Adjunctive Therapies in ARDS: Patterns of Practice and Utilization in a Referral Center

Abstract

SESSION TITLE: Acute Lung Injury & Respiratory Failure SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 01:30 PM - 03:00 PM PURPOSE: The use of adjunctive therapies in acute respiratory distress syndrome (ARDS) has significant institutional and geographical differences. We report on the utilization of adjunctive therapies over a 5 year period in a quaternary referral center. METHODS: We collected ventilator parameters (for the first 72 hours) and ICU specific interventions for the first week of ICU stay for all the patients who developed ARDS (based on Berlin definition) within 24 hours of intubation. Adjunctive therapy was defined as use of one or more of the following therapies: continuous neuromuscular blocking agents, prone positioning, inhaled vasodilators, high frequency oscillatory ventilation and extracorporeal membrane oxygenation (ECMO). RESULTS: 79 (36%) patients underwent at least one adjunctive therapy. Neuromuscular blockade 71 (90%), Inhaled Vasodilators 32 (41%), and Prone Position Ventilation 17 (22%) were the most commonly used adjunctive therapies. Patients that underwent adjunctive therapies were younger (p=0.0006), but there was no difference in underlying comorbidities or severity of illness (calculated by APACHE III score) at presentation. Patients that underwent adjunctive therapies had lower PF ratio (117 vs 163, p<0.001), higher PaCo2 (46 vs 40, p=0.0002), higher plateau pressures and PEEP on day 1. In patients receiving adjunctive interventions, tidal volumes were significantly decreased over the first 72 hours, but the plateau, peak and mean airway pressures remained significantly higher despite those changes. Use of vasopressors, analgesics and sedation was significantly higher in the patients who underwent adjunctive therapies. Mortality was not significantly higher in patients that underwent adjunctive therapies (67 % vs 46%, p=0.19), but the duration of mechanical ventilation was significantly higher in these patients (15 days vs 11 days, p=0.007). CONCLUSIONS: Adjunctive therapies were used more commonly in younger patients with a more severe ICU course. Plateau pressures were significantly higher in these patients on presentation, and they needed higher PEEP support. Despite changes in tidal volumes their mean airway and plateau pressure remained higher than patients not requiring adjunctive interventions. CLINICAL IMPLICATIONS: Rescue therapies are often administered to a sicker ARDS patient population with refractory hypoxemia. These patients stay mechanically ventilated for a longer duration, need higher degree of adjunctive life support modalities but have similar mortality rates compared to other patients. Physicians should be watchful for early signs of refractory hypoxemia and consider using adjunctive therapy early in ARDS course to improve mortality. DISCLOSURE: The following authors have nothing to disclose: Abhijit Duggal, Anirban Bhattacharyya, Saminder Kalra, Jamal Mahar, Aravdeep Jhand, Mrinalini Venkatasubramani No Product/Research Disclosure Information