Quality of Life Among Survivors of ICU Admission for COPD
Quality of Life Among Survivors of ICU Admission for COPD
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this British study of patients admitted to the ICU for COPD exacerbations, 6-month survival was better among those successfully treated with non-invasive ventilation, but even among those requiring intubation, quality of life was about what it had been prior to admission, and nearly all of the survivors would want the same treatment again.
Source: Wildman MJ, et al. Survival and quality of life for patients with COPD or asthma admitted to intensive care in a UK multicentre cohort: The COPD and Asthma Outcome Study (CAOS). Thorax 2009;64:128-132.
This paper reports on a comprehensive follow-up of patients with severe airway obstruction who were admitted to 92 ICUs or to 3 high-dependency respiratory units in the United Kingdom during 2002 and 2003. The purposes were to assess quality of life and functional status among survivors 6 months later, to determine the wishes of these survivors with respect to future similar treatment, and to examine the predictive value of both patient pre-admission functional status and physician outcome prediction on these things.
In all, 832 patients were recruited (mean age, 66 years; 49% men), of whom 78 were judged by their physicians to have "pure" asthma rather than COPD. Of the 754 patients with COPD, 394 (52%) were intubated either prior to or during their ICU stay; 179 were managed successfully with non-invasive ventilation (NIV) but were potential candidates for intubation; and 181 were "do not intubate," although many of these also received NIV. Survival to hospital discharge was 94% among patients treated with NIV who did not require intubation, 61% among those treated with invasive mechanical ventilation, and 60% among the do-not-intubate group. Of the whole cohort of 832 patients, 517 (62%) survived 6 months, and among these, 81% responded to the authors' questionnaire.
Using the EuroQol visual analog scale, on a scale of 1 to 100 with 100 best, the mean rating of survivors of their overall quality of life was 55. This is substantially lower than ratings obtained from members of the general public aged 65-74 years (previously reported to have a mean score of 77), but similar to the mean score of 51 obtained from 132 outpatients of the same age range with severe COPD in a different study. Physician prediction on admission of likely quality of life at 6 months among survivors was pessimistic as compared to the actual results obtained from the patients or their representatives at follow-up (mean predicted score 50 vs 55), and both the agreement and the discrimination of the measures used were poor. About 75% of the survivors judged their quality of life to be the same or better than in the stable period prior to ICU admission, and 95% of them indicated that they would choose the same treatment again if necessary. In keeping with other studies, pre-admission functional status was the best predictor of functional status 6 months after ICU admission, among those patients who survived.
Commentary
Most of the COPD patients in this study who survived to 6 months after ICU admission for an exacerbation of their disease had a heavy burden of symptoms as indicated by their quality-of-life scores. Nonetheless, nearly all of them would choose the same treatment again under similar circumstances, and this was true for those who had been intubated as well as for those managed with NIV.
Although this was a well-done study, the generalizability of its findings to COPD patients admitted to American ICUs is unclear. British hospitals have proportionally fewer ICU beds than U.S. hospitals, so that pre-admission selection factors that influenced the results may have been at work. The patients in this study might have been sicker than patients in American ICUs, because ICU entry criteria may have been more stringent. On the other hand, they might have had generally better prognoses, at least in the opinions of their admitting physicians, because of the higher thresholds for ICU admission.
These possible differences notwithstanding, I think this study has the following noteworthy take-home messages:
- Nearly two-thirds of the patients survived for 6 months following ICU admission, including 55% of those intubated for COPD and 48% of the do-not-intubate patients;
- The quality of life of COPD patients who survive 6 months after ICU admission is not very good, but is generally no worse than it was before admission and about the same as that among stable outpatients with severe COPD;
- Functional status in the 2 weeks prior to admission to ICU was the best overall predictor of quality of life 6 months later, should the patient survive the unit stay;
- The patients would want to do it again; and,
- Their doctors were poor predictors of functional status or overall quality of life in survivors, and tended to be more pessimistic about these things than proved actually to be the case.
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