Elizabeth Parsons, MD Senior Fellow, Division of Pulmonary & Critical Care Medicine University of Washington, Seattle WA

Elizabeth Parsons, MD Senior Fellow, Division of Pulmonary & Critical Care Medicine University of Washington, Seattle WA

How do we define a good outcome after critical illness? Health-related quality of life after critical illness Functional outcomes after critical illness

Utah Beach, June 1944.

Rancho Los Amigos Hospital, CA, 1953

Acute Lung Injury Mortality (HMC) Milberg JAMA 1995; Stapleton et al. Chest 2005

No. patients (thousands) JAMA 2010 Vol. 303: pp 2253-9. Retrospective cohort of >18 million Medicare ICU admissions Higher proportion of ICU patients require additional care after discharge 2000 Long-term acute care admissions are rising 1500 1000 500 0 1997 2006 Long-term acute care SNF/Rehab Home Died

Recovery of Function in Survivors of the Respiratory Distress Syndrome Lynn Gross McHugh, John A. Milberg, Michael E. Whitcomb, Robert B. Schoene, Richard B Maunder, and Leonard D. Hudson AJRCCM 1994, Vol 150, pp 90-94. Prospective study of ARDS survivors at HMC from 1988 through 1990 enrolled 52 of 82 eligible (63%); mean age 41 years subjects evaluated at 3, 6, and 12 mo PFTs improve to near normal in most patients (>80% pred by 6 mo) HRQL is quite low Return to work is low (56% at 1 year) Symptoms and disability NOT due to lungs

Current research recognizes the importance of patient-centered, long-term outcomes Impairment (eg, low FEV1) Functional status/disability (breathlessness) Health-related quality of life (HRQL) or well-being For individual survivors (SF-36, HUI) For entire cohort: Quality-adjusted life years (QALYs), single score reflecting length and quality of life Halpern CCM 2007.

Cognitive Emotional Physical

Quality of Life in the five years after intensive care: a cohort study Brian H Cuthbertson, Siân Roughton, David Jenkinson, Graeme MacLennan, Luke Vale Critical Care 2010, Vol. 14: R6. Prospective cohort of patients discharged from UK university hospital 2001-2002 Enrolled 300 (71%) of eligible subjects Median age 60.5yr, APACHE 18, ICU LOS 2 days Outcome assessment at 3,6,12 mo, 2.5 and 5 yr Patient function (SF-36) and QALYs (EQ-5D) 97 patients (32%) retained by 5 yr

ICU survivors accumulate significantly fewer QALYs compared to a matched cohort of the general population General population ICU cohort *p<0.0001 Cuthbertson Crit Care 2010

Angus followed 132 survivors prospectively identified with ARDS (phase II trial of NO) 104/132 participated Administered Quality of Well Being (QWB) instrument at 6 and 12 months after ARDS measure of HRQL used to calculate quality-adjusted life years (QALYs) Compared QWB scores between ARDS survivors and patients with cystic fibrosis, and normals found significantly lower HRQL in ARDS survivors than CF patients and population controls (0.59 vs. 0.78) Angus AJRCCM 2001

Symptom 6 months 12 months Lower respiratory 43% 40% Musculoskeletal 69% 71% Depression, anxiety or insomnia 57% 46% Neurologic 44% 32% Cognitive 32% 21% Angus AJRCCM 2001

Prospective follow-up study of 109 ARDS survivors assessed subjects at 3, 6 and 12 months evaluation included interview, examination, PFTs, SF-36, and functional study with six minute walk test (6MWT) Primary outcome was distance walked in 6 minutes studied potential predictors

Pronounced in physical domains Improves between 3-6 mo, but remains markedly impaired relative to controls Herridge NEJM 2003

Significant weight loss at ICU discharge mean loss of 18% body weight 71% of patients returned to baseline weight by one year All patients reported poor function due to loss of muscle bulk proximal weakness fatigue 10 patients had pain at chest tube sites persisting at one year Herridge NEJM 2003

Distance walked in 6 minutes 3 months (n=80) 6 months (n=78) 12 months (n=81) Median (m) 281 396 422 IQR 55-454 244-500 277-510 % Predicted 49% 64% 66% Predictors of impaired 6MWT at 6 months female gender treatment with corticosteroids or paralytics lung injury score >3 (also max LIS and slope) ICU acquired illness Herridge NEJM 2003

Prospective cohort of 61 patients enrolled at HMC within 10 days of ALI onset (RALI) Secondary analysis of RBC transfusion as a risk factor for physical functional impairment Measures In hospital: nerve conduction studies, handgrip, exam 6 month followup: handgrip, SF-36 Transfused patients had mean handgrip score ~ 1SD lower than non-transfused patients in hospital and at 6 months (p=0.04 and <0.01) Trend toward reduced physical function scores (p=0.07)

Herridge: recovery plateaus between 6-12 mo (SF- 36 and 6MWT) Hopkins: cohort of 74 ARDS survivors Mean APACHE 18.1, ICU LOS 30 days Primary outcome neurocognitive impairment Measured HRQL (SF-36) at 1 and 2yr 62 (84%) study retention at 2yr Hopkins AJRCCM 2005

Physical domains most severely impaired, no further recovery after 1 yr Hopkins AJRCCM 2005

Bill Shannon, Crutch

Rehabilitation after critical illness: A randomized, controlled trial Jones et al. Crit Care Med 2003 Vol 31: pp 2456-2461. 126 consecutively admitted ICU patients requiring mechanical ventilation Intervention: 6 wk self-help rehabilitation program self-directed exercise program, diary to capture adherence Primary outcomes: physical and psychological recovery at 8wk and 6 mo. post discharge Good followup (89-91% at 8wk and 77-84% at 6 mo.) Jones CCM 2003

Patient-directed rehabilitation improves physical recovery compared to routine care p=0.022 after controlling for ICU LOS Jones CCM 2003

Critical illness is associated with long-term sequellae including persistently impaired quality of life Quality of life is multifactorial Physical function is an important part of recovery after ALI and may be improved with rehabilitation strategies Studies of critical care interventions should address the impact on long-term health and well-being (physical, emotional, and cognitive)

Terri Hough, Ellen Caldwell, Erin Kross, Bill Ehlenbach, Tim Watkins, Randy Curtis, Len Hudson, Chris Seymour, Colin Cooke