Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2017

Open Access 01-12-2017 | Research

Predictors of diffuse alveolar damage in patients with acute respiratory distress syndrome: a retrospective analysis of clinical autopsies

Authors: Arnaud W. Thille, Oscar Peñuelas, José A. Lorente, Pilar Fernández-Segoviano, José-Maria Rodriguez, José-Antonio Aramburu, Julian Panizo, Andres Esteban, Fernando Frutos-Vivar

Published in: Critical Care | Issue 1/2017

Login to get access

Abstract

Background

Although diffuse alveolar damage (DAD) is considered the typical histological pattern of acute respiratory distress syndrome (ARDS), only half of patients exhibit this morphological hallmark. Patients with DAD may have higher mortality than those without DAD. Therefore, we aimed to identify the factors associated with DAD in patients with ARDS.

Methods

We analyzed autopsy samples of 356 patients who had ARDS at the time of death. DAD was assessed by two pathologists, and ARDS criteria were evaluated by two intensivists. Criteria for severe ARDS included the degree of hypoxemia and the ancillary variables of the current Berlin definition assessed within 48 h before death: radiographic severity, high positive end-expiratory pressure (PEEP) level, and physiological variables (i.e., altered respiratory system compliance and large anatomic dead space).

Results

After multivariable analysis, high PEEP levels, physiological variables, and opacities involving only three quadrants on chest radiographs were not associated with DAD. The four markers independently associated with DAD were (1) duration of evolution (OR 3.29 [1.95–5.55] for patients with ARDS ≥ 3 days, p < 0.001), (2) degree of hypoxemia (OR 3.92 [1.48–10.3] for moderate ARDS and 6.18 [2.34–16.3] for severe ARDS, p < 0.01 for both), (3) increased dynamic driving pressure (OR 1.06 [1.04–1.09], p = 0.007), and (4) radiographic severity (OR 2.91 [1.47–5.75] for patients with diffuse opacities involving the four quadrants, p = 0.002). DAD was found in two-thirds of patients with a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤ 100 mmHg and opacities involving the four quadrants.

