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Brooks D, Wright SE, Beattie A, McAllister N, Anderson NH, Roy AI, Gonsalves P, Yates B, Graziadio S, Mackie A, Davidson J, Gopal SV, Whittle R, Zahed A, Barton L, Elameer M, Tuckett J, Holmes R, Sutcliffe A, Santamaria N, de Lalouviere LLH, Gupta S, Subramaniam J, Pearson JA, Brandwood M, Burnham R, Rostron AJ, Simpson AJ. Assessment of the comparative agreement between chest radiographs and CT scans in intensive care units. J Crit Care 2024; 82:154760. [PMID: 38492522 DOI: 10.1016/j.jcrc.2024.154760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Chest radiographs in critically ill patients can be difficult to interpret due to technical and clinical factors. We sought to determine the agreement of chest radiographs and CT scans, and the inter-observer variation of chest radiograph interpretation, in intensive care units (ICUs). METHODS Chest radiographs and corresponding thoracic computerised tomography (CT) scans (as reference standard) were collected from 45 ICU patients. All radiographs were analysed by 20 doctors (radiology consultants, radiology trainees, ICU consultants, ICU trainees) from 4 different centres, blinded to CT results. Specificity/sensitivity were determined for pleural effusion, lobar collapse and consolidation/atelectasis. Separately, Fleiss' kappa for multiple raters was used to determine inter-observer variation for chest radiographs. RESULTS The median sensitivity and specificity of chest radiographs for detecting abnormalities seen on CTs scans were 43.2% and 85.9% respectively. Diagnostic sensitivity for pleural effusion was significantly higher among radiology consultants but no specialty/experience distinctions were observed for specificity. Median inter-observer kappa coefficient among assessors was 0.295 ("fair"). CONCLUSIONS Chest radiographs commonly miss important radiological features in critically ill patients. Inter-observer agreement in chest radiograph interpretation is only "fair". Consultant radiologists are least likely to miss thoracic radiological abnormalities. The consequences of misdiagnosis by chest radiographs remain to be determined.
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Affiliation(s)
- Daniel Brooks
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK; Emergency Department, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Anna Beattie
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Nadia McAllister
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Niall H Anderson
- Usher Institute, University of Edinburgh, Old Medial School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Philip Gonsalves
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Bryan Yates
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; York Health Economics Consortium, University of York, York YO10 5NQ, UK
| | - Alasdair Mackie
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - John Davidson
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Sandeep Vijaya Gopal
- Department of Radiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Robert Whittle
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Asef Zahed
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Lorna Barton
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Mathew Elameer
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - John Tuckett
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Rob Holmes
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK
| | - Alexandra Sutcliffe
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Nuria Santamaria
- Department of Radiology, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK; Department of Radiology, Clatterbridge Cancer Centre, l, Liverpool L7 8YA, UK
| | - Luke la Hausse de Lalouviere
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle Upon Tyne NE7 7DN, UK
| | - Sanjay Gupta
- Department of Radiology, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Jeevan Subramaniam
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Janaki A Pearson
- Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK; Intensive Care Unit, James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - Matthew Brandwood
- Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - Richard Burnham
- Critical Care Unit, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington NE23 6NZ, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK; Integrated Critical Care Unit, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE2 4HH, UK; NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK.
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Capela RC, de Souza RB, Sant’Anna MDFP, Sant’Anna CC. Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference. CRITICAL CARE SCIENCE 2024; 36:e20240229en. [PMID: 38865561 PMCID: PMC11152442 DOI: 10.62675/2965-2774.20240229-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/30/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To compare two methods for defining and classifying the severity of pediatric acute respiratory distress syndrome: the Berlin classification, which uses the relationship between the partial pressure of oxygen and the fraction of inspired oxygen, and the classification of the Pediatric Acute Lung Injury Consensus Conference, which uses the oxygenation index. METHODS This was a prospective study of patients aged 0 - 18 years with a diagnosis of acute respiratory distress syndrome who were invasively mechanically ventilated and provided one to three arterial blood gas samples, totaling 140 valid measurements. These measures were evaluated for correlation using the Spearman test and agreement using the kappa coefficient between the two classifications, initially using the general population of the study and then subdividing it into patients with and without bronchospasm and those with and without the use of neuromuscular blockers. The effect of these two factors (bronchospasm and neuromuscular blocking agent) separately and together on both classifications was also assessed using two-way analysis of variance. RESULTS In the general population, who were 54 patients aged 0 - 18 years a strong negative correlation was found by Spearman's test (ρ -0.91; p < 0.001), and strong agreement was found by the kappa coefficient (0.62; p < 0.001) in the comparison between Berlin and Pediatric Acute Lung Injury Consensus Conference. In the populations with and without bronchospasm and who did and did not use neuromuscular blockers, the correlation coefficients were similar to those of the general population, though among patients not using neuromuscular blockers, there was greater agreement between the classifications than for patients using neuromuscular blockers (kappa 0.67 versus 0.56, p < 0.001 for both). Neuromuscular blockers had a significant effect on the relationship between the partial pressure of oxygen and the fraction of inspired oxygen (analysis of variance; F: 12.9; p < 0.001) and the oxygenation index (analysis of variance; F: 8.3; p = 0.004). CONCLUSION There was a strong correlation and agreement between the two classifications in the general population and in the subgroups studied. Use of neuromuscular blockers had a significant effect on the severity of acute respiratory distress syndrome.
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Affiliation(s)
- Roberta Costa Capela
- Program in Maternal and Child HealthInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPostgraduate Program in Maternal and Child Health, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| | - Raquel Belmino de Souza
- Pediatric Intensive Care UnitInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPediatric Intensive Care Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| | - Maria de Fátima Pombo Sant’Anna
- Program in Maternal and Child HealthInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPostgraduate Program in Maternal and Child Health, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
| | - Clemax Couto Sant’Anna
- Program in Maternal and Child HealthInstituto de Puericultura e Pediatria Martagão GesteiraUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrazilPostgraduate Program in Maternal and Child Health, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brazil.
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Cook D, Deane A, Dionne JC, Lauzier F, Marshall JC, Arabi YM, Wilcox ME, Ostermann M, Al-Fares A, Heels-Ansdell D, Zytaruk N, Thabane L, Finfer S. Adjudication of a primary trial outcome: Results of a calibration exercise and protocol for a large international trial. Contemp Clin Trials Commun 2024; 39:101284. [PMID: 38559746 PMCID: PMC10979133 DOI: 10.1016/j.conctc.2024.101284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/31/2024] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background Ascertainment of the severity of the primary outcome of upper gastrointestinal (GI) bleeding is integral to stress ulcer prophylaxis trials. This protocol outlines the adjudication process for GI bleeding events in an international trial comparing pantoprazole to placebo in critically ill patients (REVISE: Re-Evaluating the Inhibition of Stress Erosions). The primary objective of the adjudication process is to assess episodes submitted by participating sites to determine which fulfil the definition of the primary efficacy outcome of clinically important upper GI bleeding. Secondary objectives are to categorize the bleeding severity if deemed not clinically important, and adjudicate the bleeding site, timing, investigations, and treatments. Methods Research coordinators follow patients daily for any suspected clinically important upper GI bleeding, and submit case report forms, doctors' and nurses' notes, laboratory, imaging, and procedural reports to the methods center. An international central adjudication committee reflecting diverse specialty backgrounds conducted an initial calibration exercise to delineate the scope of the adjudication process, review components of the definition, and agree on how each criterion will be considered fulfilled. Henceforth, bleeding events will be stratified by study drug, and randomly assigned to adjudicator pairs (blinded to treatment allocation, and study center). Results Crude agreement, chance-corrected agreement, or chance-independent agreement if data have a skewed distribution will be calculated. Conclusions Focusing on consistency and accuracy, central independent blinded duplicate adjudication of suspected clinically important upper GI bleeding events will determine which events fulfil the definition of the primary efficacy outcome for this stress ulcer prophylaxis trial. Registration NCT03374800 (REVISE: Re-Evaluating the Inhibition of Stress Erosions).
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Affiliation(s)
| | - Adam Deane
- University of Melbourne, Melbourne, Australia
| | | | | | | | - Yaseen M. Arabi
- King Abdullah International Medical Research Center and King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | | | - for the REVISE Investigators and the Canadian Critical Care Trials Group
- McMaster University, Hamilton, Canada
- University of Melbourne, Melbourne, Australia
- Université Laval, Québec City, Canada
- University of Toronto, Toronto, Canada
- King Abdullah International Medical Research Center and King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- University of Alberta, Edmonton, Canada
- King's College, London, United Kingdom
- Al-Amiri Hospital, Kuwait City, Kuwait
- The George Institute, Sydney, Australia
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Clerici B, Masood S, Nazy I, Tang N, Cranstone M, Liu Y, Hadzi-Tosev M, Nixon J, St John M, Shirinzadeh M, Jamula E, Kelton JG, Arnold DM. Bleeding self-assessments by patients with immune thrombocytopenia (ITP): An agreement study. Am J Hematol 2024; 99:1184-1186. [PMID: 38534202 DOI: 10.1002/ajh.27298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024]
Abstract
We designed anagreement study to compare the results of bleeding assessments done in tandem by ITP patients and trained research staff. We used a modified version of the ITP Bleeding Scale, which captured the patients' worst bleeding event at any of nine anatomical sites since the time of the last assessment. Interrater agreement was determined using the 2-way kappa for the assessment of severe vs. non-severe bleeds. We analyzed 108 consecutive patients with ITP from the McMaster ITP Registry who had duplicate bleeding assessments. Two-way agreement was excellent for gynecological (k = 0.86, 95% CI 0.71-1.02), gastrointestinal (k = 1), genitourinary (k = 1), pulmonary (k = 1) and intracranial (k = 1) bleeds; good for skin (k = 0.68, 95% CI, 0.54-0.82), oral (k = 0.76, 95% CI, 0.53-0.98) and ocular (k = 0.66, 95% CI, 0.04-1-28) bleeds; and moderate for epistaxis (k = 0.58, 95% CI, 0.21-0.95). Bleeding self-assessments by ITP patients were similar to trained research staff, but disagreements in severity grades were more frequent with skin bleeds, oral bleeds and epistaxis. Bleeding self-assessments could simplify bleeding assessments in clinical trials.
