Chest
Original ResearchCritical Care MedicineARDS: A Clinicopathological Confrontation
Section snippets
Materials and Methods
The study was approved by the ethics committee of Erasme Hospital, which waived the need for informed consent in view of the observational nature of the study. We reviewed the clinical charts and postmortem pathologic results of all adult patients (> 18 years of age) who died with ARDS over a 3-year period (January 2002 to December 2004) in the 35 medico-surgical-bed ICU of Erasme University Hospital, in whom a postmortem examination had been conducted. ARDS was defined clinically according to
Results
From a total of 9,184 admissions to the ICU during the 3-year period, 376 patients (4.1%) met the ARDS criteria. Of these, 169 patients (45%) died, and a postmortem examination was performed in 69 of them (41%). Complete data could be retrieved for 64 patients, who thus represent the database for this study (Fig 1).
Table 1 lists the characteristics of the 64 patients. The mean (± SD) Pao2/Fio2 ratio measured at the time of ARDS diagnosis was 128 ± 36 mm Hg. ARDS was due to pulmonary causes
Discussion
ARDS is a syndrome associated with a number of different diagnoses. The question is whether it is useful to try and identify a precise histologic lesion for which we currently have no specific treatment, or is this merely an academic exercise?
Our study shows that only 50% of patients with ARDS diagnosed clinically using current criteria actually had DAD lesions. Only a few other studies have evaluated rates of DAD in patients with ARDS, and they have reported similar findings.13, 17, 18 In a
Conclusion
In our study of 64 autopsies of ARDS patients, only half the patients in whom ARDS had been clinically diagnosed had the typical pathologic DAD lesions. Invasive aspergillosis was present in eight patients. There were seven major missed diagnoses, including four cases of pulmonary invasive aspergillosis and one case of invasive tuberculosis in which open lung biopsy may have helped orient therapy.
References (34)
- et al.
Mortality rates for patients with acute lung injury/ARDS have decreased over time
Chest
(2008) - et al.
Nonventilatory treatments for acute lung injury and ARDS
Chest
(2007) Pulmonary pathology of acute respiratory distress syndrome
Clin Chest Med
(2000)- et al.
Development of a clinical definition for acute respiratory distress syndrome using the Delphi technique
J Crit Care
(2005) - et al.
The role of open-lung biopsy in ARDS
Chest
(2004) - et al.
Causes and timing of death in patients with ARDS
Chest
(2005) - et al.
Why do patients who have acute lung injury/acute respiratory distress syndrome die from multiple organ dysfunction syndrome? Implications for management
Clin Chest Med
(2006) - et al.
Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study
Intensive Care Med
(2004) - et al.
Epidemiology and outcome of acute respiratory failure in intensive care unit patients
Crit Care Med
(2003) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome
N Engl J Med
(2000)
The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination
Am J Respir Crit Care Med
Identifying patients with ARDS: time for a different approach
Intensive Care Med
The search for “objective” criteria of ARDS
Intensive Care Med
Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome
Intensive Care Med
Acute respiratory distress syndrome criteria in trauma patients: why the definitions do not work
J Trauma
Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings
Ann Intern Med
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Pathophysiology of the Acute Respiratory Distress Syndrome: Insights from Clinical Studies
2021, Critical Care ClinicsCitation Excerpt :Yet, given the nonspecificity of the Berlin definition and its predecessor, the AECC definition, it is likely that while DAD is being captured, so are many other pathologic morphologies, including those unrelated to ARDS. To that end, only approximately half the patients who meet the clinical criteria for ARDS have DAD on autopsy.17–21 Even in open biopsy studies, DAD was observed in the same proportion of patients.22–24
Risk factors associated with COVID-19-associated pulmonary aspergillosis in ICU patients: a French multicentric retrospective cohort
2021, Clinical Microbiology and InfectionCitation Excerpt :Although pulmonary invasive fungal disease is typically described in the immunocompromised host, invasive pulmonary aspergillosis (IPA) has been increasingly reported in critically ill patients, including patients without classical risk factors of immunosuppression [1]. In acute respiratory distress syndrome (ARDS) patients, ~12.5% of the patients had IPA as shown by random post-mortem histopathological examination of lung tissue [2]. Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has been increasingly reported [3–5].
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2019, The Lancet Respiratory MedicineCitation Excerpt :In 21 haematology patients, including 10 in whom the lung biopsies were obtained post-mortem, inflammatory and malignant infiltrates were the most common diagnoses.85 A retrospective autopsy study of 7 haemopoietic stem cell transplant recipients showed that fungal infections, potentially steroid-responsive lung involvement, and malignant infiltrates were underdiagnosed.96 Complications associated with lung biopsies occurred in about 10% of patients who were highly selected based on platelet count, performance status, and goals of care.
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None of the authors has any conflicts of interest to disclose.
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