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Berg AC, Evans E, Okoro UE, Pham V, Foley TM, Hlas C, Kuhn JD, Nassar B, Fuller BM, Mohr NM. Respiratory Therapist-Driven Mechanical Ventilation Protocol Is Associated With Increased Lung Protective Ventilation. Respir Care 2024; 69:1071-1080. [PMID: 39013570 PMCID: PMC11349598 DOI: 10.4187/respcare.11599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
BACKGROUND Mechanical ventilation is a common life-saving procedure but can lead to serious complications, including ARDS and oxygen toxicity. Nonadherence to lung-protective ventilation guidelines is common. We hypothesized that a respiratory therapist-driven mechanical ventilation bundle could increase adherence to lung-protective ventilation and decrease the incidence of pulmonary complications in the ICU. METHODS A respiratory therapist-driven protocol was implemented on August 1, 2018, in all adult ICUs of a Midwestern academic tertiary center. The protocol targeted low tidal volume, adequate PEEP, limiting oxygen, adequate breathing frequency, and head of the bed elevation. Adherence to lung-protective guidelines and clinical outcomes were retrospectively observed in adult subjects admitted to the ICU and on ventilation for ≥ 24 h between January 2011 and December 2019. RESULTS We included 666 subjects; 68.5% were in the pre-intervention group and 31.5% were in the post-intervention group. After adjusting for body mass index and intubation indication, a significant increase in overall adherence to lung-protective ventilation guidelines was observed in the post-intervention period (adjusted odds ratio 2.48, 95% CI 1.73-3.56). Fewer subjects were diagnosed with ARDS in the post-intervention group (adjusted odds ratio 0.22, 95% CI 0.08-0.65) than in the pre-intervention group. There was no difference in the incidence of ventilator-associated pneumonia, ventilator-free days, ICU mortality, or death within 1 month of ICU discharge. CONCLUSIONS A respiratory therapist-driven protocol increased adherence to lung-protective mechanical ventilation guidelines in the ICU and was associated with decreased ARDS incidence.
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Affiliation(s)
- Alaina C Berg
- University of Iowa Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Erin Evans
- Department of Emergency Medicine, UnityPoint Health Trinity, Rock Island, Illinois
| | | | - Vivian Pham
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Tyler M Foley
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Chloe Hlas
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Justin D Kuhn
- Department of Respiratory Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Boulos Nassar
- Department of Internal Medicine-Pulmonary and Critical Care Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Brian M Fuller
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Nicholas M Mohr
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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Gibbs KW, Forbes JL, Harrison KJ, Krall JT, Isenhart AA, Taylor SP, Martin RS, O'Connell NS, Bakhru RN, Palakshappa JA, Files DC. A Pragmatic Pilot Trial Comparing Patient-Triggered Adaptive Pressure Control to Patient-Triggered Volume Control Ventilation in Critically Ill Adults. Respir Care 2023; 68:1331-1339. [PMID: 36944477 PMCID: PMC10506635 DOI: 10.4187/respcare.10803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Patient-triggered adaptive pressure control (APC) continuous mandatory ventilation (CMV) (APC-CMV) has been widely adopted as an alternative ventilator mode to patient-triggered volume control (VC) CMV (VC-CMV). However, the comparative effectiveness of the 2 ventilator modes remains uncertain. We sought to explore clinical and implementation factors pertinent to a future definitive randomized controlled trial assessing APC-CMV versus VC-CMV as an initial ventilator mode strategy. The research objectives in our pilot trial tested clinician adherence and explored clinical outcomes. METHODS In a single-center pragmatic sequential cluster crossover pilot trial, we enrolled all eligible adults with acute respiratory failure requiring mechanical ventilation admitted during a 9-week period to the medical ICU. Two-week time epochs were assigned a priori in which subjects received either APC-CMV or VC-CMV The primary outcome of the trial was feasibility, defined as 80% of subjects receiving the assigned mode within 1 h of initiation of ICU ventilation. The secondary outcome was proportion of the first 24 h on the assigned mode. Finally, we surveyed clinician stakeholders to understand potential facilitators and barriers to conducting a definitive randomized trial. RESULTS We enrolled 137 subjects who received 152 discreet episodes of mechanical ventilation during time epochs assigned to APC-CMV (n = 61) and VC-CMV (n = 91). One hundred and thirty-one episodes were included in the prespecified primary outcome. One hundred and twenty-six (96%) received the assigned mode within the first hour of ICU admission (60 of 61 subjects assigned APC-CMV and 66 of 70 assigned VC-CMV). VC-CMV subjects spent a lower proportion of first 24 h (84% [95% CI 78-89]) on the assigned mode than APC-CMV recipients (95% [95% CI 91-100]). Mixed-methods analyses identified preconceived perceptions of subject comfort by clinicians and need for real-time education to address this concern. CONCLUSIONS In this pilot pragmatic, sequential crossover trial, unit-wide allocation to a ventilator mode was feasible and acceptable to clinicians.
