Comparison of Clinical Criteria for the Acute Respiratory Distress Syndrome with Autopsy Findings

Esteban, Andrés; Fernández-Segoviano, Pilar; Frutos‐Vivar, Fernando; Aramburu, J. A.; Nájera, Laura; Ferguson, Niall D.; Alía, Inmaculada; Gordo, Federico; Ríos, Fernando

doi:10.7326/0003-4819-141-6-200409210-00009

Cited by 254 publications

(138 citation statements)

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“…For example, Thille and colleagues evaluated autopsy findings of patients meeting Berlin criteria for ARDS and identified that 45% of patients had histological findings consistent with diffuse alveolar damage (17). Earlier autopsy studies using the AmericanEuropean Consensus Criteria for clinical ARDS used by studies in our analysis also demonstrated even lower rates of diffuse alveolar damage (30 and 29%, respectively) (18,19). However, autopsy studies showed higher prevalence of diffuse alveolar damage than our study of open lung biopsy, possibly resulting from selection bias for more stable patients deemed candidates for lung biopsy than patients dying with severe ARDS.…”

Section: Discussionmentioning

confidence: 57%

Open Lung Biopsy among Critically Ill, Mechanically Ventilated Patients: A Meta-Analysis

Wong

Walkey

2015

Annals ATS

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Rationale: Open lung biopsy may be performed to guide therapy in mechanically ventilated patients with diagnostic uncertainty regarding etiology of pulmonary infiltrates. Current evidence for open lung biopsy in mechanically ventilated patients comes from single-center case series.Objectives: We performed a metaanalysis of case series to determine diagnoses, complications, and changes in therapy after lung biopsy in critically ill patients requiring mechanical ventilation. Methods:We searched Medline for case series of lung biopsies in critically ill patients requiring mechanical ventilation. We pooled results of individual case series using random effects metaanalysis models to obtain summary proportions. Measurements and Main Results:We identified 14 case series including a total of 512 mechanically ventilated patients with 530 histopathological diagnoses. The most common diagnoses were "fibrosis/pneumonitis" (n = 155, 25%; 95% confidence interval [CI], 14-37%) and infection (n = 113, 20%; 95% CI, 15-27%). Viruses were the most commonly identified infectious etiology identified on open lung biopsy, representing 50% of potential pathogens. Diffuse alveolar damage was present in a minority of specimens (n = 100, 16%; 95% CI, 8-25%). Therapeutic changes after lung biopsy occurred in 399 patients (78%; 95% CI, 64-81%). Procedure-related complications occurred in 29% of patients (95% CI, 25-33%), most commonly persistent air leak. Mortality among mechanically ventilated patients after diagnostic open lung biopsy was 54%.Conclusions: Among mechanically ventilated patients with respiratory failure of unclear etiology, lung biopsy yielded a wide range of diagnoses and was associated with a change in therapy in most patients.

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Section: Discussionmentioning

confidence: 57%

Open Lung Biopsy among Critically Ill, Mechanically Ventilated Patients: A Meta-Analysis

Wong

Walkey

2015

Annals ATS

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“…Intravascular fibrin deposition and thrombi formation lead to vascular obstruction and alterations in the microvasculature. A pathological correlate of the early phase of ALI has been termed diffuse alveolar damage and consists of hyaline membranes plus at least 1 of the following: alveolar type I or endothelial cell necrosis, edema, interstitial fibrosis, or prominent alveolar cell type II proliferation [17][18][19].…”

