• Elie Azoulay, Virginie Lemiale, Bruno Mourvillier, Maite Garrouste-Orgeas, Carole Schwebel, Stéphane Ruckly, Laurent Argaud, Yves Cohen, Bertrand Souweine, Laurent Papazian, Jean Reignier, Guillaume Marcotte, Shidasp Siami, Hatem Kallel, Michael Darmon, Jean-François Timsit, and OUTCOMEREA Study Group.
• Medical Intensive Care Unit, AP-HP, Saint-Louis hospital, ECSTRA Team, Biostatistics and CLINICAL EPIDEMIOLOGY, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France. elie.azoulay@aphp.fr.
• Intensive Care Med. 2018 Jul 1; 44 (7): 1050-1060.

RationaleThe standard of care for patients with acute respiratory distress syndrome (ARDS) has been developed based on studies that usually excluded patients with major comorbidities.ObjectivesTo describe treatments and outcomes according to comorbidities in patients with ARDS admitted to 19 ICUs (1997-2014).MethodsPatients were grouped based on comorbidities. Determinants of day-28 mortality were identified by multivariable Cox analysis stratified on center.Measurements And Main ResultsAmong 4953 ARDS patients, 2545 (51.4%) had major comorbidities; the proportion with major comorbidities increased after 2008. Hematological malignancy was associated with severe ARDS and rescue therapies for refractory hypoxemia. COPD, HIV infection, and hematological malignancy were associated with a lower likelihood of invasive mechanical ventilation on the admission day. Admission-day SOFA score was higher in patients with major comorbidities, who more often received vasopressors, dialysis, or treatment-limitation decisions. Day-28 mortality was 33.7% overall, 27.2% in patients without major comorbidities, and 31.1% (COPD) to 56% (hematological malignancy) in patients with major comorbidities. By multivariable analysis, mortality was lower in patients with COPD and higher in those with chronic heart failure, solid tumors, or hematological malignancies. Mortality was independently associated with PaO2/FiO2 and PaCO2 on day 1, ARDS of pulmonary origin, worse SOFA score, and ICU-acquired events.ConclusionsHalf the patients with ARDS had major comorbidities, which were associated with severe ARDS, multiple organ dysfunction, and day-28 mortality. These findings do not support the exclusion of ARDS patients with severe comorbidities from randomized clinical trials. Trials in ARDS patients with whatever comorbidities are warranted.

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