Timing of the Onset of Acute Respiratory Distress Syndrome: A Population-Based Study (original) (raw)
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Eight-Year Trend of Acute Respiratory Distress Syndrome
American Journal of Respiratory and Critical Care Medicine, 2011
Rationale: Significant progress has been made in understanding the pathogenesis of acute respiratory distress syndrome (ARDS). Recent advances in hospital practice may have reduced the incidence of this lethal syndrome. Objectives: To observe incidence trends and associated outcomes of ARDS.
Toward early identification of acute lung injury in the emergency department
2007
Background-There are no studies evaluating the epidemiology of pediatric acute lung injury (ALI) in the emergency department (ED), where early identification and interventions are most likely to be helpful. The purpose of this study was to describe the epidemiology of the ALI precursor acute hypoxemic respiratory failure (AHRF) in the ED. Methods-We analyzed 11,664 pediatric patient records from 16 EDs. Records were selected if oxygen saturation (SpO 2) was recorded during the visit. Virtual partial pressure of oxygen (pO 2) was calculated from SpO 2 , thus allowing calculation of ratios of pO 2 to fraction of inspired oxygen (FiO 2) (PFRs). Patients with a PFR < 300 were classified as having AHRF. Univariate analyses and logistic regression were used to test the association of clinical factors with the presence of AHRF and intubation. Results-AHRF criteria (ie, PFR < 300) were met in 121 (2.9%) of the 4,184 patients with an oxygenation measurement. The following variables were independently associated with ALI: higher Pediatric Risk of Admission II score (adjusted odds ratio [95% confidence interval (CI)] = 1.12 [1.08-1.16]; p < .001), higher heart rate (1.02 [1.01-1.03]; p = .009), a positive chest radiograph (2.35 [1.02-5.43]; p = .045), and lower temperature (0.49 [0.36-0.68]; p < .001). The final model had an R 2 = .20. Conclusion-We found nonintubated AHRF to be prevalent in the ED. The low R 2 for the regression model for AHRF underscores the lack of criteria for early identification of patients with respiratory compromise. Our findings represent an important first step toward establishing the true incidence of ALI in the pediatric ED. Keywords respiratory distress syndrome (adult); severity of illness index; oximetry Acute lung injury (ALI) and its more severe form, acute respiratory distress syndrome (ARDS), account for up to 4% of all pediatric intensive care unit admissions and between 8 to 10% of children requiring mechanical ventilation. 1 The 1994 American-European Consensus Conference (AECC) on ARDS defined diagnostic criteria for ALI as (1) a partial pressure of
Acute lung injury and the acute respiratory distress syndrome: a clinical review
2007
Introduction The aim of this study was to describe the epidemiology and management of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) in Ireland. Methods As part of a 10-week prospective national audit of patient demographics and organ failure incidence in intensive care in Ireland, all patients with ALI/ARDS in 14 participating centres were prospectively identified using American European Consensus Conference definitions. Results There were 1,029 admissions during the study period; of these, 728 patients were invasively ventilated. A total of 196 (19%) patients had ALI/ARDS, and 141 of these (72%) had ALI/ARDS on admission and a further 55 (28%) developed ALI/ ARDS after admission. For the patients with ALI/ARDS, the mean (± standard deviation) age was 58 ± 17 years and 62% were male. The most common predisposing risk factors were pneumonia (50%) and nonpulmonary sepsis (26%). Mean (± standard deviation) tidal volume/kg was 7.0 ± 1.7 ml/kg. Median (interquartile range) duration of ventilation was 6.8 (2.0 to 12.8) days. Median (interquartile range) length of stay in the intensive care unit was 10.0 (5.0 to 18.5) days. The overall intensive care unit mortality for ALI/ARDS was 32.3%. Lower baseline arterial oxygen tension/fraction of inspired oxygen ratio and higher Sequential Organ Failure Assessment scores were associated with increased mortality. Although not significant, patients receiving treatment with a statin during admission had a 73% lower odds of death (odds ratio 0.27, 95% confidence interval 0.06 to 1.21; P = 0.09). Conclusion The incidence of ALI/ARDS is high and is associated with significant mortality. Protective lung ventilation is used commonly throughout participating centres. With low tidal volume ventilation, the degree of hypoxaemia is associated with outcome. These data will inform future multicentre clinical trials in ALI/ARDS in Ireland.
Journal of Critical Care, 2018
To estimate the incidence of Acute Respiratory Distress Syndrome (ARDS) and ARDS-related mortality rates. Methods: We identified patients with a risk factor for ARDS in the National Inpatient Sample (NIS) (2006-2014). Using survey-weighted descriptive statistics we estimated annual and overall proportions of ARDS cases. Results: From over 69 million discharges, 1,151,969 ARDS discharges and 969,567 ARDS discharges with a risk factor were identified. Sepsis (46.8%), pneumonia (44.9%) and shock (44.4%) were the most common ARDS risk factor. Pancreatitis (3.4%), pulmonary contusion (1.4%) and drowning (0.2%) were the least frequently reported. Incidence rates increased from 180.7 (2006) to 220.8 (2011) and again from 182.8 (2012) to 193.4 (2014). Incidence for pneumonia, shock and sepsis-associated ARDS increased steadily, while transfusion and trauma-associated ARDS declined. Trends for gastric aspiration and pancreatitis-related ARDS remained unchanged. Shock, sepsis and transfusion-associated ARDS had higher mortality rates compared to other factors. Except for transfusion and trauma-associated ARDS, mortality rates for other factors declined. Conclusion: Although increasing incidence for ARDS was observed, mortality rates declined for most risk factors. Mortality for transfusion and trauma-associated ARDS increased in the later study period, research is needed to examine reasons for the increasing in-hospital deaths associated with these risk factors.
The changing pattern of acute respiratory distress syndrome over time: a comparison of two periods
European Respiratory Journal, 2012
This study aimed to assess whether patterns and outcomes of acute respiratory distress syndrome (ARDS) have changed due to improvements in mechanical ventilation techniques and support of critically ill patients, by comparing patients from two different periods in the same hospital. We reviewed data from all patients with a diagnosis of ARDS (according to American-European Consensus Conference criteria) who were treated in our multidisciplinary department of intensive care (Erasme Hospital, Brussels) between January 2006 and April 2009 (group B, n5210) and compared them with our previously reported data (January 1993 to February 1995) (group A, n5129). The prevalence of ARDS has decreased (from 2.5% in group A to 1.7% in group B, p,0.001). ARDS patients are now older and sepsis-related ARDS is more common. Multiple transfusion and trauma are less common causes of ARDS than in the past. Intensive care unit length of stay among survivors is shorter (13¡9 versus 17¡17 days, p50.025), and there was a trend to lower mortality rates in the more recent cohort (46% versus 52%, p50.158). Multiple organ failure (MOF) was the most common cause of death in both periods. The pattern of ARDS has changed over time in our department. Patients with ARDS are now older and more severely ill. Sepsis-related ARDS is more frequent whereas trauma-related and/or transfusion-related ARDS has decreased. MOF still represents the most frequent cause of death.
Early identification of patients with or at risk of acute lung injury
The Netherlands journal of medicine, 2009
Acute lung injury (ALI ) and its more severe form, acute respiratory distress syndrome (ARDS ), are important critical care syndromes for which the treatment options are limited once the condition is fully established. Enormous basic and clinical research efforts have led to improvements in supportive treatment, but surprisingly little has been done on the prevention of this devastating syndrome. The development and progression of ALI /ARDS may be triggered by various intrahospital exposures including but not limited to transfusion, aspiration, mechanical ventilation, certain medications and delayed treatment of shock and infection. Early recognition of patients with or at risk of ALI /ARDS is essential for designing novel prevention and treatment strategies. Automated electronic screening tools and novel scoring systems applied at the time of hospital admission may facilitate enrollment of patients into mechanistic and outcome studies, as well as future ALI /ARDS prevention trials.
