Driving Pressure: The Road Ahead

Sahetya, Sarina K.; Fan, Eddy

doi:10.4187/respcare.07226

Cited by 4 publications

(4 citation statements)

References 28 publications

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“…PEEP positive end-expiratory pressure; PBW predicted body weight; FiO 2 fraction of inspired oxygen to be controlled is the tidal volume standardized for the expected lung volume (i.e., estimated by respiratory compliance), which in practical terms is identified by the driving pressure (i.e., a bedside parameter measuring the "dynamic" strain equal to tidal volume divided the amount of aerated lung). Driving pressure, which is a function of plateau pressure and PEEP, represents the real stress applied to the respiratory system (of the lung and chest wall combined) from end-inspiration to end-expiration [45]. Similarly, mechanical power is the mechanical energy which is transferred to the respiratory system in every respiratory cycle, multiplied with each respiratory rate, and it is therefore considered as a determinant of ventilator-induced lung injury (VILI) [13,46].…”

Section: Comorbiditiesmentioning

confidence: 99%

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

et al. 2022

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Purpose:The optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes.Methods: Preplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization.Results: A total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (V T ) was 7 (Interquartile range, IQR = 6.2-8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5-9) cmH 2 0, plateau pressure was 20 cmH 2 0 (IQR = 17-23), driving pressure was 12 cmH 2 0 (IQR = 10-15), mechanical power 16.2 J/min (IQR = 12.1-21.8), ventilatory ratio was 1.27 (IQR = 1.04-1.6), and respiratory rate was 17 breaths/minute (IQR = 14-20). Median partial pressure of oxygen was 87 mmHg (IQR = 75-105), and partial pressure of carbon dioxide was

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Section: Comorbiditiesmentioning

confidence: 99%

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

et al. 2022

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“…[16] While it is acknowledged that extremely high TV (ranging from 10-15 mL/kg PBW) is considered the most significant risk factor for developing ventilator-associated lung injury; however, the relationship between ventilation strategies and patient outcomes is multifaceted and may be influenced by various factors, including driving pressure, trans-pulmonary pressure, and individual patient characteristics. [17][18][19] In the 2015 national randomized study, known as PReVENT, it was observed that even in patients without ARDS, the utilization of a low tidal volume of 4 to 6 mL/kg PBW at the initiation of ventilation resulted in improved outcomes when compared to a high tidal volume ventilation strategy using TV ranging from 8 to 10 mL/kg. [4] Another study demonstrated that an initial TV greater than 8 mL/kg PBW is associated with increased mortality in patients with complicated ARDS.…”

Section: Discussionmentioning

confidence: 99%

“…[16] While it is acknowledged that extremely high TV (ranging from 10–15 mL/kg PBW) is considered the most significant risk factor for developing ventilator-associated lung injury; however, the relationship between ventilation strategies and patient outcomes is multifaceted and may be influenced by various factors, including driving pressure, trans-pulmonary pressure, and individual patient characteristics. [17–19]…”

Section: Discussionmentioning

confidence: 99%

A prospective study on the precision of height data from electronic medical records in tidal volume calculation for lung-protective ventilation

Mohamed,

Batra,

Pang

et al. 2023

Medicine

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Lung-protective ventilation is now the norm for all patients, regardless of the presence of acute respiratory distress syndrome (ARDS), owing to the mortality associated with higher tidal volumes (TV). Clinicians calculate TV using recorded height from medical records and predicted body weight (PBW); however, the accuracy remains uncertain. Our study aimed to validate accurate TV settings for lung-protective ventilation by examining the correlation between the charted height and bedside measurements. In a single-center study, we compared PBW-based TV calculated from recorded height to PBW-based TV from measured height and identified factors causing height overestimation during charting. Our team measured patient height within 24 hours of admission using metal tape. TV calculated from recorded height (6–8 mL/kg PBW) was significantly larger (391.55 ± 65.98 to 522.07 ± 87.97) than measured height-based TV (162.62 ± 12.62 to 470.28 ± 89.64) (P < .01). In the height overestimated group, 57.7% were prescribed TV by healthcare provider, which was more than TV of 8 mL/kg of PBW, as determined by measured height. Negative predictors for height overestimation were male sex (OR: 0.45 [95% CI: 0.25–0.82]; P = .008) and presence of driver’s license information (OR: 0.45 [95% CI: 0.25–0.80]; P = .007), whereas Asian ethnicity was a positive predictor (OR: 4.34 [95% CI: 1.09–17.27]; P = .04). The height overestimation group had a higher in-patient mortality rate (38.5%) than the matched/underestimation group (20%) (P < .01). In stadiometer-limited hospitals, the PBW-based TV is overestimated using the recorded height instead of the measured height. In the group where heights were overestimated, over half of the patients received TV prescriptions from healthcare providers that surpassed the TV of calculated 8 mL/kg PBW based on their measured height. The risk factors for height overestimation include female sex, Asian ethnicity, and missing driver’s license data. Alternative height measurement methods should be explored to ensure precise ventilation settings and patient safety.

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“…None of the included RCTs incorporated assessments of lung "recruitability" in response to higher PEEP strategies. Validating strategies to assess for lung recruitability at the bedside, such as the use of oxygenation response (82), driving pressure change (83), recruitment/inflation ratio (84), stress index (85), or electrical impedance tomography (86)…”

Section: Uncertainties and Research Prioritiesmentioning

confidence: 99%

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline

Qadir,

Sahetya,

Munshi

et al. 2024

Am J Respir Crit Care Med

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Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP).Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations.Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty).Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

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Driving Pressure: The Road Ahead

Cited by 4 publications

References 28 publications

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

A prospective study on the precision of height data from electronic medical records in tidal volume calculation for lung-protective ventilation

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline

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