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Original Article • Crit. Care Sci. 36 • 2024 • https://doi.org/10.62675/2965-2774.20240208-en linkcopy

Open-access Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients

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    ABSTRACT

    Objective:  To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19.

    Methods:  This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality.

    Results:  We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure.

    Conclusion:  In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.

    Keywords: Acute respiratory distress syndrome; COVID-19; Coronavirus infections; Tidal volume; Respiration, artificial; Mortality; Intensive care units

    RESUMO

    Objetivo:  Avaliar a associação entre driving pressure e volume corrente ajustado pelo peso predito com a mortalidade em uma coorte de pacientes com síndrome do desconforto respiratório agudo por COVID-19.

    Métodos:  Estudo prospectivo e observacional que incluiu pacientes com síndrome do desconforto respiratório agudo por COVID-19 admitidos em duas unidades de terapia intensiva. Foi realizada análise multivariada para determinar se a driving pressure e o volume corrente/kg de peso predito, aferidos no primeiro dia de ventilação mecânica, associavam-se de forma independente com a mortalidade hospitalar.

    Resultados:  Foram incluídos 231 pacientes. A mediana de idade foi de 64 (53 - 74) anos, e a mediana do Simplified Acute and Physiology Score 3 foi de 45 (39 - 54). A mortalidade hospitalar foi de 51,9%. A driving pressure se associou de forma independente com a mortalidade hospitalar (razão de chance de 1,21; IC95% de 1,04 - 1,41 para cada cm H2O de aumento da driving pressure, p = 0,01). Com base na análise de dupla estratificação, encontrou-se que, para o mesmo nível de volume corrente/kg de peso predito, o risco de mortalidade hospitalar aumentava com o incremento da driving pressure. No entanto, mudanças no volume corrente/kg de peso predito não se associaram com a mortalidade quando não resultavam em aumento da driving pressure.

    Conclusão:  Em pacientes com síndrome do desconforto respiratório agudo por COVID-19, exposição a maior driving pressure, ao contrário da exposição a maior volume corrente/kg de peso predito, associou-se com maior mortalidade hospitalar. Os resultados sugerem que a driving pressure poderia ser o alvo primário para a condução da ventilação mecânica protetora nesses pacientes.

    Descritores: Síndrome do desconforto respiratório agudo; COVID-19; Infecções por coronavírus; Volume corrente; Respiração artificial; Mortalidade; Unidades de terapia intensiva

    INTRODUCTION

    Patients with acute hypoxemic respiratory failure due to COVID-19 frequently fulfill the criteria for acute respiratory distress syndrome (ARDS) diagnosis, according to the Berlin definition, and are mechanically ventilated.(1-3) Although essential for treating patients with ARDS of different etiologies, including COVID-19, mechanical ventilation (MV) can worsen inflammatory lung injury, a phenomenon known as ventilator-induced lung injury (VILI).(4) Several studies conducted in ARDS patients have shown an association between different ventilatory parameters, such as tidal volume (VT), plateau pressure (Pplat), driving pressure (DP), mechanical power (MP), and mortality.(5-8) Based on these studies, ventilatory settings should aim not only to correct hypoxemia but also to protect the lungs from VILI.(9)

    At the beginning of the pandemic, two different phenotypes were described among patients with COVID-19 who developed acute hypoxemic respiratory failure. While some patients had typical ARDS presentations, with high elastance, high lung weight and greater potential for alveolar recruitment, others, for the same level of hypoxemia, presented low elastance and low lung weight, with lower potential for alveolar recruitment.(10,11) At that time, it was not clear whether ARDS patients with COVID-19 should be ventilated with the same principles described for ARDS patients with other etiologies. However, several other studies have shown that patients with COVID-19-related ARDS have respiratory mechanics that match those of patients with classic ARDS, with a large unimodal distribution of respiratory system compliance (CRS).(12-14) These findings suggest that protective ventilatory strategies are recommended for patients with COVID-19-related ARDS and that, at the bedside, CRS might be considered to personalize ventilatory support.

    Traditionally, protective MV is based on limiting VT (4 - 8mL/kg predicted body weight [PBW]) and Pplat (30cmH2O).(9) However, adjusting the VT based on the PBW does not consider lung heterogenicity in ARDS patients. In severe forms of ARDS, only a small proportion of the lung is available for ventilation (the "baby lung" concept).(15) Therefore, for a "baby lung", even a low VT calculated for the PBW might be injurious.(16)

    Alternatively, the VT can be set considering the extent of lung involvement, which can be inferred at the bedside by the CRS. Indeed, Amato et al. demonstrated that the DP, which represents the VT normalized to the CRS, was the ventilatory parameter most strongly associated with survival. In addition, they showed that VT normalized to the PBW was not a strong predictor of survival.(6) These findings suggest that it might be better to scale VT to the aerated lung available for ventilation than to the lung size.

