© 2003 American Thoracic Society
Mechanical ventilation in patients with pulmonary fibrosisTo the Editor:In a recent study, Saydain and colleagues (1) reported poor short- and long-term prognosis in patients with pulmonary fibrosis admitted to the intensive care unit (ICU). An important question for physicians not clearly addressed in Saydain's paper, is whether patients with idiopathic pulmonary fibrosis (IPF) may benefit from mechanical ventilation (MV). These authors found that acute respiratory failure (ARF) was the most common cause of ICU admission, and in nearly half of the patients, no specific cause of ARF was found. The overall prognosis of their 38 patients was poor. The ICU mortality was 45%, hospital mortality was 63%, and 12 of 15 patients discharged alive from the hospital were dead at a median of 2 months after ICU discharge. Two publications, not cited by Saydain and colleagues (2, 3), including one conducted in our lung transplantation center (2), also studied the prognosis of patients with IPF admitted to the ICU. They may be informative to help physicians in the difficult decisions of initiating MV or not. The first study demonstrated the ineffectiveness of MV in 23 patients with advanced IPF (2). Indeed, MV did not correct oxygenation and was associated with fatal evolution in all patients except one who received a lung transplantation 6 hours after initiation of MV. As in Saydain and colleagues' study, the cause of death was not often identified. Blivet and colleagues (3) also reported 12 rapid deaths among 15 IPF patients ventilated for ARF. In this series, noninvasive ventilation (NIV) was initiated for five patients, and the three patients who could be discharged alive from the ICU presented a rapidly reversible precipitating cause of ARF (pneumothorax, n = 2; complication of anesthesia, n = 1). Finally, in another recent series of patients with either idiopathic (n = 11) or secondary (n = 3) pulmonary fibrosis who underwent MV for ARF, Fumeaux and colleagues reported 100% mortality (4). Pressure support NIV was initiated for 11 patients but was unsuccessful. As in our series, MV did not improve oxygenation, and worsened PaCO2. Taken together, these data suggest that except in the rare cases where lung transplantation can be performed shortly after initiation of MV, initiating MV in pulmonary fibrosis patients with ARF is questionable.
a Institut Mututaliste Montsouris Paris, France REFERENCES
From the Authors:Drs. Stern and Mal question the survival of patients with idiopathic pulmonary fibrosis (IPF) who require mechanical ventilation, and they appropriately cite three recent studies that appeared during the publication or our report. As indicated in our series, 19 of 38 patients with IPF underwent mechanical ventilation, with hospital mortality of 68% (13/19) (1). Taking the four studies together, a total of 68 patients with IPF were reviewed, with mortality of 55/68, or 78%.Patients with IPF are typically admitted to the intensive care unit with respiratory failure in the hope of identifying a treatable cause for exacerbation, such as infection, heart failure, or pulmonary embolism. It may be reasonable to pursue such causes aggressively, while recognizing that if early intervention is not successful, these data suggest that outlook for hospital survival is poor. Furthermore, the risk of mortality may be underestimated by scoring systems such as APACHE III. Regarding the anecdotal report of survival with lung transplantation, most patients with IPF are elderly, and in any case few centers in the world could offer a donor lung on short notice to a critically ill patient, so this is rarely a realistic option.
Mayo Clinic Rochester, Minnesota REFERENCES
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