National survey of outcomes and practices in acute respiratory distress syndrome in Singapore

Mechanical ventilation practices in Asian intensive care units: A multicenter cross-sectional study

PURPOSE

This study investigated current practices of mechanical ventilation in Asian intensive care units, focusing on tidal volume, plateau pressure, and positive end-expiratory pressure (PEEP).

MATERIALS AND METHODS

In this multicenter cross-sectional study, data on mechanical ventilation and clinical outcomes were collected. Predictors of mortality were analyzed by univariate and multivariable logistic regression. A scoring system was generated to predict 28-day mortality.

RESULTS

A total of 1408 patients were enrolled. In 138 patients with acute respiratory distress syndrome (ARDS), 65.9% were on a tidal volume ≤ 8 ml/kg predicted body weight (PBW), and 71.3% were on sufficient PEEP. In 1270 patients without ARDS, 88.8% were on a tidal volume ≤ 10 ml/kg PBW. A plateau pressure < 30 cmH2O was measured in 92.2% of patients. Mortality rates increased from 13% to 74% as the generated predictive score increased from 5 to ≥8.5. Income classification, age, SOFA score, PaO2/FiO2 ratio, plateau pressure, number of vasopressors, and steroid use were associated with mortality.

CONCLUSIONS

In Asia, low tidal volume ventilation and sufficient PEEP were underused in patients with ARDS. The majority of patients without ARDS were on intermediate tidal volumes. Country income, age, and severity of illness were associated with mortality.

Intermediate tidal volume is an acceptable option for ventilated patients with acute respiratory distress syndrome

Objective

Evidence only proves low surpasses high tidal volume (V _T) for acute respiratory distress syndrome (ARDS). Intermediate V _T is a common setting for ARDS patients and has been demonstrated as effective as low V _T in non-ARDS patients. The effectiveness of intermediate V _T in ARDS has not been studied and is the objective of this study.

Design

A retrospective cohort study.

Setting

Five ICUs with their totally 130 beds in Taiwan.

Patients or participants

ARDS patients under invasive ventilation.

Interventions

No.

Main variables of interest

28-D mortality.

Result

Totally 382 patients, with 6958 ventilator settings eligible for lung protection, were classified into low (mean V _T = 6.7 ml/kg), intermediate (mean V _T = 8.9 ml/kg) and high (mean V _T = 11.2 ml/kg) V _T groups. With similar baseline ARDS and ICU severities, intermediate and low V _T groups did not differ in 28-D mortality (47% vs. 63%, P = 0.06) or other outcomes such as 90-D mortality, ventilator-free days, ventilator-dependence rate. Multivariate analysis revealed high V _T was independently associated with 28-D and 90-D mortality, but intermediate V _T was not significantly associated with 28-D mortality (HR 1.34, CI 0.92-1.97, P = 0.13) or 90-D mortality. When the intermediate and low V _T groups were matched in propensity scores (n = 66 for each group), their outcomes were also not significantly different.

Conclusion

Intermediate V _T, with its outcomes similar to small V _T, is an acceptable option for ventilated ARDS patients. This conclusion needs verification through clinical trials.

National incidence rate and related mortality for acute respiratory distress syndrome in France

INTRODUCTION

Despite many efforts to improve mechanical ventilation strategies and the use of rescue strategies, ARDS-related mortality remains high. The primary objective of this study was to determine the incidence and 90-day mortality of ARDS patients admitted to all French ICUs following the introduction of the Berlin definition of ARDS.

PATIENTS AND METHODS

The data source for this nationwide cohort study was the French national hospital database (Programme de Médicalisation des Systèmes d'Information (PMSI)), which systematically collects administrative and medical information related to all patients hospitalised and hospital stays. Patient-level data were obtained from the PMSI database for all patients admitted to an ICU from the 1^st of January 2017, through the 31^st of December 2017. The inclusion criteria were as follows: ICU patients ≥ 18 years old with at least one International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis code of J80 (ARDS), either as a primary diagnosis or a secondary diagnosis, during their ICU stay.

RESULTS

A total of 12,846 ICU adult patients with ARDS were included. The crude incidence of ARDS was 24.6 per 100,000 person-years, varying with age from 6.7 per 100,000 person-years for those 18 through 40 years of age to 51.9 per 100,000 person-years for those 68 through 76 years of age. The in-hospital mortality rate was 51.1%. Day-90 mortality (day-1 being the ICU admission) was 51.2% and increased with age from 29.0% for patients 18 through 40 years of age to 69.3% for patients 77 years of age or older (p < 0.001). Only 53.9% of the survivors were transferred home directly after hospital discharge.

