• Tài Pham, Ary Serpa Neto, Paolo Pelosi, John Gerard Laffey, Candelaria De Haro, Jose Angel Lorente, Giacomo Bellani, Eddy Fan, Laurent Jean Brochard, Antonio Pesenti, Marcus Josephus Schultz, Antonio Artigas, and LUNG SAFE Investigators* and the European Society of Intensive Care Medicine Trials Group.
• From the Interdepartmental Division of Critical Care Medicine (T.P., J.G.L., E.F., L.J.B.) Department of Anesthesia (J.G.L.) Institute of Health Policy, Management and Evaluation (E.F.), University of Toronto, Toronto, Canada Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute (T.P., J.G.L., L.J.B.) Department of Anesthesia (J.G.L.), St. Michael's Hospital, Toronto, Canada Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.S.N.) Department of Intensive Care (A.S.N., M.J.S.) Laboratory of Experimental Intensive Care and Anesthesiology (M.J.S.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands Department of Clinical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy (P.P.) San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology, Genoa, Italy (P.P.) Department of Anaesthesia, School of Medicine, and Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland (J.G.L.) Critical Care Area, Parc Tauli Hospital University, Autonomous University of Barcelona, Barcelona, Spain (C.D.H.) Respiratory Diseases Network Biomedical Investigation Center, Barcelona, Spain (C.D.H., J.A.L., A.A.) Critical Care Department, University Hospital of Getafe, Madrid, Spain (J.A.L.) European University, Madrid, Spain (J.A.L.) School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy (G.B.) Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy (G.B.) Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada (E.F.) Department of Anesthesia, Critical Care and Emergency Medicine, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy (A.P.) Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy (A.P.) Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand (M.J.S.) Critical Care Department, Parc Tauli Health Corporation University, Autonomous University of Barcelona, Sabadell and Intensive Care Department, University Hospitals Sagrado Corazon-General de Cataluña, Quiron Salut, Barcelona-Sant Cugat del Valles, Spain (A.A.).
• Anesthesiology. 2019 Feb 1; 130 (2): 263-283.

BackgroundPatients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population.MethodsThis study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: "worsening" if moderate or severe acute respiratory distress syndrome criteria were met, "persisting" if mild acute respiratory distress syndrome criteria were the most severe category, and "improving" if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2.ResultsAmong 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in-hospital mortality was 30% (172 of 576; specifically 10% [10 of 101], 30% [63 of 210], and 37% [99 of 265] for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively), and the median (interquartile range) duration of mechanical ventilation was 7 (4, 14) days (specifically 3 [2, 5], 7 [4, 14], and 11 [6, 18] days for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively). Admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening.ConclusionsMost patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.

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