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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 210-214

Clinical profile and survival outcome of acute respiratory distress syndrome in a rural tertiary care hospital


1 Department of Medicine, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Pathology, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission02-Jun-2019
Date of Decision05-Jul-2019
Date of Acceptance30-Jul-2019
Date of Web Publication2-May-2020

Correspondence Address:
Dr. Sourya Acharya
Department of Medicine, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_116_19

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  Abstract 


Background: Acute respiratory distress syndrome (ARDS) is characterized by rapid onset severe dyspnea, hypoxemia, and diffuse bilateral pulmonary infiltrates leading to respiratory failure. This syndrome can occur even without primary damage to the lung parenchyma, and thus, they are more often classified as ARDS due to pulmonary and extrapulmonary causes. Mortality estimates range from 26% to 44% in different studies. There are several critical care scores that are in vogue in intensive care units. This study was undertaken to describe the clinical profile of ARDS and along with that the study also intended to correlate the outcome of ARDS patients with reference to these critical care scores and try to establish which score would be best to prognosticate ARDS. Aims: This study aims to study the clinical profile and survival outcome of ARDS in a rural tertiary care hospital. Materials and Methods: All patients fulfilling the inclusion criteria as per the 1994 American European Consensus Conference on ARDS definition of ARDS were included in the study. The severity of ARDS was measured by various critical care scores such as the Acute Physiology and Chronic Health Evaluation Score, Multiple Organ Dysfunction Score (MODS), Lung Injury Score (LIS), and Sequential Organ Dysfunction Assessment (SOFA score). Results: The ratio of male and female (male: female) was 1.7:1.0. Proportion of males (62.5%) was significantly higher than that of females (37.5%) (Z = 3.53;P < 0.001). Clinical disorders pneumonia (35%), sepsis with multiorgan failure (27.5%), and tropical infections (21.5%) were significantly higher than that of other etiologies (Z = 3.68;P < 0.0001). The mean age, APACHE-II score, SOFA score, LIS, and MODS were significantly higher of the patients who died during treatment as compared to the patients who were discharged alive (P < 0.0001). In receiver operating characteristics/area under curve (AUC) analysis, AUC of MODS followed by SOFA score was higher than that of other scores. Thus, MODS Score was as good as SOFA score to predict death. Conclusion: In this study, the primary pulmonary infection/pneumonia, septicemia, and tropical infections were the leading causes of ARDS. Among the various scores; MODS and SOFA score predicted the mortality more accurately.

Keywords: Lung injury score, multiorgan dysfunction score, pneumonia, sepsis, sequential organ dysfunction assessment score


How to cite this article:
Kadam N, Acharya S, Shukla S, Raisinghani N, Khandekar A. Clinical profile and survival outcome of acute respiratory distress syndrome in a rural tertiary care hospital. J Datta Meghe Inst Med Sci Univ 2019;14:210-4

How to cite this URL:
Kadam N, Acharya S, Shukla S, Raisinghani N, Khandekar A. Clinical profile and survival outcome of acute respiratory distress syndrome in a rural tertiary care hospital. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 May 28];14:210-4. Available from: http://www.journaldmims.com/text.asp?2019/14/3/210/283577




  Introduction Top


Acute respiratory distress syndrome (ARDS) is a clinical entity characterized by rapidly progressive dyspnea, hypoxemia, and diffuse bilateral pulmonary infiltrates leading to respiratory failure. It is a devastating clinical disorder with variable clinical manifestations. ARDS can occur even without primary damage to lung parenchyma and multiple secondary causes exist for the development of ARDS.[1] Mortality estimates range from 26% to 44% in different studies.[2] The diagnostic criteria are based on the American/European consensus statement for the definition of ARDS:[3]

The development of ARDS, most cases (>80%) are caused by severe sepsis syndrome and/or bacterial pneumonia, trauma, multiple transfusion, aspiration of gastric content, and drug overdose, the most frequently reported surgical condition in ARDS are pulmonary contusion, multiple bone fracture and chest wall trauma/flail chest, whereas head trauma, near-drowning, toxic inhalation, and burn are the rare cause.

