title: Comparison of community-acquired, hospital-acquired, and intensive care unit-acquired acute respiratory distress syndrome: a prospective observational cohort study.
abstract: BACKGROUND
  Acute respiratory distress syndrome (ARDS) is a syndrome characterized by diffuse pulmonary edema and severe hypoxemia that usually occurs after an injury such as sepsis, aspiration and pneumonia. Little is known about the relation between the setting where the syndrome developed and outcomes in ARDS patients.
  
  
  METHODS
  This is a 1-year prospective observational study conducted at a tertiary referred hospital. ARDS was defined by the Berlin criteria. Community-acquired ARDS, hospital-acquired ARDS and intensive care unit (ICU)-acquired ARDS were defined as ARDS occurring within 48 hours of hospital or ICU admission, more than 48 hours after hospital admission and ICU admission. The primary and secondary outcomes were short- and long- term mortality rates and ventilator-free and ICU-free days.
  
  
  RESULTS
  Of the 3002 patients screened, 296 patients had a diagnosis of ARDS, including 70 (23.7 %) with community-acquired ARDS, 83 (28 %) with hospital-acquired ARDS, and 143 (48.3 %) with ICU-acquired ARDS. The overall ICU mortality rate was not significantly different in mild, moderate and severe ARDS (50 %, 50 % and 56 %, p = 0.25). The baseline characteristics were similar other than lower rate of liver disease and metastatic malignancy in community-acquired ARDS than in hospital-acquired and ICU-acquired ARDS. A multiple logistic regression analysis indicated that age, sequential organ function assessment score and community-acquired ARDS were independently associated with hospital mortality. For community-acquired, hospital-acquired and ICU-acquired ARDS, ICU mortality rates were 37 % 61 % and 52 %; hospital mortality rates were 49 %, 74 % and 68 %. The ICU and hospital mortality rates of community-acquired ARDS were significantly lower than hospital-acquired and ICU-acquired ARDS (p = 0.001 and p = 0.001). The number of ventilator-free days was significantly lower in ICU-acquired ARDS than in community-acquired and hospital-acquired ARDS (11 ± 9, 16 ± 9, and 14 ± 10 days, p = 0.001). The number of ICU-free days was significantly higher in community-acquired ARDS than in hospital-acquired and ICU-acquired ARDS (8 ± 10, 4 ± 8, and 3 ± 6 days, p = 0.001).
  
  
  CONCLUSIONS
  Community-acquired ARDS have lower short- and long-term mortality rates than hospital-acquired or ICU-acquired ARDS.
authors.affiliation: Departments of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, (333) 5, Fu-Shing St., Kwei-Shan, Taoyuan, Taiwan. kck0502@cgmh.org.tw.|Departments of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan. kck0502@cgmh.org.tw.|Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan. kck0502@cgmh.org.tw.
authors.forename: Kuo-Chin
authors.initials: KC
authors.lastname: Kao
authors.affiliation: Departments of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, (333) 5, Fu-Shing St., Kwei-Shan, Taoyuan, Taiwan. h3226@cgmh.org.tw.|Departments of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan. h3226@cgmh.org.tw.|Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan. h3226@cgmh.org.tw.
authors.forename: Han-Chung
authors.initials: HC
authors.lastname: Hu
authors.affiliation: Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan. mengjer@cgmh.org.tw.|Departments of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan. mengjer@cgmh.org.tw.
authors.forename: Meng-Jer
authors.initials: MJ
authors.lastname: Hsieh
authors.affiliation: Departments of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan. chestmed@cgmh.org.tw.
authors.forename: Ying-Huang
authors.initials: YH
authors.lastname: Tsai
authors.affiliation: Departments of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, (333) 5, Fu-Shing St., Kwei-Shan, Taoyuan, Taiwan. cch4848@cgmh.org.tw.|Departments of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan. cch4848@cgmh.org.tw.|Department of Respiratory Therapy, Chang-Gung University College of Medicine, Taoyuan, Taiwan. cch4848@cgmh.org.tw.
authors.forename: Chung-Chi
authors.initials: CC
authors.lastname: Huang
mesh_terms: D000328:Adult; D000368:Aged; D001604:Berlin / Q000453:epidemiology; D015331:Cohort Studies; D017714:Community-Acquired Infections / Q000401:mortality* / Q000503:physiopathology; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000453:epidemiology / Q000209:etiology* / Q000401:mortality; D012307:Risk Factors