Critical Care Medicine, 2015
Current in-hospital mortality of the acute respiratory distress syndrome (ARDS) is above 40%. ARDS outcome depends on the lung injury severity within the first 24 hours of ARDS onset. We investigated whether two widely accepted cutoff values of Pao 2 /Fio 2 and positive end-expiratory pressure (PEEP) would identify subsets of patients with ARDS for predicting outcome and guiding therapy. Design: A 16-month (September 2008 to January 2010) prospective, multicenter, observational study. Setting: Seventeen multidisciplinary ICUs in Spain. Patients: We studied 300 consecutive, mechanically ventilated patients meeting American-European Consensus Conference criteria for ARDS (Pao 2 /Fio 2 ≤ 200 mm Hg) on PEEP greater than or equal to 5 cm H 2 O, and followed up until hospital discharge. Interventions: None. Measurements and Main Results: Based on threshold values for Pao 2 /Fio 2 (150 mm Hg) and PEEP (10 cm H 2 O) at ARDS onset and at 24 hours, we assigned patients to four categories: group I (Pao 2 /Fio 2 ≥ 150 on PEEP < 10), group II (Pao 2 /Fio 2 ≥ 150 on PEEP ≥ 10), group III (Pao 2 /Fio 2 < 150 on PEEP < 10), and group
Prevalence of Acute Lung Injury Among Medical Patients in the Emergency Department
Academic Emergency Medicine, 2012
Acute lung injury (ALI) affects an estimated 190,000 persons per year in U.S. intensive care units (ICUs), but little is known about its prevalence in the emergency department (ED). The objective was to describe the prevalence of ALI among mechanically ventilated adult nontrauma patients in the ED. The hypothesis was that the prevalence of ALI in adult ED patients would be low. This was a retrospective cohort study of admitted nontrauma patients presenting to an academic ED. Two trained investigators abstracted data from patient records using a standardized form. The use of mechanical ventilation in the ED was identified in two phases. First, all ED patients were screened for the current procedural terminology (CPT) code for endotracheal intubation (CPT 31500) from January 1, 2003, to December 31, 2006. Second, each patient record was reviewed to verify the use of mechanical ventilation. ALI was defined in accordance with a modified version of the American-European Consensus Conference criteria as: 1) hypoxemia defined as PaO(2) /FiO(2) ratio ≤300 mm Hg on all arterial blood gases (ABGs) in the ED and the first 24 hours of admission, 2) the presence of bilateral infiltrates on chest radiograph, and 3) the absence of left atrial hypertension. Data are presented in absolute numbers and percentages. Interobserver agreement was evaluated using the kappa statistic. Of the 552 patients who received mechanical ventilation in the ED and were subsequently admitted, a total of 134 (24.3%, 95% confidence interval [CI] = 20.8% to 28.0%) met hypoxemia criteria. Of these, 34 had evidence of left atrial hypertension, 52 did not have chest radiograph findings consistent with ALI, and two did not have a chest radiograph performed; the remaining 46 met ALI criteria. An additional two patients who died in the ED had clinical evidence of ALI. Thus, 48 of 552, or 8.7% (95% CI = 6.6% to 11.3%), met criteria for ALI. The kappa value for determination of ALI was 0.84 (95% CI = 0.54 to 1.0). The prevalence of ALI was nearly 9% in adult nontrauma patients receiving mechanical ventilation in the ED. Further study is required to determine which types of patients present to the ED with ALI, the extent to which lung protective ventilation is used, and the need for ED ventilator management algorithms.
Critical Care Medicine, 2011
cute lung injury (ALI) and the acute respiratory distress syndrome are major causes of morbidity, mortality, and cost in intensive care units (ICUs) worldwide. Lung protective ventilation (LPV), using low tidal volumes and alveolar pressures, has been shown to reduce mortality in these patients compared with traditional mechanical ventilation (1, 2). However, the practice of LPV has not been widely adopted (3-6). For example, at our own institution, we found that approximately 60% of patients with ALI did not receive LPV from 2000 to 2002 (7). One reason for underuse of LPV in eligible patients is underrecognition of ALI (7, 8). We recently demonstrated that an automated electronic system that screened for ALI using laboratory, radiographic, and demographic data from our electronic hospital information systems identified intubated patients with ALI in a cohort of ICU patients with major trauma with 86.8% sensitivity and 89% specificity compared with a reference standard established by two physician reviewers when patients with congestive heart failure (CHF) were excluded (9). Because our prior validation study was performed in a uniform population of patients with major trauma from a single ICU, the results may not have been generalizable to a more diverse population of critically ill patients. The primary purpose of this study was to prospectively assess the performance of our automated electronic ALI screening system in all ICU patients at risk for ALI in our hospital. METHODS Setting. This study was performed at the Hospital of the University of Pennsylvania, an academic medical center and one of the National Institutes of Health, National Heart, Lung and Blood Institute Acute Respiratory Distress Network Clinical Trials (ARDSNet) centers from 1994 to 2006. This study protocol was reviewed and approved by the Institutional Review Board of the University of Pennsylvania with a waiver for the requirement of written informed consent from participating subjects or their legally authorized representatives. *See also p. 209.