key: cord-0043791-f7vq8g78
authors: Auriemma, Catherine L.; Delucchi, Kevin; Liu, Kathleen D.; Calfee, Carolyn S.
title: The attributable mortality of acute respiratory distress syndrome
date: 2020-05-25
journal: Intensive Care Med
DOI: 10.1007/s00134-020-06099-y
sha: b960ae47d445266b4ea6048c4443744c7ccaa613
doc_id: 43791
cord_uid: f7vq8g78

nan

. Others have shown that multisystem organ failure can be propagated by ventilator-induced lung injury [6] . Not knowing with precision the proportion of mortality caused by other acute organ failures lies on the causal path between ARDS and mortality versus serves as a confounder makes adjustment for these variables challenging. Excluding other organ failures from the model may inflate our estimate, though we note that the APACHE and SAPS scores do incorporate acute organ failures. Fully adjusting for non-pulmonary organ failures, however, would inappropriately attenuate or fully obscure the effects of ARDS on mortality.

The authors make the important point that errors in ARDS-specific risk can have significant effects on the estimation of a necessary trial size. We agree. However, our primary conclusions still hold. One, any absolute changes in mortality by fully treating or preventing ARDS would still be relatively low. Two, trials designed to detect differences in ARDS mortality would need to be quite large. We did not provide specific numbers given limitations in the precision of our estimate. Three, trial design and efficiency could be improved by focusing enrollment on patients with severe ARDS. While the authors provide calculations showing how a trial size would differ substantially if the true value of ARDS-specific risk is half our estimate, there is no empiric data on which to base the degree of overestimation.

Establishing causality from observational data will always be challenging, and all models are inherently limited by their underlying assumptions. We are grateful that the transparency we have provided in the development of our model has prompted thoughtful discussion, and we hope it will inform improved future study design and ultimately, ongoing advancement of knowledge.

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