Conclusions

In addition to severe hypoxemia, diffuse opacities involving the four quadrants were a strong marker of DAD.
Literature
1.
Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet. 1967;2(7511):319–23.CrossRefPubMed
2.
Katzenstein AL, Bloor CM, Leibow AA. Diffuse alveolar damage—the role of oxygen, shock, and related factors: a review. Am J Pathol. 1976;85(1):209–28.PubMedPubMedCentral
3.
Tomashefski Jr JF. Pulmonary pathology of acute respiratory distress syndrome. Clin Chest Med. 2000;21(3):435–66.CrossRefPubMed
4.
Esteban A, Fernandez-Segoviano P, Frutos-Vivar F, Aramburu JA, Najera L, Ferguson ND, Alia I, Gordo F, Rios F. Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings. Ann Intern Med. 2004;141(6):440–5.CrossRefPubMed
5.
de Hemptinne Q, Remmelink M, Brimioulle S, Salmon I, Vincent JL. ARDS: a clinicopathological confrontation. Chest. 2009;135(4):944–9.CrossRefPubMed
6.
Sarmiento X, Guardiola JJ, Almirall J, Mesalles E, Mate JL, Soler M, Klamburg J. Discrepancy between clinical criteria for diagnosing acute respiratory distress syndrome secondary to community acquired pneumonia with autopsy findings of diffuse alveolar damage. Respir Med. 2011;105(8):1170–5.CrossRefPubMed
7.
Thille AW, Esteban A, Fernandez-Segoviano P, Rodriguez JM, Aramburu JA, Penuelas O, Cortes-Puch I, Cardinal-Fernandez P, Lorente JA, Frutos-Vivar F. Comparison of the Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir Crit Care Med. 2013;187(7):761–7.CrossRefPubMed
8.
Patel SR, Karmpaliotis D, Ayas NT, Mark EJ, Wain J, Thompson BT, Malhotra A. The role of open-lung biopsy in ARDS. Chest. 2004;125(1):197–202.CrossRefPubMed
9.
Papazian L, Doddoli C, Chetaille B, Gernez Y, Thirion X, Roch A, Donati Y, Bonnety M, Zandotti C, Thomas P. A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients. Crit Care Med. 2007;35(3):755–62.CrossRefPubMed
10.
Baumann HJ, Kluge S, Balke L, Yekebas E, Izbicki JR, Amthor M, Kreymann G, Meyer A. Yield and safety of bedside open lung biopsy in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome. Surgery. 2008;143(3):426–33.CrossRefPubMed
11.
Charbonney E, Robert J, Pache JC, Chevrolet JC, Eggimann P. Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology. J Crit Care. 2009;24(1):122–8.CrossRefPubMed
12.
Willetts L, Parker K, Wesselius LJ, Protheroe CA, Jaben E, Graziano P, Moqbel R, Leslie KO, Lee NA, Lee JJ. Immunodetection of occult eosinophils in lung tissue biopsies may help predict survival in acute lung injury. Respir Res. 2011;12:116.CrossRefPubMedPubMedCentral
13.
Guerin C, Bayle F, Leray V, Debord S, Stoian A, Yonis H, Roudaut JB, Bourdin G, Devouassoux-Shisheboran M, Bucher E, et al. Open lung biopsy in nonresolving ARDS frequently identifies diffuse alveolar damage regardless of the severity stage and may have implications for patient management. Intensive Care Med. 2015;41(2):222–30.CrossRefPubMed
14.
Kao KC, Hu HC, Chang CH, Hung CY, Chiu LC, Li SH, Lin SW, Chuang LP, Wang CW, Li LF, et al. Diffuse alveolar damage associated mortality in selected acute respiratory distress syndrome patients with open lung biopsy. Crit Care. 2015;19:228.CrossRefPubMedPubMedCentral
15.
Cardinal-Fernandez P, Bajwa EK, Dominguez-Calvo A, Menendez JM, Papazian L, Thompson BT. The presence of diffuse alveolar damage on open lung biopsy is associated with mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Chest. 2016;149(5):1155–64.CrossRefPubMed
16.
Definition Task Force ARDS. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526–33.
17.
Thille AW, Esteban A, Fernandez-Segoviano P, Rodriguez JM, Aramburu JA, Vargas-Errazuriz P, Martin-Pellicer A, Lorente JA, Frutos-Vivar F. Chronology of histological lesions in acute respiratory distress syndrome with diffuse alveolar damage: a prospective cohort study of clinical autopsies. Lancet Respir Med. 2013;1(5):395–401.CrossRefPubMed
18.
Tejerina E, Esteban A, Fernandez-Segoviano P, Frutos-Vivar F, Aramburu J, Ballesteros D, Rodriguez-Barbero JM. Accuracy of clinical definitions of ventilator-associated pneumonia: comparison with autopsy findings. J Crit Care. 2010;25(1):62–8.CrossRefPubMed
19.
Tejerina E, Esteban A, Fernandez-Segoviano P, Maria Rodriguez-Barbero J, Gordo F, Frutos-Vivar F, Aramburu J, Algaba A, Gonzalo Salcedo Garcia O, Lorente JA. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. Crit Care Med. 2012;40(3):842–6.CrossRefPubMed
20.