Section: Pathogenesismentioning

confidence: 99%

Pharmacotherapy of Acute Lung Injury and the Acute Respiratory Distress Syndrome

Cepkova

Matthay

2006

J Intensive Care Med

167

135

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Acute lung injury and the acute respiratory distress syndrome are common syndromes with a high mortality rate that affect both medical and surgical patients. Better understanding of the pathophysiology of acute lung injury and the acute respiratory distress syndrome and advances in supportive care and mechanical ventilation have led to improved clinical outcomes since the syndrome was first described in 1967. Although several promising pharmacological therapies, including surfactant, nitric oxide, glucocorticoids and lysofylline, have been studied in patients with acute lung injury and the acute respiratory distress syndrome, none of these pharmacological treatments reduced mortality. This article provides an overview of pharmacological therapies of acute lung injury and the acute respiratory distress syndrome tested in clinical trials and current recommendations for their use as well as a discussion of potential future pharmacological therapies including β 2 -adrenergic agonist therapy, keratinocyte growth factor, and activated protein C. Keywordsacute lung injury; acute respiratory distress syndrome; pulmonary edema; pharmacologic therapiesThe objective of this article is to review pharmacological therapeutic strategies for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Following a brief overview of definitions, epidemiology, pathophysiology, and major nonpharmacological therapies of ALI/ ARDS, we will focus on pharmacological therapies. Given the large number of therapeutic agents tested or implicated for therapy of ALI/ARDS, we attempted to organize this article according to the level of available evidence. The pharmacological therapeutic strategies are divided into 3 sections. The first 2 sections, pulmonary targeted (inhaled) and systemic pharmacological therapy, review all therapeutic agents for which human, phase I, II, or III clinical trials have been conducted. The third section focuses on potential therapies for which there are plausible pathophysiological rationale and preliminary experimental data but no clinical trials. All phase II and III clinical trials are summarized in a table that includes level [1,2] and grade [2,3] of evidence and resulting current recommendations.We searched the MEDLINE database (since 1967), the Cochrane Library, and bibliographies of retrieved articles. The literature search was performed by both authors. In the first 2 sections of this article, we include all therapies for which clinical trials in patients with ALI/ARDS have NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript been conducted and all important studies relevant to these therapies. In the third section, potential therapies, we discuss the treatments that are currently the most promising. Definitions and EpidemiologyThe acute respiratory distress syndrome is a clinical syndrome of acute inflammatory lung injury resulting from a variety of etiologies. The syndrome was first described by Ashbaugh and colleagues [4] in 1967 in a series of 12 patients, and...

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“…Diffuse alveolar damage (DAD) is a histopathological pattern of lung injury, and is the pathological correlate in most patients with acute respiratory distress syndrome (ARDS) [15][16][17][18]. Early DAD manifests an acute exudative phase that is characterised by interstitial oedema, epithelial necrosis and sloughing, the presence of fibrinous exudates in alveolar air spaces and hyaline membrane formation.…”

mentioning

confidence: 99%

Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage

Maldonado

Parambil

Yi³

et al. 2009

European Respiratory Journal

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Quantification of haemosiderin-laden macrophages in bronchoalveolar lavage fluid (BALF) has been used to diagnose diffuse alveolar haemorrhage (DAH) but has not been assessed in patients with diffuse alveolar damage (DAD).The present study analysed BALF obtained from 21 patients with DAD diagnosed by surgical lung biopsy.The median age of 21 patients with DAD was 68 yrs (range 18-79 yrs); 14 (67%) were male and 12 (57%) were immunocompromised. The median proportion of haemosiderin-laden macrophages in BALF was 5% (range 0-90%), but was o20% in seven (33%) patients, fulfilling the commonly used BALF criterion for DAH. There was a trend toward a positive correlation between the percentage of haemosiderin-laden macrophages in BALF and parenchymal haemorrhage assessed semiquantitatively by histopathological analysis. Patients with o20% haemosiderinladen macrophages in BALF showed a significantly increased mortality rate (p50.047) compared to those with ,20%.In patients with an acute onset of diffuse lung infiltrates and respiratory distress, o20% haemosiderin-laden macrophages in BALF can occur with DAD, and is not necessarily diagnostic of DAH. The finding of o20% haemosiderin-laden macrophages in BALF is associated with a worse prognosis in patients with DAD.

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Comparison of Clinical Criteria for the Acute Respiratory Distress Syndrome with Autopsy Findings

Abstract: In a series of autopsy patients, the accuracy of the American-European Consensus Conference definition of ARDS was only moderate. The definition was more accurate for patients with extrapulmonary risk factors than for patients with pulmonary risk factors.

Cited by 254 publications

References 32 publications

Open Lung Biopsy among Critically Ill, Mechanically Ventilated Patients: A Meta-Analysis

Open Lung Biopsy among Critically Ill, Mechanically Ventilated Patients: A Meta-Analysis

Pharmacotherapy of Acute Lung Injury and the Acute Respiratory Distress Syndrome

Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage

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