Effect of Lowering V<scp>t</scp> on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance

Goligher, Ewan C.; Costa, Eduardo F.; Yarnell, Christopher J.; Brochard, Laurent; Stewart, Thomas E.; Tomlinson, George; Brower, Roy G.; Slutsky, Arthur S.; Amato, M

doi:10.1164/rccm.202009-3536oc

Cited by 157 publications

(115 citation statements)

References 47 publications

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“…Interestingly, the effect of DP on ICU mortality seems to be independent from VT/kg IBW, whose increment above the traditional cutoff value [4] did not affect patient outcome. Similar results have been recently reported in nonCOVID-19 ARDS patients by a post-hoc secondary analysis of 5 randomized trials, including 1096 classical ARDS patients, which found that the bene t of lower tidal volumes (4-8 ml/kg IBW) on 60-day mortality was related to respiratory system elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than tidal volume [23].…”

Section: Discussionsupporting

confidence: 86%

“…Demographic and clinical characteristics of the study population are listed in Table 1. Charlson comorbidity index 1 [1][2] Onset of symptoms (days) 7 [3][4][5][6][7][8][9] Hospital LOS before ICU (days) 2 [1][2][3][4][5] Hospital LOS before CMV (days) 2 [1][2][3][4][5] Gas exchange, at rst day of CMV pH 7.41 [7.36-7.46] [20][21][22][23][24][25][26] Driving pressure (cmH 2 O) 11 [9][10][11][12][13] Data are expressed as median and interquartile range [IQR] or number (%). Length of CMV (days) [7][8][9][10][11][12][13][14][15][16] ICU LOS (days) [9][10][11][12][13][14]…”

Section: Resultsmentioning

confidence: 99%

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Static Compliance and Driving Pressure are Associated with ICU Mortality in Intubated COVID-19 ARDS

Boscolo

Sella

Lorenzoni

et al. 2021

Preprint

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Background: ascertaining whether respiratory system static compliance (Crs), driving pressure (DP), and tidal volume normalized for ideal body weight (VT/kg IBW) at the 1st day of controlled mechanical ventilation (CMV) are associated with intensive care unit (ICU) mortality in COVID-19 acute respiratory distress syndrome (ARDS).Methods: observational multicenter cohort study. All consecutive COVID-19 adult patients admitted to 25 ICUs belonging to the COVID-19 VENETO ICU network (February 28th-April 28th, 2020), who received CMV, were screened. Only patients fulfilling ARDS criteria and with complete records of Crs, DP and VT/kg IBW within the 1st day of CMV were included. Crs, DP and VT/kg IBW were collected in sedated, paralyzed and supine patients.Results: 704 COVID-19 patients were screened and 241 enrolled. Seventy-one patients (29%) died in ICU. The logistic regression analysis showed that: i) Crs was not linearly associated with ICU mortality (p-value for non-linearity=0.01), with a greater risk of death for values <48 ml/cmH2O; ii) the association between DP and ICU mortality was linear (p-value for non-linearity=0.68), and increasing DP from 10 to 14 cmH2O caused significant higher odds of in-ICU death (OR 1.45, 95%CI 1.06-1.99); iii) VT/kg IBW was not associated with a significant increase of the risk of death (OR 0.92, 95%CI 0.55-1.52). Multivariable analysis confirmed these findings.Conclusions: Crs <48 ml/cmH2O was associated with ICU mortality, while DP was linearly associated with mortality. DP should be kept as low as possible, even in the case of relatively preserved Crs, irrespective of VT/kg IBW, to reduce the risk of death.

