Arnaud W Thille1, Andrés Esteban2, Pilar Fernández-Segoviano3, José-María Rodriguez3, José-Antonio Aramburu3, Patricio Vargas-Errázuriz4, Ana Martín-Pellicer4, José A Lorente5, Fernando Frutos-Vivar5. 1. Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain; Medical Intensive Care Unit, University Hospital of Poitiers, Poitiers, France. 2. Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain. Electronic address: aesteban@ucigetafe.com. 3. Departamento de Anatomía Patología, Hospital Universitario de Getafe, Madrid, Spain. 4. Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain. 5. Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain; European University of Madrid, Madrid, Spain.
Abstract
BACKGROUND: Diffuse alveolar damage is the histological hallmark of acute respiratory distress syndrome (ARDS). However, the chronology of histological lesions is not well established. We aimed to determine the time to onset of exudative or proliferative changes and end-stage fibrosis in ARDS. METHODS: We analysed all patients who died between Jan 1, 1991, and Dec 31, 2010, in the intensive-care unit at the Hospital Universitario de Getafe, Madrid, Spain, and who had a clinical autopsy. Patients had to have clinical criteria for ARDS at time of death and histological features of diffuse alveolar damage at autopsy examination. Capillary congestion and intra-alveolar oedema characterised the exudative phase whereas proliferation of alveolar cell type 2 or fibroblasts, or fibrosis characterised the proliferative phase. FINDINGS: We analysed 159 patients. The prevalence of exudative changes decreased over time, being reported in 74 (90%) of 82 patients with ARDS of less than 1 week duration, 40 (74%) of 54 patients with disease of 1-3 week duration, and only four (17%) of 23 patients with disease of longer than 3 weeks' duration (p<0·0001). The incidence of proliferative changes increased over time, and was reported in 44 (54%) of 82 patients with ARDS of less than 1-week duration, 42 (78%) of 54 patients with disease duration of 1-3 weeks, and 23 (100%) of 23 patients with disease duration longer than 3 weeks (p<0·0001). Fibrosis was noted in three (4%) of 82 patients with disease of less than 1 week duration, 13 (24%) of 54 patients with disease of 1-3-weeks' duration, and 14 (61%) of 23 patients with disease longer than 3-week duration (p<0·0001). Fibrosis was more frequent in ARDS of pulmonary origin than in that of extrapulmonary origin. INTERPRETATION: Histological features of the lungs were related to duration of ARDS. Within the first week of evolution, exudative changes were predominant and fibrosis was rarely noted. Beyond the third week of evolution, proliferative changes were noted in all patients and fibrosis in two-thirds of them. Treatments with a potential effect on inflammation or fibrosis, or both, should probably focus on the first week after the onset of ARDS. FUNDING: None.
BACKGROUND:Diffuse alveolar damage is the histological hallmark of acute respiratory distress syndrome (ARDS). However, the chronology of histological lesions is not well established. We aimed to determine the time to onset of exudative or proliferative changes and end-stage fibrosis in ARDS. METHODS: We analysed all patients who died between Jan 1, 1991, and Dec 31, 2010, in the intensive-care unit at the Hospital Universitario de Getafe, Madrid, Spain, and who had a clinical autopsy. Patients had to have clinical criteria for ARDS at time of death and histological features of diffuse alveolar damage at autopsy examination. Capillary congestion and intra-alveolar oedema characterised the exudative phase whereas proliferation of alveolar cell type 2 or fibroblasts, or fibrosis characterised the proliferative phase. FINDINGS: We analysed 159 patients. The prevalence of exudative changes decreased over time, being reported in 74 (90%) of 82 patients with ARDS of less than 1 week duration, 40 (74%) of 54 patients with disease of 1-3 week duration, and only four (17%) of 23 patients with disease of longer than 3 weeks' duration (p<0·0001). The incidence of proliferative changes increased over time, and was reported in 44 (54%) of 82 patients with ARDS of less than 1-week duration, 42 (78%) of 54 patients with disease duration of 1-3 weeks, and 23 (100%) of 23 patients with disease duration longer than 3 weeks (p<0·0001). Fibrosis was noted in three (4%) of 82 patients with disease of less than 1 week duration, 13 (24%) of 54 patients with disease of 1-3-weeks' duration, and 14 (61%) of 23 patients with disease longer than 3-week duration (p<0·0001). Fibrosis was more frequent in ARDS of pulmonary origin than in that of extrapulmonary origin. INTERPRETATION: Histological features of the lungs were related to duration of ARDS. Within the first week of evolution, exudative changes were predominant and fibrosis was rarely noted. Beyond the third week of evolution, proliferative changes were noted in all patients and fibrosis in two-thirds of them. Treatments with a potential effect on inflammation or fibrosis, or both, should probably focus on the first week after the onset of ARDS. FUNDING: None.
Authors: Carolyn S Calfee; Kevin Delucchi; Polly E Parsons; B Taylor Thompson; Lorraine B Ware; Michael A Matthay Journal: Lancet Respir Med Date: 2014-05-19 Impact factor: 30.700
Authors: José A Lorente; Pablo Cardinal-Fernández; Diego Muñoz; Fernando Frutos-Vivar; Arnaud W Thille; Carlos Jaramillo; Aida Ballén-Barragán; José M Rodríguez; Oscar Peñuelas; Guillermo Ortiz; José Blanco; Bruno Valle Pinheiro; Nicolás Nin; María del Carmen Marin; Andrés Esteban; Taylor B Thompson Journal: Intensive Care Med Date: 2015-09-18 Impact factor: 17.440
Authors: Michael A Matthay; Carolyn S Calfee; Hanjing Zhuo; B Taylor Thompson; Jennifer G Wilson; Joseph E Levitt; Angela J Rogers; Jeffrey E Gotts; Jeanine P Wiener-Kronish; Ednan K Bajwa; Michael P Donahoe; Bryan J McVerry; Luis A Ortiz; Matthew Exline; John W Christman; Jason Abbott; Kevin L Delucchi; Lizette Caballero; Melanie McMillan; David H McKenna; Kathleen D Liu Journal: Lancet Respir Med Date: 2018-11-16 Impact factor: 30.700