Erick H Duan1,2,3, Neill K J Adhikari4,5, Frederick D'Aragon2,6,7, Deborah J Cook1,2,3, Sangeeta Mehta5,8, Waleed Alhazzani1,2,3, Ewan Goligher5,9, Emmanuel Charbonney10, Yaseen M Arabi11, Tim Karachi1,12, Alexis F Turgeon13,14, Lori Hand2,15, Qi Zhou2, Peggy Austin2, Jan Friedrich5,16, Francois Lamontagne6,7, François Lauzier14, Rakesh Patel17, John Muscedere18, Richard Hall19, Pierre Aslanian20, Thomas Piraino3,21, Martin Albert22, Sean M Bagshaw23, Mike Jacka23, Gordon Wood24, William Henderson25, Delbert Dorscheid26, Niall D Ferguson5,9, Maureen O Meade1,2,15. 1. 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada. 2. 2 Department of Health Research Methods, Evidence and Impact. McMaster University, Hamilton, Ontario, Canada. 3. 3 St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada. 4. 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. 5. 5 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada. 6. 6 Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada. 7. 7 Department of Anesthesia, Université de Sherbrooke, Sherbrooke, Quebec, Canada. 8. 8 Sinai Health Center, Toronto, Ontario, Canada. 9. 9 Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada. 10. 10 Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. 11. 11 King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. 12. 12 Juravinski Hospital, Hamilton, Ontario, Canada. 13. 13 Centre de Recherche du Centre Hospitalier Universitaire de Québec, Université Laval, Quebec, Quebec, Canada. 14. 14 Department of Anesthesiology and Critical Care Medicine, Division of Critical Care, Université Laval, Quebec, Quebec, Canada. 15. 15 Hamilton General Hospital, Hamilton, Ontario, Canada. 16. 16 Critical Care and Medicine Departments, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada. 17. 17 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada. 18. 18 Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada. 19. 19 Departments of Critical Care Medicine and Anesthesiology, Dalhousie University, Halifax, Nova Scotia, Canada. 20. 20 Division of Critical Care, Department of Medicine and Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada. 21. 21 Departments of Anesthesia, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada. 22. 22 Departments of Medicine and Critical Care, Centre de recherche Hôpital de Sacré-Cœur de Montréal, Université de Montréal, Montreal, Quebec, Canada. 23. 23 Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. 24. 24 Island Health Authority, Victoria, British Columbia, Canada. 25. 25 Critical Care Medicine, Vancouver General Hospital University of British Columbia, Vancouver, British Columbia, Canada; and. 26. 26 Center for Heart Lung Innovation, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
Abstract
RATIONALE: Clinicians' current practice patterns in the management of acute respiratory distress syndrome (ARDS) and refractory hypoxemia are not well described. OBJECTIVES: To describe mechanical ventilation strategies and treatment adjuncts for adults with ARDS, including refractory hypoxemia. METHODS: This was a prospective cohort study (March 2014-February 2015) of mechanically ventilated adults with moderate-to-severe ARDS requiring an FiO2 of 0.50 or greater in 24 intensive care units. RESULTS: We enrolled 664 patients: 222 (33%) with moderate and 442 (67%) with severe ARDS. On Study Day 1, mean Vt was 7.5 (SD = 2.1) ml/kg predicted body weight (n = 625); 80% (n = 501) received Vt greater than 6 ml/kg. Mean positive end-expiratory pressure (PEEP) was 10.5 (3.7) cm H2O (n = 653); 568 patients (87%) received PEEP less than 15 cm H2O. Treatment adjuncts were common (n = 440, 66%): neuromuscular blockers (n = 276, 42%), pulmonary vasodilators (n = 118, 18%), prone positioning (n = 67, 10%), extracorporeal life support (n = 29, 4%), and high-frequency oscillatory ventilation (n = 29, 4%). Refractory hypoxemia, defined as PaO2 less than 60 mm Hg on FiO2 of 1.0, occurred in 138 (21%) patients. At onset of refractory hypoxemia, mean Vt was 7.1 (SD = 2.0) ml/kg (n = 124); 95 patients (77%) received Vt greater than 6 ml/kg. Mean PEEP was 12.1 (SD = 4.4) cm H2O (n = 133); 99 patients (74%) received PEEP less than 15 cm H2O. Among patients with refractory hypoxemia, 91% received treatment adjuncts (126/138), with increased use of neuromuscular blockers (n = 87, 63%), pulmonary vasodilators (n = 57, 41%), and prone positioning (n = 32, 23%). CONCLUSIONS: Patients with moderate-to-severe ARDS receive treatment adjuncts frequently, especially with refractory hypoxemia. Paradoxically, therapies with less evidence supporting their use (e.g., pulmonary vasodilators) were over-used, whereas those with more evidence (e.g., prone positioning, neuromuscular blockade) were under-used. Patients received higher Vts and lower PEEP than would be suggested by the evidence.
