Missed or delayed diagnosis of ARDS: a common and serious problem
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REVIEW
Missed or delayed diagnosis of ARDS: a common and serious problem Giacomo Bellani1,2, Tài Pham3 and John G. Laffey4,5* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Abstract Clinical recognition of acute respiratory distress syndrome (ARDS) is delayed or missed entirely in a substantial proportion of patients. In the LUNG SAFE study, the largest international cohort of patients with ARDS, investigators were able to determine if ARDS was present, and at what stage the clinician made the diagnosis of ARDS. The diagnosis of ARDS was delayed or missed in two-thirds of patients, with the diagnosis missed entirely in 40% of patients, while ARDS recognition ranged from 51% in mild ARDS to 79% in severe cases. Failure to recognize ARDS in a timely fashion leads to failure to use strategies that improve survival in ARDS. Early diagnosis of ARDS may facilitate measures to abrogate progression of the lung injury, including protective mechanical ventilation, fluid restriction, and adjunctive measures proven to improve survival such as prone positioning. Information overload and a complex ‘syndrome’ diagnosis likely play key roles in ARDS under-recognition. Clinical under-recognition has important consequences particularly in terms of therapeutic options not considered. The development of approaches to enable more timely recognition has the potential to save lives. Keywords: Acute respiratory distress syndrome, Diagnosis, Recognition, Therapy, Outcome Introduction Early recognition of acute respiratory distress syndrome (ARDS) may be important to facilitate measures to abrogate progression of the lung injury, including protective mechanical ventilation, fluid restriction, and adjunctive measures proven to improve survival such as prone positioning. ARDS diagnosis is delayed or missed entirely in a substantial proportion of patients. In the LUNG SAFE study, the largest existing international cohort of patients with ARDS, investigators were able to determine if ARDS was present, and at what stage the clinician made the diagnosis of ARDS [1]. The diagnosis of ARDS was delayed or missed in two-thirds of patients, with the diagnosis missed entirely in 40% of patients, while ARDS *Correspondence: [email protected] 5 Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland Full author information is available at the end of the article
recognition ranged from 51% in mild ARDS to 79% in severe cases [1].
Does ARDS under‑recognition matter? Yes, several lines of evidence suggest that recognition of ARDS influences patient management. Failure of clinicians to recognize ARDS is a barrier to the use of protective lung ventilation strategies [2, 3]. The importance of early recognition and management is underscored by the finding that patients receiving higher tidal volumes shortly after the onset of ARDS onset have a higher mortality, suggesting that high tidal volume is more injurious if used earlier [4]. While in the LUNG SAFE study, patients that clinicians reco
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