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Forget MF, Wang HT, Carignan R, Dessureault A, Gravel M, Bienvenue J, Bouchard M, Durivage C, Coveney R, Munshi L. Critically Ill Older Adults' Representation in Intervention Trials: A Systematic Review. Crit Care Explor 2024; 6:e1107. [PMID: 38919511 PMCID: PMC11196082 DOI: 10.1097/cce.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVES Older adults may be under-represented in critical care research, and results may not apply to this specific population. Our primary objective was to evaluate the prevalence of inclusion of older adults across critical care trials focused on common ICU conditions or interventions. Our secondary objective was to evaluate whether older age was used as a stratification variable for randomization or outcome analysis. DESIGN SETTING AND SUBJECTS We performed a systematic review of previously published systematic reviews of randomized controlled trials (RCTs) in critical care. We searched PubMed, Ovid, CENTRAL, and Cochrane from 2009 to 2022. Systematic reviews of any interventions across five topics: acute respiratory distress syndrome (ARDS), sepsis/shock, nutrition, sedation, and mobilization were eligible. MAIN RESULTS We identified 216 systematic reviews and included a total of 253 RCTs and 113,090 patients. We extracted baseline characteristics and the reported proportion of older adults. We assessed whether any upper age limit was an exclusion criterion for trials, whether age was used for stratification during randomization or data analysis, and if age-specific subgroup analysis was present. The most prevalent topic was sepsis (78 trials, 31%), followed by nutrition (62 trials, 25%), ARDS (39 trials, 15%), mobilization (38 trials, 15%), and sedation (36 trials, 14%). Eighteen trials (7%) had exclusion criteria based on older age. Age distribution with information on older adults prevalence was given in six trials (2%). Age was considered in the analysis of ten trials (5%) using analytic methods to evaluate the outcome stratified by age. Conclusions In this systematic review, the proportion of older critically ill patients is undetermined, and it is unclear how age is or is not an effect modifier or to what extent the results are valid for older adult groups. Reporting age is important to guide clinicians in personalizing care. These results highlight the importance of incorporating older critically ill patients in future trials to ensure the results are generalizable to this growing population.
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Affiliation(s)
- Marie-France Forget
- Department of Medicine, Division of Geriatric Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Han Ting Wang
- Department of Medicine, Division of Critical Care Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Raphaelle Carignan
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Alexandre Dessureault
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Mathieu Gravel
- Department of Medicine, Faculty of Medicine, Université de Laval, Québec, QC, Canada
| | - Jeanne Bienvenue
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Maude Bouchard
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Camille Durivage
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Richard Coveney
- Teaching Division/Library, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est-de-l’île-de-Montréal, Montréal, QC, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, Sinai Health System, University of Toronto, Toronto, ON, Canada
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2
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Saha R, Pham T, Sinha P, Maddali MV, Bellani G, Fan E, Summers C, Douiri A, Rubenfeld GD, Calfee CS, Laffey JG, McAuley DF, Shankar-Hari M. Estimating the attributable fraction of mortality from acute respiratory distress syndrome to inform enrichment in future randomised clinical trials. Thorax 2023; 78:990-1003. [PMID: 37495364 PMCID: PMC10581447 DOI: 10.1136/thorax-2023-220262] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Efficiency of randomised clinical trials of acute respiratory distress syndrome (ARDS) depends on the fraction of deaths attributable to ARDS (AFARDS) to which interventions are targeted. Estimates of AFARDS in subpopulations of ARDS could improve design of ARDS trials. METHODS We performed a matched case-control study using the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE cohort. Primary outcome was intensive care unit mortality. We used nearest neighbour propensity score matching without replacement to match ARDS to non-ARDS populations. We derived two separate AFARDS estimates by matching patients with ARDS to patients with non-acute hypoxaemic respiratory failure (non-AHRF) and to patients with AHRF with unilateral infiltrates only (AHRF-UL). We also estimated AFARDS in subgroups based on severity of hypoxaemia, number of lung quadrants involved and hyperinflammatory versus hypoinflammatory phenotypes. Additionally, we derived AFAHRF estimates by matching patients with AHRF to non-AHRF controls, and AFAHRF-UL estimates by matching patients with AHRF-UL to non-AHRF controls. RESULTS Estimated AFARDS was 20.9% (95% CI 10.5% to 31.4%) when compared with AHRF-UL controls and 38.0% (95% CI 34.4% to 41.6%) compared with non-AHRF controls. Within subgroups, estimates for AFARDS compared with AHRF-UL controls were highest in patients with severe hypoxaemia (41.1% (95% CI 25.2% to 57.1%)), in those with four quadrant involvement on chest radiography (28.9% (95% CI 13.4% to 44.3%)) and in the hyperinflammatory subphenotype (26.8% (95% CI 6.9% to 46.7%)). Estimated AFAHRF was 33.8% (95% CI 30.5% to 37.1%) compared with non-AHRF controls. Estimated AFAHRF-UL was 21.3% (95% CI 312.8% to 29.7%) compared with non-AHRF controls. CONCLUSIONS Overall AFARDS mean values were between 20.9% and 38.0%, with higher AFARDS seen with severe hypoxaemia, four quadrant involvement on chest radiography and hyperinflammatory ARDS.
