Background
Methods
Setting and patients
Demographic, clinical, and laboratory data
Statistical analysis
Competing risks analysis
Results
The study
Patients’ characteristics
Variables | NC-ARDS (n = 82) | C-ARDS (n = 90) | p value |
---|---|---|---|
Age, median [IQR] | 63 [57–71] | 59 [53–69] | 0.09 |
Male gender | 54 (66%) | 74 (82%) | 0.01 |
Medical history | |||
Mc Cabe and Jackson classification | < 0.001 | ||
No underlying disease | 47 (57%) | 76 (84%) | |
Ultimately fatal | 24 (29%) | 12 (13%) | |
Rapidly fatal disease | 11 (14%) | 2 (2%) | |
Charlson comorbidity index | 2 [1–3] | 1 [0–2] | < 0.001 |
Diabetes mellitus | 23 (28%) | 39 (43%) | 0.037 |
Congestive heart failure (NYHA 3–4) | 6 (7%) | 7 (8%) | 0.91 |
Supraventricular arrhythmia | 12 (15%) | 8 (9%) | 0.24 |
Hypertension | 36 (44%) | 59 (66%) | 0.004 |
COPD | 10 (12%) | 9 (10%) | 0.64 |
Chronic renal failure | 11 (13%) | 14 (16%) | 0.69 |
Dialysis | 3 (4%) | 2 (2%) | 0.67 |
Stroke | 5 (6%) | 4 (4%) | 0.74 |
Liver cirrhosis (Child C) | 1 (1%) | 0 | 0.48 |
Current smoking | 22 (27%) | 25 (28%) | 0.89 |
Immunosuppression conditions | 40 (49%) | 16 (18%) | < 0.001 |
Solid cancer | 4 (5%) | 5 (6%) | 0.99 |
Blood cancer | 17 (21%) | 1 (1%) | < 0.001 |
Organ transplant | 9 (11%) | 5 (6%) | 0.19 |
HIV infection | 4 (5%) | 3 (3%) | 0.71 |
Sickle cell disease | 2 (2%) | 3 (3%) | 0.99 |
Others | 5 (6%) | 2 (2%) | 0.26 |
Clinical characteristics upon ICU admission | |||
SAPS II | 49 [37–67] | 36 [27–45] | < 0.001 |
Baseline SOFA—median [IQR] | 9 [5–12] | 7 [4–8] | < 0.001 |
PaO2/FiO2 ratio (mmHg) median [IQR] | 162 [101–210] | 120 [92–163] | 0.005 |
ARDS classification (Berlin definition) | 0.018 | ||
Mild | 24 (29%) | 11 (12%) | |
Moderate | 39 (48%) | 49 (54%) | |
Severe | 19 (23%) | 30 (33%) | |
Norepinephrine, n (%) | 43 (52%) | 42 (47%) | 0.45 |
Serum creatinine (µmol/L) | 108 [72–195] | 83 [6–128] | 0.004 |
White blood cell count (× 109/L) | 7.5 [0–15] | 8.2 [5–12] | 0.49 |
Lymphocyte count (× 109/L) | 0.6 [0.3–1.1] | 0.8 [0.5–1.2] | 0.03 |
Lymphocyte count (× 109/L) in non-immunocompromised patients | 0.8 [0.4–1.2] | 0.8 [0.5–1.2] | 0.62 |
Documented bacterial coinfection | 38 (48%) | 14 (16%) | < 0.001 |
Treatment during the first 24 h | |||
Antibiotics | 81 (99%) | 90 (100%) | 0.48 |
Antiviral treatment | 58 (71%) | 69 (76%) | 0.39 |
Corticosteroids (any dose)* | 30/81 (37%) | 12/87 (14%) | 0.001 |
Corticosteroids (low dose)*# | 29/81 (36%) | 10/87 (12%) | < 0.001 |
Corticosteroids (high dose)* | 1/81 (1%) | 2/87 (2%) | 0.60 |
ARDS treatment during ICU stay | |||
Corticosteroids (any dose)* | 37/81 (46%) | 35 /87 (40%) | 0.48 |
Corticosteroids (low dose)*# | 33/81 (41%) | 25/87 (29%) | 0.10 |
Corticosteroids (high dose)* | 3/81 (4%) | 10/87 (12%) | 0.06 |
Prone position | 34 (42%) | 75 (83%) | < 0.001 |
Neuromuscular blockade | 53 (65%) | 83 (92%) | < 0.001 |
Inhaled nitric oxide | 10 (12%) | 31 (34%) | 0.01 |
Extra-corporeal membrane oxygenation | 9 (11%) | 23 (26%) | 0.014 |
ICU-acquired infections | |||
First VAP | 36 (44%) | 58 (64%) | 0.007 |
Number of days of mechanical ventilation before first VAP | 7 [5–9] | 8 [5–12] | 0.89 |
Number of VAP during ICU | 0 [0–1] | 1 [0–2] | < 0.001 |
Recurrent VAP | 10 (12%) | 22 (25%) | 0.36 |
MDR VAP during ICU stay | 9 (11%) | 21 (23%) | 0.03 |
ESBL PE VAP | 9 (11%) | 18 (20%) | 0.10 |
MRSA VAP | 0 | 1 (1%) | 0.99 |
CRE VAP | 0 | 3 (3%) | 0.095 |
Sampling frequency (number/day of MV) | 0.23 [0.14–0.37] | 0.32 [0.20–0.38] | 0.03 |
Organ support and outcome during ICU stay | |||
Subglottic secretion drainage | 26 (32%) | 42 (47%) | 0.045 |
Renal replacement therapy during ICU stay | 28 (34%) | 30 (33%) | 0.91 |
Norepinephrine, n (%) | 66 (81%) | 67 (74%) | 0.34 |
ICU length of stay among survivors, days | 15 [10–20] | 30 [19–45] | < 0.001 |
Successful mechanical ventilation weaning | 54 (66%) | 46 (51%) | 0.05 |
Death at day 28 | 25 (31%) | 36 (40%) | 0.19 |
Death in the ICU | 27 (33%) | 37 (41%) | 0.27 |
