Acute Respiratory Distress Syndrome in Trauma 2007–2019: Comprehensive Patient and Center-Level Retrospective Cohort Analysis

OBJECTIVES: Acute respiratory distress syndrome (ARDS) represents a significant complication in trauma patients. Yet the epidemiology of ARDS in trauma remains incompletely characterized. We sought to define trends in ARDS frequency and the effect of temporal, patient, and center-level factors on outcomes with the hypothesis that ARDS independently predicts mortality. DESIGN: Retrospective cohort study. SETTING: Hospitals submitting data to the American College of Surgeons National Trauma Data Bank. PATIENTS: Injured patients 18 years old or older from 2007 to 2019 on mechanical ventilation (MV) for greater than or equal to 2 days were included, and patients with ARDS were compared with those without ARDS. A subgroup with transfusion data was also identified. Multivariable logistic regression models by year adjusted for patient demographics, center characteristics, and blood products identified factors independently associated with ARDS diagnosis and 30-day hospital mortality. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 384,032 injured patients on MV, ARDS was documented in 29,359 (8 per 100 MV patients) with a significant decrease over the study period (22 in 2007 vs. 3 in 2019, p < 0.001). Patient-level risk factors independently associated with ARDS were blunt injury (odds ratio [OR] 1.25; 95% CI, 1.20–1.30), severe sepsis (OR 2.16; 95% CI, 2.06–2.27), ventilator-associated pneumonia (OR 2.91; 95% CI, 2.82–3.00), and acute kidney injury (AKI, OR 2.98; 95% CI, 2.85 to 3.12). In the transfusion subset, 24-hour plasma (OR 1.02; 95% CI, 1.01–1.04) and platelets (OR 1.03; 95% CI, 1.02–1.05) were independently associated with ARDS. Crude ARDS mortality increased over the study period (2007, 15.1% vs. 2019, 29.7%, p < 0.001), and after adjusting for significant differences, ARDS was independently associated with 30-day hospital mortality (OR 1.32; 95% CI, 1.27–1.37). Independent risk factors for 30-day mortality in patients with ARDS included head injury (OR 1.54; 95% CI, 1.43–1.66), severe sepsis (OR 1.48; 95% CI, 1.34–1.63), and AKI (OR 2.72; 95% CI, 2.50–2.96). Patients with ARDS managed in Prevention and Early Treatment of Acute Lung Injury and the Extracorporeal Life Support Organization centers were less likely to die (OR 0.78; 95% CI, 0.72–0.84). CONCLUSIONS: From 2007 to 2019, ARDS decreased significantly in trauma patients. Over the same time, mortality increased to nearly 30%, and after adjusting for other risks factors, ARDS was strongly associated with 30-day mortality. Future studies should examine modifiable patient and center-level factors to improve mortality in these high-risk patients.