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Affiliation(s)
- Bianca Clerici
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Sahrish Masood
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ngan Tang
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Madison Cranstone
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Yang Liu
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Milena Hadzi-Tosev
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joanne Nixon
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Melanie St John
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maryam Shirinzadeh
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Erin Jamula
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John G Kelton
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Nasa P, Bos LD, Estenssoro E, van Haren FM, Serpa Neto A, Rocco PR, Slutsky AS, Schultz MJ. Consensus statements on the utility of defining ARDS and the utility of past and current definitions of ARDS-protocol for a Delphi study. BMJ Open 2024; 14:e082986. [PMID: 38670604 PMCID: PMC11057280 DOI: 10.1136/bmjopen-2023-082986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS), marked by acute hypoxemia and bilateral pulmonary infiltrates, has been defined in multiple ways since its first description. This Delphi study aims to collect global opinions on the conceptual framework of ARDS, assess the usefulness of components within current and past definitions and investigate the role of subphenotyping. The varied expertise of the panel will provide valuable insights for refining future ARDS definitions and improving clinical management. METHODS A diverse panel of 35-40 experts will be selected based on predefined criteria. Multiple choice questions (MCQs) or 7-point Likert-scale statements will be used in the iterative Delphi rounds to achieve consensus on key aspects related to the utility of definitions and subphenotyping. The Delphi rounds will be continued until a stable agreement or disagreement is achieved for all statements. ANALYSIS Consensus will be considered as reached when a choice in MCQs or Likert-scale statement achieved ≥80% of votes for agreement or disagreement. The stability will be checked by non-parametric χ2 tests or Kruskal Wallis test starting from the second round of Delphi process. A p-value ≥0.05 will be used to define stability. ETHICS AND DISSEMINATION The study will be conducted in full concordance with the principles of the Declaration of Helsinki and will be reported according to CREDES guidance. This study has been granted an ethical approval waiver by the NMC Healthcare Regional Research Ethics Committee, Dubai (NMCHC/CR/DXB/REC/APP/002), owing to the nature of the research. Informed consent will be obtained from all panellists before the start of the Delphi process. The study will be published in a peer-review journal with the authorship agreed as per ICMJE requirements. TRIAL REGISTRATION NUMBER NCT06159465.
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Affiliation(s)
- Prashant Nasa
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, UAE
| | - Lieuwe D Bos
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Respiratory Medicine, Amsterdam UMC, Amsterdam, Netherlands
| | - Elisa Estenssoro
- Facultad de Ciencias Médicas, Universidad Nacional de la Plata, La Plata, Argentina
- Ministerio de Salud de la Provincia de Buenos Aires, La Plata, Argentina
| | - Frank Mp van Haren
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia
- Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- Monash University, Clayton, VIC, Australia
- Austin Hospital, Heidelberg, VIC, Australia
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Patricia Rm Rocco
- Laboratory of Pulmonary Investigations, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, Oxford University, Oxford, UK
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University Vienna, Vienna, Austria
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6
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 152] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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7
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Acute Respiratory Distress Syndrome in Pregnancy: Updates in Principles and Practice. Clin Obstet Gynecol 2023; 66:208-222. [PMID: 36657055 DOI: 10.1097/grf.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute respiratory failure occurs in 0.05% to 0.3% of pregnancies and is precipitated by pulmonary and nonpulmonary insults. Acute respiratory distress syndrome (ARDS) is the rapid onset of hypoxemic respiratory failure associated with bilateral pulmonary opacities on chest imaging attributed to noncardiogenic pulmonary edema. The pathophysiological features of ARDS include hypoxemia, diminished lung volumes, and decreased lung compliance. While there is a paucity of data concerning ARDS in the pregnant individual, management principles do not vary significantly between pregnant and nonpregnant patients. The following review will discuss the diagnosis and management of the pregnant patient with ARDS.
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8
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Ranieri VM, Rubenfeld G, Slutsky AS. Rethinking Acute Respiratory Distress Syndrome after COVID-19: If a "Better" Definition Is the Answer, What Is the Question? Am J Respir Crit Care Med 2023; 207:255-260. [PMID: 36150099 PMCID: PMC9896638 DOI: 10.1164/rccm.202206-1048cp] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The definition of acute respiratory distress syndrome (ARDS) has a somewhat controversial history, with some even questioning the need for the term "ARDS." This controversy has been amplified by the coronavirus disease (COVID-19) pandemic given the marked increase in the incidence of ARDS, the relatively new treatment modalities that do not fit neatly with the Berlin definition, and the difficulty of making the diagnosis in resource-limited settings. We propose that attempts to revise the definition of ARDS should apply the framework originally developed by psychologists and social scientists and used by other medical disciplines to generate and assess definitions of clinical syndromes that do not have gold standards. This framework is structured around measures of reliability, feasibility, and validity. Future revisions of the definition of ARDS should contain the purpose, the methodology, and the framework for empirically testing any proposed definition. Attempts to revise critical illness syndromes' definitions usually hope to make them "better"; our recommendation is that future attempts use the same criteria used by other fields in defining what "better" means.
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Affiliation(s)
- V Marco Ranieri
- Alma Mater Studiorum - Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, IRCCS Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Bologna, Italy
| | - Gordon Rubenfeld
- Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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9
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Hagens LA, Van der Ven FLIM, Heijnen NFL, Smit MR, Gietema HA, Gerretsen SC, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Improvement of an interobserver agreement of ARDS diagnosis by adding additional imaging and a confidence scale. Front Med (Lausanne) 2022; 9:950827. [PMID: 36117964 PMCID: PMC9473335 DOI: 10.3389/fmed.2022.950827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) often is not recognized in clinical practice, largely due to variation in the interpretation of chest x-ray (CXR) leading to poor interobserver reliability. We hypothesized that the agreement in the interpretation of chest imaging for the diagnosis of ARDS in invasively ventilated intensive care unit patients between experts improves when using an 8-grade confidence scale compared to using a dichotomous assessment and that the agreement increases after adding chest computed tomography (CT) or lung ultrasound (LUS) to CXR. Three experts scored ARDS according to the Berlin definition based on case records from an observational cohort study using a dichotomous assessment and an 8-grade confidence scale. The intraclass correlation (ICC), imaging modality, and the scoring method were calculated per day and compared using bootstrapping. A consensus judgement on the presence of ARDS was based on the combined confidence grades of the experts, followed by a consensus meeting for conflicting scores. In total, 401 patients were included in the analysis. The best ICC was found using an 8-grade confidence scale for LUS (ICC: 0.49; 95%-CI: 0.29–0.63) and CT evaluation (ICC: 0.49; 95%-CI: 0.34–0.61). The ICC of CXR increased by 0.022 and of CT by 0.065 when 8-grade scoring was used instead of the dichotomous assessment. Adding information from LUS or chest CT increased the ICC by 0.25 when using the 8-grade confidence assessment. An agreement on the diagnosis of ARDS can increase substantially by adapting the scoring system from a dichotomous assessment to an 8-grade confidence scale and by adding additional imaging modalities such as LUS or chest CT. This suggests that a simple assessment of the diagnosis of ARDS with a chart review by one assessor is insufficient to define ARDS in future studies.
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Affiliation(s)
- Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Laura A. Hagens
| | - Fleur L. I. M. Van der Ven
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Ziekenhuis, Brandwondencentrum, Beverwijk, Netherlands
| | - Nanon F. L. Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hester A. Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Suzanne C. Gerretsen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
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10
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Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
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Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
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11
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Interobserver variability in the evaluation of primary graft dysfunction after lung transplantation: impact of radiological training and analysis of discordant cases. Radiol Med 2021; 127:145-153. [PMID: 34905128 DOI: 10.1007/s11547-021-01438-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiologic criteria for the diagnosis of primary graft dysfunction (PGD) after lung transplantation are nonspecific and can lead to misinterpretation. The primary aim of our study was to assess the interobserver agreement in the evaluation of chest X-rays (CXRs) for PGD diagnosis and to establish whether a specific training could have an impact on concordance rates. Secondary aim was to analyze causes of interobserver discordances. MATERIAL AND METHODS We retrospectively enrolled 164 patients who received bilateral lung transplantation at our institution, between February 2013 and December 2019. Three radiologists independently reviewed postoperative CXRs and classified them as suggestive or not for PGD. Two of the Raters performed a specific training before the beginning of the study. A senior thoracic radiologist subsequently analyzed all discordant cases among the Raters with the best agreement. Statistical analysis to calculate interobserver variability was percent agreement, Cohen's kappa and intraclass correlation coefficient. RESULTS A total of 473 CXRs were evaluated. A very high concordance among the two trained Raters, 1 and 2, was found (K = 0.90, ICC = 0.90), while a poorer agreement was found in the other two pairings (Raters 1 and 3: K = 0.34, ICC = 0.40; Raters 2 and 3: K = 0.35, ICC = 0.40). The main cause of disagreement (52.4% of discordant cases) between Raters 1 and 2 was the overestimation of peribronchial thickening in the absence of unequivocal bilateral lung opacities or the incorrect assessment of unilateral alterations. CONCLUSION To properly identify PGD, it is recommended for radiologists to receive an adequate specific training.
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12
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Early Identification and Diagnostic Approach in Acute Respiratory Distress Syndrome (ARDS). Diagnostics (Basel) 2021; 11:diagnostics11122307. [PMID: 34943543 PMCID: PMC8700413 DOI: 10.3390/diagnostics11122307] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 12/15/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition defined by the acute onset of severe hypoxemia with bilateral pulmonary infiltrates, in the absence of a predominant cardiac involvement. Whereas the current Berlin definition was proposed in 2012 and mainly focused on intubated patients under invasive mechanical ventilation, the recent COVID-19 pandemic has highlighted the need for a more comprehensive definition of ARDS including patients treated with noninvasive oxygenation strategies, especially high-flow nasal oxygen therapy, and fulfilling all other diagnostic criteria. Early identification of ARDS in patients breathing spontaneously may allow assessment of earlier initiation of pharmacological and non-pharmacological treatments. In the same way, accurate identification of the ARDS etiology is obviously of paramount importance for early initiation of adequate treatment. The precise underlying etiological diagnostic (bacterial, viral, fungal, immune, malignant, drug-induced, etc.) as well as the diagnostic approach have been understudied in the literature. To date, no clinical practice guidelines have recommended structured diagnostic work-up in ARDS patients. In addition to lung-protective ventilation with the aim of preventing worsening lung injury, specific treatment of the underlying cause has a central role to improve outcomes. In this review, we discuss early identification of ARDS in non-intubated patients breathing spontaneously and propose a structured diagnosis work-up.
