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Purpose To evaluate the association between acute respiratory distress syndrome (ARDS) onset time and prognosis. Methods Patients with moderate to severe ARDS (N = 876) were randomly assigned into derivation (N = 520) and validation (N = 356) datasets. Both 28-day and 60-day survival times after ARDS onset were analyzed. A data-driven cutoff point between early- and late-onset ARDS was determined on the basis of mortality risk effects of onset times. We estimated the hazard ratio (HR) and odds ratio (OR) of late-onset ARDS using a multivariate Cox proportional hazards model of survival time and a multivariate logistic regression model of mortality rate, respectively. Results Late-onset ARDS, defined as onset over 48 h after intensive care unit (ICU) admission (N = 273, 31%), was associated with shorter 28-day survival time: HR = 2.24, 95% CI 1.48-3.39, P = 1.24 x 10.sup.-4 (derivation); HR = 2.16, 95% CI 1.33-3.51, P = 1.95 x 10.sup.-3 (validation); and HR = 2.00, 95% CI 1.47-2.72, P = 1.10 x 10.sup.-5 (combined dataset). Late-onset ARDS was also associated with shorter 60-day survival time: HR = 1.70, 95% CI 1.16-2.48, P = 6.62 x 10.sup.-3 (derivation); HR = 1.78, 95% CI 1.15-2.75, P = 9.80 x 10.sup.-3 (validation); and HR = 1.59, 95% CI 1.20-2.10, P = 1.22 x 10.sup.-3 (combined dataset). Meanwhile, late-onset ARDS was associated with higher 28-day mortality rate (OR = 1.46, 95% CI 1.04-2.06, P = 0.0305) and 60-day mortality rate (OR = 1.44, 95% CI 1.03-2.02, P = 0.0313). Conclusions Late-onset moderate to severe ARDS patients had both shorter survival time and higher mortality rate in 28-day and 60-day observations., Author(s): Ruyang Zhang [sup.1] [sup.2] [sup.3], Zhaoxi Wang [sup.1], Paula Tejera [sup.1], Angela J. Frank [sup.4], Yongyue Wei [sup.2] [sup.3], Li Su [sup.1], Zhaozhong Zhu [sup.1], Yichen Guo [sup.1], Feng [...]

Purpose Use of systemic corticosteroids in acute respiratory distress syndrome (ARDS) remains controversial, and studies in children are lacking. Methods We performed an observational, single-center study in a prospectively enrolled cohort of children meeting criteria for ARDS (both Berlin 2012 and AECC 1994 acute lung injury) and pediatric ARDS (PARDS, as defined by PALICC 2015). Comprehensive analysis of corticosteroid utilization was planned, and detailed information collected on corticosteroid use, timing, treatment duration, and cumulative dose while mechanically ventilated. We assessed the association between corticosteroid exposure >24 h and outcomes. Results Of the 283 children with PARDS (37 deaths, 13 %), 169 (60 %) received corticosteroids for >24 h while ventilated: 51 % hydrocortisone, 41 % methylprednisolone, 5 % dexamethasone, 3 % combination of corticosteroids. Corticosteroid exposure >24 h was associated with increased mortality, fewer ventilator-free days at 28 days (VFD), and longer duration of ventilation in survivors in unadjusted analyses (all p 24 h in patients with [greater than or equal to]3 organ failures and immunocompromised patients. Conclusions Corticosteroid exposure >24 h was independently associated with fewer VFD and longer duration of ventilation in survivors, even after adjustment for key potential confounders, including severity of illness, oxygenation index, immunocompromised status, and number of organ failures., Author(s): Nadir Yehya [sup.1], Sabah Servaes [sup.2], Neal J. Thomas [sup.3], Vinay M. Nadkarni [sup.1], Vijay Srinivasan [sup.1] Author Affiliations: (1) grid.239552.a, 0000000106808770, Department of Anesthesiology and Critical Care Medicine, [...]

Purpose Multiple interventions have been tested in acute respiratory distress syndrome (ARDS). We examined the entire agenda of published randomized controlled trials (RCTs) in ARDS that reported on mortality and of respective meta-analyses. Methods We searched PubMed, the Cochrane Library, and Web of Knowledge until July 2013. We included RCTs in ARDS published in English. We excluded trials of newborns and children; and those on short-term interventions, ARDS prevention, or post-traumatic lung injury. We also reviewed all meta-analyses of RCTs in this field that addressed mortality. Treatment modalities were grouped in five categories: mechanical ventilation strategies and respiratory care, enteral or parenteral therapies, inhaled/intratracheal medications, nutritional support, and hemodynamic monitoring. Results We identified 159 published RCTs of which 93 had overall mortality reported (n = 20,671 patients)-44 trials (14,426 patients) reported mortality as a primary outcome. A statistically significant survival benefit was observed in eight trials (seven interventions) and two trials reported an adverse effect on survival. Among RCTs with more than 50 deaths in at least one treatment arm (n = 21), two showed a statistically significant mortality benefit of the intervention (lower tidal volumes and prone positioning), one showed a statistically significant mortality benefit only in adjusted analyses (cisatracurium), and one (high-frequency oscillatory ventilation) showed a significant detrimental effect. Across 29 meta-analyses, the most consistent evidence was seen for low tidal volumes and prone positioning in severe ARDS. Conclusions There is limited supportive evidence that specific interventions can decrease mortality in ARDS. While low tidal volumes and prone positioning in severe ARDS seem effective, most sporadic findings of interventions suggesting reduced mortality are not corroborated consistently in large-scale evidence including meta-analyses., Author(s): Adriano R. Tonelli [sup.1], Joe Zein [sup.1], Jacob Adams [sup.1], John P. A. Ioannidis [sup.2] Author Affiliations: (1) Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, , [...]

Purpose The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition. Methods We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO.sub.2/FiO.sub.2 Results During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP [greater than or equal to] 5 cmH.sub.2O and 20 (7.2 %) had PaO.sub.2/FiO.sub.2 ratio [less than or equal to]200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P > 0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P < 0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P < 0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28. Conclusions The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO.sub.2/FiO.sub.2 at study entry was independently associated with mortality., Author(s): R. Hernu [sup.1], F. Wallet [sup.2], F. Thiollière [sup.3], O. Martin [sup.4], J. C. Richard [sup.5], Z. Schmitt [sup.6], G. Wallon [sup.6], B. Delannoy [sup.7], T. Rimmelé [sup.8], C. [...]