Personalized Mechanical Ventilation, Plasma SRAGE and Survival in ARDS PDF Download

Author: Erwan Laroche
Publisher:
ISBN:
Category :
Languages : en
Pages :

Get Book Here

Book Description
Computed tomography (CT) scan lung attenuation has contributed to the recognition of focal and nonfocal phenotypes (or morphotypes), with distinct prognosis and therapeutic responses among patients with acute respiratory distress syndrome (ARDS). Plasma soluble receptor for advanced glycation end-products (sRAGE) is a marker of alveolar type I cell injury, of impaired alveolar fluid clearance, and of a nonfocal morphotype that correlates with the severity and outcome of ARDS. The objectives were to verify whether baseline plasma sRAGE discriminates between focal and nonfocal ARDS and correlates with the severity and clinical outcomes of ARDS. In addition, this stuy investigated whether changes in plasma sRAGE could inform on prognosis in ARDS and wherher plasma sRAGE kinetics over the first days following ARDS onset would be impacted differentially in focal and nonfocal morphotypes by a personalized morphotpe-targeted ventilation strategy compared to the use of a more conventional mow tidal volume strategy. Plasma sRAGE levels were measured from 235 subjects enrolled in a large multicenter randomized controlled trial of lung imaging for ventilator setting in ARDS (LIVE study). Baseline plasma sRAGE was higher in patients with nonfocal ARDS than in those with focal ARDS (median [IQR], 3,577 [2,113-8,480] pg.mL ̄1vs. 2,346 [1,133-3,218] pg.mL ̄1, P = 0.0001), and it was associated with an increased severity of ARDS. Baseline plasma sRAGE was independently associated wiht 90-day mortality in patients ventiladed with a personalized strategy, but not in those ventilated wiht a conventional low tidal volume strategy. Higher day two-to-day zero and day three-to-day zero plasma sRAGE ratios were both associated with higher 90-day mortality (HR 1.08; 95% CI 1.01 to 1.15; P = 0.02 and 1.08; 95% CI 1.02 to 1.14; P = 0.01, respectively), regardless of the study group and ARDS morphotype. There was a significant decrease in plasma sRAGE on days two and three (P = 0.02 for both timepoints) in patients with focal ARDS ventiladed with a personalized strategy. In contrast, there was a significant increase in plasma sRAGE at all timepoints (P= 0.02, 0.004, 0.01, 0.01, and 0.001 for days one, two, three, four, and six, respectively) in patients with focal ARDS ventilated with a strategy combining higher positive end-expiratory pressure and recruitment maneuvers. Plasma sRAGE decreased at all timepoints in nonfocal ARDS when the morphotype was correctly classified at baseline, but it only decreased on days three and four when it was not. Changes in plasma sRAGE at days two and three following ARDS onset were associated whit higher 90-day mortality in patients with ARDS, regardless of the study group and ARDS morphotype. A personalized approach to the ventilation of patients with focal or nonfocal ARDS may be beneficial, in part by decreasing injury to the alveolar epithelium. Plama sRAGE is a promising biomarker for endotyping patients with ARDS and for monitoring responses to ventilator settings in ARDS.