Evolution of practice patterns in the management of acute respiratory distress syndrome: A secondary analysis of two successive randomized controlled trials.

Kate C Tatham, Niall D Ferguson, Qi Zhou, Lori Hand, Peggy Austin, Ravi Taneja, Alejandro C Arroliga, Juan F Sanchez, Edgar J Jimenez, Brandon P Staub, Michelle E Kho, J Guillermo Domínguez-Cherit, Adam Mullaly, Yaseen M Arabi, Maureen O Meade

Journal: Journal of critical care 2021;65():274-281

PMID: 34280657

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Abstract

PURPOSE

We sought to examine changes in acute respiratory distress syndrome (ARDS) management over a 12-year period of two successive randomized trials.

METHODS

Analyses included baseline data, from eligible patients, prior to influence of trial protocols, and daily study data, from randomized patients, of variables not determined by trial protocols. Mixed linear regressions examined changes in practice year-on-year.

RESULTS

A total of 2376 patients met the inclusion criteria. Over the 12-year period, baseline tidal volume index decreased (9.0 to 7.0 ml/kg, p < 0.001), plateau pressures decreased (30.8 to 29.0 cmHO, p < 0.05), and baseline positive end-expiratory pressures increased (10.8 to 13.2 cmHO, p < 0.001). Volume-controlled ventilation declined from 29.4 to 14.0% (p < 0.01). Use of corticosteroids increased (baseline: 7.7 to 30.3%; on study: 32.6 to 61.2%; both p < 0.001), as did neuromuscular blockade (baseline: 12.3 to 24.5%; on study: 55.5 to 70.0%; both p < 0.01). Inhaled nitric oxide use increased (24.9 to 65.8%, p < 0.05). We observed no significant change in prone positioning (16.2 to 18.9%, p = 0.70).

CONCLUSIONS

Clear trends were apparent in tidal volume, airway pressures, ventilator modes, adjuncts and rescue therapies. With the exception of prone positioning, and outside the context of rescue therapy, these trends appear consistent with the evolving literature on ARDS management.

Address: Department of Medicine, Division of Respirology & Critical Care Medicine, University Health Network and Sinai Health System, Toronto, Canada; Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery & Cancer, Imperial College, London, United Kingdom.; Department of Medicine, Division of Respirology & Critical Care Medicine, University Health Network and Sinai Health System, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University Health Sciences Centre, Hamilton, Canada.; University of Western Ontario, Anesthesia, Medicine and Critical Care, London, Canada.; Division of Pulmonary and Critical Care Medicine, Baylor Scott and White Health, Temple, TX, United States; Texas A&M Health Sciences Centre, College of Medicine, Temple, TX, United States.; Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.; School of Rehabilitation Science, McMaster University, Hamilton, Canada.; Division of Critical Care, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México City, Mexico; School of Medicine, Instituto Tecnologico de Monterrey, Monterrey City, Mexico.; Main Line Health, Bryn Mawr Hospital, Philadelphia, PA, United States.; Intensive Care Department, College of Medicine-Riyadh, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University Health Sciences Centre, Hamilton, Canada; Interdepartmental Division of Critical Care, Hamilton Health Sciences, Critical Care, Hamilton, Canada.

DOI: 10.1016/j.jcrc.2021.06.017

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MeSH Terms: Humans, Neuromuscular Blockade, Positive-Pressure Respiration, Randomized Controlled Trials as Topic, Respiration, Artificial, Respiratory Distress Syndrome, Tidal Volume