Chest
Volume 128, Issue 5, November 2005, Pages 3098-3108
Journal home page for Chest

Clinical Investigations in Critical Care
High Tidal Volume and Positive Fluid Balance Are Associated With Worse Outcome in Acute Lung Injury

https://doi.org/10.1378/chest.128.5.3098Get rights and content

Study objectives: Recent data have suggested that ventilatory strategy could influence outcomes from acute lung injury (ALI) and ARDS. We tested the hypothesis that infection/sepsis and use of higher tidal volumes than those applied in the ARDS Network (ARDSnet) study (> 7.4 mL/kg of predicted body weight) would worsen outcome in patients with ALI/ARDS.

Design: International cohort, observational study.

Setting: One hundred ninety-eight European ICUs participating in the Sepsis Occurrence in Acutely Ill Patients study.

Patients or participants: All 3,147 adult patients admitted to one of the participating ICUs between May 1, 2002, and May 15, 2002.

Interventions: None.

Measurements and results: Patients were followed up until death, hospital discharge, or for 60 days. Of the 3,147 patients, 393 patients (12.5%) had ALI/ARDS. ICU and hospital mortality was higher in patients with ALI/ARDS than those without ALI/ARDS (38.9% vs 15.6% and 45.5% vs 21.0%, respectively; p < 0.001). A multivariable logistic regression analysis with ICU outcome as the dependent factor showed that the independent risks for mortality were as follows: presence of cancer, use of tidal volumes higher than those used by the ARDSnet study, degree of multiorgan dysfunction, and higher mean fluid balance. Sepsis, septic shock, and oxygenation at the onset of ALI/ARDS were not independently associated with higher mortality rates.

Conclusions: In addition to comorbidities and organ dysfunction, high tidal volumes and positive fluid balance are associated with a worse outcome from ALI/ARDS.

Section snippets

Study Design

This prospective, multicenter, observational study included all patients > 15 years old newly admitted to one of 198 ICUs participating in the Sepsis Occurrence in Acutely Ill Patients (SOAP) network in 24 European countries during a 14-day period from May 1, 2002, to May 15, 2002. Clinical sites were recruited by open invitation, and study participation was voluntary with no financial incentive. Institutional review board approval was either waived or expedited in all institutions, and

RESULTS

Of the 3,147 patients included in the SOAP study, 2,025 patients (64.3%) received mechanical ventilation during the ICU stay. Three hundred ninety-three patients (12.5%) had either ALI or ARDS; 85.0% of these patients had ARDS, and 15.0% had ALI. ALI/ARDS was observed on ICU admission in 329 patients (83.5%), while ALI/ARDS developed in the rest 1 to 2 days after ICU admission. Patients with ALI/ARDS had higher ICU (38.9% vs 15.6%, p < 0.001) and hospital (45.5% vs 21.0%, p < 0.001) mortality

DISCUSSION

The major finding of our study was that in addition to comorbidities such as cancer, positive fluid balance, and multiple organ failure, use of a tidal volume higher than the one used in the low tidal volume arm of the ARDSnet study was independently associated with a worse outcome from ALI/ARDS. Infection, sepsis, and septic shock were not associated with a higher mortality. It should be acknowledged that information regarding a number of factors potentially able to influence mortality in the

SOAP INVESTIGATORS

Austria: University Hospital of Vienna (G. Delle Karth); LKH Steyr (V. Draxler); LKH-Deutschlandsberg (G. Filzwieser); Otto Wagner Spital of Vienna (W. Heindl); Krems of Donau (G. Kellner, T. Bauer); Barmherzige Bruede of Linz (K. Lenz); KH Floridsdorf of Vienna (E. Rossmann); University Hospital of Innsbruck (C. Wiedermann); Belgium: CHU of Charleroi (P. Biston); Hôpitaux Iris Sud of Brussels (D. Chochrad); Clinique Europe Site St Michel of Brussels (V. Collin); C.H.U. of Liège (P. Damas);

REFERENCES (52)

  • MS Gowda et al.

    Variability of indices of hypoxemia in adult respiratory distress syndrome.

    Crit Care Med

    (1997)
  • RS Simmons et al.

    Fluid balance and the adult respiratory distress syndrome.

    Am Rev Respir Dis

    (1987)
  • VM Ranieri et al.

    Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial.

    JAMA

    (1999)
  • D Dreyfuss et al.

    Role of tidal volume FRC, and end-inspiratory volume in the development of pulmonary edema following mechanical ventilation.

    Am Rev Respir Dis

    (1993)
  • N Engl J Med

    (2000)
  • MD Eisner et al.

    Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung injury and the acute respiratory distress syndrome.

    Am J Respir Crit Care Med

    (2001)
  • CR Weinert et al.

    Impact of randomized trial results on acute lung injury ventilator therapy in teaching hospitals.

    Am J Respir Crit Care Med

    (2003)
  • MP Young et al.

    Ventilation of patients with acute lung injury and acute respiratory distress syndrome: has new evidence changed clinical practice?

    Crit Care Med

    (2004)
  • MB Amato et al.

    Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome.

    N Engl J Med

    (1998)
  • TE Stewart et al.

    Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome.

    N Engl J Med

    (1998)
  • L Brochard et al.

    Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome: The Multicenter Trial Group on Tidal Volume reduction in ARDS.

    Am J Respir Crit Care Med

    (1998)
  • RG Brower et al.

    Prospective, randomized, controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients.

    Crit Care Med

    (1999)
  • PQ Eichacker et al.

    Meta-analysis of acute lung injury and acute respiratory distress syndrome trials testing low tidal volumes.

    Am J Respir Crit Care Med

    (2002)
  • J-R Le Gall et al.

    A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study.

    JAMA

    (1993)
  • JL Vincent et al.

    Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicentric, prospective study.

    Crit Care Med

    (1998)
  • RO Crapo et al.

    Reference spirometric values using techniques and equipment that meet ATS recommendations.

    Am Rev Respir Dis

    (1981)
  • Cited by (344)

    View all citing articles on Scopus

    This study was endorsed by the European Society of Intensive Care Medicine and supported by an unrestricted grant from Abbott, Baxter, Eli Lilly, GlaxoSmithKline, and NovoNordisk.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text