Management of Acute Respiratory Distress Syndrome and Refractory Hypoxemia. A Multicenter Observational Study

doi:10.1513/AnnalsATS.201612-1042OC

Observational Study

. 2017 Dec;14(12):1818-1826.

doi: 10.1513/AnnalsATS.201612-1042OC.

Management of Acute Respiratory Distress Syndrome and Refractory Hypoxemia. A Multicenter Observational Study

Erick H Duan^{1

2

3}, Neill K J Adhikari^{4

5}, Frederick D'Aragon^{2

6

7}, Deborah J Cook^{1

2

3}, Sangeeta Mehta^{5

8}, Waleed Alhazzani^{1

2

3}, Ewan Goligher^{5

9}, Emmanuel Charbonney¹⁰, Yaseen M Arabi¹¹, Tim Karachi^{1

12}, Alexis F Turgeon^{13

14}, Lori Hand^{2

15}, Qi Zhou², Peggy Austin², Jan Friedrich^{5

16}, Francois Lamontagne^{6

7}, François Lauzier¹⁴, Rakesh Patel¹⁷, John Muscedere¹⁸, Richard Hall¹⁹, Pierre Aslanian²⁰, Thomas Piraino^{3

21}, Martin Albert²², Sean M Bagshaw²³, Mike Jacka²³, Gordon Wood²⁴, William Henderson²⁵, Delbert Dorscheid²⁶, Niall D Ferguson^{5

9}, Maureen O Meade^{1

2

15}; Canadian Critical Care Trials Group

Affiliations

¹ 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
² 2 Department of Health Research Methods, Evidence and Impact. McMaster University, Hamilton, Ontario, Canada.
³ 3 St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
⁴ 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
⁵ 5 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
⁶ 6 Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
⁷ 7 Department of Anesthesia, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
⁸ 8 Sinai Health Center, Toronto, Ontario, Canada.
⁹ 9 Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada.
¹⁰ 10 Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.
¹¹ 11 King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
¹² 12 Juravinski Hospital, Hamilton, Ontario, Canada.
¹³ 13 Centre de Recherche du Centre Hospitalier Universitaire de Québec, Université Laval, Quebec, Quebec, Canada.
¹⁴ 14 Department of Anesthesiology and Critical Care Medicine, Division of Critical Care, Université Laval, Quebec, Quebec, Canada.
¹⁵ 15 Hamilton General Hospital, Hamilton, Ontario, Canada.
¹⁶ 16 Critical Care and Medicine Departments, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
¹⁷ 17 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
¹⁸ 18 Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada.
¹⁹ 19 Departments of Critical Care Medicine and Anesthesiology, Dalhousie University, Halifax, Nova Scotia, Canada.
²⁰ 20 Division of Critical Care, Department of Medicine and Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.
²¹ 21 Departments of Anesthesia, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
²² 22 Departments of Medicine and Critical Care, Centre de recherche Hôpital de Sacré-Cœur de Montréal, Université de Montréal, Montreal, Quebec, Canada.
²³ 23 Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
²⁴ 24 Island Health Authority, Victoria, British Columbia, Canada.
²⁵ 25 Critical Care Medicine, Vancouver General Hospital University of British Columbia, Vancouver, British Columbia, Canada; and.
²⁶ 26 Center for Heart Lung Innovation, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

PMID: 28910146
DOI: 10.1513/AnnalsATS.201612-1042OC

Observational Study

Management of Acute Respiratory Distress Syndrome and Refractory Hypoxemia. A Multicenter Observational Study

Erick H Duan et al. Ann Am Thorac Soc. 2017 Dec.

. 2017 Dec;14(12):1818-1826.

doi: 10.1513/AnnalsATS.201612-1042OC.

