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01.12.2016 | Research | Ausgabe 1/2016 Open Access

Critical Care 1/2016

Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials

Zeitschrift:
Critical Care > Ausgabe 1/2016
Autoren:
Claude Guérin, Laurent Papazian, Jean Reignier, Louis Ayzac, Anderson Loundou, Jean-Marie Forel, on behalf of the investigators of the Acurasys and Proseva trials
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s13054-016-1556-2) contains supplementary material, which is available to authorized users.

Abstract

Background

Driving pressure (ΔPrs) 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 ΔPrs in two trials in which strict lung-protective mechanical ventilation was applied in ARDS. Our working hypothesis was that ΔPrs is a risk factor for mortality just like compliance (Crs) or plateau pressure (Pplat,rs) of the respiratory system.

Methods

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, ΔPrs, 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 ΔPrs, Crs, and Pplat,rs was verified, specific Cox models were used for each of them.

Results

Both trials enrolled 805 patients of whom 787 had day-1 data available, and 533 of these survived. In the univariate analysis, ΔPrs averaged 13.7 ± 3.7 and 12.8 ± 3.7 cmH2O (P = 0.002) in nonsurvivors and survivors, respectively. Colinearity between ΔPrs, 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 ΔPrs, Pplat,rs and Crs, respectively. PEEP and VT were not associated with death in any model.

Conclusions

When ventilating patients with low VT, ΔPrs 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.

Trial registration

Clinicaltrials.gov NCT00299650. Registered 6 March 2006 for the Acurasys trial.
Clinicaltrials.gov NCT00527813. Registered 10 September 2007 for the Proseva trial.
Zusatzmaterial
Additional file 1: Table S1. Multivariate Cox regression analysis for factors on day 1 including mechanical power associated with ARDS mortality at day 90. (DOC 33 kb)
13054_2016_1556_MOESM1_ESM.doc
Additional file 2: Table S2. Multivariate Cox regression analysis for factors on day 1 including plateau pressure associated with ARDS mortality at day 90. (DOC 33 kb)
13054_2016_1556_MOESM2_ESM.doc
Additional file 3: Table S3. Multivariate Cox regression analysis for factors on day 1 including compliance of the respiratory system associated with ARDS mortality at day 90. (DOC 33 kb)
13054_2016_1556_MOESM3_ESM.doc
Additional file 4: Table S4. Multivariate Cox regression analysis for factors on day 1 including a couple of collinear variables associated with ARDS mortality at day 90. (DOCX 19 kb)
13054_2016_1556_MOESM4_ESM.docx
Additional file 5: Figure S1. Kaplan-Meier graphs of the probability of survival over 90 days after inclusion of patients with ARDS according to Pplat,rs and Crs. The curves were compared by using the log rank test. (PPTX 92 kb)
13054_2016_1556_MOESM5_ESM.pptx
Additional file 6: Figure S2. Adjusted probability of survival derived from the Cox model according to ΔPrs (A) and mechanical power (B). (PPTX 89 kb)
13054_2016_1556_MOESM6_ESM.pptx
Additional file 7: Figure S3. Adjusted probability of survival derived from the Cox model according Pplat,rs (A) and Crs (B). (PPTX 90 kb)
13054_2016_1556_MOESM7_ESM.pptx
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