Tags

Type your tag names separated by a space and hit enter

Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance.
Am J Respir Crit Care Med. 2021 06 01; 203(11):1378-1385.AJ

Abstract

Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by Vt, then the effect of ventilation with lower Vt on mortality would be predicted to vary according to respiratory system elastance (Ers). Objectives: To determine whether the mortality benefit of ventilation with lower Vt varies according to Ers. Methods: In a secondary analysis of patients from five randomized trials of lower- versus higher-Vt ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized Vt strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression. Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-Vt ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63-1.02). Ers was classified as low (<2 cm H2O/[ml/kg], n = 321, 32%), intermediate (2-3 cm H2O/[ml/kg], n = 475, 46%), and high (>3 cm H2O/[ml/kg], n = 224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality ≥ 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction ≥ 5% were 29%, 58%, and 82%, respectively. Conclusions: The mortality benefit of ventilation with lower Vt in ARDS varies according to elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than Vt.

Authors+Show Affiliations

Interdepartmental Division of Critical Care Medicine. Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada. Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, Ontario, Canada.Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil. Research and Education Institute, Hospital Sírio-Libanes, São Paulo, Brazil.Interdepartmental Division of Critical Care Medicine. Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada. Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.Interdepartmental Division of Critical Care Medicine. Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.St. Joseph's Hospital, Hamilton, Ontario, Canada; and.Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.Interdepartmental Division of Critical Care Medicine. Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Brazil.

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

33439781

Citation

Goligher, Ewan C., et al. "Effect of Lowering Vt On Mortality in Acute Respiratory Distress Syndrome Varies With Respiratory System Elastance." American Journal of Respiratory and Critical Care Medicine, vol. 203, no. 11, 2021, pp. 1378-1385.
Goligher EC, Costa ELV, Yarnell CJ, et al. Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance. Am J Respir Crit Care Med. 2021;203(11):1378-1385.
Goligher, E. C., Costa, E. L. V., Yarnell, C. J., Brochard, L. J., Stewart, T. E., Tomlinson, G., Brower, R. G., Slutsky, A. S., & Amato, M. P. B. (2021). Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance. American Journal of Respiratory and Critical Care Medicine, 203(11), 1378-1385. https://doi.org/10.1164/rccm.202009-3536OC
Goligher EC, et al. Effect of Lowering Vt On Mortality in Acute Respiratory Distress Syndrome Varies With Respiratory System Elastance. Am J Respir Crit Care Med. 2021 06 1;203(11):1378-1385. PubMed PMID: 33439781.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance. AU - Goligher,Ewan C, AU - Costa,Eduardo L V, AU - Yarnell,Christopher J, AU - Brochard,Laurent J, AU - Stewart,Thomas E, AU - Tomlinson,George, AU - Brower,Roy G, AU - Slutsky,Arthur S, AU - Amato,Marcelo P B, PY - 2021/1/14/pubmed PY - 2021/8/4/medline PY - 2021/1/13/entrez KW - acute respiratory distress syndrome KW - driving pressure KW - lung-protective ventilation SP - 1378 EP - 1385 JF - American journal of respiratory and critical care medicine JO - Am J Respir Crit Care Med VL - 203 IS - 11 N2 - Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by Vt, then the effect of ventilation with lower Vt on mortality would be predicted to vary according to respiratory system elastance (Ers). Objectives: To determine whether the mortality benefit of ventilation with lower Vt varies according to Ers. Methods: In a secondary analysis of patients from five randomized trials of lower- versus higher-Vt ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized Vt strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression. Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-Vt ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63-1.02). Ers was classified as low (<2 cm H2O/[ml/kg], n = 321, 32%), intermediate (2-3 cm H2O/[ml/kg], n = 475, 46%), and high (>3 cm H2O/[ml/kg], n = 224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality ≥ 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction ≥ 5% were 29%, 58%, and 82%, respectively. Conclusions: The mortality benefit of ventilation with lower Vt in ARDS varies according to elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than Vt. SN - 1535-4970 UR - https://www.unboundmedicine.com/medline/citation/33439781/Effect_of_Lowering_Vt_on_Mortality_in_Acute_Respiratory_Distress_Syndrome_Varies_with_Respiratory_System_Elastance_ DB - PRIME DP - Unbound Medicine ER -