Abstract
IntroductionDiffuse alveolar damage (DAD) is the pathological hallmark of acute respiratory distress syndrome (ARDS), however, the presence of DAD in the clinical criteria of ARDS patients by Berlin definition is little known. This study is designed to investigate the role of DAD in ARDS patients who underwent open lung biopsy.MethodsWe retrospectively reviewed all ARDS patients who met the Berlin definition and underwent open lung biopsy from January 1999 to January 2014 in a referred medical center. DAD is characterized by hyaline membrane formation, lung edema, inflammation, hemorrhage and alveolar epithelial cell injury. Clinical data including baseline characteristics, severity of ARDS, clinical and pathological diagnoses, and survival outcomes were analyzed.ResultsA total of 1838 patients with ARDS were identified and open lung biopsies were performed on 101 patients (5.5 %) during the study period. Of these 101 patients, the severity of ARDS on diagnosis was mild of 16.8 %, moderate of 56.5 % and severe of 26.7 %. The hospital mortality rate was not significant difference between the three groups (64.7 % vs 61.4 % vs 55.6 %, p = 0.81). Of the 101 clinical ARDS patients with open lung biopsies, 56.4 % (57/101) patients had DAD according to biopsy results. The proportion of DAD were 76.5 % (13/17) in mild, 56.1 % (32/57) in moderate and 44.4 % (12/27) in severe ARDS and there is no significant difference between the three groups (p = 0.113). Pathological findings of DAD patients had a higher hospital mortality rate than non-DAD patients (71.9 % vs 45.5 %, p = 0.007). Pathological findings of DAD (odds ratio: 3.554, 95 % CI, 1.385–9.12; p = 0.008) and Sequential Organ Failure Assessment score on the biopsy day (odds ratio: 1.424, 95 % CI, 1.187–1.707; p<0.001) were significantly and independently associated with hospital mortality. The baseline demographics and clinical characteristics were not significantly different between DAD and non-DAD patients.ConclusionsThe correlation of pathological findings of DAD and ARDS diagnosed by Berlin definition is modest. A pathological finding of DAD in ARDS patients is associated with hospital mortality and there are no clinical characteristics that could identify DAD patients before open lung biopsy.
Highlights
Diffuse alveolar damage (DAD) is the pathological hallmark of acute respiratory distress syndrome (ARDS), the presence of DAD in the clinical criteria of ARDS patients by Berlin definition is little known
There was no standard treatment for patients with some specific diagnoses, such as interstitial lung disease, after the biopsy result became available. Specific treatments such as corticosteroid therapy might have influenced the survival outcome in these patients. This retrospective study demonstrated that 56.4 % of selected patients with ARDS based on the Berlin definition and who underwent open lung biopsy were identified as having DAD
As a result of the moderate agreement between clinical and pathological diagnosis of ARDS, open lung biopsy may be considered in some patients to exclude or to clarify the diagnosis
Summary
Diffuse alveolar damage (DAD) is the pathological hallmark of acute respiratory distress syndrome (ARDS), the presence of DAD in the clinical criteria of ARDS patients by Berlin definition is little known. In 1994 the American-European Consensus Conference (AECC) released its definitions of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) [1]. Several studies had challenged the AECC criteria for the diagnosis of ARDS because of its many limitations [2,3,4,5,6,7]. The pathological diagnosis of ARDS using lung biopsy was not included in the Berlin definition because of the controversial definition of the pathology and concern about surgical complications [9]. Open lung biopsy sometimes has been performed to better define the pathology and to guide therapeutic management of selected patients with ARDS [14,15,16,17]
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