scholarly journals Static compliance and driving pressure are associated with ICU mortality in intubated COVID-19 ARDS

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Annalisa Boscolo ◽  
Nicolò Sella ◽  
Giulia Lorenzoni ◽  
Tommaso Pettenuzzo ◽  
Laura Pasin ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Multivariable Analysis ◽  
Ideal Body Weight ◽  
Driving Pressure ◽  
Static Compliance ◽  
Icu Mortality ◽  
Multicenter Cohort Study ◽  
Risk Of Death ◽  
Controlled Mechanical Ventilation

Abstract Background Pathophysiological features of coronavirus disease 2019-associated acute respiratory distress syndrome (COVID-19 ARDS) were indicated to be somewhat different from those described in nonCOVID-19 ARDS, because of relatively preserved compliance of the respiratory system despite marked hypoxemia. We aim 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 are associated with intensive care unit (ICU) mortality in COVID-19 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 controlled mechanical ventilation, were screened. Only patients fulfilling ARDS criteria and with complete records of Crs, DP and VT/kg IBW within the 1st day of controlled mechanical ventilation were included. Crs, DP and VT/kg IBW were collected in sedated, paralyzed and supine patients. Results A total of 704 COVID-19 patients were screened and 241 enrolled. Seventy-one patients (29%) died in ICU. The logistic regression analysis showed that: (1) Crs was not linearly associated with ICU mortality (p value for nonlinearity = 0.01), with a greater risk of death for values < 48 ml/cmH2O; (2) the association between DP and ICU mortality was linear (p value for nonlinearity = 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); (3) 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.

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

2021 ◽  
Author(s):  
Annalisa Boscolo ◽  
Nicolò Sella ◽  
Giulia Lorenzoni ◽  
Tommaso Pettenuzzo ◽  
Laura Pasin ◽  
...  
Keyword(s):  
Multivariable Analysis ◽  
Ideal Body Weight ◽  
Driving Pressure ◽  
P Value ◽  
Static Compliance ◽  
Icu Mortality ◽  
Multicenter Cohort Study ◽  
Risk Of Death ◽  
Controlled Mechanical Ventilation ◽  
Ideal Body

Abstract 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.

scholarly journals Static compliance of the respiratory system in COVID-19 related ARDS: an international multicenter study

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Benoit Vandenbunder ◽  
◽  
Stephan Ehrmann ◽  
Michael Piagnerelli ◽  
Bertrand Sauneuf ◽  
...  
Keyword(s):  
Linear Regression ◽  
Respiratory System ◽  
Ideal Body Weight ◽  
Plateau Pressure ◽  
Chronic Hypertension ◽  
Static Compliance ◽  
Multicenter Cohort ◽  
Controlled Mechanical Ventilation ◽  
Ideal Body ◽  
International Multicenter Study

Abstract Background Controversies exist on the nature of COVID-19 related acute respiratory distress syndrome (ARDS) in particular on the static compliance of the respiratory system (Crs). We aimed to analyze the association of Crs with outcome in COVID-19-associated ARDS, to ascertain its determinants and to describe its evolution at day-14. Methods In this observational multicenter cohort of patients with moderate to severe Covid-19 ARDS, Crs was measured at day-1 and day-14. Association between Crs or Crs/ideal body weight (IBW) and breathing without assistance at day-28 was analyzed with multivariable logistic regression. Determinants were ascertained by multivariable linear regression. Day-14 Crs was compared to day-1 Crs with paired t-test in patients still under controlled mechanical ventilation. Results The mean Crs in 372 patients was 37.6 ± 13 mL/cmH2O, similar to as in ARDS of other causes. Multivariate linear regression identified chronic hypertension, low PaO2/FiO2 ratio, low PEEP, and low tidal volume as associated with lower Crs/IBW. After adjustment on confounders, nor Crs [OR 1.0 (CI 95% 0.98–1.02)] neither Crs/IBW [OR 0.63 (CI 95% 0.13–3.1)] were associated with the chance of breathing without assistance at day-28 whereas plateau pressure was [OR 0.93 (CI 95% 0.88–0.99)]. In a subset of 108 patients, day-14 Crs decreased compared to day-1 Crs (31.2 ± 14.4 mL/cmH2O vs 37.8 ± 11.4 mL/cmH2O, p < 0.001). The decrease in Crs was not associated with day-28 outcome. Conclusion In a large multicenter cohort of moderate to severe COVID-19 ARDS, mean Crs was decreased below 40 mL/cmH2O and was not associated with day-28 outcome. Crs decreased between day-1 and day-14 but the decrease was not associated with day-28 outcome.

scholarly journals The correlation of respiratory system compliance and mortality in COVID-19 acute respiratory distress syndrome: do phenotypes really exist?

