Outcome of acute respiratory distress syndrome in university and non-university hospitals in Germany

Konstantinos Raymondos, Tamme Dirks, Michael Quintel, Ulrich Molitoris, Jörg Ahrens, Thorben Dieck, Kai Johanning, Dietrich Henzler, Rolf Rossaint, Christian Putensen, Hermann Wrigge, Ralph Wittich, Maximilian Ragaller, Thomas Bein, Martin Beiderlinden, Maxi Sanmann, Christian Rabe, Jörn Schlechtweg, Monika Holler, Fernando Frutos-Vivar, Andres Esteban, Hartmut Hecker, Simone Rosseau, Vera von Dossow, Claudia Spies, Tobias Welte, Siegfried Piepenbrock, Steffen Weber-Carstens, Konstantinos Raymondos, Tamme Dirks, Michael Quintel, Ulrich Molitoris, Jörg Ahrens, Thorben Dieck, Kai Johanning, Dietrich Henzler, Rolf Rossaint, Christian Putensen, Hermann Wrigge, Ralph Wittich, Maximilian Ragaller, Thomas Bein, Martin Beiderlinden, Maxi Sanmann, Christian Rabe, Jörn Schlechtweg, Monika Holler, Fernando Frutos-Vivar, Andres Esteban, Hartmut Hecker, Simone Rosseau, Vera von Dossow, Claudia Spies, Tobias Welte, Siegfried Piepenbrock, Steffen Weber-Carstens

Abstract

Background: This study investigates differences in treatment and outcome of ventilated patients with acute respiratory distress syndrome (ARDS) between university and non-university hospitals in Germany.

Methods: This subanalysis of a prospective, observational cohort study was performed to identify independent risk factors for mortality by examining: baseline factors, ventilator settings (e.g., driving pressure), complications, and care settings-for example, case volume of ventilated patients, size/type of intensive care unit (ICU), and type of hospital (university/non-university hospital). To control for potentially confounding factors at ARDS onset and to verify differences in mortality, ARDS patients in university vs non-university hospitals were compared using additional multivariable analysis.

Results: Of the 7540 patients admitted to 95 ICUs from 18 university and 62 non-university hospitals in May 2004, 1028 received mechanical ventilation and 198 developed ARDS. Although the characteristics of ARDS patients were very similar, hospital mortality was considerably lower in university compared with non-university hospitals (39.3% vs 57.5%; p = 0.012). Treatment in non-university hospitals was independently associated with increased mortality (OR (95% CI): 2.89 (1.31-6.38); p = 0.008). This was confirmed by additional independent comparisons between the two patient groups when controlling for confounding factors at ARDS onset. Higher driving pressures (OR 1.10; 1 cmH2O increments) were also independently associated with higher mortality. Compared with non-university hospitals, higher positive end-expiratory pressure (PEEP) (mean ± SD: 11.7 ± 4.7 vs 9.7 ± 3.7 cmH2O; p = 0.005) and lower driving pressures (15.1 ± 4.4 vs 17.0 ± 5.0 cmH2O; p = 0.02) were applied during therapeutic ventilation in university hospitals, and ventilation lasted twice as long (median (IQR): 16 (9-29) vs 8 (3-16) days; p < 0.001).

Conclusions: Mortality risk of ARDS patients was considerably higher in non-university compared with university hospitals. Differences in ventilatory care between hospitals might explain this finding and may at least partially imply regionalization of care and the export of ventilatory strategies to non-university hospitals.

Keywords: Acute respiratory distress syndrome; Biphasic positive airway pressure; Care setting; Driving pressure; Mechanical ventilation.

Figures

Fig. 1
Fig. 1
Mortality of mechanically ventilated patients during their stay in the intensive care unit (ICU) and hospital, in university and non-university hospitals. ARDS acute respiratory distress syndrome
Fig. 2
Fig. 2
Probability of survival of mechanically ventilated patients after the development of ARDS, in university and non-university hospitals (after Kaplan–Meier). ARDS acute respiratory distress syndrome, no. number
Fig. 3
Fig. 3
Change over time in ventilatory parameters during the first week after onset of ARDS. a Driving pressure (= plateau pressure – PEEP), b plateau pressure, c PEEP, d compliance (= tidal volume / (plateau pressure – PEEP)), e respiratory rate, f tidal volume/kg predicted body weight. Error bars show 95% confidence intervals. *Differences between university and non-university hospitals during the day after onset of ARDS (mean ± SD): driving pressure, 14.9 ± 5.6 vs 17.3 ± 5.5 cmH2O, p = 0.007; PEEP, 10.2 ± 5.1 vs 8.0 ± 4.1 cmH2O, p = 0.002; compliance, 47.9 ± 28.0 vs 36.8 ± 19.9 ml/cmH2O, p = 0.006. PEEP also differed between university and non-university hospitals during the second day after the onset of ARDS: 10.3 ± 4.9 vs 8.4 ± 4.0 cmH2O, p = 0.004. PEEP positive end-expiratory pressure
Fig. 4
Fig. 4
Change over time in gas exchange parameters and pH after onset of ARDS. a Partial pressure of arterial oxygen tension (PaO2), b fraction of inspired oxygen (FiO2), c arterial-to-inspired-oxygen (PaO2/FiO2), d partial pressure of arterial carbon dioxide tension (PaCO2), e pH. Error bars show 95% confidence intervals
Fig. 5
Fig. 5
Ventilatory modes used during the first week after the onset of ARDS in patients in university and non-university hospitals. Pressure support ventilation was used both more often and earlier in university hospitals than in non-university hospitals (see Table 6 for p values). A/C (VC-CMV) denotes assist/control (volume-controlled continuous mechanical ventilation), PCV (PC-CMV) pressure-controlled ventilation (pressure-controlled continuous mechanical ventilation), BIPAP/APRV biphasic positive airway pressure/airway pressure release ventilation, PSV pressure-support ventilation, SIMV synchronized intermittent mandatory ventilation, NIV non-invasive ventilation

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