The Adult Respiratory Distress Syndrome: A Report of Survival and Modifying Factors

doi:10.1378/chest.101.4.1074

Chest

Volume 101, Issue 4, April 1992, Pages 1074-1079

https://doi.org/10.1378/chest.101.4.1074 Get rights and content

The adult respiratory distress syndrome (ARDS) is a form of acute lung injury characterized by arterial hypoxemia, reduced thoracic compliance, normal pulmonary capillary wedge pressure, and diffuse infiltrates on chest roentgenograms. Mortality remains high and has been associated with sepsis, organ failure, age, and predisposing factors. We prospectively identified 215 ARDS patients over 34 months to examine how these factors influence outcome. One hundred two (47 percent) of 215 patients survived. Age 65 years or older was associated with a survival of 34 percent, which was statistically different from the 53 percent survival of those patients younger than 65 years (p = 0.02). Aspiration pneumonia as a predisposing factor of ARDS was associated with a better survival (p = 0.04). Survivors had statistically less organ failure and sepsis than did nonsurvivors (p<0.05). Cause of death was determined using the criteria of Montgomery et al for irreversible organ dysfunction. Forty-five (40 percent) of our patients died of respiratory failure (not sepsis). We conclude the following: (1) survival in our ARDS patients is different from previous reports; (2) the cause of death in our ARDS patients is different from that reported by Montgomery et al in 1985; and (3) multisystem organ failure, sepsis, age, and some predisposing factors of ARDS continue to be associated with decreased survival of ARDS patients.

Section snippets

METHODS

We prospectively screened all intensive care unit (ICU) patients from May 1987 to April 1990.⁹ Patients were identified from four ICUs (thoracic, medical-surgical, shock/trauma/intermountain respiratory, and coronary care). We defined ARDS by all of the following: (1) PaO₂/PAO₂ ≤ 0.2; (2) pulmonary capillary wedge pressure (PCWP) ≤15 mm Hg or no clinical evidence of congestive heart failure; (3) diffuse bilateral infiltrates on chest roentgenogram; (4) total static thoracic compliance (Cth) ≤50

RESULTS

Two hundred fifteen ARDS patients were identified in 34 months. One hundred two patients (47 percent) survived. Fifty-nine patients were 65 years or older and 20 (34 percent) of these 59 survived. This was statistically different from the 156 patients who were younger than 65 years old with a survival of 53 percent (p = 0.02). There were significant differences between survivors and nonsurvivors with respect to age, APACHE II, and history of potentially lethal disease (Table 2).

Thirty-four

DISCUSSION

This prospective, descriptive study demonstrates three major points regarding ARDS patients. First, the cause of death in our ARDS patients is different from that previously reported by Montgomery et al.² Second, survival of ARDS patients seems to be increased from that of earlier reports, and this may be related to the first observation. Finally, multiorgan failure, sepsis, predisposing factors of ARDS, and age appear to continue to affect survival.

