Dataset Information

Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death.

ABSTRACT:

Introduction

In patients with acute respiratory distress syndrome (ARDS), the PaO₂/FiO₂ ratio at the time of ARDS diagnosis is weakly associated with mortality. We hypothesized that setting a PaO₂/FiO₂ threshold in 150 mm Hg at 24 h from moderate/severe ARDS diagnosis would improve predictions of death in the intensive care unit (ICU).

Methods

We conducted an ancillary study in 1303 patients with moderate to severe ARDS managed with lung-protective ventilation enrolled consecutively in four prospective multicenter cohorts in a network of ICUs. The first three cohorts were pooled (n = 1000) as a testing cohort; the fourth cohort (n = 303) served as a confirmatory cohort. Based on the thresholds for PaO₂/FiO₂ (150 mm Hg) and positive end-expiratory pressure (PEEP) (10 cm H₂O), the patients were classified into four possible subsets at baseline and at 24 h using a standardized PEEP-FiO₂ approach: (I) PaO₂/FiO₂ ≥ 150 at PEEP < 10, (II) PaO₂/FiO₂ ≥ 150 at PEEP ≥ 10, (III) PaO₂/FiO₂ < 150 at PEEP < 10, and (IV) PaO₂/FiO₂ < 150 at PEEP ≥ 10. Primary outcome was death in the ICU.

Results

ICU mortalities were similar in the testing and confirmatory cohorts (375/1000, 37.5% vs. 112/303, 37.0%, respectively). At baseline, most patients from the testing cohort (n = 792/1000, 79.2%) had a PaO₂/FiO₂ < 150, with similar mortality among the four subsets (p = 0.23). When assessed at 24 h, ICU mortality increased with an advance in the subset: 17.9%, 22.8%, 40.0%, and 49.3% (p < 0.0001). The findings were replicated in the confirmatory cohort (p < 0.0001). However, independent of the PEEP levels, patients with PaO₂/FiO₂ < 150 at 24 h followed a distinct 30-day ICU survival compared with patients with PaO₂/FiO₂ ≥ 150 (hazard ratio 2.8, 95% CI 2.2-3.5, p < 0.0001).

Conclusions

Subsets based on PaO₂/FiO₂ thresholds of 150 mm Hg assessed after 24 h of moderate/severe ARDS diagnosis are clinically relevant for establishing prognosis, and are helpful for selecting adjunctive therapies for hypoxemia and for enrolling patients into therapeutic trials.

SUBMITTER: Villar J

PROVIDER: S-EPMC9570540 | biostudies-literature | 2022 Sep

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death.

Villar Jesús J Fernández Cristina C González-Martín Jesús M JM Ferrando Carlos C Añón José M JM Del Saz-Ortíz Ana M AM Díaz-Lamas Ana A Bueno-González Ana A Fernández Lorena L Domínguez-Berrot Ana M AM Peinado Eduardo E Andaluz-Ojeda David D González-Higueras Elena E Vidal Anxela A Fernández M Mar MM Mora-Ordoñez Juan M JM Murcia Isabel I Tarancón Concepción C Merayo Eleuterio E Pérez Alba A Romera Miguel A MA Alba Francisco F Pestaña David D Rodríguez-Suárez Pedro P Fernández Rosa L RL Steyerberg Ewout W EW Berra Lorenzo L Slutsky Arthur S AS The Spanish Initiative For Epidemiology Stratification And Therapies Of Ards Siesta Network

Journal of clinical medicine 20220927 19

Introduction: In patients with acute respiratory distress syndrome (ARDS), the PaO2/FiO2 ratio at the time of ARDS diagnosis is weakly associated with mortality. We hypothesized that setting a PaO2/FiO2 threshold in 150 mm Hg at 24 h from moderate/severe ARDS diagnosis would improve predictions of death in the intensive care unit (ICU). Methods: We conducted an ancillary study in 1303 patients with moderate to severe ARDS managed with lung-protective ventilation enrolled consecutively in four pr ...[more]

