Top

Published in:

07-06-2022 | Acute Respiratory Distress-Syndrome | Original

Partition of respiratory mechanics in patients with acute respiratory distress syndrome and association with outcome: a multicentre clinical study

Authors: Lu Chen, Domenico L. Grieco, François Beloncle, Guang-Qiang Chen, Norberto Tiribelli, Fabiana Madotto, Sebastian Fredes, Cong Lu, Massimo Antonelli, Alain Mercat, Arthur S. Slutsky, Jian-Xin Zhou, Laurent Brochard

Published in: Intensive Care Medicine | Issue 7/2022

Abstract

Purpose

In acute respiratory distress syndrome (ARDS), physiological parameters associated with outcome may help defining targets for mechanical ventilation. This study aimed to address whether transpulmonary pressures (P_L), including transpulmonary driving pressure (DP_L), elastance-derived plateau P_L, and directly-measured end-expiratory P_L, are better associated with 60-day outcome than airway driving pressure (DP_aw). We also tested the combination of oxygenation and stretch index [PaO₂/(FiO₂*DP_aw)].

Methods

Prospective, observational, multicentre registry of ARDS patients. Respiratory mechanics were measured early after intubation at 6 kg/ml tidal volume. We compared the predictive power of the parameters for mortality at day-60 through receiver operating characteristic (ROC) and assessed their association with 60-day mortality through unadjusted and adjusted Cox regressions. Finally, each parameter was dichotomized, and Kaplan–Meier survival curves were compared.

Results

385 patients were enrolled 2 [1–4] days from intubation (esophageal pressure and arterial blood gases in 302 and 318 patients). As continuous variables, DP_aw, DP_L, and oxygenation stretch index were associated with 60-day mortality after adjustment for age and Sequential Organ Failure Assessment, whereas elastance-derived plateau P_L was not. DP_aw and DP_L performed equally in ROC analysis (P = 0.0835). DP_aw had the best-fit Cox regression model. When dichotomizing the variables, DP_aw ≥ 15, DP_L ≥ 12, plateau P_L ≥ 24, and oxygenation stretch index < 10 exhibited lower 60-day survival probability. Directly measured end-expiratory P_L ≥ 0 was associated with better outcome in obese patients.

Conclusion

DP_L was equivalent predictor of outcome than DP_aw. Our study supports the soundness of limiting lung and airway driving pressure and maintaining positive end-expiratory P_L in obese patients.

Available only for authorised users

Slutsky AS, Ranieri VM (2013) Ventilator-induced lung injury. N Engl J Med 369:2126–2136CrossRef

Acute Respiratory Distress Syndrome N, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRef

Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755CrossRef

Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van Haren F, Larsson A, McAuley DF, Ranieri M, Rubenfeld G, Thompson BT, Wrigge H, Slutsky AS, Pesenti A, Investigators LS, Group ET (2016) Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 315:788–800CrossRef

Urner M, Juni P, Hansen B, Wettstein MS, Ferguson ND, Fan E (2020) Time-varying intensity of mechanical ventilation and mortality in patients with acute respiratory failure: a registry-based, prospective cohort study. Lancet Respir Med 8:905–913CrossRef

Pereira Romano ML, Maia IS, Laranjeira LN, Damiani LP, Paisani DM, Borges MC, Dantas BG, Caser EB, Victorino JA, Filho WO, Amato MBP, Cavalcanti AB (2020) Driving pressure-limited strategy for patients with acute respiratory distress syndrome. a pilot randomized clinical trial. Ann Am Thorac Soc 17:596–604CrossRef

Baedorf Kassis E, Loring SH, Talmor D (2016) Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS. Intensive Care Med 42:1206–1213CrossRef

Loring SH, O’Donnell CR, Behazin N, Malhotra A, Sarge T, Ritz R, Novack V, Talmor D (1985) (2010) Esophageal pressures in acute lung injury: do they represent artifact or useful information about transpulmonary pressure, chest wall mechanics, and lung stress? J Appl Physiol 108:515–522CrossRef

Talmor D, Sarge T, Malhotra A, O’Donnell CR, Ritz R, Lisbon A, Novack V, Loring SH (2008) Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 359:2095–2104CrossRef

10.

Yoshida T, Amato MBP, Grieco DL, Chen L, Lima CAS, Roldan R, Morais CCA, Gomes S, Costa ELV, Cardoso PFG, Charbonney E, Richard JM, Brochard L, Kavanagh BP (2018) Esophageal manometry and regional transpulmonary pressure in lung injury. Am J Respir Crit Care Med 197:1018–1026CrossRef

11.

Tilmont A, Coiffard B, Yoshida T, Daviet F, Baumstarck K, Brioude G, Hraiech S, Forel JM, Roch A, Brochard L, Papazian L, Guervilly C (2021) Oesophageal pressure as a surrogate of pleural pressure in mechanically ventilated patients. ERJ Open Res 7:2CrossRef

12.

Gattinoni L, Carlesso E, Cadringher P, Valenza F, Vagginelli F, Chiumello D (2003) Physical and biological triggers of ventilator-induced lung injury and its prevention. Eur Respir J Suppl 47:15s–25sCrossRef

13.

Grasso S, Terragni P, Birocco A, Urbino R, Del Sorbo L, Filippini C, Mascia L, Pesenti A, Zangrillo A, Gattinoni L, Ranieri VM (2012) ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med 38:395–403CrossRef

14.

Mauri T, Yoshida T, Bellani G, Goligher EC, Carteaux G, Rittayamai N, Mojoli F, Chiumello D, Piquilloud L, Grasso S, Jubran A, Laghi F, Magder S, Pesenti A, Loring S, Gattinoni L, Talmor D, Blanch L, Amato M, Chen L, Brochard L, Mancebo J, Group PL (2016) Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 42:1360–1373CrossRef

15.