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13
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Rudolph M, van Dijk J, de Jager P, Dijkstra SK, Burgerhof JGM, Blokpoel RGT, Kneyber MCJ. Performance of acute respiratory distress syndrome definitions in a high acuity paediatric intensive care unit. Respir Res 2021; 22:256. [PMID: 34587946 PMCID: PMC8480111 DOI: 10.1186/s12931-021-01848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For years, paediatric critical care practitioners used the adult American European Consensus Conference (AECC) and revised Berlin Definition (BD) for acute respiratory distress syndrome (ARDS) to study the epidemiology of paediatric ARDS (PARDS). In 2015, the paediatric specific definition, Paediatric Acute Lung Injury Consensus Conference (PALICC) was developed. The use of non-invasive metrics of oxygenation to stratify disease severity were introduced in this definition, although this potentially may lead to a confounding effect of disease severity since it is more common to place indwelling arterial lines in sicker patients. We tested the hypothesis that PALICC outperforms AECC/BD in our high acuity PICU, which employs a liberal use of indwelling arterial lines and high-frequency oscillatory ventilation (HFOV). METHODS We retrospectively collected data from children < 18 years mechanically ventilated for at least 24 h in our tertiary care, university-affiliated paediatric intensive care unit. The primary endpoint was the difference in the number of PARDS cases between AECC/BD and PALICC. Secondary endpoints included mortality and ventilator free days. Performance was assessed by the area under the receiver operating characteristics curve (AUC-ROC). RESULTS Data from 909 out of 2433 patients was eligible for analysis. AECC/BD identified 35 (1.4%) patients (mortality 25.7%), whereas PALICC identified 135 (5.5%) patients (mortality 14.1%). All but two patients meeting AECC/Berlin criteria were also identified by PALICC. Almost half of the cohort (45.2%) had mild, 33.3% moderate and 21.5% severe PALICC PARDS at onset. Highest mortality rates were seen in patients with AECC acute lung injury (ALI)/mild Berlin and severe PALICC PARDS. The AUC-ROC for Berlin was the highest 24 h (0.392 [0.124-0.659]) after onset. PALICC showed the highest AUC-ROC at the same moment however higher than Berlin (0.531 [0.345-0.716]). Mortality rates were significantly increased in patients with bilateral consolidations (9.3% unilateral vs 26.3% bilateral, p = 0.025). CONCLUSIONS PALICC identified more new cases PARDS than the AECC/Berlin definition. However, both PALICC and Berlin performed poorly in terms of mortality risk stratification. The presence of bilateral consolidations was associated with a higher mortality rate. Our findings may be considered in future modifications of the PALICC criteria.
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Affiliation(s)
- Michelle Rudolph
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands.
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Pauline de Jager
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Sandra K Dijkstra
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. 30.001, 9700 RB, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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14
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Sathe NA, Zelnick LR, Mikacenic C, Morrell ED, Bhatraju PK, McNeil JB, Kosamo S, Hough CL, Liles WC, Ware LB, Wurfel MM. Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts. Crit Care 2021; 25:336. [PMID: 34526076 PMCID: PMC8442814 DOI: 10.1186/s13054-021-03755-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population. METHODS In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO2-to-FIO2 ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO2-to-FIO2 ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF. RESULTS Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS. CONCLUSION Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA.
| | - Leila R Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Benaroya Research Institute, Seattle, WA, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
| | - J Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Susanna Kosamo
- Department of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - W Conrad Liles
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
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15
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Leng X, Onaitis MW, Zhao Y, Xuan Y, Leng S, Jiao W, Sun X, Qin Y, Liu D, Wang M, Yang R. Risk of Acute Lung Injury after Esophagectomy. Semin Thorac Cardiovasc Surg 2021; 34:737-746. [PMID: 33984482 DOI: 10.1053/j.semtcvs.2021.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 12/25/2022]
Abstract
To develop a new approach for identifying acute lung injury (ALI) in surgical ward setting and to assess incidence rate, clinical outcomes, and risk factors for ALI cases after esophagectomy. We also compare the degree of lung injury between operative and non-operative sides. Consecutive esophageal cancer patients (n=1022) who underwent esophagectomy from Dec 2012 to Nov 2018 in our hospital were studied. An approach for identifying ALI was proposed that integrated radiographic assessment of lung edema (RALE) score to quantify degree of lung edema. Stepwise logistic regression identified risk factors for postoperative ALI incidence. The degree of bilateral lung injury was compared using the RALE score. The approach for identifying ALI in surgical ward setting was defined as acute onset, PaO2/FiO2≤300 mmHg, bilateral opacities on bedside chest radiograph with a RALE score≥16, and exclusion of cardiogenic pulmonary edema. Incidence rate of ALI was estimated to be 9.7%. ALI diagnosis was associated with multiple clinical complications, prolonged hospital stay, higher medical bills, and higher perioperative mortality. Nine risk factors including BMI, ASA class, DLCO%, duration of surgery, neutrophil percentage, high-density lipoprotein, and electrolyte disorders were identified. The RALE score of the lung lobes of the operative side was higher than the non-operative side. A new approach for identifying ALI in esophageal cancer patients receiving esophagectomy was proposed and several risk factors were identified. ALI is common and has severe outcomes. The lung lobes on the operative side are more likely to be affected than the non-operative side.
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Affiliation(s)
- Xiaoliang Leng
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mark W Onaitis
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Diego, CA, USA
| | - Yandong Zhao
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yunpeng Xuan
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shuguang Leng
- Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA; Cancer Control and Population Sciences, Comprehensive Cancer Center, University of New Mexico, Albuquerque, NM, USA; Division of Occupational and Environmental Health, School of Public Health, Qingdao University, Qingdao, China.
| | - Wenjie Jiao
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China.
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- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China; Surgery, Health management center, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiao Sun
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yi Qin
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dahai Liu
- Surgery, Health management center, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Maolong Wang
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ronghua Yang
- Division of Thoracic Surgery, Department of Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
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16
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Panizo-Alcañiz J, Frutos-Vivar F, Thille AW, Peñuelas Ó, Aguilar-Rivilla E, Muriel A, Rodríguez-Barbero JM, Jaramillo C, Nin N, Esteban A. Diagnostic accuracy of portable chest radiograph in mechanically ventilated patients when compared with autopsy findings. J Crit Care 2020; 60:6-9. [PMID: 32731104 DOI: 10.1016/j.jcrc.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/13/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Evaluate diagnostic accuracy of portable chest radiograph in mechanically ventilated patients taking autopsy findings as the gold standard and the interobserver agreement among intensivists and radiologists. MATERIALS AND METHODS Retrospective study of 422 patients over 22 years who died in the ICU, underwent an autopsy, and had at least one portable chest radiograph 72 h prior to death. Two intensivists and two radiologists independently read each chest radiograph. Sensitivity, specificity, positive and negative likelihood ratios were evaluated. Overall performance metrics accuracy between intensivists and radiologists were compared using a generalized estimating equation. Cohen's kappa coefficient was used to evaluate the interobserver agreement with the following values: <0.20:poor, 0.21-0.40:fair, 0.41-0.60:moderate, 0.61-0.80:good, 0.81-1.00:excellent. RESULTS Overall sensitivity and specificity for pneumonia was 24% and 91% respectively. Overall sensitivity and specificity for ARDS was 68% and 74% respectively. Sensitivity for pneumonia was higher among radiologists (p < 0,05). Specificity for ADRS was higher among radiologists (p < 0,05). Good interobserver agreement among radiologists and poor correlation between intensivists was found. CONCLUSIONS Chest radiographs has a moderate specificity for ARDS and a high specificity for pneumonia, with limited sensitivity in both entities. Interobserver agreement of portable chest radiograph in the mechanically ventilated patients is higher between radiologists than intensivists.
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Affiliation(s)
| | - Fernando Frutos-Vivar
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
| | - Arnaud W Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation CHU de Poitiers, ALIVE research group, INSERM CIC 1402, University of Poitiers, Poitiers, France
| | - Óscar Peñuelas
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
| | - Eva Aguilar-Rivilla
- Servicio de Radiología, Unidad de tórax, Hospital Universitario de Getafe, Madrid, Spain
| | - Alfonso Muriel
- Hospital Ramón y Cajal, Unidad de Bioestadistica Clínica, Hospital Ramón y Cajal IRYCIS, CIBERESP, Departamento Enfermeria y Fisioterapia, Universidad de Alcalá, Madrid, Spain.
| | | | - Carlos Jaramillo
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
| | - Nicolás Nin
- Hospital Español Juan José Crottogini, Unidad de Cuidados Intensivos, Montevideo, Uruguay
| | - Andrés Esteban
- Servicio de Cuidados Intensivos y Grandes Quemados, CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Madrid, Spain
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17
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Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) results in substantial mortality but remains underdiagnosed in clinical practice. Automated ARDS "sniffer" systems, tools that can automatically analyze electronic medical record data, have been developed to improve recognition of ARDS in clinical practice. OBJECTIVES To perform a systematic review examining the evidence underlying automated sniffer systems for ARDS detection. DATA SOURCES MEDLINE and Scopus databases through November 2018 to identify studies of tools using routinely available clinical data to detect patients with ARDS. DATA EXTRACTION Study design, tool description, and diagnostic performance were extracted by two reviewers. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to evaluate each study for risk of bias in four domains: patient selection, index test, reference standard, and study flow and timing. SYNTHESIS Among 480 studies identified, 9 met inclusion criteria, and they evaluated six unique ARDS sniffer tools. Eight studies had derivation and/or temporal validation designs, with one also evaluating the effects of implementing a tool in clinical practice. A single study performed an external validation of previously published ARDS sniffer tools. Studies reported a wide range of sensitivities (43-98%) and positive predictive values (26-90%) for detection of ARDS. Most studies had potential for high risk of bias identified in their study design, including patient selection (five of nine), reference standard (four of nine), and flow and timing (three of nine). In the single external validation without any perceived risks of biases, the performance of ARDS sniffer tools was worse. CONCLUSIONS Sniffer systems developed to detect ARDS had moderate to high predictive value in their derivation cohorts, although most studies had the potential for high risks of bias in study design. Methodological issues may explain some of the variability in tool performance. There remains an ongoing need for robust evaluation of ARDS sniffer systems and their impact on clinical practice. Systematic review registered with PROSPERO (CRD42015026584).
