Ferguson Niall D, Frutos-Vivar Fernando, Esteban Andrés, Fernández-Segoviano Pilar, Aramburu José Antonio, Nájera Laura, Stewart Thomas E
Interdepartmental Division of Critical Care Medicine and the Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
Crit Care Med. 2005 Oct;33(10):2228-34. doi: 10.1097/01.ccm.0000181529.08630.49.
To determine and compare the diagnostic accuracy of three clinical definitions of acute respiratory distress syndrome (ARDS): (1) the American-European consensus conference definition; (2) the lung injury score; and (3) a recently developed Delphi definition. A second objective was to determine the accuracy of clinical diagnoses of ARDS made in daily practice.
Independent comparison of autopsy findings with the daily status of clinical definitions, constructed with data abstracted retrospectively from medical records.
Tertiary intensive care unit.
One hundred thirty-eight patients from the period 1995 through 2001 who were autopsied after being mechanically ventilated.
Clinical ARDS diagnoses were determined daily without knowledge of autopsy results. Charts were reviewed for any mention of ARDS in the clinical notes. Autopsies were reviewed independently by two pathologists for the presence of diffuse alveolar damage. The sensitivity and specificity of the definitions were determined with use of diffuse alveolar damage at autopsy as the reference standard.
Diffuse alveolar damage at autopsy was documented in 42 of 138 cases (30.4%). Only 20 of these 42 patients (47.6%) had any mention of ARDS in their chart. Sensitivities and specificities (95% confidence intervals) were as follows: American-European definition, 0.83 (0.72-0.95), 0.51 (0.41-0.61); lung injury score, 0.74 (0.61-0.87), 0.77 (0.69-0.86); and Delphi definition, 0.69 (0.55-0.83), 0.82 (0.75-0.90). Specificity was significantly higher for both the lung injury score and Delphi definition than for the American-European definition (p < .001 for both), whereas comparisons of sensitivity, which was higher for the American-European definition, were not significantly different (p = .34 and p = .07, respectively).
Acute respiratory distress syndrome appears underrecognized by clinicians in patients who die with this syndrome. In this population, the specificities of existing clinical definitions vary considerably, which may be problematic for clinical trials.
确定并比较急性呼吸窘迫综合征（ARDS）三种临床定义的诊断准确性：（1）欧美共识会议定义；（2）肺损伤评分；（3）最近制定的德尔菲定义。第二个目的是确定日常实践中ARDS临床诊断的准确性。
将尸检结果与临床定义的日常情况进行独立比较，这些临床定义是根据从病历中回顾性提取的数据构建的。
三级重症监护病房。
1995年至2001年期间138例接受机械通气后进行尸检的患者。
在不知道尸检结果的情况下每天确定临床ARDS诊断。查阅病历中任何提及ARDS的临床记录。由两名病理学家独立检查尸检情况，以确定是否存在弥漫性肺泡损伤。以尸检时的弥漫性肺泡损伤作为参考标准，确定各定义的敏感性和特异性。
138例病例中有42例（30.4%）尸检记录有弥漫性肺泡损伤。这42例患者中只有20例（47.6%）病历中有任何关于ARDS的记录。敏感性和特异性（95%置信区间）如下：欧美定义，0.83（0.72 - 0.95），0.51（0.41 - 0.61）；肺损伤评分，0.74（0.61 - 0.87），0.77（0.69 - 0.86）；德尔菲定义，0.69（0.55 - 0.83），0.82（0.75 - 0.90）。肺损伤评分和德尔菲定义的特异性均显著高于欧美定义（两者p <.001），而敏感性方面，欧美定义较高，但比较结果无显著差异（分别为p = 0.34和p = 0.07）。
临床医生似乎未充分认识到死于该综合征患者中的急性呼吸窘迫综合征。在这一人群中，现有临床定义的特异性差异很大，这可能给临床试验带来问题。