2021 ◽  
Vol 8 (2) ◽  
pp. 67-74
Author(s):  
Rachel L. Choron ◽  
Stephen A. Iacono ◽  
Alexander Cong ◽  
Christopher G. Bargoud ◽  
Amanda L. Teichman ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Management Strategies ◽  
Respiratory System Compliance ◽  
Risk Of Death ◽  
Mortality Difference ◽  
Ventilator Management ◽  
Observational Cohort ◽  
Multivariable Regression ◽  
The Mean

Background: Recent literature suggests respiratory system compliance (Crs) based phenotypes exist among COVID-19 ARDS patients. We sought to determine whether these phenotypes exist and whether Crs predicts mortality. Methods: A retrospective observational cohort study of 111 COVID-19 ARDS patients admitted March 11-July 8, 2020. Crs was averaged for the first 72-hours of mechanical ventilation. Crs<30ml/cmH2O was defined as poor Crs(phenotype-H) whereas Crs≥30ml/cmH2O as preserved Crs(phenotype-L). Results: 111 COVID-19 ARDS patients were included, 40 phenotype-H and 71 phenotype-L. Both the mean PaO2/FiO2 ratio for the first 72-hours of mechanical ventilation and the PaO2/FiO2 ratio hospital nadir were lower in phenotype-H than L(115[IQR87] vs 165[87], p=0.016), (63[32] vs 75[59], p=0.026). There were no difference in characteristics, diagnostic studies, or complications between groups. Twenty-seven (67.5%) phenotype-H patients died vs 37(52.1%) phenotype-L(p=0.115). Multivariable regression did not reveal a mortality difference between phenotypes; however, a 2-fold mortality increase was noted in Crs<20 vs >50ml/cmH2O when analyzing ordinal Crs groups. Moving up one group level (ex. Crs30-39.9ml/cmH2O to 40-49.9ml/cmH2O), was marginally associated with 14% lower risk of death(RR=0.86, 95%CI 0.72, 1.01, p=0.065). This attenuated (RR=0.94, 95%CI 0.80, 1.11) when adjusting for pH nadir and PaO2/FiO2 ratio nadir. Conclusion: We identified a spectrum of Crs in COVID-19 ARDS similar to Crs distribution in non-COVID-19 ARDS. While we identified increasing mortality as Crs decreased, there was no specific threshold marking significantly different mortality based on phenotype. We therefore would not define COVID-19 ARDS patients by phenotypes-H or L and would not stray from traditional ARDS ventilator management strategies.

Lung transplantation for acute respiratory distress syndrome – a retrospective European Cohort Study

2021 ◽  
pp. 2102078
Author(s):  
Jens Gottlieb ◽  
Philipp M. Lepper ◽  
Cristina Berastegui ◽  
Beatriz Montull ◽  
Alexandra Wald ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Cohort Study ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Lung Transplantation ◽  
Distress Syndrome ◽  
Selection Process ◽  
Multivariable Analysis ◽  
Multicenter Cohort Study

BackgroundThe published experience of lung transplantation (LTX) in acute respiratory distress syndrome (ARDS) is limited. The aim of this study was to investigate the contemporary results of LTX attempts in ARDS in major European centers.MethodsWe conducted a retrospective multicenter cohort study of all patients listed for LTX between 2011 and 2019. We surveyed 68 centers in 22 European countries. All patients admitted to the waitlist for lung transplantation with a diagnosis of “ARDS//pneumonia” were included. Patients without extracorporeal membrane oxygenation (ECMO) or mechanical ventilation were excluded. Patients were followed until October 1st 2020 or death. Multivariable analysis for 1-year survival after listing and lung transplantation were performed.ResultsForty-eight centers (74%) with a total transplant activity of 12 438 lung transplants during the 9-year period gave feedback. Forty patients with a median age of 35 years were identified. Patients were listed for LTX in 18 different centers in 10 countries. Thirty-one-patients underwent LTX (0·25% of all indications) and 9 patients died on the waitlist. Ninety percent of transplanted patients were on ECMO in combination with mechanical ventilation before LTX. On multivariable analysis, transplantation during 2015 until 2019 was independently associated with better 1-year survival after LTX (odds ratio 10.493, 95% CI 1.977, 55.705, p=0.006). Sixteen survivors out of 23 patients with known status (70%) returned to work after LTX.ConclusionLTX in highly selected ARDS patients is feasible and outcome has improved in the modern era. The selection process remains ethically and technically challenging.

