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Intensive Care Medicine

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01-08-2016 | Original

Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS

Authors: Elias Baedorf Kassis, Stephen H. Loring, Daniel Talmor

Published in: Intensive Care Medicine | Issue 8/2016

Abstract

Purpose

The driving pressure of the respiratory system has been shown to strongly correlate with mortality in a recent large retrospective ARDSnet study. Respiratory system driving pressure [plateau pressure−positive end-expiratory pressure (PEEP)] does not account for variable chest wall compliance. Esophageal manometry can be utilized to determine transpulmonary driving pressure. We have examined the relationships between respiratory system and transpulmonary driving pressure, pulmonary mechanics and 28-day mortality.

Methods

Fifty-six patients from a previous study were analyzed to compare PEEP titration to maintain positive transpulmonary end-expiratory pressure to a control protocol. Respiratory system and transpulmonary driving pressures and pulmonary mechanics were examined at baseline, 5 min and 24 h. Analysis of variance and linear regression were used to compare 28 day survivors versus non-survivors and the intervention group versus the control group, respectively.

Results

At baseline and 5 min there was no difference in respiratory system or transpulmonary driving pressure. By 24 h, survivors had lower respiratory system and transpulmonary driving pressures. Similarly, by 24 h the intervention group had lower transpulmonary driving pressure. This decrease was explained by improved elastance and increased PEEP.

Conclusions

The results suggest that utilizing PEEP titration to target positive transpulmonary pressure via esophageal manometry causes both improved elastance and driving pressures. Treatment strategies leading to decreased respiratory system and transpulmonary driving pressure at 24 h may be associated with improved 28 day mortality. Studies to clarify the role of respiratory system and transpulmonary driving pressures as a prognosticator and bedside ventilator target are warranted.

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Bernard GR, Artigas A (2016) The definition of ARDS revisited: 20 years later. Intensive Care Med 42:640–642. doi:10.1007/s00134-016-4281-z CrossRefPubMed

Bernard GR, Artigas A, Brigham KL (1994) The American–European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824. doi:10.1164/ajrccm.149.3.7509706 CrossRefPubMed

Wang CY, Calfee CS, Paul DW et al (2014) One-year mortality and predictors of death among hospital survivors of acute respiratory distress syndrome. Intensive Care Med 40:388–396. doi:10.1007/s00134-013-3186-3 CrossRefPubMedPubMedCentral

Villar J, Blanco J, Kacmarek RM (2016) Current incidence and outcome of the acute respiratory distress syndrome. Curr Opin Crit Care 22(1):1–6. doi:10.1097/MCC.0000000000000266 PubMed

Anonymous (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The acute respiratory distress syndrome network. N Engl J Med 342:1301–1308. doi:10.1056/NEJM200005043421801 CrossRef

Amato MB, Barbas CS, Medeiros DM et al (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347–354. doi:10.1056/NEJM199802053380602 CrossRefPubMed

Briel M, Meade M, Mercat A et al (2010) Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 303:865–873. doi:10.1001/jama.2010.218 CrossRefPubMed

Villar J, Kacmarek RM, Perez-Mendez L, Aguirre-Jaime A (2006) A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute respiratory distress syndrome: a randomized, controlled trial. Crit Care Med 34:1311–1318. doi:10.1097/01.CCM.0000215598.84885.01 CrossRefPubMed

Gattinoni L, Quintel M (2016) Is mechanical ventilation a cure for ARDS? Intensive Care Med 42:916–917. doi:10.1007/s00134-016-4266-y CrossRefPubMed

10.

Dreyfuss D, Hubmayr R (2016) What the concept of VILI has taught us about ARDS management. Intensive Care Med 42:811–813. doi:10.1007/s00134-016-4287-6 CrossRefPubMed

11.

Slutsky AS (1999) Lung injury caused by mechanical ventilation. Chest J 116:9S–15SCrossRef

12.

