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Original Research: CRITICAL CARE MEDICINE |

Identification of Early Acute Lung Injury at Initial Evaluation in an Acute Care Setting Prior to the Onset of Respiratory Failure

Joseph E. Levitt, MD, MS; Harmeet Bedi, MD; Carolyn S. Calfee, MD; Michael K. Gould, MD, MS, FCCP; Michael A. Matthay, MD
Author and Funding Information

*From the Division of Pulmonary/Critical Care (Drs. Levitt and Bedi), Stanford University, Stanford, CA; Departments of Medicine and Anesthesia (Drs. Calfee and Matthay), Cardiovascular Research Institute, University of California, San Francisco; and VA Palo Alto Health Care System (Dr. Gould), Palo Alto, CA.

Correspondence to: Joseph E. Levitt, MD, MS, Stanford University, 300 Pasteur Dr, MC 5236, Stanford, CA 94305; e-mail: jlevitt@stanford.edu


This research was supported by NHLBI HL090833 and the Flight Attendant Medical Research Institute (Dr. Calfee), NHLBI HL51856 and NHLBI 74005 (Dr. Matthay), and resources and the use of facilities at the VA Palo Alto Health Care System (Dr. Gould).

The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(4):936-943. doi:10.1378/chest.08-2346
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Background:  Despite being a focus of intensive investigation, acute lung injury (ALI) remains a major cause of morbidity and mortality. However, the current consensus definition impedes identification of patients with ALI before they require mechanical ventilation. To establish a definition of early ALI (EALI), we carried out a prospective cohort study to identify clinical predictors of progression to ALI.

Methods:  Potential cases of EALI were identified by daily screening of chest radiographs (CXRs) for all adult emergency department and new medicine service admissions at Stanford University Hospital.

Results:  Of 1,935 screened patients with abnormal CXRs, we enrolled 100 patients admitted with bilateral opacities present < 7 days and not due exclusively to left atrial hypertension. A total of 33 of these 100 patients progressed to ALI requiring mechanical ventilation during their hospitalization. Progression to ALI was associated with immunosuppression, the modified Rapid Emergency Medicine Score, airspace opacities beyond the bases, systemic inflammatory response syndrome, and the initial oxygen requirement (> 2 L/min). On multivariate analysis, only an initial oxygen requirement > 2 L/min predicted progression to ALI (odds ratio, 8.1; 95% confidence interval, 2.7 to 24.5). A clinical diagnosis of EALI, defined by hospital admission with bilateral opacities on CXR not exclusively due to left atrial hypertension and an initial oxygen requirement of > 2 L/min, was 73% sensitive and 79% specific for progression to ALI.

Conclusions:  A new clinical definition of EALI may have value in identifying patients with ALI early in their disease course.

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