by Gaetano Florio, Matteo Ferrari, Edward A. Bittner,
Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena
Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi,
Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai…
Background
Limited data exist regarding ventilation in patients with
class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory
distress syndrome (ARDS). The aim of the present study was to determine whether
an individualized titration of mechanical ventilation according to
cardiopulmonary physiology reduces the mortality in patients with class III
obesity and ARDS.
Methods
In this retrospective study, we enrolled adults admitted to
the ICU from 2012 to 2017 who had class III obesity and ARDS and received
mechanical ventilation for > 48 h. Enrolled patients were divided in two
cohorts: one cohort (2012–2014) had ventilator settings determined by the
ARDSnet table for lower positive end-expiratory pressure/higher inspiratory
fraction of oxygen (standard protocol-based cohort); the other cohort
(2015–2017) had ventilator settings determined by an individualized protocol
established by a lung rescue team (lung rescue team cohort). The lung rescue
team used lung recruitment maneuvers, esophageal manometry, and hemodynamic
monitoring.
Results
The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2),
and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2).
Patients in the standard protocol-based cohort compared to lung rescue team
cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012;
hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13–0.78] and 3 months
(41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16–0.74), and this effect
persisted at 6 months and 1 year (incidence of death unchanged 41%
versus 22%, P = 0.006; HR 0.35; CI95% 0.16–0.74).
Conclusion
Individualized titration of mechanical ventilation by a lung
rescue team was associated with decreased mortality compared to use of an
ARDSnet table.
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