• Gaetano Florio, Matteo Ferrari, Edward A Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai, Kathryn Hibbert, Jean Kwo, Richard M Pino, Jeanine Wiener-Kronish, AmatoMarcelo B PMBPPulmonary Division, Cardio-Pulmonary Department, Heart Institute (Incor), Hospital Das Clinicas da FMUSP, University of Sao Paulo, Sao Paulo, Brazil., Pankaj Arora, Robert M Kacmarek, Lorenzo Berra, and investigators of the lung rescue team.
• Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA.
• Crit Care. 2020 Jan 15; 24 (1): 44.

BackgroundLimited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS.MethodsIn this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012-2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015-2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring.ResultsThe standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13-0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74).ConclusionIndividualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.

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