There are very few studies on the pattern of ARDS seen in our country.[4],[5],[6] Much of the available data on the clinical course of patients with ARDS are from western literature.[7],[8],[9]

This prospective study will attempt to evaluate the etiology and outcome of ARDS patients admitted to medicine intensive care unit (ICU) of AVBRH hospital.

Aims

The primary aim of this study was to describe the clinical profile and survival outcome of ARDS with the secondary objectives to determine the etiology and natural course of ARDS in the medical ICU, to correlate the survival outcome of ARDS with different critical care scores such as Acute Physiology and Chronic Health Evaluation II (APACHE II), Multiple Organ Dysfunction Score (MODS), Sequential Organ Dysfunction Assessment (SOFA), and Lung Injury Scores (LISs), and to establish a single critical care score that predicts the outcome most accurately as compared to other scores.


  Materials and Methods Top


Source of data

Patients admitted to the Medicine ICU with a diagnosis of ARDS of AVBR Hospital, Sawangi (Meghe), Wardha, Maharashtra, India.

Type of study

This is a cross-sectional study design.

Duration of study

One year (May 2018–May 2019).

Inclusion criteria

Based on the American/European consensus statement for the definition of ARDS

  1. Acute onset of dyspnea
  2. Bilateral infiltrates on chest X-ray
  3. The absence of clinical signs of left atrial hypertension left heart failure or if pulmonary catheter is present, then pulmonary capillary wedge pressure (PCWP) <18 mmHg
  4. PaO2/FiO2≤200 mmHg.


Exclusion criteria

  1. Clinical or investigative procedures suggestive of left-sided cardiac dysfunction
  2. Significant underlying lung diseases, such as preexisting chronic obstructive pulmonary disease, fibrotic lung diseases, and interstitial lung disease
  3. Age <15 years
  4. Those discharged against medical advice.


Methods of collection of data

All the patients admitted to the ICU of our hospital during May 2018–May 2019, who are fitting into the inclusion criteria, will be taken into the study. Patient or his relatives who were ready to give consent were studied in detail as per the pro forma.

The detailed clinical history included the onset, duration, and the progression of the presenting complaints. It also included a search for the etiology of the condition leading to ARDS. On clinical examination, the vital parameters were recorded. The respiratory system, abdominal, cardiovascular, and central nervous systems were examined in detail. The patient was investigated initially with the required tests. The severity of the illness was measured by the APACHE Score,[9] MODS,[8] LIS,[7] and SOFA Score.[10] These scores were calculated on admission to our ICU.

Statistical analysis

Statistical analysis was performed with the help of Epi Info™ Division of Health Informatics & Surveillance (DHIS), Center for Surveillance, Epidemiology & Laboratory Services (CSELS) is a trademark of the Centers for Disease Control and Prevention.

Descriptive statistical analyses were performed to calculate the means with corresponding standard deviations (SDs). The test of proportion was used to find the Standard Normal Deviate (Z) to compare the different proportions. Receiver operating characteristic curve (ROC) was used to compare the performance of different scores for diagnostic purposes. P < 0.05 was considered statistically significant.


  Results Top


Among the clinical disorders pneumonia (35.0%), sepsis with multi-organ failure (27.5%), and tropical infections (21.5%) were significantly higher than that of other etiologies (Z = 3.68; P < 0.0001) [Table 1].
Table 1: Baseline characteristics of the study participants

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Most of the patients were discharged alive (60%) which was significantly higher than that of patients who died during treatment (40%) (Z = 2.82; P = 0.0046).

The mean age, APACHE II score, SOFA score, LIS, and MODS were significantly higher of the patients who died during treatment as compared to the patients who were discharged alive (P < 0.0001) [Table 3], [Table 4], [Table 5].
Table 2: Etiology of the patients with acute respiratory distress syndrome (clinical disorders associated with acute respiratory distress syndrome)

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Table 3: Final outcome of the patients

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Table 4: Comparison of parameters of acute respiratory distress syndrome who survived and patients who died

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Table 5: Area under the curve of the scores to predict death

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However, the mean duration of hospital stay was significantly lower of the patients who died during treatment as compared to the patients who were discharged alive (P < 0.0001) [Graph 1].



The area under curve (AUC) of MODS followed by SOFA score was higher than that of other scores. Thus, MODS Score was as good as SOFA score to predict death. However, all other scores were good to predict death.


