Airway Pressure Release Ventilation for Moderate-to-severe Acute Respiratory Distress Syndrome
- Conditions
- Acute Respiratory Distress Syndrome
- Interventions
- Device: Low tidal volume ventilationDevice: Airway pressure release ventilation
- Registration Number
- NCT04156438
- Lead Sponsor
- Saskatchewan Health Authority - Regina Area
- Brief Summary
This study will examine the feasibility of a large clinical trial investigating the effectiveness of airway pressure release ventilation and low tidal volume ventilation for patients with moderate-to-severe acute respiratory distress syndrome.
- Detailed Description
Acute respiratory distress syndrome (ARDS) is a disease that has an incidence of 5% of hospitalized mechanically ventilated patients. ARDS is associated with high morbidity and mortality in critically ill patients, with mortality reported as high as 45% in severe ARDS. Patients who develop ARDS will require mechanical ventilation. Patients with ARDS are graded by the partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) into three categories of severity: mild (PaO2/FiO2 201-300 mm Hg), moderate (PaO2/FiO2 101-200 mmHg), and severe (PaO2/FiO2 ≤ 100).
Volutrauma and barotrauma are thought to contribute to the development of ARDS and alter mortality. The damage that occurs to the lungs manifests itself as inflammation, which leads to poor gas exchange of oxygen and carbon dioxide. Several strategies of lung-protective mechanical ventilation have been investigated in ARDS, including the use of low tidal volume ventilation (LTVV) or ARDSNet strategy, high frequency oscillation ventilation (HFOV), and airway pressure release ventilation (APRV). Lung protective strategies may be best beneficial prior to the onset of the development of ARDS or early in the course of the disease. As a result of the ARDSNet trial, LTVV has been adopted as the usual standard of care of ventilation and safest mode of ventilation for patients with ARDS.
Recently, APRV has been proposed as a potential alternative to LTVV. APRV is a form of ventilation that keeps the lungs inflated through the majority of the breath cycle and allows patients to breathe spontaneously above this level of inflation. APRV allows for spontaneous respiration with increased airway pressure, potentially allowing for decreased sedation, shorter duration of mechanical ventilation, and decreased need for vasopressors. APRV has been associated with possible reduction in incidence of ARDS and in-hospital mortality in non-randomized observational studies. In patients with established ARDS, the use of APRV has also not been well studied, with most studies limited to small observational studies often with no comparison group. One randomized trial using APRV alone had less than 30% of patients having a diagnosis of ARDS and did not show any difference in any outcomes. Recently, Zhou and colleagues conducted a randomized trial comparing APRV to conventional ventilation in 138 mechanically ventilated patients with mild to severe ARDS and found that APRV may shorten the duration of mechanical ventilation and reduce intensive care unit (ICU) length of stay.
While some of these studies had shown promise of APRV compared to LTVV, there has not been acceptance of APRV into guidelines as first line ventilation, and recommendations of institutions such as the Canadian Agency for Drugs and Technology in Health (CADTH) recommends interpreting these results with caution. Consequently, there remains clinical equipoise on this issue. Some ICU clinicians will currently use APRV as a rescue mode of ventilation in ARDS in their clinical practice while others will continue with the use of LTVV. We would like to randomize patients to LTVV or APRV and examine the feasibility of conducting a large multicentre randomized controlled trial in Canada.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 1
- Fulfilling the diagnostic criteria of ARDS, according to the Berlin definition
- Moderate to severe ARDS as defined as a PaO2: FiO2 ratio of ≤150 during invasive mechanical ventilation
- Endotracheal intubation and mechanical ventilation for ARDS less than 48 hours
-
Age less than 18 years
-
Pregnancy
-
Intracranial hypertension (suspected or confirmed)
-
Severe chronic obstructive pulmonary disease as defined by either:
- FEV1/FVC less than 50% predicted, or
- Chronic hypercarbia (PaCO2>45 mmHg), chronic hypoxemia (PaO2 < 55 mmHg) on room air, and/or elevated admission serum HCO3 >30 mmol/L
-
Presence of documented barotrauma, i.e. pneumothorax
-
Treatment with extracorporeal support (ECMO) at enrollment
-
Refractory shock
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Advanced directives indicating preferences to not have advanced life support
-
Moribund patient, i.e. not expected to survive longer than 24 hours
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Low tidal volume ventilation Low tidal volume ventilation Conventional low tidal volume ventilation Airway pressure release ventilation Airway pressure release ventilation Early use of airway pressure release ventilation
- Primary Outcome Measures
Name Time Method Informed consent rate Informed consent rate will be measured over a 1 year period of the pilot study A successful informed consent rate will be defined as ≥70% of substitute decision makers or patients approached choosing to participate in this trial
Protocol adherence rate Protocol adherence will be measured for each study patient, and compiled over the duration of the pilot study (i.e. 1 year). An adherence rate of at least 80% will be considered successful.
Recruitment rate Recruitment rate will be measured over the one year of the pilot study. A successful recruitment rate will be achieving at least 15 patients over the 1 year period.
- Secondary Outcome Measures
Name Time Method In-hospital mortality Up to 365 days Death, at hospital discharge
Hospital length of stay Up to 365 days Length of stay in the hospital in days
Length/duration of mechanical ventilation Up to 365 days Length of time patient was on mechanical ventilation
Incidence of tracheostomy Up to 365 days Incidence of tracheostomy during their ICU stay
ICU length of stay Up to 365 days Length of stay in the intensive care unit
28-day mortality Up to Day 28 Death, measured from time of enrollment until 28 days.
Trial Locations
- Locations (1)
Regina General Hospital
🇨🇦Regina, Saskatchewan, Canada