Is ARDS Important to Recognize?

Transcription

1 Is ARDS Important to Recognize? Lorraine B. Ware MD Vanderbilt University Financial Disclosures: research funding from Boehringer Ingelheim, Global Blood Therapeutics

2 Why diagnose ARDS? -initiate specific therapy -prognostic importance -eligibility for clinical trials -cannot advance the field without recognition of patients with ARDS

3 Denver, 50 Years Ago

4 459 ICUs, 50 countries, 5 continents Incidence and outcome of ARDS in 4 winter weeks 4499 with acute hypoxemic respiratory failure 3022 had ARDS (10% of ICU admissions, 23% of mechanically ventilated admissions) Only 60% had clinician recognition of ARDS Only 34% had clinician recognition on day 1 of ARDS Bellani G et al, JAMA 2016;315:

5 Underdiagnosis = Undertreatment? Bellani G et al, JAMA 2016;315:

6 ARDS Diagnosis in the VALID cohort Vanderbilt Medical ICU 1341 patients Sensitivity of 42%, Specificity of 95% Vanderbilt Trauma ICU 375 patients Performance of Clinician Recognition Clinician recognition of ARDS Sensitivity of 31%, Specificity of 93% Gold Standard ARDS ARDS Not ARDS Total ARDS Not ARDS Total

7 Recognition of ARDS does not impact tidal volume when low tidal volume is standard protocol for acute respiratory failure

8 Delay in implementation of low tidal volume is associated with higher ICU mortality Model derived from serial tidal volume observations in 482 ARDS patients Needham DM et al, Am J Respir Crit Care Med 2015;191:

9 ARDS 28-day mortality is still 30-40% Bellani G et al, JAMA 2016;315:

10 How can we improve recognition of ARDS? 1. Education 2. Automated sniffers 3. Use of SpO2/FiO2 to supplement blood gas data 4. Diagnostic biomarkers

11 How can we improve recognition of ARDS? 1. Education Educate providers at all levels Emphasize that recognition is a cornerstone of appropriate treatment Early acute lung injury Multinational effort

12 Underlying diagnoses that are important to recognize Condition Pneumonia Non-pulmonary sepsis Pancreatitis Potential change in therapy Exposure history, appropriate cultures, serologies, antibiotics Identify source, need for surgical or catheter drainage Identify etiology to guide treatment

13 Alternative diagnoses that are important to recognize Condition Diffuse Alveolar Hemorrhage Pulmonary Alveolar Proteinosis Acute Interstitial Pneumonia Cryptogenic Organizing Pneumonia Acute Eosinophilic Pneumonia Cardiogenic Pulmonary Edema Potential change in therapy Glucocorticoids, transfusion, immunosuppressive therapy Whole lung lavage, granulocyte macrophage colony-stimulating factor Glucocorticoids Glucocorticoids Glucocorticoids Treatment specific for underlying cause (ischemia, heart failure, valvular insufficiency etc.) Adapted from Janz and Ware, Clin Chest Med 2014, 35:685

14 How can we improve recognition of ARDS? 1. Education 2. Automated sniffers automated recognition of blood gas results and/or radiographic reports to identify patients who meet Berlin definition of ARDS

15 Cumulative daily sensitivity of electronic sniffers and clinician recognition compared to gold standard ARDS diagnosis McKown A et al, J Intens Care Med 2017

16 How can we improve recognition of ARDS? 1. Education 2. Automated sniffers 3. Use of SpO2/FiO2 to supplement blood gas data Pulse oximetry is continuously available and non-invasive PaO 2 /FiO = SpO 2 /FiO PaO 2 /FiO = SpO 2 /FiO Rice et al. Chest. 2007; 132:410-7

17 Use of SpO 2 /FiO 2 for Diagnosis of ARDS yields similar patients/outcomes Diagnosis by P/F N = 238 Diagnosis by S/F N = 124 P value NIPPV at Diagnosis 21 (9%) 18 (14%) ICU Days 10 ± 8 9 ± Vent Days 7 ± 7 7 ± Vent-free Days 13 ± ± Hospital Days 17 ± ± Hospital Mortality 85 (36%) 45 (36%) Chen et al, Chest Dec;148:

18 How can we improve recognition of ARDS? 1. Education 2. Automated sniffers 3. Use of SpO2/FiO2 to supplement blood gas data 4. Diagnostic biomarkers Is there a single or panel of biomarkers that can be used to diagnose ARDS?

19 Comparison of 11 plasma biomarkers in a case control study of sepsis patients with and without ARDS Ware et al, Critical Care 2013;17:R253

20 RAGE SPD CC16

21 ROC curve analysis for diagnosis of ARDS using 5 biomarker panel Plasma Biomarkers SP-D RAGE IL-8 CC16 IL-6 AUC 0.75 AUC 0.78 AUC 0.82 Ware et al, Critical Care 2013;17:R253

22 ROC curve analysis for diagnosis of ARDS in trauma patients biomarker panel Biomarkers RAGE Ang-2 CC16 IL-8 VWF SP-D TNF-a PCPIII BNP IL-10 PAI-1 Validation cohorts AUC 0.70, 0.78 Trauma Surg Acute Care Open August 28, 2 (1) e000121;

23 Summary Is it important to recognize ARDS YES! Opportunities for improving ARDS recognition Education Automation SpO2/FiO2 Diagnostic biomarkers