  Discussion Top


In our study, the mean age (mean ± SD) of the patients was 47.45 ± 13.73 years with a range of 20–80 years. Most of the patients were aged ≥40 (75.0%) which was significantly higher than other age groups (Z = 8.08; P < 0.001). The ratio of male and female (male:female) was 1.7:1.0. The proportion of males (62.5%) was significantly higher than that of females (37.5%) (Z = 3.53; P < 0.001).

Bhadade et al., from Mumbai[6] and Vigg et al., from Hyderabad[5] reported figures of 37.9 years and 39.2 ± 2.5 years, respectively, for the mean age of the patients. Some western studies found the mean age to be 60 years and 60.6 years, respectively.[11],[12] In a study by Ingle and Bade, 42 of 70 patients were male, indicating that gender distribution had male predominance.[4] This finding was similar to the study conducted by de Hemptinne et al., in which 59% of ARDS patients were male.[13]

The next factor assessed was the etiology of ARDS. In our study, clinical disorders associated with ARDS were identified to be primary pulmonary infection (pneumonia) (35%), sepsis with multi-organ failure (27.5%), followed by tropical infections (21.5%) which were significantly higher than that of other etiologies (Z = 3.68; P < 0.0001). Pneumonia has been found to be the most common cause for ARDS in many other studies. A study found 58% of the cases having pneumonia.[14] Similar finding was noted in a study done in the United States, where the pulmonary source of sepsis was found in 43% cases. Vigg et al., in India, reported that 30% of cases of ARDS were due to pneumonia, whereas other causes included gastrointestinal disease (25%) and polytrauma (12%).[5] The study done by Bhadade et al.,[6] in India, found a significant percentage of cases of ARDS secondary to tropical infections (53.5%) out of which 27.6% cases to be of malaria, 20.7% cases of leptospirosis, and 5.2% cases of malaria with dengue. In our study as well, a significant number of patients had such tropical infections, as show in [Table 2]. The distribution of various tropical infections was different in our study, and this could be due to the regional differences in the occurrence of these infections, considering significant variation in the areas that studies were conducted across.

When patient outcomes were assessed in the given study, a majority of the patients were discharged alive (60.0%) which was noted to be higher than the percentage of patients suffering mortality (40.0%) (Z = 2.82; P = 0.0046). A 9-year, retrospective review of 980 patients with ARDS (1990–1998), found a significant decrease in death rates during this time from 70% to 51.5%.[15] A study done by ARDS network in 2005 noted a mortality rate of 26%.[16] In developed countries, the decrease in mortality rates of ARDS is due to the improvement in the management strategies of these patients. The mortality rate in the present study was noted to be 40%. This is lower than data that has been reported from some studies in India, where the authors have noted up to 57%.[17]

In the study conducted, it was found that the mean age, APACHE 2 score, SOFA score, LIS, and MODS were found to be significantly higher among patients who died, as compared to the patients who were discharged (P < 0.0001). The mean APACHE II score in our study was 24.56 ± 7.88 among nonsurvivors, while that among survivors was found to be 13.93 ± 6.77. APACHE II scores were also noted to be significantly higher among patients who died as compared to the patients who were discharged (P < 0.0001). Multiple other studies have also observed the APACHE II score to be greater among the patients died as compared to discharged patients.[14],[17],[18]

In our study, the mean SOFA score among nonsurvivors was 15.38 ± 3.36, while the mean score who died was found to be 7.63 ± 2.73 s. The SOFA score was found to be significantly higher amongst the patients who died, as compared to the patients who were discharged (P < 0.0001). A similar difference was observed in a study from the Postgraduate Institute of Medical Education and Research, Chandigarh, and investigators observed the mean SOFA score among patients who died to be 10 while that among survivors was noted to be 7.[17]

In the study conducted, LIS scores too were noted to be significantly higher in patients who died, as compared to the patients who were discharged (P < 0.0001) In another study by Rocco et al., predictors at the onset of ARDS were found to be with a LIS score >2.76.[16] On the assessment of patients who died by Vigg et al., the mean LIS score was found to be 2.76 (±1.8).[5] In a study by Herridge et al., acute lung injury (ALI) scores were noted to be significant predictors of mortality on the day of admission to ICU.[14] The author also noted that LIS scores >2 had a higher association with mortality and noted that these scoring systems were equally effective in predicting mortality in ALI/ARDS due to tropical diseases.

