Impact of extended lung protection during mechanical ventilation on lung recovery in patients with COVID-19 ARDS: a phase II randomized controlled trial.

Autor: Costa ELV; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.; Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil.; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil., Alcala GC; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil., Tucci MR; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil., Goligher E; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.; Toronto General Hospital Research Institute, Toronto, Canada., Morais CC; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.; Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, PE, Brazil., Dianti J; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.; Toronto General Hospital Research Institute, Toronto, Canada., Nakamura MAP; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil., Oliveira LB; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil., Pereira SM; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada., Toufen C Jr; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil., Barbas CSV; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil.; Adult ICU Albert Einstein Hospital, São Paulo, Brazil., Carvalho CRR; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil., Amato MBP; Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil. marcelo.amato@fm.usp.br.; Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil. marcelo.amato@fm.usp.br.
Jazyk: angličtina
Zdroj: Annals of intensive care [Ann Intensive Care] 2024 Jun 08; Vol. 14 (1), pp. 85. Date of Electronic Publication: 2024 Jun 08.
DOI: 10.1186/s13613-024-01297-z
Abstrakt: Background: Protective ventilation seems crucial during early Acute Respiratory Distress Syndrome (ARDS), but the optimal duration of lung protection remains undefined. High driving pressures (ΔP) and excessive patient ventilatory drive may hinder lung recovery, resulting in self-inflicted lung injury. The hidden nature of the ΔP generated by patient effort complicates the situation further. Our study aimed to assess the feasibility of an extended lung protection strategy that includes a stepwise protocol to control the patient ventilatory drive, assessing its impact on lung recovery.
Methods: We conducted a single-center randomized study on patients with moderate/severe COVID-19-ARDS with low respiratory system compliance (C RS  < 0.6 (mL/Kg)/cmH 2 O). The intervention group received a ventilation strategy guided by Electrical Impedance Tomography aimed at minimizing ΔP and patient ventilatory drive. The control group received the ARDSNet low-PEEP strategy. The primary outcome was the modified lung injury score ( m LIS), a composite measure that integrated daily measurements of C RS , along with oxygen requirements, oxygenation, and X-rays up to day 28. The m LIS score was also hierarchically adjusted for survival and extubation rates.
Results: The study ended prematurely after three consecutive months without patient enrollment, attributed to the pandemic subsiding. The intention-to-treat analysis included 76 patients, with 37 randomized to the intervention group. The average m LIS score up to 28 days was not different between groups (P = 0.95, primary outcome). However, the intervention group showed a faster improvement in the m LIS (1.4 vs. 7.2 days to reach 63% of maximum improvement; P < 0.001), driven by oxygenation and sustained improvement of X-ray (P = 0.001). The intervention group demonstrated a sustained increase in C RS up to day 28 (P = 0.009) and also experienced a shorter time from randomization to room-air breathing (P = 0.02). Survival at 28 days and time until liberation from the ventilator were not different between groups.
Conclusions: The implementation of an individualized PEEP strategy alongside extended lung protection appears viable. Promising secondary outcomes suggested a faster lung recovery, endorsing further examination of this strategy in a larger trial. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT04497454) on August 04, 2020.
(© 2024. The Author(s).)
Databáze: MEDLINE
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