Correspondence
Survivors of the Acute Respiratory Distress Syndrome
N Engl J Med 2003; 348:2149-2150May 22, 2003
- Article
To the Editor:
Given the extreme muscle wasting and severe weight loss experienced by patients with the acute respiratory distress syndrome (ARDS) during their illness, the description by Herridge et al. (Feb. 20 issue)1 of survivors' persistent functional disability one year after discharge from the intensive care unit (ICU) is hardly surprising. The average weight loss at the time of discharge was 18 percent of the initial body weight and occurred over a median period of 25 days. Surely the authors are describing a pattern of severe malnutrition, and there is good evidence, at least from studies in patients undergoing long-term dialysis, that malnutrition is independently associated with a poor quality of life.2,3 The improvement over the 12-month period was presumably related in part to correction of this malnourished state. Yet neither the authors nor the editorialists4 comment on the importance of nutritional support. It would be interesting to know how these patients were fed during (and after) their stay in the ICU (if indeed they were fed), since total parenteral nutrition is unlikely to have been of any benefit.5 Sadly, the Cinderella status of nutritional support seems to have been confirmed once again.
5 ReferencesDavid J. Bihari, F.R.A.C.P.
Prince of Wales Hospital, Sydney, NSW 2021, Australia
biharid@aol.com 1
Herridge MS ,Cheung AM ,Tansey CM , et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003;348:683-694
Full Text | Web of Science | Medline2
Ohri-Vachaspati P ,Sehgal AR . Quality of life implications of inadequate protein nutrition among hemodialysis patients. J Ren Nutr 1999;9:9-13
CrossRef | Medline3
Laws RA ,Tapsell LC ,Kelly J . Nutritional status and its relationship to quality of life in a sample of chronic hemodialysis patients. J Ren Nutr 2000;10:139-147
CrossRef | Medline4
Hudson LD ,Lee CM . Neuromuscular sequelae of critical illness. N Engl J Med 2003;348:745-747
Full Text | Web of Science | Medline5
Heyland DK ,MacDonald S ,Keefe L ,Drover JW . Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA 1998;280:2013-2019
CrossRef | Web of Science | Medline
To the Editor:
Herridge et al. found that survivors of ARDS had problems with ambulation after one year, as indicated by the six-minute–walk test. Some years ago, we reported on motor convalescence in 50 patients with ARDS1; 22 percent of those who survived for one year were unable to walk 50 m without aid. Poor motor outcome was predicted by electromyographic abnormalities, which were associated with a number of organ failures, during the ICU stay.2 In the discussion by Herridge et al., it seems as if polyneuropathy and myopathy after prolonged intensive care came as a surprise. Why did the authors not anticipate neurologic problems and incorporate electromyographic studies into their investigation?
2 ReferencesFrans S.S. Leijten, M.D., Ph.D.
Rudolf Magnus Institute of Neuroscience, 3584 CX Utrecht, the Netherlands
fleijten@neuro.azu. nl 1
Leijten FSS ,Harinck-de Weerd JE ,Poortvliet DCJ ,de Weerd AW . The role of polyneuropathy in motor convalescence after prolonged mechanical ventilation. JAMA 1995;274:1221-1225
CrossRef | Web of Science | Medline2
Leijten FSS ,De Weerd AW ,Poortvliet DCJ ,De Ridder VA ,Ulrich C ,Harink-De Weerd JE . Critical illness polyneuropathy in multiple organ dysfunction syndrome and weaning from the ventilator. Intensive Care Med 1996;22:856-861
CrossRef | Web of Science | Medline
To the Editor:
In their study of survivors of ARDS, Herridge and colleagues observed that the distance patients walked in six minutes was reduced up to one year after their discharge from the ICU. The authors conclude that this change was due to muscle wasting and weakness. Similarly, in patients with chronic obstructive pulmonary disease, weakness of the quadriceps muscles has been shown to contribute significantly to reductions in the distance walked in six minutes, independently of pulmonary function.1 In that study, muscle force was assessed with the use of a standardized and validated method.2 In contrast, in the study by Herridge and colleagues, assessments of muscle weakness and wasting were based solely on the investigators' “impression” and on patients' subjective reports. Although strong circumstantial evidence is present, Herridge and colleagues do not provide objective measures of muscle force or mass in their report. Hence, their conclusion appears to be premature. We strongly encourage the measurement of muscle force and mass in patients who have critical illnesses or prolonged hospital stays. Such measurements may be significant predictors of survival.3,4
