Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy

Jean-Marie Forel, François Voillet, Daniel Pulina, Arnaud Gacouin, Gilles Perrin, Karine Barrau, Samir Jaber, Jean-Michel Arnal, Mohamed Fathallah, Pascal Auquier, Antoine Roch, Elie Azoulay, Laurent Papazian, Jean-Marie Forel, François Voillet, Daniel Pulina, Arnaud Gacouin, Gilles Perrin, Karine Barrau, Samir Jaber, Jean-Michel Arnal, Mohamed Fathallah, Pascal Auquier, Antoine Roch, Elie Azoulay, Laurent Papazian

Abstract

Introduction: Ventilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy.

Methods: This prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis.

Results: Ninety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective.

Conclusions: In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment.

Figures

Figure 1
Figure 1
Kaplan-Meier estimates of the cumulative probability of developing ventilator-associated pneumonia according to the number of days on mechanical ventilation in the group of 98 patients with severe acute respiratory distress syndrome who developed a ventilator-associated pneumonia.
Figure 2
Figure 2
Hazard rate for ventilator-associated pneumonia over time after the diagnosis of severe acute respiratory distress syndrome. The hazard function evaluates the conditional probability of ventilator-associated pneumonia on the next day in an event-free patient. The hazard rate is the event rate per day over the duration of mechanical ventilation.
Figure 3
Figure 3
Probability of survival through day 90 in patients with and without ventilator-associated pneumonia.
Figure 4
Figure 4
Probability of breathing without assistance from the day of inclusion to day 90.

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