Embracing the Heterogeneity of ARDS

Maley, Jason H.; Thompson, B. Taylor

doi:10.1016/j.chest.2018.11.016

Cited by 13 publications

(10 citation statements)

References 12 publications

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“…The rapidly improving ARDS patients were not excluded in the present study. Twelve of 107 (11.2%) patients were rapidly improving ARDS in our study, which was similar to the previous RCT of ARDS (about 10–15%) [ 31 , 32 ]. Rapidly improving ARDS might negatively affect the prognostic enrichment and contribute to the failure of therapeutic trials [ 31 ].…”

Section: Discussionsupporting

confidence: 91%

Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial

Chi

Yang

et al. 2021

Crit Care

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Background Individualized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT) has potential interest in the optimization of ventilation distribution in acute respiratory distress syndrome (ARDS). The aim of the study was to determine whether early individualized titration of PEEP with EIT improved outcomes in patients with ARDS. Methods A total of 117 ARDS patients receiving mechanical ventilation were randomly assigned to EIT group (n = 61, PEEP adjusted based on ventilation distribution) or control group (n = 56, low PEEP/FiO2 table). The primary outcome was 28-day mortality. Secondary and exploratory outcomes were ventilator-free days, length of ICU stay, incidence of pneumothorax and barotrauma, and difference in Sequential Organ Failure Assessment (SOFA) score at day 1 (ΔD1-SOFA) and day 2 (ΔD2-SOFA) compared with baseline. Measurements and main results There was no statistical difference in the value of PEEP between the EIT group and control group, but the combination of PEEP and FiO2 was different between groups. In the control group, a significantly positive correlation was found between the PEEP value and the corresponding FiO2 (r = 0.47, p < 0.00001) since a given matched table was used for PEEP settings. Diverse combinations of PEEP and FiO2 were found in the EIT group (r = 0.05, p = 0.68). There was no significant difference in mortality rate (21% vs. 27%, EIT vs. control, p = 0.63), ICU length of stay (13.0 (7.0, 25.0) vs 10.0 (7.0, 14.8), median (25th–75th percentile); p = 0.17), and ventilator-free days at day 28 (14.0 (2.0, 23.0) vs 19.0 (0.0, 24.0), p = 0.55) between the two groups. The incidence of new barotrauma was zero. Compared with control group, significantly lower ΔD1-SOFA and ΔD2-SOFA were found in the EIT group (p < 0.001) in a post hoc comparison. Moreover, the EIT group exhibited a significant decrease of SOFA at day 2 compared with baseline (paired t-test, difference by − 1 (− 3.5, 0), p = 0.001). However, the control group did show a similar decrease (difference by 1 (− 2, 2), p = 0.131). Conclusion Our study showed a 6% absolute decrease in mortality in the EIT group: a statistically non-significant, but clinically non-negligible result. This result along with the showed improvement in organ function might justify further reserach to validate the beneficial effect of individualized EIT-guided PEEP setting on clinical outcomes of patients with ARDS. Trial registration: ClinicalTrials, NCT02361398. Registered 11 February 2015—prospectively registered, https://clinicaltrials.gov/show/NCT02361398.

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Section: Discussionsupporting

confidence: 91%

Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial

Chi

Yang

et al. 2021

Crit Care

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“…A subphenotype of ARDS characterised by rapid improvement (riARDS), who no longer met Berlin criteria or were extubated within one day of study enrolment has been described in ARDS network clinical trials. 18 It is possible that this group may consist of patients who have been misclassified as having ARDS due to limitations of the Berlin definition, 49 though it is also possible that this is a novel clinical or biological subphenotype.…”

Section: Clinical Ards Subphenotypesmentioning

confidence: 99%

Subphenotypes in critical care: translation into clinical practice

Reddy

Sinha

O'Kane

et al. 2020

The Lancet Respiratory Medicine

150

133

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Despite the progression of supportive care in intensive care medicine, advancements in disease-modifying therapeutic options have been slow. Many trials conducted in intensive care medicine have failed to identify treatment benefit. One of the reasons implicated is the underlying heterogeneity of critical care syndromes. There are numerous approaches proposed to dividing these populations into more meaningful subgroups (subphenotypes), though some may be more useful than others. Clinical and biomarker-driven subclassification systems have been proposed for acute respiratory distress syndrome, sepsis, acute kidney injury, and pancreatitis. Identifying those systems that are most useful and biologically-meaningful will lead to further understanding of the pathophysiology of critical care syndromes while also allowing us to focus recruitment in future therapeutic trials to predicted responders. This review discusses recently proposed subphenotypes of critical illness syndromes and highlights the issues that will need to be addressed in order to translate them into clinical practice. Key messages• A variety of subgroups (subphenotypes) of sepsis, acute kidney injury, and acute respiratory distress syndrome patients have been identified that differ in prevalence and mortality.• In retrospective analyses, some subphenotypes have shown differential treatment response to randomised interventions which showed no effect in the overall population.• Mechanistic studies in subphenotypes of critical illness syndromes may allow us to better understand their pathophysiological basis and develop novel targeted therapies.• In order to translate subphenotypes to the bedside, we will need to develop rapid realtime assays for subphenotype assignment, compare disparate subphenotyping strategies prospectively in heterogeneous cohorts, and freely share data.

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“…ARDS is a heterogeneous entity in its clinical presentation, course, and outcomes. [10][11][12] While it is often referred to as a distinct entity, the clinical syndrome of ARDS may be a collection of distinct types of lung injuries with similar appearances on chest radiographs and clinical presentations. Specifically within the peri-arrest context, a multitude of factors could precipitate and contribute to the development of ARDS such as aspiration, ventilator-induced injury, reperfusion injury, and pulmonary contusion.…”

Section: Discussionmentioning

confidence: 99%