RATIONALE: Clinicians' current practice patterns in the management of acute respiratory distress syndrome (ARDS) and refractory hypoxemia are not well described. OBJECTIVES: To describe mechanical ventilation strategies and treatment adjuncts for adults with ARDS, including refractory hypoxemia. METHODS: This was a prospective cohort study (March 2014-February 2015) of mechanically ventilated adults with moderate-to-severe ARDS requiring an FiO2 of 0.50 or greater in 24 intensive care units. RESULTS: We enrolled 664 patients: 222 (33%) with moderate and 442 (67%) with severe ARDS. On Study Day 1, mean Vt was 7.5 (SD = 2.1) ml/kg predicted body weight (n = 625); 80% (n = 501) received Vt greater than 6 ml/kg. Mean positive end-expiratory pressure (PEEP) was 10.5 (3.7) cm H2O (n = 653); 568 patients (87%) received PEEP less than 15 cm H2O. Treatment adjuncts were common (n = 440, 66%): neuromuscular blockers (n = 276, 42%), pulmonary vasodilators (n = 118, 18%), prone positioning (n = 67, 10%), extracorporeal life support (n = 29, 4%), and high-frequency oscillatory ventilation (n = 29, 4%). Refractory hypoxemia, defined as PaO2 less than 60 mm Hg on FiO2 of 1.0, occurred in 138 (21%) patients. At onset of refractory hypoxemia, mean Vt was 7.1 (SD = 2.0) ml/kg (n = 124); 95 patients (77%) received Vt greater than 6 ml/kg. Mean PEEP was 12.1 (SD = 4.4) cm H2O (n = 133); 99 patients (74%) received PEEP less than 15 cm H2O. Among patients with refractory hypoxemia, 91% received treatment adjuncts (126/138), with increased use of neuromuscular blockers (n = 87, 63%), pulmonary vasodilators (n = 57, 41%), and prone positioning (n = 32, 23%). CONCLUSIONS:Patients with moderate-to-severe ARDS receive treatment adjuncts frequently, especially with refractory hypoxemia. Paradoxically, therapies with less evidence supporting their use (e.g., pulmonary vasodilators) were over-used, whereas those with more evidence (e.g., prone positioning, neuromuscular blockade) were under-used. Patients received higher Vts and lower PEEP than would be suggested by the evidence.
Authors: Courtney M Rowan; Margaret J Klein; Deyin Doreen Hsing; Mary K Dahmer; Philip C Spinella; Guillaume Emeriaud; Amanda B Hassinger; Byron E Piñeres-Olave; Heidi R Flori; Bereketeab Haileselassie; Yolanda M Lopez-Fernandez; Ranjit S Chima; Steven L Shein; Aline B Maddux; Jon Lillie; Ledys Izquierdo; Martin C J Kneyber; Lincoln S Smith; Robinder G Khemani; Neal J Thomas; Nadir Yehya Journal: Am J Respir Crit Care Med Date: 2020-06-01 Impact factor: 21.405
Authors: Anuj B Mehta; Allan J Walkey; Douglas Curran-Everett; Daniel Matlock; Ivor S Douglas Journal: Crit Care Med Date: 2019-03 Impact factor: 7.598
Authors: Anica C Law; Natalia Forbath; Sharon O'Donoghue; Jennifer P Stevens; Allan J Walkey Journal: Am J Respir Crit Care Med Date: 2020-04-15 Impact factor: 21.405
Authors: Chad H Hochberg; Kevin J Psoter; Sarina K Sahetya; Eric P Nolley; Shakir Hossen; William Checkley; Meeta P Kerlin; Michelle N Eakin; David N Hager Journal: Crit Care Explor Date: 2022-05-13
Authors: Abhishek Jha; Francesco Vasques; Barnaby Sanderson; Kathleen Daly; Guy Glover; Nicholas Ioannou; Duncan Wyncoll; Peter Sherren; Chris Langrish; Chris Meadows; Andrew Retter; Richard Paul; Nicholas A Barrett; Luigi Camporota Journal: J Intensive Care Soc Date: 2020-06-01