BACKGROUND: Little information is available about the geo-economic variations in demographics, management, and outcomes of patients with acute respiratory distress syndrome (ARDS). We aimed to characterise the effect of these geo-economic variations in patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE). METHODS: LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensive-care units in 50 countries across six continents. Inclusion criteria were admission to a participating intensive-care unit (including transfers) within the enrolment window and receipt of invasive or non-invasive ventilation. One of the trial's secondary aims was to characterise variations in the demographics, management, and outcome of patients with ARDS. We used the 2016 World Bank countries classification to define three major geo-economic groupings, namely European high-income countries (Europe-High), high-income countries in the rest of the world (rWORLD-High), and middle-income countries (Middle). We compared patient outcomes across these three groupings. LUNG SAFE is registered with ClinicalTrials.gov, number NCT02010073. FINDINGS: Of the 2813 patients enrolled in LUNG SAFE who fulfilled ARDS criteria on day 1 or 2, 1521 (54%) were recruited from Europe-High, 746 (27%) from rWORLD-High, and 546 (19%) from Middle countries. We noted significant geographical variations in demographics, risk factors for ARDS, and comorbid diseases. The proportion of patients with severe ARDS or with ratios of the partial pressure of arterial oxygen (PaO2) to the fractional concentration of oxygen in inspired air (FiO2) less than 150 was significantly lower in rWORLD-High countries than in the two other regions. Use of prone positioning and neuromuscular blockade was significantly more common in Europe-High countries than in the other two regions. Adjusted duration of invasive mechanical ventilation and length of stay in the intensive-care unit were significantly shorter in patients in rWORLD-High countries than in Europe-High or Middle countries. High gross national income per person was associated with increased survival in ARDS; hospital survival was significantly lower in Middle countries than in Europe-High or rWORLD-High countries. INTERPRETATION: Important geo-economic differences exist in the severity, clinician recognition, and management of ARDS, and in patients' outcomes. Income per person and outcomes in ARDS are independently associated. FUNDING: European Society of Intensive Care Medicine, St Michael's Hospital, University of Milan-Bicocca.

Adult Intensive Care and Burn Unit University Hospital of Lausanne Lausanne Switzerland; Department of Medical Intensive Care University Hospital of Angers Angers France

Centre for Experimental Medicine Queen's University of Belfast Belfast Northern Ireland UK; Wellcome Wolfson Institute for Experimental Medicine Belfast Northern Ireland UK; Regional Intensive Care Unit Royal Victoria Hospital A and E Grosvenor Road Belfast Northern Ireland UK

CIBER de Enfermedades Respiratorias Hospital Universitario de Getafe Universidad Europea Madrid Spain

CIBER de Enfermedades Respiratorias Hospital Universitario de Getafe Universidad Europea Madrid Spain; Hospital Español Montevideo Uruguay

Departamento de Medicina Intensiva Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile

Department of Anaesthesia Galway University Hospitals and National University of Ireland Galway Galway Ireland

Department of Anesthesia St Michael's Hospital Toronto ON Canada; Department of Critical Care Medicine St Michael's Hospital Toronto ON Canada; Keenan Research Centre for Biomedical Science Li Ka Shing Knowledge Institute St Michael's Hospital Toronto ON Canada; Department of Anesthesia University of Toronto Toronto ON Canada; Department of Physiology University of Toronto Toronto ON Canada; Interdepartmental Division of Critical Care Medicine University of Toronto Toronto ON Canada

Department of Anesthesiology and Intensive Care Medicine School of Medicine International University of Health and Welfare Narita Japan

Department of Anesthesiology and Intensive Care Medicine University of Leipzig Leipzig Germany

Department of Anesthesiology Perioperative Medicine and Intensive Care J E Purkinje University Masaryk Hospital Usti nad Labem Czech Republic; Department of Research and Development and Department of Anesthesiology and Intensive Care Charles University Prague Prague Czech Republic; Faculty of Medicine in Hradec Kralove Hradec Kralove Czech Republic

Department of Critical Care Medicine Bombay Hospital Institute of Medical Sciences Mumbai India

Department of Critical Care Medicine Nanjing Zhongda Hospital School of Medicine Southeast University Nanjing 210009 China

Department of Intensive Care Hospital San Juan de Dios and Department of Intensive Care Hospital CIMA San Jose Council of Critical Medicine University of Costa Rica San Pedro Montes de Oca Costa Rica

Department of Intensive Care VU University Medical Centre Amsterdam Netherlands

Dipartimento di Anestesia Rianimazione ed Emergenza Urgenza Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico and Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti Università degli Studi di Milano Milan Italy

Division of Critical Care Department of Anaesthesiology Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway

Division of Pulmonary and Critical Care Department of Medicine Massachusetts General Hospital Harvard Medical School Boston MA USA

Intensive Care Department King Saud Bin Abdulaziz University for Health Sciences Riyadh Saudi Arabia; Respiratory Services King Abdulaziz Medical City Ministry of National Guard Health Affairs Riyadh Saudi Arabia; King Abdullah International Medical Research Center Riyadh Saudi Arabia

Intensive Care Unit Canberra Hospital Canberra ACT Australia; Australian National University Canberra ACT Australia

Interdepartmental Division of Critical Care Medicine University of Toronto Toronto ON Canada; Institute of Health Policy Management and Evaluation University of Toronto Toronto ON Canada; Department of Medicine University Health Network and Mount Sinai Hospital Toronto ON Canada

Interdepartmental Division of Critical Care Medicine University of Toronto Toronto ON Canada; Program in Trauma Emergency and Critical Care Sunnybrook Health Sciences Center Toronto ON Canada

Keenan Research Centre for Biomedical Science Li Ka Shing Knowledge Institute St Michael's Hospital Toronto ON Canada; Interdepartmental Division of Critical Care Medicine University of Toronto Toronto ON Canada

Keenan Research Centre for Biomedical Science Li Ka Shing Knowledge Institute St Michael's Hospital Toronto ON Canada; Interdepartmental Division of Critical Care Medicine University of Toronto Toronto ON Canada; Sorbonne Universités UPMC Université Paris 06 Paris France

Research Center on Public Health Department of Medicine and Surgery University of Milano Bicocca Monza Italy

Research Center on Public Health Department of Medicine and Surgery University of Milano Bicocca Monza Italy; Department of Emergency and Intensive Care San Gerardo Hospital Monza Italy

Sapienza Università di Roma Dipartimento di Anestesia e Rianimazione Policlinico Umberto 1 Rome Italy

Section of Adult Critical Care Department of Medicine The Medical City Pasig Philippines

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ClinicalTrials.gov
NCT02010073