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Affiliation(s)
- Kevin W Gibbs
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Jonathan L Forbes
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kelsey J Harrison
- Department of Respiratory Care, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jennifer Tw Krall
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Aubrae A Isenhart
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephanie P Taylor
- Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Internal Medicine, Wake Forest School of Medicine, Charlotte, North Carolina
| | - R Shayn Martin
- Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, North Carolina
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Rita N Bakhru
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jessica A Palakshappa
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
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3
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Kassis EB, Hu S, Lu M, Johnson A, Bose S, Schaefer MS, Talmor D, Lehman LWH, Shahn Z. Titration of Ventilator Settings to Target Driving Pressure and Mechanical Power. Respir Care 2022; 68:respcare.10258. [PMID: 35868844 PMCID: PMC9994280 DOI: 10.4187/respcare.10258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Driving pressure (ΔP) and mechanical power (MP) may be important mediators of lung injury in acute respiratory distress syndrome (ARDS) however there is little evidence for strategies directed at lowering these parameters. We applied predictive modeling to estimate the effects of modifying ventilator parameters on ΔP and MP. METHODS 2,622 ARDS patients (Berlin criteria) from the Medical Information Mart for Intensive Care IV database (MIMIC-IV version1.0) admitted to the intensive care unit (ICU) at Beth Israel Deaconess Medical Center between 2008 and 2019 were included. Flexible confounding-adjusted regression models for time varying data were fit to estimate the effects of adjusting PEEP and tidal volume (VT) on ΔP, and adjusting VT and respiratory rate (f) on MP. RESULTS Reduction in VT reduced ΔP and MP, with more pronounced effect on MP with lower compliance. Strategies reducing f, consistently increased MP (when VT was adjusted to maintain consistent minute ventilation). Adjustment of PEEP yielded a U-shaped effect on ΔP. CONCLUSIONS This novel conditional modeling confirmed expected response patterns for ΔP, with the response to adjustments depending on patients' lung mechanics. Furthermore a VT -driven approach should be favored over a f -driven approach when aiming to reduce MP.
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Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, 02115
| | - Stephanie Hu
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge MA, 02142
| | - MingYu Lu
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge MA, 02142
| | - Alistair Johnson
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge MA, 02142
| | - Somnath Bose
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, 02115
| | - Maximilian S Schaefer
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, 02115
| | - Daniel Talmor
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, 02115
| | - Li-Wei H Lehman
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge MA, 02142
- MIT-IBM Watson AI Lab, Cambridge, Massachusetts
| | - Zach Shahn
- Department of Epidemiology and Biostatistics, CUNY School of Public Health
- IBM Research, Yorktown Heights NY, 10598
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What's to Be Found in the Wisdom of the Crowd? Ann Am Thorac Soc 2021; 18:1957-1959. [PMID: 34851245 PMCID: PMC8641824 DOI: 10.1513/annalsats.202105-574ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Hendrickson KW, Peltan ID, Brown SM. The Epidemiology of Acute Respiratory Distress Syndrome Before and After Coronavirus Disease 2019. Crit Care Clin 2021; 37:703-716. [PMID: 34548129 PMCID: PMC8449138 DOI: 10.1016/j.ccc.2021.05.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kathryn W Hendrickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT 84112, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center
| | - Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT 84112, USA; Pulmonary Division, Department of Medicine, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT 84112, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center.
