Maintenance of low driving pressure in patients with early acute respiratory distress syndrome significantly affects outcomes

Hsun-Hsien Chang ,Wan-Lin Chen ,Wei-Lun Liu,Kuo-Chen Cheng,Chung‐Han Ho ,Ching-Min Wang,Shu-Chen Kung,Han‐Shui Hsu

doi:10.1186/s12931-021-01912-8

Abstract

BackgroundDriving pressure (∆P) is an important factor that predicts mortality in acute respiratory distress syndrome (ARDS). We test the hypothesis that serial changes in daily ΔP rather than Day 1 ΔP would better predict outcomes of patients with ARDS.MethodsThis retrospective cohort study enrolled patients admitted to five intensive care units (ICUs) at a medical center in Taiwan between March 2009 and January 2018 who met the criteria for ARDS and received the lung-protective ventilation strategy. ∆P was recorded daily for 3 consecutive days after the diagnosis of ARDS, and its correlation with 60-day survival was analyzed.ResultsA total of 224 patients were enrolled in the final analysis. The overall ICU and 60-day survival rates were 52.7% and 47.3%, respectively. ∆P on Days 1, 2, and 3 was significantly lower in the survival group than in the nonsurvival group (13.8 ± 3.4 vs. 14.8 ± 3.7, p = 0.0322, 14 ± 3.2 vs. 15 ± 3.5, p = 0.0194, 13.6 ± 3.2 vs. 15.1 ± 3.4, p = 0.0014, respectively). The patients were divided into four groups according to the daily changes in ∆P, namely, the low ∆P group (Day 1 ∆P < 14 cmH2O and Day 3 ∆P < 14 cmH2O), decrement group (Day 1 ∆P ≥ 14 cmH2O and Day 3 ∆P < 14 cmH2O), high ∆P group (Day 1 ∆P ≥ 14 cmH2O and Day 3 ∆P ≥ 14 cmH2O), and increment group (Day 1 ∆P < 14 cmH2O and Day 3 ∆P ≥ 14 cmH2O). The 60-day survival significantly differed among the four groups (log-rank test, p = 0.0271). Compared with the low ΔP group, patients in the decrement group did not have lower 60-day survival (adjusted hazard ratio 0.72; 95% confidence interval [CI] 0.31–1.68; p = 0.4448), while patients in the increment group had significantly lower 60-day survival (adjusted hazard ratio 1.96; 95% CI 1.11–3.44; p = 0.0198).ConclusionsDaily ∆P remains an important predicting factor for survival in patients with ARDS. Serial changes in daily ΔP might be more informative than a single Day 1 ΔP value in predicting survival of patients with ARDS.

Highlights

Driving pressure (∆P) is an important factor that predicts mortality in acute respiratory distress syn‐ drome (ARDS)
Several therapeutic strategies that may assist in the treatment of ARDS have been proposed, such as the lung-protective ventilation strategy, lung recruitment maneuvers, prone positions, and extracorporeal membrane oxygenation (ECMO) [5]
A total of 330 patients diagnosed with ARDS were admitted to our Intensive care unit (ICU) and received mechanical ventilation during the study period

Summary

Introduction

Driving pressure (∆P) is an important factor that predicts mortality in acute respiratory distress syn‐ drome (ARDS). Several therapeutic strategies that may assist in the treatment of ARDS have been proposed, such as the lung-protective ventilation strategy, lung recruitment maneuvers, prone positions, and extracorporeal membrane oxygenation (ECMO) [5]. Several large randomized clinical studies have confirmed that the lung-protective strategy is still the mainstream treatment for ARDS [4,5,6,7]; no lung physiological parameter can predict mortality. Driving pressure (∆P), proposed in 2015 [8], is a simple calculation formula that can reflect the true pressure condition of the lung due to pathological changes and ventilator settings. Other studies have pointed out that the use of dynamic ∆P to predict mortality in patients with ARDS using ECMO yields similar results [11]

Methods

Results

Discussion

Conclusion