title: A Quantile Analysis of Plateau and Driving Pressures: Effects on Mortality in Patients With Acute Respiratory Distress Syndrome Receiving Lung-Protective Ventilation.
abstract: OBJECTIVE
  The driving pressure (plateau pressure minus positive end-expiratory pressure) has been suggested as the major determinant for the beneficial effects of lung-protective ventilation. We tested whether driving pressure was superior to the variables that define it in predicting outcome in patients with acute respiratory distress syndrome.
  
  
  METHODS
  A secondary analysis of existing data from previously reported observational studies.
  
  
  METHODS
  A network of ICUs.
  
  
  METHODS
  We studied 778 patients with moderate to severe acute respiratory distress syndrome.
  
  
  METHODS
  None.
  
  
  RESULTS
  We assessed the risk of hospital death based on quantiles of tidal volume, positive end-expiratory pressure, plateau pressure, and driving pressure evaluated at 24 hours after acute respiratory distress syndrome diagnosis while ventilated with standardized lung-protective ventilation. We derived our model using individual data from 478 acute respiratory distress syndrome patients and assessed its replicability in a separate cohort of 300 acute respiratory distress syndrome patients. Tidal volume and positive end-expiratory pressure had no impact on mortality. We identified a plateau pressure cut-off value of 29 cm H2O, above which an ordinal increment was accompanied by an increment of risk of death. We identified a driving pressure cut-off value of 19 cm H2O where an ordinal increment was accompanied by an increment of risk of death. When we cross tabulated patients with plateau pressure less than 30 and plateau pressure greater than or equal to 30 with those with driving pressure less than 19 and driving pressure greater than or equal to 19, plateau pressure provided a slightly better prediction of outcome than driving pressure in both the derivation and validation cohorts (p < 0.0000001).
  
  
  CONCLUSIONS
  Plateau pressure was slightly better than driving pressure in predicting hospital death in patients managed with lung-protective ventilation evaluated on standardized ventilator settings 24 hours after acute respiratory distress syndrome onset.
authors.affiliation: 1CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. 2Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain. 3Intensive Care Unit, Hospital General de Ciudad Real, Ciudad Real, Spain. 4Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain. 5Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain. 6Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain. 7Intensive Care Unit, Hospital Universitario Morales Meseguer, Murcia, Spain. 8Intensive Care Unit, Hospital Universitario A Coruña, Coruña, Spain. 9Intensive Care Unit, Hospital Virgen de La Luz, Cuenca, Spain. 10Intensive Care Unit, Hospital Clínico Universitario, Valladolid, Spain. 11Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain. 12Intensive Care Unit, Hospital Universitario Virgen de Arrixaca, Murcia, Spain. 13Intensive Care Unit, Hospital Universitario N.S. de Candelaria, Santa Cruz de Tenerife, Spain. 14Department of Surgical Sciences, Anesthesiology & Critical Care, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden. 15Intensive Care Unit, Hospital Virgen de la Concha, Zamora, Spain. 16Intensive Care Unit, Hospital Universitario Carlos Haya, Málaga, Spain. 17Critical Care Center, Corporació Sanitaria Parc Taulí, Sabadell, Spain. 18Research Unit, Hospital Universitario NS de Candelaria, Santa Cruz de Tenerife, Spain. 19Department of Respiratory Care, Massachusetts General Hospital, Boston, MA. 20Department of Anesthesia, Harvard University, Boston, MA.
authors.forename: Jesús
authors.initials: J
authors.lastname: Villar
authors.forename: Carmen
authors.initials: C
authors.lastname: Martín-Rodríguez
authors.forename: Ana M
authors.initials: AM
authors.lastname: Domínguez-Berrot
authors.forename: Lorena
authors.initials: L
authors.lastname: Fernández
authors.forename: Carlos
authors.initials: C
authors.lastname: Ferrando
authors.forename: Juan A
authors.initials: JA
authors.lastname: Soler
authors.forename: Ana M
authors.initials: AM
authors.lastname: Díaz-Lamas
authors.forename: Elena
authors.initials: E
authors.lastname: González-Higueras
authors.forename: Leonor
authors.initials: L
authors.lastname: Nogales
authors.forename: Alfonso
authors.initials: A
authors.lastname: Ambrós
authors.forename: Demetrio
authors.initials: D
authors.lastname: Carriedo
authors.forename: Mónica
authors.initials: M
authors.lastname: Hernández
authors.forename: Domingo
authors.initials: D
authors.lastname: Martínez
authors.forename: Jesús
authors.initials: J
authors.lastname: Blanco
authors.forename: Javier
authors.initials: J
authors.lastname: Belda
authors.forename: Dácil
authors.initials: D
authors.lastname: Parrilla
authors.forename: Fernando
authors.initials: F
authors.lastname: Suárez-Sipmann
authors.forename: Concepción
authors.initials: C
authors.lastname: Tarancón
authors.forename: Juan M
authors.initials: JM
authors.lastname: Mora-Ordoñez
authors.forename: Lluís
authors.initials: L
authors.lastname: Blanch
authors.forename: Lina
authors.initials: L
authors.lastname: Pérez-Méndez
authors.forename: Rosa L
authors.initials: RL
authors.lastname: Fernández
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kacmarek
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D064887:Observational Studies as Topic; D012121:Respiration, Artificial / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000401:mortality* / Q000628:therapy*; D012720:Severity of Illness Index; D014797:Vital Capacity