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Impact of Clinician Recognition of Acute Respiratory Distress Syndrome on Evidenced-Based Interventions in the Medical ICU. Crit Care Explor 2021; 3:e0457. [PMID: 34250497 PMCID: PMC8263322 DOI: 10.1097/cce.0000000000000457] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acute respiratory distress syndrome is underrecognized in the ICU, but it remains uncertain if acute respiratory distress syndrome recognition affects evidence-based acute respiratory distress syndrome care in the modern era. We sought to determine the rate of clinician-recognized acute respiratory distress syndrome in an academic medical ICU and understand how clinician-recognized-acute respiratory distress syndrome affects clinical care and patient-centered outcomes. DESIGN Observational cohort study. SETTING Single medical ICU at an academic tertiary-care hospital. PATIENTS Nine hundred seventy-seven critically ill adults (381 with expert-adjudicated acute respiratory distress syndrome) enrolled from 2006 to 2015. INTERVENTIONS Clinician-recognized-acute respiratory distress syndrome was identified using an electronic keyword search of clinical notes in the electronic health record. We assessed the classification performance of clinician-recognized acute respiratory distress syndrome for identifying expert-adjudicated acute respiratory distress syndrome. We also compared differences in ventilator settings, diuretic prescriptions, and cumulative fluid balance between clinician-recognized acute respiratory distress syndrome and unrecognized acute respiratory distress syndrome. MEASUREMENTS AND MAIN RESULTS Overall, clinician-recognized-acute respiratory distress syndrome had a sensitivity of 47.5%, specificity 91.1%, positive predictive value 77.4%, and negative predictive value 73.1% for expert-adjudicated acute respiratory distress syndrome. Among the 381 expert-adjudicated acute respiratory distress syndrome cases, we did not observe any differences in ventilator tidal volumes between clinician-recognized-acute respiratory distress syndrome and unrecognized acute respiratory distress syndrome, but clinician-recognized-acute respiratory distress syndrome patients had a more negative cumulative fluid balance (mean difference, -781 mL; 95% CI, [-1,846 to +283]) and were more likely to receive diuretics (49.3% vs 35.7%, p = 0.02). There were no differences in mortality, ICU length of stay, or ventilator-free days. CONCLUSIONS Acute respiratory distress syndrome recognition was low in this single-center study. Although acute respiratory distress syndrome recognition was not associated with lower ventilator volumes, it was associated with differences in behaviors related to fluid management. These findings have implications for the design of future studies promoting evidence-based acute respiratory distress syndrome interventions in the ICU.
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Use of Machine Learning to Screen for Acute Respiratory Distress Syndrome Using Raw Ventilator Waveform Data. Crit Care Explor 2021; 3:e0313. [PMID: 33458681 PMCID: PMC7803688 DOI: 10.1097/cce.0000000000000313] [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] [Indexed: 11/26/2022] Open
Abstract
To develop and characterize a machine learning algorithm to discriminate acute respiratory distress syndrome from other causes of respiratory failure using only ventilator waveform data. Design Retrospective, observational cohort study. Setting Academic medical center ICU. Patients Adults admitted to the ICU requiring invasive mechanical ventilation, including 50 patients with acute respiratory distress syndrome and 50 patients with primary indications for mechanical ventilation other than hypoxemic respiratory failure. Interventions None. Measurements and Main Results Pressure and flow time series data from mechanical ventilation during the first 24-hours after meeting acute respiratory distress syndrome criteria (or first 24-hr of mechanical ventilation for non-acute respiratory distress syndrome patients) were processed to extract nine physiologic features. A random forest machine learning algorithm was trained to discriminate between the patients with and without acute respiratory distress syndrome. Model performance was assessed using the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value. Analyses examined performance when the model was trained using data from the first 24 hours and tested using withheld data from either the first 24 hours (24/24 model) or 6 hours (24/6 model). Area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value were 0.88, 0.90, 0.71, 0.77, and 0.90 (24/24); and 0.89, 0.90, 0.75, 0.83, and 0.83 (24/6). Conclusions Use of machine learning and physiologic information derived from raw ventilator waveform data may enable acute respiratory distress syndrome screening at early time points after intubation. This approach, combined with traditional diagnostic criteria, could improve timely acute respiratory distress syndrome recognition and enable automated clinical decision support, especially in settings with limited availability of conventional diagnostic tests and electronic health records.
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Performance Measure Development, Use, and Measurement of Effectiveness Using the Guideline on Mechanical Ventilation in Acute Respiratory Distress Syndrome. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2020; 16:1463-1472. [PMID: 31774323 PMCID: PMC6956829 DOI: 10.1513/annalsats.201909-665st] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Guideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012. This report summarizes the proceedings of a follow-up workshop convened to advance the ATS’s work in performance measure development and guideline implementation. To illustrate the application of the ATS’s performance measure development framework, we used the example of a low–tidal volume ventilation performance measure created de novo from the 2017 ATS/European Society of Intensive Care Medicine/Society of Critical Care Medicine mechanical ventilation in acute respiratory distress syndrome clinical practice guideline. We include a detailed explanation of the rationale for the specifications chosen, identification of areas in need of further validity testing, and a preliminary strategy for pilot testing of the performance measure. Pending additional resources and broader performance measure expertise, issuing “preliminary performance measures” and their specifications alongside an ATS clinical practice guideline offers a first step to further the ATS’s guideline implementation agenda. We recommend selectively proceeding with full performance measure development for those measures with positive early user feedback and the greatest potential impact in accordance with ATS leadership guidance.
