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Michael G. Seneff, MD; Douglas P. Wagner, PhD; Randall P. Wagner, MD; Jack E. Zimmerman, MD; William A. Knaus, MD

JAMA. 1995;274(23):1852-1857.

Abstract
Objective.
—To describe outcomes and identify variables associated with hospital and 1-year survival for patients admitted to an intensive care unit (ICU) with an acute exacerbation of chronic obstructive pulmonary disease (COPD).

Design.
—Prospective, multicenter, inception cohort study.

Setting.
—Forty-two ICUs at 40 US hospitals.

Patients.
—A total of 362 admissions for COPD exacerbation selected from the Acute Physiology and Chronic Health Evaluation (APACHE) III database of 17440 ICU admissions.

Measurements and Results.
—Hospital mortality for the 362 admissions was 24%. For the 167 patients aged 65 years or older, mortality was 30% at hospital discharge, 41% at 90 days, 47% at 180 days, and 59% at 1 year. Median survival for all patients was 224 days, and median survival for the patients who died within 1 year was 30.5 days. On multiple regression analysis, variables associated with hospital mortality included age, severity of respiratory and nonrespiratory organ system dysfunction, and hospital length of stay before ICU admission. Development of nonrespiratory organ system dysfunction was the major predictor of hospital mortality (60% of total explanatory power) and 180-day outcomes (54% of explanatory power). Respiratory physiological variables (respiratory rate, serum pH, Paco₂, Pao₂, and alveolar-arterial difference in partial pressure of oxygen [Pao₂—Pao₂]) indicative of advanced dysfunction were more strongly associated with 180-day mortality rates (22% of explanatory power) than hospital death rates (4% of explanatory power). After controlling for severity of illness, mechanical ventilation at ICU admission was not associated with either hospital mortality or subsequent survival.

Conclusions.
—Patients with COPD admitted to an ICU for an acute exacerbation have a substantial hospital mortality (24%). For patients aged 65 years or older, mortality doubles in 1 year from 30% to 59%. Hospital and longer-term mortality is closely associated with development of nonrespiratory organ system dysfunction; severity of the underlying respiratory function substantially influences mortality following hospital discharge. The need for mechanical ventilation at ICU admission did not influence either short- or long-term outcomes. Physicians should be aware of these relationships when making treatment decisions or evaluating new therapies.

(JAMA. 1995;274:1852-1857)

Author Affiliations
From the ICU Research Unit, Department of Anesthesiology (Drs Seneff, D. P. Wagner, Zimmerman, and Knaus), and the Pulmonary Division, Department of Medicine (Dr R. P. Wagner), George Washington University, Washington, DC. Drs Knaus and D. P. Wagner are now with the ICU Research Team, University of Virginia Medical School, Charlottesville.

Footnotes
Drs Knaus, Zimmerman, and D. P. Wagner are founders and minority equity shareholders of APACHE Medical Systems Inc, McLean, Va, a for-profit Delawarebased corporation that funded, in part, the research for the APACHE III study. APACHE Medical Systems Inc markets a software-based clinical information system based upon some of the concepts described in this article. Drs Knaus, Zimmerman, and D. P. Wagner, as full-time employees of George Washington University, are not permitted to receive any direct financial payment from APACHE Medical Systems Inc.

Reprint requests to the George Washington University Medical Center, 901 23rd St NW, Washington, DC 20037 (Dr Seneff).

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