Dataset Information

Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome.

ABSTRACT:

Objective

Evidence only proves low surpasses high tidal volume (V _T) for acute respiratory distress syndrome (ARDS). Intermediate V _T is a common setting for ARDS patients and has been demonstrated as effective as low V _T in non-ARDS patients. The effectiveness of intermediate V _T in ARDS has not been studied and is the objective of this study.

Design

A retrospective cohort study.

Setting

Five ICUs with their totally 130 beds in Taiwan.

Patients or participants

ARDS patients under invasive ventilation.

Interventions

No.

Main variables of interest

28-D mortality.

Result

Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V _T = 6.7 ml/kg), intermediate (mean V _T = 8.9 ml/kg) and high (mean V _T = 11.2 ml/kg) V _T groups. With similar baseline ARDS and ICU severities, intermediate and low V _T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V _T was independently associated with 28-D and 90-D mortality, but intermediate V _T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V _T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different.

Conclusion

Intermediate V _T, with its outcomes similar to small V _T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.

SUBMITTER: Wu SH

PROVIDER: S-EPMC9597521 | biostudies-literature | 2022 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome.

Wu S-H SH Kor C-T CT Li C-Y CY Hsiao Y-C YC

Medicina intensiva 20220429 11

<h4>Objective</h4>Evidence only proves low surpasses high tidal volume (<i>V</i> <sub>T</sub>) for acute respiratory distress syndrome (ARDS). Intermediate <i>V</i> <sub>T</sub> is a common setting for ARDS patients and has been demonstrated as effective as low <i>V</i> <sub>T</sub> in non-ARDS patients. The effectiveness of intermediate <i>V</i> <sub>T</sub> in ARDS has not been studied and is the objective of this study.<h4>Design</h4>A retrospective cohort study.<h4>Setting</h4>Five ICUs with ...[more]

PMID: 36313965

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Project description:OBJECTIVE:Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use. DESIGN:Retrospective cross-sectional study. SETTING:One academic and three community hospitals in the Chicago region. PATIENTS:A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013. MEASUREMENTS AND MAIN RESULTS:Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5?mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30?cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8?mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8?mL/kg predicted body weight. CONCLUSIONS:More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.

Project description:OBJECTIVES:Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. DATA SOURCES:We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. STUDY SELECTION AND DATA EXTRACTION:Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. DATA SYNTHESIS:Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. CONCLUSIONS:Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.

Project description:BackgroundProne position is frequently used in patients with acute respiratory distress syndrome (ARDS), especially during the Coronavirus disease 2019 pandemic. Our study investigated the ability of pulse pressure variation (PPV) and its changes during a tidal volume challenge (TVC) to assess preload responsiveness in ARDS patients under prone position.MethodsThis was a prospective study conducted in a 25-bed intensive care unit at a university hospital. We included patients with ARDS under prone position, ventilated with 6 mL/kg tidal volume and monitored by a transpulmonary thermodilution device. We measured PPV and its changes during a TVC (ΔPPV TVC6-8) after increasing the tidal volume from 6 to 8 mL/kg for one minute. Changes in cardiac index (CI) during a Trendelenburg maneuver (ΔCITREND) and during end-expiratory occlusion (EEO) at 8 mL/kg tidal volume (ΔCI EEO8) were recorded. Preload responsiveness was defined by both ΔCITREND ≥ 8% and ΔCI EEO8 ≥ 5%. Preload unresponsiveness was defined by both ΔCITREND < 8% and ΔCI EEO8 < 5%.ResultsEighty-four sets of measurements were analyzed in 58 patients. Before prone positioning, the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen was 104 ± 27 mmHg. At the inclusion time, patients were under prone position for 11 (2-14) hours. Norepinephrine was administered in 83% of cases with a dose of 0.25 (0.15-0.42) µg/kg/min. The positive end-expiratory pressure was 14 (11-16) cmH2O. The driving pressure was 12 (10-17) cmH2O, and the respiratory system compliance was 32 (22-40) mL/cmH2O. Preload responsiveness was detected in 42 cases. An absolute change in PPV ≥ 3.5% during a TVC assessed preload responsiveness with an area under the receiver operating characteristics (AUROC) curve of 0.94 ± 0.03 (sensitivity: 98%, specificity: 86%) better than that of baseline PPV (0.85 ± 0.05; p = 0.047). In the 56 cases where baseline PPV was inconclusive (≥ 4% and < 11%), ΔPPV TVC6-8 ≥ 3.5% still enabled to reliably assess preload responsiveness (AUROC: 0.91 ± 0.05, sensitivity: 97%, specificity: 81%; p < 0.01 vs. baseline PPV).ConclusionIn patients with ARDS under low tidal volume ventilation during prone position, the changes in PPV during a TVC can reliably assess preload responsiveness without the need for cardiac output measurements.Trial registrationClinicalTrials.gov (NCT04457739). Registered 30 June 2020 -Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04457739.

Dataset Information

Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome.

Objective

Design

Setting

Patients or participants

Interventions

Main variables of interest

Result

Conclusion

Publications

Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome.

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