A predictive Score for Pulmonary Complications in Mechanically Ventilated Patients in a Surgical Intensive Care Unit

Main Article Content

Nattachai Hemtanon
Ornin Chintabanyat
Ajana Trisukhonth
Chayanan Thanakiattiwibun
Annop Piriyapatsom


Background: Two-thirds of patients in a surgical intensive care unit (SICU)require mechanical ventilation. However, pulmonary complications and its associated risk factors are not adequately identified in these patients. Objectives: To identify the risk factors and to develop a predictive score for pulmonary complications in mechanically ventilated patients in a SICU. Methods: Mechanically ventilated patients admitted to a SICU were included in this prospective study. The onset of pulmonary complications within seven days after mechanical ventilation support was observed. A multivariate analysis with a logistic regression model was used to identify variables associated with the development of pulmonary complications and a predictive score was subsequently developed. Results: There were 306 patients included in this study and of these, 36.6% experienced pulmonary complications during the study period. An abnormal chest radiograph, hypoalbuminemia, and presence of respiratory, cardiovascular, and renal dysfunction upon SICU admission were the independent risk factors identified. The area under the receiver-operating characteristic curves for the predictive score was 0.768 (95% CI, 0.713-0.822). The best cut-off value was 8.5, which yielded 71.4% (95% CI, 62.1-79.6%) sensitivity and 71.7% (64.8-77.9%) specificity. Conclusion: The incidence of pulmonary complications among mechanically ventilated patients in a SICU is high. Five independent risk factors were identified, and a new predictive score was developed which had a fair discriminative power. Further external validation is needed to verify its accuracy.

Article Details

Original articles


Whiting J, Edriss H, Nugent K. Frequency and etiology of ventilator-associated events in the medical intensive care unit. Am J Med Sci. 2015;350:453-7.

Soto GJ, Kor DJ, Park PK, et al. Lung injury prediction score in hospitalized patients at risk of acute respiratory distress syndrome. Crit Care Med. 2016;44:2182-91.

Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152:157-66.

Jerath A, Laupacis A, Austin PC, Wunsch H, Wijeysundera DN. Intensive care utilization following major noncardiac surgical procedures in Ontario, Canada: a population-based study. Intensive Care Med. 2018;44:1427-35.

Fernandes A, Rodrigues J, Lages P, et al. Root causes and outcomes of postoperative pulmonary complications after abdominal surgery: a retrospective observational cohort study. Patient Saf Surg. 2019;13:40.

Wagner DP, Draper EA. Acute physiology and chronic health evaluation (APACHE II) and Medicare reimbursement. Health Care Financ Rev. 1984;Suppl:91-105.

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-29.

Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707-10.

Sakr Y, Lobo SM, Moreno RP, et al. Patterns and early evolution of organ failure in the intensive care unit and their relation to outcome. Crit Care. 2012;16:R222.

Lambden S, Laterre PF, Levy MM, Francois B. The SOFA score-development, utility and challenges of accurate assessment in clinical trials. Crit Care. 2019;23:374.

Mazo V, Sabate S, Canet J, et al. Prospective external validation of a predictive score for postoperative pulmonary complications. Anesthesiology. 2014;121:219-31.

Gajic O, Dabbagh O, Park PK, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med. 2011;183:462-70.

Trillo-Alvarez C, Cartin-Ceba R, Kor DJ, et al. Acute lung injury prediction score: derivation and validation in a population-based sample. Eur Respir J. 2011;37:604-9.

Chittawatanarat K, Jaikriengkrai K, Permpikul C, Thai Society of Critical Care Medicine Study G. Survey of respiratory support for intensive care patients in 10 tertiary hospital of Thailand. J Med Assoc Thai. 2014;97Suppl 1:S8-14.

Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol. 2015;32:88-105.

Carter JV, Pan J, Rai SN, Galandiuk S. ROC-ing along: Evaluation and interpretation of receiver operating characteristic curves. Surgery. 2016;159:1638-45.

Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113:1338-50.

Damian D, Esquenazi J, Duvvuri U, Johnson JT, Sakai T. Incidence, outcome, and risk factors for postoperative pulmonary complications in head and neck cancer surgery patients with free flap reconstructions. J Clin Anesth. 2016;28:12-8.

investigators LV. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS-an observational study in 29 countries. Eur J Anaesthesiol. 2017;34:492-507.

Ferrando C, Soro M, Unzueta C, et al. Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): a randomised controlled trial. Lancet Respir Med. 2018;6:193-203.

Zilberberg MD, Luippold RS, Sulsky S, Shorr AF. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States. Crit Care Med. 2008;36:724-30.

Foster CA, Charles EJ, Turrentine FE, Sohn MW, Kron IL, Jones RS. Development and validation of procedure-specific risk score for predicting postoperative pulmonary complication: a NSQIP analysis. J Am Coll Surg. 2019;229:355-65e3.

Fu MC, Buerba RA, Grauer JN. Preoperative nutritional status as an adjunct predictor of major postoperative complications following anterior cervical discectomy and fusion. Clin Spine Surg. 2016;29:167-72.

Thongprayoon C, Cheungpasitporn W, Chewcharat A, Mao MA, Thirunavukkarasu S, Kashani KB. Risk of acute respiratory failure among hospitalized patients with various admission serum albumin levels: a cohort study. Medicine (Baltimore). 2020;99:e19352.

Milford EM, Reade MC. Resuscitation fluid choices to preserve the endothelial glycocalyx. Crit Care. 2019;23:77.

Hawiger J. Heartfelt sepsis: microvascular injury due to genomic storm. Kardiol Pol. 2018;76:1203-16.

Chignalia AZ, Weinberg G, Dull RO. Norepinephrine induces lung microvascular endothelial cell death by NADPH oxidase-dependent activation of caspase-3. Oxid Med Cell Longev. 2020;2020:2563764.

Faubel S, Edelstein CL. Mechanisms and mediators of lung injury after acute kidney injury. Nat Rev Nephrol. 2016;12:48-60.

Darmon M, Clec’h C, Adrie C, et al. Acute respiratory distress syndrome and risk of AKI among critically ill patients. Clin J Am Soc Nephrol. 2014;9:1347-53.

Bauman ZM, Gassner MY, Coughlin MA, Mahan M, Watras J. Lung injury prediction score is useful in predicting acute respiratory distress syndrome and mortality in surgical critical care patients. Crit Care Res Pract. 2015;2015:157408.