title: The epidemiology of acute respiratory distress syndrome in patients presenting to the emergency department with severe sepsis.
abstract: BACKGROUND
  Acute respiratory distress syndrome (ARDS) is a serious complication of sepsis, and sepsis-associated ARDS is associated with significant morbidity and mortality. To date, no study has directly examined the epidemiology of ARDS in severe sepsis from the earliest presentation to the health care system, the emergency department (ED).
  
  
  METHODS
  This was a single-center retrospective, observational cohort study of 778 adults with severe sepsis presenting to the ED. The primary outcome was the development of ARDS requiring mechanical ventilation during the first 5 hospital days. Acute respiratory distress syndrome was defined using the Berlin definition. We used multivariable logistic regression to identify risk factors associated independently with ARDS development.
  
  
  RESULTS
  The incidence of ARDS was 6.2% (48/778 patients) in the entire cohort. Acute respiratory distress syndrome development varied across the continuum of care: 0.9% of patients fulfilled criteria for ARDS in the ED, 1.4% admitted to the ward developed ARDS, and 8.9% admitted to the intensive care unit developed ARDS. Acute respiratory distress syndrome developed a median of 1 day after admission and was associated with a 4-fold higher risk of in-hospital mortality (14% vs. 60%, P < 0.001). Independent risk factors associated with increased risk of ARDS development included intermediate (2-3.9 mmol/L) (P = 0.04) and high (≥4) serum lactate levels (P = 0.008), Lung Injury Prediction score (P < 0.001), and microbiologically proven infection (P = 0.01).
  