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Affiliation(s)
- Rohit Saha
- Criticlal Care, King's College Hospital NHS Trust, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Tài Pham
- Service de médecine intensive-réanimation, Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
- Equipe d'Epidémiologie respiratoire intégrative, CESP, Paris-Saclay University, Gif-sur-Yvette, France
| | - Pratik Sinha
- Department of Anaesthesiology, Washington University in St Louis, St Louis, Missouri, USA
| | - Manoj V Maddali
- Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California, USA
| | - Giacomo Bellani
- Emergency and Intensive Care, University of Milan-Bicocca, Monza, Italy
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Charlotte Summers
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK
| | - Gordon D Rubenfeld
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carolyn S Calfee
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - John Gerard Laffey
- Anaesthesia, School of Medicine, National University of Ireland Galway, Galway, Ireland
- National Centre for Biomedical Engineering Sciences, National University of Ireland Galway, Galway, Ireland
| | - Daniel Francis McAuley
- ICU, QUB, Belfast, UK
- School of Medicine,Dentistry and Biomedical Sciences, Queen's University Belfast Wellcome-Wolfson Institute for Experimental Medicine, Belfast, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
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3
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Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Har M. The Impact of Sample Size Misestimations on the Interpretation of ARDS Trials: Systematic Review and Meta-analysis. Chest 2022; 162:1048-1062. [PMID: 35643115 DOI: 10.1016/j.chest.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Indeterminate randomized controlled trials (RCTs) in ARDS may arise from sample size misspecification, leading to abandonment of efficacious therapies. RESEARCH QUESTIONS If evidence exists for sample size misspecification in ARDS RCTs, has this led to rejection of potentially beneficial therapies? Does evidence exist for prognostic enrichment in RCTs using mortality as a primary outcome? STUDY DESIGN AND METHODS We identified 150 ARDS RCTs commencing recruitment after the 1994 American European Consensus Conference ARDS definition and published before October 31, 2020. We examined predicted-observed sample size, predicted-observed control event rate (CER), predicted-observed average treatment effect (ATE), and the relationship between observed CER and observed ATE for RCTs with mortality and nonmortality primary outcome measures. To quantify the strength of evidence, we used Bayesian-averaged meta-analysis, trial sequential analysis, and Bayes factors. RESULTS Only 84 of 150 RCTs (56.0%) reported sample size estimations. In RCTs with mortality as the primary outcome, CER was overestimated in 16 of 28 RCTs (57.1%). To achieve predicted ATE, interventions needed to prevent 40.8% of all deaths, compared with the original prediction of 29.3%. Absolute reduction in mortality ≥ 10% was observed in 5 of 28 RCTs (17.9%), but predicted in 21 of 28 RCTs (75%). For RCTs with mortality as the primary outcome, no association was found between observed CER and observed ATE (pooled OR: β = -0.04; 95% credible interval, -0.18 to 0.09). We identified three interventions that are not currently standard of care with a Bayesian-averaged effect size of > 0.20 and moderate strength of existing evidence: corticosteroids, airway pressure release ventilation, and noninvasive ventilation. INTERPRETATION Reporting of sample size estimations was inconsistent in ARDS RCTs, and misspecification of CER and ATE was common. Prognostic enrichment strategies in ARDS RCTs based on all-cause mortality are unlikely to be successful. Bayesian methods can be used to prioritize interventions for future effectiveness RCTs.
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Affiliation(s)
- Rohit Saha
- Critical Care Centre, King's College London, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Benjamin Assouline
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georgina Mason
- Critical Care Centre, King's College London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, United Kingdom; National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Charlotte Summers
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manu Shankar-Har
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom.
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4
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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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5
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Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Hari M. Impact of differences in acute respiratory distress syndrome randomised controlled trial inclusion and exclusion criteria: systematic review and meta-analysis. Br J Anaesth 2021; 127:85-101. [PMID: 33812666 PMCID: PMC9768208 DOI: 10.1016/j.bja.2021.02.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Control-arm mortality varies between acute respiratory distress syndrome (ARDS) RCTs. METHODS We systematically reviewed ARDS RCTs that commenced recruitment after publication of the American-European Consensus (AECC) definition (MEDLINE, Embase, and Cochrane central register of controlled trials; January 1994 to October 2020). We assessed concordance of RCT inclusion criteria to ARDS consensus definitions and whether exclusion criteria are strongly or poorly justified. We estimated the proportion of between-trial difference in control-arm 28-day mortality explained by the inclusion criteria and RCT design characteristics using meta-regression. RESULTS A literature search identified 43 709 records. One hundred and fifty ARDS RCTs were included; 146/150 (97.3%) RCTs defined ARDS inclusion criteria using AECC/Berlin definitions. Deviations from consensus definitions, primarily aimed at improving ARDS diagnostic certainty, frequently related to duration of hypoxaemia (117/146; 80.1%). Exclusion criteria could be grouped by rationale for selection into strongly or poorly justified criteria. Common poorly justified exclusions included pregnancy related, age, and comorbidities (infectious/immunosuppression, hepatic, renal, and human immunodeficiency virus/acquired immunodeficiency syndrome). Control-arm 28-day mortality varied between ARDS RCTs (mean: 29.8% [95% confidence interval: 27.0-32.7%; I2=88.8%; τ2=0.02; P<0.01]), and differed significantly between RCTs with different Pao2:FiO2 ratio inclusion thresholds (26.6-39.9 kPa vs <26.6 kPa; P<0.01). In a meta-regression model, inclusion criteria and RCT design characteristics accounted for 30.6% of between-trial difference (P<0.01). CONCLUSIONS In most ARDS RCTs, consensus definitions are modified to use as inclusion criteria. Between-RCT mortality differences are mostly explained by the Pao2:FiO2 ratio threshold within the consensus definitions. An exclusion criteria framework can be applied when designing and reporting exclusion criteria in future ARDS RCTs.
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Affiliation(s)
- Rohit Saha
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Georgina Mason
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, UK; National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Manu Shankar-Hari
- Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Immunology & Microbial Sciences, King's College London, London, UK.