CONCLUSIONS

The incidence and mortality of ARDS in adults in France are higher than that generally reported in other countries.

Acute respiratory distress syndrome (ARDS) as an adverse event following immunization: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data

This is a Brighton Collaboration Case Definition of the term “Acute Respiratory Distress Syndrome – ARDS” to be utilized in the evaluation of adverse events following immunization. The Case Definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of vaccines for SARS-CoV-2 vaccines and other emerging pathogens. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected Expert Reviewers prior to submission. The comments of the reviewers were taken into consideration and edits incorporated in this final manuscript.

Validation of age, PaO2/FlO2 and plateau pressure score in Korean patients with acute respiratory distress syndrome: a retrospective cohort study

Background

A predictive scoring system for acute respiratory distress syndrome (ARDS) patients, which incorporates age, PaO₂/FlO₂, and plateau pressure, APPS, was developed recently. It was validated externally in a Caucasian population but has not been studied in Asian populations. The aim of this study was to validate APPS in Korean ARDS patients.

Methods

We retrospectively reviewed the medical records of patients who were diagnosed with ARDS using the Berlin criteria and admitted to the medical ICU at Seoul National University Hospital from January 2015 to December 2016. The validation of the APPS was performed by evaluating its calibration and predictive accuracy. Its calibration was plotted and quantified using the Hosmer–Lemeshow test. Its predictive accuracy was assessed by calculating the area under the receiver operating characteristics (AUC–ROC) curve.

Results

A total of 116 patients were analyzed, 32 of whom survived. Of the 116 patients, 11 (9.5%) were classified as APPS grade 1 (score 3–4), 88 (75.9%) as grade 2 (score 5–7) and 17 (14.6%) as grade 3 (score 8–9). In-hospital mortality was 27.3% for grade 1, 73.9% for grade 2 and 94.1% for grade 3 (P for trend < 0.001). The APPS was well calibrated (Hosmer–Lemeshow test, P = 0.578) and its predictive accuracy was acceptable (AUC–ROC 0.704, 95% confidence interval 0.599–0.809).

Conclusions

The APPS predicted in-hospital mortality in Korean patients with ARDS with similar power to its application in a Western population and with acceptable predictive accuracy.

Trial registration

Retrospectively registered.

Risk factors for outcomes of acute respiratory distress syndrome patients: a retrospective study

Background

The determination of risk factors for acute respiratory distress syndrome (ARDS) patients remains a challenge. Our study aims to explore the epidemiology and risk factors affecting outcomes of ARDS patients and provide a theoretical basis for patients' prognosis.

Methods

This retrospective study included 207 ARDS patients admitted to the general intensive care unit (ICU) in the Second Affiliated Hospital of Harbin Medical University from Jan 1st, 2016 to Jan 1st, 2017. The criteria were defined according to the Berlin Definition, and clinical data were collected from the medical record system. The mortality rate and duration of mechanical ventilation were compared in ARDS patients. Furthermore, logistic regression analysis was applied to screen clinically accessible risk factors for survival and duration of mechanical ventilation.

Results

The total mortality in ARDS patients was 39.13% (81/207) compared to 13.57% (151/1,113) in the whole ICU population. The period prevalence of mild, moderate and severe ARDS was 39.61% (82/207), 37.20% (77/207) and 23.19% (48/207), respectively. Logistic regression analysis showed that acute physiology and chronic health evaluation II (APACHE II) score (OR 3.4316; 95% CI: 1.3130-8.9686; P=0.0119), number of organ failure (OR 3.4928; 95% CI: 1.9775-6.1693; P<0.0001), mean arterial pressure (MAP) (OR 5.1049; 95% CI: 1.8317-14.2274; P=0.0018), driving pressure (OR 6.0017; 95% CI: 2.1746-16.5641; P=0.0005) and lactate level (OR 4.0754; 95% CI: 1.6114-10.3068; P=0.0030) were influence factors for survival; severity of ARDS (OR 1.6715; 95% CI: 1.0307-2.7108; P=0.0373), ventilator-associated pneumonia (VAP) (OR 7.3746; 95% CI: 2.9799-18.2505; P<0.0001) and transfusion history (OR 2.2822; 95% CI: 1.0462-4.9783; P=0.0381) were influence factors for duration of mechanical ventilation.

Conclusions

Higher APACHE II score, more organ failures, lower MAP, higher driving pressure and higher lactate level are risk factors for survival. Higher severity of ARDS, VAP and transfusion history are risk factors for prolonged duration of mechanical ventilation. Application of these parameters would enable intensivists to treat their patients more precisely and comprehensively.