  
  CONCLUSIONS
  In patients presenting to the ED with severe sepsis, the rate of sepsis-associated ARDS development varied across the continuum of care. Acute respiratory distress syndrome developed rapidly and was associated with significant mortality. Elevated serum lactate levels in the ED and a recently validated clinical prediction score were independently associated with the development of ARDS in severe sepsis.
authors.affiliation: *Pulmonary, Allergy, and Critical Care Division, Department of Medicine, and †Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‡Pulmonary and Allergy Associates, Morristown, New Jersey, and §Morristown Medical Center, Morristown, New Jersey; ∥Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ¶Department of Anesthesiology, Columbia University Medical Center, New York, New York; and #Department of Emergency Medicine, Medstar Washington Hospital Center, Washington, DC, and **Georgetown University School of Medicine, Washington, DC.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.forename: Chirag V
authors.initials: CV
authors.lastname: Shah
authors.forename: Nuala J
authors.initials: NJ
authors.lastname: Meyer
authors.forename: David F
authors.initials: DF
authors.lastname: Gaieski
authors.forename: Sarah
authors.initials: S
authors.lastname: Lyon
authors.forename: Andrea N
authors.initials: AN
authors.lastname: Miltiades
authors.forename: Munish
authors.initials: M
authors.lastname: Goyal
authors.forename: Barry D
authors.initials: BD
authors.lastname: Fuchs
authors.forename: Scarlett L
authors.initials: SL
authors.lastname: Bellamy
authors.forename: Jason D
authors.initials: JD
authors.lastname: Christie
mesh_terms: D018806:APACHE; D000368:Aged; D015415:Biomarkers / Q000097:blood; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D019344:Lactic Acid / Q000097:blood; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania / Q000453:epidemiology; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D018805:Sepsis / Q000150:complications / Q000453:epidemiology*
chemical_list: D015415:Biomarkers; D019344:Lactic Acid
references.citation: Am J Respir Crit Care Med. 2013 Apr 1;187(7):736-42
references.pmid: 23328529
references.citation: Chest. 1983 Jan;83(1):40-2
references.pmid: 6848333
references.citation: Crit Care Med. 2013 May;41(5):1167-74
references.pmid: 23442987
references.citation: Am J Epidemiol. 1993 Dec 1;138(11):923-36
references.pmid: 8256780
references.citation: N Engl J Med. 2005 Oct 20;353(16):1685-93
references.pmid: 16236739
references.citation: Crit Care Med. 2007 May;35(5):1284-9
references.pmid: 17414725
references.citation: Am J Respir Crit Care Med. 2012 Jun 15;185(12):1307-15
references.pmid: 22492988
references.citation: Chest. 1999 Jul;116(1 Suppl):74S-82S
references.pmid: 10424602
references.citation: N Engl J Med. 2001 Nov 8;345(19):1368-77
references.pmid: 11794169
references.citation: Crit Care Med. 2009 May;37(5):1670-7
references.pmid: 19325467
references.citation: Am J Respir Crit Care Med. 2011 Feb 15;183(4):462-70
references.pmid: 20802164
references.citation: Intensive Care Med. 2007 Jun;33(6):970-7
references.pmid: 17431582
references.citation: J Am Med Inform Assoc. 2009 Jul-Aug;16(4):503-8
references.pmid: 19390095
references.citation: N Engl J Med. 2000 May 4;342(18):1301-8
references.pmid: 10793162
references.citation: Crit Care Med. 2001 Jul;29(7):1303-10
references.pmid: 11445675
references.citation: Chest. 2005 Aug;128(2):525-32
references.pmid: 16100134
references.citation: Crit Care. 2012 Jun 19;16(3):223
references.pmid: 22713281
references.citation: Crit Care Med. 2003 Apr;31(4):1250-6
references.pmid: 12682500
references.citation: Shock. 2013 Jul;40(1):11-4
references.pmid: 23649098
references.citation: Crit Care Med. 2000 Jul;28(7):2187-92
references.pmid: 10921539
references.citation: Crit Care Med. 2008 May;36(5):1518-22
references.pmid: 18434908
references.citation: JAMA. 2012 Oct 24;308(16):1651-9
references.pmid: 23093163
references.citation: Crit Care Med. 2005 Jun;33(6):1191-8
references.pmid: 15942330
references.citation: Arch Intern Med. 1979 Aug;139(8):867-9
references.pmid: 464700
references.citation: Crit Care Med. 1985 Oct;13(10):818-29
references.pmid: 3928249
references.citation: Chest. 2009 Jul;136(1):102-109
references.pmid: 19318675
references.citation: Chest. 1997 May;111(5):1301-5
references.pmid: 9149587
references.citation: Crit Care Med. 2008 Aug;36(8):2309-15
references.pmid: 18664786
references.citation: Crit Care Med. 2003 Mar;31(3):869-77
references.pmid: 12626999
references.citation: N Engl J Med. 2011 Apr 7;364(14):1293-304
references.pmid: 21470008
references.citation: Acad Emerg Med. 2012 Sep;19(9):E1011-8
references.pmid: 22978727
references.citation: Am J Respir Crit Care Med. 1994 Mar;149(3 Pt 1):818-24
references.pmid: 7509706
references.citation: Crit Care. 2007;11(5):R96
references.pmid: 17784960
references.citation: JAMA. 2012 Jun 20;307(23):2526-33
references.pmid: 22797452
references.citation: Crit Care Med. 2013 Apr;41(4):945-53
references.pmid: 23385099
references.citation: Ann Intern Med. 1983 May;98(5 Pt 1):593-7
references.pmid: 6846973
references.citation: Shock. 2013 Jan;39(1):28-38
references.pmid: 23247119
references.citation: Int J Epidemiol. 1999 Oct;28(5):964-74
references.pmid: 10597998
references.citation: Crit Care. 2009;13(5):R150
references.pmid: 19758459
references.citation: Am J Respir Crit Care Med. 2003 May 1;167(9):1210-4
references.pmid: 12615616
references.citation: Crit Care Med. 2007 Aug;35(8):1928-36
references.pmid: 17581480
references.citation: J Surg Res. 1998 Nov;80(1):44-51
references.pmid: 9790813
references.citation: Crit Care Med. 2003 Apr;31(4):1053-9
references.pmid: 12682472