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6
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Juschten J, Tuinman PR, Guo T, Juffermans NP, Schultz MJ, Loer SA, Girbes ARJ, de Grooth HJ. Between-trial heterogeneity in ARDS research. Intensive Care Med 2021; 47:422-434. [PMID: 33713156 PMCID: PMC7955690 DOI: 10.1007/s00134-021-06370-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
Purpose Most randomized controlled trials (RCTs) in patients with acute respiratory distress syndrome (ARDS) revealed indeterminate or conflicting study results. We aimed to systematically evaluate between-trial heterogeneity in reporting standards and trial outcome. Methods A systematic review of RCTs published between 2000 and 2019 was performed including adult ARDS patients receiving lung-protective ventilation. A random-effects meta-regression model was applied to quantify heterogeneity (non-random variability) and to evaluate trial and patient characteristics as sources of heterogeneity. Results In total, 67 RCTs were included. The 28-day control-group mortality rate ranged from 10 to 67% with large non-random heterogeneity (I2 = 88%, p < 0.0001). Reported baseline patient characteristics explained some of the outcome heterogeneity, but only six trials (9%) reported all four independently predictive variables (mean age, mean lung injury score, mean plateau pressure and mean arterial pH). The 28-day control group mortality adjusted for patient characteristics (i.e. the residual heterogeneity) ranged from 18 to 45%. Trials with significant benefit in the primary outcome reported a higher control group mortality than trials with an indeterminate outcome or harm (mean 28-day control group mortality: 44% vs. 28%; p = 0.001). Conclusion Among ARDS RCTs in the lung-protective ventilation era, there was large variability in the description of baseline characteristics and significant unexplainable heterogeneity in 28-day control group mortality. These findings signify problems with the generalizability of ARDS research and underline the urgent need for standardized reporting of trial and baseline characteristics. Supplementary Information The online version of this article (10.1007/s00134-021-06370-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Juschten
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. .,Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - P R Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - T Guo
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Division of System Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - N P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - M J Schultz
- Department of Intensive Care, Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A R J Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J de Grooth
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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7
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Routsi C, Magira E, Kokkoris S, Siembos I, Vrettou C, Zervakis D, Ischaki E, Malahias S, Sigala I, Asimakos A, Daidou T, Kaltsas P, Douka E, Sotiriou A, Markaki V, Temberikidis P, Koroneos A, Politis P, Mastora Z, Dima E, Tsoutsouras T, Papahatzakis I, Gioni P, Strilakou A, Maragouti A, Mizi E, Kanavou A, Sarri A, Gavrielatou E, Mentzelopoulos S, Kalomenidis I, Papastamopoulos V, Kotanidou A, Zakynthinos S. Hospital Resources May Be an Important Aspect of Mortality Rate among Critically Ill Patients with COVID-19: The Paradigm of Greece. J Clin Med 2020; 9:jcm9113730. [PMID: 33233686 PMCID: PMC7699728 DOI: 10.3390/jcm9113730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 01/10/2023] Open
Abstract
For critically ill patients with coronavirus disease 2019 (COVID-19) who require intensive care unit (ICU) admission, extremely high mortality rates (even 97%) have been reported. We hypothesized that overburdened hospital resources by the extent of the pandemic rather than the disease per se might play an important role on unfavorable prognosis. We sought to determine the outcome of such patients admitted to the general ICUs of a hospital with sufficient resources. We performed a prospective observational study of adult patients with COVID-19 consecutively admitted to COVID—designated ICUs at Evangelismos Hospital, Athens, Greece. Among 50 patients, ICU and hospital mortality was 32% (16/50). Median PaO2/FiO2 was 121 mmHg (interquartile range (IQR), 86–171 mmHg) and most patients had moderate or severe acute respiratory distress syndrome (ARDS). Hospital resources may be an important aspect of mortality rates, since severely ill COVID-19 patients with moderate and severe ARDS may have understandable mortality, provided that they are admitted to general ICUs without limitations on hospital resources.
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Affiliation(s)
- Christina Routsi
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Eleni Magira
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Stelios Kokkoris
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Ilias Siembos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Charikleia Vrettou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Dimitris Zervakis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Sotiris Malahias
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Ioanna Sigala
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Andreas Asimakos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Theodora Daidou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Panagiotis Kaltsas
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Evangelia Douka
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Adamandia Sotiriou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Vassiliki Markaki
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Prodromos Temberikidis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Apostolos Koroneos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Panagiotis Politis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Zafiria Mastora
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Efrosini Dima
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Theodoros Tsoutsouras
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Ioannis Papahatzakis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Panagiota Gioni
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Athina Strilakou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Aikaterini Maragouti
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Eleftheria Mizi
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Ageliki Kanavou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Aikaterini Sarri
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Evdokia Gavrielatou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Spyros Mentzelopoulos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Ioannis Kalomenidis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Vassilios Papastamopoulos
- Fifth Department of Internal Medicine, Unit for Infectious Diseases, ‘Evangelismos’ Hospital, 45–47 Ipsilandou Street, GR-10675 Athens, Greece;
| | - Anastasia Kotanidou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
| | - Spyros Zakynthinos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45–47 Ipsilandou St, GR-10675 Athens, Greece; (C.R.); (E.M.); (S.K.); (I.S.); (C.V.); (D.Z.); (E.I.); (S.M.); (I.S.); (A.A.); (T.D.); (P.K.); (E.D.); (A.S.); (V.M.); (P.T.); (A.K.); (P.P.); (Z.M.); (E.D.); (T.T.); (I.P.); (P.G.); (A.S.); (A.M.); (E.M.); (A.K.); (A.S.); (E.G.); (S.M.); (I.K.); (A.K.)
- Correspondence:
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Griffiths MJD, McAuley DF, Perkins GD, Barrett N, Blackwood B, Boyle A, Chee N, Connolly B, Dark P, Finney S, Salam A, Silversides J, Tarmey N, Wise MP, Baudouin SV. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res 2019; 6:e000420. [PMID: 31258917 PMCID: PMC6561387 DOI: 10.1136/bmjresp-2019-000420] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/01/2019] [Indexed: 12/16/2022] Open
Abstract
The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.
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Affiliation(s)
| | - Danny Francis McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, West Midlands, UK
| | | | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Andrew Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nigel Chee
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, NIHR Biomedical Research Centre, University of Manchester, Manchester, Greater Manchester, UK
| | - Simon Finney
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Aemun Salam
- Peri-Operative Medicine, Barts Health NHS Trust, London, UK
| | - Jonathan Silversides
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Nick Tarmey
- Academic Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | | | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Sklar MC, Patel BK, Beitler JR, Piraino T, Goligher EC. Optimal Ventilator Strategies in Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2019; 40:81-93. [PMID: 31060090 PMCID: PMC7117088 DOI: 10.1055/s-0039-1683896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mechanical ventilation practices in patients with acute respiratory distress syndrome (ARDS) have progressed with a growing understanding of the disease pathophysiology. Paramount to the care of affected patients is the delivery of lung-protective mechanical ventilation which prioritizes tidal volume and plateau pressure limitation. Lung protection can probably be further enhanced by scaling target tidal volumes to the specific respiratory mechanics of individual patients. The best procedure for selecting optimal positive end-expiratory pressure (PEEP) in ARDS remains uncertain; several relevant issues must be considered when selecting PEEP, particularly lung recruitability. Noninvasive ventilation must be used with caution in ARDS as excessively high respiratory drive can further exacerbate lung injury; newer modes of delivery offer promising approaches in hypoxemic respiratory failure. Airway pressure release ventilation offers an alternative approach to maximize lung recruitment and oxygenation, but clinical trials have not demonstrated a survival benefit of this mode over conventional ventilation strategies. Rescue therapy with high-frequency oscillatory ventilation is an important option in refractory hypoxemia. Despite a disappointing lack of benefit (and possible harm) in patients with moderate or severe ARDS, possibly due to lung hyperdistention and right ventricular dysfunction, high-frequency oscillation may improve outcome in patients with very severe hypoxemia.
