Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries

Abstract

IMPORTANCE Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS). OBJECTIVES To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts-for example prone positioning-in routine clinical practice for patients fulfilling the ARDS Berlin Definition. DESIGN, SETTING, AND PARTICIPANTS The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents. EXPOSURES Acute respiratory distress syndrome. MAIN OUTCOMES AND MEASURES The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS. RESULTS Of 29 144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H 2 O. Prone positioning was used in 16.3% (95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9% (95% CI, 31.4%-38.5%) for those with mild, 40.3% (95% CI, 37.4%-43.3%) for those with moderate, and 46.1% (95% CI, 41.9%-50.4%) for those with severe ARDS. CONCLUSIONS AND RELEVANCE Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the management of patients with ARDS.

Will all ARDS patients be receiving mechanical ventilation in 2035? No

“…Consequently, despite initial reduction, ARDS patients' deaths remain unacceptably high. Mortality rates for a recent multicenter cohort of mild, moderate, and severe ARDS patients were 35, 40, and 46 %, respectively [1]. Although lowering the tidal volume also lowered mortality-despite initially worse oxygenation-we advance that the current protective MV strategies cannot sufficiently minimize VILI and foster lung healing [2].…”

“…Therapeutic interventions (high positive end-expiratory pressure (PEEP), lung-protective ventilation, neuromuscular blockers, prone positioning) have demonstrated benefits early during the course of severe ARDS. However, ARDS appears to be underrecognized and undertreated [1], leaving room for improvement in the near future. Early detection of initial lung damage may allow timely implementation of preventive strategies to avoid progression towards more severe ARDS.…”

Indications for extracorporeal support: why do we need the results of the EOLIA trial?

“…It must also be emphasized that the most recent studies reported mortality rates for patients with the most severe forms of ARDS, defined as hypoxemia or hypercapnia refractory to initial management and treated conventionally, exceeding 60% [1][2][3]. The results of the first randomized trial were disappointing, but it should be noted that it took place many years ago, when the technology was in its infancy.…”

“…Acute respiratory distress syndrome (ARDS) is a severe lung disease, the associated mortality rate of which remains high [1]. The most severe forms of the disease, of which hypoxemia resulting from pulmonary involvement is the most profound, have an even worse prognosis, with mortality exceeding 60% [2,3], despite recourse to exceptional adjunctive therapies, such as inhaled NO [4], recruitment maneuvers [5], or prone positioning [6].…”

Respiratory extracorporeal membrane oxygenation for severe sepsis and septic shock in adults: a propensity score analysis in a multicenter retrospective observational study

“…Among patients with sepsis, the lung is the most common infection site1, 2, 3 and the presence of respiratory failure in these patients was found to be an independent risk factor for hospital mortality 1, 2. Therefore, the treatment of severe respiratory failure constitutes a significant portion of the sepsis treatment regimen.…”