Effect of lowering vt on mortality in acute respiratory distress syndrome varies with respiratory system elastance

Ewan C. Goligher, Eduardo L.V. Costa, Christopher J. Yarnell, Laurent J. Brochard, Thomas E. Stewart, George Tomlinson, Roy G. Brower, Arthur S. Slutsky, Marcelo P.B. Amato

Research output: Contribution to journalArticlepeer-review

Abstract

Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by VT, then the effect of ventilation with lower VT on mortality would be predicted to vary according to respiratory system elastance (Ers). Objectives: To determine whether the mortality benefit of ventilation with lower VT varies according to Ers. Methods: In a secondary analysis of patients from five randomized trials of lower- versus higher-VT ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized VT strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression. Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-VT ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63–1.02). Ers was classified as low (,2 cm H2O/[ml/kg], n 5 321, 32%), intermediate (2–3 cm H2O/[ml/kg], n 5 475, 46%), and high (.3 cm H2O/[ml/kg], n 5 224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality > 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction > 5% were 29%, 58%, and 82%, respectively. Conclusions: The mortality benefit of ventilation with lower VT in ARDS varies according to elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than VT.

Original languageEnglish (US)
Pages (from-to)1378-1385
Number of pages8
JournalAmerican journal of respiratory and critical care medicine
Volume203
Issue number11
DOIs
StatePublished - Jun 1 2021

Keywords

  • Acute respiratory distress syndrome
  • Driving pressure
  • Lung-protective ventilation

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine

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