title: Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome.
abstract: OBJECTIVE
  The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized.
  
  
  METHODS
  Secondary analysis of a prospective observational cohort study.
  
  
  METHODS
  Vanderbilt University Medical Center.
  
  
  METHODS
  Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support.
  
  
  METHODS
  None.
  
  
  RESULTS
  Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results.
  
  
  CONCLUSIONS
  A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.
authors.affiliation: 1Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.3Department of Critical Care Medicine, Taichung Veteran General Hospital, Taichung, Taiwan.4Section of Pulmonary and Critical Care Medicine, Department of Medicine, Louisiana State University School of Medicine New Orleans, LA.5Division of Pulmonary and Critical Care, University of California, San Francisco, San Francisco, CA.6Departments Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA.
authors.forename: Kirsten Neudoerffer
authors.initials: KN
authors.lastname: Kangelaris
authors.forename: Lorraine B
authors.initials: LB
authors.lastname: Ware
authors.forename: Chen Yu
authors.initials: CY
authors.lastname: Wang
authors.forename: David R
authors.initials: DR
authors.lastname: Janz
authors.forename: Hanjing
authors.initials: H
authors.lastname: Zhuo
authors.forename: Michael A
authors.initials: MA
authors.lastname: Matthay
authors.forename: Carolyn S
authors.initials: CS
authors.lastname: Calfee
mesh_terms: D005260:Female; D006801:Humans; D007440:Intubation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome