Clinical science
The influence of race on the development of acute lung injury in trauma patients

https://doi.org/10.1016/j.amjsurg.2010.02.003Get rights and content

Abstract

Background

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are sequelae of severe trauma. It is unknown if certain races are at greater risk of developing ALI/ARDS, and once established, if there are racial differences in the severity of lung injury or mortality.

Methods

Retrospective cohort study of 4,397 trauma patients (1,831 Caucasians, 871 African-Americans, 886 Hispanics, and 809 Asian/Pacific Islanders) requiring intensive care unit (ICU) admission between 1996 and 2007 at an urban Level I trauma center.

Results

African-American patients were most likely to present in shock with penetrating trauma and receive a massive transfusion. The incidence of ALI/ARDS was similar by race (P = .99). Among patients who developed ALI/ARDS, there was no evidence to support a difference in partial pressure of oxygen in arterial blood to fraction of inspired oxygen (Pao2/Fio2) (P = .33), lung injury score (P = .67), or mortality (P = .78) by race.

Conclusions

Despite differences in baseline characteristics, the incidence of ALI/ARDS, severity of lung injury, and mortality were similar by race.

Section snippets

Patient sample, study design, and clinical data

We assembled a retrospective cohort that included all trauma patients ≥14 years old who were either admitted to the intensive care unit (ICU) or went to the operating room after evaluation in the Emergency Department (ED) at San Francisco General Hospital, an urban Level I trauma center, between April 1, 1996 and December 31, 2007. The cohort consisted of 4,397 patients: 1,831 Caucasians, 871 African-Americans, 886 Hispanics, and 809 Asian/Pacific Islanders (Fig. 1). Data on race were missing

Results

We found significant racial differences in the mechanism of injury (penetrating vs blunt), presence of shock upon presentation to the ED, number of units of PRBCs transfused, and demographics (Table 1). Approximately half of the African-American patients and a quarter of the Hispanic patients presented with penetrating trauma. In addition, African-American patients were most likely to present with shock and to receive a massive transfusion compared with patients of other races. Furthermore,

Comments

Despite significant differences in baseline characteristics by race, namely age, mechanism of injury (penetrating vs blunt), and in particular shock upon presentation to the ED and the number of units of PRBCs transfused, the incidence of ALI/ARDS was similar by race. In this study as well as in prior trauma studies, shock10 and transfusion of PRBCs10, 11 are independent predictors for developing ALI/ARDS. Furthermore, the risk of developing ALI/ARDS increases as the number of units of PRBCs

Conclusions

1In conclusion, despite racial differences in the mechanism of injury, shock upon presentation to the ED, and the number of units of PRBCs transfused within the first 24 hours of admission, the incidence of ALI/ARDS was similar by race in this trauma cohort. Furthermore, among patients who developed ALI/ARDS, there was no evidence to support a difference in the severity of lung injury or mortality by race.

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    These are important observations that the reader should bear in mind. Importantly, we noted that African American race was an independent predictor for development of ARDS, in contrast with previous reports on effect of race on trauma-related ARDS [25], but consistent with recent genome-wide associations that have confirmed a higher risk of all-cause ARDS in African Americans [26]. We aim to look at the effect of race on ARDS incidence and mortality in a separate project.

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    However, race and gender are not clear independent risk factors for developing ARDS. In an observational study of trauma patients, African Americans were more likely to present with shock and penetrating trauma and to receive massive transfusions, but there was no difference in risk-adjusted rates of ALI among whites, African Americans, Hispanics, and Asian/Pacific Islanders.52 Analysis of a large national database of patients with blunt trauma suggested a protective effect of African American race with respect to ARDS incidence.53

  • Increased intracranial pressure is associated with the development of acute lung injury following severe traumatic brain injury

    2013, Clinical Neurology and Neurosurgery
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    No statistically significant differences were found between the incidence rates of ALI reported in the present study and previous reports in which 42 of 137 and 20 of 100 Caucasian patients developed ALI following severe TBI [1,3]. This result supports the study of Brown et al., which reported that race did not significantly influence the incidence of ALI following severe trauma [16]. Systemic inflammatory response syndrome is a clinicopathological manifestation of acute-phase inflammation caused by a variety of etiologies.

  • Sex, race, and the development of acute lung injury

    2013, Chest
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    Contrary to the findings of Moss et al,4 we did not find a relationship between ALI-related mortality and sex or race after adjusting for differences in clinical presentation. Our findings support the work of Erickson et al5 and Brown et al,36 who found that differences at hospital presentation accounted, in part, for disparities in ALI mortality. We acknowledge that our sample size may have limited our ability to detect whether disparities existed in ALI-related mortality, and our results may have differed had we included patients who presented with ALI or broadened the study population to include any patient who developed ALI rather than only at-risk patients, or had we examined long-term outcomes rather than hospital mortality.

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L.M.B is supported by NIH T32 GM008258-21; M.A.M. is supported by HL51856.

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