PMID: 36233592

Similar Datasets

Project description:BackgroundSeveral studies have investigated the correlation between physiological parameters and the risk of acute respiratory distress syndrome (ARDS), in addition, etiology-associated heterogeneity in ARDS has become an emerging topic quite recently; however, the intersection between the two, which is early prediction of target conditions in etiology-specific ARDS, has not been well-studied. We aimed to develop and validate a machine-learning model for the early prediction of moderate-to-severe condition of inhalation-induced ARDS.MethodsClinical expertise was applied with data-driven analysis. Using data from electronic intensive care units (retrospective derivation cohort) and the three most accessible vital signs (i.e. heart rate, temperature, and respiratory rate) together with feature engineering, we applied a random forest approach during the time window of 90 h that ended 6 h prior to the onset of moderate-to-severe respiratory failure (the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤ 200 mmHg).ResultsThe trained random forest classifier was validated using two independent validation cohorts, with an area under the curve of 0.9127 (95% confidence interval 0.8713-0.9542) and 0.9026 (95% confidence interval 0.8075-1), respectively. A Stable and Interpretable RUle Set (SIRUS) was used to extract rules from the RF to provide guidelines for clinicians. We identified several predictive factors, including resp_96h_6h_min < 9, resp_96h_6h_mean ≥ 16.1, HR_96h_6h_mean ≥ 102, and temp_96h_6h_max > 100, that could be used for predicting inhalation-induced ARDS (moderate-to-severe condition) 6 h prior to onset in critical care units. ('xxx_96h_6h_min/mean/max': the minimum/mean/maximum values of the xxx vital sign collected during a 90 h time window beginning 96 h prior to the onset of ARDS and ending 6 h prior to the onset from every recorded blood gas test).ConclusionsThis newly established random forest‑based interpretable model shows good predictive ability for moderate-to-severe inhalation-induced ARDS and may assist clinicians in decision-making, as well as facilitate the enrolment of patients in prevention programmes to improve their outcomes.

Project description:BackgroundPaediatric acute respiratory distress syndrome (PARDS) is a manifestation of severe, life-threatening lung injury necessitating mechanical ventilation with mortality rates ranging up to 40-50%. Neuromuscular blockade agents (NMBAs) may be considered to prevent patient self-inflicted lung injury in PARDS patients, but two trials in adults with severe ARDS yielded conflicting results. To date, randomised controlled trials (RCT) examining the effectiveness and efficacy of NMBAs for PARDS are lacking. We hypothesise that using NMBAs for 48 h in paediatric patients younger than 5 years of age with early moderate-to-severe PARDS will lead to at least a 20% reduction in cumulative respiratory morbidity score 12 months after discharge from the paediatric intensive care unit (PICU).MethodsThis is a phase IV, multicentre, randomised, double-blind, placebo-controlled trial performed in level-3 PICUs in the Netherlands. Eligible for inclusion are children younger than 5 years of age requiring invasive mechanical ventilation with positive end-expiratory pressure (PEEP) ≥ 5 cm H2O for moderate-to-severe PARDS occurring within the first 96 h of PICU admission. Patients are randomised to continuous infusion of rocuronium bromide or placebo for 48 h. The primary endpoint is the cumulative respiratory morbidity score 12 months after PICU discharge, adjusted for confounding by age, gestational age, family history of asthma and/or allergy, season in which questionnaire was filled out, day-care and parental smoking. Secondary outcomes include respiratory mechanics, oxygenation and ventilation metrics, pulmonary and systemic inflammation markers, prevalence of critical illness polyneuropathy and myopathy and metrics for patient outcome including ventilator free days at day 28, length of PICU and hospital stay, and mortality DISCUSSION: This is the first paediatric trial evaluating the effects of muscular paralysis in moderate-to-severe PARDS. The proposed study addresses a huge research gap identified by the Paediatric Acute Lung Injury Consensus Collaborative by evaluating practical needs regarding the treatment of PARDS. Paediatric critical care practitioners are inclined to use interventions such as NMBAs in the most critically ill. This liberal use must be weighed against potential side effects. The proposed study will provide much needed scientific support in the decision-making to start NMBAs in moderate-to-severe PARDS.Trial registrationClinicalTrials.gov NCT02902055 . Registered on September 15, 2016.

