Clinical Characteristics and Outcomes of Sepsis-Related vs Non-Sepsis-Related ARDS

Abstract

A RDS, the more severe form of acute lung injury (ALI), is a common and lethal disease in ICUs worldwide. Clinically, ARDS is characterized by acute respiratory failure with severe hypoxemia and diffuse pulmonary infi ltrates. Despite recent advances in critical care and signifi cant efforts invested in the basic research and clinical trials of ARDS, its mortality rate (35%-45%) has remained relatively unchanged since 1994. 1 ARDS usually develops in patients with predisposing conditions that induce systemic infl ammatory response, such as sepsis, pneumonia, major trauma, multiple transfusions, aspiration, and acute pancreatitis, among which sepsis is the most common cause of ARDS. [2][3][4][5] In a large prospective cohort study, severe sepsis with a suspected pulmonary source (46%) or a nonpulmonary source (33%) was the most common risk factor for ALI. 6 On the other hand, only Background: ARDS may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS, but little is known about the differences between sepsis-related and non-sepsis-related ARDS. Methods: A total of 2,786 patients with ARDS-predisposing conditions were enrolled consecutively into a prospective cohort, of which 736 patients developed ARDS. We defi ned sepsis-related ARDS as ARDS developing in patients with sepsis and non-sepsis-related ARDS as ARDS developing after nonseptic injuries, such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. Results: Compared with patients with non-sepsis-related ARDS (n 5 62), patients with sepsisrelated ARDS (n 5 524) were more likely to be women and to have diabetes, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (median, 78 vs 65, P , .0001). There were no differences in lung injury score, blood pH, Pa O 2 /F IO 2 ratio, and Pa CO 2 on ARDS diagnosis. However, patients with sepsis-related ARDS had signifi cantly lower Pa O 2 /F IO 2 ratios than patients with nonsepsis-related ARDS patients on ARDS day 3 ( P 5 .018), day 7 ( P 5 .004), and day 14 ( P 5 .004) (repeated-measures analysis, P 5 .011). Compared with patients with non-sepsis-related ARDS, those with sepsis-related had a higher 60-day mortality (38.2% vs 22.6%; P 5 .016), a lower successful extubation rate (53.6% vs 72.6%; P 5 .005), and fewer ICU-free days ( P 5 .0001) and ventilatorfree days ( P 5 .003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality (hazard ratio, 1.26; 95% CI, 0.71-2.22). Conclusion: Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ...

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