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      Timing of Intubation and Clinical outcomes in Adults with ARDS

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          Abstract

          Objective

          The incidence, clinical characteristics and outcomes of critically-ill, non-intubated patients with evidence of the acute respiratory distress syndrome (ARDS) remain inadequately characterized.

          Design

          Secondary analysis of a prospective observational cohort study.

          Setting

          Vanderbilt University Medical Center.

          Patients

          Among adult patients enrolled in a large, multi-intensive care unit prospective cohort study between the years of 2006 and 2011, we studied intubated and non-intubated patients with ARDS as defined by acute hypoxemia (PaO 2/FiO 2 ≤ 300 or SpO 2/FiO 2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support.

          Interventions

          None.

          Measurements and Main Results

          Of 457 patients with ARDS, 106 (23%) were not intubated at the time of meeting all other ARDS criteria. Non-intubated patients had lower morbidity and severity of illness compared to intubated patients; however, mortality at 60 days was the same (36%) in both groups (P=0.91). Of the 106 non-intubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this “late” intubation subgroup had significantly higher 60-day mortality (56%) compared to both the “early” intubation group (36%, P<0.03) and to patients never requiring intubation (26%, P=0.002). Increased mortality in the “late” intubation group persisted at 2 years follow-up. Adjustment for baseline clinical and demographic differences did not change the results.

          Conclusions

          A substantial proportion of critically ill adults with ARDS were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining ARDS prior to need for positive pressure ventilation are needed so that these patients can be enrolled in clinical trials and to facilitate early recognition and treatment of ARDS.

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          Author and article information

          Journal
          0355501
          3206
          Crit Care Med
          Crit. Care Med.
          Critical care medicine
          0090-3493
          1530-0293
          16 February 2016
          January 2016
          01 January 2017
          : 44
          : 1
          : 120-129
          Affiliations
          [1 ]Department of Medicine, Divisions of Hospital Medicine, University of California, San Francisco
          [2 ]Department of Pathology, Microbiology and Immunology, Division of Allergy, Pulmonary and Critical Care Medicine, Taichung Veteran General Hospital, Taichung, Taiwan
          [3 ]Department of Critical Care Medicine, Taichung Veteran General Hospital, Taichung, Taiwan
          [4 ]Department of Medicine, Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine New Orleans
          [5 ]Department of Medicine, Pulmonary and Critical Care, University of California, San Francisco
          [6 ]Department Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco
          Author notes
          Corresponding author: Kirsten N. Kangelaris, Box 0131, 533 Parnassus Ave UC Hall, University of California, San Francisco, San Francisco, CA 94143-0131. kirsten.kangelaris@ 123456ucsf.edu , Telephone: (415) 476-4852, Fax: (415) 476-4818
          Article
          PMC4774861 PMC4774861 4774861 nihpa753236
          10.1097/CCM.0000000000001359
          4774861
          26474112
          d6a7e2e7-8318-4f53-983b-2bf9a15abe91
          History
          Categories
          Article

          Clinical Outcomes,Critical Care,Critical Illness,Mechanical Ventilation,Acute Respiratory Failure,Intensive Care,Early Acute Lung Injury,Acute respiratory distress syndrome,Acute lung injury

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