Journal Article

Comparison of limited driving pressure ventilation and low tidal volume strategies in adults with acute respiratory failure on mechanical ventilation: a randomized controlled trial

Suppasilp, Chaiyawat, Viarasilpa, Tanuwong, Subpinyo, Santi, Tongyoo, Surat, Permpikul, Chairat, Deawtrakulchai, Phitphiboon

2024

Overview

Background: Ventilator-induced lung injury (VILI) presents a grave risk to acute respiratory failure patients undergoing mechanical ventilation. Low tidal volume (LTV) ventilation has been advocated as a protective strategy against VILI. However, the effectiveness of limited driving pressure (plateau pressure minus positive end-expiratory pressure) remains unclear. Objectives: This study evaluated the efficacy of LTV against limited driving pressure in preventing VILI in adults with respiratory failure. Design: A single-centre, prospective, open-labelled, randomized controlled trial. Methods: This study was executed in medical intensive care units at Siriraj Hospital, Mahidol University, Bangkok, Thailand. We enrolled acute respiratory failure patients undergoing intubation and mechanical ventilation. They were randomized in a 1:1 allocation to limited driving pressure (LDP; ⩽15 cmH2O) or LTV (⩽8 mL/kg of predicted body weight). The primary outcome was the acute lung injury (ALI) score 7 days post-enrolment. Results: From July 2019 to December 2020, 126 patients participated, with 63 each in the LDP and LTV groups. The cohorts had the mean (standard deviation) ages of 60.5 (17.6) and 60.9 (17.9) years, respectively, and they exhibited comparable baseline characteristics. The primary reasons for intubation were acute hypoxic respiratory failure (LDP 49.2%, LTV 63.5%) and shock-related respiratory failure (LDP 39.7%, LTV 30.2%). No significant difference emerged in the primary outcome: the median (interquartile range) ALI scores for LDP and LTV were 1.75 (1.00–2.67) and 1.75 (1.25–2.25), respectively (p = 0.713). Twenty-eight-day mortality rates were comparable: LDP 34.9% (22/63), LTV 31.7% (20/63), relative risk (RR) 1.08, 95% confidence interval (CI) 0.74–1.57, p = 0.705. Incidences of newly developed acute respiratory distress syndrome also aligned: LDP 14.3% (9/63), LTV 20.6% (13/63), RR 0.81, 95% CI 0.55–1.22, p = 0.348. Conclusions: In adults with acute respiratory failure, the efficacy of LDP and LTV in averting lung injury 7 days post-mechanical ventilation was indistinguishable. Clinical trial registration: The study was registered with the ClinicalTrials.gov database (identification number NCT04035915). Plain language summary Limited breathing pressure or low amount of air given to the lung; which one is better for adults who need breathing help by ventilator machine We conducted this research at Siriraj Hospital in Bangkok, Thailand, aiming to compare two ways of helping patients with breathing problems. We studied 126 patients who were randomly put into two groups. One group received a method where the pressure during breathing was limited (limited driving pressure: LDP), and the other group got a method where the amount of air given to the lungs was kept low (low tidal volume: LTV). We checked how bad the lung injury was at seven days later. The results showed that there was no difference between the two methods. Both ways of helping patients breathe had similar outcomes, and neither was significantly better than the other in preventing lung problems. The study suggests that both approaches work about the same for patients who need help with breathing using a machine.

• Publisher: SAGE Publications,SAGE PUBLICATIONS, INC,SAGE Publishing
• Subject: Adult / Aged / Clinical trials / Female / Humans / Intubation / Lung - physiopathology / Male / Middle Aged / Positive-Pressure Respiration - adverse effects / Positive-Pressure Respiration - methods / Prospective Studies / Respiration, Artificial - adverse effects / Respiratory Distress Syndrome - mortality / Respiratory Distress Syndrome - physiopathology / Respiratory Distress Syndrome - therapy / Respiratory failure / Respiratory Insufficiency - physiopathology / Respiratory Insufficiency - therapy / Risk Factors / Thailand / Tidal Volume / Time Factors / Treatment Outcome / Ventilator-Induced Lung Injury - etiology / Ventilator-Induced Lung Injury - prevention & control / Ventilators