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Objectives: To assess the outcome of children who required endotracheal intubation after bone marrow transplantation and to determine whether prognostic indicators that might assist decision-making regarding the institution of mechanical ventilation could be identified., Design: Retrospective chart review., Setting: Critical care, reverse isolation unit at a university hospital., Patients: Fifty-four pediatric bone marrow transplant recipients who required endotracheal intubation., Interventions: None., Measurements and Main Results: The following variables were assessed for effect on survival: a) the presence of additional nonhematoporetic organ system failure; b) the duration of required ventilatory assistance; c) the etiology of respiratory failure; d) the presence of significant graft vs. host disease; and e) the underlying disease for which the transplant was done. Six of 54 intubated pediatric bone marrow transplant recipients were extubated and discharged from the hospital. No patient with a diagnosis of leukemia or with multiple organ system failure could be extubated or discharged from the hospital. The presence of pulmonary parenchymal disease indicated poor prognosis for survival., Conclusions: The decision to intubate a pediatric bone marrow transplant patient remains a difficult one. In this population, multiple organ system failure and primary pulmonary parenchymal disease were associated with a high mortality rate. These factors should be taken into account before and throughout the course of mechanical ventilation in this patient population.

We reviewed the hospital charges, underlying diagnoses, and hospital outcomes in 39 patients with adult respiratory distress syndrome (ARDS) admitted to the respiratory ICU of a university hospital between July 1979 and June 1981. Charges per patient ranged from $9263 to $187,893 with a median of $52,894. Median ICU charges were $2430/day. Only 7 patients survived their hospitalization. Compared to nonsurvivors, survivors had longer ICU and hospital stays but lower daily ICU charges ($1683 vs. $2760,p = .001). Only 1 of 27 patients with underlying hematologic/oncologic diseases survived, compared to 6 of 12 patients with other underlying diseases. Charges and outcomes in this study reflect the underlying patient population and philosophy of care at the study institution. Considering the high costs and poor outcomes in ARDS patients with underlying hematologic/oncologic problems, we recommend that the appropriateness of aggressive treatment be reconsidered.

We reviewed the ICU courses of 50 bone marrow transplant recipients treated for respiratory problems. Seven of nine postoperative patients survived compared to one of 40 patients with progressive interstitial pneumonia. Nonsurvivors accounted for 94% of the ICU days, 98% of intubated days, and 99% of blood products used. All survivors were extubated within 4 days. Intensive respiratory care is effective for patients with readily reversible causes of respiratory failure, but is generally futile for patients with progressive interstitial pneumonia. We recommend providing these patients with realistic prognostic estimates early in their treatment.

Changes in intrathoracic pressure during the respiratory cycle cause variations in pulmonary vascular pressures. This affects pulmonary hemodynamic measurements in critically ill patients, particularly those receiving mechanical ventilation. With certain newer ventilators, the machine-pressure and/or expiratory-flow signal can be graphed simultaneously with hemodynamic pressure. The end-expiratory point determined from these graphs can be used to identify the corresponding wedge pressure on the hemodynamic tracing.