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, 23 (1), 398

Risk Factors for the Development of Acute Respiratory Distress Syndrome in Mechanically Ventilated Adults in Peru: A Multicenter Observational Study

Collaborators, Affiliations

Risk Factors for the Development of Acute Respiratory Distress Syndrome in Mechanically Ventilated Adults in Peru: A Multicenter Observational Study

Ena Gupta et al. Crit Care.

Abstract

Background: Clinical and epidemiological differences between acute respiratory distress syndrome (ARDS) that presents at the initiation of mechanical ventilation [MV] (ARDS at MV onset) and that which develops during the course of MV (ARDS after MV onset) are not well understood. We conducted an observational study in five Peruvian ICUs to characterize differences between ARDS at MV onset and after MV onset and identify risk factors for the development of ARDS after MV onset.

Methods: We consecutively enrolled critically ill patients with acute respiratory failure requiring at least 24 h of mechanical ventilation and followed them prospectively during the first 28 days and compared baseline characteristics and clinical outcomes by ARDS status.

Results: We enrolled 1657 participants on MV (mean age 60.0 years, 55% males) of whom 334 (20.2%) had ARDS at MV onset and 180 (10.9%) developed ARDS after MV onset. Average tidal volume at the initiation of MV was 8.7 mL/kg of predicted body weight (PBW) for participants with ARDS at MV onset, 8.6 mL/kg PBW for those who developed ARDS after MV onset, and 8.5 mL/kg PBW for those who never developed ARDS (p = 0.23). Overall, 90-day mortality was 56% and 55% for ARDS after MV onset and ARDS at MV onset, respectively, as compared to 46% among those who never developed ARDS (p < 0.01). Adults with ARDS had a higher body mass index (BMI) than those without ARDS (27.3 vs 26.5 kg/m2, p < 0.01). Higher peak pressure (adjusted interquartile OR = 1.51, 95% CI 1.21-1.88), higher mean airway pressure (adjusted interquartile OR = 1.41, 95% CI 1.13-1.76), and higher positive end-expiratory pressure (adjusted interquartile OR = 1.29, 95% CI 1.10-1.50) at MV onset were associated with a higher odds of developing ARDS after MV onset.

Conclusions: In this study of mechanically ventilated patients, 31% of study participants had ARDS at some point during their ICU stay. Optimal lung-protective ventilation was not used in a majority of patients. Patients with ARDS after MV onset had a similar 90-day mortality as those with ARDS at MV onset. Higher airway pressures at MV onset, higher PEEP, and higher BMI were associated with the development of ARDS after MV onset.

Keywords: Acute respiratory distress syndrome; Critically ill; Mechanical ventilation; Prevention.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Probability of survival by time in the ICU stratified by ARDS status. Those with no ARDS, shown in blue, had better 90-day survival than those with ARDS at mechanical ventilation [MV] onset (green) or ARDS after mechanical ventilation [MV] onset (red). The participants with ARDS on presentation had a worse survival median survival as compared to those with in-ICU ARDS (40 days vs 60 days) but similar 90-day survival
Fig. 2
Fig. 2
Cumulative incidences of achieving unassisted breathing including being discharged alive and death in the 28-day period of follow-up among the three categories of participants: with no ARDS, ARDS at mechanical ventilation [MV] onset, and who developed ARDS after mechanical ventilation [MV] onset from left to right
Fig. 3
Fig. 3
Unadjusted odds ratios of developing ARDS after mechanical ventilation onset vs no ARDS. Interquartile odds ratios are used for continuous variables. Interquartile odds ratios represent an increase in odds of developing ARDS after mechanical ventilation [MV] onset when the variable in question increases from lower 25th quartile to 75th quartile. The diamonds represent the odds ratio and the black bins represent 95% CI intervals. The dotted line is the line of null effect and separates odds in favor of developing in-ICU ARDS on the right and odds against developing in-ICU ARDS to the left of the dotted line. Cstatic, static compliance; VT, tidal volume per kg of predicted body weight; Pdriv, driving pressure; Pplat, plateau pressure; Pmean, mean airway pressure; Ppeak, peak inspiratory airway pressure
Fig. 4
Fig. 4
Adjusted odds ratios of developing ARDS after mechanical ventilation onset as compared to no ARDS. All the variables shown were analyzed in separate multivariable models to avoid collinearity. All regression models were adjusted for age, sex, hospital, PEEP, and BMI. Interquartile odds ratios are used for continuous variables. Interquartile odds ratios represent an increase in odds of developing ARDS after mechanical ventilation [MV] onset when the variable in question increases from the lower 25th to the 75th percentile. The diamonds represent the odds ratio, and the black bins represent 95% CI intervals. The dotted line is the line of null effect and separates odds in favor of developing ARDS after mechanical ventilation [MV] onset to the right and odds against developing ARDS after mechanical ventilation [MV] onset to the left of the dotted line. Cstatic, static compliance; Pdriv, driving pressure; Pplat, plateau pressure; Pmean, mean pressure; Ppeak, peak pressure

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