ARDSnet... Excluded patients did well?!

[europeman]

I don't have the ref now but I'm sure one of you do. It wasn't in the ardsnet supplemental, but it was collected data and published.

There were thousands of eligible patient..... The majority of which were excluded for this and that. Those excluded patients continued on 10cc/kg standard of care. The included patients in the study were then randomized to 12 or 6cc. Mortality of the 6cc was lower than the 12 but still equal to the 10!


Am I missing something? Isn't that odd?

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[europeman]

Such a huge study.... Yet the 10cc/kg "excluded group" had same mortality rate as 6cc." no commentary?

 

[europeman]

http://www.ccmpitt.com/ebm/ards/185-ardsnet controversy.pdf

nice review 0f the controversy and politics at the time.

 

[europeman]

Crickets.......

 

[souljah1]

I'd need to see the ref in order to interpret this. Were those excluded patients less sick? They were excluded pre randomization so its possible we are comparing apples (6cc in sick people) to organges (10cc in healthy people). Cannot make comparisons between those that went on to get randomized and those that were excluded.

 

[ORL10]

Agree, not apples and oranges. Also there was rumor that the 12cc and high plateau pressure used in the study was higher than was standard of care at some shops (probably not when compared to community non-acdemic hospitals) which generated a lot of controversy around the subject that you eluded to.

What we do know is that 6 is better than 12 and that lower plateau's better than higher plateaus. We also think we know from retrospective studies, that 6 is probably better than 10, (THE DATA is that the incidence of ARDS is decreasing which is very dirty data and likely is multi-factorial, of which a component could be the lower TV used today than previously).

Also, related but not the same, there has been a decent body of literature growing in NON-ARDS patients which has compared 10cc - 6cc both in the operating room and patients at risk of lung injury and the JAMA meta-analysis showed a benefit of 6-8 vs. 10-12 cc/kg IBW TV with modest PEEP.

http://www.ccm.pitt.edu/sites/default/files/calendar_event_articles/singh.pdf

 

[europeman]

Here you go....

 

[europeman]

What we know, I agree, is that 6 is better than 12. And that 6, with assist control, gives me a mortality of 32%.

That's horrendous.

We should keep striving for better.... Not be happy with this just yet and automatically think therefore that this is the end all be all.

Moreover, ARDSNet had a LOT of controversy and baggage/political issues surrounding it. The point is, while it is certainly a valuable study, it does not prove that assist control is the end all be all.

Individual patients are unique...... Different populations have different characteristics. So to think giving all of them with ARDS a tidal vol of 6 is equally more beneficial than other methods I think is taking the ardsnet data too far..... If you are at a tertiary institution and such. Fine if you are community joe... Don't use your brain. Just do ardsnet.

Thoughts on the above publication, which had to use the freedom of information act to get this data from the ards network because, frankly, they didn't want to provide it?

 

[ORL10]

I'm confused what are you recommending?

The express trial looked at using higher plateau's to maintain recruitability and many people are already finessing PEEP to evaluate stress index in ventilated patients. The Alveoli and LUVs trials failed but had non-physiologic end points in using PEEP.

Are you suggesting APRV is much better, if so in which patients how would you know?

Is HFOV better, it doesn't seem like it from the OSCAR and OSCILLATE trials and not to mention the ref standard in canada was ARDSnet, where in the UK it was standard physician practice and the TV were on avg higher than in the canadian trial ( mean was higher than 8cc/kg of IBW vs. about 7cc/kg on avg with a goal of 6). Also the OSCILLATE trial was stopped early for harm maybe because the control group was more like ARDSnet and had improved mortality at 30 days (35% vs. 47%), where the UK OSCAR trial showed no difference in mortality (41% vs. 41%) but both groups had higher mortality than the protocoled ARDSnet control group in OSCILLATE.

Lastly, don't think anyone is happy with mortality of 32%, but its better than 40% which was what was seen previously. Also the incidence, as I eluded to earlier, of ARDS is declining. There are tons of trials that have looked at steroids, fish oil, feeding, neuromuscular blockers early and for short duration, stem cells, statins etc... Many on-going so people are moving towards finding better patient outcomes.

I guess I'm wondering what you are proposing? I'm all for a one size does not fit all approach, and titrating to more physiologic end points like stress index, compliance, maybe esophageal manometry, but this is all cutting edge and evolving, and we always have to be careful of being TOO ahead of the curve, IMHO.

 

[Hernandez]

I get the feeling he's hawking APRV, which works....in a small subset of patients but lacks and substantial data behind it. We know LTV is equivalent and like better than HFOV (in most patients) and proning helps (supposedly), paralytics help(the nurses), ECMO likely works better (in a subset of patients) (until they bleed in spectacular fashion)

But hey, the experiment group in the proning trial had a mortality of 16%!

 

[europeman]

We were proning here for literally YEARS before the last big study came out because we saw time after time in our shop that the results were fantastic. The biggest issue is nursing training so you don't kill anyone in the process!

Anyway for me of course it's APRV! Hernandez sees right thru me!

Aprv is the epitome of a mode which you can adapt to the patient rather than the other way around though. Patient is basically allowed to breath at a cpap on their own and it's much more comfortable and they get recruited. It's just so much more physiologic.

I actually found an hold Habashi video which explains it very nicely..... So much mis understanding about this mode!

Guys I grew up with ARDSnet too! I'm not nuts! It's like a cult the ApRV cult versis ARDSnet cult people! Can't we all just get along haha

Anyway watch below.... I actually just found these! Check em out.

 

[europeman]

Anyone have thoughts on these videos?