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Ventilatory strategies in septic patients

Results from a nationwide observational trial

Beatmungsstrategien bei septischen Patienten

Ergebnisse einer nationalen Observationsstudie

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Abstract

Background

Mortality in intensive care unit (ICU) patients is affected by multiple variables. The possible impact of the mode of ventilation has not yet been clarified; therefore, a secondary analysis of the “epidemiology of sepsis in Germany” study was performed. The aims were (1) to describe the ventilation strategies currently applied in clinical practice, (2) to analyze the association of the different modes of ventilation with mortality and (3) to investigate whether the ratio between arterial partial pressure of oxygen and inspired fraction of oxygen (PF ratio) and/or other respiratory variables are associated with mortality in septic patients needing ventilatory support.

Methods

A total of 454 ICUs in 310 randomly selected hospitals participated in this national prospective observational 1-day point prevalence of sepsis study including 415 patients with severe sepsis or septic shock according to the American College of Chest Physicians/Society of Critical Care Medicine criteria.

Results

Of the 415 patients, 331 required ventilatory support. Pressure controlled ventilation (PCV) was the most frequently used ventilatory mode (70.6 %) followed by assisted ventilation (AV 21.7 %) and volume controlled ventilation (VCV 7.7 %). Hospital mortality did not differ significantly among patients ventilated with PCV (57 %), VCV (71 %) or AV (51 %, p = 0.23). A PF ratio equal or less than 300 mmHg was found in 83.2 % of invasively ventilated patients (n = 316). In AV patients there was a clear trend to a higher PF ratio (204 ± 70 mmHg) than in controlled ventilated patients (PCV 179 ± 74 mmHg, VCV 175 ± 75 mmHg, p = 0.0551). Multiple regression analysis identified the tidal volume to pressure ratio (tidal volume divided by peak inspiratory airway pressure, odds ratio OR = 0.94, 95 % confidence interval 95% CI = 0.89–0.99), acute renal failure (OR = 2.15, 95% CI = 1.01–4.55) and acute physiology and chronic health evaluation (APACHE) II score (OR = 1.09, 95% CI = 1.03–1.15) but not the PF ratio (univariate analysis OR = 0.998, 95 % CI = 0.995–1.001) as independent risk factors for in-hospital mortality.

Conclusions

This representative survey revealed that severe sepsis or septic shock was frequently associated with acute lung injury. Different ventilatory modes did not affect mortality. The tidal volume to inspiratory pressure ratio but not the PF ratio was independently associated with mortality.

Zusammenfassung

Hintergrund

Die Überlebenswahrscheinlichkeit von Patienten auf der Intensivstation wird von verschiedenen Faktoren beeinflusst. Der mögliche Einfluss der Beatmungsform auf die Sterblichkeit ist bis jetzt nicht ausreichend untersucht worden. Daher wurde eine Sekundäranalyse der „Prävalenz der Sepsis in Deutschland-Studie“ mit den Zielen durchgeführt, 1) die aktuelle Beatmungstherapie bei septischen Patienten zu beschreiben, 2) den Einfluss verschiedener Beatmungsformen auf die Sterblichkeit zu untersuchen und 3) herauszufinden, ob die Sterblichkeit der Patienten mit dem Horowitz-Index (HI, Quotient aus dem arteriellen Sauerstoffpartialdruck und der inspiratorischen Sauerstofffraktion) und/oder anderen respiratorischen Faktoren assoziiert ist.

Material und Methoden

An dieser nationalen, prospektiven, multizentrischen Observationsstudie nahmen 454 Intensivstationen von 310 zufällig ausgewählten Krankenhäusern teil. In die Studie wurden 415 Patienten, die die Kriterien einer schweren Sepsis oder eines septischen Schocks erfüllten, aufgenommen.

