Fabiana Madotto1,2, Tài Pham2,3,4, Giacomo Bellani5,6, Lieuwe D Bos7, Fabienne D Simonis7, Eddy Fan8,9, Antonio Artigas10, Laurent Brochard2,3,4, Marcus J Schultz7,11, John G Laffey12,13,14,15,16. 1. Research Center on Public Health, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy. 2. Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Canada. 3. Department of Critical Care Medicine, St Michael's Hospital, Toronto, Canada. 4. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. 5. School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. 6. Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy. 7. Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands. 8. Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada. 9. Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. 10. Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain. 11. Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. 12. Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Canada. john.laffey@nuigalway.ie. 13. Department of Critical Care Medicine, St Michael's Hospital, Toronto, Canada. john.laffey@nuigalway.ie. 14. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. john.laffey@nuigalway.ie. 15. Department of Anesthesia, St Michael's Hospital and University of Toronto, Toronto, Canada. john.laffey@nuigalway.ie. 16. Anaesthesia, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland. john.laffey@nuigalway.ie.
Abstract
PURPOSE: To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mortality risk, and to determine the utility of day 2 ARDS reclassification. METHODS: Our primary objective, in this secondary LUNG SAFE analysis, was to compare outcome in patients with resolved versus confirmed ARDS after 24 h. Secondary objectives included identifying factors associated with ARDS persistence and mortality, and the utility of day 2 ARDS reclassification. RESULTS: Of 2377 patients fulfilling the ARDS definition on the first day of ARDS (day 1) and receiving invasive mechanical ventilation, 503 (24%) no longer fulfilled the ARDS definition the next day, 52% of whom initially had moderate or severe ARDS. Higher tidal volume on day 1 of ARDS was associated with confirmed ARDS [OR 1.07 (CI 1.01-1.13), P = 0.035]. Hospital mortality was 38% overall, ranging from 31% in resolved ARDS to 41% in confirmed ARDS, and 57% in confirmed severe ARDS at day 2. In both resolved and confirmed ARDS, age, non-respiratory SOFA score, lower PEEP and P/F ratio, higher peak pressure and respiratory rate were each associated with mortality. In confirmed ARDS, pH and the presence of immunosuppression or neoplasm were also associated with mortality. The increase in area under the receiver operating curve for ARDS reclassification on day 2 was marginal. CONCLUSIONS: ARDS, whether resolved or confirmed at day 2, has a high mortality rate. ARDS reclassification at day 2 has limited predictive value for mortality. The substantial mortality risk in severe confirmed ARDS suggests that complex interventions might best be tested in this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT02010073.
PURPOSE: To evaluate patients with resolved versus confirmed ARDS, identify subgroups with substantial mortality risk, and to determine the utility of day 2 ARDS reclassification. METHODS: Our primary objective, in this secondary LUNG SAFE analysis, was to compare outcome in patients with resolved versus confirmed ARDS after 24 h. Secondary objectives included identifying factors associated with ARDS persistence and mortality, and the utility of day 2 ARDS reclassification. RESULTS: Of 2377 patients fulfilling the ARDS definition on the first day of ARDS (day 1) and receiving invasive mechanical ventilation, 503 (24%) no longer fulfilled the ARDS definition the next day, 52% of whom initially had moderate or severe ARDS. Higher tidal volume on day 1 of ARDS was associated with confirmed ARDS [OR 1.07 (CI 1.01-1.13), P = 0.035]. Hospital mortality was 38% overall, ranging from 31% in resolved ARDS to 41% in confirmed ARDS, and 57% in confirmed severe ARDS at day 2. In both resolved and confirmed ARDS, age, non-respiratory SOFA score, lower PEEP and P/F ratio, higher peak pressure and respiratory rate were each associated with mortality. In confirmed ARDS, pH and the presence of immunosuppression or neoplasm were also associated with mortality. The increase in area under the receiver operating curve for ARDS reclassification on day 2 was marginal. CONCLUSIONS: ARDS, whether resolved or confirmed at day 2, has a high mortality rate. ARDS reclassification at day 2 has limited predictive value for mortality. The substantial mortality risk in severe confirmed ARDS suggests that complex interventions might best be tested in this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT02010073.
Entities:
Keywords:
ARDS Survival; ARDS reassessment; Berlin criteria ARDS; Persisting ARDS
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