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Section: Discussionsupporting

confidence: 86%

Section: Resultsmentioning

confidence: 99%

Static Compliance and Driving Pressure are Associated with ICU Mortality in Intubated COVID-19 ARDS

Boscolo

Sella

Lorenzoni

et al. 2021

Preprint

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“…The model has been widely used in studying patient-specific lung mechanics in ventilated ICU patients and Neonatal ICU patients [18], [52]- [57]. Golinger et al have shown that these parameters are associated with mortality [58], and it should be minimized to improve patient outcome. Similarly, van Drunen et al, Chiew et al, Lambermont et al has shown that it can be used to track patient disease progression, and how to titrate ventilation pressure settings [48], [52], [59].…”

Section: Data Management Platform (Dmp)mentioning

confidence: 99%

Network Data Acquisition and Monitoring System for Intensive Care Mechanical Ventilation Treatment

Chiew

Wang

et al. 2021

IEEE Access

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The rise of model-based and machine learning methods have created increasingly realistic opportunities to implement personalized, patient-specific mechanical ventilation (MV) in the ICU. These methods require monitoring of real-time patient ventilation waveform data (VWD) during MV treatment. However, there are relatively few non-invasive and/or non-proprietary systems to monitor and record patientspecific lung condition in real-time. In this paper, we present a CARE network data acquisition and monitoring system (CARENet) to automate data collection and to remotely monitor patient-specific lung condition and ventilation parameters. The automated system acquires VWD from a mechanical ventilator using a data acquisition device (DAQ), stores data in network-attached storage (NAS), and processes VWDs via a data management platform (DMP) web application. The web application enables real-time and retrospective modelbased monitoring and analysis of clinical MV data. In particular, CARENet provides detailed breath-by-breath patient-specific respiratory mechanics, as well as the overall trends assessing changes in patient condition. Validation testing with a retrospective data set illustrated how breath-to-breath and time-varying patientventilator interaction during MV can be monitored, and, in turn, can be used to guide MV treatment. The network data acquisition system design presented is low-cost, open, and enables continuous, automated, scalable, realtime collection and analysis of waveform data, to help improve decision making, care, and outcomes in MV.

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“…One might reasonably question the relative places of the flow-determined maximal intracycle power above pressure threshold (M) and the 'above elastic pressure threshold' energy (A) within the hierarchy of damaging mechanical influences; this ranking awaits further biological evidence. For the individual tidal cycle, transpulmonary plateau pressure and driving pressures are perhaps pre-eminent variables that influence VILI risk and clinical outcomes (4,12,14,15).…”

Section: Unresolved Questionsmentioning

confidence: 99%

Intracycle Power and Ventilation Mode as Potential Contributors to Ventilator-Induced Lung Injury

Marini

Crooke

Tawfik

et al. 2021

Preprint

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Background: High rates of inflation energy delivery coupled with transpulmonary tidal pressures of sufficient magnitude may augment the risk of damage to vulnerable, stress-focused units within a mechanically heterogeneous lung. Apart from flow amplitude, the clinician-selected flow waveform, a relatively neglected dimension of inflation power, may distribute inflation energy non-uniformly among alveoli with different mechanical properties. Our primary objectives were to develop a mathematical model of intracycle inflation power that allows comparisons among the flow modes commonly encountered in clinical practice: constant, linearly decelerating, exponentially decelerating (pressure control), and spontaneous (sinusoidal).Methods: We first tested the predictions of our mathematical model of passive inflation with the physical performance of a mechanical ventilator-lung system that simulated ventilation to three types of patients: normal, severe ARDS, and severe airflow obstruction. After verification, model predictions were then generated for 5000 ‘virtual ARDS patients’. Holding constant the tidal volume and inflation time between modes, the validated model varied the flow profile and quantitated intensity and timing of potentially damaging ‘elastic’ energy and intracycle power (pressure-flow product) developed in response to random combinations of machine settings and severity levels for ARDS.Results: Our modeling indicates that while the varied flow patterns ultimately deliver similar total amounts of alveolar energy during each breath, they differ profoundly regarding the potentially damaging pattern with which that energy distributes over time during inflation. Pressure control imposed relatively high maximal intracycle power.Conclusions: Flow amplitude and waveform may be relatively neglected and modifiable determinants of VILI risk when ventilating ARDS.

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Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance

Cited by 157 publications

References 47 publications

Static Compliance and Driving Pressure are Associated with ICU Mortality in Intubated COVID-19 ARDS

Static Compliance and Driving Pressure are Associated with ICU Mortality in Intubated COVID-19 ARDS

Network Data Acquisition and Monitoring System for Intensive Care Mechanical Ventilation Treatment

Intracycle Power and Ventilation Mode as Potential Contributors to Ventilator-Induced Lung Injury

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