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18
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Global and Regional Diagnostic Accuracy of Lung Ultrasound Compared to CT in Patients With Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:1599-1606. [PMID: 31464770 DOI: 10.1097/ccm.0000000000003971] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Lung CT is the reference imaging technique for acute respiratory distress syndrome, but requires transportation outside the intensive care and x-ray exposure. Lung ultrasound is a promising, inexpensive, radiation-free, tool for bedside imaging. Aim of the present study was to compare the global and regional diagnostic accuracy of lung ultrasound and CT scan. DESIGN A prospective, observational study. SETTING Intensive care and radiology departments of a University hospital. PATIENTS Thirty-two sedated, paralyzed acute respiratory distress syndrome patients (age 65 ± 14 yr, body mass index 25.9 ± 6.5 kg/m, and PaO2/FIO2 139 ± 47). INTERVENTIONS Lung CT scan and lung ultrasound were performed at positive end-expiratory pressure 5 cm H2O. A standardized assessment of six regions per hemithorax was used; each region was classified for the presence of normal aeration, alveolar-interstitial syndrome, consolidation, and pleural effusion. Agreement between the two techniques was calculated, and diagnostic variables were assessed for lung ultrasound using lung CT as a reference. MEASUREMENTS AND MAIN RESULTS Global agreement between lung ultrasound and CT ranged from 0.640 (0.391-0.889) to 0.934 (0.605-1.000) and was on average 0.775 (0.577-0.973). The overall sensitivity and specificity of lung ultrasound ranged from 82.7% to 92.3% and from 90.2% to 98.6%, respectively. Similar results were found with regional analysis. The diagnostic accuracy of lung ultrasound was significantly higher when those patterns not reaching the pleural surface were excluded (area under the receiver operating characteristic curve: alveolar-interstitial syndrome 0.854 [0.821-0.887] vs 0.903 [0.852-0.954]; p = 0.049 and consolidation 0.851 [0.818-0.884] vs 0.896 [0.862-0.929]; p = 0.044). CONCLUSIONS Lung ultrasound is a reproducible, sensitive, and specific tool, which allows for bedside detections of the morphologic patterns in acute respiratory distress syndrome. The presence of deep lung alterations may impact the diagnostic performance of this technique.
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López-Fernández YM, Smith LS, Kohne JG, Weinman JP, Modesto-Alapont V, Reyes-Dominguez SB, Medina A, Piñeres-Olave BE, Mahieu N, Klein MJ, Flori HR, Jouvet P, Khemani RG. Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study. Intensive Care Med 2020; 46:1382-1393. [PMID: 32451578 PMCID: PMC7246298 DOI: 10.1007/s00134-020-06074-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Purpose Definitions of acute respiratory distress syndrome (ARDS) include radiographic criteria, but there are concerns about reliability and prognostic relevance. This study aimed to evaluate the independent relationship between chest imaging and mortality and examine the inter-rater variability of interpretations of chest radiographs (CXR) in pediatric ARDS (PARDS). Methods Prospective, international observational study in children meeting Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria for PARDS, which requires new infiltrate(s) consistent with pulmonary parenchymal disease, without mandating bilateral infiltrates. Mortality analysis focused on the entire cohort, whereas inter-observer variability used a subset of patients with blinded, simultaneous interpretation of CXRs by intensivists and radiologists. Results Bilateral infiltrates and four quadrants of alveolar consolidation were associated with mortality on a univariable basis, using CXRs from 708 patients with PARDS. For patients on either invasive (IMV) or non-invasive ventilation (NIV) with PaO2/FiO2 (PF) ratios (or SpO2/FiO2 (SF) ratio equivalent) > 100, neither bilateral infiltrates (OR 1.3 (95% CI 0.68, 2.5), p = 0.43), nor 4 quadrants of alveolar consolidation (OR 1.6 (0.85, 3), p = 0.14) were associated with mortality. For patients with PF ≤ 100, bilateral infiltrates (OR 3.6 (1.4, 9.4), p = 0.01) and four quadrants of consolidation (OR 2.0 (1.14, 3.5), p = 0.02) were associated with higher mortality. A subset of 702 CXRs from 233 patients had simultaneous interpretations. Interobserver agreement for bilateral infiltrates and quadrants was “slight” (kappa 0.31 and 0.33). Subgroup analysis showed agreement did not differ when stratified by PARDS severity but was slightly higher for children with chronic respiratory support (kappa 0.62), NIV at PARDS diagnosis (kappa 0.53), age > 10 years (kappa 0.43) and fluid balance > 40 ml/kg (kappa 0.48). Conclusion Bilateral infiltrates and quadrants of alveolar consolidation are associated with mortality only for those with PF ratio ≤ 100, although there is high- inter-rater variability in these chest-x ray parameters. Electronic supplementary material The online version of this article (10.1007/s00134-020-06074-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Biocruces Health Research Institute, Cruces University Hospital, Plaza Cruces 12, 48903, Barakaldo, Bizkaia, Basque Country, Spain.
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joseph G Kohne
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan CS. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jason P Weinman
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Alberto Medina
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Byron E Piñeres-Olave
- Department of Pediatric Critical Care Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Natalie Mahieu
- Department of Radiology, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA.,Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan CS. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Philippe Jouvet
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
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20
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In Brief. Curr Probl Surg 2020. [DOI: 10.1016/j.cpsurg.2020.100778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Mowery NT, Terzian WTH, Nelson AC. Acute lung injury. Curr Probl Surg 2020; 57:100777. [PMID: 32505224 DOI: 10.1016/j.cpsurg.2020.100777] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 02/24/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Nathan T Mowery
- Associate Professor of Surgery, Wake Forest Medical Center, Winston-Salem, NC.
| | | | - Adam C Nelson
- Acute Care Surgery Fellow, Wake Forest Medical Center, Winston-Salem, NC
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22
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Ranieri VM, Pettilä V, Karvonen MK, Jalkanen J, Nightingale P, Brealey D, Mancebo J, Ferrer R, Mercat A, Patroniti N, Quintel M, Vincent JL, Okkonen M, Meziani F, Bellani G, MacCallum N, Creteur J, Kluge S, Artigas-Raventos A, Maksimow M, Piippo I, Elima K, Jalkanen S, Jalkanen M, Bellingan G. Effect of Intravenous Interferon β-1a on Death and Days Free From Mechanical Ventilation Among Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2020; 323:725-733. [PMID: 32065831 DOI: 10.1001/jama.2019.22525] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Acute respiratory distress syndrome (ARDS) is associated with high mortality. Interferon (IFN) β-1a may prevent the underlying event of vascular leakage. OBJECTIVE To determine the efficacy and adverse events of IFN-β-1a in patients with moderate to severe ARDS. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, parallel-group trial conducted at 74 intensive care units in 8 European countries (December 2015-December 2017) that included 301 adults with moderate to severe ARDS according to the Berlin definition. The radiological and partial pressure of oxygen, arterial (Pao2)/fraction of inspired oxygen (Fio2) criteria for ARDS had to be met within a 24-hour period, and the administration of the first dose of the study drug had to occur within 48 hours of the diagnosis of ARDS. The last patient visit was on March 6, 2018. INTERVENTIONS Patients were randomized to receive an intravenous injection of 10 μg of IFN-β-1a (144 patients) or placebo (152 patients) once daily for 6 days. MAIN OUTCOMES AND MEASURES The primary outcome was a score combining death and number of ventilator-free days at day 28 (score ranged from -1 for death to 27 if the patient was off ventilator on the first day). There were 16 secondary outcomes, including 28-day mortality, which were tested hierarchically to control type I error. RESULTS Among 301 patients who were randomized (mean age, 58 years; 103 women [34.2%]), 296 (98.3%) completed the trial and were included in the primary analysis. At 28 days, the median composite score of death and number of ventilator-free days at day 28 was 10 days (interquartile range, -1 to 20) in the IFN-β-1a group and 8.5 days (interquartile range, 0 to 20) in the placebo group (P = .82). There was no significant difference in 28-day mortality between the IFN-β-1a vs placebo groups (26.4% vs 23.0%; difference, 3.4% [95% CI, -8.1% to 14.8%]; P = .53). Seventy-four patients (25.0%) experienced adverse events considered to be related to treatment during the study (41 patients [28.5%] in the IFN-β-1a group and 33 [21.7%] in the placebo group). CONCLUSIONS AND RELEVANCE Among adults with moderate or severe ARDS, intravenous IFN-β-1a administered for 6 days, compared with placebo, resulted in no significant difference in a composite score that included death and number of ventilator-free days over 28 days. These results do not support the use of IFN-β-1a in the management of ARDS. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02622724.
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Affiliation(s)
- V Marco Ranieri
- Alma Mater Studiorum-Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Bologna, Italy
| | - Ville Pettilä
- Division of Intensive Care, Department of Anesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Peter Nightingale
- Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - David Brealey
- Critical Care, University College London Hospitals, NHS Foundation Trust and National Institute for Health Research Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London, London, United Kingdom
| | - Jordi Mancebo
- Department of Intensive Care, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Ricard Ferrer
- Department of Intensive Care/SODIR Research Group-VHIR Hospital Universitari Vall d'Hebron UCI, Barcelona, Spain
| | - Alain Mercat
- Médecine Intensive-Réanimation CHU d'Angers, Université d'Angers, Angers, France
| | - Nicolò Patroniti
- Dipartimento di scienze diagnostiche e integrate, Università degli studi di Genova, Genova, Italy
| | - Michael Quintel
- Anesthesiology and Operative Intensive Care Medicine, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marjatta Okkonen
- Division of Intensive Care, Department of Anesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ferhat Meziani
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de réanimation, Strasbourg, France
| | | | - Niall MacCallum
- Critical Care, University College London Hospitals, NHS Foundation Trust and National Institute for Health Research Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London, London, United Kingdom
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonio Artigas-Raventos
- Corporacion Sanitaria Universitaria Parc Tauli CIBER Enfermedades Respiratorias Autonomous University of Barcelona, Sabadell, Spain
| | | | | | - Kati Elima
- Medicity research Laboratory, University of Turku, Turku, Finland
| | - Sirpa Jalkanen
- Medicity research Laboratory, University of Turku, Turku, Finland
| | | | - Geoff Bellingan
- Critical Care, University College London Hospitals, NHS Foundation Trust and National Institute for Health Research Biomedical Research Centre at University College London Hospitals NHS Foundation Trust and University College London, London, United Kingdom
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Grune J, Beyhoff N, Hegemann N, Lauryn JH, Kuebler WM. From bedside to bench: lung ultrasound for the assessment of pulmonary edema in animal models. Cell Tissue Res 2020; 380:379-392. [PMID: 32009189 PMCID: PMC7210222 DOI: 10.1007/s00441-020-03172-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
Traditionally, the lung has been excluded from the ultrasound organ repertoire and, hence, the application of lung ultrasound (LUS) was largely limited to a few enthusiastic clinicians. Yet, in the last decades, the recognition of the previously untapped diagnostic potential of LUS in intensive care medicine has fueled its widespread use as a rapid, non-invasive and radiation-free bedside approach with excellent diagnostic accuracy for many of the most common causes of acute respiratory failure, e.g., cardiogenic pulmonary edema, pneumonia, pleural effusion and pneumothorax. Its increased clinical use has also incited attention for the potential usefulness of LUS in preclinical studies with small animal models mimicking lung congestion and pulmonary edema formation. Application of LUS to small animal models of pulmonary edema may save time, is cost-effective, and may reduce the number of experimental animals due to the possibility of serial evaluations in the same animal as compared with traditional end-point measurements. This review provides an overview of the emerging field of LUS with a specific focus on its application in animal models and highlights future perspectives for LUS in preclinical research.
