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Abstract
BACKGROUND: The unifying goal of lung-protective ventilation strategies in ARDS is to minimize the strain and stress applied by mechanical ventilation to the lung to reduce ventilator-induced lung injury (VILI). The relative contributions of the magnitude and frequency of mechanical stress and the end-expiratory pressure to the development of VILI is unknown. Consequently, it is uncertain whether the risk of VILI is best quantified in terms of tidal volume (VT), driving pressure (ΔP), or mechanical power.
METHODS: The correlation between differences in VT, ΔP, and mechanical power and the magnitude of mortality benefit in trials of lung-protective ventilation strategies in adult subjects with ARDS was assessed by meta-regression. Modified mechanical power was computed including PEEP (Powerelastic), excluding PEEP (Powerdynamic), and using ΔP (Powerdriving). The primary analysis incorporated all included trials. A secondary subgroup analysis was restricted to trials of lower versus higher PEEP strategies.
RESULTS: We included 9 trials involving 4,731 subjects in the analysis. Odds ratios for moderation derived from meta-regression showed that variations in VT, ΔP, and Powerdynamic were associated with increased mortality with odds ratios of 1.24 (95% CI 1.03–1.49), 1.31 (95% CI 1.03–1.66), and 1.37 (95% CI 1.05–1.78), respectively. In trials comparing higher versus lower PEEP strategies, Powerelastic was increased in the higher PEEP arm (24 ± 1.7 vs 20 ± 1.5 J/min, respectively), whereas the other parameters were not affected on average by a higher PEEP ventilation strategy.
CONCLUSIONS: In trials of lung-protective ventilation strategies, VT, ΔP, Powerelastic, Powerdynamic, and Powerdriving exhibited similar moderation of treatment effect on mortality. In this study, modified mechanical power did not add important information on the risk of death from VILI in comparison to VT or ΔP.
Footnotes
- Correspondence: Ewan C Goligher MD PhD, Toronto General Hospital, 585 University Ave, 11-PMB Room 192, Toronto ON M5G 2N2, Canada. E-mail: ewan.goligher{at}uhn.ca
Dr Goligher has disclosed relationships with Getinge and Timpel. Dr Fan has disclosed relationships with ALung Technologies and MC3 Cardiopulmonary. Dr Brochard has disclosed relationships with Medtronic|Covidien, Air Liquide, Philips, Sentec, General Electric, and Fisher & Paykel. The other authors have disclosed no conflicts of interest.
- Copyright © 2021 by Daedalus Enterprises
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