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Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome.

ABSTRACT: To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome (ARDS).We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in 1998, 2004, and 2010. We used multivariable logistic regression and a propensity score analysis to examine the association between hypercapnia and ICU mortality.We included 1899 patients with ARDS in this study. The relationship between maximum PaCO2 in the first 48 h and mortality suggests higher mortality at or above PaCO2 of ?50 mmHg. Patients with severe hypercapnia (PaCO2 ?50 mmHg) had higher complication rates, more organ failures, and worse outcomes. After adjusting for age, SAPS II score, respiratory rate, positive end-expiratory pressure, PaO2/FiO2 ratio, driving pressure, pressure/volume limitation strategy (PLS), corrected minute ventilation, and presence of acidosis, severe hypercapnia was associated with increased risk of ICU mortality [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.32 to 2.81; p = 0.001]. In patients with severe hypercapnia matched for all other variables, ventilation with PLS was associated with higher ICU mortality (OR 1.58, CI 95% 1.04-2.41; p = 0.032).Severe hypercapnia appears to be independently associated with higher ICU mortality in patients with ARDS.Clinicaltrials.gov identifier, NCT01093482.

SUBMITTER: Nin N

PROVIDER: S-EPMC5630225 | biostudies-literature | 2017 Feb

REPOSITORIES: biostudies-literature

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Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome.

Nin Nicolas N Muriel Alfonso A Peñuelas Oscar O Brochard Laurent L Lorente José Angel JA Ferguson Niall D ND Raymondos Konstantinos K Ríos Fernando F Violi Damian A DA Thille Arnaud W AW González Marco M Villagomez Asisclo J AJ Hurtado Javier J Davies Andrew R AR Du Bin B Maggiore Salvatore M SM Soto Luis L D'Empaire Gabriel G Matamis Dimitrios D Abroug Fekri F Moreno Rui P RP Soares Marco Antonio MA Arabi Yaseen Y Sandi Freddy F Jibaja Manuel M Amin Pravin P Koh Younsuck Y Kuiper Michael A MA Bülow Hans-Henrik HH Zeggwagh Amine Ali AA Anzueto Antonio A Sznajder Jacob I JI Esteban Andres A

Intensive care medicine 20170120 2

<h4>Purpose</h4>To analyze the relationship between hypercapnia developing within the first 48 h after the start of mechanical ventilation and outcome in patients with acute respiratory distress syndrome (ARDS).<h4>Patients and methods</h4>We performed a secondary analysis of three prospective non-interventional cohort studies focusing on ARDS patients from 927 intensive care units (ICUs) in 40 countries. These patients received mechanical ventilation for more than 12 h during 1-month periods in ...[more]

PMID: 28108768

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Project description:OBJECTIVES:Prior studies suggest hypothermia may be beneficial in acute respiratory distress syndrome, but cooling causes shivering and increases metabolism. The objective of this study was to assess the feasibility of performing a randomized clinical trial of hypothermia in patients with acute respiratory distress syndrome receiving treatment with neuromuscular blockade because they cannot shiver. DESIGN:Retrospective study and pilot, prospective, open-label, feasibility study. SETTING:Medical ICU. PATIENTS:Retrospective review of 58 patients with acute respiratory distress syndrome based on Berlin criteria and PaO2/FIO2 less than 150 who received neuromuscular blockade. Prospective hypothermia treatment in eight acute respiratory distress syndrome patients with PaO2/FIO2 less than 150 receiving neuromuscular blockade. INTERVENTION:Cooling to 34-36°C for 48 hours. MEASUREMENTS AND MAIN RESULTS:Core temperature, hemodynamics, serum glucose and electrolytes, and P/F were sequentially measured, and medians (interquartile ranges) presented, 28-day ventilator-free days, and hospital mortality were calculated in historical controls and eight cooled patients. Average patient core temperature was 36.7°C (36-37.3°C), and fever occurred during neuromuscular blockade in 30 of 58 retrospective patients. In the prospectively cooled patients, core temperature reached target range less than or equal to 4 hours of initiating cooling, remained less than 36°C for 92% of the 48 hours cooling period without adverse events, and was lower than the controls (34.35°C [34-34.8°C]; p < 0.0001). Compared with historical controls, the cooled patients tended to have lower hospital mortality (75% vs 53.4%; p = 0.26), more ventilator-free days (9 [0-21.5] vs 0 [0-12]; p = 0.16), and higher day 3 P/F (255 [160-270] vs 171 [120-214]; p = 0.024). CONCLUSIONS:Neuromuscular blockade alone does not cause hypothermia but allowed acute respiratory distress syndrome patients to be effectively cooled. Results support conducting a randomized clinical trial of hypothermia in acute respiratory distress syndrome and the feasibility of studying acute respiratory distress syndrome patients receiving neuromuscular blockade.

