Acute respiratory distress syndrome: Underrecognition by clinicians

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.