Contemporary ventilator management in patients with and at risk of ALI/ARDS.
BACKGROUND
Ventilator practices in patients at risk for acute lung injury (ALI) and ARDS are unclear. We examined factors associated with choice of set tidal volumes (VT), and whether VT < 8 mL/kg predicted body weight (PBW) relates to the development of ALI/ARDS.


METHODS
We performed a secondary analysis of a multicenter cohort of adult subjects at risk of lung injury with and without ALI/ARDS at onset of invasive ventilation. Descriptive statistics were used to describe ventilator practices in specific settings and ALI/ARDS risk groups. Logistic regression analysis was used to determine the factors associated with the use of VT < 8 mL/kg PBW and the relationship of VT to ALI/ARDS development and outcome.


RESULTS
Of 829 mechanically ventilated patients, 107 met the criteria for ALI/ARDS at time of intubation, and 161 developed ALI/ARDS after intubation (post-intubation ALI/ARDS). There was significant intercenter variability in initial ventilator settings, and in the incidence of ALI/ARDS and post-intubation ALI/ARDS. The median VT was 7.96 (IQR 7.14-8.94) mL/kg PBW in ALI/ARDS subjects, and 8.45 (IQR 7.50-9.55) mL/kg PBW in subjects without ALI/ARDS (P = .004). VT decreased from 8.40 (IQR 7.38-9.37) mL/kg PBW to 7.97 (IQR 6.90-9.23) mL/kg PBW (P < .001) in those developing post-intubation ALI/ARDS. Among subjects without ALI/ARDS, VT ≥ 8 mL/kg PBW was associated with shorter height and higher body mass index, while subjects with pneumonia were less likely to get ≥ 8 mL/kg PBW. Initial VT ≥ 8 mL/kg PBW was not associated with the post-intubation ALI/ARDS (adjusted odds ratio 1.30, 95% CI 0.74-2.29) or worse outcomes. Post-intubation ALI/ARDS subjects had mortality similar to subjects intubated with ALI/ARDS.


CONCLUSIONS
Clinicians seem to respond to ALI/ARDS with lower initial VT. Initial VT, however, was not associated with the development of post-intubation ALI/ARDS or other outcomes.
Division of Pulmonary and Critical Care Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey 07103, USA. changsy@umdnj.edu
Steven Y
SY
Chang
Ousama
O
Dabbagh
Ognen
O
Gajic
Amee
A
Patrawalla
Marie-Carmelle
MC
Elie
Daniel S
DS
Talmor
Atul
A
Malhotra
Adebola
A
Adesanya
Harry L
HL
Anderson
James M
JM
Blum
Pauline K
PK
Park
Michelle Ng
MN
Gong
D055371:Acute Lung Injury / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D000328:Adult; D000368:Aged; D015992:Body Mass Index; D001835:Body Weight; D015331:Cohort Studies; D005260:Female; D006304:Health Status; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012307:Risk Factors; D013990:Tidal Volume