Abstract
There have been no report of objective clinical characteristics or prognostic factors that predict fatal outcome of acute respiratory distress syndrome (ARDS) since the Berlin definition was published. The aim of this study is to identify clinically available predictors that distinguish between two phenotypes of fatal ARDS due to pneumonia. In total, 104 cases of Japanese patients with pneumonia-induced ARDS were extracted from our prospectively collected database. Fatal cases were divided into early (< 7 days after diagnosis) and late (≥ 7 days) death groups, and clinical variables and prognostic factors were statistically evaluated. Of the 50 patients who died within 180 days, 18 (36%) and 32 (64%) were in the early (median 2 days, IQR [1, 5]) and late (median 16 days, IQR [13, 29]) death groups, respectively. According to multivariate regression analyses, the APACHE II score (HR 1.25, 95%CI 1.12–1.39, p < 0.001) and the disseminated intravascular coagulation score (HR 1.54, 95%CI 1.15–2.04, p = 0.003) were independent prognostic factors for early death. In contrast, late death was associated with high-resolution computed tomography (HRCT) score indicating early fibroproliferation (HR 1.28, 95%CI 1.13–1.42, p < 0.001) as well as the disseminated intravascular coagulation score (HR 1.24, 95%CI 1.01–1.52, p = 0.039). The extent of fibroproliferation on HRCT, and the APACHE II scores along with coagulation abnormalities, should be considered for use in predictive enrichment and personalized medicine for patients with ARDS due to pneumonia.
Highlights
There have been no report of objective clinical characteristics or prognostic factors that predict fatal outcome of acute respiratory distress syndrome (ARDS) since the Berlin definition was published
Eighteen (36%) died less than 7 days following diagnosis, and almost all deaths (88%) were due to sepsis syndrome associated with multiple organ failure or shock
Of 32 patients (64%) who died after ≥ 7 days, 22 (68%) died of sepsis syndrome and 10 (32%) of irreversible respiratory failure
Summary
There have been no report of objective clinical characteristics or prognostic factors that predict fatal outcome of acute respiratory distress syndrome (ARDS) since the Berlin definition was published. Previous studies of the causes and timing of death due to ARDS in the 1980s and 1990s have reported and classified fatal cases into early and late death and emphasized primary or secondary septic syndrome as a common cause of d eath. Previous studies of the causes and timing of death due to ARDS in the 1980s and 1990s have reported and classified fatal cases into early and late death and emphasized primary or secondary septic syndrome as a common cause of d eath6,7 Such categorization based on timing and cause of death can likely define subgroups within the uninflamed and hyperinflammatory clinical phenotypes. The intensity of systemic inflammation caused by pneumonia (pneumonia sepsis) in each patient possibly reflects the uninflamed and hyperinflammatory clinical phenotypes that may predict the clinical course and outcome Another viewpoint regarding the clinical characteristics of ARDS is based on lung pathology. We previously reported the clinical significance and prognostic value of high-resolution computed tomography (HRCT) for the prediction of mortality or ventilator-associated outcomes associated with secondary septic syndrome in A RDS14,15
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