scholarly journals Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome

2019 ◽  
Vol 131 (3) ◽  
pp. 594-604 ◽  
Author(s):  
Giacomo Bellani ◽  
Alice Grassi ◽  
Simone Sosio ◽  
Stefano Gatti ◽  
Brian P. Kavanagh ◽  
...  
Keyword(s):  
Respiratory System ◽  
Odds Ratio ◽  
Pressure Support ◽  
Distress Syndrome ◽  
Peak Pressure ◽  
Plateau Pressure ◽  
Assisted Ventilation ◽  
Driving Pressure ◽  
Respiratory System Compliance ◽  
Controlled Mechanical Ventilation

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Driving pressure, the difference between plateau pressure and positive end-expiratory pressure (PEEP), is closely associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). Although this relationship has been demonstrated during controlled mechanical ventilation, plateau pressure is often not measured during spontaneous breathing because of concerns about validity. The objective of the present study is to verify whether driving pressure and respiratory system compliance are independently associated with increased mortality during assisted ventilation (i.e., pressure support ventilation). Methods This is a retrospective cohort study conducted on 154 patients with ARDS in whom plateau pressure during the first three days of assisted ventilation was available. Associations between driving pressure, respiratory system compliance, and survival were assessed by univariable and multivariable analysis. In patients who underwent a computed tomography scan (n = 23) during the stage of assisted ventilation, the quantity of aerated lung was compared with respiratory system compliance measured on the same date. Results In contrast to controlled mechanical ventilation, plateau pressure during assisted ventilation was higher than the sum of PEEP and pressure support (peak pressure). Driving pressure was higher (11 [9–14] vs. 10 [8–11] cm H2O; P = 0.004); compliance was lower (40 [30–50] vs. 51 [42–61] ml · cm H2O-1; P &lt; 0.001); and peak pressure was similar, in nonsurvivors versus survivors. Lower respiratory system compliance (odds ratio, 0.92 [0.88–0.96]) and higher driving pressure (odds ratio, 1.34 [1.12–1.61]) were each independently associated with increased risk of death. Respiratory system compliance was correlated with the aerated lung volume (n = 23, r = 0.69, P &lt; 0.0001). Conclusions In patients with ARDS, plateau pressure, driving pressure, and respiratory system compliance can be measured during assisted ventilation, and both higher driving pressure and lower compliance are associated with increased mortality.

scholarly journals The Correlation of Respiratory System Compliance and Mortality in COVID-19 Acute Respiratory Distress Syndrome: Do Phenotypes Really Exist?

2021 ◽  
Author(s):  
Rachel L. Choron ◽  
Stephen A. Iacono ◽  
Alexander Cong ◽  
Christopher G. Bargoud ◽  
Amanda L. Teichman ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory System ◽  
Management Strategies ◽  
Respiratory System Compliance ◽  
Risk Of Death ◽  
Mortality Difference ◽  
Ventilator Management ◽  
Observational Cohort ◽  
Multivariable Regression ◽  
The Mean

Abstract Background: Recent literature suggests respiratory system compliance (Crs) based phenotypes exist among COVID-19 ARDS patients. We sought to determine whether these phenotypes exist and whether Crs predicts mortality. Methods: A retrospective observational cohort study of 111 COVID-19 ARDS patients admitted March 11-July 8, 2020. Crs was averaged for the first 72-hours of mechanical ventilation. Crs < 30ml/cmH2O was defined as poor Crs(phenotype-H) whereas Crs ≥ 30ml/cmH2O as preserved Crs(phenotype-L). Results: 111 COVID-19 ARDS patients were included, 40 phenotype-H and 71 phenotype-L. Both the mean PaO2/FiO2 ratio for the first 72-hours of mechanical ventilation and the PaO2/FiO2 ratio hospital nadir were lower in phenotype-H than L(115[IQR87] vs 165[87], p = 0.016), (63[32] vs 75[59], p = 0.026). There were no difference in characteristics, diagnostic studies, or complications between groups. Twenty-seven (67.5%) phenotype-H patients died vs 37(52.1%) phenotype-L(p = 0.115). Multivariable regression did not reveal a mortality difference between phenotypes; however, a 2-fold mortality increase was noted in Crs < 20 vs > 50ml/cmH2O when analyzing ordinal Crs groups. Moving up one group level (ex. Crs30-39.9ml/cmH2O to 40-49.9ml/cmH2O), was marginally associated with 14% lower risk of death(RR = 0.86, 95%CI 0.72, 1.01, p = 0.065). This attenuated(RR = 0.94, 95%CI 0.80, 1.11) when adjusting for pH nadir and PaO2/FiO2 ratio nadir. Conclusion: We identified a spectrum of Crs in COVID-19 ARDS similar to Crs distribution in non-COVID-19 ARDS. While we identified increasing mortality as Crs decreased, there was no specific threshold marking significantly different mortality based on phenotype. We therefore would not define COVID-19 ARDS patients by phenotypes-H or L and would not stray from traditional ARDS ventilator management strategies.

