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Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States

2021; Elsevier BV; Volume: 160; Issue: 4 Linguagem: Inglês

10.1016/j.chest.2021.05.047

1931-3543

Nida Qadir, Raquel R. Bartz, Mary Cooter, Catherine L. Hough, Michael J. Lanspa, Valerie Banner‐Goodspeed, Jen‐Ting Chen, Shewit P. Giovanni, Dina Gomaa, Michael W. Sjoding, Negin Hajizadeh, Jordan C. Komisarow, Abhijit Duggal, Ashish K. Khanna, Rahul Kashyap, Akram Khan, Steven Y. Chang, Joseph E. Tonna, Harry L. Anderson, Janice M. Liebler, Jarrod Mosier, Peter E. Morris, Alissa Genthon, Irene K. Louh, Mark Tidswell, R. Scott Stephens, Annette Esper, David J. Dries, Anthony Martinez, Kraftin E. Schreyer, William Bender, Anupama Tiwari, Pramod Guru, Sinan Hanna, Michelle N. Gong, Pauline K. Park, Jay S. Steingrub, Mark Tidswell, Valerie Banner‐Goodspeed, Kristin Brierley, Julia Larson, Ariel Mueller, Tereza Pinkhasova, Daniel Talmor, Imoigele P. Aisiku, Rebecca M. Baron, Lauren Fredenburgh, Alissa Genthon, Peter C. Hou, Anthony F. Massaro, Raghu R. Seethala, Abhijit Duggal, Duncan Hite, Ashish K. Khanna, Daniel Brodie, Irene K. Louh, Briana Short, Raquel R. Bartz, Mary Cooter, Jordan C. Komisarow, Anupama Tiwari, William Bender, James M. Blum, Annette Esper, Greg S. Martin, Eileen M. Bulger, Catherine L. Hough, Anna Ungar, Samuel M. Brown, Colin K. Grissom, Eliotte L. Hirshberg, Michael J. Lanspa, Ithan D. Peltan, Roy G. Brower, Sarina K. Sahetya, R. Scott Stephens, Pramod Guru, J. Kyle Bohman, Hongchuan Coville, Ognjen Gajic, Rahul Kashyap, John C. O’Horo, Jorge-Bleik Ataucuri-Vargas, Jen‐Ting Chen, Michelle N. Gong, Fiore Mastroianni, Negin Hajizadeh, Jamie S. Hirsch, Michael Qui, Molly Stewart, Akram Khan, Ebaad Haq, Makrina Kamel, Olivia Krol, Kimberly Lerner, David J. Dries, John J. Marini, Valentina Amaral, Anthony Martinez, Harry L. Anderson, J. P. Brown, Michael Brozik, Heidi Kemmer, Janet Obear, Nina T. Gentile, Kraftin E. Shreyer, Charles B. Cairns, Cameron Hypes, Joshua Malo, Jarrod Mosier, Bhupinder Natt, Steven Y. Chang, Scott Hu, Ishan Mehta, Nida Qadir, Richard D. Branson, Dina Gomaa, Betty J. Tsuei, Sandipan Dhar, Ashley Montgomery-Yates, Peter E. Morris, Tina Chen, Sinan Hanna, Pauline K. Park, Michael W. Sjoding, Alfredo Lee Chang, Perren J. Cobb, Janice M. Liebler, Estelle S. Harris, Nate Hatton, Gia Lewis, Stephen H. McKellar, Sanjeev Raman, Joseph E. Tonna, Ellen Caldwell, Sarah Dean, Shewit P. Giovanni,

Sepsis Diagnosis and Treatment

Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States?We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed.A total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes.ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov.