|Year : 2021 | Volume
| Issue : 1 | Page : 22-26
Underlying diseases and in-hospital mortality of acute respiratory failure patients: Indonesian prospective cohort study
Menaldi Rasmin1, Mia Elhidsi1, Prasenohadi1, Wiendo Syah Putra Yahya1, Yusup Subagio Sutanto2, Ana Rima Setijadi2, Ngakan Putu Parsama Putra3, Ungky agus Setyawan3, Oea Khairsyaf4, Russilawati4, Deddy Herman5, Mulyadi6, Teuku Zulfikar7, Dewi Behtri Yanifitri7
1 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Persahabatan Hospital, Universitas Indonesia, Jakarta, Indonesia
2 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Dr. Moewardi Hospital, Universitas Negeri Sebelas Maret, Solo, Indonesia
3 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Dr. Saiful Anwar Hospital, Universitas Brawijaya, Malang, Indonesia
4 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Dr. M. Djamil Hospital, Universitas Andalas, Padang, Indonesia
5 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Dr. Achmad Moechtar Hospital, Universitas Andalas, Padang, Indonesia
6 Faculty of Medicine, Universitas Nahdlatul Ulama, Surabaya, Indonesia
7 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Dr. Zainoel Abidin Hospital, Universitas Syiah Kuala, Aceh, Indonesia
|Date of Submission||30-Jun-2020|
|Date of Decision||05-Aug-2020|
|Date of Acceptance||15-Sep-2020|
|Date of Web Publication||27-Jan-2021|
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Persahabatan Hospital, Universitas Indonesia, Jalan Persahabatan Raya No. 1, Rawamangun, Jakarta 13230
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Epidemiologic data of acute respiratory failure (ARF) are limited. This study aims to investigate the underlying diseases and in-hospital mortality of patients with ARF in Indonesia. Materials and Methods: An observational prospective cohort study involving patients with ARF in six hospitals was conducted. Data were collected between January and December 2017. Data on the type of ARF, quick sepsis-related organ failure assessment (qSOFA) score, underlying diseases, and in-hospital mortality were documented. Proportions were compared using Chi-square or Fisher exact tests. Multivariable regression models with variable selection based on a stepwise backward elimination were run to analyze the risk factors for in-hospital mortality. Results: A total of 412 patients (median age: 56-years-old) were included. Most of the subjects were male (66.9%), hypoxemic (55.3%), and acute onset (86.4%). The most commonly encountered underlying diseases were pneumonia (58.7%), chronic obstructive pulmonary disease (25.5%), lung tuberculosis (25.2%), lung cancer (16.5%), noncystic fibrosis bronchiectasis (11.9%), congestive heart failure (10.2%), and chronic kidney disease (CKD) (3.2%). There were 65% of patients received only oxygen therapy, invasive mechanical ventilation was utilized for 30.8% of patients, and 4.1% of patients underwent noninvasive mechanical ventilation. There were 201 (48.79%) in-hospital mortality cases. The risk factors of in-hospital mortality were qSOFA ≥2 (odds ratio [OR]: 2.420, 95% confidence interval [CI] 1.599–3.662; P = 0.000) and CKD (OR: 3.871, 95% CI 1.024–14.631; P = 0.046). Conclusions: Most of the underlying diseases of ARF in Indonesia are communicable diseases. Patients with qSOFA ≥2 and CKD have a higher risk of death during hospitality.
Keywords: Acute respiratory failure, diseases, in-hospital mortality
|How to cite this article:|
Rasmin M, Elhidsi M, Prasenohadi, Putra Yahya WS, Sutanto YS, Setijadi AR, Parsama Putra NP, Setyawan Ua, Khairsyaf O, Russilawati, Herman D, Mulyadi, Zulfikar T, Yanifitri DB. Underlying diseases and in-hospital mortality of acute respiratory failure patients: Indonesian prospective cohort study. J Nat Sc Biol Med 2021;12:22-6
|How to cite this URL:|
Rasmin M, Elhidsi M, Prasenohadi, Putra Yahya WS, Sutanto YS, Setijadi AR, Parsama Putra NP, Setyawan Ua, Khairsyaf O, Russilawati, Herman D, Mulyadi, Zulfikar T, Yanifitri DB. Underlying diseases and in-hospital mortality of acute respiratory failure patients: Indonesian prospective cohort study. J Nat Sc Biol Med [serial online] 2021 [cited 2021 Apr 13];12:22-6. Available from: http://www.jnsbm.org/text.asp?2021/12/1/22/307850
| Introduction|| |
Epidemiologic studies on the incidence and mortality rate of patients with acute respiratory failure (ARF) in Indonesia are inadequate despite being a tropical country with a high health burden due to communicable diseases. On the contrary, several countries have reported their incidence, mortality, and risk factors for mortality related to ARF. Previous studies reported a 40%–60% mortality rate among patients with ARF.,, A prospective, single-centered study involving 150 ARF patients at Persahabatan Hospital, Jakarta, Indonesia, showed that 86% of ARF diagnosis was established in the emergency ward. Unfortunately, a significant number of cases were encountered in patients within productive ages. This multi-center study on ARF focuses on the underlying diseases and in-hospital mortality due to ARF in Indonesia.
