Are we unjustifiably denying intensive care support to patients suffering severe COPD exacerbation?

Abstract

Objective

To determine whether clinicians’ prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival.

Design

Prospective cohort study.

Setting

92 intensive care units and three respiratory high dependency units in the United Kingdom.

Participants

832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two.

Main outcome measures

Outcome predicted by clinicians. Observed survival at 180 days.

Results

517 patients (62%) survived to 180 days. Clinicians’ prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units.

Conclusions

Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians’ prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.

Reproduced with permission from BMJ Publishing Group Ltd.