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Original Research: Critical Care |

Clinical Predictors of Hospital Mortality Differ Between Direct and Indirect ARDS

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

FUNDING/SUPPORT: This work was supported by the National Institutes of Health [grants HL103836 (L. B. W.), HL126671 (J. A. B.), HL087738 (C. M. S.), and HL131621 (C. S. C.)], a Vanderbilt Faculty Research Scholars Award (C. M. S.), and a Jiangsu Government Scholarship for Overseas Studies (JS-2013-270 [L. L.]).

aDepartment of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People’s Republic of China

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

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

dDepartment of Biostatistics, Vanderbilt University Medical Center, Nashville, TN

eDepartments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA

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

CORRESPONDENCE TO: Ciara M. Shaver, MD, PhD, Vanderbilt University Medical Center, 1161 21st Ave S, Medical Center North, T-1218, Nashville, TN 37232


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(4):755-763. doi:10.1016/j.chest.2016.09.004
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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  This retrospective observational cohort study included 417 patients with ARDS. Each patient was classified as having direct (pneumonia or aspiration, n = 250) or indirect (nonpulmonary sepsis or pancreatitis, n = 167) ARDS.

Results  Patients with direct ARDS had higher lung injury scores (3.0 vs 2.8; P < .001), lower Simplified Acute Physiology Score II scores (51 vs 62; P < .001), lower Acute Physiology and Chronic Health Evaluation II scores (27 vs 30; P < .001), and fewer nonpulmonary organ failures (1 vs 2; P < .001) compared with patients with indirect ARDS. Hospital mortality was similar (28% vs 31%). In patients with direct ARDS, age (OR, 1.29 per 10 years; P = .01; test for interaction, P = .03), lung injury scores (OR, 2.29 per point; P = .001; test for interaction, P = .058), and number of nonpulmonary organ failures (OR, 1.67; P = .01) were independent risk factors for increased hospital mortality. Preexisting diabetes mellitus was an independent risk factor for reduced hospital mortality (OR, 0.47; P = .04; test for interaction, P = .02). In indirect ARDS, only the number of organ failures was an independent predictor of mortality (OR, 2.08; P < .001).

Conclusions  Despite lower severity of illness and fewer organ failures, patients with direct ARDS had mortality rates similar 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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