Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials

Guérin, Claude; Papazian, Laurent; Reignier, Jean; Ayzac, Louis; Loundou, Anderson; Forel, Jean-Marie; trials, Proseva

doi:10.1186/s13054-016-1556-2

Cited by 193 publications

(169 citation statements)

References 23 publications

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“…Therefore, a change in elastance, which may follow an intervention, indicates a change in lung mechanics which transcends the setting of a specific value of driving pressure. When plateau pressure, tidal volume and PEEP are set within the tight ranges of a protective ventilation, driving pressure per se may not offer any additional advantage over the indices of lung mechanics such as elastance, compliance or plateau pressure as recently shown by Guerin et al (38). Indeed, independently from sophisticated statistics, the best association between outcome and driving pressure instead of tidal volume/kg IBW is self-evident considering the relationship between the two variables:…”

Section: Driving Pressurementioning

confidence: 99%

Driving pressure and mechanical power: new targets for VILI prevention

et al. 2017

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Several factors have been recognized as possible triggers of ventilator-induced lung injury (VILI).The first is pressure (thus the 'barotrauma'), then the volume (hence the 'volutrauma'), finally the cyclic opening-closing of the lung units ('atelectrauma'). Less attention has been paid to the respiratory rate and the flow, although both theoretical considerations and experimental evidence attribute them a significant role in the generation of VILI. The initial injury to the lung parenchyma is necessarily mechanical and it could manifest as an unphysiological distortion of the extracellular matrix and/or as micro-fractures in the hyaluronan, likely the most fragile polymer embedded in the matrix. The order of magnitude of the energy required to break a molecular bond between the hyaluronan and the associated protein is 1.12×10 -16 Joules (J), 70-90% higher than the average energy delivered by a single breath of 1L assuming a lung elastance of 10 cmH 2 O/L (0.5 J). With a normal statistical distribution of the bond strength some polymers will be exposed each cycle to an energy large enough to rupture. Both the extracellular matrix distortion and the polymer fractures lead to inflammatory increase of capillary permeability with edema if a pulmonary blood flow is sufficient. The mediation analysis of higher vs. lower tidal volume and PEEP studies suggests that the driving pressure, more than tidal volume, is the best predictor of VILI, as inferred by increased mortality. This is not surprising, as both tidal volume and respiratory system elastance (resulting in driving pressure) may independently contribute to the mortality. For the same elastance driving pressure is a predictor similar to plateau pressure or tidal volume. Driving pressure is one of the components of the mechanical power, which also includes respiratory rate, flow and PEEP. Finding the threshold for mechanical power would greatly simplify assessment and prevention of VILI.

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Section: Driving Pressurementioning

confidence: 99%

Driving pressure and mechanical power: new targets for VILI prevention

et al. 2017

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“…The role of driving pressure, the current stronger predictor of mortality in ARDS (41), is under investigation. We recently observed that driving pressure share the same information as plateau pressure to predict survival in ARDS patients receiving lung protective mechanical ventilation (42).…”

Section: Evidencementioning

confidence: 96%

Prone positioning acute respiratory distress syndrome patients

Guérin¹

2017

Ann. Transl. Med.

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Prone position has been used in acute respiratory distress syndrome (ARDS) patients for more than 40 years in ICU. After having demonstrated its capability to significantly improve oxygenation in a large number of patients, sometimes dramatically, this procedure has been found to prevent ventilatorinduced lung injury, the primary concern for the intensivists managing ARDS patients. Over the time, This strategy has eventually been found efficient to improve patient outcome in selected ARDS patients.In this review, we will go over the rationale and then the evidence of using prone position in ARDS patients. RationaleThe early reason that prompted clinicians to turn ARDS patient to prone was oxygenation improvement. This effect, sometimes dramatic (1), was observed in the large majority of patients. Therefore from the early onset the clinicians used proning to improve oxygenation. This effect resulted from a reduction in intra-pulmonary shunt. For the intra-pulmonary shunt to go down two possibilities do exist, either more ventilation in well perfused areas or less perfusion in poorly ventilated lung regions. The latter mechanism was considered as true as intuitively it was thought that the change in gravity direction will affect the lung perfusion in the same way, i.e., less perfusion towards dorsal lung regions, now non-dependent, in the prone position. Several experiments found that the dorsal lung regions when in the prone position still had the highest amount of blood flowing through them (2-8). Therefore, this unexpected finding argued against the second mechanism to explain the reduction in intra-pulmonary shunt. Therefore, better ventilation towards well perfused areas accounts for the common scenario to explain better oxygenation in prone (9).With the recognition of ventilator-induced lung injury (VILI) it turned out that prone position was also able to modulate it. Animal studies, like that of Broccard et al. (10), demonstrated that prone position, as compared to supine

