Epidemiology and outcome of acute lung injury in European intensive care units

Results from the ALIVE study

Abstract

Objectives

To re-examine the epidemiology of acute lung injury (ALI) in European intensive care units (ICUs).

Design and setting

A 2-month inception cohort study in 78 ICUs of 10 European countries.

Patients

All patients admitted for more than 4 h were screened for ALI and followed up to 2 months.

Measurements and main results

Acute lung injury occurred in 463 (7.1%) of 6,522 admissions and 16.1% of all mechanically ventilated patients; 65.4% cases occurred on ICU admission. Among 136 patients initially presenting with “mild ALI” (200< PaO2/FiO2 ≤300), 74 (55%) evolved to acute respiratory distress syndrome (ARDS) within 3 days. Sixty-two patients (13.4%) remained with mild ALI and 401 had ARDS. The crude ICU and hospital mortalities were 22.6% and 32.7% (p<0.001), and 49.4% and 57.9% (p=0.0005), respectively, for mild ALI and ARDS. ARDS patients initially received a mean tidal volume of 8.3±1.9 ml/kg and a mean PEEP of 7.7±3.6 cmH2O; air leaks occurred in 15.9%. After multivariate analysis, mortality was associated with age (odds ratio (OR) =1.2 per 10 years; 95% confidence interval (CI): 1.05–1.36), immuno-incompetence (OR: 2.88; Cl: 1.57–5.28), the severity scores SAPS II (OR: 1.16 per 10% expected mortality; Cl: 1.02–1.31) and logistic organ dysfunction (OR: 1.25 per point; Cl: 1.13–1.37), a pH less than 7.30 (OR: 1.88; Cl: 1.11–3.18) and early air leak (OR: 3.16; Cl: 1.59–6.28).

Conclusions

Acute lung injury was frequent in our sample of European ICUs (7.1%); one third of patients presented with mild ALI, but more than half rapidly evolved to ARDS. While the mortality of ARDS remains high, that of mild ALI is twice as low, confirming the grading of severity between the two forms of the syndrome.

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References

  1. 1.

    Ashbaugh DG, Bigelow DB, Petty TL, Levine BE (1967) Acute respiratory distress in adults. Lancet 2:319–323

    CAS  Article  Google Scholar 

  2. 2.

    Ware LB, Matthay MA (2000) The acute respiratory distress syndrome. N Engl J Med 342:1334–1349

    CAS  Article  Google Scholar 

  3. 3.

    Artigas A, Bernard GR, Carlet J, Dreyfuss D, Gattinoni L, Hudson LD, Lamy M, Marini JJ, Matthay MA, Pinsky MR, Spragg R, Suter PM (1998) The American-European consensus conference on ARDS, Part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies and issues related to recovery and remodeling. Intensive Care Med 24:378–398

    CAS  Article  Google Scholar 

  4. 4.

    Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson LD, Lamy M, Le Gall JR, Morris AH, Spragg R (1994) The American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes and clinical trials coordination. Am J Respir Crit Care Med 149:818–824

    CAS  Article  Google Scholar 

  5. 5.

    Villar J, Slutsky AS (1989) The incidence of the adult respiratory distress syndrome. Am Rev Respir Dis 140:814–816

    CAS  Article  Google Scholar 

  6. 6.

    Lewandowski K, Metz J, Deutschmann C, Prieβ H, Kuhlen R, Artigas A, Falke K (1995) Incidence, severity and mortality of acute respiratory failure in Berlin, Germany. Am J Respir Crit Care Med 151:1121–1125

    CAS  PubMed  Google Scholar 

  7. 7.

    Thomsen GE, Morris AH (1995) Incidence of the adult respiratory distress syndrome in the state of Utah. Am J Respir Crit Care Med 152:963–971

    Article  Google Scholar 

  8. 8.

    Luhr OR, Antonsen K, Karlsson M, Aardal S, Thorsteinsson A, Frostell CG, Bonde J (1999) Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark and Iceland. The ARF Study Group. Am J Respir Crit Care Med 159:1849–1861

    CAS  Article  Google Scholar 

  9. 9.

