Differential Effect of Positive End-Expiratory Pressure Strategies in Patients With ARDS: A Bayesian Analysis of Clinical Subphenotypes.
| Autor: | Siuba MT; Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH. Electronic address: siubam@ccf.org., Bulgarelli L; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH., Duggal A; Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH., Cavalcanti AB; Hcor Research Institute, São Paulo, Brazil., Zampieri FG; Hcor Research Institute, São Paulo, Brazil., Rey DA; Research Department, Endpoint Health, Inc., Palo Alto, CA., Lucena WDR; Research Department, Endpoint Health, Inc., Palo Alto, CA., Maia IS; Hcor Research Institute, São Paulo, Brazil., Paisani DM; Hcor Research Institute, São Paulo, Brazil., Laranjeira LN; Hcor Research Institute, São Paulo, Brazil., Neto AS; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia., Deliberato RO; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Biostatistics, Health Informatics and Data Science (BHIDS), University of Cincinnati College of Medicine, Cincinnati, OH. |
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| Jazyk: | angličtina |
| Zdroj: | Chest [Chest] 2024 Oct; Vol. 166 (4), pp. 754-764. Date of Electronic Publication: 2024 May 18. |
| DOI: | 10.1016/j.chest.2024.04.011 |
| Abstrakt: | Background: ARDS is a heterogeneous condition with two subphenotypes identified by different methodologies. Our group similarly identified two ARDS subphenotypes using nine routinely available clinical variables. However, whether these are associated with differential response to treatment has yet to be explored. Research Question: Are there differential responses to positive end-expiratory pressure (PEEP) strategies on 28-day mortality according to subphenotypes in adult patients with ARDS? Study Design and Methods: We evaluated data from two prior ARDS trials (Higher vs Lower Positive End-Expiratory Pressures in Patients With the ARDS [ALVEOLI] and the Alveolar Recruitment in ARDS Trial [ART]) that compared different PEEP strategies. We classified patients into one of two subphenotypes as described previously. We assessed the differential effect of PEEP with a Bayesian hierarchical logistic model for the primary outcome of 28-day mortality. Results: We analyzed data from 1,559 patients with ARDS. Compared with lower PEEP, a higher PEEP strategy resulted in higher 28-day mortality in patients with subphenotype A disease in the ALVEOLI study (OR, 1.61; 95% credible interval [CrI], 0.90-2.94) and ART (OR, 1.73; 95% CrI, 1.01-2.98), with a probability of harm resulting from higher PEEP in this subphenotype of 94.3% and 97.7% in the ALVEOLI and ART studies, respectively. Higher PEEP was not associated with mortality in patients with subphenotype B disease in each trial (OR, 0.95 [95% CrI, 0.51-1.73] and 1.00 [95% CrI, 0.63-1.55], respectively), with probability of benefit of 56.4% and 50.7% in the ALVEOLI and ART studies, respectively. These effects were not modified by Pao Interpretation: We found evidence of differential response to PEEP strategies across two ARDS subphenotypes, suggesting possible harm with a higher PEEP strategy in one subphenotype. These observations may assist with predictive enrichment in future clinical trials. Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: W. d. R. L. and D. A. R. are employees of Endpoint Health, Inc. A. S. N. reports receiving personal fees from Dräger unrelated to the submitted work. A. D. is on the steering committee for Alung Technologies. R. O. D. is a scientific advisor for Endpoint Health, Inc., and is a shareholder. None declared (M. T. S., L. B., A. B. C., F. G. Z., I. S. M., D. M. P., L. N. L.). (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.) |
| Databáze: | MEDLINE |
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