Effect of Esophageal Pressure–guided Positive End-Expiratory Pressure on Survival from Acute Respiratory Distress Syndrome: A Risk-based and Mechanistic Reanalysis of the EPVent-2 Trial

• DOI: 10.1164/rccm.202009-3539oc
• Publication Date: 2021-08-31T17:45:33Z
• Authors: Todd Sarge; Elias Baedorf-Kassis; Valerie Banner-Go...; Victor Novack; Stephen H. Loring; Michelle N. Gong; Deborah Cook; Daniel Talmor; Jeremy R. Beitler; Emily Fish; Sayuri Jinadasa; Ray Ritz; Joseph Previtera; Lawrence Lee; France Clarke; Tom Piraino; Joseph Levitt; Rosemary Vojnik; Pauline Park; Kristin Brierley; Carl Haas; Andrew Weirauch; Eddy Fan; Andrea Matte; R. Scott Harris; Mamary Kone; Stephen Heard; Karen Longtine; François Lellouche; Pierre-Alexandre ...; Lewis Rubinson; Jennifer Titus Mc...; Donald E. G. Grie...; Denise Foster; Richard Oeckler; Amy Amsbaugh; Edgar Jimenez; Valerie Danesh; Arthur S. Slutsky; Jesse Hall; Rolf D. Hubmayr; Gordon Rubenfeld; David Schoenfeld
• Keywords: Transpulmonary pressure; Positive End-Expiratory Pressure

Rationale: In acute respiratory distress syndrome (ARDS), the effect of positive end-expiratory pressure (PEEP) may depend on extent to which multiorgan dysfunction contributes risk death, and precision with PEEP is titrated attenuate atelectrauma without exacerbating overdistension. Objectives: To evaluate whether lung mechanics modified treatment in EPVent-2 (Esophageal Pressure-guided Ventilation 2) trial, a multicenter trial esophageal (Pes)-guided versus empirical high moderate severe ARDS. Methods: This post hoc reanalysis evaluated for heterogeneity mortality by baseline dysfunction, determined via Acute Physiology Chronic Health Evaluation II (APACHE-II). It also transpulmonary near 0 cm H2O was associated survival. Measurements Main Results: All 200 participants were included. Treatment 60-day differed severity (P = 0.03 interaction). Pes-guided lower among patients APACHE-II less than median value (hazard ratio, 0.43; 95% confidence interval, 0.20–0.92) have had opposite higher 1.69; 0.93–3.05). Independent group or severity, lowest when titration achieved H2O. Conclusions: The survival PEEP, compared severity. closer greater more negative values. These findings warrant prospective testing future trial.