“…Moreover, studies in patients with ARDS and cancer have also demonstrated a trend toward improved survival. 33,37 Thus, enrolling cancer patients in randomized clinical trials is important. 38…”
ARDS has a high mortality in the acute setting, with long-term disability among disease survivors. In 1967, David Ashbaugh and colleagues first described the clinical features of ARDS, which were notably similar to the infantile respiratory distress syndrome. Half a century later, ARDS remains underrecognized and is associated with high mortality rates. Valuable insights from observational studies fail to demonstrate a mortality benefit in randomized controlled trials (RCTs). In the absence of a pharmacologic cure, supportive ventilator strategies limit rather than treat the ongoing lung injury. Interestingly, ARDS has higher mortality rates in observational studies compared to RCTs. Comparing mortality rates between ARDS studies and trials is problematic, partly due to varying time-points at which mortality is reported. Discerning the true mortality attributable to ARDS is also difficult. The diagnostic criteria for ARDS are mainly clinical and lack the objectivity of a laboratory test or biomarker. Nonetheless, these factors are common to both studies and trials, and fail to explain the higher mortality rate of ARDS observational studies. Disease heterogeneity and complex patient characteristics can also confound mortality estimation in ARDS. We therefore examined patient and trial factors that could influence mortality outcomes in ARDS observational studies and RCTs. Unlike RCTs, observational studies include ARDS subjects with severe comorbidities and those requesting limited care. Less stringent selection criteria could thereby contribute to high mortality rates in ARDS observational studies. In contrast, exclusion criteria in RCTs meticulously scrutinize patient characteristics, confining the type and number of eligible subjects. As a result, the task of identifying, consenting, and randomizing eligible patients within the enrollment window is challenging, further decreasing the number of subjects enrolled. Moreover, ARDS RCTs strictly adhere to lung-protective strategies, while ARDS observational studies continually demonstrate variable compliance. This review highlights the impact of patient- and trial-related factors on influencing mortality rates in ARDS observational studies and RCTs.
“…Moreover, studies in patients with ARDS and cancer have also demonstrated a trend toward improved survival. 33,37 Thus, enrolling cancer patients in randomized clinical trials is important. 38…”
ARDS has a high mortality in the acute setting, with long-term disability among disease survivors. In 1967, David Ashbaugh and colleagues first described the clinical features of ARDS, which were notably similar to the infantile respiratory distress syndrome. Half a century later, ARDS remains underrecognized and is associated with high mortality rates. Valuable insights from observational studies fail to demonstrate a mortality benefit in randomized controlled trials (RCTs). In the absence of a pharmacologic cure, supportive ventilator strategies limit rather than treat the ongoing lung injury. Interestingly, ARDS has higher mortality rates in observational studies compared to RCTs. Comparing mortality rates between ARDS studies and trials is problematic, partly due to varying time-points at which mortality is reported. Discerning the true mortality attributable to ARDS is also difficult. The diagnostic criteria for ARDS are mainly clinical and lack the objectivity of a laboratory test or biomarker. Nonetheless, these factors are common to both studies and trials, and fail to explain the higher mortality rate of ARDS observational studies. Disease heterogeneity and complex patient characteristics can also confound mortality estimation in ARDS. We therefore examined patient and trial factors that could influence mortality outcomes in ARDS observational studies and RCTs. Unlike RCTs, observational studies include ARDS subjects with severe comorbidities and those requesting limited care. Less stringent selection criteria could thereby contribute to high mortality rates in ARDS observational studies. In contrast, exclusion criteria in RCTs meticulously scrutinize patient characteristics, confining the type and number of eligible subjects. As a result, the task of identifying, consenting, and randomizing eligible patients within the enrollment window is challenging, further decreasing the number of subjects enrolled. Moreover, ARDS RCTs strictly adhere to lung-protective strategies, while ARDS observational studies continually demonstrate variable compliance. This review highlights the impact of patient- and trial-related factors on influencing mortality rates in ARDS observational studies and RCTs.
“…These patients were mainly receiving thoracic irradiation for lung cancer and to a lesser extent Hodgkin lymphoma [10,11]. It is difficult to determine an accurate survival rate for patients with malignancies who develop ARDS, since these patients are generally excluded from the majority of observational studies and interventional trials [12]. Nonetheless, in one study, Azoulay et al concluded that patients with solid tumors, including breast cancer, who developed ARDS had a lower mortality rate compared to patients with hematological malignancies [13].…”
Unusual or unexpected effect of treatment Background:Radiotherapy is often used as an adjuvant therapy in breast cancer following surgical resection of the primary malignant tumor. It has multiple respiratory side effects, but acute respiratory distress syndrome (ARDS) is a rare complication. We describe here the case of a woman with breast cancer who developed ARDS 1 week after her final radiotherapy session.
Case Report:A 69-year-old female with breast cancer presented 1 week after her final session of radiotherapy. She had developed a sudden onset of hypotension unresponsive to fluids, oxygen desaturation unresponsive to high flow oxygen, and new bilateral infiltrates had appeared on chest x-ray (CXR) predominant in the left upper lobe, which was interestingly the main area affected by the radiotherapy beams. A diagnosis of atypical ARDS secondary to radiotherapy was established. She was intubated and a low tidal volume/high positive end-expiratory pressure (PEEP) strategy was utilized to manage her condition. After 48 hours, the infiltrates diminished remarkably, and she was extubated the following day. On discharge, she had a completely normal CXR; a computed tomography (CT) chest performed 1 month later showed complete resolution of the alveolar opacities.
Conclusions:ARDS remains an extremely rare complication of thoracic radiotherapy. However, physicians must be wary of its development in order to diagnose it quickly and treat accordingly.
“…The change in mortality for adult cancer patients with ARDS is striking: 89 % mortality 1990–1995 vs. 52 % 2007–2011 [14]. This raises the possibility of a greater gain from more widespread use of non-invasive ventilation in this population [15, 16]. This hypothesis is currently under investigation in children (“SCARF” trial ISRCTN82853500) and adults (“IVNICTUS” trial NCT01915719).Fig.…”
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