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Epidemiology, Mechanical Power, and 3-Year Outcomes in Acute Respiratory Distress Syndrome Patients Using Standardized Screening. An Observational Cohort Study. Ann Am Thorac Soc 2020; 16:1263-1272. [PMID: 31247145 PMCID: PMC6812172 DOI: 10.1513/annalsats.201812-910oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Limited data on the epidemiology of acute respiratory distress syndrome (ARDS) using a standardized screening program exist. Objectives: To describe the population-based incidence of hypoxemic respiratory failure and ARDS using a prospective standardized screening protocol; and to describe the mechanical ventilation practice and the mechanical power and examine their association with 28-day and 3-year survival outcomes. Methods: A prospective standardized screening program for ARDS, as a quality improvement initiative, was initiated at four adult intensive care units over a 27-month period. An ancillary analysis of this observational cohort was performed. Patients requiring mechanical ventilation for ≥24 hours underwent prospective and consecutive screening using standardized ventilator settings. Patient physiological data and outcomes were collected prospectively through an electronic clinical-information system and retrospectively analyzed to apply Berlin criteria. Results: Screened were 7,944 patients, among which 986 (12.4%) had hypoxemic respiratory failure (arterial oxygen tension to inspired fraction of oxygen ratio ≤300), and 731 (9.2%) met criteria for ARDS. Age-adjusted incidence of hypoxemic respiratory failure and ARDS were 37.7 and 27.6 cases per 100,000 person-years, respectively. Patients sustaining the diagnosis of ARDS had a hospital mortality of 26.5% for mild, 31.8% for moderate, and 60.0% for severe ARDS and a 3-year mortality of 43.5% for mild, 46.9% for moderate, and 71.1% for severe ARDS. Mechanical power >22 J/min was associated with increased 28-day hospital and 3-year mortality. Determinants of mechanical power associated with lower 28-day hospital and 3-year survival included plateau pressure >30 cm H2O and driving pressure >15 cm H2O, but not tidal volumes >8 ml/kg of predicted body weight. Conclusions: Using standardized screening, a large proportion of patients with hypoxemic respiratory failure met criteria for ARDS. Increasing ARDS severity was associated with increased 28-day hospital and 3-year mortality. Increased mechanical power was associated with increased mortality. Potentially modifiable determinants of mechanical power associated with lower survival included plateau pressure and driving pressure.
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Semler MW, Bernard GR, Aaron SD, Angus DC, Biros MH, Brower RG, Calfee CS, Colantuoni EA, Ferguson ND, Gong MN, Hopkins RO, Hough CL, Iwashyna TJ, Levy BD, Martin TR, Matthay MA, Mizgerd JP, Moss M, Needham DM, Self WH, Seymour CW, Stapleton RD, Thompson BT, Wunderink RG, Aggarwal NR, Reineck LA. Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care. NHLBI Working Group Report. Am J Respir Crit Care Med 2020; 202:511-523. [PMID: 32150460 PMCID: PMC7427373 DOI: 10.1164/rccm.201908-1595ws] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 03/06/2020] [Indexed: 12/14/2022] Open
Abstract
Preventing, treating, and promoting recovery from critical illness due to pulmonary disease are foundational goals of the critical care community and the NHLBI. Decades of clinical research in acute respiratory distress syndrome, acute respiratory failure, pneumonia, and sepsis have yielded improvements in supportive care, which have translated into improved patient outcomes. Novel therapeutics have largely failed to translate from promising preclinical findings into improved patient outcomes in late-phase clinical trials. Recent advances in personalized medicine, "big data," causal inference using observational data, novel clinical trial designs, preclinical disease modeling, and understanding of recovery from acute illness promise to transform the methods of pulmonary and critical care clinical research. To assess the current state of, research priorities for, and future directions in adult pulmonary and critical care research, the NHLBI assembled a multidisciplinary working group of investigators. This working group identified recommendations for future research, including 1) focusing on understanding the clinical, physiological, and biological underpinnings of heterogeneity in syndromes, diseases, and treatment response with the goal of developing targeted, personalized interventions; 2) optimizing preclinical models by incorporating comorbidities, cointerventions, and organ support; 3) developing and applying novel clinical trial designs; and 4) advancing mechanistic understanding of injury and recovery to develop and test interventions targeted at achieving long-term improvements in the lives of patients and families. Specific areas of research are highlighted as especially promising for making advances in pneumonia, acute hypoxemic respiratory failure, and acute respiratory distress syndrome.
