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    Murray Score for Acute Lung Injury

    Stratifies severity of acute lung injury, and is also used for ECMO patient selection.
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    INSTRUCTIONS

    Use in patients with severe hypoxemic respiratory failure from acute respiratory distress syndrome (ARDS). May be used with other clinical factors to help select patients for extracorporeal membrane oxygenation (ECMO).

    When to Use
    Pearls/Pitfalls
    Why Use
    • Patients with severe hypoxemic respiratory failure from acute respiratory distress syndrome (ARDS).
    • May be used in conjunction with other clinical factors (e.g. age, comorbidities, etiology of respiratory failure, presence of other organ dysfunction, duration of endotracheal intubation) to help determine whether a patient may benefit from extracorporeal life support.
    • Indicates severity of ARDS; should not be used by itself to determine candidacy for ECMO.
    • Should not be used to characterize severity of other forms of acute or chronic respiratory failure, or to assign severity to patients with ARDS manifested by severe, uncompensated respiratory acidosis.
    • Not applicable to patients being considered for ECMO for cardiac failure.
    • Provides a relatively standardized method of assessing severity of lung injury in the setting of ARDS and helps guide which patients may benefit from extracorporeal life support.
    • ECMO has expanded management options for patients with severe forms of ARDS; however, optimal criteria and timing of ECMO for initiation are unestablished. The Murray Score is one system that may help guide practitioners in selecting appropriate candidates for this treatment.
    Unknown
    None
    1 quadrant
    2 quadrants
    3 quadrants
    4 quadrants
    Unknown
    ≥300
    225-299
    175-224
    100-174
    <100
    Unknown
    ≤5
    6–8
    9–11
    12–14
    ≥15
    Unknown
    ≥80
    60–79
    40–59
    20–39
    ≤19

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    According to the Extracorporeal Life Support Organization (ELSO) guidelines:

    • Patients with ARDS and a Murray Score of 3-4 may be considered for ECMO cannulation in the correct clinical setting.
    • Patients with a Murray Score >2 could be considered for transfer to a center with ECMO capabilities.

    It is important to consider all other patient factors as well as contraindications and risks of ECMO. Relative contraindications include:

    • Any condition that would limit the benefit of ECMO (such as severe neurologic injury or advanced malignancy).
    • Any contraindication to anticoagulation.
    • High FiO requirements or high-pressure mechanical ventilation >7 days.
    • Limited vascular access.

    Management

    Once the decision is made to initiate ECMO, the patient should be transferred and managed at a center experienced at treating patients with extracorporeal life support. The following algorithm highlights the basic considerations for types of ECMO cannulation strategies based on the different pathophysiological indications.

    Once the patient is supported on extracorporeal life support with direct oxygenation and removal of carbon dioxide from the blood, it may be possible to apply low-volume, low-pressure ventilation strategies, which is the underlying principle for ARDS management.

    Adapted from the ELSO Red Book, 5th Edition (Brogan et al).

    Critical Actions

    The Murray Score is only a guide and should not supercede clinical judgement by clinicians about the appropriateness of ECMO initiation.

    In the only modern clinical trial evaluating ECMO for ARDS (the CESAR Trial in Lancet 2009), the indications for ECMO in patients with ARDS included Murray Scores 3-4 or a pH <7.20 despite optimal conventional treatment. Patients with Murray Scores >2 and P/F ratio <150 should be considered for transfer to an ECMO center.

    Formula

    Addition of the selected points, then divide by the number of inputs selected:

     Variable

    Points

    Consolidation on CXR

    None

    0

    1 quadrant

    1

    2 quadrants

    2

    3 quadrants

    3

    4 quadrants

    4

    PaO2/FiO2 ratio

    ≥300

    0

    225–299

    1

    175–224

    2

    100–174

    3

    <100

    4

    PEEP, cm H2O

    ≤5

    0

    6–8

    1

    9–11

    2

    12–14

    3

    ≥15

    4

    Compliance, ml/cm H2O

    VT / ( PIP – PEEP )

    ≥80

    0

    60–79

    1

    40–59

    2

    20–39

    3

    ≤19

    4

    Facts & Figures

    Interpretation:

    Murray Score

    Severity

    0

    No lung injury

    0.1–2.5

    Mild to moderate

    >2.5

    Severe

    If Murray Score ≥3.0, then patient should be considered for ECMO referral.

    Evidence Appraisal

    Originally developed by John Murray to assess the severity of acute lung injury in ARDS, the Murray Score was later used in the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial to help determine which patients with ARDS were appropriate for ECMO.

    The CESAR trial is the only modern randomized trial comparing “conventional” ventilatory management for patients with ARDS to a protocolized management at a specialty center that included ECMO when deemed necessary.

    180 patients were randomized, and 53% in the conventional group died or had severe disability at 6 months, versus 37% in the ECMO group (p = 0.03). Of note, low tidal-volume ventilation was used in only 70% of patients in the conventional group, and not all patients randomized to the treatment group ultimately received ECMO.

    Literature

    Dr. John F. Murray

    About the Creator

    John F. Murray, MD, is professor emeritus of medicine at the University of California in San Francisco. He served as chief of the pulmonary and critical care division at San Francisco General Hospital. Dr. Murray’s research interests are focused on pulmonology.

    To view Dr. John F. Murray's publications, visit PubMed

    Content Contributors
    • Peter Liou, MD
    Reviewed By
    • Cara Agerstrand, MD
    About the Creator
    Dr. John F. Murray
    Content Contributors
    • Peter Liou, MD
    Reviewed By
    • Cara Agerstrand, MD