A Quantile Analysis of Plateau and Driving Pressures:... : Critical Care Medicine (original) (raw)

Clinical Investigations

A Quantile Analysis of Plateau and Driving Pressures: Effects on Mortality in Patients With Acute Respiratory Distress Syndrome Receiving Lung-Protective Ventilation*

Villar, Jesús MD, PhD, FCCM1,2; Martín-Rodríguez, Carmen MD3; Domínguez-Berrot, Ana M. MD4; Fernández, Lorena MD5; Ferrando, Carlos MD, PhD6; Soler, Juan A. MD, PhD7; Díaz-Lamas, Ana M. MD8; González-Higueras, Elena MD, PhD9; Nogales, Leonor MD10; Ambrós, Alfonso MD, PhD3; Carriedo, Demetrio MD, PhD4; Hernández, Mónica MD11; Martínez, Domingo MD12; Blanco, Jesús MD, PhD1,5; Belda, Javier MD, PhD6; Parrilla, Dácil MD13; Suárez-Sipmann, Fernando MD, PhD1,14; Tarancón, Concepción MD15; Mora-Ordoñez, Juan M. MD16; Blanch, Lluís MD, PhD1,17; Pérez-Méndez, Lina MD, PhD1,18; Fernández, Rosa L. MSc1,2; Kacmarek, Robert M. PhD, RTT19,20

1CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.

2Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain.

3Intensive Care Unit, Hospital General de Ciudad Real, Ciudad Real, Spain.

4Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain.

5Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain.

6Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain.

7Intensive Care Unit, Hospital Universitario Morales Meseguer, Murcia, Spain.

8Intensive Care Unit, Hospital Universitario A Coruña, Coruña, Spain.

9Intensive Care Unit, Hospital Virgen de La Luz, Cuenca, Spain.

10Intensive Care Unit, Hospital Clínico Universitario, Valladolid, Spain.

11Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain.

12Intensive Care Unit, Hospital Universitario Virgen de Arrixaca, Murcia, Spain.

13Intensive Care Unit, Hospital Universitario N.S. de Candelaria, Santa Cruz de Tenerife, Spain.

14Department of Surgical Sciences, Anesthesiology & Critical Care, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden.

15Intensive Care Unit, Hospital Virgen de la Concha, Zamora, Spain.

16Intensive Care Unit, Hospital Universitario Carlos Haya, Málaga, Spain.

17Critical Care Center, Corporació Sanitaria Parc Taulí, Sabadell, Spain.

18Research Unit, Hospital Universitario NS de Candelaria, Santa Cruz de Tenerife, Spain.

19Department of Respiratory Care, Massachusetts General Hospital, Boston, MA.

20Department of Anesthesia, Harvard University, Boston, MA.

*See also p. 919.

This study is registered with www.clinicaltrials.gov (NCT00435110, NCT00736892, NCT02288949).

Additional investigators from the Spanish Initiative for Epidemiology, Stratification and Therapies of ARDS (SIESTA) Network are listed in Appendix 1.

Drs. Villar and Kacmarek designed the original study. Drs. Martín-Rodríguez, Domínguez-Berrot, Fernández, Ferrando, Soler, Díaz-Lamas, González-Higueras, Nogales, Ambrós, Carriedo, Hernández, Martínez, Blanco, Belda, Parrilla, Suárez-Sipmann, Tarancón, Mora-Ordoñez, and Blanch enrolled patients and collected the data. Dr. Villar obtained funding for the study. Drs. Villar, Martín-Rodríguez, Domínguez-Berrot, Fernández, Ferrando, Soler, Díaz-Lamas, González-Higueras, Nogales, Ambrós, Carriedo, Hernández, Martínez, Blanco, Belda, Parrilla, Suárez-Sipmann, Tarancón, Mora-Ordoñez, Blanch, Pérez-Méndez, Fernández, and Kacmarek made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and approved the final version to be published. Drs. Villar, Blanco, Belda, Suárez-Sipmann, Pérez-Méndez, Fernández, and Kacmarek wrote the first draft. Drs. Villar, Fernández, Pérez-Méndez, and Kacmarek performed and supervised data management and statistical analysis. Drs. Villar, Fernández, and Pérez-Méndez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by Instituto de Salud Carlos III (CB06/06/1088, PI10/0393, PI13/0119), Fundación Mutua Madrileña (AP101822012), and Asociación Científica Pulmón y Ventilación Mecánica.

Dr. Villar received funding from a research grant from Maquet. Dr. Suárez-Sipmann received funding from Maquet Critical Care (consulting services). Dr. Kacmarek received funding from Covidien (consulting on airway care), Orange Medical (consultant on Mechanical Ventilation), Teleflex (consultant on humidification); he disclosed a grant from Venner Medical on airway care, funding from lecturing for Teleflex, and for the 2016 AARC meeting industry sponsored session sponsored by Covidien. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Abstract

Objectives:

The driving pressure (plateau pressure minus positive end-expiratory pressure) has been suggested as the major determinant for the beneficial effects of lung-protective ventilation. We tested whether driving pressure was superior to the variables that define it in predicting outcome in patients with acute respiratory distress syndrome.

Design:

A secondary analysis of existing data from previously reported observational studies.

Setting:

A network of ICUs.

Patients:

We studied 778 patients with moderate to severe acute respiratory distress syndrome.

Interventions:

None.

Measurements and Main Results:

We assessed the risk of hospital death based on quantiles of tidal volume, positive end-expiratory pressure, plateau pressure, and driving pressure evaluated at 24 hours after acute respiratory distress syndrome diagnosis while ventilated with standardized lung-protective ventilation. We derived our model using individual data from 478 acute respiratory distress syndrome patients and assessed its replicability in a separate cohort of 300 acute respiratory distress syndrome patients. Tidal volume and positive end-expiratory pressure had no impact on mortality. We identified a plateau pressure cut-off value of 29 cm H2O, above which an ordinal increment was accompanied by an increment of risk of death. We identified a driving pressure cut-off value of 19 cm H2O where an ordinal increment was accompanied by an increment of risk of death. When we cross tabulated patients with plateau pressure less than 30 and plateau pressure greater than or equal to 30 with those with driving pressure less than 19 and driving pressure greater than or equal to 19, plateau pressure provided a slightly better prediction of outcome than driving pressure in both the derivation and validation cohorts (p < 0.0000001).

Conclusions:

Plateau pressure was slightly better than driving pressure in predicting hospital death in patients managed with lung-protective ventilation evaluated on standardized ventilator settings 24 hours after acute respiratory distress syndrome onset.