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Affiliation(s)
- Jana Grune
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, 10117, Berlin, Germany
| | - Niklas Beyhoff
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, 10117, Berlin, Germany.,Institute of Pharmacology, Center for Cardiovascular Research, Charité-Universitätsmedizin Berlin, Hessische St 3-4, 10115, Berlin, Germany
| | - Niklas Hegemann
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, 10117, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, 13353, Berlin, Germany
| | - Jonathan H Lauryn
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, 10117, Berlin, Germany
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,German Centre for Cardiovascular Research (DZHK), partner site Berlin, 10117, Berlin, Germany. .,The Keenan Research Centre for Biomedical Science at St. Michael's, Toronto, Canada. .,Departments of Surgery and Physiology, University of Toronto, Toronto, Canada.
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24
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Yu X, Chan W, Swartz MD, Piller LB. Joint models of dynamics of mothers’ stress and children’s disease. COMMUN STAT-SIMUL C 2019. [DOI: 10.1080/03610918.2018.1468455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Xiaoying Yu
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Wenyaw Chan
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michael D. Swartz
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Linda B. Piller
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Houston, Texas, USA
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25
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Clear as Mud: Diagnostic Uncertainty in Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2019; 16:197-199. [PMID: 30707063 DOI: 10.1513/annalsats.201810-697ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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26
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Chest Radiography for Diagnosing Acute Respiratory Distress Syndrome-Fishing in the Dark? Crit Care Med 2019; 46:820-821. [PMID: 29652710 DOI: 10.1097/ccm.0000000000003041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Schwarz S, Muckenhuber M, Benazzo A, Beer L, Gittler F, Prosch H, Röhrich S, Milos R, Schweiger T, Jaksch P, Klepetko W, Hoetzenecker K. Interobserver variability impairs radiologic grading of primary graft dysfunction after lung transplantation. J Thorac Cardiovasc Surg 2019; 158:955-962.e1. [DOI: 10.1016/j.jtcvs.2019.02.134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 11/28/2022]
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Cereda M, Xin Y, Goffi A, Herrmann J, Kaczka DW, Kavanagh BP, Perchiazzi G, Yoshida T, Rizi RR. Imaging the Injured Lung: Mechanisms of Action and Clinical Use. Anesthesiology 2019; 131:716-749. [PMID: 30664057 PMCID: PMC6692186 DOI: 10.1097/aln.0000000000002583] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, ON, Canada
| | - Jacob Herrmann
- Departments of Anesthesia and Biomedical Engineering, University of Iowa, IA
| | - David W. Kaczka
- Departments of Anesthesia, Radiology, and Biomedical Engineering, University of Iowa, IA
| | | | - Gaetano Perchiazzi
- Hedenstierna Laboratory and Uppsala University Hospital, Uppsala University, Sweden
| | - Takeshi Yoshida
- Hospital for Sick Children, University of Toronto, ON, Canada
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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A novel evaluation of two related and two independent algorithms for eye movement classification during reading. Behav Res Methods 2019; 50:1374-1397. [PMID: 29766396 DOI: 10.3758/s13428-018-1050-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nystrӧm and Holmqvist have published a method for the classification of eye movements during reading (ONH) (Nyström & Holmqvist, 2010). When we applied this algorithm to our data, the results were not satisfactory, so we modified the algorithm (now the MNH) to better classify our data. The changes included: (1) reducing the amount of signal filtering, (2) excluding a new type of noise, (3) removing several adaptive thresholds and replacing them with fixed thresholds, (4) changing the way that the start and end of each saccade was determined, (5) employing a new algorithm for detecting PSOs, and (6) allowing a fixation period to either begin or end with noise. A new method for the evaluation of classification algorithms is presented. It was designed to provide comprehensive feedback to an algorithm developer, in a time-efficient manner, about the types and numbers of classification errors that an algorithm produces. This evaluation was conducted by three expert raters independently, across 20 randomly chosen recordings, each classified by both algorithms. The MNH made many fewer errors in determining when saccades start and end, and it also detected some fixations and saccades that the ONH did not. The MNH fails to detect very small saccades. We also evaluated two additional algorithms: the EyeLink Parser and a more current, machine-learning-based algorithm. The EyeLink Parser tended to find more saccades that ended too early than did the other methods, and we found numerous problems with the output of the machine-learning-based algorithm.
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Reilly JP, Calfee CS, Christie JD. Acute Respiratory Distress Syndrome Phenotypes. Semin Respir Crit Care Med 2019; 40:19-30. [PMID: 31060085 DOI: 10.1055/s-0039-1684049] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The acute respiratory distress syndrome (ARDS) phenotype was first described over 50 years ago and since that time significant progress has been made in understanding the biologic processes underlying the syndrome. Despite this improved understanding, no pharmacologic therapies aimed at the underlying biology have been proven effective in ARDS. Increasingly, ARDS has been recognized as a heterogeneous syndrome characterized by subphenotypes with distinct clinical, radiographic, and biologic differences, distinct outcomes, and potentially distinct responses to therapy. The Berlin Definition of ARDS specifies three severity classifications: mild, moderate, and severe based on the PaO2 to FiO2 ratio. Two randomized controlled trials have demonstrated a potential benefit to prone positioning and neuromuscular blockade in moderate to severe phenotypes of ARDS only. Precipitating risk factor, direct versus indirect lung injury, and timing of ARDS onset can determine other clinical phenotypes of ARDS after admission. Radiographic phenotypes of ARDS have been described based on a diffuse versus focal pattern of infiltrates on chest imaging. Finally and most promisingly, biologic subphenotypes or endotypes have increasingly been identified using plasma biomarkers, genetics, and unbiased approaches such as latent class analysis. The potential of precision medicine lies in identifying novel therapeutics aimed at ARDS biology and the subpopulation within ARDS most likely to respond. In this review, we discuss the challenges and approaches to subphenotype ARDS into clinical, radiologic, severity, and biologic phenotypes with an eye toward the future of precision medicine in critical care.
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Affiliation(s)
- John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carolyn S Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with many disease processes that injure the lung, culminating in increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite enhanced understanding of molecular mechanisms, advances in ventilatory strategies, and general care of the critically ill patient, mortality remains unacceptably high. The Berlin definition of ARDS has now replaced the American-European Consensus Conference definition. The recently concluded Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) provided worldwide epidemiological data of ARDS including prevalence, geographic variability, mortality, and patterns of mechanical ventilation use. Failure of clinical therapeutic trials prompted the investigation and subsequent discovery of two distinct phenotypes of ARDS (hyper-inflammatory and hypo-inflammatory) that have different biomarker profiles and clinical courses and respond differently to the random application of positive end expiratory pressure (PEEP) and fluid management strategies. Low tidal volume ventilation remains the predominant mainstay of the ventilatory strategy in ARDS. High-frequency oscillatory ventilation, application of recruitment maneuvers, higher PEEP, extracorporeal membrane oxygenation, and alternate modes of mechanical ventilation have failed to show benefit. Similarly, most pharmacological therapies including keratinocyte growth factor, beta-2 agonists, and aspirin did not improve outcomes. Prone positioning and early neuromuscular blockade have demonstrated mortality benefit, and clinical guidelines now recommend their use. Current ongoing trials include the use of mesenchymal stem cells, vitamin C, re-evaluation of neuromuscular blockade, and extracorporeal carbon dioxide removal. In this article, we describe advances in the diagnosis, epidemiology, and treatment of ARDS over the past decade.
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Affiliation(s)
- Rahul S Nanchal
- Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathon D Truwit
- Pulmonary and Critical Care Medicine, Froedtert & Medical College of Wisconsin, Milwaukee, WI, USA
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See KC, Ong V, Tan YL, Sahagun J, Taculod J. Chest radiography versus lung ultrasound for identification of acute respiratory distress syndrome: a retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:203. [PMID: 30119687 PMCID: PMC6098581 DOI: 10.1186/s13054-018-2105-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 06/22/2018] [Indexed: 11/30/2022]
Abstract
Background Lung ultrasound may be a reasonable alternative to chest radiography for the identification of acute respiratory distress syndrome (ARDS), but the diagnostic performance of lung ultrasound for ARDS is uncertain. We therefore analyzed the clinical outcomes of ARDS diagnosed according to the Berlin Definition, using either chest radiography (Berlin-CXR) or lung ultrasound (Berlin-LUS) as an alternative imaging method. Methods This was a retrospective observational study in a 20-bed medical intensive care unit (ICU). Patients who required noninvasive ventilation or invasive ventilation for hypoxemic respiratory failure on ICU admission from August 2014 to March 2017 were included. Both chest radiography and lung ultrasound were performed routinely upon ICU admission. Comparisons were made using either the Berlin-CXR or Berlin-LUS definitions to diagnose ARDS with respect to the patient characteristics and clinical outcomes for each definition. ICU and hospital mortality were the main outcome measures for both definitions. Results The first admissions of 456 distinct patients were analyzed. Compared with the 216 patients who met the Berlin-CXR definition (ICU mortality 19.4%, hospital mortality 36.1%), 229 patients who met the Berlin-LUS definition (ICU mortality 22.7%, hospital mortality 34.5%) and 79 patients who met the Berlin-LUS but not the Berlin-CXR definition (ICU mortality 21.5%, hospital mortality 29.1%) had similar outcomes. In contrast, the 295 patients who met either definition had higher mortality than the 161 patients who did not meet either definition (ICU mortality 20.0% versus 12.4%, P = 0.041; hospital mortality 34.2% versus 24.2%, P = 0.027). Compared with Berlin-CXR, Berlin-LUS had a positive predictive value of 0.66 (95% confidence interval 0.59–0.72) and a negative predictive value of 0.71 (0.65–0.77). Among the 216 Berlin-CXR ARDS patients, 150 patients (69.4%) also fulfilled Berlin-LUS definition. Conclusions For the identification of ARDS using the Berlin definition, both chest radiography and lung ultrasound were equally related to mortality. The Berlin definition using lung ultrasound helped identify patients at higher risk of death, even if these patients did not fulfill the conventional Berlin definition using chest radiography. However, the moderate overlap of patients when chest imaging modalities differed suggests that chest radiography and lung ultrasound should be complementary rather than used interchangeably. Electronic supplementary material The online version of this article (10.1186/s13054-018-2105-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory & Critical Care Medicine, University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Venetia Ong
- Department of Medical Affairs, National University Hospital, Singapore, Singapore
| | - Yi Lin Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Juliet Sahagun
- Division of Critical Care-Respiratory Therapy, National University Hospital, Singapore, Singapore
| | - Juvel Taculod
- Division of Critical Care-Respiratory Therapy, National University Hospital, Singapore, Singapore
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Daher P, Teixeira PG, Coopwood TB, Brown LH, Ali S, Aydelotte JD, Ford BJ, Hensely AS, Brown CV. Mild to Moderate to Severe: What Drives the Severity of ARDS in Trauma Patients? Am Surg 2018. [DOI: 10.1177/000313481808400623] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a complex inflammatory process with multifactorial etiologies. Risk factors for its development have been extensively studied, but factors associated with worsening severity of disease, as defined by the Berlin criteria, are poorly understood. A retrospective chart and trauma registry review identified trauma patients in our surgical intensive care unit who developed ARDS, defined according to the Berlin definition, between 2010 and 2015. The primary outcome was development of mild, moderate, or severe ARDS. A logistic regression model identified risk factors associated with developing ARDS and with worsening severity of disease. Of 2704 total patients, 432 (16%) developed ARDS. Of those, 100 (23%) were categorized as mild, 176 (41%) as moderate, and 156 (36%) as severe. Two thousand two hundred and seventy-two patients who did not develop ARDS served as controls. Male gender, blunt trauma, severe head and chest injuries, and red blood cell as well as total blood product transfusions are independent risk factors associated with ARDS. Worsening severity of disease is associated with severe chest trauma and volume of plasma transfusion. Novel findings in our study include the association between plasma transfusions and specifically severe chest trauma with worsening severity of ARDS in trauma patients.