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Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, New York
| | - Thomas Piraino
- Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,Department of Respiratory Therapy, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
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10
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Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Med 2018; 46:1820-1831. [PMID: 30247273 PMCID: PMC6277052 DOI: 10.1097/ccm.0000000000003406] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. DATA SOURCES We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. STUDY SELECTION AND DATA EXTRACTION Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. DATA SYNTHESIS Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. CONCLUSIONS Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.
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Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Carolyn S. Calfee
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
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Mentzelopoulos SD, Anninos H, Malachias S, Zakynthinos SG. "Low-" versus "high"-frequency oscillation and right ventricular function in ARDS. A randomized crossover study. J Intensive Care 2018; 6:58. [PMID: 30202530 PMCID: PMC6122746 DOI: 10.1186/s40560-018-0327-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Recent, large trials of high-frequency oscillation (HFO) versus conventional ventilation (CV) in acute respiratory distress syndrome (ARDS) reported negative results. This could be explained by an HFO-induced right ventricular (RV) dysfunction/failure due to high intrathoracic pressures and hypercapnia. We hypothesized that HFO strategies aimed at averting/attenuating hypercapnia, such as "low-frequency" (i.e., 4 Hz) HFO and 4-Hz HFO with tracheal-gas insufflation (HFO-TGI), may result in an improved RV function relative to "high-frequency" (i.e., 7 Hz) HFO (which may promote hypercapnia) and similar RV function relative to lung protective CV. Methods We studied 17 patients with moderate-to-severe ARDS [PaO2-to-inspiratory O2 fraction ratio (PaO2/FiO2) < 150]. RV function was assessed by transesophageal echocardiography (TEE). Patients received 60 min of CV for TEE-guided, positive end-expiratory pressure (PEEP) "optimization" and subsequent stabilization; 60 min of 4-Hz HFO for "study mean airway pressure (mPaw)" titration to peripheral oxygen saturation ≥ 95%, without worsening RV function as assessed by TEE; 60 min of each tested HFO strategy in random order; and another 60 min of CV using the pre-HFO, TEE-guided PEEP setting. Study measurements (i.e., gas exchange, hemodynamics, and TEE data) were obtained over the last 10 min of pre-HFO CV, of each one of the three tested HFO strategies, and of post-HFO CV. Results The mean "study HFO mPaw" was 8-10 cmH2O higher relative to pre-HFO CV. Seven-Hz HFO versus 4-Hz HFO and 4-Hz HFO-TGI resulted in higher mean ± SD right-to-left ventricular end-diastolic area ratio (RVEDA/LVEDA) (0.64 ± 0.15 versus 0.56 ± 0.14 and 0.52 ± 0.10, respectively, both p < 0.05). Higher diastolic/systolic eccentricity indexes (1.33 ± 0.19/1.42 ± 0.17 versus 1.21 ± 0.10/1.26 ± 0.10 and 1.17 ± 0.11/1.17 ± 0.13, respectively, all p < 0.05). Seven-Hz HFO resulted in 18-28% higher PaCO2 relative to all other ventilatory strategies (all p < 0.05). Four-Hz HFO-TGI versus pre-HFO CV resulted in 15% lower RVEDA/LVEDA, and 7%/10% lower diastolic/systolic eccentricity indexes (all p < 0.05). Mean PaO2/FiO2 improved by 77-80% during HFO strategies versus CV (all p < 0.05). Mean cardiac index varied by ≤ 10% among strategies. Percent changes in PaCO2 among strategies were predictive of concurrent percent changes in measures of RV function (R2 = 0.21-0.43). Conclusions In moderate-to-severe ARDS, "short-term" 4-Hz HFO strategies resulted in better RV function versus 7-Hz HFO, partly attributable to improved PaCO2 control, and similar or improved RV function versus CV. Trial registration This study was registered 40 days prior to the enrollment of the first patient at ClinicalTrials.gov, ID no. NCT02027129, Principal Investigator Spyros D. Mentzelopoulos, date of registration January 3, 2014.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
| | - Hector Anninos
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
| | - Sotirios Malachias
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
| | - Spyros G Zakynthinos
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
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12
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High-Frequency Oscillation for Adult Patients with Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2018; 14:S289-S296. [PMID: 29043832 DOI: 10.1513/annalsats.201704-341ot] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE By minimizing tidal lung strain and maintaining alveolar recruitment, high-frequency oscillatory ventilation (HFOV) may protect against ventilator-induced lung injury. OBJECTIVES To summarize the current evidence in support of the use of HFOV in adult patients with acute respiratory distress syndrome. METHODS We conducted a systematic review and meta-analysis of randomized trials comparing mortality rates with the use of HFOV versus conventional mechanical ventilation for adult patients with acute respiratory distress syndrome. Eligible trials were identified from previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapies were collected; effects were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS Six trials were eligible for inclusion (total n = 1,715 patients). Four trials mandated lung-protective ventilation in the control group and one trial applied a higher positive end-expiratory pressure (PEEP) ventilation strategy in the control group. None of the trials were judged to be at high risk of bias, though all were unblinded. In trials that did not systematically employ any cointerventions with HFOV and that targeted low tidal volumes in the patients randomized to conventional ventilation (primary analysis), HFOV had no significant effect on mortality (three trials; risk ratio [RR], 1.14; 95% confidence interval [CI], 0.88 to 1.48; evidence grade = high). Pooled analysis of all six trials also did not suggest a significant mortality reduction (RR, 0.94; 95% CI, 0.71 to 1.24; evidence grade = low). The single trial that employed a conventional ventilation strategy with both lower tidal volumes and higher PEEP as control reported higher mortality in patients receiving HFOV (RR, 1.41; 95% CI, 1.12 to 1.79). HFOV was not associated with improved oxygenation after 24 hours (five trials; mean increase of 10 mm Hg; 95% CI, -16 to 37 mm Hg). Rates of barotrauma were not different between HFOV and conventional ventilation, although significant benefit or harm could not be excluded (RR, 1.15; 95% CI, 0.61 to 2.17). CONCLUSIONS Published randomized trials suggest that HFOV is not associated with a mortality benefit, and may even be harmful in comparison to ventilation with low tidal volumes and higher levels of PEEP.
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13
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Meade MO, Young D, Hanna S, Zhou Q, Bachman TE, Bollen C, Slutsky AS, Lamb SE, Adhikari NKJ, Mentzelopoulos SD, Cook DJ, Sud S, Brower RG, Thompson BT, Shah S, Stenzler A, Guyatt G, Ferguson ND. Severity of Hypoxemia and Effect of High-Frequency Oscillatory Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:727-733. [PMID: 28245137 DOI: 10.1164/rccm.201609-1938oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE High-frequency oscillatory ventilation (HFOV) is theoretically beneficial for lung protection, but the results of clinical trials are inconsistent, with study-level meta-analyses suggesting no significant effect on mortality. OBJECTIVES The aim of this individual patient data meta-analysis was to identify acute respiratory distress syndrome (ARDS) patient subgroups with differential outcomes from HFOV. METHODS After a comprehensive search for trials, two reviewers independently identified randomized trials comparing HFOV with conventional ventilation for adults with ARDS. Prespecified effect modifiers were tested using multivariable hierarchical logistic regression models, adjusting for important prognostic factors and clustering effects. MEASUREMENTS AND MAIN RESULTS Data from 1,552 patients in four trials were analyzed, applying uniform definitions for study variables and outcomes. Patients had a mean baseline PaO2/FiO2 of 114 ± 39 mm Hg; 40% had severe ARDS (PaO2/FiO2 <100 mm Hg). Mortality at 30 days was 321 of 785 (40.9%) for HFOV patients versus 288 of 767 (37.6%) for control subjects (adjusted odds ratio, 1.17; 95% confidence interval, 0.94-1.46; P = 0.16). This treatment effect varied, however, depending on baseline severity of hypoxemia (P = 0.0003), with harm increasing with PaO2/FiO2 among patients with mild-moderate ARDS, and the possibility of decreased mortality in patients with very severe ARDS. Compliance and body mass index did not modify the treatment effect. HFOV increased barotrauma risk compared with conventional ventilation (adjusted odds ratio, 1.75; 95% confidence interval, 1.04-2.96; P = 0.04). CONCLUSIONS HFOV increases mortality for most patients with ARDS but may improve survival among patients with severe hypoxemia on conventional mechanical ventilation.
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Affiliation(s)
- Maureen O Meade
- 1 Department of Medicine and.,2 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Steven Hanna
- 1 Department of Medicine and.,2 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Qi Zhou
- 1 Department of Medicine and.,2 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Casper Bollen
- 5 Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Arthur S Slutsky
- 6 Interdepartmental Division of Critical Care Medicine.,8 Department of Medicine, and.,7 Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | | | - Neill K J Adhikari
- 6 Interdepartmental Division of Critical Care Medicine.,8 Department of Medicine, and.,9 Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Canada
| | | | - Deborah J Cook
- 1 Department of Medicine and.,2 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sachin Sud
- 11 Trillium Health Partners, University of Toronto, Mississauga, Ontario, Canada
| | - Roy G Brower
- 12 Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Sanjoy Shah
- 14 University Hospitals Bristol, National Health Service Foundation Trust, Bristol, United Kingdom
| | - Alex Stenzler
- 15 12th Man Technologies, Garden Grove, California; and
| | - Gordon Guyatt
- 1 Department of Medicine and.,2 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Niall D Ferguson
- 6 Interdepartmental Division of Critical Care Medicine.,8 Department of Medicine, and.,16 Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,17 Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto General Research Institute, Toronto, Canada
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14
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Sklar MC, Fan E, Goligher EC. High-Frequency Oscillatory Ventilation in Adults With ARDS: Past, Present, and Future. Chest 2017; 152:1306-1317. [PMID: 28684287 DOI: 10.1016/j.chest.2017.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/29/2017] [Accepted: 06/16/2017] [Indexed: 01/12/2023] Open
Abstract
High-frequency oscillatory ventilation (HFOV) is a unique mode of mechanical ventilation that uses nonconventional gas exchange mechanisms to deliver ventilation at very low tidal volumes and high frequencies. The properties of HFOV make it a potentially ideal mode to prevent ventilator-induced lung injury in patients with ARDS. Despite a compelling physiological basis and promising experimental data, large randomized controlled trials have not detected an improvement in survival with the use of HFOV, and its use as an early lung-protective strategy in patients with ARDS may be harmful. Nevertheless, HFOV still has an important potential role in the management of refractory hypoxemia. Careful attention should be paid to right ventricular function and lung stress when applying HFOV. This review discusses the physiological principles, clinical evidence, practical applications, and future prospects for the use of HFOV in patients with ARDS.
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Affiliation(s)
- Michael C Sklar
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.
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15
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Fan E, Del Sorbo L, Goligher EC, Hodgson CL, Munshi L, Walkey AJ, Adhikari NKJ, Amato MBP, Branson R, Brower RG, Ferguson ND, Gajic O, Gattinoni L, Hess D, Mancebo J, Meade MO, McAuley DF, Pesenti A, Ranieri VM, Rubenfeld GD, Rubin E, Seckel M, Slutsky AS, Talmor D, Thompson BT, Wunsch H, Uleryk E, Brozek J, Brochard LJ. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 195:1253-1263. [DOI: 10.1164/rccm.201703-0548st] [Citation(s) in RCA: 807] [Impact Index Per Article: 115.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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16
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Sud S, Sud M, Friedrich JO, Wunsch H, Meade MO, Ferguson ND, Adhikari NKJ. High-frequency oscillatory ventilation versus conventional ventilation for acute respiratory distress syndrome. Cochrane Database Syst Rev 2016; 4:CD004085. [PMID: 27043185 PMCID: PMC6516956 DOI: 10.1002/14651858.cd004085.pub4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND High-frequency oscillation (HFO) is an alternative to conventional mechanical ventilation that is sometimes used to treat people with acute respiratory distress syndrome, but effects on oxygenation, mortality and adverse clinical outcomes are uncertain. This review was originally published in 2004 and was updated in 2013 and again in 2015. OBJECTIVES To determine the effects of HFO compared to conventional mechanical ventilation on physiological outcomes, clinical outcomes, and mortality when used for the treatment of acute respiratory distress syndrome (ARDS). SEARCH METHODS We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Ovid), MEDLINE (Ovid), EMBASE (Ovid), and ISI, from inception to December 2015. We conducted the original search in 2002. We manually searched reference lists from included studies and review articles; searched conference proceedings of the American Thoracic Society (1994 to 2015), Society of Critical Care Medicine (1994 to 2015), European Society of Intensive Care Medicine (1994 to 2015), and American College of Chest Physicians (1994 to 2015); contacted clinical experts in the field; and searched for unpublished and ongoing trials in clinicaltrials.gov and controlled-trials.com. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing treatment using HFO with conventional mechanical ventilation for children and adults diagnosed with ARDS. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data on clinical, physiological, and safety outcomes according to a predefined protocol. We contacted investigators of all included studies to clarify methods and obtain additional data. We used random-effects models in the analyses. MAIN RESULTS We include 10 RCTs (n = 1850); almost all participants had moderate or severe ARDS. For the primary analysis, the risk of bias was low in three studies and unclear in five studies; the overall quality of evidence was very low due to imprecision, inconsistency, indirectness and methodologic limitations. In participants randomized to HFO, there was no significant difference in hospital or 30-day mortality (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.72 to 1.16; P = 0.46, I² = 66%; 8 trials, 1779 participants, 807 deaths) compared with conventional ventilation. One large multicentre RCT was terminated early because of increased mortality in participants randomized to HFO compared to mechanical ventilation with low tidal volume and high positive end expiratory pressure, with HFO reserved only as a rescue therapy. We found substantial between-trial statistical heterogeneity (I² = 0% to 66%) for clinical outcomes, including mortality. AUTHORS' CONCLUSIONS The findings of this systematic review suggest that HFO does not reduce hospital and 30-day mortality due to ARDS; the quality of evidence was very low. Our findings do not support the use of HFO as a first-line strategy in people undergoing mechanical ventilation for ARDS.
