Do patients with unilateral opacities have a similar outcome than patients with ARDS? An ancillary analysis of the lung safe study
CCCF ePoster library. PHAM T. Oct 2, 2017; 198214
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Dr. Tài PHAM
Dr. Tài PHAM
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Do patients with unilateral opacities have a similar outcome than patients with ARDS? An ancillary analysis of the lung safe study

Pham, Tài1,2, Laffey, JG 3,4, Bellani, G5,6, Fan E1,7, Bugedo G8, Lorente JA9, Rios F10, Bruhn A8, Brochard L1,2, Rubenfeld GD1,11, on behalf of the LUNG SAFE Investigators

1Interdepartmental division of Critical Care Medicine, University of Toronto, Toronto, Canada,

2Keenan Research Centre for Biomedical Science, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada,

3 Departments of Anesthesia, Physiology and Interdepartmental division of Critical Care Medicine, University of Toronto, Toronto, Canada,

4Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Canada,

5Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy,

6 School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy,

7Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada,

8Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,

9 CIBER de Enfermedades Respiratorias, Universidad Europea, Hospital Universitario de Getafe, Madrid, Spain,

10 Intensive Care Unit, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina,

11 Program in Trauma, Emergency and Critical Care Organization, Sunnybrook Health Sciences Centre, Toronto, Canada

According to the BERLIN definition, chest imaging must show bilateral opacities to fulfil ARDS criteria (1). Chest X-ray interpretation is challenging in the ICU with poor inter-rater reliability (2,3). There is no data in the literature comparing patients with ARDS to hypoxemic patients having unilateral airspace disease.
We aimed to compare the outcome of patients with ARDS to patients of similar severity having only unilateral opacity/opacities on the chest X-ray.

We enrolled all intubated patients included in the LUNG SAFE study (4) with hypoxemia (PaO2/FiO2 ratio<300mmHg) and compared patients fulfilling the ARDS definition to patients who fulfilled the same other criteria but whose chest imaging only showed unilateral opacities involving 1 or 2 quadrant(s) (Unilateral Acute Hypoxemic Respiratory Failure « u AHRF »). The number of quadrants involved was available for all patients. In order to determine in an adjusted analysis the factors associated with outcome, severity variables associated with hospital mortality with a p-value<0.20 in a bivariable analysis were selected as candidate variables for multivariable logistic regressions.
A total of 3146 patients were included in the present analysis comprising 2377 patients with ARDS and 769 patients with uAHRF. Patients with uAHRF were less severe than ARDS and their main characteristics and outcome are presented in Table 1.

Among patients with uAHRF, 451 (71%) had 1 quadrant involved, 188 (29%) had 2 as compared to 978 (42%), 535 (23%) and 830 (35%) patients with ARDS who had respectively 2, 3 or 4 quadrants involved on the chest imaging.
In a multivariable analysis adjusting on baseline severity (age, weight, pH, non-pulmonary SOFA score, PaO2/FiO2 ratio, respiratory rate, peak inspiratory pressure, medical cause of admission, chronic liver failure, immunodeficiency, pancreatitis, the present of concomitant cardiac failure), bilateral opacities were associated with increased hospital mortality (OR=1.35, 95%CI=1.09-1.67, p<0.01). In the same model using number of quadrants instead of bilateral status, having 3 quadrants (OR=1.42, 95%CI =1.05-1.93 p=0.02) or 4 quadrants (OR=1.54, 95%CI =1.16-2.06, p<0.01) involved were associated with higher mortality.
We then restricted the analysis to the 1166 patients with 2 quadrants involved. Their main characteristics and outcome are presented in Table 2.
There was no difference of mortality between the 188 uAHRF and 978 ARDS in bivariate (33% vs 36%, p=0.51) or multivariable analysis: OR=1.17, 95%CI =0.82-1.68, p=0.39.
Patients with uAHRF have a high mortality comparable to ARDS with 2 quadrants involved. The total number of quadrants involved is as important as the bilateral characteristic of the parenchymal injury. Although, the ability of physicians to reliably count the number of involved quadrants was not tested, 3 or 4 quadrants of radiographic involvement are associated with independent risk of death.

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