Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States

Abstract

BACKGROUND: Although specific interventions previously demonstrated benefit in patients with the ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.RESEARCH QUESTION: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO 2 to FIO 2 ratio of # 150 with positive endexpiratory pressure of $ 5 cm H 2 O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed.RESULTS: A total of 2,466 patients were enrolled. Median baseline PaO 2 to FIO 2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, # 6.5 mL/kg predicted body weight; plateau pressure, peak inspiratory pressure, or both, # 30 mm H 2 O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.

Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome

“…Practice variation has recently been described in non-COVID ARDS, showing variance in tidal volume and ventilation pressures ( 7 ). We have now shown practice variation is still clearly demonstrable in a relatively homogenous underlying disease mechanism that shows evolvement over the duration of the pandemic.…”

Phenotypes and subphenotypes of delirium: a review of current categorisations and suggestions for progression

“…For example, reduced sleep quality is common in the ICU [ 48 ], and associated with delirium [ 49 ]. A quality improvement process designed to feasibly promote sleep in critical care has been associated with reductions in night-time noise levels, delirium, and coma [ 50 – 52 ]. This process may be conducted stepwise, beginning with disturbance reduction, moving to non-pharmacological methods, and then adding pharmacological aid for those patients whom did not show sleep improvement after the first two stages [ 50 ].…”

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

“…Early prone positioning has been shown to reduce mortality in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) in a randomized controlled trial (1) and meta-analyses (2, 3), and is recommended in patients with ARDS by multiple guidelines (4, 5). However, prior to the COVID-19 pandemic, large multinational studies showed that proning was only used in 6–14% of patients with ARDS overall and in 16–33% of those with severe ARDS (6–9). Reasons for low adoption have included under-recognition of ARDS by clinicians (10, 11), a view of proning as rescue therapy (7, 12), clinician preference for other adjunctive interventions (12), and a presumption that proning is labor intensive (12, 13).…”