Project description:BACKGROUND:Clinical and epidemiological differences between acute respiratory distress syndrome (ARDS) that presents at the initiation of mechanical ventilation [MV] (ARDS at MV onset) and that which develops during the course of MV (ARDS after MV onset) are not well understood. We conducted an observational study in five Peruvian ICUs to characterize differences between ARDS at MV onset and after MV onset and identify risk factors for the development of ARDS after MV onset. METHODS:We consecutively enrolled critically ill patients with acute respiratory failure requiring at least 24?h of mechanical ventilation and followed them prospectively during the first 28?days and compared baseline characteristics and clinical outcomes by ARDS status. RESULTS:We enrolled 1657 participants on MV (mean age 60.0?years, 55% males) of whom 334 (20.2%) had ARDS at MV onset and 180 (10.9%) developed ARDS after MV onset. Average tidal volume at the initiation of MV was 8.7?mL/kg of predicted body weight (PBW) for participants with ARDS at MV onset, 8.6?mL/kg PBW for those who developed ARDS after MV onset, and 8.5?mL/kg PBW for those who never developed ARDS (p =?0.23). Overall, 90-day mortality was 56% and 55% for ARDS after MV onset and ARDS at MV onset, respectively, as compared to 46% among those who never developed ARDS (p <?0.01). Adults with ARDS had a higher body mass index (BMI) than those without ARDS (27.3 vs 26.5?kg/m2, p <?0.01). Higher peak pressure (adjusted interquartile OR?=?1.51, 95% CI 1.21-1.88), higher mean airway pressure (adjusted interquartile OR?=?1.41, 95% CI 1.13-1.76), and higher positive end-expiratory pressure (adjusted interquartile OR?=?1.29, 95% CI 1.10-1.50) at MV onset were associated with a higher odds of developing ARDS after MV onset. CONCLUSIONS:In this study of mechanically ventilated patients, 31% of study participants had ARDS at some point during their ICU stay. Optimal lung-protective ventilation was not used in a majority of patients. Patients with ARDS after MV onset had a similar 90-day mortality as those with ARDS at MV onset. Higher airway pressures at MV onset, higher PEEP, and higher BMI were associated with the development of ARDS after MV onset.

Project description:BackgroundSome unanswered questions persist regarding the effectiveness of corticosteroids for severe coronavirus disease 2019 (COVID-19) patients. We aimed to assess the clinical effect of corticosteroids on intensive care unit (ICU) mortality among mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients.MethodsThis was a retrospective study of prospectively collected data conducted in 70 ICUs (68 Spanish, one Andorran, one Irish), including mechanically ventilated COVID-19-associated ARDS patients admitted between February 6 and September 20, 2020. Individuals who received corticosteroids for refractory shock were excluded. Patients exposed to corticosteroids at admission were matched with patients without corticosteroids through propensity score matching. Primary outcome was all-cause ICU mortality. Secondary outcomes were to compare in-hospital mortality, ventilator-free days at 28 days, respiratory superinfection and length of stay between patients with corticosteroids and those without corticosteroids. We performed survival analysis accounting for competing risks and subgroup sensitivity analysis.ResultsWe included 1835 mechanically ventilated COVID-19-associated ARDS, of whom 1117 (60.9%) received corticosteroids. After propensity score matching, ICU mortality did not differ between patients treated with corticosteroids and untreated patients (33.8% vs. 30.9%; p = 0.28). In survival analysis, corticosteroid treatment at ICU admission was associated with short-term survival benefit (HR 0.53; 95% CI 0.39-0.72), although beyond the 17th day of admission, this effect switched and there was an increased ICU mortality (long-term HR 1.68; 95% CI 1.16-2.45). The sensitivity analysis reinforced the results. Subgroups of age < 60 years, severe ARDS and corticosteroids plus tocilizumab could have greatest benefit from corticosteroids as short-term decreased ICU mortality without long-term negative effects were observed. Larger length of stay was observed with corticosteroids among non-survivors both in the ICU and in hospital. There were no significant differences for the remaining secondary outcomes.ConclusionsOur results suggest that corticosteroid treatment for mechanically ventilated COVID-19-associated ARDS had a biphasic time-dependent effect on ICU mortality. Specific subgroups showed clear effect on improving survival with corticosteroid use. Therefore, further research is required to identify treatment-responsive subgroups among the mechanically ventilated COVID-19-associated ARDS patients.

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Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome.

Publications

Severe hypercapnia and outcome of mechanically ventilated patients with moderate or severe acute respiratory distress syndrome.

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