    Therefore, we hypothesize that among COVID-19 ARDS patients, DP, as opposed to VT based on the PBW, is associated with survival. The aim of our study was to evaluate the association between DP or VT and mortality in a cohort of COVID-19 ARDS patients.

    METHODS

    Study population

    This was a prospective cohort study conducted between April 2020 and June 2021 in two COVID-19 dedicated intensive care units (ICUs) in Juiz de Fora (Minas Gerais, Brazil): Hospital Universitário of the Universidade Federal de Juiz de Fora (13 beds) and Hospital Regional Dr. João Penido (20 beds). The study followed the principles of the Declaration of Helsinki and was approved by the Hospital Universitário of the Universidade Federal de Juiz de Fora Ethics Committee and National Research Ethics Committee (CAAE: 30282920.5.1001.5133). Close relatives of the patients provided written informed consent.

    All consecutive patients aged 18 years or older who were admitted to one of the participating ICUs with COVID-19 confirmed by reverse transcription polymerase chain reaction (RT-PCR) were eligible for participation if they had ARDS according to the Berlin criteria and were invasively ventilated.(1) Patients who were ventilated for more than 24 hours before admission to the participant ICU and those for whom life-sustaining treatment was withheld were excluded.

    Data collection

    At admission to the ICU, we collected demographic and clinical data and calculated the following scores: Simplified Acute Physiology Score 3 (SAPS 3), Sequential Organ Failure Assessment (SOFA), and Charlson comorbidity index. The SOFA score was also calculated for the first three days of MV.

    We defined Day 0 (D0) as the calendar day when a patient was intubated. The following ventilatory parameters were collected at D0 after stabilization of the patient: ventilatory mode, VT, respiratory rate (RR), positive end-expiratory pressure (PEEP), Pplat, DP (Pplat minus total PEEP), and CRS (VT divided by DP). The VT was also expressed as VT normalized to the PBW (mL/kg PBW). The PBW was calculated by the following equation: PBW = 50 + 0.91 × (height expressed in cm – 152.4), for males; PBW = 45.5 + 0.91 × (height expressed in cm – 152.4), for females.(17) Arterial blood gas analysis was performed simultaneously with the ventilatory parameters. The same ventilatory parameters were collected on Days 1 and 2, as close to 8 a.m. as possible.

    Both ICUs adopted a protocol of protective MV. The initial ventilatory mode was either volume-controlled ventilation or pressure-controlled ventilation, adjusted to offer a VT of 6mL/kg PBW. The VT was reduced to 4 - 5mL/kg PBW to ensure that the DP was ≤ 15cmH2O. In these patients, to maintain the same minute of ventilation recorded before the reduction in VT, the RR was increased to 35 breaths/min. Conversely, a VT of up to 8mL/kg PBW was allowed to improve patient-ventilator synchrony or to correct acidosis, provided that the DP was ≤ 15cmH2O.

    Positive end-expiratory pressure and fraction of inspired oxygen (FiO2) were adjusted according to the ARDSnet table (low PEEP table) to maintain oxygen saturation (SpO2) between 93% and 96%.(17) Patients with a ratio of arterial oxygen partial pressure to fraction of inspired oxygen (PaO2/FiO2) < 150mmHg with a PEEP ≥ 10cmH2O were switched to the prone position and ventilated in this position for 16-18 hours. The criteria for stopping prone treatment were as follows: (1) improvement in oxygenation (PaO2/FiO2 ≥ 150mmHg with PEEP ≤ 10cm H2O, four hours after the end of the prone session); (2) decrease in the PaO2/FiO2 >20% in the prone position relative to the ratio in the supine position; and (3) complications occurring during the prone session. If prone positioning was contraindicated or if it was ineffective at increasing PaO2/FiO2, a recruitment maneuver with incremental PEEP levels (up to 25cm H2O), followed by a decremental PEEP titration according to the best CRS was performed. Extracorporeal membrane oxygenation and inhaled nitric oxide were not available in the participating ICUs.

    The ventilator mode was switched to pressure support in alert patients when the PEEP was ≤ 10cmH2O and the patients were awake enough to breathe in this mode. The pressure support level was started with the level necessary to achieve a VT of 6 to 8mL/kg PBW and an RR of 12 to 30 respirations per minute (rpm). Pressure support was reduced in 2cmH2O every 2 – 4 hours provided that the patient remained comfortable, with a VT of 6 to 8mL/kg PBW and an RR of 12 - 30rpm. A patient was assumed to be ready for extubation if they presented PaO2/FiO2 > 200mmHg and an RR between 8 and 30rpm with no signs of respiratory distress for at least 30 minutes while ventilated with a pressure support of 7cmH2O, PEEP ≤ 8cm H2O, and FiO2 ≤0.4, providing that he or she was clinically stable. Patients ventilated for more than 14 days were considered for tracheostomy if they presented one of the following indications: MV expected to last at least seven days more, Glasgow coma score lower than 8, inadequate swallowing or cough reflex with retention of sputum. Weaning with a tracheostomy followed the same protocol described above.

