Limiting Dynamic Driving Pressure in Patients Requiring Mechanical Ventilation.

Autor:	Urner M; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.; Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.; Department of Medicine, University of Toronto, Toronto, ON, Canada.; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.; Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.; Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands.; Toronto General Hospital Research Institute, Toronto, ON, Canada.; Department of Physiology, University of Toronto, Toronto, ON, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada., Jüni P; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.; Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.; Department of Medicine, University of Toronto, Toronto, ON, Canada.; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.; Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.; Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands.; Toronto General Hospital Research Institute, Toronto, ON, Canada.; Department of Physiology, University of Toronto, Toronto, ON, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada., Rojas-Saunero LP; Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands., Hansen B; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.; Toronto General Hospital Research Institute, Toronto, ON, Canada., Brochard LJ; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.; Department of Medicine, University of Toronto, Toronto, ON, Canada.; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada., Ferguson ND; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.; Department of Medicine, University of Toronto, Toronto, ON, Canada.; Toronto General Hospital Research Institute, Toronto, ON, Canada., Fan E; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.; Department of Medicine, University of Toronto, Toronto, ON, Canada.; Toronto General Hospital Research Institute, Toronto, ON, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada.
Jazyk:	angličtina
Zdroj:	Critical care medicine [Crit Care Med] 2023 Jul 01; Vol. 51 (7), pp. 861-871. Date of Electronic Publication: 2023 Mar 27.
DOI:	10.1097/CCM.0000000000005844
Abstrakt:	Objectives: Previous studies reported an association between higher driving pressure (∆P) and increased mortality for different groups of mechanically ventilated patients. However, it remained unclear if sustained intervention on ∆P, in addition to traditional lung-protective ventilation, improves outcomes. We investigated if ventilation strategies limiting daily static or dynamic ∆P reduce mortality compared with usual care in adult patients requiring greater than or equal to 24 hours of mechanical ventilation. Design: For this comparative effectiveness study, we emulated pragmatic clinical trials using data from the Toronto Intensive Care Observational Registry recorded between April 2014 and August 2021. The per-protocol effect of the interventions was estimated using the parametric g-formula, a method that controls for baseline and time-varying confounding, as well as for competing events in the analysis of longitudinal exposures. Setting: Nine ICUs from seven University of Toronto-affiliated hospitals. Patients: Adult patients (≥18 yr) requiring greater than or equal to 24 hours of mechanical ventilation. Interventions: Receipt of a ventilation strategy that limited either daily static or dynamic ∆P less than or equal to 15 cm H 2 O compared with usual care. Measurements and Main Results: Among the 12,865 eligible patients, 4,468 of (35%) were ventilated with dynamic ∆P greater than 15 cm H 2 O at baseline. Mortality under usual care was 20.1% (95% CI, 19.4-20.9%). Limiting daily dynamic ∆P less than or equal to 15 cm H 2 O in addition to traditional lung-protective ventilation reduced adherence-adjusted mortality to 18.1% (95% CI, 17.5-18.9%) (risk ratio, 0.90; 95% CI, 0.89-0.92). In further analyses, this effect was most pronounced for early and sustained interventions. Static ∆P at baseline were recorded in only 2,473 patients but similar effects were observed. Conversely, strict interventions on tidal volumes or peak inspiratory pressures, irrespective of ∆P, did not reduce mortality compared with usual care. Conclusions: Limiting either static or dynamic ∆P can further reduce the mortality of patients requiring mechanical ventilation. Competing Interests: Dr. Urner received funding from Vanier Canada Graduate Scholarship from the Canadian Institutes of Health Research (CIHR). Dr. Brochard’s institution received funding from Medtronic, Draeger, Stimit, and Vitalair; he disclosed the equipment was from Fisher & Paykel and Sentec. Drs. Ferguson and Fan received funding from Baxter. Dr. Ferguson received funding from Getinge and Xenios. Dr. Fan received funding from the New Investigator Award from the CIHR, Abbott, ALung Technologies, Fresenius Medical Care, MC3 Cardiopulmonary, Aerogen, GE Healthcare, Inspira, and Vasomune. The remaining authors have disclosed that they do not have any potential conflicts of interest. (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)
Databáze:	MEDLINE
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