Authors

Affiliations

¹ 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
² 2 Department of Health Research Methods, Evidence and Impact. McMaster University, Hamilton, Ontario, Canada.
³ 3 St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
⁴ 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
⁵ 5 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
⁶ 6 Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
⁷ 7 Department of Anesthesia, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
⁸ 8 Sinai Health Center, Toronto, Ontario, Canada.
⁹ 9 Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada.
¹⁰ 10 Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.
¹¹ 11 King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
¹² 12 Juravinski Hospital, Hamilton, Ontario, Canada.
¹³ 13 Centre de Recherche du Centre Hospitalier Universitaire de Québec, Université Laval, Quebec, Quebec, Canada.
¹⁴ 14 Department of Anesthesiology and Critical Care Medicine, Division of Critical Care, Université Laval, Quebec, Quebec, Canada.
¹⁵ 15 Hamilton General Hospital, Hamilton, Ontario, Canada.
¹⁶ 16 Critical Care and Medicine Departments, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
¹⁷ 17 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
¹⁸ 18 Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada.
¹⁹ 19 Departments of Critical Care Medicine and Anesthesiology, Dalhousie University, Halifax, Nova Scotia, Canada.
²⁰ 20 Division of Critical Care, Department of Medicine and Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.
²¹ 21 Departments of Anesthesia, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.
²² 22 Departments of Medicine and Critical Care, Centre de recherche Hôpital de Sacré-Cœur de Montréal, Université de Montréal, Montreal, Quebec, Canada.
²³ 23 Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
²⁴ 24 Island Health Authority, Victoria, British Columbia, Canada.
²⁵ 25 Critical Care Medicine, Vancouver General Hospital University of British Columbia, Vancouver, British Columbia, Canada; and.
²⁶ 26 Center for Heart Lung Innovation, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

PMID: 28910146
DOI: 10.1513/AnnalsATS.201612-1042OC

Abstract

Rationale: Clinicians' current practice patterns in the management of acute respiratory distress syndrome (ARDS) and refractory hypoxemia are not well described.

Objectives: To describe mechanical ventilation strategies and treatment adjuncts for adults with ARDS, including refractory hypoxemia.

Methods: This was a prospective cohort study (March 2014-February 2015) of mechanically ventilated adults with moderate-to-severe ARDS requiring an Fi_O₂ of 0.50 or greater in 24 intensive care units.

Results: We enrolled 664 patients: 222 (33%) with moderate and 442 (67%) with severe ARDS. On Study Day 1, mean Vt was 7.5 (SD = 2.1) ml/kg predicted body weight (n = 625); 80% (n = 501) received Vt greater than 6 ml/kg. Mean positive end-expiratory pressure (PEEP) was 10.5 (3.7) cm H₂O (n = 653); 568 patients (87%) received PEEP less than 15 cm H₂O. Treatment adjuncts were common (n = 440, 66%): neuromuscular blockers (n = 276, 42%), pulmonary vasodilators (n = 118, 18%), prone positioning (n = 67, 10%), extracorporeal life support (n = 29, 4%), and high-frequency oscillatory ventilation (n = 29, 4%). Refractory hypoxemia, defined as Pa_O₂ less than 60 mm Hg on Fi_O₂ of 1.0, occurred in 138 (21%) patients. At onset of refractory hypoxemia, mean Vt was 7.1 (SD = 2.0) ml/kg (n = 124); 95 patients (77%) received Vt greater than 6 ml/kg. Mean PEEP was 12.1 (SD = 4.4) cm H₂O (n = 133); 99 patients (74%) received PEEP less than 15 cm H₂O. Among patients with refractory hypoxemia, 91% received treatment adjuncts (126/138), with increased use of neuromuscular blockers (n = 87, 63%), pulmonary vasodilators (n = 57, 41%), and prone positioning (n = 32, 23%).

Conclusions: Patients with moderate-to-severe ARDS receive treatment adjuncts frequently, especially with refractory hypoxemia. Paradoxically, therapies with less evidence supporting their use (e.g., pulmonary vasodilators) were over-used, whereas those with more evidence (e.g., prone positioning, neuromuscular blockade) were under-used. Patients received higher Vts and lower PEEP than would be suggested by the evidence.

Keywords: acute respiratory distress syndrome; lung protective ventilation; neuromuscular blocking agents; prone positioning; refractory hypoxemia.

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Comment in

Refractory Hypoxemia and Acute Respiratory Distress Syndrome Adjunctive Therapies: An Open Question?
Claar DD, Hyzy RC. Claar DD, et al. Ann Am Thorac Soc. 2017 Dec;14(12):1768-1769. doi: 10.1513/AnnalsATS.201707-547ED. Ann Am Thorac Soc. 2017. PMID: 29192824 No abstract available.

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Management of Acute Respiratory Distress Syndrome and Refractory Hypoxemia. A Multicenter Observational Study

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Management of Acute Respiratory Distress Syndrome and Refractory Hypoxemia. A Multicenter Observational Study

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