Acute respiratory distress syndrome in patients with and without diffuse alveolar damage: an autopsy study

Objective To demonstrate that among patients with acute respiratory distress syndrome (ARDS), the presence of diffuse alveolar damage (DAD) at histological examination, as compared to its absence, defines a specific subphenotype. Methods We studied 149 patients who died in our ICU with the clinical...

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Published in:	Intensive care medicine 2015-11, Vol.41 (11), p.1921-1930
Main Authors:	Lorente, José A., Cardinal-Fernández, Pablo, Muñoz, Diego, Frutos-Vivar, Fernando, Thille, Arnaud W., Jaramillo, Carlos, Ballén-Barragán, Aida, Rodríguez, José M., Peñuelas, Oscar, Ortiz, Guillermo, Blanco, José, Pinheiro, Bruno Valle, Nin, Nicolás, del Carmen Marin, María, Esteban, Andrés, Thompson, Taylor B.
Format:	Article
Language:	eng
Subjects:	Acute respiratory distress syndrome Analysis Anesthesiology Autopsy Brazil Care and treatment Colombia Critical Care Medicine Emergency Medicine Humans Intensive Medical research Medicine Medicine & Public Health Medicine, Experimental Multicenter Studies as Topic Multivariate Analysis Original Pain Medicine Pediatrics Phenotype Pneumology/Respiratory System Pulmonary Alveoli - pathology Respiratory distress syndrome Respiratory Distress Syndrome, Adult - classification Respiratory Distress Syndrome, Adult - pathology Retrospective Studies
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Summary:	Objective To demonstrate that among patients with acute respiratory distress syndrome (ARDS), the presence of diffuse alveolar damage (DAD) at histological examination, as compared to its absence, defines a specific subphenotype. Methods We studied 149 patients who died in our ICU with the clinical diagnosis of ARDS according to the Berlin Definition (BD) and who had autopsy examination. We compared the change over time of different clinical variables in patients with ( n = 49) and without ( n = 100) DAD. A predictive model for the presence of DAD was developed and validated in an independent cohort of 57 patients with ARDS and postmortem examination (21 of them with DAD). Results Patients with DAD, as compared to patients without DAD, had a lower PaO 2 /FiO 2 ratio and dynamic respiratory system compliance, and a higher SOFA score and INR, and were more likely to die of hypoxemia and less likely to die of shock. In multivariate analysis, variables associated with DAD [odds ratio, 95 % confidence interval (CI)] were PaO 2 /FiO 2 ratio [0.988 (0.981–0.995)], dynamic respiratory system compliance [0.937 (0.892–0.984)] and age [0.972 (0.946–0.999)]. Areas under the ROC curve (95 % CI) for the classification of DAD using the regression model or the BD were, respectively, 0.74 (0.65–0.82) and 0.64 (0.55–0.72) ( p = 0.03). In the validation cohort, the areas under the ROC curve for the diagnosis of DAD were 0.73 (0.56–0.90) and 0.67 (0.54–0.81) for the regression model and the BD, respectively. Conclusions The presence of DAD appears to define a specific subphenotype in patients with ARDS. Targeting patients with DAD within the population of patients with the clinical diagnosis of ARDS might be appropriate to find effective therapies for this condition.
ISSN:	0342-4642 1432-1238