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Original Research |

Clinical predictors of hospital mortality differ between direct and indirect acute respiratory distress syndrome

Liang Luo, MD; Ciara M. Shaver, MD, PhD; Zhiguo Zhao, PhD; Tatsuki Koyama, PhD; Carolyn S. Calfee, MD; Julie A. Bastarache, MD; Lorraine B. Ware, MD
Author and Funding Information

Conflicts of Interest: CSC has served on the medical advisory boards for Glaxo Smith Kline and Boehringer Ingelheim. All remaining authors have no conflicts of interest to disclose.

Funding: This work was supported by the National Institutes of Health grants HL103836 (LBW), HL126671 (JAB), HL087738 (CMS), HL131621 (CSC), a Vanderbilt Faculty Research Scholars Award (CMS), and a Jiangsu Government Scholarship for Overseas Studies JS-2013-270 (LL).

1Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China

2Department of Critical Care Medicine, Wuxi No’2 People’s Hospital, Wuxi, China

3Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN

4Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN

5Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA

6Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN

Corresponding Author: Ciara M. Shaver, MD, PhD, 1161 21st Avenue South, Medical Center North, T-1218, Nashville, TN 37232.


Copyright 2016, . All Rights Reserved.


Chest. 2016. doi:10.1016/j.chest.2016.09.004
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Abstract

Background  Direct (pulmonary) and indirect (extrapulmonary) ARDS are distinct syndromes with important pathophysiologic differences. The goal of this study was to determine whether clinical characteristics and predictors of mortality differ between direct or indirect ARDS.

Methods  A retrospective observational cohort study of 417 ARDS patients. Each patient was classified as having direct (pneumonia or aspiration, n=250) or indirect ARDS (non-pulmonary sepsis or pancreatitis, n=167).

Results  Patients with direct ARDS had higher lung injury scores (LIS, 3.0 vs. 2.8, p<0.001), lower SAPS II scores (51 vs. 62, p<0.001), lower APACHE II scores (27 vs. 30, p<0.001), and fewer non-pulmonary organ failures (1 vs. 2, p<0.001) compared to patients with indirect ARDS. Hospital mortality was similar (28 vs. 31%). In patients with direct ARDS, age (OR 1.29 per 10 yrs, p=0.01, p for interaction=0.03), LIS (OR 2.29 per point, p=0.001, p for interaction=0.058), and number of non-pulmonary organ failures (OR 1.67, p=0.01) were independent risk factors for increased hospital mortality, while pre-existing DM was an independent risk factor for reduced hospital mortality (OR 0.47, p=0.04, p for interaction=0.02). In indirect ARDS, only number of organ failures was an independent predictor of mortality (OR 2.08, p<0.001).

Conclusions  Despite lower severity of illness and fewer organ failures, patients with direct ARDS had similar mortality to patients with indirect ARDS. Factors previously associated with mortality during ARDS were only associated with mortality in direct ARDS. These findings suggest that direct and indirect ARDS have distinct features that may differentially affect risk prediction and clinical outcomes.


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