Ventilation practices in burn patients-an international prospective observational cohort study

Marcus J Schultz, Janneke Horn, Markus W Hollmann, Benedikt Preckel, Gerie J Glas, Kirsten Colpaert, Manu Malbrain, Ary Serpa Neto, Karim Asehnoune, Marcello Gamma de Abreu, Ignacio Martin-Loeches, Paolo Pelosi, Folke Sjöberg, Jan M Binnekade, Berry Cleffken, Nicole P Juffermans, Paul Knape, Bert G Loef, David P Mackie, Perenlei Enkhbaatar, Nadia Depetris, Anders Perner, Eva Herrero, Lucia Cachafeiro, Marc Jeschke, Jeffrey Lipman, Matthieu Legrand, Johannes Horter, Athina Lavrentieva, Gerie Glas, Alex Kazemi, Anne Berit Guttormsen, Frederik Huss, Mark Kol, Helen Wong, Therese Starr, Luc De Crop, Wilson de Oliveira Filho, João Manoel Silva Junior, Cintia M C Grion, Marc G Jeschke, Marjorie Burnett, Frederik Mondrup, Francois Ravat, Mathieu Fontaine, Karim Asehoune, Renan Le Floch, Mathieu Jeanne, Morgane Bacus, Maïté Chaussard, Marcus Lehnhardt, Bassem Daniel Mikhail, Jochen Gille, Aidan Sharkey, Nicole Trommel, Auke C Reidinga, Nadine Vieleers, Anna Tilsley, Henning Onarheim, Maria Teresa Bouza, Alexander Agrifoglio, Filip Fredén, Tina Palmieri, Lynda E Painting, LAMiNAR investigators, Marcus J Schultz, Janneke Horn, Markus W Hollmann, Benedikt Preckel, Gerie J Glas, Kirsten Colpaert, Manu Malbrain, Ary Serpa Neto, Karim Asehnoune, Marcello Gamma de Abreu, Ignacio Martin-Loeches, Paolo Pelosi, Folke Sjöberg, Jan M Binnekade, Berry Cleffken, Nicole P Juffermans, Paul Knape, Bert G Loef, David P Mackie, Perenlei Enkhbaatar, Nadia Depetris, Anders Perner, Eva Herrero, Lucia Cachafeiro, Marc Jeschke, Jeffrey Lipman, Matthieu Legrand, Johannes Horter, Athina Lavrentieva, Gerie Glas, Alex Kazemi, Anne Berit Guttormsen, Frederik Huss, Mark Kol, Helen Wong, Therese Starr, Luc De Crop, Wilson de Oliveira Filho, João Manoel Silva Junior, Cintia M C Grion, Marc G Jeschke, Marjorie Burnett, Frederik Mondrup, Francois Ravat, Mathieu Fontaine, Karim Asehoune, Renan Le Floch, Mathieu Jeanne, Morgane Bacus, Maïté Chaussard, Marcus Lehnhardt, Bassem Daniel Mikhail, Jochen Gille, Aidan Sharkey, Nicole Trommel, Auke C Reidinga, Nadine Vieleers, Anna Tilsley, Henning Onarheim, Maria Teresa Bouza, Alexander Agrifoglio, Filip Fredén, Tina Palmieri, Lynda E Painting, LAMiNAR investigators

Abstract

Background: It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it. This study aimed to determine ventilation practices in burn intensive care units (ICUs) and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28 (VFD-28).

Methods: This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation. Low tidal volume (V T) was defined as V T ≤ 8 mL/kg predicted body weight (PBW). Levels of positive end-expiratory pressure (PEEP) and maximum airway pressures were collected. The association between V T and VFD-28 was analyzed using a competing risk model. Ventilation settings were presented for all patients, focusing on the first day of ventilation. We also compared ventilation settings between patients with and without inhalation trauma.

Results: A total of 160 patients from 28 ICUs in 16 countries were included. Low V T was used in 74% of patients, median V T size was 7.3 [interquartile range (IQR) 6.2-8.3] mL/kg PBW and did not differ between patients with and without inhalation trauma (p = 0.58). Median VFD-28 was 17 (IQR 0-26), without a difference between ventilation with low or high V T (p = 0.98). All patients were ventilated with PEEP levels ≥5 cmH2O; 80% of patients had maximum airway pressures <30 cmH2O.

Conclusion: In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients, irrespective of the presence of inhalation trauma. Use of low V T was not associated with a reduction in VFD-28.

Trial registration: Clinicaltrials.gov NCT02312869. Date of registration: 9 December 2014.

Keywords: Critical care; Inhalation trauma; Lung-protective; Mechanical ventilation.

© The Author(s) 2021. Published by Oxford University Press.

Figures

Figure 1.
Figure 1.
Ventilator settings on the first day of ventilation of patients with and without inhalation trauma. Cumulative frequency distributions from the following parameters measured on the first day of mechanical ventilation: (a) VT, (b) maximum airway pressure, (c) PEEP, (d) driving pressure. Vertical dotted lines: predefined cut-off values for each variable. Horizontal dotted lines: proportion of patients reaching the cut-offs. Driving pressure: plateau (or peak) pressure minus PEEP. VT tidal volume, PEEP positive end-expiratory pressure, PBW predicted body weight
Figure 2.
Figure 2.
Distribution of ventilatory parameters on the first day of mechanical ventilation. Distribution of positive end-expiratory pressure (PEEP), inspired fraction of oxygen (FiO2), respiratory rate and maximum airway pressure vs tidal volume (VT). Dotted lines (horizontal and vertical) represent cut-off values for each variable. (a) PEEP, (b) FiO2, (c) respiratory rate, (d) maximum airway pressure
Figure 3.
Figure 3.
Cumulative incidence curves for ventilation status of patients ventilated with low vs high tidal volume size at day 28 and day 90. Sub-distribution hazard ratio: the magnitude is affected by both time to extubation and probability of death; calculated using the Cox proportional hazard model. (a) Ventilation status at day 28, (b) ventilation status at day 90. VT tidal volume

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