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Affiliation(s)
- Pamela Daher
- Dell Medical School, University of Texas at Austin, Austin, Texas and
| | - Pedro G. Teixeira
- Dell Medical School, University of Texas at Austin, Austin, Texas and
| | | | - Lawrence H. Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas and
| | - Sadia Ali
- Dell Medical School, University of Texas at Austin, Austin, Texas and
| | | | - Brent J. Ford
- University of Texas Medical Branch Galveston, Galveston, Texas
| | - Adam S. Hensely
- University of Texas Medical Branch Galveston, Galveston, Texas
| | - Carlos V. Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas and
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Continued under-recognition of acute respiratory distress syndrome after the Berlin definition: what is the solution? Curr Opin Crit Care 2018; 23:10-17. [PMID: 27922845 DOI: 10.1097/mcc.0000000000000381] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Timely recognition of acute respiratory distress syndrome (ARDS) may allow for more prompt management and less exacerbation of lung injury. However, the absence of a diagnostic test for ARDS means that the diagnosis of ARDS requires clinician recognition in what is usually a complicated and evolving illness. We review data concerning the extent of recognition of ARDS in the era of the Berlin definition of ARDS. RECENT FINDINGS ARDS continues to be under-recognized - even in the era of the more recent 'Berlin' definition, and significant delay in its recognition is common. Factors contributing to under-recognition may include the complexity of ARDS biology, low specificity of the consensus (diagnostic) criteria, and concerns about reliable interpretation of the chest radiograph. Understandably, 'external' factors are also at play: ICU occupancy and higher patient to clinician ratio impair recognition of ARDS. Timely recognition of ARDS appears important, as it is associated with the use of higher PEEP, prone positioning and neuromuscular blockade which can lower mortality. Computer-aided decision tools seem diagnostically useful, and together with the integration of reliable biomarkers, may further enhance and speed recognition of this syndrome. SUMMARY Significant numbers of patients with ARDS are still unrecognized by clinicians in the era of the Berlin definition of ARDS, with potentially important consequences for patient management and outcome.
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Antonio ACP, Teixeira C, Castro PS, Zanardo AP, Gazzana MB, Knorst M. Usefulness of radiological signs of pulmonary congestion in predicting failed spontaneous breathing trials. J Bras Pneumol 2018; 43:253-258. [PMID: 29364998 PMCID: PMC5687960 DOI: 10.1590/s1806-37562016000000360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 06/18/2017] [Indexed: 01/15/2023] Open
Abstract
Objective: Inspiratory fall in intrathoracic pressure during a spontaneous breathing trial (SBT) may precipitate cardiac dysfunction and acute pulmonary edema. We aimed to determine the relationship between radiological signs of pulmonary congestion prior to an SBT and weaning outcomes. Methods: This was a post hoc analysis of a prospective cohort study involving patients in an adult medical-surgical ICU. All enrolled individuals met the eligibility criteria for liberation from mechanical ventilation. Tracheostomized subjects were excluded. The primary endpoint was SBT failure, defined as the inability to tolerate a T-piece trial for 30-120 min. An attending radiologist applied a radiological score on interpretation of digital chest X-rays performed before the SBT. Results: A total of 170 T-piece trials were carried out; SBT failure occurred in 28 trials (16.4%), and 133 subjects (78.3%) were extubated at first attempt. Radiological scores were similar between SBT-failure and SBT-success groups (median [interquartile range] = 3 [2-4] points vs. 3 [2-4] points; p = 0.15), which, according to the score criteria, represented interstitial lung congestion. The analysis of ROC curves demonstrated poor accuracy (area under the curve = 0.58) of chest x-rays findings of congestion prior to the SBT for discriminating between SBT failure and SBT success. No correlation was found between fluid balance in the 48 h preceding the SBT and radiological score results (ρ = −0.13). Conclusions: Radiological findings of pulmonary congestion should not delay SBT indication, given that they did not predict weaning failure in the medical-surgical critically ill population. (ClinicalTrials.gov identifier: NCT02022839 [http://www.clinicaltrials.gov/])
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Affiliation(s)
- Ana Carolina Peçanha Antonio
- . Unidade de Terapia Intensiva Adulto, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil.,. Hospital Moinhos de Vento, Porto Alegre (RS) Brasil
| | | | - Priscylla Souza Castro
- . Hospital Moinhos de Vento, Porto Alegre (RS) Brasil.,. Unidade de Terapia Intensiva, Hospital Mãe de Deus, Porto Alegre (RS) Brasil
| | | | | | - Marli Knorst
- . Programa de Pós-Graduação em Pneumologia, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS) Brasil
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38
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Fong KM, Au SY, Lily Chan KL, George Ng WY. Update on management of acute respiratory distress syndrome. AIMS MEDICAL SCIENCE 2018. [DOI: 10.3934/medsci.2018.2.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Sjoding MW, Hofer TP, Co I, Courey A, Cooke CR, Iwashyna TJ. Interobserver Reliability of the Berlin ARDS Definition and Strategies to Improve the Reliability of ARDS Diagnosis. Chest 2017; 153:361-367. [PMID: 29248620 DOI: 10.1016/j.chest.2017.11.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/27/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Failure to reliably diagnose ARDS may be a major driver of negative clinical trials and underrecognition and treatment in clinical practice. We sought to examine the interobserver reliability of the Berlin ARDS definition and examine strategies for improving the reliability of ARDS diagnosis. METHODS Two hundred five patients with hypoxic respiratory failure from four ICUs were reviewed independently by three clinicians, who evaluated whether patients had ARDS, the diagnostic confidence of the reviewers, whether patients met individual ARDS criteria, and the time when criteria were met. RESULTS Interobserver reliability of an ARDS diagnosis was "moderate" (kappa = 0.50; 95% CI, 0.40-0.59). Sixty-seven percent of diagnostic disagreements between clinicians reviewing the same patient was explained by differences in how chest imaging studies were interpreted, with other ARDS criteria contributing less (identification of ARDS risk factor, 15%; cardiac edema/volume overload exclusion, 7%). Combining the independent reviews of three clinicians can increase reliability to "substantial" (kappa = 0.75; 95% CI, 0.68-0.80). When a clinician diagnosed ARDS with "high confidence," all other clinicians agreed with the diagnosis in 72% of reviews. There was close agreement between clinicians about the time when a patient met all ARDS criteria if ARDS developed within the first 48 hours of hospitalization (median difference, 5 hours). CONCLUSIONS The reliability of the Berlin ARDS definition is moderate, driven primarily by differences in chest imaging interpretation. Combining independent reviews by multiple clinicians or improving methods to identify bilateral infiltrates on chest imaging are important strategies for improving the reliability of ARDS diagnosis.
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Affiliation(s)
- Michael W Sjoding
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Ivan Co
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Anthony Courey
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Colin R Cooke
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI; Institute for Social Research, Ann Arbor, MI
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Reilly JP, Christie JD, Meyer NJ. Fifty Years of Research in ARDS. Genomic Contributions and Opportunities. Am J Respir Crit Care Med 2017; 196:1113-1121. [PMID: 28481621 PMCID: PMC5694838 DOI: 10.1164/rccm.201702-0405cp] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Clinical factors alone poorly explain acute respiratory distress syndrome (ARDS) risk and ARDS outcome. In the search for individual factors that may influence ARDS risk, the past 20 years have witnessed the identification of numerous genes and genetic variants that are associated with ARDS. The field of ARDS genomics has cycled from candidate gene association studies to bias-free approaches that identify new candidates, and increasing effort is made to understand the functional consequences that may underlie significant associations. More recently, methodologies of causal inference are being applied to maximize the information gained from genetic associations. Although challenges of sample size, both recognized and unrecognized phenotypic heterogeneity, and the paucity of early ARDS lung tissue limit some applications of the rapidly evolving field of genomic investigation, ongoing genetic research offers unique contributions to elucidating ARDS pathogenesis and the paradigm of precision ARDS medicine.