| Materials and Methods|| |
This study was an observational prospective cohort study. Primary data were collected from adult (>17-year-old patients) admitted to six hospitals in Indonesia between January and December 2017. Our centers included hospitals in Java island (Persahabatan Hospital, Jakarta; Dr. Moewardi Hospital, Solo; and Saiful Anwar Hospital, Malang), and Sumatera island (Dr. M. Djamil Hospital, Padang; Dr. Achmad Moechtar Hospital, Bukit Tinggi; and Dr. Zainoel Abidin, Aceh). Patients' clinical characteristics, diagnosis, type of respiratory failure, the onset of respiratory failure, and patients' outcomes were collected.
Hypoxemic ARF is defined as measured arterial oxygen pressure (PaO2) <60 mmHg, arterial oxygen saturation (SaO2) <91%, and partial pressure of arterial oxygen over the fraction of inspired oxygen (PaO2/FiO2) ratio <300. Hypercapnic ARF is diagnosed in patients with arterial carbon dioxide pressure (PaCO2) >50 cmH2O and pH <7.35 or increase in PaCO2 >10 mmHg from baseline value. Indication for an invasive mechanical ventilator (IMV) included bradypnea or apnoea due to loss of consciousness, respiratory muscle fatigue, refractory hypoxemia, sputum retention, neuromuscular diseases, and an abrupt increase of intracranial pressure. Disease severity was assessed based on quick sepsis-related organ failure assessment (qSOFA). All data were collected by the managing physicians. Collected data were saved in each research hospital registry form. Subjects with incomplete data were excluded.
This study has been granted ethical approval by the Institutional Review Board of Persahabatan Hospital (Ethical Clearance No. 01/KEPK-RSUPP/01/2017), released on January 24, 2017. Statistical analysis was performed by Chi-square or Fisher exact test using SPSS version 21 (IBM Corp, Armonk, NY, USA). Multivariable regression models with variable selection based on a stepwise backward elimination were run to analyze the risk factors for in-hospital mortality. P value below 0.05 was considered to be significant.
| Results|| |
A total of 446 patients were enrolled, and 34 subjects were excluded due to incomplete clinical data and lost to follow-up. Therefore, 412 subjects were included in the descriptive analysis [Table 1]. The age range of the patients was 20–90-year-old, and the median of patients' age was 56-years-old. Subjects were dominated by the elderly (>60-year-old) (41.5%). The total of male patients was twice the females (male: 276 [66.9%], female: 136 [33.1%]). Hypoxemic and hypercapnic ARF proportions were comparable. A more significant portion of the ARF cases was diagnosed in hospital, and most of the patients came in severe condition. About 9.2% of patients had refractory ARF.
The ten most commonly encountered underlying diseases in this study were pneumonia, chronic obstructive pulmonary diseases (COPD), pulmonary tuberculosis (TB), lung cancer, bronchiectasis, congestive heart failure (CHF), cor pulmonale, chronic kidney disease (CKD), cerebrovascular diseases (CVD), and postsurgical complications [Table 2]. The proportion of patients with pneumonia was similar between elderly and younger patients; no significant difference between genders was found. Nevertheless, ARF incidence tended to incline in the elderly with CHF and COPD. Conversely, ARF proportion in pulmonary TB patients was higher in a younger patient (<45-year-old). The proportion of ARF in COPD patients was higher in male patients in comparison to female counterparts.