Ergebnisse

Es waren 331 der 415 teilnehmenden Patienten beatmungspflichtig. Druckkontrollierte Beatmung („pressure controlled ventilation“, PCV) war die am häufigsten benutzte Beatmungsform (70,6%), gefolgt von assistierter Spontanatmung („assisted ventilation“, AV; 21,7%) und volumenkontrollierter Beatmung („volume controlled ventilation“, VCV; 7,7%). Die Krankenhaussterblichkeit unterschied sich nicht signifikant zwischen PCV (57%), VCV (71%) und AV (51%; p = 0,23). Einen HI ≤300 mmHg zeigten 83,2% der invasiv beatmeten Patienten (n = 316). Bei assistiert-beatmeten Patienten konnte ein klarer Trend zu einem höheren HI (204 ± 70 mmHg) im Vergleich zu PCV (179 ± 74 mmHg) und VCV (175 ± 75 mmHg; p = 0,0551) festgestellt werden. Die multivariate logistische Regressionsanalyse identifizierte das Verhältnis zwischen dem Atemzugvolumen und dem Inspirationsdruck [“odds ratio“ (OR) = 0,94; 95%-Konfidenzintervall (95%-KI) 0,89–0,99], die renale Dysfunktion (OR = 2,15; 95%-KI 1,01–4,55) und den „Acute Physiology And Chronic Health Evaluation (APACHE) II Score“ (OR = 1,09; 95%-KI 1,03–1,15), aber nicht den HI (univariate Analyse OR = 0,998, 95%-KI 0,995–1,001) als unabhängige Risikofaktoren für den Tod der Patienten.

Schlussfolgerungen

Diese repräsentative Beobachtungsstudie zeigte, dass die schwere Sepsis oder der septische Schock häufig mit einer Lungenschädigung einhergehen. Unterschiedliche Beatmungsformen beeinflussen hierbei nicht die Sterblichkeit der Patienten. Das Verhältnis von Atemzugvolumen zu Inspirationsdruck, aber nicht der HI war unabhängig mit der Sterblichkeit assoziiert.

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Acknowledgements

The study was supported by the Federal Ministry of Education and Research, Berlin, Germany (BMBF, Grant No. 01 KI 0106) and an unrestricted grant from Lilly Germany, Bad Homburg, Germany. Neither party was actively involved in any phase of the study (design and conduct of the study, collection, management, analysis and interpretation of the data, preparation, review and decision to submit the manuscript for publication).

The authors thank all the ICU physicians throughout Germany who participated and devoted their time to the study.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany

    D. Schädler, G. Elke, I. Frerichs, J. Scholz & N. Weiler

  2. Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany

    C. Engel & M. Loeffler

  3. Clinical Trial Center Leipzig, University of Leipzig, Leipzig, Germany

    H. Bogatsch

  4. Department of Intensive Care Medicine, Helios Hospital Berlin-Buch, Berlin, Germany

    R. Kuhlen

  5. Department of Anesthesiology, University Hospital Aachen, Aachen, Germany

    R. Rossaint

  6. Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany

    M. Quintel

  7. Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University Jena, Jena, Germany

    F.M. Brunkhorst & K. Reinhart

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  1. D. Schädler
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  2. G. Elke
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  3. C. Engel
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  10. F.M. Brunkhorst
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  11. M. Loeffler
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  13. N. Weiler
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Consortia

For the German Competence Network Sepsis (SepNet)

Corresponding author

Correspondence to D. Schädler.

Additional information

D.S. participated in the design of the study, analyzed and interpreted the data and drafted the manuscript. G.E. participated in the design of the study and helped to draft the manuscript. C.E. and H.B. performed the statistical analysis and helped to draft the manuscript. I.F. helped to draft and revise the manuscript. R.K., M.Q. and J.S. helped in the analysis and interpretation of the data. R.R. helped in the analysis and interpretation of the data and helped to draft the manuscript. F.M.B. and K.R. participated in the design of the study and helped in the analysis and interpretation of the data. M.L. helped in the statistical analysis and interpretation of the data. N.W. participated in the design, analysis and interpretation of the data and helped to draft the manuscript. All authors have critically revised and approved the final manuscript.

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Schädler, D., Elke, G., Engel, C. et al. Ventilatory strategies in septic patients. Anaesthesist 62, 27–33 (2013). https://doi.org/10.1007/s00101-012-2121-2

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