maximum recovery landmark achieved by 28 days among survivors.ngray barswhite barsP

The percentage of patients ( = 631) who achieved the recovery landmarks (as defined in Methods section) was similar between the group 70 years of age or older ( ) and the group younger than 70 years of age ( ) ( > 0.2). ICU = intensive care unit; SBT = spontaneous breathing trial.

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Figure 4.
Histogram of the rate of progress through recovery landmarks achieved by 28 days among survivors.Pwhite barsgray barsSBTPICUPnonsurvivorsP

The mean time from enrollment to passing a 2-hour spontaneous breathing trial was similar between both age groups ( > 0.2) ( = younger patients; = older patients). However, the older patients took more time to progress from passing the 2-hour spontaneous breathing trial ( ) to achieving 48 hours of unassisted breathing ( = 0.002) and from 48-hour unassisted breathing to being discharged from the intensive care unit ( ) without use of a ventilator ( = 0.005). Among , the patients 70 years of age or older did not differ from those younger than 70 years of age for any of these time intervals (data not shown; for all time intervals, > 0.2).

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Summary for Patients

Recovery Rate and Prognosis in Older Persons Who Develop Acute Lung Injury and the Acute Respiratory Distress Syndrome

The summary below is from the full report titled “Recovery Rate and Prognosis in Older Persons Who Develop Acute Lung Injury and the Acute Respiratory Distress Syndrome.” It is in the 1 January 2002 issue of Annals of Internal Medicine (volume 136, pages 25-36). The authors are EW Ely, AP Wheeler, BT Thompson, M Ancukiewicz, KP Steinberg, and GR Bernard, for the Acute Respiratory Distress Syndrome Network.

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