On the assessment of MODS in this study, MODS scores were also found to be significantly higher among patients significantly higher in patients who had suffered mortality, as compared to the patients who were discharged (P < 0.0001). In the study by Rocco et al.,[16] predictors at the onset of ARDS were found to be MODS >8 or more. On assessment by authors Vigg et al., of patients who had died,[5] the mean MODS was found to be 9 (±2). In the study by Herridge et al. the median MODS score on 1st day was 10 among the nonsurvivors.

[14] Chabukswar and Baviskar noted that MODS score was a significant predictor of mortality on the day of admission to the ICU.[18] The author also noted that a MODS of >4 had higher association with mortality. The mean MODS score in patients who died was found to be 5.3. These scoring systems were equally effective in predicting mortality in ALI/ARDS due to tropical diseases.

In this study, the mean duration of hospital stay was significantly lower of the patients who died during the treatment, as compared to the patients who were discharged (P < 0.0001). Studies from India and Australia have reported a mean hospital stay of 10.5 ± 2 days and 9.4 days, respectively.[18],[19] However, the mean duration of ICU stay and hence, hospital stay in a study done by Navarrete-Navarro et al., was higher, i.e., 28.5 ± 24.5 days. A reason for this may be the fact that the study included only trauma patients with ARDS.[20] The shorter mean duration of hospital stay noted in the study may be due to lower percentage of trauma cases which usually have a prolonged ICU and hospital stay, as reported in a study from surgical ICU of an academic trauma center in the United States of America, in comparison to other studies conducted in India.[20],[21]

In the given study, the AUC of MODS followed by SOFA score was higher than that of other scores. Thus, MODS Score was found to be as good as SOFA score to predict mortality in patients. Gajic et al. assessed mortality in ARDS patients and noted that ROC curve was 0.84 (vs. 0.74, P = 0.05).[22]

In 1998, Monchi et al. evaluated the ability of different severity scores such as the simplified acute physiology score (SAPS) and SAPS II, organ system failure, and LIS to predict ARDS outcome and concluded that the SAPS II was better to predict ARDS severity, while ARDS mortality was better related to the triggering risk factors of ARDS (direct or indirect lung injury associated with ARDS within the first 24 h).[23] A LIS score >4 was noted to have 69% sensitivity and 78% specificity for identifying patients who would develop ARDS after admission. Conversely, Damluji et al. reported imprecise mortality prediction among patients with low, intermediate, and high risk of ARDS, probably due to an overly broad patient cohort.[24]

Limitations

The sample size of this study was small because it was a prospective study of 1-year duration, second, the study did not use the “The Berlin definition of ARDS,” because we did not intend to classify the ARDS per se according to severity.


  Conclusion Top


ARDS is a devastating clinical condition that can occur with various etiologies. In this study, the primary pulmonary infection/pneumonia, septicemia, and tropical infections were the leading causes of ARDS. Among the various scores, MODS and SOFA score predicted the mortality more accurately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Acute respiratory distress syndrome. In: Levy BC, Shapiro SD, editors. Harrison's Principles of Internal Medicine. 17th ed. New Delhi: McGraw Hill: 2008. p. 1680-4.  Back to cited text no. 2
    
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Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994;149:818-24.  Back to cited text no. 3
    
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Ingle VV, Bade S. Clinical profile of acute respiratory distress syndrome: Two years experience at a tertiary care center. Int J Contemp Med Surg Radiol 2018;3:B171-3.  Back to cited text no. 4
    
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Vigg A, Mantri S, Vigg A, Vigg A. Clinical profile of ARDS. J Assoc Physicians India 2003;51:855-8.  Back to cited text no. 5
    
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Bhadade RR, de Souza RA, Harde MJ, Khot A. Clinical characteristics and outcomes of patients with acute lung injury and ARDS. J Postgrad Med 2011;57:286-90.  Back to cited text no. 6
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Damluji A, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Fan E, Shanholtz C, et al. Short-term mortality prediction for acute lung injury patients: External validation of the Acute Respiratory Distress Syndrome Network prediction model. Crit Care Med 2011;39:1023-8.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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