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Affiliation(s)
- Sachin Sud
- Trillium Health Center, University of TorontoDivision of Critical Care, Department of MedicineMississaugaONCanada
- Trillium Health PartnersInstitute for Better HealthMississaugaOntarioCanada
| | - Maneesh Sud
- University of TorontoDepartment of MedicineSuite RFE 3‐805200 Elizabeth StreetTorontoONCanadaM5G 2C4
| | - Jan O Friedrich
- Keenan Research Centre/Li Ka Shing Knowledge Institute; St Michael’s Hospital, Dalla Lana School of Public Health, University of TorontoInterdepartmental Division of Critical CareTorontoONCanada
| | - Hannah Wunsch
- University of TorontoDepartment of AnesthesiaTorontoONCanada
| | - Maureen O Meade
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHamiltonONCanadaL8N 3Z5
| | - Niall D Ferguson
- University Health Network and Mount Sinai Hospital, University of TorontoInterdepartmental Division of Critical Care Medicine600 University AveSuite 18‐206TorontoONCanadaM5G 1X5
| | - Neill KJ Adhikari
- Sunnybrook Health Sciences CentreDepartment of Critical Care MedicineTorontoCanada
- University of TorontoInterdepartmental Division of Critical CareTorontoCanada
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17
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Meta-analysis of High-frequency Oscillation in Acute Respiratory Distress Syndrome and Accuracy of Results. Anesthesiology 2016; 124:246-7. [PMID: 26669995 DOI: 10.1097/aln.0000000000000930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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18
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Wang C, Wang X, Chi C, Guo L, Guo L, Zhao N, Wang W, Pi X, Sun B, Lian A, Shi J, Li E. Lung ventilation strategies for acute respiratory distress syndrome: a systematic review and network meta-analysis. Sci Rep 2016; 6:22855. [PMID: 26955891 PMCID: PMC4783789 DOI: 10.1038/srep22855] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/23/2016] [Indexed: 02/03/2023] Open
Abstract
To identify the best lung ventilation strategy for acute respiratory distress syndrome (ARDS), we performed a network meta-analysis. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and the Web of Science were searched, and 36 eligible articles were included. Compared with higher tidal volumes with FiO2-guided lower positive end-expiratory pressure [PEEP], the hazard ratios (HRs) for mortality were 0.624 (95% confidence interval (CI) 0.419-0.98) for lower tidal volumes with FiO2-guided lower PEEP and prone positioning and 0.572 (0.34-0.968) for pressure-controlled ventilation with FiO2-guided lower PEEP. Lower tidal volumes with FiO2-guided higher PEEP and prone positioning had the greatest potential to reduce mortality, and the possibility of receiving the first ranking was 61.6%. Permissive hypercapnia, recruitment maneuver, and low airway pressures were most likely to be the worst in terms of all-cause mortality. Compared with higher tidal volumes with FiO2-guided lower PEEP, pressure-controlled ventilation with FiO2-guided lower PEEP and lower tidal volumes with FiO2-guided lower PEEP and prone positioning ventilation are associated with lower mortality in ARDS patients. Lower tidal volumes with FiO2-guided higher PEEP and prone positioning ventilation and lower tidal volumes with pressure-volume (P-V) static curve-guided individual PEEP are potential optimal strategies for ARDS patients.
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Affiliation(s)
- Changsong Wang
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of critical care medicine, the Third Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoyang Wang
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Anesthesiology, JILIN GUO WEN Hospital, Gongzhuling, China
| | - Chunjie Chi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Libo Guo
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Guo
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Nana Zhao
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Weiwei Wang
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xin Pi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bo Sun
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ailing Lian
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jinghui Shi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Enyou Li
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
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In Reply. Anesthesiology 2016; 124:247-8. [DOI: 10.1097/aln.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Ursulet L, Roussiaux A, Belcour D, Ferdynus C, Gauzere BA, Vandroux D, Jabot J. Right over left ventricular end-diastolic area relevance to predict hemodynamic intolerance of high-frequency oscillatory ventilation in patients with severe ARDS. Ann Intensive Care 2015; 5:25. [PMID: 26380993 PMCID: PMC4573736 DOI: 10.1186/s13613-015-0068-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/08/2015] [Indexed: 01/19/2023] Open
Abstract
Background High-frequency oscillatory ventilation (HFOV) does not improve the prognosis of ARDS patients despite an improvement in oxygenation. This paradox may partly be explained by HFOV hemodynamic side-effects on right ventricular function. Our goal was to study the link between HFOV and hemodynamic effects and to test if the pre-HFOV right over left ventricular end-diastolic area (RVEDA/LVEDA) ratio, as a simple parameter of afterload-related RV dysfunction, could be used to predict HFOV hemodynamic intolerance in patients with severe ARDS. Methods Twenty-four patients were studied just before and within 3 h of HFOV using transthoracic echocardiography and transpulmonary thermodilution. Results Before HFOV, the mean PaO2/FiO2 ratio was 89 ± 23. The number of patients with a RVEDA/LVEDA ratio >0.6 significantly increased after HFOV [11 (46 %) vs. 17 (71 %)]. Although HFOV did not significantly decrease the arterial pressure (systolic, diastolic, mean and pulse pressure), it significantly decreased the cardiac index (CI) by 13 ± 18 % and significantly increased the RVEDA/LVEDA ratio by 14 ± 11 %. A significant correlation was observed between pre-HFOV RVEDA/LVEDA ratio and CI diminution after HFOV (r = 0.78; p < 0.0001). A RVEDA/LVEDA ratio superior to 0.6 resulted in a CI decrease >15 % during HFOV with a sensitivity of 80 % (95 % confidence interval 44–98 %) and a specificity of 79 % (confidence interval 49–95 %). Conclusion The RVEDA/LVEDA ratio measured just before HFOV predicts the hemodynamic intolerance of this technique in patients with severe ARDS. A high ratio under CMV raises questions about the use of HFOV in such patients. Trial registration: ClinicalTrials.gov: NCT01167621
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Affiliation(s)
- Lionel Ursulet
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Arnaud Roussiaux
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Dominique Belcour
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Cyril Ferdynus
- Methodological Support and Biostatistics Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Bernard-Alex Gauzere
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - David Vandroux
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Julien Jabot
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
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Hupp SR, Turner DA, Rehder KJ. Is there still a role for high-frequency oscillatory ventilation in neonates, children and adults? Expert Rev Respir Med 2015; 9:603-18. [PMID: 26290121 DOI: 10.1586/17476348.2015.1077119] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Critically ill patients with respiratory pathology often require mechanical ventilation and while low tidal volume ventilation has become the mainstay of treatment, achieving adequate gas exchange may not be attainable with conventional ventilator modalities. In attempt to achieve gas exchange goals and also mitigate lung injury, high frequency ventilation is often implemented which couples low tidal volumes with sustained mean airway pressure. This manuscript presents the physiology of high-frequency oscillatory ventilation, reviews the currently available data on its use and provides strategies and approaches for this mode of ventilation.