scholarly journals Utility of SpO2/FiO2 ratio for acute hypoxemic respiratory failure with bilateral opacities in the ICU

PLoS ONE ◽  
2021 ◽  
Vol 16 (1) ◽  
pp. e0245927
Author(s):  
Yosuke Fukuda ◽  
Akihiko Tanaka ◽  
Tetsuya Homma ◽  
Keisuke Kaneko ◽  
Tomoki Uno ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Hospital Mortality ◽  
Prognostic Markers ◽  
Apache Ii ◽  
Icu Mortality ◽  
Hypoxemic Respiratory Failure ◽  
Acute Hypoxemic Respiratory Failure ◽  
Risk Of Death ◽  
Saps Ii

Acute hypoxemic respiratory failure (AHRF) with bilateral opacities causes fatalities in the intensive care unit (ICU). It is often difficult to identify the causes of AHRF at the time of admission. The SpO2 to FiO2 (S/F) ratio has been recently used as a non-invasive and alternative marker of the PaO2/FiO2 (P/F) ratio in acute respiratory failure. This retrospective cohort study was conducted from October 2010 to March 2019 at the Showa University Hospital, Tokyo, Japan. We enrolled 94 AHRF patients who had bilateral opacities and received mechanical ventilation in ICU to investigate their prognostic markers including S/F ratio. Significant differences were observed for APACHE II, S/F ratio, PaO2/FiO2 (P/F) ratio, and ventilator−free-days at day 28 for ICU mortality, and for age, S/F ratio, P/F ratio, duration of mechanical ventilation, and ventilator−free days at day 28 for hospital mortality. Multivariate logistic regression analysis showed that the S/F ratio was significantly and independently associated with the risk of death during in ICU (p = 0.003) and hospitalization (p = 0.002). The area under the receiver operating characteristic curves (AUC) based on the S/F ratio were significantly greater than those based on simplified acute physiology score (SAPS) II and sequential organ failure assessment (SOFA) for ICU mortality (0.785 in S/F ratio vs. 0.575 in SAPS II, p = 0.012; 0.785 in S/F ratio vs 0.594 in SOFA, p = 0.021) and for hospital mortality (0.701 in S/F ratio vs. 0.502 in SAPS II, p = 0.012; 0.701 in S/F ratio vs. 0.503 in SOFA, p = 0.005). In the subanalysis for bacterial pneumonia and interstitial lung disease groups, the AUC based on the S/F ratio was the greatest among all prognostic markers, including APACHE II, SAPS II, and SOFA. The S/F ratio may be a useful and noninvasive predictive prognostic marker for acute hypoxemic respiratory failure with bilateral opacities in the ICU.

scholarly journals Development and validation of a prediction model for tocilizumab failure in hospitalized patients with SARS-CoV-2 infection

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0247275
Author(s):  
Cristina Mussini ◽  
Alessandro Cozzi-Lepri ◽  
Marianna Menozzi ◽  
Marianna Meschiari ◽  
Erica Franceschini ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Risk Score ◽  
Treatment Initiation ◽  
Multivariable Analysis ◽  
Secondary Analysis ◽  
Severe Pneumonia ◽  
Composite Endpoint ◽  
Secondary Outcome ◽  
Multicenter Cohort Study ◽  
Derivation Cohort

Background The aim of this secondary analysis of the TESEO cohort is to identify, early in the course of treatment with tocilizumab, factors associated with the risk of progressing to mechanical ventilation and death and develop a risk score to estimate the risk of this outcome according to patients’ profile. Methods Patients with COVID-19 severe pneumonia receiving standard of care + tocilizumab who were alive and free from mechanical ventilation at day 6 after treatment initiation were included in this retrospective, multicenter cohort study. Multivariable logistic regression models were built to identify predictors of mechanical ventilation or death by day-28 from treatment initiation and β-coefficients were used to develop a risk score. Secondary outcome was mortality. Patients with the same inclusion criteria as the derivation cohort from 3 independent hospitals were used as validation cohort. Results 266 patients treated with tocilizumab were included. By day 28 of hospital follow-up post treatment initiation, 40 (15%) underwent mechanical ventilation or died [26 (10%)]. At multivariable analysis, sex, day-4 PaO2/FiO2 ratio, platelets and CRP were independently associated with the risk of developing the study outcomes and were used to generate the proposed risk score. The accuracy of the score in AUC was 0.80 and 0.70 in internal validation and test for the composite endpoint and 0.92 and 0.69 for death, respectively. Conclusions Our score could assist clinicians in identifying, early after tocilizumab administration, patients who are likely to progress to mechanical ventilation or death, so that they could be selected for eventual rescue therapies.

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