Our study demonstrates that the cause of

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Clinical Predictors of Hospital Mortality Differ Between Direct and Indirect ARDS
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Citation Excerpt :
To our knowledge, this study is the first description of distinct associations among clinical characteristics and hospital mortality in patients with direct vs indirect ARDS. Advanced age is a well-recognized independent risk factor for mortality in patients with ARDS.7,13,35-41 In the present study, the independent association of increased hospital mortality with age was limited to direct ARDS.
Direct (pulmonary) and indirect (extrapulmonary) ARDS are distinct syndromes with important pathophysiologic differences. The goal of this study was to determine whether clinical characteristics and predictors of mortality differ between direct or indirect ARDS.
This retrospective observational cohort study included 417 patients with ARDS. Each patient was classified as having direct (pneumonia or aspiration, n = 250) or indirect (nonpulmonary sepsis or pancreatitis, n = 167) ARDS.
Patients with direct ARDS had higher lung injury scores (3.0 vs 2.8; P < .001), lower Simplified Acute Physiology Score II scores (51 vs 62; P < .001), lower Acute Physiology and Chronic Health Evaluation II scores (27 vs 30; P < .001), and fewer nonpulmonary organ failures (1 vs 2; P < .001) compared with patients with indirect ARDS. Hospital mortality was similar (28% vs 31%). In patients with direct ARDS, age (OR, 1.29 per 10 years; P = .01; test for interaction, P = .03), lung injury scores (OR, 2.29 per point; P = .001; test for interaction, P = .058), and number of nonpulmonary organ failures (OR, 1.67; P = .01) were independent risk factors for increased hospital mortality. Preexisting diabetes mellitus was an independent risk factor for reduced hospital mortality (OR, 0.47; P = .04; test for interaction, P = .02). In indirect ARDS, only the number of organ failures was an independent predictor of mortality (OR, 2.08; P < .001).
Despite lower severity of illness and fewer organ failures, patients with direct ARDS had mortality rates similar to patients with indirect ARDS. Factors previously associated with mortality during ARDS were only associated with mortality in direct ARDS. These findings suggest that direct and indirect ARDS have distinct features that may differentially affect risk prediction and clinical outcomes.
Comparison of hospital mortality and long-term survival in patients with acute lung injury/ARDS vs cardiogenic pulmonary edema
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Early differential diagnosis of acute lung injury (ALI) vs cardiogenic pulmonary edema (CPE) is important for selecting the most appropriate therapy, but the prognostic implications of this distinction have not been studied. Accurate prognostic information is essential for providing appropriate informed consent prior to initiation of mechanical ventilation.
This is a long-term follow-up study of a previously established population-based cohort of critically ill adult patients with acute pulmonary edema admitted at a tertiary-care center during 2006 to 2009, in which post hoc expert review had established ALI vs CPE diagnosis. Using logistic and Cox regression, hospital mortality and long-term survival were compared in patients with ALI vs patients with CPE.
Of 328 patients (ALI = 155, CPE = 173), 240 patients (73%) died during a median follow-up of 160 days. After adjusting for confounders, patients with ALI were significantly more likely to die in the hospital (OR = 4.2, 95% CI = 2.3-7.8, n = 325,P< .001), but among hospital survivors the risk of death during follow-up was the same in both groups (hazard ratio = 1.13, 95% CI = 0.79-1.62, n = 229,P= .50). Independent predictors of mortality included age and APACHE (Acute Physiology and Chronic Health Evaluation) III score. Results were similar when restricting patients with ALI to the subset with ARDS (Berlin definition). In post hoc analyses, the mortality rate in hospital survivors compared with the general US population was significantly higher during the first 2 years but essentially converged by year five.
Although hospital mortality is higher in patients with ALI/ARDS compared with patients with CPE, long-term survival is similar in hospital survivors from both groups.
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Citation Excerpt :
This may have important implications for the care of critically ill patients, since the reported incidence of ARDS in the ICU ranges from 2.4% to 7.5% and is as high as 23% for mechanically ventilated patients.20–22 Mortality rates among adults with ARDS have declined from upwards of 50% initially to between 35% and 40%, but reducing mortality below this threshold has continued to elude clinicians.23–27 The ability to detect a treatable bacterial organism contributing to pulmonary dysfunction in mechanically ventilated patients, particularly those with ARDS, could have a substantial impact on outcomes in this population.
Community-acquired respiratory distress syndrome (CARDS) toxin is a unique Mycoplasma pneumoniae virulence factor. Molecular assays targeting this toxin are more sensitive than existing diagnostics, but these assays have not been used to investigate the role of M pneumoniae as a nosocomial infection in critical illness. We sought to determine the incidence of M pneumoniae among mechanically ventilated subjects using these novel assays and to investigate the impact of this pathogen on pulmonary outcomes.
We conducted a prospective observational study enrolling subjects with suspected ventilator-associated pneumonia (VAP) undergoing BAL in the surgical trauma ICU at a level I trauma center. Lavage fluid and serum samples were tested for M pneumoniae using assays to detect CARDS toxin gene sequences, protein, or antitoxin antibodies.
We collected samples from 37 subjects, with 41% (15 of 37) testing positive using these assays. The positive and negative groups did not differ significantly in baseline demographic characteristics, including age, sex, injury severity, or number of ventilator days before bronchoscopy. The positive group had significantly fewer ventilator-free days (P = .04) and lower average oxygenation (P = .02). These differences were most pronounced among subjects with ARDS.
Evidence is provided that M pneumoniae is present in a substantial number of subjects with suspected VAP. Subjects testing positive experience a significantly longer ventilator course and worse oxygenation compared with subjects testing negative.
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Supported in part by grant HL 36787 from the National Institutes of Health, the Deseret Foundation, and by the Respiratory Distress Syndrome Foundation.

Manuscript received May 31; revision accepted August 19

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Chest

Clinical Investigations in Critical CareThe Adult Respiratory Distress Syndrome: A Report of Survival and Modifying Factors

Section snippets

METHODS

RESULTS

DISCUSSION

Lancet

Am J Cardiol

Chest

Chest

Causes of mortality in patients with adult respiratory distress syndrome

Am Rev Respir Dis

Multiple organ system failure and infection in the adult respiratory distress syndrome

Ann Intern Med

Incidence, site and outcome of infections in patients with the adult respiratory distress syndrome

Am Rev Respir Dis

Physiology of aging related to outcome in the adult respiratory distress syndrome

J Appl Physiol

Determinants of survival in the adult respiratory distress syndrome (ARDS)

Am Rev Respir Dis

Etiology, demography, and outcome

Clinical Investigations in Critical Care
The Adult Respiratory Distress Syndrome: A Report of Survival and Modifying Factors