Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan.
Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan.
Ther Adv Respir Dis. 2020 Jan-Dec;14:1753466620936877. doi: 10.1177/1753466620936877.
Disease severity may change in the first week after acute respiratory distress syndrome (ARDS) onset. The aim of this study was to evaluate whether the reclassification of disease severity after 48 h (i.e. day 3) of ARDS onset could help in predicting mortality and determine factors associated with ARDS persistence and mortality.
We performed a secondary analysis of a 3-year prospective, observational cohort study of ARDS in a tertiary care referral center. Disease severity was reclassified after 48 h of enrollment, and cases that still fulfilled the Berlin criteria were regarded as nonresolving ARDS.
A total of 1034 ARDS patients were analyzed. Overall hospital mortality was 57.7% (56.7%, 57.5%, and 58.6% for patients with initial mild, moderate, and severe ARDS, respectively, = 0.189). On day 3 reclassification, the hospital mortality rates were as follows: resolved (42.1%), mild (47.9%), moderate (62.4%), and severe ARDS (76.1%) (< 0.001). Patients with improving severity on day 3 had lower mortality (48.8%), whereas patients with the same or worsening severity on day 3 had higher mortality (62.7% and 76.3%, respectively). Patients who were older, had lower PaO/FiO, or higher positive end-expiratory pressure on day 1 were significantly associated with nonresolving ARDS on day 3. A Cox regression model with ARDS severity as a time-dependent covariate and competing risk analysis demonstrated that ARDS severity was independently associated with hospital mortality, and nonresolving ARDS had significantly increased hazard of death than resolved ARDS (< 0.0001). Cumulative mortality curve for ARDS severity comparisons demonstrated significantly different (overall comparison, < 0.001).
Reclassification of disease severity after 48 h of ARDS onset could help to divide patients into subgroups with greater separation in terms of mortality.
急性呼吸窘迫综合征（ARDS）发作后第一周疾病严重程度可能发生变化。本研究旨在评估 ARDS 发作后 48 小时（即第 3 天）重新分类疾病严重程度是否有助于预测死亡率，并确定与 ARDS 持续存在和死亡率相关的因素。
我们对一家三级转诊中心进行的为期 3 年的前瞻性、观察性 ARDS 队列研究进行了二次分析。在入组后 48 小时重新分类疾病严重程度，仍符合柏林标准的病例被视为非缓解性 ARDS。
共分析了 1034 例 ARDS 患者。总体住院死亡率为 57.7%（初始轻度、中度和重度 ARDS 患者分别为 56.7%、57.5%和 58.6%，=0.189）。在第 3 天重新分类时，住院死亡率如下：缓解（42.1%）、轻度（47.9%）、中度（62.4%）和重度 ARDS（76.1%）（<0.001）。第 3 天严重程度改善的患者死亡率较低（48.8%），而第 3 天严重程度相同或恶化的患者死亡率较高（分别为 62.7%和 76.3%）。第 1 天年龄较大、PaO/FiO 较低或呼气末正压较高的患者，第 3 天非缓解性 ARDS 的发生率显著升高。以 ARDS 严重程度为时间依赖性协变量的 Cox 回归模型和竞争风险分析表明，ARDS 严重程度与住院死亡率独立相关，非缓解性 ARDS 的死亡风险显著高于缓解性 ARDS（<0.0001）。ARDS 严重程度比较的累积死亡率曲线表明，死亡率存在显著差异（总体比较，<0.001）。
ARDS 发作后 48 小时重新分类疾病严重程度可帮助将患者分为死亡率差异更大的亚组。
