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ARDS TRIALS UPDATE 2015 Jeffrey L. Garland, MD, FCCP Departments of Medicine, Critical Care Medicine, and Pulmonary Medicine Mayo Clinic Florida Jacksonville, Florida
NIPPV HFOV ECMO Macrolides Nitric Oxide and Epoprostenol Beta Agonists Surfactant Statins Anti-oxidants Red Cell Transfusions Nutrition GI Prophylaxis
LOW TIDAL VOLUME VENTILATION (LTVV) • ARDS Network Trial. NEJM 2000; 342:1301. • Patients with ARDS randomized to LTVV (6 cc/kgm IBW) vs Conventional ventilation (12 cc/kgm IBW). • Study stopped after 861 patients enrolled due to lower mortality to hospital discharge (31% vs 39.8%, p = 0.007). • LTVV with more ventilator free days by day 28 (12 vs 10).
Mean (+SE) Mortality Rate among 257 Patients with Acute Lung Injury and the Acute Respiratory Distress Syndrome Who Were Assigned to Receive Traditional Tidal Volumes and 260 Such Patients Who Were Assigned to Receive Lower Tidal Volumes, According to the Quartile of Static Compliance of the Respiratory System before Randomization.
TheAcuteRespiratoryDistressSyndromeNetwork.N EnglJ Med 2000;342:1301-1308.
LOW TIDAL VOLUME VENTILATION • Metanalysis of six randomized trials. Ann Intern Med 2009; 151:566. • 1297 patients. LTVV vs conventional • Improved 28 day mortality (27% vs 37%) and hospital mortality (35% vs 43%). • Metanalysis of four randomized trials. Cochrane 2013. • 1149 patients. LTVV vs conventional. • Reduced hospital mortality (34% vs 41%).
LOW TIDAL VOLUME VENTILATION SUMMARY OF TRIALS • LTVV is overall very well tolerated. Main complication of permissive hypercarbia is generally well tolerated. • Overall evidence supporting LTVV is very strong and LTVV has become the standard of care.
HIGH PEEP STRATEGY • The second part of the Open Ventilation model. • Mechanisms of Action: • Opens collapsed alveoli, which decreases alveolar overdistention of open alveoli. • Reduces atelectrauma. • Both should reduce lung injury.
HIGH PEEP STRATEGY • Multiple ways to do High PEEP: • Set PEEP at 2 cm above the lower inflection point of the PV curve. • Do recruitment maneuver and then slowly decrease PEEP until static lung compliance decreases 2% and go 2 cm H2O above this. • Use PEEP/FiO2 high PEEP arm from the ARDS Network trial . • Apply highest PEEP to keep plateau pressure under 30 cm H2O.
HIGH PEEP STRATEGY • JAMA 2010; 305:865. Metanalysis of 2299 patients. • High PEEP improved oxygenation and increased vent free days. • Lower ICU mortality (29% vs 33%), but no lower hospital mortality overall. • In subgroup with P/F = 150, on FiO2