Alexandre Demoule1, Massimo Antonelli2, Peter Schellongowski3, Peter Pickkers4, Marcio Soares5, Tine Meyhoff6, Jordi Rello7, Philippe R Bauer8, Andry van de Louw9, Virgine Lemiale10, David Grimaldi11, Ignacio Martin-Loeches12, Martin Balik13, Sangeeta Mehta14, Achille Kouatchet15, Andreas Barratt-Due16, Miia Valkonen17, Jean Reignier18, Victoria Metaxa19, Anne-Sophie Moreau20, Gaston Burghi21, Djamel Mokart22, Julien Mayaux23, Michael Darmon9, Elie Azoulay9. 1. AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France. Electronic address: alexandre.demoule@aphp.fr. 2. Department of Anesthesia, Intensive Care and Emergency Medicine, Fondazione Ospedale Universitario A. Gemelli IRCCS; Istituto di Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore, Rome, Italy. 3. Department of Medicine I, Medical University of Vienna, Vienna, Austria. 4. Department of Intensive Care Medicine (710), Radboud University Medical Center, Nijmegen, The Netherlands. 5. Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduação em Clínica Médica, Rio De Janeiro, Brazil. 6. Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. 7. CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain. 8. Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. 9. Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA. 10. Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France. 11. Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium. 12. Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO) and Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, Caring for Critically Ill Immuno-compromised Patients Multinational Network (Nine-I). St James Hospital, Dublin, Ireland. 13. Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic. 14. Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada. 15. Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France. 16. Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. 17. Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. 18. Medical Intensive Care Unit, Hôtel Dieu-HME University Hospital of Nantes, Nantes, France. 19. Department of Critical Care, King's College Hospital, NHS Foundation Trust, London, England. 20. Critical Care Center, CHU Lille, School of Medicine, University of Lille, Lille, France. 21. Terapia Intensiva, Hospital Maciel, Montevideo, Uruguay. 22. Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France. 23. AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
Abstract
BACKGROUND: In view of the high mortality rate of immunocompromised patients with ARDS, it is important to identify targets for improvement. RESEARCH QUESTION: This study investigated factors associated with mortality in this specific ARDS population, including factors related to respiratory mechanics (plateau pressure [Pplat,rs], compliance [Crs], and driving pressure [ΔPrs]). STUDY DESIGN AND METHODS: This study consisted of a predefined secondary analysis of the EFRAIM data. Overall, 789 of 1,611 patients met the Berlin criteria for ARDS, and Pplat,rs, ΔPrs, and Crs were available for 494 patients. A hierarchical model was used to assess factors at ARDS onset independently associated with hospital mortality. RESULTS: Hospital mortality was 56.3%. After adjustment, variables independently associated with hospital mortality included ARDS of undetermined etiology (OR, 1.66; 95% CI, 1.01-2.72), need for vasopressors (OR, 1.91; 95% CI, 1.27-2.88), and need for renal replacement therapy (OR, 2.02; 95% CI, 1.37-2.97). ARDS severity according to the Berlin definition, neutropenia on admission, and the type of underlying disease were not significantly associated with mortality. Before adjustment, higher Pplat,rs, higher ΔPrs, and lower Crs were associated with higher mortality. Addition of each of these individual variables to the final hierarchical model revealed a significant association with mortality: ΔPrs (OR, 1.08; 95% CI, 1.05-1.12), Pplat,rs (OR, 1.07; 95% CI, 1.04-1.11), and Crs (OR, 0.97; 95% CI, 0.95-0.98). Tidal volume was not associated with mortality. INTERPRETATION: In immunocompromised patients with ARDS, respiratory mechanics provide additional prognostic information to predictors of hospital mortality. Studies designed to define lung-protective ventilation guided by these physiological variables may be warranted in this specific population.
BACKGROUND: In view of the high mortality rate of immunocompromised patients with ARDS, it is important to identify targets for improvement. RESEARCH QUESTION: This study investigated factors associated with mortality in this specific ARDS population, including factors related to respiratory mechanics (plateau pressure [Pplat,rs], compliance [Crs], and driving pressure [ΔPrs]). STUDY DESIGN AND METHODS: This study consisted of a predefined secondary analysis of the EFRAIM data. Overall, 789 of 1,611 patients met the Berlin criteria for ARDS, and Pplat,rs, ΔPrs, and Crs were available for 494 patients. A hierarchical model was used to assess factors at ARDS onset independently associated with hospital mortality. RESULTS: Hospital mortality was 56.3%. After adjustment, variables independently associated with hospital mortality included ARDS of undetermined etiology (OR, 1.66; 95% CI, 1.01-2.72), need for vasopressors (OR, 1.91; 95% CI, 1.27-2.88), and need for renal replacement therapy (OR, 2.02; 95% CI, 1.37-2.97). ARDS severity according to the Berlin definition, neutropenia on admission, and the type of underlying disease were not significantly associated with mortality. Before adjustment, higher Pplat,rs, higher ΔPrs, and lower Crs were associated with higher mortality. Addition of each of these individual variables to the final hierarchical model revealed a significant association with mortality: ΔPrs (OR, 1.08; 95% CI, 1.05-1.12), Pplat,rs (OR, 1.07; 95% CI, 1.04-1.11), and Crs (OR, 0.97; 95% CI, 0.95-0.98). Tidal volume was not associated with mortality. INTERPRETATION: In immunocompromised patients with ARDS, respiratory mechanics provide additional prognostic information to predictors of hospital mortality. Studies designed to define lung-protective ventilation guided by these physiological variables may be warranted in this specific population.
Authors: Andrew K Gold; Dane R Scantling; Dominique A Brundidge; Maurizio F Cereda; Michael J Scott; Timothy G Gaulton Journal: Int J Crit Illn Inj Sci Date: 2021-06-29