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Affiliation(s)
| | - David A Turner
- a Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Kyle J Rehder
- a Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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High-frequency Ventilation Does Not Provide Mortality Benefit in Comparison with Conventional Lung-protective Ventilation in Acute Respiratory Distress Syndrome. Anesthesiology 2015; 122:841-51. [DOI: 10.1097/aln.0000000000000306] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Abstract
Background:
Despite implementation of lung-protective ventilation strategy, acute respiratory distress syndrome is associated with significant mortality, which necessitates the evaluation of ventilatory modes other than conventional lung-protective strategy. This meta-analysis of the randomized controlled trials has been undertaken to know whether high-frequency oscillatory ventilation (HFOV) provides any mortality benefit over conventional ventilation in adult patients with acute respiratory distress syndrome.
Methods:
Published randomized controlled trials comparing HFOV with conventional lung-protective ventilation in adult patients with acute respiratory distress syndrome were included in this meta-analysis.
Results:
A total 1,759 patient data from seven randomized controlled trials have been analyzed here. Primary outcome of the review is in-hospital/30-day mortality and secondary outcomes are duration of intensive care unit stay, duration of mechanical ventilation, requirement of additional treatment, and complications associated with the interventions. HFOV does not offer any in-hospital/30-day mortality benefit (386 of 886 in HFOV vs. 368 of 873 in conventional ventilation; risk ratio, 0.96; 95% CI, 0.77 to 1.19; P = 0.70) over conventional ventilation. It may also prolong the duration of mechanical ventilation (mean difference, 1.18 days; 95% CI, 0.00 to 2.35 days; P = 0.05). Duration of intensive care unit stay (mean difference, 1.24 days; 95% CI, −0.08 to 2.56 days; P = 0.06) and requirement of neuromuscular blocker is similar between two treatment arm. Incidence of refractory hypoxemia is significantly less (risk ratio, 0.60; 95% CI, 0.39 to 0.93; P = 0.02) with the use of HFOV. HFOV is not associated with increased incidence of barotrauma and refractory hypotension.
Conclusion:
HFOV should not be used routinely in all adult patients with acute respiratory distress syndrome as primary ventilation strategy in place of conventional lung-protective ventilation.
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Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review. Crit Care Med 2014; 42:2278-89. [PMID: 25098333 DOI: 10.1097/ccm.0000000000000504] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis). DATA SOURCES PubMed, Scopus, and EMBASE. STUDY SELECTION Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT. DATA EXTRACTION Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat. DATA SYNTHESIS Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02). CONCLUSIONS For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.
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Huang CT, Lin HH, Ruan SY, Lee MS, Tsai YJ, Yu CJ. Efficacy and adverse events of high-frequency oscillatory ventilation in adult patients with acute respiratory distress syndrome: a meta-analysis. Crit Care 2014; 18:R102. [PMID: 24886674 PMCID: PMC4075239 DOI: 10.1186/cc13880] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/07/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction Theoretically, high-frequency oscillatory ventilation (HFOV) achieves all goals of a lung-protective ventilatory mode and seems ideal for the treatment of adult patients with acute respiratory distress syndrome (ARDS). However, its effects on mortality and adverse clinical outcomes remain uncertain given the paucity of high-quality studies in this area. This meta-analysis was performed to evaluate the efficacy and adverse events of HFOV in adults with ARDS. Methods We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials through February 2014 to retrieve randomized controlled trials of HFOV in adult ARDS patients. Two independent reviewers extracted data on study methods, clinical and physiological outcomes and adverse events. The primary outcome was 30-day or hospital mortality. Risk of bias was evaluated with the Cochrane Collaboration’s tool. Mortality, oxygenation and adverse effects of HFOV were compared to those of conventional mechanical ventilation. A random-effects model was applied for meta-analysis. Results A total of five trials randomly assigning 1,580 patients met inclusion criteria. Pooled data showed that HFOV significantly improved oxygenation on day one of therapy (four studies; 24% higher; 95% confidence interval (CI) 11 to 40%; P <0.01). However, HFOV did not reduce mortality risk (five studies; risk ratio (RR) 1.04; 95% CI 0.83 to 1.31; P = 0.71) and two early terminated studies suggested a harmful effect of HFOV in ARDS (two studies; RR 1.33; 95% CI 1.09 to 1.62; P <0.01). Safety profiles showed that HFOV was associated with a trend toward increased risk of barotrauma (five studies; RR 1.19; 95% CI 0.83 to 1.72; P = 0.34) and unfavorable hemodynamics (five studies; RR 1.16; 95% CI 0.97 to 1.39; P = 0.12). Conclusions HFOV improved oxygenation in adult patients with ARDS; however, it did not confer a survival benefit and might cause harm in the era of lung-protective ventilation strategy. The evidence suggests that HFOV should not be a routine practice in ARDS and further studies specifically selecting patients for this ventilator mode should be pursued.