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Affiliation(s)
| | | | - Shawn D. Aaron
- Division of Respirology, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Michelle H. Biros
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Roy G. Brower
- Division of Pulmonary and Critical Care Medicine and
| | - Carolyn S. Calfee
- Department of Medicine and
- Department of Anesthesia, University of California, San Francisco, San Francisco, California
| | | | - Niall D. Ferguson
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine
- Department of Physiology, and
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Gong
- Department of Epidemiology
- Department of Population Health, and
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Ramona O. Hopkins
- Department of Psychology, Brigham Young University, Provo, Utah
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
| | - Catherine L. Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Bruce D. Levy
- Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas R. Martin
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Michael A. Matthay
- Department of Medicine and
- Department of Anesthesia, University of California, San Francisco, San Francisco, California
| | - Joseph P. Mizgerd
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Marc Moss
- Division of Pulmonary Sciences & Critical Care, University of Colorado, Denver, Colorado
| | | | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher W. Seymour
- Department of Critical Care Medicine and
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Renee D. Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont, Burlington, Vermont
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Harvard University, Boston, Massachusetts
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
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Abstract
Ventilation-induced lung injury results from mechanical stress and strain that occur during tidal ventilation in the susceptible lung. Classical descriptions of ventilation-induced lung injury have focused on harm from positive pressure ventilation. However, injurious forces also can be generated by patient effort and patient–ventilator interactions. While the role of global mechanics has long been recognized, regional mechanical heterogeneity within the lungs also appears to be an important factor propagating clinically significant lung injury. The resulting clinical phenotype includes worsening lung injury and a systemic inflammatory response that drives extrapulmonary organ failures. Bedside recognition of ventilation-induced lung injury requires a high degree of clinical acuity given its indistinct presentation and lack of definitive diagnostics. Yet the clinical importance of ventilation-induced lung injury is clear. Preventing such biophysical injury remains the most effective management strategy to decrease morbidity and mortality in patients with acute respiratory distress syndrome and likely benefits others at risk.
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Affiliation(s)
- Purnema Madahar
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Department of Medicine, New York-Presbyterian Hospital, New York City, NY, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA.,Department of Medicine, New York-Presbyterian Hospital, New York City, NY, USA
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12
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Lanspa MJ, Peltan ID, Jacobs JR, Sorensen JS, Carpenter L, Ferraro JP, Brown SM, Berry JG, Srivastava R, Grissom CK. Driving pressure is not associated with mortality in mechanically ventilated patients without ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:424. [PMID: 31881909 PMCID: PMC6935179 DOI: 10.1186/s13054-019-2698-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/09/2019] [Indexed: 11/17/2022]
Abstract
Background In patients with acute respiratory distress syndrome (ARDS), low tidal volume ventilation has been associated with reduced mortality. Driving pressure (tidal volume normalized to respiratory system compliance) may be an even stronger predictor of ARDS survival than tidal volume. We sought to study whether these associations hold true in acute respiratory failure patients without ARDS. Methods This is a retrospectively cohort analysis of mechanically ventilated adult patients admitted to ICUs from 12 hospitals over 2 years. We used natural language processing of chest radiograph reports and data from the electronic medical record to identify patients who had ARDS. We used multivariable logistic regression and generalized linear models to estimate associations between tidal volume, driving pressure, and respiratory system compliance with adjusted 30-day mortality using covariates of Acute Physiology Score (APS), Charlson Comorbidity Index (CCI), age, and PaO2/FiO2 ratio. Results We studied 2641 patients; 48% had ARDS (n = 1273). Patients with ARDS had higher mean APS (25 vs. 23, p < .001) but similar CCI (4 vs. 3, p = 0.6) scores. For non-ARDS patients, tidal volume was associated with increased adjusted mortality (OR 1.18 per 1 mL/kg PBW increase in tidal volume, CI 1.04 to 1.35, p = 0.010). We observed no association between driving pressure or respiratory compliance and mortality in patients without ARDS. In ARDS patients, both ΔP (OR1.1, CI 1.06–1.14, p < 0.001) and tidal volume (OR 1.17, CI 1.04–1.31, p = 0.007) were associated with mortality. Conclusions In a large retrospective analysis of critically ill non-ARDS patients receiving mechanical ventilation, we found that tidal volume was associated with 30-day mortality, while driving pressure was not.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA. .,Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT, USA.
| | - Ithan D Peltan
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.,Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Jason R Jacobs
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA
| | - Jeffrey S Sorensen
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA
| | - Lori Carpenter
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA
| | - Jeffrey P Ferraro
- Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.,Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Jay G Berry
- Division of General Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Raj Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Inpatient Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Shock Trauma ICU, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.,Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT, USA
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