Abstract
The aim of this retrospective and international study is to identify those clinical variables associated with diffuse alveolar damage (DAD), and to explore the impact of DAD on hospital mortality risk. Inclusion criteria were: adult patients with acute respiratory distress syndrome (ARDS) undergoing open lung biopsy (OLB) during their intensive care unit (ICU) management. The main end-points were: DAD and hospital mortality. In the training (n = 193) and validation cohorts (n = 65), the respiratory rate (odd ratio (OR) 0.956; confidence interval (CI) 95% 0.918; 0.995) and coronary ischemia (OR 5.974; CI95% 1.668; 21.399) on the day of ARDS had an average area under the receiver operating characteristic curve (AUROC) of 0.660 (CI95% 0.585; 0.736) and 0.562 (0.417; 0.706), respectively. PEEP (OR 1.131; CI95% 1.051; 1.218) and coronary ischemia (OR 6.820; CI95% 1.856; 25.061) on the day of OLB had an average AUROC of 0.696 (CI95% 0.621; 0.769) and 0.534 (CI95% 0.391; 0.678), respectively, to predict DAD. DAD (OR 2.296; CI95% 1.228; 4.294), diabetes mellitus requiring insulin (OR 0.081; CI95% 0.009; 0.710) and the respiratory rate (OR 1.045; CI95% 1.001; 1.091) on the day of ARDS had an average AUROC of 0.659 (CI95% 0.583; 0.737) and 0.513 (CI95% 0.361; 0.664) to predict hospital mortality and DAD (OR 2.081; CI95% 1.053; 4.114), diabetes mellitus requiring insulin (OR 0.093; CI95% 0.009; 0.956), PaCO2 (OR 1.051; CI95% 1.019; 1.084), and platelets count (OR 0.999; CI95% 0.999; 0.999) the day of OLB had an average AUROC of 0.778 (CI95% 0.710; 0.843) and 0.634 (CI95%0.481; 0.787) to predict hospital mortalty in the training and validation cohorts, respectively. In conclusion, DAD could not to be predicted clinically and was significantly associated with hospital mortality.
Highlights
Acute respiratory distress syndrome (ARDS) remains a challenge for intensivists given its incidence (almost 10% of all intensive care unit (ICU) admissions) and high mortality rate [1]
Exploring the correlation between clinical and pathological diagnosis is important because: (a) ARDS outcome has been shown to be dependent on the presence or absence of diffuse alveolar damage (DAD) [3,4,5,7]; (b) the prevalence of DAD may explain why the beneficial effects of most pharmacological treatments in animal models [8] have not been observed in clinical practice [9,10,11]; and (c) several non-DAD pathological patterns correspond to diseases with specific treatments [7,10,12]
The main findings of the present study were that DAD could not be predicted clinically and was significantly associated with hospital mortality (DAD was associated with an increased risk of death in pooled logistic regression model (PLRM) at the time of both the ARDS and the open lung biopsy (OLB) days)
Summary
Acute respiratory distress syndrome (ARDS) remains a challenge for intensivists given its incidence (almost 10% of all intensive care unit (ICU) admissions) and high mortality rate [1]. Several studies on patients [3,4,5] or autopsies [6] have reported that only half of the subjects with ARDS had DAD. Tissue sampling is required to make the diagnosis of DAD This can only be done with open lung biopsy (OLB). Only one predictive model for DAD has been reported [6], but it is limited as it is based on autopsy data. This study proposed a predictive model of mortality, the discriminatory capability of this model was not reported and it was not validated in an independent cohort. All of the above data were obtained from small series of patients, and there is a need to develop a model to predict DAD, as well as to define its impact on ARDS outcome
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