Game Changing Evidence: Airway and Breathing

I am an intensive care trainee wanting to get a better understanding of the literature in intensive care medicine.

This 6 part series is intended to identify and summarise landmark papers in various aspects of management in ICU.

It is in no way intended to be comprehensive or exhaustive.

It is also intended to promote discussion – please let me know if you think I have excluded anything.

Click on the studies to get the lowdown…

[az_accordion_section] [accordion title=”CESAR 2009″ id=”acc-1″]

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial.

Lancet. 2009; 374(9698): 1351-63

Abstract

The Lowdown

180 patients with severe but potentially reversible respiratory failure
Exclusions: Peak inspiratory pressure more than 30, FiO2 greater than 80% for more than 7 days, contraindication to anticoagulation
Randomly allocated to conventional ventilator management, or referral to a tertiary hospital for consideration of ECMO (patients allocated to this groups were transferred to a tertiary centre, and commenced on an ARDS protocol for 12 hours, then initiated on ECMO if there was no improvement)
17 patients randomised to the ECMO group, but improved so didn’t actually receiv ECMO
No standardised treatment protocol for conventional management group
Primary endpoint (survival without severe disability at 6 months) improved with the ECMO group (63% vs 47%, P=0.03)

Take Home Message

In patients with severe ARDS, transferral to a tertiary centre with the capability for ECMO had increased survival without severe disability at 6 months.

[/accordion] [accordion title=”Scales 2008″ id=”acc-2″]

The effect of tracheostomy timing during critical illness on long-term survival

Crit Care Med 2008 Sep;36(9):2547-57

Abstract

The Lowdown

Retrospective, observational cohort study of 10,927 mechanically ventilated patients undergoing tracheostomy
Classified as early (less than 10 days = 1/3 of patients) or late (greater than 10 days = 2/3 of patients)
Patients receiving early tracheostomy had lower 90-day (34.8% vs. 36.9%; p 0.032), 1 yr (46.5% vs. 49.8%; p 0.001), and study mortality (63.9% vs. 67.2%; p < 0.001) than patients receiving late tracheostomy
Provides guidance regarding timing but not patient selection for tracheostomy

Take Home Message

This observational cohort study suggests that there may be a mortality benefit in early versus late tracheostomy in patients requiring mechanical ventilation.

[/accordion] [accordion title=”Meduri 2007″ id=”acc-3″]

Methylprednisolone infusion in early severe ARDS: results of a randomized controlled trial

Chest. 2007; 131(4): 954-63

Abstract

The Lowdown

91 patients with severe ARDS onset within 72 hours
Randomised to methylprednisolone 1mg/kg/day for 14 days then weaning for further 14 days, or placebo
Primary endpoint: improvement in lung injury score (LIS) after 7 days of treatment significantly better in treatment group (69.8% vs 35.7%, p = 0.02)
Significant improvement also seen in duration of mechanical ventilation (p = 0.002), ICU stay (p = 0.007), and ICU mortality (20.6% vs 42.9%; p = 0.03)

Take Home Message

In patients with early ARDS, prolonged, low dose methylprednisolone improved lung function, duration of mechanical ventilation and ICU length of stay.

[/accordion] [accordion title=”LaSRS 2006″ id=”acc-4″]

Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome

N Engl J Med. 2006; 354(16): 1671-84

Abstract

The Lowdown

180 patients with ARDS requiring ventilation, 7-28 days after onset
Exclusions: prior corticosteroid use, immunosuppression, COPD
Randomised to either IV methylprednisolone or placebo for 2 weeks, then weaning dose
Primary outcome (60-day mortality) not different between methylprednisolone and placebo
Increased mortality in the group commenced on steroids 14 days after onset (35% vs 8%, p = 0.02)

Take Home Message

In patients with ARDS present for more than 7 days, methylprednisolone did not improve 60-day mortality.

There was increased mortality in the group who commenced steroids after 14 days since onset of ARDS.

[/accordion] [accordion title=”ARDSnet 2000″ id=”acc-5″]

Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome

N Engl J Med 2000; 342:1301-1308

Abstract

The Lowdown

861 patients with ALI/ ARDS requiring mechanical ventilation
Exclusions: more than 36 hours since diagnosis, raised ICP, chronic respiratory disease
Randomised to either traditional tidal volume (12ml/kg) or low tidal volume (6ml/kg)
Primary endpoints: death before discharge (31 vs 39.8%, p = 0.007), and ventilator free days between 1- 28 days improved with lower tidal volumes.