Chen L, Chen GQ, Shore K, Shklar O, Martins C, Devenyi B, Lindsay P, McPhail H, Lanys A, Soliman I, Tuma M, Kim M, Porretta K, Greco P, Every H, Hayes C, Baker A, Friedrich JO, Brochard L (2017) Implementing a bedside assessment of respiratory mechanics in patients with acute respiratory distress syndrome. Crit Care 21:84CrossRef

16.

Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS (2012) Acute respiratory distress syndrome: the berlin definition. JAMA 307:2526–2533

17.

Washko GR, O’Donnell CR, Loring SH (1985) (2006) Volume-related and volume-independent effects of posture on esophageal and transpulmonary pressures in healthy subjects. J Appl Physiol 100:753–758CrossRef

18.

Lanteri CJ, Kano S, Sly PD (1994) Validation of esophageal pressure occlusion test after paralysis. Pediatr Pulmonol 17:56–62CrossRef

19.

Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J (1982) A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis 126:788–791

20.

Gattinoni L, Tonetti T, Cressoni M, Cadringher P, Herrmann P, Moerer O, Protti A, Gotti M, Chiurazzi C, Carlesso E, Chiumello D, Quintel M (2016) Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med 42:1567–1575CrossRef

21.

Hanley JA, McNeil BJ (1983) A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 148:839–843CrossRef

22.

R Core Team (2018) R: A Language and Environment for Statistical Computing. In: Book R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, City

23.

Coudroy R, Vimpere D, Aissaoui N, Younan R, Bailleul C, Couteau-Chardon A, Lancelot A, Guerot E, Chen L, Brochard L, Diehl JL (2020) Prevalence of complete airway closure according to body mass index in acute respiratory distress syndrome: pooled cohort analysis. Anesthesiology 2:2

24.

De Santis SR, TeggiaDroghi M, Fumagalli J, Marrazzo F, Florio G, Grassi LG, Gomes S, Morais CCA, Ramos OPS, Bottiroli M, Pinciroli R, Imber DA, Bagchi A, Shelton K, Sonny A, Bittner EA, Amato MBP, Kacmarek RM, Berra L, Lung Rescue I (2020) High pleural pressure prevents alveolar overdistension and hemodynamic collapse in ARDS with class III obesity. Am J Respir Crit Care Med 2:2

25.

Marini JJ, Rocco PRM, Gattinoni L (2020) Static and dynamic contributors to ventilator-induced lung injury in clinical practice. pressure, energy, and power. Am J Respir Crit Care Med 201:767–774CrossRef

26.

Costa ELV, Slutsky AS, Brochard LJ, Brower R, Serpa-Neto A, Cavalcanti AB, Mercat A, Meade M, Morais CCA, Goligher E, Carvalho CRR, Amato MBP (2021) Ventilatory variables and mechanical power in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 204:303–311CrossRef

27.

Jardin F, Genevray B, Brun-Ney D, Bourdarias JP (1985) Influence of lung and chest wall compliances on transmission of airway pressure to the pleural space in critically ill patients. Chest 88:653–658CrossRef

28.

Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guerin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L, Group PW (2014) The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 189:520–531CrossRef

29.

Cavalcanti AB, Amato MBP, Serpa-Neto A (2019) The elusive search for “Best PEEP” and whether esophageal pressure monitoring helps. JAMA 321:839–841CrossRef

30.

Beitler JR, Sarge T, Banner-Goodspeed VM, Gong MN, Cook D, Novack V, Loring SH, Talmor D, Group EPS (2019) Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy vs an empirical high PEEP-Fio2 strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA 321:846–857CrossRef

31.

Muscedere JG, Mullen JB, Gan K, Slutsky AS (1994) Tidal ventilation at low airway pressures can augment lung injury. Am J Respir Crit Care Med 149:1327–1334CrossRef

32.

Chen L, Del Sorbo L, Grieco DL, Junhasavasdikul D, Rittayamai N, Soliman I, Sklar MC, Rauseo M, Ferguson ND, Fan E, Richard JM, Brochard L (2020) Potential for lung recruitment estimated by the recruitment-to-inflation ratio in acute respiratory distress syndrome. a clinical trial. Am J Respir Crit Care Med 201:178–187CrossRef

33.

Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, Wood AM, Carpenter JR (2009) Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ 338:b2393CrossRef

Title: Partition of respiratory mechanics in patients with acute respiratory distress syndrome and association with outcome: a multicentre clinical study
Authors: Lu Chen
Domenico L. Grieco
François Beloncle
Guang-Qiang Chen
Norberto Tiribelli
Fabiana Madotto
Sebastian Fredes
Cong Lu
Massimo Antonelli
Alain Mercat
Arthur S. Slutsky
Jian-Xin Zhou
Laurent Brochard
Publication date: 07-06-2022
Publisher: Springer Berlin Heidelberg
Keyword: Acute Respiratory Distress-Syndrome
Published in: Intensive Care Medicine / Issue 7/2022
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-022-06724-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Partition of respiratory mechanics in patients with acute respiratory distress syndrome and association with outcome: a multicentre clinical study

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 7/2022

Integrating palliative care into the ICU: a lasting and developing legacy

Brave enough

Major candidate variables to guide personalised treatment with steroids in critically ill patients with COVID-19: CIBERESUCICOVID study

Is (1,3)-β-d-glucan useless to guide antifungal therapy in ICU?

Beyond failure or success: reflections on the ethical justifications for time-limited trial of intensive care

Basic ultrasound skill for intensivists: future scope for expansion of the recommendations of the European Society of Intensive Care Medicine