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“…Pada kelompok risiko dengan delta pressure tinggi, risiko mortalitas akan meningkat 45% bila dibandingkan dengan kelompok subyek dengan delta pressure rendah. 7 Pada penelitian ini digunakan uji statistik chi square, hanya variabel delta pressure yang digunakan sebagai variabel independen dan mortalitas sebagai variabel dependen.…”

Section: Pembahasanunclassified

“…Namun demikian, faktor delta pressure tidak dapat terlepas dari faktor lain yang berpengaruh terhadap luasnya bagian paru yang dapat berfungsi untuk pertukaran oksigen, seperti PEEP dan volume tidal. [18][19][20] Pada penelitan yang dilakukan oleh Guerin dkk 7 disebutkan bahwa faktor delta pressure bukanlah satu-satunya faktor independen dalam memprediksi mortalitas. Faktor besarnya PEEP dan volume tidal yang diberikan juga berkontribusi untuk terjadinya mortalitas.…”

Section: Pembahasanunclassified

Perbandingan Mortalitas Pasien Anak dengan Acute Respiratory Distress Syndrome yang Menggunakan Delta Pressure Tinggi dan Rendah

Bramantyo¹,

Martuti²,

Pudjiastuti³

2018

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Latar belakang. Strategi ventilasi protektif paru (protective lung strategy) direkomendasikan dalam penanganan pasien acute respiratory distress syndrome (ARDS). Strategi tersebut mencakup pembatasan PEEP dan delta pressure pada penggunaan ventilator untuk mencegah mortalitas. Pembatasan delta pressure ≤13 mmHg diharapkan dapat menurunkan angka mortalitas pasien ARDS dengan ventilator. Tujuan. Mengetahui perbandingan mortalitas pasien anak dengan ARDS yang menggunakan delta pressure tinggi dan rendah. Metode. Penelusuran rekam medis pasien anak berusia 1 bulan-18 tahun yang menderita ARDS yang dirawat di PICU dengan menggunakan ventilator. Hasil. Studi cross sectional dari bulan September 2016 sampai dengan Maret 2017 terhadap 32 pasien anak berumur 1 bulan-18 tahun yang menderita ARDS, didapatkan hasil bahwa mortalitas pasien anak dengan ARDS lebih tinggi pada penggunaan setting ventilator dengan delta pressure tinggi (ΔP>13 cmH 2 O) dibandingkan dengan yang menggunakan pengaturan ventilator dengan delta pressure yang rendah (ΔP≤13 cmH 2 O) (p<0,001, OR 45,00 (IK95%: 5,02). Kesimpulan. Pasien anak dengan ARDS yang menggunakan setting ventilator dengan delta pressure rendah, mortalitasnya lebih rendah dibandingkan dengan yang menggunakan pengaturan ventilator dengan delta pressure tinggi. Sari Pediatri 2017;19(3):156-60

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Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials

Cited by 193 publications

References 23 publications

Driving pressure and mechanical power: new targets for VILI prevention

Driving pressure and mechanical power: new targets for VILI prevention

Prone positioning acute respiratory distress syndrome patients

Perbandingan Mortalitas Pasien Anak dengan Acute Respiratory Distress Syndrome yang Menggunakan Delta Pressure Tinggi dan Rendah

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