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J Crit Care. 2013 Oct;28(5):663-8. doi: 10.1016/j.jcrc.2013.05.012. Epub 2013 Jun 24.

Acute respiratory distress syndrome: underrecognition by clinicians.

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  • 1National SpR Academic Fellowship Programme, St Vincent's University Hospital, Dublin 4, Ireland. Electronic address: frohlics@yahoo.co.uk.

Abstract

BACKGROUND:

Previous reports suggest that acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is underdiagnosed in both adult and pediatric clinical practice. Underrecognition of this condition may be a barrier to instituting a low tidal volume ventilation strategy. This study aimed to determine the accuracy of clinical diagnoses of ARDS in daily practice using the American European Consensus Conference (AECC) criteria as a criterion standard and to investigate whether clinical recognition of ARDS altered ventilator management.

METHODS:

This retrospective study included intensive care unit (ICU) patients who died and underwent postmortem examination. Two independent reviewers assigned each patient to those with ALI/ARDS or no ALI. For those who met AECC criteria for ARDS, all patient records were reviewed for the presence of a documented diagnosis of the condition. The accuracy of the clinicians in diagnosing ALI/ARDS was determined, and ventilator settings between the clinically "diagnosed" and "non-diagnosed" groups were compared. The diagnostic accuracy in predetermined subgroups (those with diffuse alveolar damage, with ≥3 affected chest x-ray quadrants, with diagnosis≥3 days, with pulmonary vs extrapulmonary cause) was also examined.

RESULTS:

Of 98 consecutive ICU patients who died and underwent autopsy, 51 met the inclusion criteria. Sixteen of 51 patients (31.3%) who had ALI/ARDS according to the AECC criteria had this recorded in their clinical notes. Those with histologic evidence of ALI/ARDS (diffuse alveolar damage) and with a more severe chest x-ray pattern or who satisfied the criteria for a number of consecutive days were no more likely to have a clinical diagnosis of ALI/ARDS recorded. However, those with a pulmonary cause of ALI/ARDS were more likely to have a diagnosis recorded. Tidal volumes, positive end-expiratory pressure, and mean airway pressure were higher in those with a clinical diagnosis of ARDS.

CONCLUSIONS:

Acute respiratory distress syndrome is underrecognized by clinicians in ICU, and recognition does not result in lower tidal volume ventilation. Significant barriers remain to the recognition of ALI/ARDS and application of an evidence-based ventilator strategy.

Copyright © 2013 Elsevier Inc. All rights reserved.

KEYWORDS:

Acute lung injury; Acute respiratory distress syndrome; Clinical diagnosis

[PubMed - indexed for MEDLINE]
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