Still in ICU or in weaning center (until May 28th, 2020) | 0 | 8 (9%) | 0.007 |
Coinfection at ICU admission
VAP occurrence and risk factors
VAP documentation and management
Microorganisms | NC-ARDS (n = 36) | C-ARDS (n = 58) |
---|---|---|
Gram-negative bacilli | ||
Haemophilus sp | 4 (11%) | 0 |
Enterobacteriaceae | 17 (47%) | 42 (72%) |
Enterobacter sp | 4 (11%) | 23 (40%) |
Klebsiella pneumoniae | 6 (17%) | 4 (7%) |
Citrobacter sp | 1 (3%) | 2 (4%) |
Escherichia coli | 4 (11%) | 10 (17%) |
Hafnia | 0 | 2 (4%) |
Morganella morganii | 1 (3%) | 0 |
Serratia | 2 (6%) | 1 (2%) |
Proteus | 0 | 4 (7%) |
Extended-spectrum beta-lactamase-producing enterobacteriaceae | 7 (19%) | 10 (18%) |
Carbapenem-resistant enterobacteriaceae | 0 | 1 (2%) |
Non-fermenting gram-negative bacilli | 20 (56%) | 24 (41%) |
Acinetobacter sp | 1 (3%) | 1 (2%) |
Pseudomonas sp | 17 (47%) | 16 (28%) |
Burkholderia Cepacia | 0 | 1 (2%) |
Stenotrophomonas maltophilia | 2 (6%) | 3 (5%) |
Gram-positive bacteria | 0 | 4 (3%) |
Streptococcus pneumoniae | 0 | 0 |
Others Streptococcus sp | 0 | 2 (4%) |
Methicillin-sensitive Staphylococcus aureus | 0 | 2 (4%) |
Methicillin-resistant Staphylococcus aureus | 0 | 0 |
Enterococcus faecalis | 0 | 1 (2%) |
Polymicrobial | 4 (11%) | 13 (22%) |
Diagnostic sampling techniques | ||
Bronchoalveolar lavage | 4 (11%) | 3 (5%) |
Blind protected telescope catheter | 32 (89%) | 55 (95%) |
Invasive aspergillosis
NC-ARDS (n = 82) | C-ARDS (n = 90) | p value | |
---|---|---|---|
IAPA case definition | |||
Proven invasive pulmonary aspergillosis: Biopsy or brush specimen of airway plaque, pseudomembrane, or ulcer showing hyphal elements and Aspergillus growth on culture or positive Aspergillus PCR on tissue. Lung biopsy showing invasive fungal elements and Aspergillus growth on culture or positive Aspergillus PCR on tissue | 0 | 0 | |
Probable invasive pulmonary aspergillosis | 17 (21%) | 7 (8%) | 0.01 |
Probable invasive pulmonary aspergillosis diagnosed at ICU admission | 9 (53%) | 3 (43%) | |
Time from admission to diagnosis of probable pulmonary aspergillosis during ICU stay, days | 10 [7–14] | 6 [5–11] | |
Aspergillus tracheobronchitis | 1 (1%) | 1 (1%) | 0.95 |
Airway plaque, pseudomembrane, or ulcer | 3/49 | 1/24 | |
IAPA in patients without documented Aspergillus tracheobronchitis | 16 (20%) | 6 (7%) | 0.01 |
Pulmonary infiltrate | 82 | 90 | |
Cavitating infiltrate (not attributed to another cause) | 1 | 1 | |
Serum GM index > 0.5 | 6/40 | 5/88 | |
BAL GM index ≥ 1.0 | 5/31 | 0/0 | |
Positive BAL culture | 10/50 | 4/24 | |
Crude AspICU criteria | |||
Proven invasive pulmonary aspergillosis: | 0 | 0 | |
Putative invasive pulmonary aspergillosis | 12 (15%) | 2 (2%) | 0.003 |
1. Aspergillus-positive lower respiratory tract specimen culture* | 17 | 6 | |
2. Compatible signs and symptoms | 16 | 6 | |
3. Abnormal medical imaging by portable chest X-ray or CT-scan | 14 | 5 | |
4a. Host risk factors | 9 | 0 | |
4b. Semiquantitative Aspergillus-positive culture of BAL fluid (+ or ++), without bacterial growth together with a positive cytological smear showing branching hyphae | 8 | 2 | |
Colonization | 5 (6%) | 4 (5%) | 0.63 |
Modified AspICU criteria | |||
Proven invasive pulmonary aspergillosis: | 0 | 0 | |
Putative invasive pulmonary aspergillosis | 15 (18%) | 6 (7%) | 0.02 |
Mycological criteria | 18 | 7 | |
Histopathology or direct microscopic evidence of dichotomous septate hyphae with positive culture for Aspergillus on tissue | 0 | 0 | |
Serum GM index > 0.5 | 6/40 | 5/88 | |
BAL GM index ≥ 1.0 | 5/31 | 0/0 | |
Positive BAL culture | 10/50 | 4/24 | |
Compatible signs and symptoms§ | 17/18 | 6/7 | |
Abnormal medical imaging by portable chest X-ray or CT-scan§ | 16/18 | 7/7 | |
Other diagnostic criteria | |||
Aspergillus PCR on lower respiratory tract: positive cases / performed cases | 0 /7 (0%) | 16 /81(20%) | |
1,3-β-D-glucan: positive cases /performed cases | 8/23(35%) | 9 /88(10%) |