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Age, PaO2/FIO2, and Plateau Pressure Score: A Proposal for a Simple Outcome Score in Patients With the Acute Respiratory Distress Syndrome*

Villar, Jesús MD, PhD, FCCM; Ambrós, Alfonso MD, PhD; Soler, Juan Alfonso MD, PhD; Martínez, Domingo MD; Ferrando, Carlos MD, PhD; Solano, Rosario MD; Mosteiro, Fernando MD; Blanco, Jesús MD, PhD; Martín-Rodríguez, Carmen MD; Fernández, María del Mar MD, PhD; López, Julia MD; Díaz-Domínguez, Francisco J. MD; Andaluz-Ojeda, David MD, PhD; Merayo, Eleuterio MD; Pérez-Méndez, Lina MD, PhD; Fernández, Rosa Lidia MSc; Kacmarek, Robert M. PhD, RRT

doi: 10.1097/CCM.0000000000001653
Clinical Investigations

Objectives: Although there is general agreement on the characteristic features of the acute respiratory distress syndrome, we lack a scoring system that predicts acute respiratory distress syndrome outcome with high probability. Our objective was to develop an outcome score that clinicians could easily calculate at the bedside to predict the risk of death of acute respiratory distress syndrome patients 24 hours after diagnosis.

Design: A prospective, multicenter, observational, descriptive, and validation study.

Setting: A network of multidisciplinary ICUs.

Patients: Six-hundred patients meeting Berlin criteria for moderate and severe acute respiratory distress syndrome enrolled in two independent cohorts treated with lung-protective ventilation.

Interventions: None.

Measurements and Main Results: Using individual demographic, pulmonary, and systemic data at 24 hours after acute respiratory distress syndrome diagnosis, we derived our prediction score in 300 acute respiratory distress syndrome patients based on stratification of variable values into tertiles, and validated in an independent cohort of 300 acute respiratory distress syndrome patients. Primary outcome was in-hospital mortality. We found that a 9-point score based on patient’s age, PaO2/FIO2 ratio, and plateau pressure at 24 hours after acute respiratory distress syndrome diagnosis was associated with death. Patients with a score greater than 7 had a mortality of 83.3% (relative risk, 5.7; 95% CI, 3.0–11.0), whereas patients with scores less than 5 had a mortality of 14.5% (p < 0.0000001). We confirmed the predictive validity of the score in a validation cohort.

Conclusions: A simple 9-point score based on the values of age, PaO2/FIO2 ratio, and plateau pressure calculated at 24 hours on protective ventilation after acute respiratory distress syndrome diagnosis could be used in real time for rating prognosis of acute respiratory distress syndrome patients with high probability.

Supplemental Digital Content is available in the text.

1CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.

2Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain.

3Intensive Care Unit, Hospital General de Ciudad Real, Ciudad Real, Spain.

4Intensive Care Unit, Hospital Universitario Morales Meseguer, Murcia, Spain.

5Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain.

6Post-Surgical Unit, Department of Anesthesia, Hospital Clínico de Valencia, Valencia, Spain.

7Intensive Care Unit, Hospital Virgen de la Luz, Cuenca, Spain.

8Intensive Care Unit, Hospital Universitario A Coruña, Coruña, Spain.

9Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain.

10Intensive Care Unit, Hospital Universitario Mutua de Terrassa, Barcelona, Spain.

11Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain.

12Intensive Care Unit, Hospital General de León, León, Spain.

13Intensive Care Unit, Hospital Clínico de Valladolid, Valladolid, Spain.

14Intensive Care Unit, Hospital del Bierzo, Ponferrada, León, Spain.

15Research Unit, Hospital Universitario NS de Candelaria, Santa Cruz de Tenerife, Spain.

16Department of Respiratory Care, Massachusetts General Hospital, Boston, MA.

17Department of Anesthesia, Harvard University, Boston, MA.

*See also p. 1437.

A list of Stratification and Outcome of Acute Respiratory Distress Syndrome (STANDARDS) Network investigators are listed in Appendix 2.

This study has been registered with (NCT 00736892 and NCT02288949).

Drs. Villar, Pérez-Méndez, and Kacmarek designed the original study. Drs. Ambrós, Soler, Martínez, Ferrando, Solano, Mosteiro, Blanco, Martín-Rodríguez, Fernández, López, Díaz-Domínguez, Andaluz-Ojeda, and Merayo enrolled patients and collected the data. Dr. Villar obtained funding for the study. Drs. Villar, Pérez-Méndez, Fernández, Kacmarek, Ambrós, Soler, Martínez, Ferrando, Solano, Mosteiro, Blanco, Martín-Rodríguez, Fernández, López, Díaz-Domínguez, Andaluz-Ojeda, and Merayo made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data and to drafting the article or revising it critically for important intellectual content and approved the final version to be published. Drs. Villar, Fernández, and Kacmarek wrote the first draft. Drs. Villar, Fernández, Pérez-Méndez, and Kacmarek performed and supervised data management and statistical analysis. Drs. Villar, Fernández, and Pérez-Méndez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Supported, in part, by Instituto de Salud Carlos III (CB06/06/1088, PI10/0393, and PI13/0119), Fundación Mutua Madrileña (AP101822012), and Asociación Científica Pulmón y Ventilación Mecánica. The funding agencies had no role in the study design, data collection and analysis, decision to publish, or preparation of the article.

Dr. Villar has received a research grant from Maquet. Dr. Kacmarek served as a consultant for Covidien and Orange Med on mechanical ventilators and received research grants from Covidien and Venner Medical for evaluation of mechanical ventilators and airways. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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