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Affiliation(s)
- John P. Reilly
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine
- Center for Translational Lung Biology, and
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine
- Center for Translational Lung Biology, and
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J. Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine
- Center for Translational Lung Biology, and
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Thille AW, Peñuelas O, Lorente JA, Fernández-Segoviano P, Rodriguez JM, Aramburu JA, Panizo J, Esteban A, Frutos-Vivar F. Predictors of diffuse alveolar damage in patients with acute respiratory distress syndrome: a retrospective analysis of clinical autopsies. Crit Care 2017; 21:254. [PMID: 29052522 PMCID: PMC5649062 DOI: 10.1186/s13054-017-1852-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background Although diffuse alveolar damage (DAD) is considered the typical histological pattern of acute respiratory distress syndrome (ARDS), only half of patients exhibit this morphological hallmark. Patients with DAD may have higher mortality than those without DAD. Therefore, we aimed to identify the factors associated with DAD in patients with ARDS. Methods We analyzed autopsy samples of 356 patients who had ARDS at the time of death. DAD was assessed by two pathologists, and ARDS criteria were evaluated by two intensivists. Criteria for severe ARDS included the degree of hypoxemia and the ancillary variables of the current Berlin definition assessed within 48 h before death: radiographic severity, high positive end-expiratory pressure (PEEP) level, and physiological variables (i.e., altered respiratory system compliance and large anatomic dead space). Results After multivariable analysis, high PEEP levels, physiological variables, and opacities involving only three quadrants on chest radiographs were not associated with DAD. The four markers independently associated with DAD were (1) duration of evolution (OR 3.29 [1.95–5.55] for patients with ARDS ≥ 3 days, p < 0.001), (2) degree of hypoxemia (OR 3.92 [1.48–10.3] for moderate ARDS and 6.18 [2.34–16.3] for severe ARDS, p < 0.01 for both), (3) increased dynamic driving pressure (OR 1.06 [1.04–1.09], p = 0.007), and (4) radiographic severity (OR 2.91 [1.47–5.75] for patients with diffuse opacities involving the four quadrants, p = 0.002). DAD was found in two-thirds of patients with a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤ 100 mmHg and opacities involving the four quadrants. Conclusions In addition to severe hypoxemia, diffuse opacities involving the four quadrants were a strong marker of DAD.
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Affiliation(s)
- Arnaud W Thille
- CHU de Poitiers, Réanimation Médicale, Poitiers, France. .,INSERM CIC 1402 ALIVE Group, Université de Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France.
| | - Oscar Peñuelas
- Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Universidad Europea de Madrid, Madrid, Spain
| | - José A Lorente
- Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Universidad Europea de Madrid, Madrid, Spain
| | - Pilar Fernández-Segoviano
- Departamento de Anatomía Patológica, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - José-Maria Rodriguez
- Departamento de Anatomía Patológica, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - José-Antonio Aramburu
- Departamento de Anatomía Patológica, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Julian Panizo
- Departamento de Radiodiagnóstico, Hospital Universitario de Getafe, Madrid, Spain
| | - Andres Esteban
- Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Universidad Europea de Madrid, Madrid, Spain
| | - Fernando Frutos-Vivar
- Departamento de Cuidados Intensivos, Hospital Universitario de Getafe, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Universidad Europea de Madrid, Madrid, Spain
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Pham T, Rubenfeld GD. Fifty Years of Research in ARDS. The Epidemiology of Acute Respiratory Distress Syndrome. A 50th Birthday Review. Am J Respir Crit Care Med 2017; 195:860-870. [PMID: 28157386 DOI: 10.1164/rccm.201609-1773cp] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Since its first description 50 years ago, no other intensive care syndrome has been as extensively studied as acute respiratory distress syndrome (ARDS). Despite this extensive body of research, many basic epidemiologic questions remain unsolved. The lack of gold standard tests jeopardizes accurate diagnosis and translational research. Wide variation in the population incidence has been reported, making even simple estimates of the burden of disease problematic. Despite these limitations, there has been an increase in the understanding of pathophysiology and important risk factors both for the development of ARDS and for important patient-centered outcomes like mortality. In this Critical Care Perspective, we discuss the historical context of ARDS description and attempts at its definition. We highlight the epidemiologic challenges of studying ARDS, as well as other intensive care syndromes, and propose solutions to address them. We update the current knowledge of ARDS trends in incidence and mortality, risk factors, and recently described endotypes.
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Affiliation(s)
- Tài Pham
- 1 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,2 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; and
| | - Gordon D Rubenfeld
- 1 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Program in Trauma, Emergency, and Critical Care Organization, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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The Montreux definition of neonatal ARDS: biological and clinical background behind the description of a new entity. THE LANCET RESPIRATORY MEDICINE 2017; 5:657-666. [PMID: 28687343 DOI: 10.1016/s2213-2600(17)30214-x] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/22/2017] [Accepted: 04/24/2017] [Indexed: 11/21/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is undefined in neonates, despite the long-standing existing formal recognition of ARDS syndrome in later life. We describe the Neonatal ARDS Project: an international, collaborative, multicentre, and multidisciplinary project which aimed to produce an ARDS consensus definition for neonates that is applicable from the perinatal period. The definition was created through discussions between five expert members of the European Society for Paediatric and Neonatal Intensive Care; four experts of the European Society for Paediatric Research; two independent experts from the USA and two from Australia. This Position Paper provides the first consensus definition for neonatal ARDS (called the Montreux definition). We also provide expert consensus that mechanisms causing ARDS in adults and older children-namely complex surfactant dysfunction, lung tissue inflammation, loss of lung volume, increased shunt, and diffuse alveolar damage-are also present in several critical neonatal respiratory disorders.
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Rezoagli E, Fumagalli R, Bellani G. Definition and epidemiology of acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:282. [PMID: 28828357 DOI: 10.21037/atm.2017.06.62] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fifty years ago, Ashbaugh and colleagues defined for the first time the acute respiratory distress syndrome (ARDS), one among the most challenging clinical condition of the critical care medicine. The scientific community worked over the years to generate a unified definition of ARDS, which saw its revisited version in the Berlin definition, in 2014. Epidemiologic information about ARDS is limited in the era of the new Berlin definition, and wide differences are reported among countries all over the world. Despite decades of study in the field of lung injury, ARDS is still so far under-recognized, with 2 out of 5 cases missed by clinicians. Furthermore, although advances of ventilator strategies in the management of ARDS associated with outcome improvements-such as protective mechanical ventilation, lower driving pressure, higher PEEP levels and prone positioning-ARDS appears to be undertreated and mortality remains elevated up to 40%. In this review, we cover the history that led to the current worldwide accepted Berlin definition of ARDS and we summarize the recent data regarding ARDS epidemiology.
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Affiliation(s)
- Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
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Siddiqui S, Puthucheary Z, Phua J, Ho B, Tan J, Chuin S, Lim NL, Soh CR, Loo CM, Tan AYH, Mukhopadhyay A, Khan FA, Johan A, Tan AH, MacLaren G, Taculod J, Ramos B, Han TA, Cove ME. National survey of outcomes and practices in acute respiratory distress syndrome in Singapore. PLoS One 2017; 12:e0179343. [PMID: 28622342 PMCID: PMC5473557 DOI: 10.1371/journal.pone.0179343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/26/2017] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION In the past 20 years, our understanding of acute respiratory distress syndrome (ARDS) management has improved, but the worldwide incidence and current outcomes are unclear. The reported incidence is highly variable, and no studies specifically characterise ARDS epidemiology in Asia. This observation study aims to determine the incidence, mortality and management practices of ARDS in a high income South East Asian country. METHODS We conducted a prospective, population based observational study in 6 public hospitals. During a one month period, we identified all ARDS patients admitted to public hospital intensive care units (ICU) in Singapore, according to the Berlin definition. Demographic information, clinical management data and ICU outcome data was collected. RESULTS A total of 904 adult patients were admitted to ICU during the study period and 15 patients met ARDS criteria. The unadjusted incidence of ARDS was 4.5 cases per 100,000 population, accounting for 1.25% of all ICU patients. Most patients were male (75%), Chinese (62%), had pneumonia (73%), and were admitted to a Medical ICU (56%). Management strategies varied across all ICUs. In-hospital mortality was 40% and median length of ICU stay was 7 days. CONCLUSION The incidence of ARDS in a developed S.E Asia country is comparable to reported rates in European studies.
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Affiliation(s)
| | - Zudin Puthucheary
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
- Centre for Human Health and Performance, University College London, London, United Kingdom
| | - Jason Phua
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | - Benjamin Ho
- Departments of Medicine and Anaesthesia, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jonathan Tan
- Departments of Medicine and Anaesthesia, Tan Tock Seng Hospital, Singapore, Singapore
| | - Siau Chuin
- Department of Medicine and Anaesthesia, Changi General Hospital, Singapore, Singapore
| | - Noelle Louise Lim
- Department of Medicine and Anaesthesia, Changi General Hospital, Singapore, Singapore
| | - Chai Rick Soh
- Department of Medicine and Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Chian Min Loo
- Department of Medicine and Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Addy Y. H. Tan
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | - Faheem Ahmed Khan
- Department of Critical Care, Ng Teng Fong General Hospital, Jurong Health, Singapore, Singapore
| | - Azman Johan
- Khoo Teck Puat Hospital, Yishun, Singapore, Singapore
| | - Aik Hau Tan
- Department of Medicine and Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Graeme MacLaren
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | - Juvel Taculod
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
| | | | - Tun Aung Han
- School of Nursing, Ngee Ann Polytechnic, Singapore, Singapore
| | - Matthew E. Cove
- Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
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Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT, Ablordeppey E, Keeperman J, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017; 70:406-418.e4. [PMID: 28259481 DOI: 10.1016/j.annemergmed.2017.01.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. METHODS This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions. RESULTS A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63). CONCLUSION Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.
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Affiliation(s)
- Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Ian T Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher Palmer
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Enyo Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jacob Keeperman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert J Stephens
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Angelina A Kolomiets
- School of Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Richard S Hotchkiss
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
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Peng JM, Qian CY, Yu XY, Zhao MY, Li SS, Ma XC, Kang Y, Zhou FC, He ZY, Qin TH, Yin YJ, Jiang L, Hu ZJ, Sun RH, Lin JD, Li T, Wu DW, An YZ, Ai YH, Zhou LH, Cao XY, Zhang XJ, Sun RQ, Chen EZ, Du B. Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study. Crit Care 2017; 21:12. [PMID: 28107822 PMCID: PMC5251343 DOI: 10.1186/s13054-017-1606-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/04/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Poor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists' chest radiograph interpretations for ARDS diagnosis. METHODS We conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force ("the panel") before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs. RESULTS Overall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 ± 14.8% before training vs. 55.3 ± 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 ± 0.406 vs. 0.461 ± 0.575, p = 0.792), Fleiss's kappa (0.133 ± 0.575 vs. 0.178 ± 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470). CONCLUSIONS The radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (registration number NCT01704066 ) on 6 October 2012.
