Pulmonary Vascular Dysfunction Is Associated with Poor Outcomes in Patients with Acute Lung Injury

Rationale Despite the recognition that acute lung injury (ALI) can elevate pulmonary artery (PA) pressure and right ventricular after-load, the impact of pulmonary vascular dysfunction on outcomes of these patients is not well defined. Objectives: To investigate the impact of pulmonary vascular dysfunction in patients with acute lung injury. Methods: Secondary analysis of the Fluid and Catheter Treatment Trial. A total of 501 patients who received a PA catheter were evaluated for associations between increases in transpulmonary gradient (TPG) (PA mean pressure - PA occlusion pressure) or pulmonary vascular resistance index (PVRi) and 60-day mortality, ventilator-, intensive care unit (ICU)-, and cardiovascular-free days (days with mean arterial pressure 60 mm Hg off vasopressor support). Measurements and Main Results: We were able to measure the TPG in 475 (95%) and the PVRi in 470 (92%) patients. Patients with an elevated baseline TPG had an increased 60-day mortality (30 versus 19%; P = 0.02), and lower numbers of median ventilator- [25-75% quartiles] (15 [0-22] versus 19 [7-24]; P = 0.005), ICU- (14 [0-21] versus 18 [5-22]; P = 0.005), and cardiovascular-free days (23 [12-27] versus 25 [18-27]; P = 0.03). The median PVRi (305 [204-431] dyne s/cm(5)/m(2)) was elevated early in the course of ALI. PVRi was statistically higher in patients who died (326 [209-518] versus 299 [199-416]; P = 0.01). In individual multivariate models, TPG and PVRi remained independent risk factors for 60-day mortality and decrease in the number of ventilator-, ICU-, and cardiovascular-free days. Conclusions: Pulmonary vascular dysfunction is common in ALI, and is independently associated with poor outcomes. Future trials targeting pulmonary vascular dysfunction may be indicated.