Pre-Pandemic Regional Trends in Patients hospitalized with Acute Respiratory Distress Syndrome in Germany

Ingo Sagoschen (Mainz)1, K. Keller (Mainz)1, I. T. Farmakis (Mainz)2, P. Lurz (Mainz)1, L. Hobohm (Mainz)3

1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; 2Universitätsmedizin der Johannes Gutenberg-Universität Mainz Centrum für Thrombose und Hämostase Mainz, Deutschland; 3Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland



The initial phase of the COVID 19 pandemic focused primarily on the resources available for the intensive care treatment of patients with SARS CoV-2 related acute respiratory syndrome.

Enourmous efforts were made to mobilize technical an human resources to provide the higes possible number of intensive care beds to the people of Germany. But ARDS was present on ICU´s before the COVID 19 pendemic. Altough significant progress had been made in understanding the pathophysiology of acute respiratory distress syndrome (ARDS) over the last 30 years ARDS it is still a life-threatening medical condition with a high mortality rate. Little is known about temporal trends and regional variations in Germany before the pandemic.


We analyzed data on the characteristics, comorbidities and in-hospital outcomes for all hospitalized patients with ARDS in Germany between 2005 and 2019. Diagnoses were coded according to the International Classification of Diseases and Related Health Problems, 10th Revision with German Modification (ICD-10-GM), and diagnostic, surgical or interventional procedures according to the German Procedure Classification (OPS, surgery and procedures codes. The computed study analyses were performed on our behalf by the Research Data Center of the Federal Statistical Office and the Statistical Offices of the federal states in Wiesbaden, Germany. 


Overall, 8,369,723 inpatients aged ≥18 years were included in this analysis; among these, 155,872 (1.9%) were coded with the diagnosis of ARDS.  The annual number of ARDS cases increased from 7,286 in 2005 to 13,722 in 2019 in parallel with a significant decrease of in-hospital mortality (Figure 1). Overall, 74,751 (48.0%) patients with ARDS died during the in-hospital stay and in-hospital case-fatality grew exponentially with age. Independent predictors of in-hospital fatality with an OR >2 were age ≥70 years, necessity of ECMO, severe liver disease, acute renal failure, dialysis, shock and cardio-pulmonary resuscitation. Most patients with ARDS were treated in hospitals in urban areas (n=56,582) with a high case-fatality rate (49.7%), but also with concomitant high proportion rate of mechanical ventilation (23.7%) compared to hospitals in suburban or rural areas (Figure2). 


The number of patients with ARDS increased markedly in Germany between 2005 and 2019, in parallel with a decrease of in-hospital fatality. Our findings may suggest that general management of ARDS have improved over time and might draw more attention to predictors for in-hospital fatality in patients hospitalized with ARDS. The need for mechanical ventilation and a poor outcome was more likely in urban areas – this might be accentuated by patient transfer to specialized high care centers usually located in urban settings. These findings should be futher interpreted in relation to the distributions and outcomes during the pandemic and especially in the years after the high impact of SARS CoV-2 on ICU resources. 
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