Hospital Incidence and Outcomes of the Acute Respiratory Distress Syndrome Using the Kigali Modification of the Berlin Definition.
BACKGROUND
Estimates of the incidence of the acute respiratory distress syndrome (ARDS) in high- and middle-income countries vary from 10.1 to 86.2 per 100,000 person-years in the general population. The epidemiology of ARDS has not been reported for a low-income country at the level of the population, hospital, or intensive care unit (ICU). The Berlin definition may not allow identification of ARDS in resource-constrained settings.


OBJECTIVE
To estimate the incidence and outcomes of ARDS at a Rwandan referral hospital using the Kigali modification of the Berlin definition: without requirement for positive end-expiratory pressure, hypoxia cutoff of SpO2/FiO2 less than or equal to 315, and bilateral opacities on lung ultrasound or chest radiograph.


METHODS
We screened every adult patient for hypoxia at a public referral hospital in Rwanda for 6 weeks. For every patient with hypoxia, we collected data on demographics and ARDS risk factors, performed lung ultrasonography, and evaluated chest radiography when available.


RESULTS
Forty-two (4.0%) of 1,046 hospital admissions met criteria for ARDS. Using various prespecified cutoffs for the SpO2/FiO2 ratio resulted in almost identical hospital incidence values. Median age for patients with ARDS was 37 years, and infection was the most common risk factor (44.1%). Only 30.9% of patients with ARDS were admitted to an ICU, and hospital mortality was 50.0%. Using traditional Berlin criteria, no patients would have met criteria for ARDS.


CONCLUSIONS
ARDS seems to be a common and fatal syndrome in a hospital in Rwanda, with few patients admitted to an ICU. The Berlin definition is likely to underestimate the impact of ARDS in low-income countries, where resources to meet the definition requirements are lacking. Although the Kigali modification requires validation before widespread use, we hope this study stimulates further work in refining an ARDS definition that can be consistently used in all settings.
1 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, and.|2 Department of Medicine and.
Elisabeth D
ED
Riviello
3 Department of Anesthesia, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
Willy
W
Kiviri
3 Department of Anesthesia, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
Theogene
T
Twagirumugabe
4 Department of Anesthesia, Critical Care and Pain Management, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Ariel
A
Mueller
4 Department of Anesthesia, Critical Care and Pain Management, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Valerie M
VM
Banner-Goodspeed
4 Department of Anesthesia, Critical Care and Pain Management, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Laurent
L
Officer
5 Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
Victor
V
Novack
6 University Teaching Hospital of Kigali, Kigali, Rwanda; and.
Marguerite
M
Mutumwinka
4 Department of Anesthesia, Critical Care and Pain Management, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
Daniel S
DS
Talmor
7 Department of Critical Care Medicine and Department of Medicine, Sunnybrook Hospital, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.
Robert A
RA
Fowler
D000328:Adult; D003906:Developing Countries / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006779:Hospitals, Public / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011859:Radiography; D012128:Respiratory Distress Syndrome / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D012307:Risk Factors; D012432:Rwanda / Q000453:epidemiology; D016896:Treatment Outcome; D014463:Ultrasonography; D055815:Young Adult
Africa; acute respiratory distress syndrome; epidemiology