PREDICTORS OF ACUTE RESPIRATORY-FAILURE AFTER BONE-MARROW TRANSPLANTATION IN CHILDREN

Objective: To determine factors associated with acute respiratory fail ure after bone marrow transplantation which can be identified before t he onset of lung disease. Design: Population-based, retrospective stud y. Setting: A referral-based pediatric intensive care unit and bone ma rrow transplant center. Patients: Thirty-nine patients with lung disea se (abnormal chest radiograph or a need for supplemental oxygen) were identified from a group of 318 pediatric bone marrow transplant patien ts from 1978 to 1988. Thirty-four of 39 patients with complete data we re further classified into patients with mild lung disease (recovery w ithout needing endotracheal intubation, n = 16) and patients with acut e respiratory failure (requirement for endotracheal intubation, n = 18 ).Interventions: Regression analyses were performed to define risk fac tors for development of respiratory failure (multivariate logistic reg ression) and for a shortened interval between the identification of lu ng disease and respiratory failure (Cox proportional hazards analysis) . Measurements and Main Results: Ninety-three percent (15/16) of patie nts with mild lung disease survived. Conversely, only 9% (2/23) of pat ients with respiratory failure survived. Predictors of respiratory fai lure included graft vs. host disease (odds ratio 28.3, 95% confidence interval 1.9-421, p = .015), a prelung disease (baseline) circulating creatinine concentration of >1.5 mg/dL (>132.6 mu mol/L) (odds ratio 2 8.4, 95% confidence interval 1.4-577, p = .029), and male gender (odds ratio 14.6, 95% confidence interval 1-210, p = .049). Predictors of a shortened time to onset of respiratory failure included baseline seru m creatinine value of >1.5 mg/dL (>132.6 mu mol/L) (hazard ratio 6.2, 95% confidence interval 1.5-26.5, p = .013) and baseline total bilirub in concentration >1.4 mg/dL (>23.9 mu mol/L) (hazard ratio 4.5, 95% co nfidence interval 0.98-20.7, p = .053). The median time to onset of re spiratory failure was 4 days in patients with baseline creatinine valu es greater than or equal to 1.5 mg/dL (>132.6 mu mol/L) and 5 days in patients with baseline bilirubin concentrations greater than or equal to 1.4 mg/dL (>23.9 mu mol/L) vs. >26 days in patients with creatinine <1.5 mg/dL (<132.6 mu mol/L) and >29 days in patients with bilirubin <1.4 mg/dL (<23.9 mu mol/L) (Kaplan-Meier analysis). Conclusions: Rena l and liver dysfunction preceded clinical evidence of lung disease in bone marrow transplant patients who developed respiratory failure. Lun g disease leading to respiratory failure and adult respiratory distres s syndrome appears to develop as one component of the multiple organ f ailure syndrome in pediatric bone marrow transplant patients.