Acute respiratory distress syndrome after spontaneous intracerebral hemorrhage*

Abstract

Objectives: Acute respiratory distress syndrome develops commonly in critically ill patients in response to an injurious stimulus. The prevalence and risk factors for development of acute respiratory distress syndrome after spontaneous intracerebral hemorrhage have not been reported. We sought to determine the prevalence of acute respiratory distress syndrome after intracerebral hemorrhage, characterize risk factors for its development, and assess its impact on patient outcomes.

Design: Retrospective cohort study at two academic centers.

Patients: We included consecutive patients presenting from June 1, 2000, to November 1, 2010, with intracerebral hemorrhage requiring mechanical ventilation. We excluded patients with age less than 18 years, intracerebral hemorrhage secondary to trauma, tumor, ischemic stroke, or structural lesion; if they required intubation only during surgery; if they were admitted for comfort measures; or for a history of immunodeficiency.

Interventions: None.

Measurements and main results: Data were collected both prospectively as part of an ongoing cohort study and by retrospective chart review. Of 1,665 patients identified by database query, 697 met inclusion criteria. The prevalence of acute respiratory distress syndrome was 27%. In unadjusted analysis, high tidal volume ventilation was associated with an increased risk of acute respiratory distress syndrome (hazard ratio, 1.79 [95% CI, 1.13-2.83]), as were male sex, RBC and plasma transfusion, higher fluid balance, obesity, hypoxemia, acidosis, tobacco use, emergent hematoma evacuation, and vasopressor dependence. In multivariable modeling, high tidal volume ventilation was the strongest risk factor for acute respiratory distress syndrome development (hazard ratio, 1.74 [95% CI, 1.08-2.81]) and for inhospital mortality (hazard ratio, 2.52 [95% CI, 1.46-4.34]).

Conclusions: Development of acute respiratory distress syndrome is common after intubation for intracerebral hemorrhage. Modifiable risk factors, including high tidal volume ventilation, are associated with its development and in-patient mortality.

Figure 1

Selection process for patients included in the fnal cohort. ICH = intracerebral hemorrhage, CMO = comfort measures only, BWH = Brigham and Women’s Hospital, MGH = Massachusetts General Hospital..

Figure 2

A, Development of acute respiratory distress syndrome (ARDS) stratifed by hospital day with 95% CIs. B, Development of ARDS stratifed by exposure to high tidal-volume ventilation with 95% CIs. PBW = predicted body weight.

Figure 3

Patients categorized by percent of time ventilated at a tidal volume greater than 8 mL/kg predicted body weight (PBW).