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Affiliation(s)
- Jin-Min Peng
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730 People’s Republic of China
| | - Chuan-Yun Qian
- Department of Emergency Medicine, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Street, Kunming, 650032 People’s Republic of China
| | - Xiang-You Yu
- Department of Critical Care Medicine, First Affiliated Hospital, Xinjiang Medical University, 1 Liyushan Road, Urumqi, 830054 People’s Republic of China
| | - Ming-Yan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital, Harbin Medical University, 23 Youzheng Street, Harbin, 150001 People’s Republic of China
| | - Shu-Sheng Li
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, 1095 Jiefang Road, Wuhan, 430030 People’s Republic of China
| | - Xiao-Chun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Shenyang, 110001 People’s Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, 610041 People’s Republic of China
| | - Fa-Chun Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital, Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Chongqing, 400016 People’s Republic of China
| | - Zhen-Yang He
- Department of Critical Care Medicine, Hainan Provincial People’s Hospital, No. 19 Xiuhua Road, Haikou, 570311 People’s Republic of China
| | - Tie-He Qin
- Department of Critical Care Medicine, Guangdong General Hospital, 106 Zhongshan Er Road, Guangzhou, 510080 People’s Republic of China
| | - Yong-Jie Yin
- Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, 18 Ziqiang Street, Changchun, 130041 People’s Republic of China
| | - Li Jiang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, A20 Fuxingmenwai Street, Beijing, 100038 People’s Republic of China
| | - Zhen-Jie Hu
- Department of Critical Care Medicine, Hebei Medical University Fourth Hospital, 12 Jiankang Road, Shijiazhuang, 050011 People’s Republic of China
| | - Ren-Hua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, 158 Shangtang Road, Hangzhou, 310014 People’s Republic of China
| | - Jian-Dong Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005 People’s Republic of China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, 2 Chongwenmennei Street, Beijing, 100730 People’s Republic of China
| | - Da-Wei Wu
- Department of Critical Care Medicine, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012 People’s Republic of China
| | - You-Zhong An
- Department of Critical Care Medicine, Peking University People’s Hospital, 11 Xizhimen South Street, Beijing, 100044 People’s Republic of China
| | - Yu-Hang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
| | - Li-Hua Zhou
- Department of Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical College, 1 Tongdao North Street, Huhhot, 010050 People’s Republic of China
| | - Xiang-Yuan Cao
- Department of Critical Care Medicine, Affiliated Hospital of Ningxia Medical University, 804 Shengli South Street, Yinchuan, 750004 People’s Republic of China
| | - Xi-Jing Zhang
- Surgical ICU, Department of Anesthesia, Xijing Hospital, 127 Chang Le Xi Road, Xi’an, 710032 People’s Republic of China
| | - Rong-Qing Sun
- Surgical ICU, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052 Henan People’s Republic of China
| | - Er-Zhen Chen
- Ruijin Hospital, Shanghai Jiao Tong University, No. 197 Ruijin Er Road, Shanghai, 200025 People’s Republic of China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730 People’s Republic of China
| | - for the China Critical Care Clinical Trial Group (CCCCTG)
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730 People’s Republic of China
- Department of Emergency Medicine, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Street, Kunming, 650032 People’s Republic of China
- Department of Critical Care Medicine, First Affiliated Hospital, Xinjiang Medical University, 1 Liyushan Road, Urumqi, 830054 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital, Harbin Medical University, 23 Youzheng Street, Harbin, 150001 People’s Republic of China
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, 1095 Jiefang Road, Wuhan, 430030 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, 155 North Nanjing Street, Shenyang, 110001 People’s Republic of China
- Department of Critical Care Medicine, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, 610041 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital, Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Chongqing, 400016 People’s Republic of China
- Department of Critical Care Medicine, Hainan Provincial People’s Hospital, No. 19 Xiuhua Road, Haikou, 570311 People’s Republic of China
- Department of Critical Care Medicine, Guangdong General Hospital, 106 Zhongshan Er Road, Guangzhou, 510080 People’s Republic of China
- Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, 18 Ziqiang Street, Changchun, 130041 People’s Republic of China
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, A20 Fuxingmenwai Street, Beijing, 100038 People’s Republic of China
- Department of Critical Care Medicine, Hebei Medical University Fourth Hospital, 12 Jiankang Road, Shijiazhuang, 050011 People’s Republic of China
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, 158 Shangtang Road, Hangzhou, 310014 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005 People’s Republic of China
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, 2 Chongwenmennei Street, Beijing, 100730 People’s Republic of China
- Department of Critical Care Medicine, Qilu Hospital, Shandong University, 107 Wenhua Xi Road, Jinan, 250012 People’s Republic of China
- Department of Critical Care Medicine, Peking University People’s Hospital, 11 Xizhimen South Street, Beijing, 100044 People’s Republic of China
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008 People’s Republic of China
- Department of Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical College, 1 Tongdao North Street, Huhhot, 010050 People’s Republic of China
- Department of Critical Care Medicine, Affiliated Hospital of Ningxia Medical University, 804 Shengli South Street, Yinchuan, 750004 People’s Republic of China
- Surgical ICU, Department of Anesthesia, Xijing Hospital, 127 Chang Le Xi Road, Xi’an, 710032 People’s Republic of China
- Surgical ICU, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052 Henan People’s Republic of China
- Ruijin Hospital, Shanghai Jiao Tong University, No. 197 Ruijin Er Road, Shanghai, 200025 People’s Republic of China
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McNamee JJ, Gillies MA, Barrett NA, Agus AM, Beale R, Bentley A, Bodenham A, Brett SJ, Brodie D, Finney SJ, Gordon AJ, Griffiths M, Harrison D, Jackson C, McDowell C, McNally C, Perkins GD, Tunnicliffe W, Vuylsteke A, Walsh TS, Wise MP, Young D, McAuley DF. pRotective vEntilation with veno-venouS lung assisT in respiratory failure: A protocol for a multicentre randomised controlled trial of extracorporeal carbon dioxide removal in patients with acute hypoxaemic respiratory failure. J Intensive Care Soc 2016; 18:159-169. [PMID: 28979565 DOI: 10.1177/1751143716681035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
One of the few interventions to demonstrate improved outcomes for acute hypoxaemic respiratory failure is reducing tidal volumes when using mechanical ventilation, often termed lung protective ventilation. Veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R) can facilitate reducing tidal volumes. pRotective vEntilation with veno-venouS lung assisT (REST) is a randomised, allocation concealed, controlled, open, multicentre pragmatic trial to determine the clinical and cost-effectiveness of lower tidal volume mechanical ventilation facilitated by vv-ECCO2R in patients with acute hypoxaemic respiratory failure. Patients requiring intubation and mechanical ventilation for acute hypoxaemic respiratory failure will be randomly allocated to receive either vv-ECCO2R and lower tidal volume mechanical ventilation or standard care with stratification by recruitment centre. There is a need for a large randomised controlled trial to establish whether vv-ECCO2R in acute hypoxaemic respiratory failure can allow the use of a more protective lung ventilation strategy and is associated with improved patient outcomes.
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Affiliation(s)
- J J McNamee
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Chief Scientists Office NHS Research Scotland, Clydebank, UK
| | - N A Barrett
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.,King's Health Partners Academic Health Science Centre, London, UK
| | - A M Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - R Beale
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.,King's Health Partners Academic Health Science Centre, London, UK
| | - A Bentley
- Acute Intensive Care Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.,Centre for Respiratory Medicine & Allergy, University of Manchester, UK
| | - A Bodenham
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, UK
| | - S J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - D Brodie
- Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA
| | - S J Finney
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - A J Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - M Griffiths
- National Heart & Lung Institute, Imperial College, London, UK.,National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - D Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - C Jackson
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - C McDowell
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - C McNally
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - G D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Heart of England NHS Foundation Trust, Birmingham, UK
| | - W Tunnicliffe
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - A Vuylsteke
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - T S Walsh
- Anaesthetics, Critical Care and Pain Medicine, School of Clinical Sciences, College of Medicine, Edinburgh University, Edinburgh, UK
| | - M P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - D Young
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - D F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
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Abstract
Acute respiratory distress syndrome presents as hypoxia and bilateral pulmonary infiltrates on chest imaging in the absence of heart failure sufficient to account for this clinical state. Management is largely supportive, and is focused on protective mechanical ventilation and the avoidance of fluid overload. Patients with severe hypoxaemia can be managed with early short-term use of neuromuscular blockade, prone position ventilation, or extracorporeal membrane oxygenation. The use of inhaled nitric oxide is rarely indicated and both β2 agonists and late corticosteroids should be avoided. Mortality remains at approximately 30%.
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Affiliation(s)
- Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - Daniel F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland, UK.
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50
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Sjoding MW, Cooke CR, Iwashyna TJ, Hofer TP. Acute Respiratory Distress Syndrome Measurement Error. Potential Effect on Clinical Study Results. Ann Am Thorac Soc 2016; 13:1123-8. [PMID: 27159648 PMCID: PMC5015753 DOI: 10.1513/annalsats.201601-072oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/07/2016] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Identifying patients with acute respiratory distress syndrome (ARDS) is a recognized challenge. Experts often have only moderate agreement when applying the clinical definition of ARDS to patients. However, no study has fully examined the implications of low reliability measurement of ARDS on clinical studies. OBJECTIVES To investigate how the degree of variability in ARDS measurement commonly reported in clinical studies affects study power, the accuracy of treatment effect estimates, and the measured strength of risk factor associations. METHODS We examined the effect of ARDS measurement error in randomized clinical trials (RCTs) of ARDS-specific treatments and cohort studies using simulations. We varied the reliability of ARDS diagnosis, quantified as the interobserver reliability (κ-statistic) between two reviewers. In RCT simulations, patients identified as having ARDS were enrolled, and when measurement error was present, patients without ARDS could be enrolled. In cohort studies, risk factors as potential predictors were analyzed using reviewer-identified ARDS as the outcome variable. MEASUREMENTS AND MAIN RESULTS Lower reliability measurement of ARDS during patient enrollment in RCTs seriously degraded study power. Holding effect size constant, the sample size necessary to attain adequate statistical power increased by more than 50% as reliability declined, although the result was sensitive to ARDS prevalence. In a 1,400-patient clinical trial, the sample size necessary to maintain similar statistical power increased to over 1,900 when reliability declined from perfect to substantial (κ = 0.72). Lower reliability measurement diminished the apparent effectiveness of an ARDS-specific treatment from a 15.2% (95% confidence interval, 9.4-20.9%) absolute risk reduction in mortality to 10.9% (95% confidence interval, 4.7-16.2%) when reliability declined to moderate (κ = 0.51). In cohort studies, the effect on risk factor associations was similar. CONCLUSIONS ARDS measurement error can seriously degrade statistical power and effect size estimates of clinical studies. The reliability of ARDS measurement warrants careful attention in future ARDS clinical studies.
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Affiliation(s)
- Michael W. Sjoding
- Department of Internal Medicine and
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Colin R. Cooke
- Department of Internal Medicine and
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Theodore J. Iwashyna
- Department of Internal Medicine and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Social Research, Ann Arbor, Michigan; and
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Timothy P. Hofer
- Department of Internal Medicine and
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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