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Prevalence of ARDS
Only a few studies have reported the
prevalence of ARDS in general intensive
care unit (ICU) populations. From the
large Acute Physiology and Chronic
Health Evaluation (APACHE) III database, Knaus et al. (2) reported that only
2.4% (423 of 17,440) of all ICU admissions met the diagnosis of ARDS. However, the diagnosis of ARDS was defined
retrospectively on the basis of the admission and International Classification of
Disease, 9th revision (ICD-9), discharge
and not on respiratory variables, so this
prevalence is probably an underestimation.
Two French studies reported that of
all ICU admissions, only ~7% met the
ARDS diagnosis criteria; in a single medical ICU, Monchi et al. (3) reported that
7.4% (259 of 3,511) of patients met the
ARDS criteria, and in a multicenter study
of primarily medical ICU patients, Roupie
et al. (4) reported a prevalence of 6.9%
(67 of 976). A recent multicenter Australian study (5) reported that 7.5% (148 of
1,977) of a mixed ICU population met the
ARDS criteria. A European study (ALIVE)
(6) involving 78 ICUs from nine countries, in which all patients (n 5,457)
were admitted to one of the participating
units for at least 4 hrs during a 2-month
study period, noted that 7.4% had, or
developed, ALI/ARDS (2.8% ALI and 5.3%
Causes of Death
Most studies have indicated that nonsurvivors of ARDS usually die of nonresCrit Care Med 2003 Vol. 31, No. 4 (Suppl.)
Table 1. Reported mortality from acute respiratory distress syndrome in general intensive care unit
populations
Authors (Reference No.)
Year
No. of Patients
Mortality, %
1995
1995
1997
1997
1998
1998
1998
1998
1998
1998
1999
1999
1999
1999
2000
2000
2000
2000
2001
2001
2002
2002
2002
2002
179
123
129
256
81
56
259
58
725
60
221
84
59
61
95
134
429
79
111
152
231
148
179
73
62
58
52
54
58
61
65
38
40
47
41
20
37
60
44
58
40
59
52
48
52
34
42
52
ventricular dysfunction (3) and the presence of acute renal failure (22).
It is quite remarkable that the degree
of hypoxemia does not seem to be an
important prognostic factor. Luhr et al.
(10) reported that the 90-day mortality
was 41% for ARF without ALI, 42% for
ALI not fulfilling ARDS criteria, and 41%
for ARDS. In a subsequent study (21),
these investigators emphasized again that
the degree of hypoxemia was unimportant in terms of predicting mortality.
Likewise, Valta et al. (23) reported that
the PaO2/FIO2 ratio at the onset of ARDS
averaged 114 mm Hg in survivors and
109 mm Hg in nonsurvivors. Figure 1
illustrates the factors that can affect outcome after the initial insult responsible
for the development of ALI.
Figure 1. Schematic representation of the principal factors determining a poor outcome over
time, including the severity of the primary insult,
the host response (e.g., mediator release, immunosuppression), the effects of therapy (including
the potentially harmful effect of mechanical ventilation), and possible complications (e.g., nosocomial infections, thromboembolism, gastrointestinal bleeding).
he relatively high
mortality rates of
acute lung injury/
Conclusions
Figure 2. Schematic representation of possible time courses of organ dysfunction over time illustrating
the point that all nonsurvivors are likely to develop multiple organ failure before death. Hence, it may
be more informative to evaluate the time course rather than the maximum degree of organ dysfunction in survivors and nonsurvivors.
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focused on the time course of organ dysfunction. This could allow the development of good studies that evaluate the
effects of new interventions on both mortality and morbidity.
REFERENCES
1. Bernard GR, Artigas A, Brigham KL, et al:
The American-European Consensus Conference on ARDS: Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149:
818 824
2. Knaus WA, Sun X, Hakim RB, et al: Evaluation of definitions for adult respiratory distress syndrome. Am J Respir Crit Care Med
1994; 150:311317
3. Monchi M, Bellenfant F, Cariou A, et al: Early
predictive factors of survival in the acute
respiratory distress syndrome. Am J Respir
Crit Care Med 1998; 158:1076 1081
4. Roupie E, Lepage E, Wysocki M, et al: Prevalence, etiologies and outcome of the acute
respiratory distress syndrome among hypoxemic ventilated patients. Intensive Care Med
1999; 25:920 929
5. Bersten AD, Edibam C, Hunt T, et al: Incidence and mortality of acute lung injury and
the acute respiratory distress syndrome in
three Australian States. Am J Respir Crit
Care Med 2002; 165:443 448
6. Brun-Buisson C, Minelli C, Brazzi L, et al:
The European Survey of acute lung injury
and ARDS: Preliminary results of the ALIVE
study. Abstr. Intensive Care Med 2000;
26(Suppl 3):617
7. Minelli C, Brun-Buisson C, Brazzi L, et al:
Variability between countries in the occurrence of ALI and ARDS: Preliminary results
of the ALIVE European Study. Abstr. Intensive Care Med 2000; 26(Suppl 3):329
8. Trouillet JL, Chastre J, Vuagnat A, et al:
Ventilator-associated pneumonia caused by
potentially drug-resistant bacteria. Am J
Respir Crit Care Med 1998; 157:531539
9. Markowicz P, Wolff M, Djedaini K, et al:
Multicenter prospective study of ventilatorassociated pneumonia during acute respiratory distress syndrome: Incidence, prognosis,
and risk factors. ARDS Study Group. Am J
Respir Crit Care Med 2000; 161:19421948
10. Luhr OR, Antonsen K, Karlsson M, et al:
Incidence and mortality after acute respiratory failure and acute respiratory distress
syndrome in Sweden, Denmark, and Iceland:
The ARF Study Group. Am J Respir Crit Care
Med 1999; 159:1849 1861
11. Esteban A, Anzueto A, Frutos F, et al: Characteristics and outcomes in adult patients
receiving mechanical ventilation: A 28-day
international study. JAMA 2002; 287:
345355
12. Goh AY, Chan PW, Lum LC, et al: Incidence
of acute respiratory distress syndrome: A
comparison of two definitions. Arch Dis
Child 1998; 79:256 259
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