In this study, about 30.8% of patients should be managed using IMV, whereas 4.1% received noninvasive mechanical ventilation (NIV). Despite that, oxygen therapy was perceived as adequate for 65% of patients. The mean duration for in-hospital treatment was 7 days (range: 1–64 days). A relatively high in-hospital mortality rate was documented in this study (48.97%) [Table 3]. Multivariate analysis suggested that patients with a higher qSOFA score (≥2) and those who had CKD as the underlying disease had three-and four-times higher risk for death during hospitality, respectively [Table 4].
| Discussion|| |
To the best of our knowledge, this study is the first prospective cohort, observational, multi-center study on ARF in Indonesia using primary data instead of secondary data from the medical record or disease code (i.e., International Classification of Diseases;). Our study showed that ARF is more common in male patients compared to females (male: female = 2:1). Further, a higher percentage of patients were in their productive periods (45–65-year-old). A previous study in Indonesia reported that the mean age of the patient with ARF was 51-year-old. This result is considerably different from developed countries, which reported elderly patients as a more suspectable population., Hypercapnic respiratory failure percentage in this study was high (44.7%); however, this figure remains slightly lower than the previous report.
Communicable diseases cover a large portion of diseases related to ARF. In our study, pneumonia was the most commonly found underlying disease in ARF patients, and its proportion is relatively similar between age groups (elderly vs. younger population) and genders. On the other hand, a higher percentage of ARF were found in elderly patients with CHF and COPD as comorbid. In line with the current study, Kao et al. suggested that chronic pulmonary diseases, CVD, CHF, and moderate to severe CKD are associated with ARF in the elderly population On the contrary, our study suggested that ARF in TB patients are more frequently found in younger (<45-year-old) patients. ARF in COPD patients was found to be higher in females in comparison to male subjects. In light of the higher prevalence of TB in Indonesia, several diseases such as COPD and bronchiectasis might serve as a complication or sequel of TB., Both COPD and TB share a place as significant health burdens in developing countries. Worse, they might be further complicated by the potential progress of COPD to cardiovascular diseases, including cor pulmonale. The proportion of cor pulmonale and high right chambers pressure in patients with destroyed lungs is approximately 59%. Most of the ARF cases in patients with destroyed lungs are owing to pneumonia.
The outcome of ARF is highly dependent on the patient's clinical condition and adequate and appropriate management. The management of ARF should cover all processes in the emergency ward, intensive care units (ICUs), or wards, where applicable. The management of ARF is an escalated strategy using conventional oxygen therapy at initiation and can be wisely escalated to NIV, IMV, and finally, extracorporeal membrane oxygenation. Oxygen therapy in initial dyspnoea management should be monitored closely in terms of patient's response and saturation during the first 30 min, a responsive escalation to a more advanced strategy (e.g., intubation) should be initiated when indicated., Conventional oxygen therapy using a simple mask or rebreathing mask often being chosen as the initial or alternative therapy when the mechanical ventilator is limited (e.g., remote area, postdisaster condition or pandemic where demand for the ventilator is considerably rising). Similar considerations should also be applied for terminally ill patients due to pulmonary diseases because an invasive ventilator often is avoided. An invasive ventilator can be an alternative, particularly for patients with chronic pulmonary diseases and hypercapnic respiratory failure.,
Patient with CKD who falls into ARF has a higher risk of death during the treatment. Prior studies on CKD patients showed that pulmonary disease, including ARF, might increase the risk of death in this population., Observational study involving 30,000 patients treated in ICU from 54 hospitals in 23 countries reported that 5.7% of the patient experienced ARF during the in-hospital treatment, and about 75% of those patients were dialysis patients. Chronic renal failure leads to pulmonary complications, including lung edema, fibrinous pleuritis, lung calcification, and a more susceptible condition to TB infection. Furthermore, chronic renal failure is commonly accompanied by diabetes, hypertension, coronary artery disease, CHF, and chronic pulmonary disease. The mortality of patients with respiratory failure depends on the underlying disease's severity and the degree of respiratory failure. Our study measured the disease severity level using qSOFA (generally used for sepsis) despite its less accuracy in mortality prediction. Other studies might use another scoring, such as Apache II.
| Conclusions|| |
Communicable, infectious diseases persistently dominate the percentage of underlying diseases causing ARF in Indonesia. The in-hospital mortality rate due to ARF is high, with approximately half of the total patient died because of ARF during treatment. Patient with CKD as underlying disease and those who have qSOFA score ≥2 has a higher risk for in-hospital mortality.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]