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ARDS following oesophagectomy: a comparison of two trials.

ABSTRACT: Introduction:The Beta Agonist Lung Injury Trial-Prevention (BALTI-P) translational substudy and Vitamin D to Prevent Acute Lung Injury Following Oesophagectomy (VINDALOO) trials recruited patients undergoing oesophagectomy, 4?years apart. The acute respiratory distress syndrome (ARDS) rates were lower in the VINDALOO trial. We sought to identify changes between these two trials and identify risk factors for ARDS in oesophagectomy. Methods:There were data available from 61 patients in the BALTI-P substudy and 68 from VINDALOO. Databases were available for both trials; additional data were collected. Multivariate logistic regression was used to analyse risk factors for ARDS and postoperative complications in the cohorts combined. Results:Logistic regression analysis showed active smoking was associated with an increase in ARDS (OR 3.91; 95% CI 1.33 to 11.5) and dihydropyridine use (OR 5.34;95% CI 1.56 to 18.3). Hospital length of stay was longer for those who took dihydropyridines (median 29 days (IQR 17-42) vs 13 days (IQR 10-18), P=0.0007) or were diabetic (median 25 days (IQR 14-39) vs 13 (IQR 10-19), P=0.023) but not for current smokers (median in never/ex-smokers 13 (IQR 10-23) vs current smokers 15 (IQR 11-20), P=0.73). Conclusions:Smoking cessation trials should be promoted. Dihydropyridine effects perioperatively require further clinical and mechanistic evaluation. Patients undergoing oesophagectomy are a useful model for studying perioperative ARDS.

SUBMITTER: Howells PA

PROVIDER: S-EPMC5687524 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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ARDS following oesophagectomy: a comparison of two trials.

Howells Phillip A PA Aldridge Kerrie A KA Parekh Dhruv D Park Daniel D Tucker Olga O Dancer Rachel C A RCA Gao Fang F Perkins Gavin D GD Thickett David R DR

BMJ open respiratory research 20171102 1

<h4>Introduction</h4>The Beta Agonist Lung Injury Trial-Prevention (BALTI-P) translational substudy and Vitamin D to Prevent Acute Lung Injury Following Oesophagectomy (VINDALOO) trials recruited patients undergoing oesophagectomy, 4 years apart. The acute respiratory distress syndrome (ARDS) rates were lower in the VINDALOO trial. We sought to identify changes between these two trials and identify risk factors for ARDS in oesophagectomy.<h4>Methods</h4>There were data available from 61 patients ...[more]

PMID: 29435341

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Project description:BACKGROUND:Animal trials contribute to major achievements in medical science. The so-called lavage model is frequently used to evaluate ventilation strategies in acute respiratory distress syndrome (ARDS) using electrical impedance tomography (EIT). But, the lavage model itself might have systematic impacts on EIT parameters. Therefore, we established an additional experimental model, in which ARDS is caused by intravenously administered lipopolysaccharide (LPS). In this study, we want to examine if EIT measurements provide consistent results in both experimental models or whether the pathophysiology of the model influences the findings. Overall, we want to compare both experimental models regarding clinical parameters and EIT-derived indices, namely the global inhomogeneity (GI) index and the regional ventilation delay (RVD) index. METHODS:Nineteen pigs were included in this study, allocated to the control group (CO; n = 5), lavage group (LAV; n = 7) and LPS group (LPS; n = 7). After baseline measurements and the establishment of ARDS, assessment of respiratory mechanics, hemodynamics, gas exchange and EIT recordings were performed hourly over eight hours. RESULTS:In both experimental ARDS models, EIT measurements provided reliable results. But, the GI and the RVD index did not show consistent results as compared to the CO group. Initially, GI and RVD index were higher in the LAV group but not in the LPS group as compared to the CO group. This effect disappeared during the study. Furthermore, the GI index and the RVD index were higher in the LAV group compared to the LPS group in the beginning as well. This, once again, disappeared. Clinical lung injury parameters remained more stable when using LPS. CONCLUSION:The two models showed quite different influences on the GI and RVD index. This implies, that the underlying pathophysiology affects EIT parameters and thus the findings. Hence, translation to EIT-guided clinical therapy in humans suffering from ARDS might be limited.

Project description:Driving pressure (?Prs) 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 ?Prs in two trials in which strict lung-protective mechanical ventilation was applied in ARDS. Our working hypothesis was that ?Prs is a risk factor for mortality just like compliance (Crs) or plateau pressure (Pplat,rs) of the respiratory system.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, ?Prs, 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 ?Prs, Crs, and Pplat,rs was verified, specific Cox models were used for each of them.Both trials enrolled 805 patients of whom 787 had day-1 data available, and 533 of these survived. In the univariate analysis, ?Prs averaged 13.7?±?3.7 and 12.8?±?3.7 cmH2O (P?=?0.002) in nonsurvivors and survivors, respectively. Colinearity between ?Prs, 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 ?Prs, Pplat,rs and Crs, respectively. PEEP and VT were not associated with death in any model.When ventilating patients with low VT, ?Prs 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.Clinicaltrials.gov NCT00299650 . Registered 6 March 2006 for the Acurasys trial. Clinicaltrials.gov NCT00527813 . Registered 10 September 2007 for the Proseva trial.

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ARDS following oesophagectomy: a comparison of two trials.

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ARDS following oesophagectomy: a comparison of two trials.

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