A lung rescue team improves survival in obesity with acute respiratory distress syndrome

Gaetano Florio, Matteo Ferrari, Edward A Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai, Kathryn Hibbert, Jean Kwo, Richard M Pino, Jeanine Wiener-Kronish, Marcelo B P Amato, Pankaj Arora, Robert M Kacmarek, Lorenzo Berra, investigators of the lung rescue team, Gaetano Florio, Matteo Ferrari, Edward A Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai, Kathryn Hibbert, Jean Kwo, Richard M Pino, Jeanine Wiener-Kronish, Marcelo B P Amato, Pankaj Arora, Robert M Kacmarek, Lorenzo Berra, David Imber, Daniel Fisher, Daniel Chipman, Carolyn LaVita, Gaetano Florio, Matteo Ferrari, Edward A Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai, Kathryn Hibbert, Jean Kwo, Richard M Pino, Jeanine Wiener-Kronish, Marcelo B P Amato, Pankaj Arora, Robert M Kacmarek, Lorenzo Berra, investigators of the lung rescue team, Gaetano Florio, Matteo Ferrari, Edward A Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai, Kathryn Hibbert, Jean Kwo, Richard M Pino, Jeanine Wiener-Kronish, Marcelo B P Amato, Pankaj Arora, Robert M Kacmarek, Lorenzo Berra, David Imber, Daniel Fisher, Daniel Chipman, Carolyn LaVita

Abstract

Background: Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS.

Methods: In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012-2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015-2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring.

Results: The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13-0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74).

Conclusion: Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.

Keywords: ARDS; Cardiopulmonary physiology; Mechanical ventilation; Mortality; Obesity.

Conflict of interest statement

Dr. MBP Amato reports that his research laboratory has received grants from the Covidien/Medtronics (research on mechanical ventilation), Orange Med and Timpel S.A. (Electrical Impedance Tomography) outside the submitted work. Dr. R. Kacmarek is a consultant for Medtronic and Orange Med and has received research grants from Medtronic and Venner Medical. Dr. L. Berra is supported by National Institutes of Health/National Heart, Lung and Blood Institute (Bethesda, Maryland) grant n 1 K23 HL128882- AQ21 01A1 for the project titled “Hemolysis and Nitric Oxide”. The other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Standard protocol-based approach versus lung rescue team approach. According to the standard protocol-based approach, ARDS patients were essentially treated setting the mechanical ventilator in accordance with the indications provided by ARDSnet tables (panel 1). Conversely, an individualized lung rescue team approach (panel 2) involved a thorough (multidisciplinary) assessment of respiratory mechanics, including esophageal pressure monitoring (2, A), as well as the patient’s response to lung recruitment. The best-PEEP was titrated based on a decremental PEEP trial, while hemodynamics was assessed by means of transthoracic echocardiography (2, B). PEEP, positive end-expiratory pressure; FiO2, inspiratory fraction of oxygen; PL, transpulmonary pressure
Fig. 2
Fig. 2
Kaplan-Meier survival of ARDS patients. Survival of patients in the standard protocol-based and lung rescue team cohorts. aHazard ratio and P value calculated after correction for common ICU confounders (APACHE, age, BMI, PaO2/FiO2 ratio)

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