    Outcomes

    The primary outcome was hospital mortality. Secondary outcomes included 28-day mortality, ICU mortality, duration of MV and length of stay in the ICU and hospital.

    Statistical analysis

    The sample size was based on the number of patients admitted to the participating ICUs who met the inclusion criteria and constituted a convenience sample. Therefore, these findings should be interpreted as exploratory.

    Continuous variables are reported as medians (quartile 25% - quartile 75%) and were compared with the Wilcoxon rank-sum test, and categorical variables are reported as numbers and relative proportions and were compared with the chi-square test. The VT/kg PBW, Pplat and DP on Days 1 and 2 are presented in cumulative distribution plots.

    Multivariable logistic models were used to evaluate whether VT/kg PBW and DP were independently associated with hospital mortality. In both models, confounders were selected using a directed acyclic graph (DAG) (Figures 1S and 2S - Supplementary Material). In the model with VT/kg PBW as the independent variable of interest, the selected confounders were sex, CRS, DP, and RR. In the model with DP as the independent variable of interest, the selected confounders were CRS and VT/kg PBW.

    In addition, we performed a double stratification analysis to evaluate the association between DP and in-hospital mortality when VT/kg PBW was kept constant. First, we created six quantiles of VT/kg PBW. Second, each quantile was stratified into three quantiles of increasing DP. Third, for each stratum of VT/kg PBW, we merged the three clusters of DP, forming three subsamples with matched average VT/kg PBW and increasing average DP. We repeated the double stratification analysis to obtain three subsamples with matched average DP and increasing average VT/kg PBW.

    All analyses were conducted with Stata 15.1 (Stata CorpLP, College Statio, TX, USA), and the significance level was set at 0.05.

    RESULTS

    During the study period, 546 patients were admitted to the participating ICUs, and 296 met the inclusion criteria. Among those patients, 65 were excluded, and 231 constituted the final cohort. The main reasons for exclusion were that they were invasively ventilated for more than 24 hours before admission to the ICU and that they had been started on palliative care by the treatment team (Figure 1).

    Figure 1
    Study participant flow chart.

    The patients had a median age of 64 years (IQR 53 - 74), 52.8% (122 patients) were male, the median SAPS 3 score was 45 (IQR 39 - 54), 56.2% (121 patients) had moderate ARDS, and 19.5% (42 patients) had severe ARDS. The most prevalent comorbidities were hypertension and diabetes (Table 1). The hospital mortality rate was 51.9% (120 patients). Patients who survived were younger and had lower SAPS-3, SOFA, and Charlson comorbidity index scores. Diabetes, cardiovascular disease, and chronic kidney disease were more prevalent among nonsurvivors (Table 1). Patients who survived had a lower DP and greater CRS but similar VT/kg PBW, Pplat, Ppeak, and PEEP (Table 2, Figure 2). The PaO2/FiO2 ratio and pH were greater in patients who survived (Table 2).

    Thumbnail
    Table 1
    Baseline demographic and clinical characteristics of patients
    Figure 2
    Ventilatory parameters on the first day of mechanical ventilation.
    Thumbnail
    Table 2
    Respiratory parameters on Day 1 of mechanical ventilation and clinical outcomes

    According to the multivariate analysis, DP was independently associated with in-hospital mortality. Nevertheless, no statistically significant association was found between VT/kg PBW and in-hospital mortality (Table 3). Based on the double stratification analysis, we found that for the same level of VT/kg PBW, the risk of hospital death increased with increasing DP (Table 4). However, for the same DP, the risk of hospital death did not increase with increasing VT/kg PBW (Table 4).

    Thumbnail
    Table 3
    Multivariable logistic regression assessing the association between tidal volume or driving pressure and hospital mortality
    Thumbnail
    Table 4
    Double stratification analysis: impact of tidal volume/kg predicted body weight when driving pressure is kept constant and of driving pressure when tidal volume/kg predicted body weight is kept constant

    Regarding the secondary outcomes, at the end of the 28-day follow-up, 86 (37.2%) patients had died. The ICU mortality rate was 47.6% (110 patients). The median ICU stay was 16 (IQR 9 - 28) days, and the median hospital stay was 22 (12 - 38) days.

    DISCUSSION

    This observational study evaluated a cohort of patients with COVID-19 who met the ARDS criteria and underwent invasive MV. DP, which represents VT normalized for CRS, was independently associated with in-hospital mortality. However, when the VT was adjusted for PBW, no statistically significant association with hospital mortality was identified.