    Bersten AD, Edibam C, Hunt T, Moran J (2002) Incidence and mortality of acute lung injury and the acute respiratory distress syndrome in three Australian States. Am J Respir Crit Care Med 165:443–448

    Article  Google Scholar 

  10. 10.

    Goss CH, Brower RG, Hudson LD, Rubenfeld GD (2003) Incidence of acute lung injury in the United States. Crit Care Med 31:1607–1611

    Article  Google Scholar 

  11. 11.

    Monchi M, Bellenfant F, Cariou A, Joly LM, Thebert D, Laurent I, Dhainaut J-F, Brunet F (1998) Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. Am J Respir Crit Care Med 158:1076–1081

    CAS  Article  Google Scholar 

  12. 12.

    Roupie E, Lepage E, Wysocki M, Fagon JY, Chastre J, Dreyfuss D, Mentec H, Carlet J, Brun-Buisson C, Lemaire F, Brochard L (1999) Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. SRLF Collaborative Group on Mechanical Ventilation. Société de Réanimation de Langue Française. Intensive Care Med 25:920–929

    CAS  Article  Google Scholar 

  13. 13.

    Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguia C, Nightingale P, Arroliga AC, Tobin MJ (2002) Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 287:345–355

    Article  Google Scholar 

  14. 14.

    Suchyta MR, Clemmer TP, Elliot CG, Orme JFJ, Weaver LK (1992) The adult respiratory distress syndrome. A report of survival and modifying factors. Chest 101:1074–1079

    CAS  Article  Google Scholar 

  15. 15.

    Page B, Vieillard-Baron A, Beauchet A, Aegerter P, Prin S, Jardin F (2003) Low stretch ventilation strategy in acute respiratory distress syndrome: Eight years of clinical experience in a single center. Crit Care Med 31:765–769

    Article  Google Scholar 

  16. 16.

    Doyle RL, Szaflarski N, Modin GW, Wiener-Kronish JP, Matthay MA (1995) Identification of patients with acute lung injury. Predictors of mortality. Am J Respir Crit Care Med 152:1818–1824

    CAS  Article  Google Scholar 

  17. 17.

    Knaus WA, Sun X, Hakim RB, Wagner DP (1994) Evaluation of definitions for the adult respiratory distress syndrome. Am J Respir Crit Care Med 150:311–317

    CAS  Article  Google Scholar 

  18. 18.

    Sloane PJ, Gee MH, Gottlieb JE, Albertine KH, Peters SP, Burns JR, Machiedo G, Fish JE (1992) A multicenter registry of patients with acute respiratory distress syndrome. Physiology and outcome. Am Rev Respir Dis 146:419–426

    CAS  Article  Google Scholar 

  19. 19.

    Rubenfeld GD (2003) Epidemiology of acute lung injury. Crit Care Med 31:S276-S284

    Article  Google Scholar 

  20. 20.

    Vincent JL, Sakr Y, Ranieri VM (2003) Epidemiology and outcome of acute respiratory failure in intensive care unit patients. Crit Care Med 31:S296-S299

    CAS  Article  Google Scholar 

  21. 21.

    Villar J, Perez-Mendez L, Kacmarek RM (1999) Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome. Intensive Care Med 25:930–935

    CAS  Article  Google Scholar 

  22. 22.

    Artigas A, Carlet J, Le Gall JR, Chastang C, Blanch L, Fernandez R (1991) Clinical presentation, prognostic factors and outcome of ARDS in the European collaborative study, 1985–1987. In: Zapol W, Lemaire F (eds) Adult respiratory distress syndrome. Dekker, New York, pp 37–64

  23. 23.

    Le Gall JR, Klar J, Lemeshow S, Saulnier F, Alberti C, Artigas A, Teres D, The ICU Scoring Group (1996) The logistic organ dysfunction system: a new way to assess organ dysfunction in the intensive care unit. JAMA 276:802–810

    Article  Google Scholar 

  24. 24.

    Le Gall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on a European-North American multicenter study. JAMA 270:2957–2963

    Article  Google Scholar 

  25. 25.

    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II, a severity of disease classification system. Crit Care Med 13:818–829

    CAS  Article  Google Scholar 

  26. 26.

    Kay R, Little S (1987) Transformation of the explanatory variables in the logistic regression model for binary data. Biometrika 74:495–501

    Article  Google Scholar 

  27. 27.

