When patients develop acute respiratory failure, accurately identifying the underlying etiology is essential for determining the best treatment, but it can be challenging to differentiate between common diagnoses in clinical practice. Machine learning models could improve medical diagnosis by augmenting clinical decision making and play a role in the diagnostic evaluation of patients with acute respiratory failure. While machine learning models have been developed to identify common findings on chest radiographs (e.g. pneumonia), augmenting these approaches by also analyzing clinically relevant data from the electronic health record (EHR) could aid in the diagnosis of acute respiratory failure. Machine learning models were trained to predict the cause of acute respiratory failure (pneumonia, heart failure, and/or COPD) using chest radiographs and EHR data from patients within an internal cohort using diagnoses based on physician chart review. Models were also tested on patients in an external cohort using discharge diagnosis codes. A model combining chest radiographs and EHR data outperformed models based on each modality alone for pneumonia and COPD. For pneumonia, the combined model AUROC was 0.79 (0.78-0.79), image model AUROC was 0.73 (0.72-0.75), and EHR model AUROC was 0.73 (0.70-0.76); for COPD, combined: 0.89 (0.83-0.91), image: 0.85 (0.77-0.89), and EHR: 0.80 (0.76-0.84); for heart failure, combined: 0.80 (0.77-0.84), image: 0.77 (0.71-0.81), and EHR: 0.80 (0.75-0.82). In the external cohort, performance was consistent for heart failure and COPD, but declined slightly for pneumonia. Overall, machine learning models combing chest radiographs and EHR data can accurately differentiate between common causes of acute respiratory failure. Further work is needed to determine whether these models could aid clinicians in the diagnosis of acute respiratory failure in clinical settings.

While deep learning has shown promise in improving the automated diagnosis of disease based on chest X-rays, deep networks may exhibit undesirable behavior related to shortcuts. This paper studies the case of spurious class skew in which patients with a particular attribute are spuriously more likely to have the outcome of interest. For instance, clinical protocols might lead to a dataset in which patients with pacemakers are disproportionately likely to have congestive heart failure. This skew can lead to models that take shortcuts by heavily relying on the biased attribute. We explore this problem across a number of attributes in the context of diagnosing the cause of acute hypoxemic respiratory failure. Applied to chest X-rays, we show that i) deep nets can accurately identify many patient attributes including sex (AUROC = 0.96) and age (AUROC >= 0.90), ii) they tend to exploit correlations between such attributes and the outcome label when learning to predict a diagnosis, leading to poor performance when such correlations do not hold in the test population (e.g., everyone in the test set is male), and iii) a simple transfer learning approach is surprisingly effective at preventing the shortcut and promoting good generalization performance. On the task of diagnosing congestive heart failure based on a set of chest X-rays skewed towards older patients (age >= 63), the proposed approach improves generalization over standard training from 0.66 (95% CI: 0.54-0.77) to 0.84 (95% CI: 0.73-0.92) AUROC. While simple, the proposed approach has the potential to improve the performance of models across populations by encouraging reliance on clinically relevant manifestations of disease, i.e., those that a clinician would use to make a diagnosis.