4 ReferencesMartijn A. Spruit, M.Sc., P.T.
Benoit Nemery, Ph.D., M.D.
Katholieke Universiteit Leuven, B-3000 Leuven, Belgium
martijn.spruit@uz. kuleuven. ac. be Marc Decramer, Ph.D., M.D.
Universitair Ziekenhuis Gasthuisberg, B-3000 Leuven, Belgium1
Gosselink R ,Troosters T ,Decramer M . Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med 1996;153:976-980
Web of Science | Medline2
Decramer M ,Lacquet LM ,Fagard R ,Rogiers P . Corticosteroids contribute to muscle weakness in chronic airflow obstruction. Am J Respir Crit Care Med 1994;150:11-16
Web of Science | Medline3
Decramer M ,de Bock V ,Dom R . Functional and histologic picture of steroid-induced myopathy in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996;153:1958-1964
Web of Science | Medline4
Marquis K ,Debigare R ,Lacasse Y , et al. Midthigh muscle cross-sectional area is a better predictor of mortality than body mass index in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2002;166:809-813
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Bihari comments on the lack of discussion of nutritional support in our article and on the possibility that malnutrition may be another, independent contributor to weight loss and long-term muscle wasting in survivors of ARDS. We agree with his comments. Our group did not prospectively collect data on the manner in which patients were fed during or after their ICU stay, and we acknowledge that this issue is important and warrants further study. The use of early and optimal nutritional support may represent another way in which daily practice in the ICU could affect patients' long-term outcomes.
Dr. Leijten asks why we did not anticipate long-term neuromuscular sequelae in survivors of ARDS and prospectively incorporate electromyography or nerve-conduction testing into our study to document the prevalence of these findings. Our group was aware of the literature on polyneuropathy and myopathy in survivors of ARDS and critical illness, but when we began our study, in 1998, we never expected that persistent neuromuscular dysfunction would be the major cause of long-term functional disability and impaired quality of life in these patients. We agree that neuromuscular disease is currently underdiagnosed in the ICU and that electromyography, nerve-conduction testing, and consultation with colleagues in neurology and physiatry may represent important and underused resources.
Dr. Spruit and colleagues comment that our conclusion — that survivors of ARDS have muscle weakness — may be premature because we did not provide any objective measure of muscle force or mass in our article. We agree that assessment of specific measures of muscle force and mass represent potentially important adjuncts to quantify muscle bulk and the degree of muscle weakness in the ICU and their improvement during the rehabilitation period after discharge. In our study, each survivor of ARDS underwent physical examination, as detailed in the article, and the examination included bedside testing of muscle power. Therefore, our conclusions were not based solely on impressions and patients' reports; there was also objective evidence of muscle weakness on physical examination.
Margaret S. Herridge, M.D., M.P.H.
University of Toronto, Toronto, ON M5G 2C4, Canada
margaret.herridge@uhn. on. ca for the Toronto ARDS Outcomes Group
- Citing Articles (1)
Citing Articles
1
Dale M. Needham, David W. Dowdy, Pedro A. Mendez-Tellez, Margaret S. Herridge, Peter J. Pronovost. (2005) Studying outcomes of intensive care unit survivors: measuring exposures and outcomes. Intensive Care Medicine 31:9, 1153-1160
CrossRef
