Airway pressures, tidal volumes, and mortality in patients with acute respiratory distress syndrome

Objective:To determine the usual practice for setting tidal volume and other ventilatory parameters in patients with acute respiratory distress syndrome (ARDS) in the late 1990s and to determine the independent effects of these practices on intensive care unit mortality. Design:Subanalysis of a prospective observational study. Multivariable logistic regression was used to analyze the effects of ventilatory management on mortality. Setting:A total of 361 intensive care units in 20 countries in March 1998. Patients:A total of 467 mechanically ventilated patients with ARDS. Interventions:None. Measurements and Main Results:The mean tidal volume used in the first week of ARDS was 8.8 mL/kg measured body weight, and there was great variability in these tidal volumes (sd = 2.0). Tidal volumes were significantly lower in patients with (n = 265) than without (n = 202) a recorded plateau pressure (8.6 vs. 9.1 mL/kg, p = .01). The overall intensive care unit mortality rate was 60.2%. In addition to the strong influence of organ failures and higher levels of inspired oxygen, late-onset ARDS (onset after >48 hrs of mechanical ventilation; odds ratio, 2.09) was independently associated with mortality. In addition, lower levels of positive end-expiratory pressure were independently associated with higher mortality (odds ratio, 0.91; 1 cm of H2O increments). Neither inspiratory pressures nor tidal volumes were independently associated with mortality, and there was no evidence of increased mortality with the use of lower inspiratory pressures. Conclusions:This descriptive study demonstrated considerable interpatient variability in tidal volumes during the study period. In addition to traditional prognostic indicators, timing of ARDS onset and the use of low levels of positive end-expiratory pressure or no positive end-expiratory pressure during the first week may adversely influence outcome in ARDS patients.

[1]  ntonio,et al.  EFFECT OF PRONE POSITIONING ON THE SURVIVAL OF PATIENTS WITH ACUTE RESPIRATORY FAILURE , 2001 .

[2]  M. Lamy,et al.  The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. , 1994, American journal of respiratory and critical care medicine.

[3]  S. Epstein,et al.  Acute lung injury in the medical ICU: comorbid conditions, age, etiology, and hospital outcome. , 1998, American journal of respiratory and critical care medicine.

[4]  D. Tierney,et al.  Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure. , 2015, The American review of respiratory disease.

[5]  J. Dhainaut,et al.  Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. , 1998, American journal of respiratory and critical care medicine.

[6]  Kristian Antonsen,et al.  Incidence and Mortality after Acute Respiratory Failure and Acute Respiratory Distress Syndrome in Sweden, Denmark, and Iceland , 1999 .

[7]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[8]  R. EnriqueLaval.  Daniel Alcides Carrión , 2003 .

[9]  D. A. Robertson,et al.  THE UNIVERSITY OF CHICAGO. , 1907, Science.

[10]  R. Levine.  Institutional review boards. , 1989, BMJ.

[11]  C. Gross,et al.  Impact of randomized trial results on acute lung injury ventilator therapy in teaching hospitals. , 2003, American journal of respiratory and critical care medicine.

[12]  Rian,et al.  PULMONARY DEAD-SPACE FRACTION AS A RISK FACTOR FOR DEATH IN THE ACUTE RESPIRATORY DISTRESS SYNDROME , 2002 .

[13]  Andrew D Bersten,et al.  Incidence and mortality of acute lung injury and the acute respiratory distress syndrome in three Australian States. , 2002, American journal of respiratory and critical care medicine.

[14]  Lynn J. Verhey,et al.  State of the Art? New proton medical facilities for the Massachusetts General Hospital and the University of California Davis Medical Center , 1993 .

[15]  Arthur S Slutsky,et al.  Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. , 1998, The New England journal of medicine.

[16]  D. Schoenfeld,et al.  Meta-analysis of acute lung injury and acute respiratory distress syndrome trials. , 2002, American journal of respiratory and critical care medicine.

[17]  R. Steinbrook.  How best to ventilate? Trial design and patient safety in studies of the acute respiratory distress syndrome. , 2003, The New England journal of medicine.

[18]  G. Rubenfeld,et al.  Meta-analysis of tidal volumes in ARDS. , 2003, American journal of respiratory and critical care medicine.

[19]  David W. Hosmer,et al.  Applied Logistic Regression , 1991 .

[20]  J. Sznajder,et al.  Adverse effects of large tidal volume and low PEEP in canine acid aspiration. , 1991, The American review of respiratory disease.

[21]  Diane P. Martin,et al.  Effect of acute lung injury and acute respiratory distress syndrome on outcome in critically ill trauma patients* , 2004, Critical care medicine.

[22]  David M. Shade,et al.  Prospective, randomized, controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients. , 1999, Critical care medicine.

[23]  C. Carvalho,et al.  Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. , 1998, The New England journal of medicine.

[24]  M. Tobin.  Culmination of an era in research on the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[25]  L. Hudson,et al.  Causes of Mortality in Patients with the Adult Respiratory Distress Syndrome , 1985, The American review of respiratory disease.

[26]  F Lemaire,et al.  Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. The Multicenter Trail Group on Tidal Volume reduction in ARDS. , 1998, American journal of respiratory and critical care medicine.

[27]  Brooks De.  Addenbrooke's Hospital, Cambridge , 1857 .

[28]  G. Guyatt,et al.  Survey of interventions for the prevention and treatment of acute respiratory distress syndrome* , 2004, Critical care medicine.

[29]  Arthur S Slutsky,et al.  Tidal ventilation at low airway pressures can augment lung injury. , 1994, American journal of respiratory and critical care medicine.

[30]  Charles Natanson,et al.  Meta-analysis of acute lung injury and acute respiratory distress syndrome trials testing low tidal volumes. , 2002, American journal of respiratory and critical care medicine.

[31]  J. Vincent,et al.  Epidemiology and outcome of acute respiratory failure in intensive care unit patients , 2003, Critical care medicine.

[32]  N. O'Brien,et al.  University of Missouri-Columbia. , 1988, Missouri medicine.

[33]  T. Stewart.  Controversies around lung protective mechanical ventilation. , 2002, American journal of respiratory and critical care medicine.

[34]  K Antonsen,et al.  Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland. The ARF Study Group. , 1999, American journal of respiratory and critical care medicine.

[35]  M. Wysocki,et al.  Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients , 1999, Intensive Care Medicine.

[36]  Salvador Benito,et al.  Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. , 2002, JAMA.

[37]  J. Drazen.  Controlling research trials. , 2003, The New England journal of medicine.

[38]  Arthur S Slutsky,et al.  One-year outcomes in survivors of the acute respiratory distress syndrome. , 2003, The New England journal of medicine.

[39]  Arthur S Slutsky,et al.  Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. , 1999, JAMA.

[40]  Arnaldo Dubin,et al.  Incidence, clinical course, and outcome in 217 patients with acute respiratory distress syndrome , 2002, Critical care medicine.

[41]  Arthur S Slutsky,et al.  ARDSNet lower tidal volume ventilatory strategy may generate intrinsic positive end-expiratory pressure in patients with acute respiratory distress syndrome. , 2002, American journal of respiratory and critical care medicine.

[42]  K Marcdante,et al.  Medical College of Wisconsin. , 2000, Academic medicine : journal of the Association of American Medical Colleges.

[43]  M. Griffiths,et al.  Ventilator-associated lung injury , 2003, The Lancet.

[44]  M. Matthay,et al.  Identification of patients with acute lung injury. Predictors of mortality. , 1995, American journal of respiratory and critical care medicine.

[45]  Marek Ancukiewicz,et al.  Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. , 2009, The New England journal of medicine.