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Factors Associated With Elevated Plateau Pressure in Patients With Acute Lung Injury Receiving Lower Tidal Volume Ventilation

Prescott, Hallie C. MD1,2; Brower, Roy G. MD3; Cooke, Colin R. MD, MSc4; Phillips, Gary MAS5; O’Brien, James M. MD, MSc6; for the National Institutes of Health Acute Respiratory Distress Syndrome Investigators

Critical Care Medicine:
doi: 10.1097/CCM.0b013e3182741790
Clinical Investigations
Abstract

Objectives: Lung-protective ventilation with lower tidal volume and lower plateau pressure improves mortality in patients with acute lung injury and acute respiratory distress syndrome. We sought to determine the incidence of elevated plateau pressure in acute lung injury /acute respiratory distress syndrome patients receiving lower tidal volume ventilation and to determine the factors that predict elevated plateau pressure in these patients.

Patients: We used data from 1398 participants in Acute Respiratory Distress Syndrome Network trials, who received lower tidal volume ventilation (≤ 6.5mL/kg predicted body weight).

Design: We considered patients with a plateau pressure greater than 30cm H2O and/or a tidal volume less than 5.5mL/kg predicted body weight on study day 1 to have “elevated plateau pressure.” We used logistic regression to identify baseline clinical variables associated with elevated plateau pressure and to develop a model to predict elevated plateau pressure using a subset of 1,188 patients. We validated the model in the 210 patients not used for model development.

Setting: Medical centers participating in Acute Respiratory Distress Syndrome Network clinical trials.

Interventions: None.

Measurements and Main Results: Of the 1,398 patients in our study, 288 (20.6%) had elevated plateau pressure on day 1. Severity of illness indices and demographic factors (younger age, greater body mass index, and non-white race) were independently associated with elevated plateau pressure. The multivariable logistic regression model for predicting elevated plateau pressure had an area under the receiving operator characteristic curve of 0.71 for both the developmental and the validation subsets.

Conclusions: acute lung injury patients receiving lower tidal volume ventilation often have a plateau pressure that exceeds Acute Respiratory Distress Syndrome Network goals. Race, body mass index, and severity of lung injury are each independently associated with elevated plateau pressure. Selecting a smaller initial tidal volume for non-white patients and patients with higher severity of illness may decrease the incidence of elevated plateau pressure. Prospective studies are needed to evaluate this approach.

Author Information

1 Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH.

2 Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI.

3 Pulmonary and Critical Care Medicine, John Hopkins University School of Medicine, Baltimore, MD.

4 University of Michigan, Robert Wood Johnson Clinical Scholars Program and Center for Healthcare Outcomes & Policy, Ann Arbor, MI.

5 The Ohio State University Center for Biostatistics, Columbus, OH.

6 Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/ccmjournal).

Supported, in part, by National Heart, Lung, and Blood Institute (NHLBI) contract NO1-HR-46054–46064 and NO1-HR 56165–56179.s

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: hallieprescott@gmail.com

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins