Respiratory Care Services, Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
Critical Care Division, Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
Respir Care. 2019 May;64(5):493-501. doi: 10.4187/respcare.06165. Epub 2019 Apr 16.
The Berlin definition of ARDS does not account for nonpulmonary organ failure, which is a major determinant of outcome. We examined whether an increasing severity of hypoxemia across the Berlin definition classifications also corresponded with evidence of multiple organ dysfunction on the day of ARDS onset. We also examined the representation of major etiologies for ARDS across the Berlin definition classifications.
This single-center, retrospective study examined 15 years of data from a quality assurance program that monitored the use of lung-protective ventilation in ARDS. We analyzed 1,747 subjects without chronic kidney disease or severe chronic liver disease at ARDS onset. The most abnormal laboratory values at ARDS onset were analyzed as cutoff values to assess organ dysfunction. Data were analyzed by using non-parametric analysis of variance (Kruskall-Wallis test) and the Dunn post test. Categorical variables were compared by using the Fisher exact test. Alpha was set at 0.05. Factors independently associated with mortality were assessed by multivariate logistic regression modeling.
Nonpulmonary organ dysfunction was present in at least 1 system at ARDS onset that increased with severity: 80% (mild), 83% (moderate), and 90% (severe). ARDS etiologies varied as severity increased: trauma-associated lung injury steadily decreased, whereas lung injury associated with aspiration and pneumonia steadily increased. Hospital mortality also increased significantly with the Berlin definition classifications: mild (22%), moderate (30%), and severe (47%). Multivariate logistic regression modeling revealed that the Berlin definition of severe ARDS was independently associated with mortality, as were cutoff values for renal and hepatic function as well as acidemia. Normal hematologic function and the absence of standard exclusion criteria used for therapeutic clinical trials in ARDS were protective.
Nonpulmonary organ dysfunction was present at ARDS onset in most subjects and was more pronounced as ARDS severity increased. The Berlin definition classification of ARDS provided an elegant scheme for studying the syndrome because it coincided with increasing multiple organ dysfunction.
柏林定义的 ARDS 并未考虑非肺部器官衰竭，而后者是决定预后的主要因素。我们研究了在柏林定义分类中，随着低氧血症严重程度的增加，是否也与 ARDS 发病当天的多个器官功能障碍的证据相对应。我们还研究了在柏林定义分类中 ARDS 的主要病因的表现。
这项单中心回顾性研究检查了 15 年来质量保证计划监测 ARDS 中肺保护性通气使用情况的数据。我们分析了 1747 名在 ARDS 发病时没有慢性肾病或严重慢性肝病的患者。在 ARDS 发病时，最异常的实验室值被分析为临界值，以评估器官功能障碍。使用非参数方差分析（Kruskal-Wallis 检验）和 Dunn 后检验进行数据分析。使用 Fisher 精确检验比较分类变量。设α值为 0.05。使用多元逻辑回归模型评估与死亡率独立相关的因素。
至少有 1 个系统在 ARDS 发病时存在非肺部器官功能障碍，且随着严重程度的增加而增加：轻度（80%）、中度（83%）和重度（90%）。随着严重程度的增加，ARDS 的病因也有所不同：与创伤相关的肺损伤逐渐减少，而与吸入和肺炎相关的肺损伤则逐渐增加。医院死亡率也随着柏林定义分类显著增加：轻度（22%）、中度（30%）和重度（47%）。多元逻辑回归模型显示，柏林定义的严重 ARDS 与死亡率独立相关，肾功能和肝功能以及酸中毒的临界值也是如此。正常的血液功能和 ARDS 治疗性临床试验中使用的标准排除标准的缺失是保护性的。
在大多数患者中，在 ARDS 发病时已经存在非肺部器官功能障碍，并且随着 ARDS 严重程度的增加而更加明显。柏林定义的 ARDS 分类为研究该综合征提供了一个优雅的方案，因为它与多个器官功能障碍的增加相对应。
