Etiologies, diagnostic work-up and outcomes of acute respiratory distress syndrome with no common risk factor: a prospective multicenter study

Nicolas de Prost, Tài Pham, Guillaume Carteaux, Armand Mekontso Dessap, Christian Brun-Buisson, Eddy Fan, Giacomo Bellani, John Laffey, Alain Mercat, Laurent Brochard, Bernard Maître, LUNG SAFE investigators, ESICM trials group, REVA network, Nicolas de Prost, Tài Pham, Guillaume Carteaux, Armand Mekontso Dessap, Christian Brun-Buisson, Eddy Fan, Giacomo Bellani, John Laffey, Alain Mercat, Laurent Brochard, Bernard Maître, LUNG SAFE investigators, ESICM trials group, REVA network

Abstract

Background: Patients meeting the Berlin definition for the acute respiratory distress syndrome (ARDS) might lack exposure to one or more "common" risk factors and exhibit different clinical phenotype and outcomes. We aimed to compare the clinical presentation and outcome of ARDS patients with or without risk factors, the impact on hospital mortality, and to assess the diagnostic work-up performed. The current study is an ancillary analysis of an international, multicenter, prospective cohort study (the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure, LUNG SAFE). Patients meeting ARDS criteria within 2 days of acute hypoxemic respiratory failure onset were included in the study and categorized as having risk factors or not. Outcomes were compared using propensity score matching.

Results: Among 2813 patients, 234 (8.3% [7.3-9.3]) had no ARDS risk factor identified. These were older, had more frequent chronic diseases and presented with less severe SOFA and non-pulmonary SOFA scores (p < 0.001). Compared to other ARDS, CT scan (32.1 vs 23.9%, p < 0.001) and open lung biopsy (2.6 vs 0.2%, p < 0.001) were slightly more frequent but left heart filling pressures assessment was not (69.4 vs 68.4%, p > 0.99). Among ARDS with no risk factor, 45 patients (19.2%) had a specific diagnosis made. As compared to others, patients having ARDS with no risk factor had a lower ICU but not hospital mortality (34.6 vs 40.0%; p = 0.12). A matched cohort analysis confirmed the lack of significant difference in mortality.

Conclusion: Eight percent of ARDS patients have no identified risk factor, 80% of whom have no etiological diagnosis made. The outcome of ARDS with no risk factor was comparable to other ARDS but few had a comprehensive diagnostic work-up, potentially leading to missed curable diseases. Trial registration clinicaltrials.gov Identifier: NCT02010073.

Keywords: Berlin definition; Diagnostic techniques and procedures; Outcomes; Respiratory distress syndrome, adult.

Figures

Fig. 1
Fig. 1
Flow of patients with acute hypoxic respiratory failure (AHRF) enrolled in the study. ICU, intensive care unit; ARDS, acute respiratory distress syndrome; COPD, chronic obstructive respiratory disease; a Patients could have more than one cause of acute hypoxic respiratory failure; b Factors identified during the course of ICU stay
Fig. 2
Fig. 2
Covariates balances as measured by standardized differences across groups exposed or not to ARDS risk factors. Standardized differences are shown before (closed circles) and after (open circles) propensity score matching (including the variable “Peak inspiratory pressure”). PEEP, positive end-expiratory pressure; COPD, chronic obstructive pulmonary disease; NIV, non-invasive ventilation
Fig. 3
Fig. 3
Kaplan–Meier curves of hospital survival probability in the whole (non-matched) cohort (a) and in the propensity score-matched cohort (b). ARDS patients with no risk factor identified (red curve) exhibited a non-significantly different probability of mortality during hospital stay, as compared with those having one or more risk factor identified (blue curve) both in the whole (a, p = 0.13, by the log-rank test) and the matched cohort (b, p = 0.73 by the Cox proportional hazard model)