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Vrettou CS, Zakynthinos SG, Malachias S, Mentzelopoulos SD. The effect of high-frequency oscillatory ventilation combined with tracheal gas insufflation on extravascular lung water in patients with acute respiratory distress syndrome: a randomized, crossover, physiologic study. J Crit Care 2014; 29:568-73. [PMID: 24814973 DOI: 10.1016/j.jcrc.2014.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/31/2014] [Accepted: 03/25/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE High-frequency oscillation combined with tracheal gas insufflation (HFO-TGI) improves oxygenation in patients with acute respiratory distress syndrome (ARDS). There are limited physiologic data regarding the effects of HFO-TGI on hemodynamics and pulmonary edema during ARDS. The aim of this study was to investigate the effect of HFO-TGI on extravascular lung water (EVLW). MATERIALS AND METHODS We conducted a prospective, randomized, crossover study. Consecutive eligible patients with ARDS received sessions of conventional mechanical ventilation with recruitment maneuvers (RMs), followed by HFO-TGI with RMs, or vice versa. Each ventilatory technique was administered for 8 hours. The order of administration was randomly assigned. Arterial/central venous blood gas analysis and measurement of hemodynamic parameters and EVLW were performed at baseline and after each 8-hour period using the single-indicator thermodilution technique. RESULTS Twelve patients received 32 sessions. Pao2/fraction of inspired oxygen and respiratory system compliance were higher (P<.001 for both), whereas extravascular lung water index to predicted body weight and oxygenation index were lower (P=.021 and .029, respectively) in HFO-TGI compared with conventional mechanical ventilation. There was a significant correlation between Pao2/fraction of inspired oxygen improvement and extravascular lung water index drop during HFO-TGI (Rs=-0.452, P=.009). CONCLUSIONS High-frequency oscillation combined with tracheal gas insufflation improves gas exchange and lung mechanics in ARDS and potentially attenuates EVLW accumulation.
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Affiliation(s)
- Charikleia S Vrettou
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece.
| | - Spyros G Zakynthinos
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Sotirios Malachias
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
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Pelosi P, Sutherasan Y. High-frequency oscillatory ventilation with tracheal gas insufflation: the rescue strategy for brain-lung interaction. Crit Care 2013; 17:R179. [PMID: 23981807 PMCID: PMC4057213 DOI: 10.1186/cc12862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The occurrence of moderate to severe acute respiratory distress syndrome due to traumatic brain injury is not uncommon and is associated with an extremely high incidence of morbidity and mortality. Owing to the complex interaction between the lung and brain, protective ventilation for the lung with lower tidal volume and higher positive end-expiratory pressure with or without mild hypercapnia might be harmful for the brain, and maintaining normocapnia or mild hypocapnia by increasing tidal volume or respiratory rate (or both) with lower positive end-expiratory pressure levels for protecting the brain might lead to ventilator-induced lung injury. Balancing the end-point between lungs and brain becomes a challenging issue, and non-conventional modes of mechanical ventilation might play a role in the more difficult clinical cases. In this commentary, the authors discuss the rationale, based on the physiologic principle of targeting both vital organs, of applying high-frequency oscillation and tracheal gas insufflation in acute respiratory distress syndrome patients with traumatic brain injury.
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Affiliation(s)
- Paolo Pelosi
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated
Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16132, Genova,
Italy
| | - Yuda Sutherasan
- Ramathibodi Hospital, Rama 6 Road, Mahidol University, 10400, Bangkok,
Thailand
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Vrettou CS, Zakynthinos SG, Malachias S, Mentzelopoulos SD. High-frequency oscillation and tracheal gas insufflation in patients with severe acute respiratory distress syndrome and traumatic brain injury: an interventional physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R136. [PMID: 23844839 PMCID: PMC4057500 DOI: 10.1186/cc12815] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 07/11/2013] [Indexed: 01/25/2023]
Abstract
Introduction In acute respiratory distress syndrome (ARDS), combined high-frequency oscillation (HFO) and tracheal gas insufflation (TGI) improves gas exchange compared with conventional mechanical ventilation (CMV). We evaluated the effect of HFO-TGI on PaO2/fractional inspired O2 (FiO2) and PaCO2, systemic hemodynamics, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) in patients with traumatic brain injury (TBI) and concurrent severe ARDS. Methods We studied 13 TBI/ARDS patients requiring anesthesia, hyperosmolar therapy, and ventilation with moderate-to-high CMV-tidal volumes for ICP control. Patients had PaO2/FiO2 <100 mm Hg at end-expiratory pressure ≥10 cm H2O. Patients received consecutive, daily, 12-hour rescue sessions of HFO-TGI interspersed with 12-hour periods of CMV. HFO-TGI was discontinued when the post-HFO-TGI PaO2/FiO2 exceeded 100 mm Hg for >12 hours. Arterial/central-venous blood gases, hemodynamics, and ICP were recorded before, during (every 4 hours), and after HFO-TGI, and were analyzed by using repeated measures analysis of variance. Respiratory mechanics were assessed before and after HFO-TGI. Results Each patient received three to four HFO-TGI sessions (total sessions, n = 43). Pre-HFO-TGI PaO2/FiO2 (mean ± standard deviation (SD): 83.2 ± 15.5 mm Hg) increased on average by approximately 130% to163% during HFO-TGI (P < 0.01) and remained improved by approximately 73% after HFO-TGI (P < 0.01). Pre-HFO-TGI CMV plateau pressure (30.4 ± 4.5 cm H2O) and respiratory compliance (37.8 ± 9.2 ml/cm H2O), respectively, improved on average by approximately 7.5% and 20% after HFO-TGI (P < 0.01 for both). During HFO-TGI, systemic hemodynamics remained unchanged. Transient improvements were observed after 4 hours of HFO-TGI versus pre-HFO-TGI CMV in PaCO2 (37.7 ± 9.9 versus 41.2 ± 10.8 mm Hg; P < 0.01), ICP (17.2 ± 5.4 versus 19.7 ± 5.9 mm Hg; P < 0.05), and CPP (77.2 ± 14.6 versus 71.9 ± 14.8 mm Hg; P < 0.05). Conclusions In TBI/ARDS patients, HFO-TGI may improve oxygenation and respiratory mechanics, without adversely affecting PaCO2, hemodynamics, or ICP. These findings support the use of HFO-TGI as a rescue ventilatory strategy in patients with severe TBI and imminent oxygenation failure due to severe ARDS.
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