Development and validation of machine learning-based prediction for in-hospital mortality in ICU patients with severe community-acquired pneumonia and respiratory failure

Background Accurate prediction of in-hospital mortality for patients with severe community-acquired pneumonia (SCAP) complicated by respiratory failure admitted to the intensive care unit (ICU) remains a critical challenge. This study aimed to develop and validate a machine learning (ML) model to predict this risk and compare its performance with conventional scoring systems. Methods In this retrospective study, data from 164 patients with SCAP and respiratory failure admitted to the ICU between January 2017 and January 2024 were analyzed. Patients were randomly divided into a training set ( n = 114) and a validation (test) set ( n = 50). Forty-five clinical features collected at admission were used as candidate predictors. The Least Absolute Shrinkage and Selection Operator (LASSO) regression was employed for feature selection. Six ML models, including Gradient Boosting Decision Tree (GBDT), Random Forest (RF), eXtreme Gradient Boosting (XGBoost), Decision Tree(DT),Support Vector Machine (SVM), and Logistic Regression(LR), were constructed and evaluated.Use SHAP analysis to assess the contribution of each feature in a machine learning model. Construct a nomogram using the top six most influential features. Results The GBDT model demonstrated the best predictive performance, achieving an area under the receiver operating characteristic curve (AUC) of 0.83 (95% CI: 0.757–0.927) in the internal validation set, significantly outperforming the Acute Physiology and Chronic Health Evaluation II (APACHE-II, AUC = 0.70). Calibration curves demonstrated good agreement between predicted and observed mortality risks, particularly across the mid-probability range. Decision curve analysis indicated that the model provided a higher net benefit than “treat-all” and “treat-none” strategies across a broad range of threshold probabilities. SHapley Additive exPlanations (SHAP) analysis identified lactate, D-dimer, temperature, albumin, Prothrombin Time and Fraction of Inspired Oxygen as the six most influential predictors of in-hospital mortality. Based on these key predictors, we further developed a simplified nomogram to facilitate bedside risk estimation. Conclusion The GBDT ML model, developed from routinely available clinical data, provides a highly accurate and clinically interpretable tool for predicting in-hospital mortality in SCAP patients with respiratory failure. It outperforms traditional severity scores and holds promise for assisting clinicians in risk stratification and early intervention.