Driving pressure and survival in the acute respiratory distress syndrome.

By M. Amato, M. Meade, Arthur S Slutsky, L. Brochard, E. Costa, D. Schoenfeld, T. Stewart, M. Briel, D. Talmor, A. Mercat and 3 more. New England Journal of Medicine, 2015

2,273 citations recorded by the source corpus.

BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (VT), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (CRS) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size), we hypothesized that driving pressure (ΔP=VT/CRS), in which VT is intrinsically normalized to functional lung size (instead of predicted lung size in healthy persons), would be an index more strongly associated with survival than VT or PEEP in patients who are not actively breathing. METHODS Using a statistical tool known as multilevel mediation analysis to analyze individual data from 3562 patients with ARDS enrolled in nine previously reported randomized trials, we examined ΔP as an independent variable associated with survival. In the mediation analysis, we estimated the isolated effects of changes in ΔP resulting from randomized ventilator settings while minimizing confounding due to the baseline severity of lung disease. RESULTS Among ventilation variables, ΔP was most strongly associated with survival. A 1-SD increment in ΔP (approximately 7 cm of water) was associated with increased mortality (relative risk, 1.41; 95% confidence interval [CI], 1.31 to 1.51; P<0.001), even in patients receiving "protective" plateau pressures and VT (relative risk, 1.36; 95% CI, 1.17 to 1.58; P<0.001). Individual changes in VT or PEEP after randomization were not independently associated with survival; they were associated only if they were among the changes that led to reductions in ΔP (mediation effects of ΔP, P=0.004 and P=0.001, respectively). CONCLUSIONS We found that ΔP was the ventilation variable that best stratified risk. Decreases in ΔP owing to changes in ventilator settings were strongly associated with increased survival. (Funded by Fundação de Amparo e Pesquisa do Estado de São Paulo and others.).

Subfields: Pulmonary and Respiratory Medicine, Sociology and Political Science

View Paper: https://www.semanticscholar.org/paper/5c01213d5ac21a87adaa435b220cc544cdf9237b

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In Pulmonary and Respiratory Medicine

1. Arthur S Slutsky
2. W. Organization
3. Jean-Louis Vincent

Citations in the corpus

• Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance (2020, background): “Although high driving pressure (plateau pressure − PEEP) may more accurately predict increased mortality in ARDS compared with high tidal volume or plateau pressure (36), data from RCTs of ventilation strategies that target driving pressure are not currently available.”
• The intensive care medicine research agenda for airways, invasive and noninvasive mechanical ventilation (2017, background): “Several important examples pertain to ventilation: the level of PEEP applied to a given patient may help or harm, depending on recruitability, driving pressure, and pressure baseline [36].”
• Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. (2016, background): “Surviving patients 23 (14-40) 23 (14-40) 22 (13-40) 26 (14-43) .”
• Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 (2017, background): “A recent patient-level mediation analysis suggested that a tidal volume that results in a driving pressure (plateau pressure minus set PEEP) below 12–15 cm H 2 O may be advantageous in patients without spontaneous breathing efforts (359).”
• Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure. (2017, background): “is the ratio of tidal volume to tidal respiratory system compliance, the latter being a crude marker of lung volume (7).”
• Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial (2017, neutral): “Time since onset of ARDS, median (IQR), h 15 (7-34) 16 (7-30)”