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Critical Care
Published in: Critical Care 1/2016

Open Access 01-12-2016 | Research

Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials

Authors: Claude Guérin, Laurent Papazian, Jean Reignier, Louis Ayzac, Anderson Loundou, Jean-Marie Forel, on behalf of the investigators of the Acurasys and Proseva trials

Published in: Critical Care | Issue 1/2016

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Abstract

Background

Driving pressure (ΔPrs) across the respiratory system is suggested as the strongest predictor of hospital mortality in patients with acute respiratory distress syndrome (ARDS). We wonder whether this result is related to the range of tidal volume (VT). Therefore, we investigated ΔPrs in two trials in which strict lung-protective mechanical ventilation was applied in ARDS. Our working hypothesis was that ΔPrs is a risk factor for mortality just like compliance (Crs) or plateau pressure (Pplat,rs) of the respiratory system.

Methods

We performed secondary analysis of data from 787 ARDS patients enrolled in two independent randomized controlled trials evaluating distinct adjunctive techniques while they were ventilated as in the low VT arm of the ARDSnet trial. For this study, we used VT, positive end-expiratory pressure (PEEP), Pplat,rs, Crs, ΔPrs, and respiratory rate recorded 24 hours after randomization, and compared them between survivors and nonsurvivors at day 90. Patients were followed for 90 days after inclusion. Cox proportional hazard modeling was used for mortality at day 90. If colinearity between ΔPrs, Crs, and Pplat,rs was verified, specific Cox models were used for each of them.

Results

Both trials enrolled 805 patients of whom 787 had day-1 data available, and 533 of these survived. In the univariate analysis, ΔPrs averaged 13.7 ± 3.7 and 12.8 ± 3.7 cmH2O (P = 0.002) in nonsurvivors and survivors, respectively. Colinearity between ΔPrs, Crs and Pplat,rs, which was expected as these variables are mathematically coupled, was statistically significant. Hazard ratios from the Cox models for day-90 mortality were 1.05 (1.02–1.08) (P = 0.005), 1.05 (1.01–1.08) (P = 0.008) and 0.985 (0.972–0.985) (P = 0.029) for ΔPrs, Pplat,rs and Crs, respectively. PEEP and VT were not associated with death in any model.

Conclusions

When ventilating patients with low VT, ΔPrs is a risk factor for death in ARDS patients, as is Pplat,rs or Crs. As our data originated from trials from which most ARDS patients were excluded due to strict inclusion and exclusion criteria, these findings must be validated in independent observational studies in patients ventilated with a lung protective strategy.

Trial registration

Clinicaltrials.gov NCT00299650. Registered 6 March 2006 for the Acurasys trial.
Clinicaltrials.gov NCT00527813. Registered 10 September 2007 for the Proseva trial.
Appendix
Available only for authorised users
Literature
1.
ARDSnet. 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. 2000;342(18):1301–8.CrossRef
2.
Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347–54.CrossRefPubMed
3.
Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–55.CrossRefPubMed
4.
Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–16.CrossRefPubMed
5.
Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68.CrossRefPubMed
6.
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149(3):818–24.CrossRefPubMed
7.
Cressoni M, Gotti M, Chiurazzi C, Massari D, Algieri I, Amini M, Cammaroto A, Brioni M, Montaruli C, Nikolla K, et al. Mechanical power and development of ventilator-induced lung injury. Anesthesiology. 2016;124(5):1100–8.CrossRefPubMed
8.
Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van Haren F, Larsson A, McAuley DF, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800.CrossRefPubMed
9.
10.
11.
Mekontso Dessap A, Boissier F, Charron C, Begot E, Repesse X, Legras A, Brun-Buisson C, Vignon P, Vieillard-Baron A. Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. Intensive Care Med. 2016;42(5):862–70.CrossRefPubMed
12.
Baedorf Kassis E, Loring SH, Talmor D. Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS. Intensive Care Med. 2016;42(8):1206–13.CrossRefPubMed
13.
Beitler JR, Guerin C, Ayzac L, Mancebo J, Bates DM, Malhotra A, Talmor D. PEEP titration during prone positioning for acute respiratory distress syndrome. Crit Care. 2015;19:436.CrossRefPubMedPubMedCentral
14.
Gattinoni L, Carlesso E, Santini A. Physiology versus evidence-based guidance for critical care practice. Crit Care. 2015;19 Suppl 3:S7.PubMedPubMedCentral
15.
Cressoni M, Gotti M, Chiurazzi C, Massari D, Algieri I, Amini M, Cammaroto A, Brioni M, Montaruli C, Nikolla K, et al. Mechanical power and development of ventilator-induced lung injury. Anesthesiology. 2016.
16.
Gattinoni L, Tonetti T, Cressoni M, Cadringher P, Herrmann P, Moerer O, Protti A, Gotti M, Chiurazzi C, Carlesso E, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Med. 2016;42(10):1567–75.CrossRefPubMed
17.
18.
Beitler JR, Goligher EC, Schmidt M, Spieth PM, Zanella A, Martin-Loeches I, Calfee CS, Cavalcanti AB. Personalized medicine for ARDS: the 2035 research agenda. Intensive Care Med. 2016;42(5):756–67.CrossRefPubMed
19.
Chiumello D, Cressoni M, Carlesso E, Caspani ML, Marino A, Gallazzi E, Caironi P, Lazzerini M, Moerer O, Quintel M, et al. Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome. Crit Care Med. 2014;42(2):252–64.CrossRefPubMed
20.
Chiumello D, Cressoni M, Colombo A, Babini G, Brioni M, Crimella F, Lundin S, Stenqvist O, Gattinoni L. The assessment of transpulmonary pressure in mechanically ventilated ARDS patients. Intensive Care Med. 2014;40(11):1670–8.CrossRefPubMed
21.
Chiumello D, Guerin C. Understanding the setting of PEEP from esophageal pressure in patients with ARDS. Intensive Care Med. 2015.
22.
Chiumello D, Marino A, Brioni M, Cigada I, Menga F, Colombo A, Crimella F, Algieri I, Cressoni M, Carlesso E, et al. Lung recruitment assessed by respiratory mechanics and computed tomography in patients with acute respiratory distress syndrome. What is the relationship? Am J Respir Crit Care Med. 2016;193(11):1254–63.CrossRefPubMed
23.
Cressoni M, Chiumello D, Carlesso E, Chiurazzi C, Amini M, Brioni M, Cadringher P, Quintel M, Gattinoni L. Compressive forces and computed tomography-derived positive end-expiratory pressure in acute respiratory distress syndrome. Anesthesiology. 2014;121(3):572–81.CrossRefPubMed
24.
Metadata
Title
Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials
Authors
Claude Guérin
Laurent Papazian
Jean Reignier
Louis Ayzac
Anderson Loundou
Jean-Marie Forel
on behalf of the investigators of the Acurasys and Proseva trials
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-016-1556-2

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