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Original Research: CRITICAL CARE |

Decision Support Tool for Early Differential Diagnosis of Acute Lung Injury and Cardiogenic Pulmonary Edema in Medical Critically Ill PatientsAcute Lung Injury vs Cardiogenic Pulmonary Edema

Christopher N. Schmickl; Khurram Shahjehan, MD; Guangxi Li, MD; Rajanigandha Dhokarh, MD; Rahul Kashyap, MD; Christopher Janish; Anas Alsara, MD; Allan S. Jaffe, MD; Rolf D. Hubmayr, MD; Ognjen Gajic, MD; for the National Institutes of Health, National Heart, Lung, and Blood Institute ARDS Network
Author and Funding Information

From Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) (Messrs Schmickl and Janish and Drs Shahjehan, Li, Dhokarh, Kashyap, Alsara, and Gajic), Division of Pulmonary and Critical Care Medicine (Dr Hubmayr), and the Division of Cardiology (Dr Jaffe), Mayo Clinic, Rochester, MN; the University Witten-Herdecke (Mr Schmickl), Witten, Germany; the Pulmonary Division (Dr Li), Department of Guang’anmen Hospital, China Academy of Chinese Medical Science, Beijing, China; and the Department of Pulmonary and Critical Care Medicine (Dr Dhokarh), Lahey Clinic, Burlington, MA.

Correspondence to: Christopher Schmickl, Schnieglingerstrasse 225, 90427 Nuremberg, Germany; e-mail: cschmickl83@gmail.com


Mr Schmickl and Dr Shahjehan contributed equally to this study.

Funding/Support: This work was supported in part by Mayo Clinic Critical Care Research Committee and the National Library of Medicine [Grant RC1 LM10468].

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


© 2012 American College of Chest Physicians


Chest. 2012;141(1):43-50. doi:10.1378/chest.11-1496
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Background:  At the onset of acute hypoxic respiratory failure, critically ill patients with acute lung injury (ALI) may be difficult to distinguish from those with cardiogenic pulmonary edema (CPE). No single clinical parameter provides satisfying prediction. We hypothesized that a combination of those will facilitate early differential diagnosis.

Methods:  In a population-based retrospective development cohort, validated electronic surveillance identified critically ill adult patients with acute pulmonary edema. Recursive partitioning and logistic regression were used to develop a decision support tool based on routine clinical information to differentiate ALI from CPE. Performance of the score was validated in an independent cohort of referral patients. Blinded post hoc expert review served as gold standard.

Results:  Of 332 patients in a development cohort, expert reviewers (κ, 0.86) classified 156 as having ALI and 176 as having CPE. The validation cohort had 161 patients (ALI = 113, CPE = 48). The score was based on risk factors for ALI and CPE, age, alcohol abuse, chemotherapy, and peripheral oxygen saturation/Fio2 ratio. It demonstrated good discrimination (area under curve [AUC] = 0.81; 95% CI, 0.77-0.86) and calibration (Hosmer-Lemeshow [HL] P = .16). Similar performance was obtained in the validation cohort (AUC = 0.80; 95% CI, 0.72-0.88; HL P = .13).

Conclusions:  A simple decision support tool accurately classifies acute pulmonary edema, reserving advanced testing for a subset of patients in whom satisfying prediction cannot be made. This novel tool may facilitate early inclusion of patients with ALI and CPE into research studies as well as improve and rationalize clinical management and resource use.

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