    Hosmer DW, Lemeshow S (1989) Applied logistic regression. Wiley, New York, pp 84–106

  28. 28.

    Abel SJC, Finney SJ, Brett SJ, Keogh BF, Morgan CJ, Evans TW (1998) Reduced mortality in association with the acute respiratory distress syndrome (ARDS). Thorax 53:292–294

    CAS  Article  Google Scholar 

  29. 29.

    Milberg JA, Davis DR, Steinberg KP, Hudson LD (1995) Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983–1993. JAM A 273:306–309

    CAS  Article  Google Scholar 

  30. 30.

    Anzueto A, Baughman RP, Guntupalli KK, Weg JG, Wiederman HP, Artigas A, Lemaire F, Long W, Zaccardelli D, Pattishall EN, The Exosurf Acute Respiratory Distress Syndrome-Sepsis Study Group (1996) Aerosolized surfactant in adults with sepsis-induced acute respiratory distress syndrome. N Engl J Med 334:1417–1421

    CAS  Article  Google Scholar 

  31. 31.

    ARDS Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308

    Article  Google Scholar 

  32. 32.

    Krafft P, Fridrich P, Pernerstorfer T, Fitzgerald RD, Koc D, Schneider B, Hammerle AF, Stelzer H (1996) The acute respiratory distress syndrome: definitions, severity and clinical outcome. An analysis of 101 clinical investigations. Intensive Care Med 22:519–529

    CAS  Article  Google Scholar 

  33. 33.

    Eisner MD, Thompson T, Hudson LD, Luce JM, Hayden D, Schoenfeld D, Matthay MA (2001) Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung injury and the acute respiratory distress syndrome. Am J Respir Crit Care Med 164:231–236

    CAS  Article  Google Scholar 

  34. 34.

    Squara P, Dhainaut JF, Artigas A, Carlet J (1998) Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS Study. Intensive Care Med 24:1018–1028

    CAS  Article  Google Scholar 

  35. 35.

    Eisner MD, Thompson BT, Schoenfeld D, Anzueto A, Matthay MA (2002) Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress syndrome. Am J Respir Crit Care Med 165:978–982

    Article  Google Scholar 

  36. 36.

    Boussarsar M, Thierry G, Jaber S, Roudot-Thoraval F, Lemaire F, Brochard L (2002) Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome. Intensive Care Med 28:406–413

    Article  Google Scholar 

  37. 37.

    Gammon RB, Shin MS, Buchalter SE (1992) Pulmonary barotrauma in mechanical ventilation. Patterns and risk factors. Chest 102:568–572

    CAS  Article  Google Scholar 

  38. 38.

    Gammon RB, Shin MS, Groves RH, Hardin JM, Hsu C, Buchalter SE (1995) Clinical risk factors for pulmonary barotrauma: a multivariate analysis. Am J Respir Crit Care Med 152:1235–1240

    CAS  Article  Google Scholar 

  39. 39.

    Weg JG, Anzueto A, Balk RA, Wiederman HP, Pattishall EN, Schork MA, Wagner LA (1998) The relation of pneumothorax and other air leaks to mortality in the acute respiratory distress syndrome. N Engl J Med 338:341–346

    CAS  Article  Google Scholar 

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Acknowledgements

This study was supported by the Working Group on Acute Respiratory Failure of the European Society of Intensive Care Medicine and by an unrestricted grant from Marion Merell Dow. The authors thank the many ICU physicians across Europe who participated and devoted their time to the ALIVE study (See ‘Appendix’ in the ESM), and Prof. Laurent Brochard for his helpful suggestions.

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Correspondence to Christian Brun-Buisson.

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An erratum to this article is available at https://doi.org/10.1007/s00134-003-2136-x.

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Brun-Buisson, C., Minelli, C., Bertolini, G. et al. Epidemiology and outcome of acute lung injury in European intensive care units. Intensive Care Med 30, 51–61 (2004). https://doi.org/10.1007/s00134-003-2022-6

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Keywords

  • Epidemiology
  • Acute lung injury
  • Acute respiratory distress syndrome
  • Mechanical ventilation
  • Positive pressure ventilation
  • Barotrauma