Impact of Clinician Recognition of Acute Respiratory Distress Syndrome on Evidenced-Based Interventions in the Medical ICU

Abstract

OBJECTIVES:. Acute respiratory distress syndrome is underrecognized in the ICU, but it remains uncertain if acute respiratory distress syndrome recognition affects evidence-based acute respiratory distress syndrome care in the modern era. We sought to determine the rate of clinician-recognized acute respiratory distress syndrome in an academic medical ICU and understand how clinician-recognized-acute respiratory distress syndrome affects clinical care and patient-centered outcomes. DESIGN:. Observational cohort study. SETTING:. Single medical ICU at an academic tertiary-care hospital. PATIENTS:. Nine hundred seventy-seven critically ill adults (381 with expert-adjudicated acute respiratory distress syndrome) enrolled from 2006 to 2015. INTERVENTIONS:. Clinician-recognized-acute respiratory distress syndrome was identified using an electronic keyword search of clinical notes in the electronic health record. We assessed the classification performance of clinician-recognized acute respiratory distress syndrome for identifying expert-adjudicated acute respiratory distress syndrome. We also compared differences in ventilator settings, diuretic prescriptions, and cumulative fluid balance between clinician-recognized acute respiratory distress syndrome and unrecognized acute respiratory distress syndrome. MEASUREMENTS AND MAIN RESULTS:. Overall, clinician-recognized-acute respiratory distress syndrome had a sensitivity of 47.5%, specificity 91.1%, positive predictive value 77.4%, and negative predictive value 73.1% for expert-adjudicated acute respiratory distress syndrome. Among the 381 expert-adjudicated acute respiratory distress syndrome cases, we did not observe any differences in ventilator tidal volumes between clinician-recognized-acute respiratory distress syndrome and unrecognized acute respiratory distress syndrome, but clinician-recognized-acute respiratory distress syndrome patients had a more negative cumulative fluid balance (mean difference, –781 mL; 95% CI, [–1,846 to +283]) and were more likely to receive diuretics (49.3% vs 35.7%, p = 0.02). There were no differences in mortality, ICU length of stay, or ventilator-free days. CONCLUSIONS:. Acute respiratory distress syndrome recognition was low in this single-center study. Although acute respiratory distress syndrome recognition was not associated with lower ventilator volumes, it was associated with differences in behaviors related to fluid management. These findings have implications for the design of future studies promoting evidence-based acute respiratory distress syndrome interventions in the ICU.