Among adults with acute respiratory distress syndrome (ARDS), prehospital vulnerability as measured by Vulnerable Elders Survey (VES) was prevalent and significantly associated with 1-year mortality, according to a study published in the Annals of the American Thoracic Society.
In this longitudinal analysis, researchers examined data from the multicenter Lung Injury Prevention Study with Aspirin (LIPS-A), which included 390 adults with a high risk for ARDS, 301 of whom were included in the analysis. The researchers examined associations between prehospital vulnerability and 1-year mortality as a primary long-term outcome, while the association between prehospital vulnerability and ARDS development and 28-day mortality were primary short-term outcomes. The participants analyzed had all completed a VES at baseline, and the association between vulnerability and outcomes were described using Cox regression and multivariable logistic regression analyses.
The median age of the patients was 56 (interquartile [IQR] range, 46-68), and the most common risk factors for ARDS were pneumonia (59.6%) and suspected sepsis (76.5%). VES scores ranged from 0-10, with a median IQR of 2.0 (0-6). Based on VES scores ≥3, 142 participants (47.0%) were classified as vulnerable, of which only 14 participants (9.9%) would have been classified as vulnerable based on age alone (>85 years=3 points). In addition, 30 of the 301 (10.0%) participants developed ARDS, and prehospital vulnerability was not significantly associated with its development (10 of 143 [7.0%] in participants with prehospital vulnerability vs 20 of 158 [12.7%] in those without vulnerability; adjusted odds ratio [aOR], 0.54; P =.15). Only 26 of 301 participants were dead by day 28, and prehospital vulnerability was not associated with 28-day mortality (aOR, 0.95; P =.90).
Among the 270 survivors, 48 participants (17.8%) were dead within 1 year. After adjusting for the minimal set of variables used to estimate the total effect of prehospital vulnerability on mortality (including body mass index, age, cognitive impairment, and comorbidity score), vulnerability remained significantly associated with 1-year mortality (aHR, 2.20; P =.03), and every 1-point increase in VES score at baseline was associated with an 18% increase in risk of death over time (aHR, 1.18; P =.03).
Study limitations included the possibility of selection bias, a potential for type 2 error, and a lack of new validation of VES completed by proxy respondents. Nonetheless, study investigators concluded, “in a cohort of adults at high risk of ARDS, pre-hospital vulnerability was highly prevalent. Pre-hospital vulnerability was associated with higher 1-year mortality but not with ARDS or short-term mortality. Future studies in critical care could pivot towards using screening tools such as the VES for identifying adults at high risk of long-term adverse outcomes in order to test pilot interventions geared towards improving long-term outcomes in critically ill adults.”
Hope AA, Chen JT, Kaufman DA, et al. The association between pre-hospital vulnerability, ARDS development and mortality among at-risk adults: Results from the LIPS-A clinical trial [published online August 27, 2019]. Ann Am Thorac Soc. doi:10.1513/AnnalsATS.201902-116OC