Project description:OBJECTIVES:Prior studies suggest hypothermia may be beneficial in acute respiratory distress syndrome, but cooling causes shivering and increases metabolism. The objective of this study was to assess the feasibility of performing a randomized clinical trial of hypothermia in patients with acute respiratory distress syndrome receiving treatment with neuromuscular blockade because they cannot shiver. DESIGN:Retrospective study and pilot, prospective, open-label, feasibility study. SETTING:Medical ICU. PATIENTS:Retrospective review of 58 patients with acute respiratory distress syndrome based on Berlin criteria and PaO2/FIO2 less than 150 who received neuromuscular blockade. Prospective hypothermia treatment in eight acute respiratory distress syndrome patients with PaO2/FIO2 less than 150 receiving neuromuscular blockade. INTERVENTION:Cooling to 34-36°C for 48 hours. MEASUREMENTS AND MAIN RESULTS:Core temperature, hemodynamics, serum glucose and electrolytes, and P/F were sequentially measured, and medians (interquartile ranges) presented, 28-day ventilator-free days, and hospital mortality were calculated in historical controls and eight cooled patients. Average patient core temperature was 36.7°C (36-37.3°C), and fever occurred during neuromuscular blockade in 30 of 58 retrospective patients. In the prospectively cooled patients, core temperature reached target range less than or equal to 4 hours of initiating cooling, remained less than 36°C for 92% of the 48 hours cooling period without adverse events, and was lower than the controls (34.35°C [34-34.8°C]; p < 0.0001). Compared with historical controls, the cooled patients tended to have lower hospital mortality (75% vs 53.4%; p = 0.26), more ventilator-free days (9 [0-21.5] vs 0 [0-12]; p = 0.16), and higher day 3 P/F (255 [160-270] vs 171 [120-214]; p = 0.024). CONCLUSIONS:Neuromuscular blockade alone does not cause hypothermia but allowed acute respiratory distress syndrome patients to be effectively cooled. Results support conducting a randomized clinical trial of hypothermia in acute respiratory distress syndrome and the feasibility of studying acute respiratory distress syndrome patients receiving neuromuscular blockade.

Project description:Rationale: There are limited therapeutic options for patients with coronavirus disease (COVID-19)-related acute respiratory distress syndrome with inflammation-mediated lung injury. Mesenchymal stromal cells offer promise as immunomodulatory agents. Objectives: Evaluation of efficacy and safety of allogeneic mesenchymal cells in mechanically-ventilated patients with moderate or severe COVID-19-induced respiratory failure. Methods: Patients were randomized to two infusions of 2 million cells/kg or sham infusions, in addition to the standard of care. We hypothesized that cell therapy would be superior to sham control for the primary endpoint of 30-day mortality. The key secondary endpoint was ventilator-free survival within 60 days, accounting for deaths and withdrawals in a ranked analysis. Measurements and Main Results: At the third interim analysis, the data and safety monitoring board recommended that the trial halt enrollment as the prespecified mortality reduction from 40% to 23% was unlikely to be achieved (n = 222 out of planned 300). Thirty-day mortality was 37.5% (42/112) in cell recipients versus 42.7% (47/110) in control patients (relative risk [RR], 0.88; 95% confidence interval, 0.64-1.21; P = 0.43). There were no significant differences in days alive off ventilation within 60 days (median rank, 117.3 [interquartile range, 60.0-169.5] in cell patients and 102.0 [interquartile range, 54.0-162.5] in control subjects; higher is better). Resolution or improvement of acute respiratory distress syndrome at 30 days was observed in 51/104 (49.0%) cell recipients and 46/106 (43.4%) control patients (odds ratio, 1.36; 95% confidence interval, 0.57-3.21). There were no infusion-related toxicities and overall serious adverse events over 30 days were similar. Conclusions: Mesenchymal cells, while safe, did not improve 30-day survival or 60-day ventilator-free days in patients with moderate and/or severe COVID-19-related acute respiratory distress syndrome.

Dataset Information

Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death.

Introduction

Methods

Results

Conclusions

Publications

Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets