Abstract
It remains uncertain how best to set positive end-expiratory pressure (PEEP) for mechanically ventilated patients with the acute respiratory distress syndrome (ARDS). Among patients on low tidal volume ventilation (LTVV), we investigated if further adherence to the low PEEP/FIO2 (inspired oxygen fraction) table would be associated with better survival compared to nonadherence. Patients with ARDS, admitted directly from the Emergency Department to our 20-bed Medical Intensive Care Unit (ICU) from August 2016 to July 2017, were retrospectively studied. To determine adherence to the low PEEP/FIO2 table, PEEP and FIO2 12 h after ICU admission were used, to reflect ventilator adjustments by ICU clinicians after initial stabilization. Logistic regression was used to analyze hospital mortality as an outcome with adherence to the low PEEP/FIO2 as the key independent variable, adjusted for age, APACHE II score, initial P/F ratio and initial systolic blood pressure. 138 patients with ARDS were analysed. Overall adherence to the low PEEP/FIO2 table was 75.4%. Among patients on LTVV, nonadherence to the low PEEP/FIO2 table was associated with increased mortality compared to adherence (adjusted odds ratio 4.10, 95% confidence interval 1.68–9.99, P = 0.002). Patient characteristics at baseline were not associated with adherence to the low PEEP/FIO2 table.
Highlights
To improve survival of patients with acute respiratory distress syndrome (ARDS)[1], an optimal mechanical ventilation strategy includes low tidal volume ventilation (LTVV)[2] and avoidance of either hypoxemia or h yperoxemia[3]
We examined the association of adherence to the low positive end-expiratory pressure (PEEP)/FIO2 table with age, gender, body-mass index, Acute Physiology and Chronic Health Evaluation (APACHE) II score, primary diagnosis, comorbid conditions, initial arterial oxygen partial pressure to inspired oxygen fraction (P/F) ratio, initial systolic blood pressure, use of vasopressors within the first 24 h of Intensive Care Unit (ICU) admission, ICU/hospital mortality, ICU/hospital length-of-stay and ventilator-free days through day 2825
Between patients who demonstrated nonadherence to the low PEEP/FIO2 table, compared to those who demonstrated adherence, there were no significant differences found for age, gender, APACHE II score, primary diagnosis, comorbid conditions, initial parameters (P/F ratio, tidal volume corrected for ideal body weight, systolic blood pressure) (Table 2)
Summary
To improve survival of patients with acute respiratory distress syndrome (ARDS)[1], an optimal mechanical ventilation strategy includes low tidal volume ventilation (LTVV)[2] and avoidance of either hypoxemia or h yperoxemia[3]. One way is to target an end-expiratory transpulmonary pressure of 0–10 cm H2O to reduce cyclic alveolar collapse, and an end-inspiratory transpulmonary pressure ≤ 25 cm H2O to reduce alveolar o verdistension[9]. This requires measurement of pleural pressure using an esophageal balloon catheter. Randomized trials of PEEP titration using the low versus high PEEP/FIO2 tables have been not demonstrated superiority of either table[4]. The most convenient and user-friendly method remains following the low PEEP/FIO2 table, which was used in the landmark ARMA trial of low versus high tidal volume v entilation[18]. We aimed to study the patient characteristics and clinical outcomes of adherence to the low PEEP/FIO2 table
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