References

    1. Force Ards Definition Task, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–2533.
    1. Gajic O, Dabbagh O, Park PK, Adesanya A, Chang SY, Hou P, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med. 2011;183:462–470. doi: 10.1164/rccm.201004-0549OC.
    1. Kao KC, Hu HC, Chang CH, Hung CY, Chiu LC, Li SH, et al. Diffuse alveolar damage associated mortality in selected acute respiratory distress syndrome patients with open lung biopsy. Crit Care. 2015;19:228. doi: 10.1186/s13054-015-0949-y.
    1. Thille AW, Esteban A, Fernandez-Segoviano P, Rodriguez JM, Aramburu JA, Penuelas O, et al. Comparison of the Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir Crit Care Med. 2013;187:761–767. doi: 10.1164/rccm.201211-1981OC.
    1. Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med. 1998;158:3–11. doi: 10.1164/ajrccm.158.1.9708031.
    1. Calfee CS, Delucchi K, Parsons PE, Thompson BT, Ware LB, Matthay MA, et al. Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials. The Lancet Respiratory medicine. 2014;2:611–620. doi: 10.1016/S2213-2600(14)70097-9.
    1. Gibelin A, Parrot A, Maitre B, Brun-Buisson C, Mekontso Dessap A, Fartoukh M, et al. Acute respiratory distress syndrome mimickers lacking common risk factors of the Berlin definition. Intensive Care Med. 2016;42:164–172. doi: 10.1007/s00134-015-4064-y.
    1. Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315:788–800. doi: 10.1001/jama.2016.0291.
    1. Haukoos JS, Lewis RJ. The propensity score. JAMA. 2015;314:1637–1638. doi: 10.1001/jama.2015.13480.
    1. Papazian L, Calfee CS, Chiumello D, Luyt CE, Meyer NJ, Sekiguchi H, et al. Diagnostic workup for ARDS patients. Intensive Care Med. 2016;42:674–685. doi: 10.1007/s00134-016-4324-5.
    1. Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012;38:1573–1582. doi: 10.1007/s00134-012-2682-1.
    1. Guerin C, Thompson T, Brower R. The ten diseases that look like ARDS. Intensive Care Med. 2015;41:1099–1102. doi: 10.1007/s00134-014-3608-x.
    1. Schwarz MI, Albert RK. “Imitators” of the ARDS: implications for diagnosis and treatment. Chest. 2004;125:1530–1535. doi: 10.1378/chest.125.4.1530.
    1. Patel SR, Karmpaliotis D, Ayas NT, Mark EJ, Wain J, Thompson BT, et al. The role of open-lung biopsy in ARDS. Chest. 2004;125:197–202. doi: 10.1378/chest.125.1.197.
    1. Esteban A, Fernandez-Segoviano P, Frutos-Vivar F, Aramburu JA, Najera L, Ferguson ND, et al. Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings. Ann Intern Med. 2004;141:440–445. doi: 10.7326/0003-4819-141-6-200409210-00009.
    1. Cardinal-Fernandez P, Bajwa EK, Dominguez-Calvo A, Menendez JM, Papazian L, Thompson BT. The presence of diffuse alveolar damage on open lung biopsy is associated with mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Chest. 2016;149:1155–1164. doi: 10.1016/j.chest.2016.02.635.
    1. Guerin C, Bayle F, Leray V, Debord S, Stoian A, Yonis H, et al. Open lung biopsy in nonresolving ARDS frequently identifies diffuse alveolar damage regardless of the severity stage and may have implications for patient management. Intensive Care Med. 2015;41:222–230. doi: 10.1007/s00134-014-3583-2.
    1. Lorente JA, Cardinal-Fernandez P, Munoz D, Frutos-Vivar F, Thille AW, Jaramillo C, et al. Acute respiratory distress syndrome in patients with and without diffuse alveolar damage: an autopsy study. Intensive Care Med. 2015;41:1921–1930. doi: 10.1007/s00134-015-4046-0.
    1. Papazian L, Doddoli C, Chetaille B, Gernez Y, Thirion X, Roch A, et al. A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients. Crit Care Med. 2007;35:755–762. doi: 10.1097/01.CCM.0000257325.88144.30.
    1. Aublanc M, Perinel S, Guerin C. Acute respiratory distress syndrome mimics: the role of lung biopsy. Curr Opin Crit Care. 2017;23:24–29. doi: 10.1097/MCC.0000000000000373.
    1. Libby LJ, Gelbman BD, Altorki NK, Christos PJ, Libby DM. Surgical lung biopsy in adult respiratory distress syndrome: a meta-analysis. Ann Thorac Surg. 2014;98:1254–1260. doi: 10.1016/j.athoracsur.2014.05.029.
    1. Brochard L, Pham T, Rubenfeld G. Does my patient really have ARDS? Intensive Care Med. 2016;42:656–658. doi: 10.1007/s00134-016-4332-5.
    1. Cardinal-Fernandez P, Pey C, Kao KC. ARDS: Time to “separate the wheat from the chaff”. J Crit Care. 2016;34:31–32. doi: 10.1016/j.jcrc.2016.03.015.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する