Background

The impact of underlying comorbidities on the clinical presentation, management and outcomes in patients with ARDS is poorly understood and deserves further investigation.

Objectives

We examined these issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study.

Methods

In this secondary analysis of the patient cohort enrolled in the LUNG SAFE study, our primary objective was to determine the frequency, and impact of comorbidities on the management and ICU survival of patients with ARDS. Secondary outcomes relating to comorbidities included their impact on ventilatory management, the development of organ failures, and on end-of-life care.

Results

Of 2813 patients in the study population, 1692 (60%) had 1 or more comorbidities, of whom 631 (22.4%) had chronic respiratory impairment, 290 (10.3%) had congestive heart failure, 286 (10.2%) had chronic renal failure, 112 (4%) had chronic liver failure, 584 (20.8%) had immune incompetence, and 613 (21.8%) had diabetes. Multiple comorbidities were frequently present, with 423 (25%) having 2 and 182 (11%) having at least 3 or more comorbidities. The use of invasive ventilation (1379 versus 998, 82 versus 89%), neuromuscular blockade (301 versus 249, 18 versus 22%), prone positioning (97 versus 104, 6 versus 9%) and ECMO (32 versus 46, 2 versus 4%) were each significantly reduced in patients with comorbidities as compared to patients with no comorbidity (1692 versus 1121, 60 versus 40%). ICU mortality increased from 27% (n = 303) in patients with no comorbidity to 39% (n = 661) in patients with any comorbidity. Congestive heart failure, chronic liver failure and immune incompetence were each independently associated with increased ICU mortality. Chronic liver failure and immune incompetence were independently associated with more decisions to limitation of life supporting measures.

Conclusions

Most patients with ARDS have significant comorbidities, they receive less aggressive care, and have worse outcomes. Enhancing the care of these patients must be a priority for future clinical studies.

Trial registration LUNG-SAFE is registered with ClinicalTrials.gov, number NCT02010073.

中文翻译：

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合并症的存在改变了急性呼吸窘迫综合征患者的管理并恶化了患者的预后：来自 LUNG SAFE 研究的见解

背景

潜在合并症对 ARDS 患者临床表现、管理和结局的影响知之甚少，值得进一步研究。

目标

我们在参加大型观察性研究的ARDS患者中检查了这些问题，以了解严重急性呼吸衰竭 (LUNG SAFE) 研究的全球影响。

方法

在对参加 LUNG SAFE 研究的患者队列进行的二次分析中，我们的主要目标是确定合并症对 ARDS 患者的管理和 ICU 生存率的频率和影响。与合并症相关的次要结果包括它们对通气管理、器官衰竭的发展和临终关怀的影响。

结果

在研究人群中的 2813 名患者中，1692 名（60%）患有 1 种或多种合并症，其中 631 名（22.4%）患有慢性呼吸功能障碍，290 名（10.3%）患有充血性心力衰竭，286 名（10.2%）患有慢性肾衰竭, 112 人 (4%) 患有慢性肝功能衰竭, 584 人 (20.8%) 患有免疫功能不全, 613 人 (21.8%) 患有糖尿病。经常存在多种合并症，其中 423 例 (25%) 有 2 种，182 例 (11%) 有至少 3 种或更多合并症。使用有创通气（1379 对 998、82 对 89%）、神经肌肉阻滞（301 对 249、18 对 22%）、俯卧位（97 对 104、6 对 9%）和 ECMO（32 对 46、2 对与没有合并症的患者相比，合并症患者的死亡率均显着降低（1692 对 1121，60 对 40%）。ICU 死亡率从 27% ( n = 303) 在没有合并症的患者中占 39% ( n  = 661) 在有任何合并症的患者中。充血性心力衰竭、慢性肝功能衰竭和免疫功能不全与ICU死亡率增加独立相关。慢性肝功能衰竭和免疫功能不全与更多限制生命支持措施的决定独立相关。

结论

大多数 ARDS 患者有严重的合并症，他们接受的治疗不太积极，结果也更差。加强对这些患者的护理必须是未来临床研究的优先事项。

试验注册LUNG-SAFE 在 ClinicalTrials.gov 注册，编号为 NCT02010073。