12 Outcomes in Ventilated Burn Patients with Acute Respiratory Distress Syndrome: An Evaluation of Early High-PEEP Strategy Using Berlin Criteria.

Abstract

Abstract Introduction Acute respiratory distress syndrome (ARDS) remains a formidable sequela, complication, and mortality risk in patients with large burns with or without inhalation injury. Alveolar recruitment using higher positive end expiratory Pressures (PEEP) after the onset of ARDS has been tried with varying success. Subsequent studies have identified benefits for several rescue maneuvers in ARDS patients with refractory hypoxemia. A preventive strategy utilizing an early recruitment maneuver, however, has not, to our knowledge, been explored in ventilated burn patients. The purpose of this study was to evaluate the natural progression and clinical outcomes of ARDS severity (mild, moderate, and severe) using Berlin criteria in ventilated burn patients treated with an early high-PEEP ventilator strategy. Methods A single-center retrospective review of burn patients who were mechanically ventilated for more than 48 hours utilizing an early high-PEEP ventilator strategy was performed at our Level 1 trauma and regional burn center. ARDS severity was defined according to the Berlin criteria. Demographic data, as well as respiratory and clinical outcomes were evaluated. Results Eighty-three patients met inclusion criteria and were analyzed. According to the Berlin definition, 42.1% of patients met ARDS criteria on admission and nearly all patients (85.5%) developed ARDS within the first seven days: 28 (34%) mild, 32 (38.6%) moderate, and 11 (13.3%) severe ARDS. The mean percent total body surface area (%TBSA) was 24.6 ± 22.1, with 68.7% of patients diagnosed with inhalation injury. The highest incidence of ARDS was 57.8% on day 2 of admission. Most cases remained in the mild to moderate ARDS category with severe ARDS (2.4%) being less common by hospital day 7. Overall, 30-day in-hospital and inhalation injury mortality rates were 9.6% and 15.8%, respectively. No correlation was observed between plateau pressures (22.8), mean arterial pressures (84.4), or vasopressor requirements; and oxygen requirements down trended quickly over the first 24–48 hours. Conclusions In our study, prophylactic, immediate, high-PEEP in mechanically ventilated burn patients was associated with trends toward decreased severity and more rapid resolution of ARDS in the first week following burn injury. This correlated with lower 30-day in-hospital mortality in this population. This