Key result
Severe respiratory failure in intermediate-risk PE is linked to ~5-fold higher 30-day PE-related death.
Why the study?
In hemodynamically stable intermediate-risk patients with acute PE, there is debate about whether respiratory failure should drive clinical management and its prognostic role required assessment.
Does the severity of respiratory failure (defined by SpO2:FiO2 classes) predict time to death due to pulmonary embolism at 30 days in intermediate-risk patients with acute, symptomatic pulmonary embolism?
Cohort (n=3,874)
Yes
Does the severity of respiratory failure (defined by SpO2:FiO2 classes) predict time to death due to pulmonary embolism at 30 days in intermediate-risk patients with acute, symptomatic pulmonary embolism?
Answers are grounded in this paper and cite their sources.
In patients with acute intermediate-risk pulmonary embolism, greater severity of respiratory failure defined by SpO2:FiO2 classes independently identifies patients at increased risk for PE-related and in-hospital mortality.
Background For hemodynamically stable patients with acute pulmonary embolism (PE) who are at an increased risk of death based on clinical criteria (i.e. intermediate-risk patients), there is a debate about whether respiratory failure should drive clinical management. We aimed at assessing the prognostic role of respiratory failure, in intermediate-risk patients with acute, symptomatic PE from a prospective, multicentre study (COPE). Methods Respiratory failure was classified according to global definition of acute respiratory distress syndrome (ARDS) based on the oxygen saturation-to-inspired oxygen flow (SpO2:FiO2) into absent (SpO2:FiO2 >315), mild (235< SpO2:FiO2 ≤315), moderate (148< SpO2:FiO2 ≤235) and severe (SpO2:FiO2 ≤148). The primary outcome for this analysis was time to death due to PE at 30 days. In-hospital death and in-hospital death or clinical deterioration were also reported. Results Among 5,213 patients with acute, symptomatic PE included in the COPE study, 3,874 intermediate-risk patients were included in this analysis. At admission, respiratory failure was absent in 3233 (82.9%), mild in 326 (8.4%), moderate in 292 (7.5%) and severe in 33 (0.8%). Death due to PE occurred in 1.2%, 1.2%, 3.4% and 6.0% of patients with absent, mild, moderate or severe respiratory failure, respectively; in-hospital death in 2.7%, 4.9%, 5.1% and 12.1% of patients with absent, mild, moderate or severe respiratory failure, respectively. The severity of respiratory failure was associated with the risk for death due to PE and for in-hospital death independently with respect to the intermediate risk category (no right ventricle dysfunction [RVD], normal troponin; RVD or increased troponin; RVD and increased troponin). Conclusions In patients with acute PE at intermediate risk for death, severity of respiratory failure defined according to global definition by classes of SpO2:FiO2 is associated with the risk for death. Whether different treatment strategies should be adopted based on severity of respiratory failure should be defined.
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Becattini et al. (2026) conducted a cohort in Intermediate-risk acute symptomatic pulmonary embolism (n=3,874). Respiratory failure severity (mild: 235< SpO2:FiO2 ≤315; moderate: 148< SpO2:FiO2 ≤235; severe: SpO2:FiO2 ≤148) vs. Absent respiratory failure (SpO2:FiO2 >315) was evaluated on Time to death due to pulmonary embolism at 30 days. Respiratory failure severity in intermediate-risk acute PE was associated with increased 30-day PE-related death (1.2% absent, 1.2% mild, 3.4% moderate, and 6.0% severe).
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