Slutsky AS, Ranieri VM (2013) Ventilator-induced lung injury. N Engl J Med 369:2126–2136. doi:10.1056/NEJMra1208707 CrossRefPubMed

13.

Amato MB, Meade MO, Slutsky AS et al (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755. doi:10.1056/NEJMsa1410639 CrossRefPubMed

14.

Loring SH, Malhotra A (2015) Driving pressure and respiratory mechanics in ARDS. N Engl J Med 372:776–777. doi:10.1056/NEJMe1414218 CrossRefPubMedPubMedCentral

15.

Talmor D, Sarge T, Malhotra A et al (2008) Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 359:2095–2104. doi:10.1056/NEJMoa0708638 CrossRefPubMedPubMedCentral

16.

Talmor D, Sarge T, O’Donnell CR, Ritz R, Malhotra A, Lisbon A, Loring SH (2006) Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 34:1389–1394. doi:10.1097/01.CCM.0000215515.49001.A2 CrossRefPubMedPubMedCentral

17.

Akoumianaki E, Maggiore SM, Valenza F et al (2014) The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 189:520–531. doi:10.1164/rccm.201312-2193CI CrossRefPubMed

18.

Beitler JR, Goligher EC, Schmidt M et al (2016) Personalized medicine for ARDS: the 2035 research agenda. Intensive Care Med 42:756–767. doi:10.1007/s00134-016-4331-6 CrossRefPubMed

19.

Brower RG, Lanken PN, MacIntyre N et al (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351:327–336. doi:10.1056/NEJMoa032193 CrossRefPubMed

20.

Grasso S, Fanelli V, Cafarelli A, Anaclerio R, Amabile M, Ancona G, Fiore T (2005) Effects of high versus low positive end-expiratory pressures in acute respiratory distress syndrome. Am J Respir Crit Care Med 171:1002–1008 (200407-940OC [pii])CrossRefPubMed

21.

Meade MO, Cook DJ, Guyatt GH et al (2008) Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299:637–645. doi:10.1001/jama.299.6.637 CrossRefPubMed

22.

Mercat A, Richard JC, Vielle B et al (2008) Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 299:646–655. doi:10.1001/jama.299.6.646 CrossRefPubMed

23.

Gattinoni L, Pesenti A, Avalli L, Rossi F, Bombino M (1987) Pressure-volume curve of total respiratory system in acute respiratory failure. Computed tomographic scan study. Am Rev Respir Dis 136:730–736. doi:10.1164/ajrccm/136.3.730 CrossRefPubMed

24.

Gattinoni L, Pesenti A (2005) The concept of “baby lung”. Intensive Care Med 31:776–784. doi:10.1007/s00134-005-2627-z CrossRefPubMed

25.

Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L (2016) The “baby lung” became an adult. Intensive Care Med 42:663–673. doi:10.1007/s00134-015-4200-8 CrossRefPubMed

26.

Luecke T, Pelosi P (2005) Clinical review: positive end-expiratory pressure and cardiac output. Crit Care 9:607–621 (cc3877 [pii])CrossRefPubMedPubMedCentral

27.

Suter PM, Fairley B, Isenberg MD (1975) Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med 292:284–289. doi:10.1056/NEJM197502062920604 CrossRefPubMed

28.

Gattinoni L, Caironi P, Cressoni M et al (2006) Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 354:1775–1786CrossRefPubMed

29.

Eisner MD, Thompson BT, Schoenfeld D, Anzueto A, Matthay MA, Network Acute Respiratory Distress Syndrome (2002) Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress syndrome. Am J Respir Crit Care Med 165:978–982. doi:10.1164/ajrccm.165.7.2109059 CrossRefPubMed

Title: Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS
Authors: Elias Baedorf Kassis
Stephen H. Loring
Daniel Talmor
Publication date: 01-08-2016
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 8/2016
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-016-4403-7

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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