Chest
Volume 135, Issue 4, April 2009, Pages 944-949
Journal home page for Chest

Original Research
Critical Care Medicine
ARDS: A Clinicopathological Confrontation

https://doi.org/10.1378/chest.08-1741Get rights and content

Background

The heterogeneity of populations meeting criteria for ARDS may explain in part why no specific treatment has yet been shown to decrease mortality. To define the pathologic alterations associated with the syndrome, particularly the typical pattern of diffuse alveolar damage (DAD), and to evaluate whether etiologies or precipitating factors were missed, we evaluated patients who died with a clinical diagnosis of ARDS and who had a postmortem examination.

Methods

We conducted a 3-year (2002 to 2004) review of all patients with ARDS (using the American-European Consensus Conference criteria) who died in our ICU and had a postmortem examination. Discrepancies between antemortem and postmortem diagnoses were classified as major and minor using the Goldman classification.

Results

Of 9,184 hospital admissions, 376 patients had a clinical diagnosis of ARDS. Of these, 169 died; 69 had a postmortem examination, and 64 of these had complete data for analysis. The main cause of death was multiple organ failure (27 of 64 patients). Postmortem examination revealed DAD in 32 patients (50%), pneumonia without DAD in 16 patients (25%), and invasive pulmonary aspergillosis in 8 patients (12.5%). Major unexpected findings were found in 15 patients (23%): 7 Goldman class I (including 4 cases of invasive pulmonary aspergillosis and 1 of disseminated tuberculosis) and 8 Goldman class II.

Conclusions

In this study, ARDS remains a heterogeneous syndrome because only half of patients with ARDS had typical DAD. Open lung biopsy, if performed, might have led to appropriate therapy and potentially better outcome in five of the patients.

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)

  • Adhikari N, Burns KE, Meade MO. Pharmacologic therapies for adults with acute lung injury and acute respiratory...
  • GR Bernard et al.

    The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination

    Am J Respir Crit Care Med

    (1994)
  • DP Schuster

    Identifying patients with ARDS: time for a different approach

    Intensive Care Med

    (1997)
  • DP Schuster

    The search for “objective” criteria of ARDS

    Intensive Care Med

    (2007)
  • J Villar et al.

    Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome

    Intensive Care Med

    (1999)
  • RA Dicker et al.

    Acute respiratory distress syndrome criteria in trauma patients: why the definitions do not work

    J Trauma

    (2004)
  • A Esteban et al.

    Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings

    Ann Intern Med

    (2004)
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    None of the authors has any conflicts of interest to disclose.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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