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Original Research: CRITICAL CARE MEDICINE |

An Alternative Method of Acute Lung Injury Classification for Use in Observational Studies

Chirag V. Shah, MD; Paul N. Lanken, MD, FCCP; A. Russell Localio, PhD; Robert Gallop, PhD; Scarlett Bellamy, ScD; Shwu-Fan Ma, PhD; Carlos Flores, PhD; Jeremy M. Kahn, MD; Barbara Finkel, MSN; Barry D. Fuchs, MD, FCCP; Joe G. N. Garcia, MD; Jason D. Christie, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Allergy, and Critical Care Medicine (Drs Shah, Lanken, Kahn, Fuchs, and Christie and Ms Finkel), Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; Centers for Clinical Epidemiology and Biostatistics (Drs Shah, Localio, Bellamy, Kahn, and Christie), University of Pennsylvania School of Medicine, Philadelphia, PA; Mathematics, Applied Statistics Program (Dr Gallop), West Chester University, West Chester, PA; Section of Pulmonary and Critical Care Medicine (Drs Ma and Garcia), Department of Medicine, University of Chicago School of Medicine, Chicago, IL; Unidad de Investigacion (Dr Flores), Hospital Universitario NS de Candelaria, Tenerife, Spain; and CIBER de Enfermedades Respiratorias (Dr Flores), Instituto de Salud Carlos III, Madrid, Spain.

Correspondence to: Jason D. Christie, MD, FCCP, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Blockley Hall, Rm 719, 423 Guardian Dr, Philadelphia, PA; e-mail: jchristi@mail.med.upenn.edu


Funding/Support: This work was supported by the National Institutes of Health [Grants P50HL60290, HL079063, T32 HL07891] and EMER07/001.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(5):1054-1061. doi:10.1378/chest.09-2697
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Background:  In observational studies using acute lung injury (ALI) as an outcome, a spectrum of lung injury and difficult-to-interpret chest radiographs (CXRs) may hamper efforts to uncover risk factor associations. We assessed the impact of excluding patients with difficult-to-classify or equivocal ALI diagnosis on clinical and genetic risk factor associations for ALI after trauma.

Methods:  This study was of a prospective cohort of 280 critically ill trauma patients. The primary outcome was the development of ALI. Patients were classified into one of three groups: (1) definite ALI (patients who fulfilled the American-European Consensus Conference [AECC] criteria for ALI), (2)equivocal ALI (patients who had difficult-to-interpret CXRs), and (3) definite non-ALI. We compared clinical and genetic ALI risk factor associations between two classification schemes: AECC classification (definite ALI vs rest) and alternative classification (definite ALI vs definite non-ALI, excluding equivocal ALI).

Results:  Ninety-three (35%) patients were classified as definite ALI, 67 (25%) as equivocal, and 104 (39%) as definite non-ALI. Estimates of clinical and genetic ALI risk factor associations were farther from the null using the alternative classification. In a multivariable risk factor model, the C statistic of the alternative classification was significantly higher than that derived from the AECC classification (0.82 vs 0.74; P < .01).

Conclusions:  The ability to detect ALI risk factors may be improved by excluding patients with equivocal or difficult-to-classify ALI. Such analyses may provide improved ability to detect clinical and genetic risk factor associations in future epidemiologic studies of ALI.

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