Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study.

Autor:	Qadir N; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA., Bartz RR; Division of Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC., Cooter ML; Division of Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC., Hough CL; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR., Lanspa MJ; Division of Pulmonary Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT; Intermountain Medical Center, Murray, UT., Banner-Goodspeed VM; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA., Chen JT; Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY., Giovanni S; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA., Gomaa D; Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH., Sjoding MW; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI., Hajizadeh N; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY., Komisarow J; Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA; Department of Neurosurgery, Duke University Medical Center, Durham, NC., Duggal A; Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH., Khanna AK; Section of Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, OH., Kashyap R; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN., Khan A; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR., Chang SY; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA., Tonna JE; Divisions of Cardiothoracic Surgery and Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT., Anderson HL 3rd; Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, MI., Liebler JM; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA., Mosier JM; Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ., Morris PE; Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY., Genthon A; Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ., Louh IK; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; New York-Presbyterian Hospital., Tidswell M; Division of Pulmonary and Critical Care Medicine Baystate Medical Center and University of Massachusetts Medical School, Springfield, MA., Stephens RS; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD., Esper AM; Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA., Dries DJ; Department of Surgery, Regions Medical Center, St. Paul, MN., Martinez A; Division of Critical Care, St. Agnes Hospital, Baltimore, MD., Schreyer KE; Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA., Bender W; Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA., Tiwari A; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Albany Medical College, Albany, NY., Guru PK; Division of Critical Care Medicine, Department of Medicine, Mayo Clinic, Jacksonville, FL., Hanna S; Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI., Gong MN; Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY., Park PK; Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI. Electronic address: parkpk@med.umich.edu.
Jazyk:	angličtina
Zdroj:	Chest [Chest] 2021 Oct; Vol. 160 (4), pp. 1304-1315. Date of Electronic Publication: 2021 Jun 04.
DOI:	10.1016/j.chest.2021.05.047
Abstrakt:	Background: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao 2 to Fio 2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H 2 O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Results: A total of 2,466 patients were enrolled. Median baseline Pao 2 to Fio 2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H 2 O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Interpretation: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Trial Registry: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov. (Copyright © 2021. Published by Elsevier Inc.)
Databáze:	MEDLINE
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