Resolved versus confirmed ARDS after 24 h: insights from the LUNG SAFE study

• Published in: Intensive care medicine Vol. 44; no. 5; pp. 564 - 577
• Main Authors: Madotto, Fabiana, Pham, Tài, Bellani, Giacomo, Bos, Lieuwe D., Simonis, Fabienne D., Fan, Eddy, Artigas, Antonio, Brochard, Laurent, Schultz, Marcus J., Laffey, John G.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-05-2018; Springer; Springer Nature B.V
• Subjects: Adult; Aged; Analysis; Anesthesiology; Argentina; China; Critical Care Medicine; Disease Progression; Emergency Medicine; Female; France; Germany; Health risk assessment; Humans; Immunosuppression; Immunotherapy; Intensive; Intensive care; Ireland; Japan; Lungs; Male; Massachusetts; Mechanical ventilation; Medicine; Medicine & Public Health; Mexico; Middle Aged; Morocco; Mortality; Ontario; Original; Pain Medicine; Patients; Peak pressure; Pediatrics; Pneumology/Respiratory System; Portugal; Reclassification; Remission Induction; Respiration; Respiration, Artificial - adverse effects; Respiratory diseases; Respiratory Distress Syndrome, Adult - classification; Respiratory Distress Syndrome, Adult - diagnosis; Respiratory Distress Syndrome, Adult - mortality; Respiratory Distress Syndrome, Adult - therapy; Respiratory rate; Risk Factors; Saudi Arabia; Spain; Subgroups; United Kingdom; Uruguay; Ventilation; Argentina; Uruguay; Japan; United Kingdom; Portugal; Spain; Saudi Arabia; Morocco; Massachusetts; China; Ireland; Mexico; France; Ontario; Germany; ARDS reassessment; Persisting ARDS; ARDS Survival; Berlin criteria ARDS
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-018-5152-6

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.