Etiologies, diagnostic work-up and outcomes of acute respiratory distress syndrome with no common risk factor: a prospective multicenter study

Nicolas De Prost,Tài Pham,Bernard Maître,Eddy Fan,Laurent Brochard,For The Lung Safe Investigators ,Giacomo Bellani,Christian Brun-Buisson,John Laffey,Alain Mercat,The Reva Network ,The Esicm Trials Group ,Guillaume Carteaux,Armand Mekontso Dessap

doi:10.1186/s13613-017-0281-6

Abstract

BackgroundPatients meeting the Berlin definition for the acute respiratory distress syndrome (ARDS) might lack exposure to one or more “common” risk factors and exhibit different clinical phenotype and outcomes. We aimed to compare the clinical presentation and outcome of ARDS patients with or without risk factors, the impact on hospital mortality, and to assess the diagnostic work-up performed. The current study is an ancillary analysis of an international, multicenter, prospective cohort study (the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure, LUNG SAFE). Patients meeting ARDS criteria within 2 days of acute hypoxemic respiratory failure onset were included in the study and categorized as having risk factors or not. Outcomes were compared using propensity score matching.ResultsAmong 2813 patients, 234 (8.3% [7.3–9.3]) had no ARDS risk factor identified. These were older, had more frequent chronic diseases and presented with less severe SOFA and non-pulmonary SOFA scores (p < 0.001). Compared to other ARDS, CT scan (32.1 vs 23.9%, p < 0.001) and open lung biopsy (2.6 vs 0.2%, p < 0.001) were slightly more frequent but left heart filling pressures assessment was not (69.4 vs 68.4%, p > 0.99). Among ARDS with no risk factor, 45 patients (19.2%) had a specific diagnosis made. As compared to others, patients having ARDS with no risk factor had a lower ICU but not hospital mortality (34.6 vs 40.0%; p = 0.12). A matched cohort analysis confirmed the lack of significant difference in mortality.ConclusionEight percent of ARDS patients have no identified risk factor, 80% of whom have no etiological diagnosis made. The outcome of ARDS with no risk factor was comparable to other ARDS but few had a comprehensive diagnostic work-up, potentially leading to missed curable diseases.Trial registration clinicaltrials.gov Identifier: NCT02010073

Highlights

Patients meeting the Berlin definition for the acute respiratory distress syndrome (ARDS) might lack exposure to one or more “common” risk factors and exhibit different clinical phenotype and outcomes
We have recently reported that 7.5% of ARDS patients had no common risk factors of the Berlin definition identified during intensive care unit (ICU) stay and that these patients showed different clinical features and outcomes than others [7], suggesting individualizing this subgroup of patients could be of interest
Prevalence of ARDS with no risk factor identified A total of 4499 patients met the acute hypoxemic respiratory failure criteria of the LUNG SAFE study, of whom 2813 (62.5% [61.1–63.9]) had ARDS on day 1 or 2 (Fig. 1) and were included in the current analysis

Summary

Introduction

Patients meeting the Berlin definition for the acute respiratory distress syndrome (ARDS) might lack exposure to one or more “common” risk factors and exhibit different clinical phenotype and outcomes. We aimed to compare the clinical presentation and outcome of ARDS patients with or without risk factors, the impact on hospital mortality, and to assess the diagnostic work-up performed. To the best of our knowledge, no large-scale prospective study has assessed the clinical phenotype, the prevalence, the management and the outcomes of ARDS patients with no common risk factor of the Berlin definition. We took advantage of the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) [8] and designed the ancillary ASTEROID study (ArdS with no Risk factor from the Berlin Definition), which was approved by the steering committee of the LUNG SAFE study before patient enrollment began. We aimed to (1) determine the prevalence of ARDS with no risk factor identified; (2) evaluate the diagnostic work-up performed and the etiologies of ARDS in this subgroup of patients; and (3) compare the clinical presentation and outcome of patients having ARDS with no risk factors to those of others

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