Decision Support Tool for Early Differential Diagnosis of Acute Lung Injury and Cardiogenic Pulmonary Edema in Medical Critically III Patients
Decision Support Tool for Early Differential Diagnosis of Acute Lung Injury and Cardiogenic Pulmonary Edema in Medical Critically III Patients
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DOI：
10.1378/chest.11-1496
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发表时间：
2012-01-01
期刊：
影响因子：
9.6
通讯作者：
Gajic, Ognjen
中科院分区：
文献类型：
--
作者：
Schmickl, Christopher N.;Shahjehan, Khurram;Gajic, Ognjen
背景资料：在急性缺氧性呼吸衰竭发作时，急性肺损伤（ALI）危重患者可能难以与心源性肺水肿（CPE）患者区分开来。没有单一的临床参数提供令人满意的预测。我们假设，这些组合将有助于早期鉴别diagnosis. Methods：在一个以人群为基础的回顾性发展队列，验证电子监测确定重症急性肺水肿的成人患者。递归分割和逻辑回归被用来开发一个基于常规临床信息的决策支持工具，以区分ALI和CPE。在一个独立的转诊患者队列中验证了评分的性能。结果：在一个发展队列的332例患者中，专家评审员（Kappa，0.86）将156例归类为ALI，176例归类为CPE。验证队列有161例患者（ALI = 113，CPE = 48）。该评分基于ALI和CPE的危险因素、年龄、酗酒、化疗和外周血氧饱和度/FIO（2）比值。其表现出良好的区分度（曲线下面积[AUC]= 0.81; 95% CI，0.77 - 0.86）和校准（Hosmer-Lemeshow [HL] P = 0.16）。在验证队列中获得了类似的性能（AUC = 0.80; 95%CI，0.72 - 0.88; HL P = 0.13）。结论：一个简单的决策支持工具可以准确地对急性肺水肿进行分类，为无法做出满意预测的患者子集保留高级测试。这种新的工具可能有助于早期纳入ALI和CPE患者的研究，以及改善和合理化的临床管理和资源使用。胸部2012; 141（1）：43 - 50
Background: At the onset of acute hypoxic respiratory failure, critically ill patients with acute lung injury (ALI) may be difficult to distinguish from those with cardiogenic pulmonary edema (CPE). No single clinical parameter provides satisfying prediction. We hypothesized that a combination of those will facilitate early differential diagnosis.Methods: In a population-based retrospective development cohort, validated electronic surveillance identified critically ill adult patients with acute pulmonary edema. Recursive partitioning and logistic regression were used to develop a decision support tool based on routine clinical information to differentiate ALI from CPE. Performance of the score was validated in an independent cohort of referral patients. Blinded post hoc expert review served as gold standard.Results: Of 332 patients in a development cohort, expert reviewers (kappa, 0.86) classified 156 as having ALI and 176 as having CPE. The validation cohort had 161 patients (ALI = 113, CPE = 48). The score was based on risk factors for ALI and CPE, age, alcohol abuse, chemotherapy, and peripheral oxygen saturation/FIO(2) ratio. It demonstrated good discrimination (area under curve [AUC] = 0.81; 95% CI, 0.77-0.86) and calibration (Hosmer-Lemeshow [HL] P = .16). Similar performance was obtained in the validation cohort (AUC = 0.80; 95% CI, 0.72-0.88; HL P = .13).Conclusions: A simple decision support tool accurately classifies acute pulmonary edema, reserving advanced testing for a subset of patients in whom satisfying prediction cannot be made. This novel tool may facilitate early inclusion of patients with ALI and CPE into research studies as well as improve and rationalize clinical management and resource use. CHEST 2012; 141(1):43-50