Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS – Generating Evidence Study

• Type of Material: Article
• Authors: Nida Qadir, University of California Los Angeles; Raquel R. Bartz, Duke University; Mary L. Cooter, Duke University; Catherine L. Hough, Oregon Health and Science University; Michael J. Lanspa, University of Utah; Valerie M. Banner-Goodspeed, Beth Israel Deaconess Medical Center; Jen-Ting Chen, Albert Einstein College; Shewit Giovanni, University of Washington; Annette Esper, Emory University; Pauline K. Park, University of California Los Angeles
• Language: English
• Date: 2021-10-01
• Publisher: Elsevier
• Publication Version: Final Published Version
• Copyright Statement: © 2021 Published by Elsevier Inc under license from the American College of Chest Physicians.
• Final Published Version (URL): http://dx.doi.org/10.1016/j.chest.2021.05.047
• Title of Journal or Parent Work: CHEST
• Volume: 160
• Issue: 4
• Start Page: 1304
• End Page: 1315
• Grant/Funding Information: None declared.
• Keywords: prone positioning; ARDS; mechanical ventilation; neuromuscular blockade; corticosteroids; extracorporeal membrane oxygenation
• Research Categories: Health Sciences, Health Care Management; Biology, Neuroscience

Abstract

Background 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. Research Question What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods 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. Results 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. Interpretation 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.