    Since 2000, when the ARMA Study showed that ventilating ARDS patients with lower VT and lower Pplat decreases mortality,(17) guidelines on the management of ARDS have recommended that these patients receive MV with limited VT (4 - 8mL/kg PBW) and Pplat (lower than 30cmH2O).(9) Despite the benefits of ventilating ARDS patients with low VT, especially when compared with VT of 12mL/kg PBW, adjusting the VT only by the PBW has been criticized by some authors because this strategy does not consider the severity of ARDS or the amount of lung tissue that is ventilated.(16,18) For example, Terragni et al., analyzing ARDS patients with computed tomography, demonstrated that, in patients with large nonaerated areas (characterizing a "small baby lung"), lowering VT to 6mL/kg PBW and limiting Pplat to 30cmH2O may not be sufficient to avoid hyperinflation and to minimize VILI.(16)

    An alternative strategy to minimize VILI in ARDS patients is to normalize VT to CRS by targeting DP (DP = VT/CRS) as a protective parameter. Since the stress and strain that lead to VILI are determined both by VT and end-expiratory lung volume, the latter determined by the amount of aerated tissue and represented by the CRS, DP might be a better predictor of mortality than VT or Pplat.(19) The DP can be easily calculated at the bedside, and several observational studies have shown its association with mortality.(20,21) Moreover, Amato et al., analyzing data from ARDS patients enrolled in a previous randomized trial that compared different ventilatory strategies, showed that higher DP predicted lower survival, whereas higher Pplat and VT were associated with lower survival only in patients with elevated DP.(6)

    Our results, obtained among COVID-19 patients who developed ARDS, are consistent with those showing that DP is a better predictor of mortality than VT/kg PBW. In our cohort, a higher DP, as opposed to a higher VT based on the PBW, was associated with greater hospital mortality. In addition, at constant levels of VT/kg PBW, we observed that DP was associated with mortality, while at constant levels of DP, an increase in VT/kg PBW was not associated with a greater risk of death. In fact, in our cohort, we showed a lower risk of death with increasing VT/kg PBW, although the difference was not statistically significant. This finding might reflect the strategy of setting the ventilatory parameters. Since we used our protective MV to maintain the DP lower than 15cmH2O, patients with lower CRS may have been ventilated with lower VT/kg PBW, resulting in an association between lower VT/kg PBW and higher mortality. However, we cannot exclude the possibility that VT/kg PBW reduction in patients with higher CRS is not harmful by itself, as it increases the risk of asynchrony and the necessity of deep sedation and neuromuscular blockade.(22,23) This impact of respiratory mechanics on the effect of lowering VT in ARDS patients was recently demonstrated. The authors showed that the effect of decreasing VT on mortality varied according to CRS and that the difference in the risk of death between patients with higher and lower VT was statistically significant only in patients with low CRS.(24)

    Our study has several relevant limitations. The cohort was formed in only two dedicated COVID-19 ICUs that followed the same protocol for ventilatory management. Therefore, the results may not be generalizable to other ICUs. Ventilatory parameters were collected only on the first three days of MV and may not represent those applied during the following days. We cannot exclude the possibility that ventilatory parameters and adjuvant therapies applied beyond Day 3 influenced mortality. As is common in observational studies, the knowledge of ICU teams about the study being conducted could have interfered with the way patients were ventilated, increasing adherence to protective MV. Over the 15 months of the study, changes in the management, not related to MV, of patients with COVID-19, as well as the experience acquired by the ICU teams, may have influenced the survival of these patients, and the causal model might not have been able to identify them. We do not have data regarding ventilatory support before intubation (high-flow nasal cannula or noninvasive ventilation). Therefore, the possible effects of these treatments could not be assessed in this study. This was an observational study, and the analyzed relationships (C-ARDS cohort with protective MV and protective MV with hospital mortality) might have been influenced by residual confounding factors not included in the DAGs. Therefore, causality cannot be assured.

    CONCLUSION

    In our cohort of acute respiratory distress syndrome patients with COVID-19, exposure to greater driving pressure was associated with greater hospital mortality. However, there was no significant association between tidal volume adjusted for predicted body weight and hospital mortality. These results suggest that lung-protective mechanical ventilation might primarily target driving pressure rather than tidal volume adjusted by predicted body weight.

    • Financial support
      This study was supported by a Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

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    Edited by

    • Responsible editor: Bruno Adler Maccagnan Pinheiro Besen https://orcid.org/0000-0002-3516-9696

    Publication Dates

    • Publication in this collection
      10 May 2024
    • Date of issue
      2024

    History

    • Received
      14 Aug 2023
    • Accepted
      06 Jan 2024
    Creative Common - by 4.0
    This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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