Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

Jong, Audrey De; Cossic, Jeanne; Verzilli, Daniel; Monet, Clément; Carr, Julie; Conseil, Mathieu; Monnin, Marion; Cissé, Moussa; Belafia, Fouad; Molinari, Nicolas; Chanques, Gérald; Jaber, Samir

doi:10.1007/s00134-018-5241-6

Cited by 80 publications

(74 citation statements)

References 36 publications

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“…However, this association was not replicated in obese patients with ARDS. 108 The authors concluded that in obese patients, a higher part of the pressure generated by the ventilator is used to distend the chest wall rather than the lung, so that the plateau pressure (i.e., the pressure used to distend the respiratory system) is high, but pleural pressure may be too. Another interesting result of the study is that airway driving pressure in both surviving and nonsurviving obese patients with ARDS was well within the limits that previous studies identified as "safe," as if obesity was a condition generating lower airway driving pressures.…”

Section: Mechanical Ventilationmentioning

confidence: 99%

Pathophysiology and Management of Acute Respiratory Distress Syndrome in Obese Patients

Umbrello

Fumagalli

Pesenti

et al. 2019

Semin Respir Crit Care Med

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A rising prevalence of obesity is reported over time and throughout the world. At the same time, the acute respiratory distress syndrome (ARDS) remains an important public health problem, accounting for approximately 10% of intensive care unit admissions and leading to significant hospital mortality. Even in the absence of acute illnesses, obesity affects respiratory mechanics and gas exchange in the setting of a restrictive disease. In the presence of ARDS, obesity adds various challenges to a safe and effective management of respiratory support. Difficult airway management, altered lung and chest wall physiology, and positional gas trapping are routinely encountered. The management of such difficult cases is generally empiric, as it is based on small-sized, physiologic studies or on suggestions from the general anesthesia literature. The present review focuses on those cases in which ARDS is coincident with obesity, with the aim of presenting treatment options based on the current evidence. The first part summarizes the epidemiology of obesity and ARDS. Then the diagnostic challenges due to obesity-related artifacts of the different imaging techniques will be presented. A subsequent, detailed description of the altered respiratory anatomy and physiology of obesity will provide help in selecting an optimal, individually tailored strategy of support. Furthermore, we will discuss how esophageal manometry should be used to adjust the settings of positive end-expiratory pressure and tidal volume; the challenges of prone positioning and extracorporeal support; and the optimal strategies for weaning from mechanical ventilation, including when and how to perform a tracheostomy.

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Section: Mechanical Ventilationmentioning

confidence: 99%

Pathophysiology and Management of Acute Respiratory Distress Syndrome in Obese Patients

Umbrello

Fumagalli

Pesenti

et al. 2019

Semin Respir Crit Care Med

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“…Surprisingly, this important finding seems not to be of value for obese ARDS patients. The retrospective analysis presented by de Jong et al [10] on the impact of ∆P on 90-day mortality in 100 obese (BMI ≥ 30) and 262 non-obese ARDS patients revealed a significant relationship between ∆P and mortality only in non-obese patients. The ∆P on day 1 was significantly lower in non-obese ARDS patients (11.9 ± 4.2 cmH 2 O) who had survived 90 days compared to non-obese non-survivors (15.2 ± 5.2 cmH 2 O, p < 0.001).…”

mentioning

confidence: 98%

“…Amato et al [8] described a ∆P of 15 cmH 2 O as a threshold discriminating between a good outcome of ARDS patients (relative risk of death ≤ 1 with ∆P ≤ 15 cmH 2 O) and a higher risk of mortality with ∆P > 15 cmH 2 O. The study by de Jong et al [10] presented 'safe' ∆P levels (≤ 15 cmH 2 O) for the majority of obese ARDS patients. Is obesity per se a lung protective precondition generating low(er) ∆P values?…”

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confidence: 99%

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Driving pressure in obese ventilated patients: another brick in the (chest) wall

Bein

2018

Intensive Care Med

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The incidence of obesity is increasing worldwide, and obese or severely obese patients often present with several comorbidities. Obesity is associated with significant complications, and an increase in the mortality of obese patients after hospital admission compared to non-obese patients is justified [1]. The proportion of obesity in patients presenting with acute respiratory distress syndrome (ARDS) has not been investigated systematically, but data from the influenza A (H1N1) pandemic in 2009 suggested that obese patients were overrepresented compared to the general population [2]. The management of ARDS in patients with obesity is a special challenge, since obesity and severe obesity are associated with marked derangements in lung and chest wall mechanics [3].In clinical studies on obese mechanically ventilated patients without lung injury [4] or with ARDS [5], specific changes in respiratory system mechanics were observed (Table 1). These findings may help develop a better understanding of a suitable ventilation strategy in obesity. In all studies, static respiratory compliance (C st,rs ) was reduced with a rising level of obesity [expressed by body mass index (BMI)], while elastance (the reciprocal of compliance) tended to increase. These changes in C st,rs were due to compliance reduction in both parts of the respiratory system: the lung and the chest wall. In other words, during mechanical ventilation in obese patients, the lungs and predominantly the chest wall become 'stiffer' . This finding-observed in obese lung-healthy patients as well in ARDS patients-deserves attention and interpretation. Physiologically, the chest wall (rib cage and abdomen) is elastic, and the interaction between the lungs and the chest wall is finely balanced under spontaneous breathing [7]. The chest wall tends to expand outward, while the lungs tend to collapse. The 'mediator' between both is the pleural pressure. The reduction of chest wall compliance (C st,w ) in obesity is mainly due to the increase of intraabdominal pressure in these patients [3], which results in a lower lung volume for the same pleural pressure.In a large retrospective analysis of the data of 3562 ARDS patients from nine studies, Amato et al. [8] demonstrated that elevated driving pressure (∆P), a parameter expressing the relation between tidal volume and functional lung size (compliance of the respiratory system) = V T /C st,rs , was an independent ventilation variable strongly associated with increased mortality, while changes in tidal volume or positive end-expiratory pressure were not independent predictors of the outcome. An actual systematic review [9] reconfirmed the retrospective data of Amato et al. [8] by analysing the data of four prospective randomized studies (3252 patients): a higher ∆P was associated with a significantly higher mortality in ARDS patients.

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“…The need for mechanical ventilation leads to a significantly higher mortality [3]. The outcome of these patients was poor in the past [4].…”

Section: Introductionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation in Predominantly Leuco- and Thrombocytopenic Haematologic/Oncologic Patients with Acute Respiratory Distress Syndrome - a Single-Centre Experience

et al. 2018

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Aims: The acute respiratory distress syndrome (ARDS) is a frequent condition following pneumonia in immunocompromised cancer patients. Extracorporeal membrane oxygenation (ECMO) may serve as a rescue therapy in refractory ARDS but has still not been studied in predominantly leuco- and thrombocytopenic cancer patients. Patients and Methods: In this monocentric, retrospective, observational study, we assessed all cancer patients treated with ECMO for ARDS between 2013 and 2017. Results: 25 patients, 11 of whom underwent haematopoietic stem cell transplantation (SCT), were analysed. The main reason for ARDS was pneumonia in 72%. All patients were under invasive ventilation at ECMO. All but 9/3 patients suffered from leuco-/thrombocytopenia due to anti-cancer treatment or underlying disease. Overall, 17 patients (68%) died on ECMO, whereas 5 patients survived to hospital discharge (20%). All patients after recent allogeneic (allo-)SCT have died. 4 patients experienced severe bleeding events. Conclusions: Discouraging survival rates in patients treated after allo-SCT do not support the use of ECMO for ARDS in this patient subgroup. On the contrary, cancer patients in at least stable disease otherwise eligible for full-code intensive care unit management, even those with severe thrombocytopenia, may be potential candidates for ECMO in case of severe ARDS failing conventional measures.

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Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

Abstract: Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

Cited by 80 publications

References 36 publications

Pathophysiology and Management of Acute Respiratory Distress Syndrome in Obese Patients

Pathophysiology and Management of Acute Respiratory Distress Syndrome in Obese Patients

Driving pressure in obese ventilated patients: another brick in the (chest) wall

Extracorporeal Membrane Oxygenation in Predominantly Leuco- and Thrombocytopenic Haematologic/Oncologic Patients with Acute Respiratory Distress Syndrome - a Single-Centre Experience

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