[Chest在线发表]:临床医生根据柏林定义诊断ARDS的一致性 | 中国病理生理学会危重病医学专业委员会
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2018年01月30日 时讯速递, 进展交流 暂无评论

Interobserver Reliability of the Berlin ARDS Definition and Strategies to Improve the Reliability of ARDS Diagnosis: Reliability of Berlin ARDS Diagnosis

Michael W. Sjoding, Timothy P. Hofer, Ivan Co, et al.

Chest 2017 Dec 14

DOI: http://dx.doi.org/10.1016/j.chest.2017.11.037

Background 背景

Failure to reliably diagnose ARDS may be a major driver of negative clinical trials and underrecognition and treatment in clinical practice. We sought to examine the interobserver reliability of the Berlin ARDS definition and examine strategies for improving the reliability of ARDS diagnosis.


Methods 方法

Two hundred five patients with hypoxic respiratory failure from four ICUs were reviewed independently by three clinicians, who evaluated whether patients had ARDS, the diagnostic confidence of the reviewers, whether patients met individual ARDS criteria, and the time when criteria were met.


Results 结果

Interobserver reliability of an ARDS diagnosis was “moderate” (kappa = 0.50; 95% CI, 0.40-0.59). Sixty-seven percent of diagnostic disagreements between clinicians reviewing the same patient was explained by differences in how chest imaging studies were interpreted, with other ARDS criteria contributing less (identification of ARDS risk factor, 15%; cardiac edema/volume overload exclusion, 7%). Combining the independent reviews of three clinicians can increase reliability to “substantial” (kappa = 0.75; 95% CI, 0.68-0.80). When a clinician diagnosed ARDS with “high confidence,” all other clinicians agreed with the diagnosis in 72% of reviews. There was close agreement between clinicians about the time when a patient met all ARDS criteria if ARDS developed within the first 48 hours of hospitalization (median difference, 5 hours).

ARDS诊断的观察者间一致性为中等 (kappa = 0.50; 95% CI, 0.40-0.59)。临床医生对同一名患者诊断不一致时,67%源于对胸部影像学检查结果的判读,ARDS其他标准所占比例较少(明确ARDS危险因素,15%;排除心源性肺水肿/容量负荷过多,7%)。综合3名临床医生各自的判断可将诊断可靠性提高到高度 (kappa = 0.75; 95% CI, 0.68-0.80)。当一名临床医生诊断ARDS具有“高度可信性”时,72%的情况下其他医生也赞同这一诊断。如果患者在入院48小时内发生ARDS,临床医生有关患者满足ARDS所有标准的时间的判断具有高度一致性(差异中位数,5小时)。

Conclusions 结论

The reliability of the Berlin ARDS definition is moderate, driven primarily by differences in chest imaging interpretation. Combining independent reviews by multiple clinicians or improving methods to identify bilateral infiltrates on chest imaging are important strategies for improving the reliability of ARDS diagnosis.



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