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      National survey of outcomes and practices in acute respiratory distress syndrome in Singapore

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          Abstract

          Introduction

          In the past 20 years, our understanding of acute respiratory distress syndrome (ARDS) management has improved, but the worldwide incidence and current outcomes are unclear. The reported incidence is highly variable, and no studies specifically characterise ARDS epidemiology in Asia. This observation study aims to determine the incidence, mortality and management practices of ARDS in a high income South East Asian country.

          Methods

          We conducted a prospective, population based observational study in 6 public hospitals. During a one month period, we identified all ARDS patients admitted to public hospital intensive care units (ICU) in Singapore, according to the Berlin definition. Demographic information, clinical management data and ICU outcome data was collected.

          Results

          A total of 904 adult patients were admitted to ICU during the study period and 15 patients met ARDS criteria. The unadjusted incidence of ARDS was 4.5 cases per 100,000 population, accounting for 1.25% of all ICU patients. Most patients were male (75%), Chinese (62%), had pneumonia (73%), and were admitted to a Medical ICU (56%). Management strategies varied across all ICUs. In-hospital mortality was 40% and median length of ICU stay was 7 days.

          Conclusion

          The incidence of ARDS in a developed S.E Asia country is comparable to reported rates in European studies.

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          Most cited references29

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          Acute respiratory distress syndrome: the Berlin Definition.

          V Ranieri, Gordon D Rubenfeld, B Taylor Thompson … (2013)
          The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.
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            Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries.

            Giacomo Bellani, John Laffey, Tài Pham … (2016)
            Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS).
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              Driving pressure and survival in the acute respiratory distress syndrome.

              Marcelo Amato, Maureen Meade, Arthur Slutsky … (2015)
              Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (VT), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (CRS) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size), we hypothesized that driving pressure (ΔP=VT/CRS), in which VT is intrinsically normalized to functional lung size (instead of predicted lung size in healthy persons), would be an index more strongly associated with survival than VT or PEEP in patients who are not actively breathing.
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                Author and article information

                Contributors
                Chiara Lazzeri: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 16 June 2017
                Publication date Collection: 2017
                Volume: 12
                Issue: 6
                Electronic Location Identifier: e0179343
                Affiliations
                [1 ]Khoo Teck Puat Hospital, Yishun, Singapore, Singapore
                [2 ]Departments of Medicine, Anaesthesia and Surgery, National University Hospital, National University Health System, Singapore, Singapore
                [3 ]Centre for Human Health and Performance, University College London, London, United Kingdom
                [4 ]Departments of Medicine and Anaesthesia, Tan Tock Seng Hospital, Singapore, Singapore
                [5 ]Department of Medicine and Anaesthesia, Changi General Hospital, Singapore, Singapore
                [6 ]Department of Medicine and Anaesthesia, Singapore General Hospital, Singapore, Singapore
                [7 ]Department of Critical Care, Ng Teng Fong General Hospital, Jurong Health, Singapore, Singapore
                [8 ]School of Nursing, Ngee Ann Polytechnic, Singapore, Singapore
                Azienda Ospedaliero Universitaria Careggi, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: SS MC.

                • Data curation: SS JP BH ZP J. Tan CS NLL CRS CML AYT AM FAK AJ AHT GM J. Taculod BR TAH MC.

                • Formal analysis: SS MC.

                • Funding acquisition: SS MC JP.

                • Investigation: SS MC.

                • Methodology: SS MC JP.

                • Project administration: SS JP BH ZP J. Tan CS NLL CRS CML AYT AM FAK AJ AHT GM J. Taculod BR TAH MC.

                • Resources: SS JP BH ZP J. Tan CS NLL CRS CML AYT AM FAK AJ AHT GM J. Taculod BR TAH MC.

                • Software: MC.

                • Supervision: SS MC GM JP ZP.

                • Validation: SS MC.

                • Visualization: SS MC JP ZP.

                • Writing – original draft: SS MC.

                • Writing – review & editing: JP ZP GM.

                Author information
                http://orcid.org/0000-0003-3686-2190
                Article
                Publisher ID: PONE-D-17-04252
                DOI: 10.1371/journal.pone.0179343
                PMC ID: 5473557
                PubMed ID: 28622342
                SO-VID: 3a5e2e7b-42c2-46a5-ba44-f589842a4cdc
                Copyright © © 2017 Siddiqui et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 2 February 2017
                Date accepted : 26 May 2017
                Page count
                Figures: 0, Tables: 2, Pages: 9
                Funding
                Funded by: SICM NICER
                Award ID: n/a
                Award Recipient :
                ORCID: http://orcid.org/0000-0003-3686-2190
                Funded by: funder-id http://dx.doi.org/10.13039/501100001349, National Medical Research Council;
                Award ID: NMRC/TA/0015/2013
                Award Recipient :
                The authors acknowledge the following as the total funding sources for this study: 1. SICM NICER grant: logistical, non-monetary, support from the Society of Intensive Care Medicine Singapore. This was in the form of Ngee Ann Polytechnic students (8) who collected the data for the study for one month. 2. NMRC (National medical research council) grant for Dr, Matthew Cove (partial support for this study): This was in the shape of salary support for all his research related activity. (NMRC/TA/0015/2013) (MEC). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Acute Respiratory Distress Syndrome
                Subject: Medicine and Health Sciences
                Subject: Critical Care and Emergency Medicine
                Subject: Respiratory Failure
                Subject: Acute Respiratory Distress Syndrome
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Respiratory Failure
                Subject: Acute Respiratory Distress Syndrome
                Subject: People and Places
                Subject: Geographical Locations
                Subject: Asia
                Subject: Singapore
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Care Facilities
                Subject: Hospitals
                Subject: Intensive Care Units
                Subject: People and Places
                Subject: Geographical Locations
                Subject: Asia
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Care Facilities
                Subject: Hospitals
                Subject: People and places
                Subject: Population groupings
                Subject: Ethnicities
                Subject: Ethnic Malays
                Subject: People and Places
                Subject: Population Groupings
                Subject: Ethnicities
                Subject: Chinese People
                Subject: Medicine and Health Sciences
                Subject: Pulmonology
                Subject: Pneumonia
                Custom metadata
                Data Availability Our ethics approval only approves use of the data for the purposes of this study, and only grants access to the data by specified investigators because it contains identifiable data. Therefore, the full data set cannot be made freely available without breaching our IRB guidelines. It can be made available upon request. Requestor would first need IRB approval from Singapore’s Domain Specific Institutional Review Board (DSRB). A version of the data file with all identifiers removed is included as Supporting Information, and original data can be obtained from authors after permission from DSRB at dsrb@ 123456nhg.com.sg .

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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