• Alexandre Demoule, Massimo Antonelli, Peter Schellongowski, Peter Pickkers, Marcio Soares, Tine Meyhoff, Jordi Rello, Philippe R Bauer, Andry van de Louw, Virgine Lemiale, David Grimaldi, Ignacio Martin-Loeches, Martin Balik, Sangeeta Mehta, Achille Kouatchet, Andreas Barratt-Due, Miia Valkonen, Jean Reignier, Victoria Metaxa, Anne-Sophie Moreau, Gaston Burghi, Djamel Mokart, Julien Mayaux, Michael Darmon, Elie Azoulay, and EFRAIM Investigators.
• AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France. Electronic address: alexandre.demoule@aphp.fr.
• Chest. 2020 Nov 1; 158 (5): 1947-1957.

BackgroundIn view of the high mortality rate of immunocompromised patients with ARDS, it is important to identify targets for improvement.Research QuestionThis study investigated factors associated with mortality in this specific ARDS population, including factors related to respiratory mechanics (plateau pressure [Pplat,rs], compliance [Crs], and driving pressure [ΔPrs]).Study Design And MethodsThis study consisted of a predefined secondary analysis of the EFRAIM data. Overall, 789 of 1,611 patients met the Berlin criteria for ARDS, and Pplat,rs, ΔPrs, and Crs were available for 494 patients. A hierarchical model was used to assess factors at ARDS onset independently associated with hospital mortality.ResultsHospital mortality was 56.3%. After adjustment, variables independently associated with hospital mortality included ARDS of undetermined etiology (OR, 1.66; 95% CI, 1.01-2.72), need for vasopressors (OR, 1.91; 95% CI, 1.27-2.88), and need for renal replacement therapy (OR, 2.02; 95% CI, 1.37-2.97). ARDS severity according to the Berlin definition, neutropenia on admission, and the type of underlying disease were not significantly associated with mortality. Before adjustment, higher Pplat,rs, higher ΔPrs, and lower Crs were associated with higher mortality. Addition of each of these individual variables to the final hierarchical model revealed a significant association with mortality: ΔPrs (OR, 1.08; 95% CI, 1.05-1.12), Pplat,rs (OR, 1.07; 95% CI, 1.04-1.11), and Crs (OR, 0.97; 95% CI, 0.95-0.98). Tidal volume was not associated with mortality.InterpretationIn immunocompromised patients with ARDS, respiratory mechanics provide additional prognostic information to predictors of hospital mortality. Studies designed to define lung-protective ventilation guided by these physiological variables may be warranted in this specific population.Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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