Comparison of Clinical Criteria for the Acute Respiratory Distress Syndrome with Autopsy Findings

21 September 2004 | Volume 141 Issue 6 | Pages 440-445

Background: The American–European Consensus Conference definition for the acute respiratory distress syndrome (ARDS) has never been validated.

Objective: To compare clinical criteria for ARDS with autopsy findings.

Design: Independent comparison of autopsy findings with clinical characteristics retrospectively abstracted from medical records.

Setting: Tertiary medical–surgical intensive care unit.

Participants: 382 patients who underwent clinical autopsy.

Measurements: Sensitivity, specificity, and likelihood ratios for clinical criteria were calculated in 3 cohorts by using diffuse alveolar damage at autopsy as the reference standard. The 3 cohorts were 1) all patients, 2) patients with any risk factor for ARDS, and 3) patients who were separated according to their pulmonary or extrapulmonary risk factors.

Results: 127 patients (33%) met the clinical criteria, and 112 (29%) had diffuse alveolar damage. In all patients, the sensitivity of the clinical definition was 75% (95% CI, 66% to 82%) and the specificity was 84% (CI, 79% to 88%). In 284 patients with risk factors, the sensitivity was 76% (CI, 67% to 83%) and the specificity was 75% (CI, 68% to 81%). Compared with patients with pulmonary risk factors, patients with extrapulmonary risk factors had significantly higher sensitivity (61% vs. 85%; P = 0.009) and the specificity did not statistically significantly differ (69% vs. 78%; P > 0.2).

Limitations: Only patients who died and underwent autopsy could be included in this study, so these results may not apply to less severe cases of ARDS.

Conclusions: In a series of autopsy patients, the accuracy of the American–European Consensus Conference definition of ARDS was only moderate. The definition was more accurate for patients with extrapulmonary risk factors than for patients with pulmonary risk factors.

Editors' Notes Context Do all patients who meet clinical criteria for the acute respiratory distress syndrome (ARDS) have diffuse alveolar damage? Contribution Of 382 patients who had autopsies after dying in an intensive care unit, 127 met clinical criteria for ARDS. The sensitivity and specificity of clinical criteria for identifying patients with diffuse alveolar damage at autopsy were 75% and 84%, respectively. People with extrapulmonary risk factors, such as sepsis syndrome, more often had findings of diffuse alveolar damage than did those with only pulmonary risk factors, such as pneumonia. Implications In severely ill patients, clinical criteria and pathologic findings for ARDS are not closely linked. –The Editors

 

Author and Article Information

From the Hospital Universitario de Getafe, Madrid, Spain, and University Health Network, University of Toronto, Toronto, Ontario, Canada.

Acknowledgments: The authors thank Victor Abraira from Unidad de Bioestadística of Hospital Ramón y Cajal, Madrid, Spain, for statistical advice.

Grant Support: By Red Gira G03/063 and Red Respira C03/11, Instituto de Salud Carlos III, Spain. Dr. Ferguson was supported by a Canadian Institutes of Health Research, Canadian Lung Association, postdoctoral fellowship.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Andrés Esteban, MD, PhD, Unidad de Cuidados Intensivos Hospital Universitario de Getafe, Carretera de Toledo Km 12,500 Getafe 28905, Madrid, Spain; e-mail, aesteban{at}ucigetafe.com.

Author Contributions: Conception and design: A. Esteban, P. Fernández-Segoviano, F. Frutos-Vivar, L. Nájera, I. Alía, F. Gordo, F. Ríos.

Analysis and interpretation of the data: A. Esteban, P. Fernández-Segoviano, F. Frutos-Vivar, J.A. Aramburu, L. Nájera, N.D. Ferguson, I. Alía, F. Gordo, F. Ríos.

Drafting of the article: A. Esteban, F. Frutos-Vivar, I. Alía.

Critical revision of the article for important intellectual content: A. Esteban, P. Fernández-Segoviano, F. Frutos-Vivar, J.A. Aramburu, L. Nájera, N.D. Ferguson.

Final approval of the article: N.D. Ferguson.

Statistical expertise: N.D. Ferguson

Current Author Addresses: Drs. Esteban, Frutos-Vivar, and Alía: Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo Km 12,500, Getafe 28905, Madrid, Spain.

Drs. Fernández-Segoviano, Aramburu, and Nájera: Department of Pathology, Hospital Universitario de Getafe, Carretera de Toledo Km 12,500, Getafe 28905, Madrid, Spain.

Dr. Ferguson: Respirology and Critical Care Medicine, University Health Network, Toronto Western Hospital, EC2-024, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.

Dr. Gordo: Intensive Care Unit, Fundación Hospital de Alcorcón, Budapest, 1, Alcorcón 28922, Madrid, Spain.

Dr. Ríos: Hospital Profesor Posadas, Poniente Illia s/n y Marconi, El Palomar 1706, Buenos Aires, Argentina.