Lorente JA, Cardinal-Fernandez P, Munoz D, Frutos-Vivar F, Thille AW, Jaramillo C, Ballen-Barragan A, Rodriguez JM, Penuelas O, Ortiz G, et al. Acute respiratory distress syndrome in patients with and without diffuse alveolar damage: an autopsy study. Intensive Care Med. 2015;41(11):1921–30.CrossRefPubMed
21.
Rouby JJ, Puybasset L, Cluzel P, Richecoeur J, Lu Q, Grenier P, CT Scan ARDS Study Group. Regional distribution of gas and tissue in acute respiratory distress syndrome. II. Physiological correlations and definition of an ARDS severity score. Intensive Care Med. 2000;26(8):1046–56.CrossRefPubMed
22.
Puybasset L, Gusman P, Muller JC, Cluzel P, Coriat P, Rouby JJ, CT Scan ARDS Study Group. Regional distribution of gas and tissue in acute respiratory distress syndrome. III. Consequences for the effects of positive end-expiratory pressure. Intensive Care Med. 2000;26(9):1215–27.CrossRefPubMed
23.
Galiatsou E, Kostanti E, Svarna E, Kitsakos A, Koulouras V, Efremidis SC, Nakos G. Prone position augments recruitment and prevents alveolar overinflation in acute lung injury. Am J Respir Crit Care Med. 2006;174(2):187–97.CrossRefPubMed
24.
Mrozek S, Jabaudon M, Jaber S, Paugam-Burtz C, Lefrant JY, Rouby JJ, Asehnoune K, Allaouchiche B, Baldesi O, Leone M, et al. Elevated plasma levels of sRAGE are associated with nonfocal CT-based lung imaging in patients with ARDS: a prospective multicenter study. Chest. 2016;150(5):998–1007.CrossRefPubMed
25.
Calfee CS, Delucchi K, Parsons PE, Thompson BT, Ware LB, Matthay MA. Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials. Lancet Respir Med. 2014;2(8):611–20.CrossRefPubMedPubMedCentral
26.
Famous KR, Delucchi K, Ware LB, Kangelaris KN, Liu KD, Thompson BT, Calfee CS, ARDS Network. Acute respiratory distress syndrome subphenotypes respond differently to randomized fluid management strategy. Am J Respir Crit Care Med. 2017;195(3):331–8.PubMed
27.
Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.CrossRef
28.
Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic V, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177(2):170–7.CrossRefPubMed
29.
Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Penuelas O, Abraira V, Raymondos K, Rios F, Nin N, Apezteguia C, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med. 2013;188(2):220–30.CrossRefPubMed
30.
Rubenfeld GD, Caldwell E, Granton J, Hudson LD, Matthay MA. Interobserver variability in applying a radiographic definition for ARDS. Chest. 1999;116(5):1347–53.CrossRefPubMed
31.
Meade MO, Cook RJ, Guyatt GH, Groll R, Kachura JR, Bedard M, Cook DJ, Slutsky AS, Stewart TE. Interobserver variation in interpreting chest radiographs for the diagnosis of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2000;161(1):85–90.CrossRefPubMed
32.
Figueroa-Casas JB, Brunner N, Dwivedi AK, Ayyappan AP. Accuracy of the chest radiograph to identify bilateral pulmonary infiltrates consistent with the diagnosis of acute respiratory distress syndrome using computed tomography as reference standard. J Crit Care. 2013;28(4):352–7.CrossRefPubMed
Metadata
Title
Predictors of diffuse alveolar damage in patients with acute respiratory distress syndrome: a retrospective analysis of clinical autopsies
Authors
Arnaud W. Thille
Oscar Peñuelas
José A. Lorente
Pilar Fernández-Segoviano
José-Maria Rodriguez
José-Antonio Aramburu
Julian Panizo
Andres Esteban
Fernando Frutos-Vivar
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2017
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-017-1852-5

Other articles of this Issue 1/2017

Critical Care 1/2017 Go to the issue

Letter

Optimal doses of caspofungin during continuous venovenous hemodiafiltration in critically ill patients

Research

Vasculotide reduces pulmonary hyperpermeability in experimental pneumococcal pneumonia

Research

Role of vasopressin and terlipressin in refractory shock compared to conventional therapy in the neonatal and pediatric population: a systematic review, meta-analysis, and trial sequential analysis

Research

Time course of blood lactate levels, inflammation, and mitochondrial function in experimental sepsis

Research

Hyperfibrinolysis in severe isolated traumatic brain injury may occur without tissue hypoperfusion: a retrospective observational multicentre study

Research

A clinical prediction model to identify patients at high risk of hemodynamic instability in the pediatric intensive care unit