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Sathe, N.A., Zelnick, L.R., Mikacenic, C. et al. Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts. Crit Care 25, 336 (2021).

Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts

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Author: Sathe, Neha A.1; Zelnick, Leila R.2; Mikacenic, Carmen1,3;
Organizations: 1Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
2Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
3Benaroya Research Institute, Seattle, WA, USA
4Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
5Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
6Department of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
7Division of Pulmonary and Critical Care, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
8Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
9Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 1.5 MB)
Persistent link:
Language: English
Published: Springer Nature, 2021
Publish Date: 2021-10-07


Background: Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population.

Methods: In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO₂-to-FIO₂ ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO₂-to-FIO₂ ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF.

Results: Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS.

Conclusion: Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF.

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Series: Critical care
ISSN: 1364-8535
ISSN-E: 1875-7081
ISSN-L: 1364-8535
Volume: 25
Issue: 1
Article number: 336
DOI: 10.1186/s13054-021-03755-7
Type of Publication: A1 Journal article – refereed
Field of Science: 3121 General medicine, internal medicine and other clinical medicine
3126 Surgery, anesthesiology, intensive care, radiology
Funding: Authors received funding from the National Heart, Lung, and Blood Institute: T32HL007287, F32HL158088 (NAS); K23HL144916 (EDM); K24HL103836, R01HL135849 (LBW), as well as the National Institute of Diabetes, Digestive and Kidney Disease: K23DK116967 (PKB). The funding sources had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
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