Persistent severe acute respiratory distress syndrome for the prognostic enrichment of trials
Journal
PLoS ONE
Journal Volume
15
Journal Issue
1
Date Issued
2020
Author(s)
Abstract
Background Acute respiratory distress syndrome (ARDS) is heterogeneous. As an indication of the heterogeneity of ARDS, there are patients whose syndrome improves rapidly (i.e., within 24 hours), others whose hypoxemia improves gradually and still others whose severe hypoxemia persists for several days. The latter group of patients with persistent severe ARDS poses challenges to clinicians. We attempted to assess the baseline characteristics and outcomes of persistent severe ARDS and to identify which variables are useful to predict it. Methods A secondary analysis of patient-level data from the ALTA, EDEN and SAILS ARDSNet clinical trials was conducted. We defined persistent severe ARDS as a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2:FiO2) of equal to or less than 100 mmHg on the second study day following enrollment. Regularized logistic regression with an L1 penalty [Least Absolute Shrinkage and Selection Operator (LASSO)] techniques were used to identify predictive variables of persistent severe ARDS. Results Of the 1531 individuals with ARDS alive on the second study day after enrollment, 232 (15%) had persistent severe ARDS. Of the latter, 100 (43%) individuals had mild or moderate hypoxemia at baseline. Usage of vasopressors was greater [144/232 (62%) versus 623/ 1299 (48%); p<0.001] and baseline severity of illness was higher in patients with versus without persistent severe ARDS. Mortality at 60 days [95/232 (41%) versus 233/1299 (18%); p<0.001] was higher, and ventilator-free (p<0.001), intensive care unit-free [0 (0–14) versus 19 (7–23); p<0.001] and non-pulmonary organ failure-free [3 (0–21) versus 20 (1–26); p<0.001] days were fewer in patients with versus without persistent severe ARDS. PaO2:FiO2, FiO2, hepatic failure and positive end-expiratory pressure at enrollment were useful predictive variables. Conclusions Patients with persistent severe ARDS have distinct baseline characteristics and poor prognosis. Identifying such patients at enrollment may be useful for the prognostic enrichment of trials. ? 2020 Sanchez et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
SDGs
Other Subjects
hypertensive agent; oxygen; adult; adult respiratory distress syndrome; arterial oxygen tension; Article; controlled study; disease severity; drug use; female; human; hypoxemia; intensive care unit; liver failure; major clinical study; male; mortality; positive end expiratory pressure; predictive value; prognosis; adult respiratory distress syndrome; arterial pressure; complication; hypoxia; metabolism; middle aged; partial pressure; pathophysiology; physiology; randomized controlled trial (topic); Adult; Arterial Pressure; Female; Humans; Hypoxia; Male; Middle Aged; Oxygen; Partial Pressure; Prognosis; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome, Adult
Type
journal article