Intensive care medicine · 2026
Respiratory mechanics modifies the impact of ventilator settings on clinical outcome in patients with acute brain injury.
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Grieco Domenico Luca, Stronati Alessandro, Robba Chiara, Rosà Tommaso, Iavarone Ida G, Rezoagli Emanuele, Bongiovanni Filippo, Dell'Anna Antonio M, Cardu Alessandro, Graziano Francesca, Galimberti Stefania, Caricato Anselmo, Patroniti Nicolò, Taccone Fabio Silvio, Citerio Giuseppe, Antonelli Massimo
Аннотация
PURPOSE: To investigate whether respiratory system elastance (ERS) modifies the associations of tidal volume (VT) and respiratory rate with clinical outcomes in mechanically ventilated patients with acute brain injury.
METHODS: In this post hoc analysis of the VENTIBRAIN study, ERS was computed as the ratio of driving pressure (ΔP) to VT/PBW. Effect modification by ERS on outcome associations was assessed.
RESULTS: In 1158 patients, VT was similar across ERS tertiles (median 7.9, 7.6 and 7.1 mL/kg), resulting in a marked ΔP gradient across tertiles (median 5, 9, and 12 cmH2O). Higher VT was associated with lower ICU mortality in patients with low ERS (OR 0.52, 95%CI 0.36-0.74) but not in those with high ERS (OR 1.16, 95% CI 0.89-1.51; Pint < 0.001). Higher respiratory rate was associated with worse outcomes, particularly at low ERS, with the association attenuating at higher ERS. The Bayesian optimal VT/PBW decreased continuously with ERS, from 11.4 mL/kg at ERS 0.5 cmH2O/(mL/kg) (≈ ΔP 6 cmH2O) to 4.4 mL/kg at ERS 2.5 cmH2O/(mL/kg) (≈ ΔP 11 cmH2O), while the optimal respiratory rate increased from 15 to 19 breaths/min. At constant alveolar ventilation, 1-cmH2O ΔP increase had comparable prognostic impact to ≈ 3 breaths/min respiratory rate increases. These results were consistent irrespective of ARDS diagnosis.
CONCLUSIONS: The impact of ventilator settings is modulated by ERS. A physiological framework for VT adjustment could consider ΔP along with the respiratory rate required to maintain isocapnia, with outcome effects governed by a trade-off of ≈ 3 breaths/min per 1-cmH2O change in ΔP.
METHODS: In this post hoc analysis of the VENTIBRAIN study, ERS was computed as the ratio of driving pressure (ΔP) to VT/PBW. Effect modification by ERS on outcome associations was assessed.
RESULTS: In 1158 patients, VT was similar across ERS tertiles (median 7.9, 7.6 and 7.1 mL/kg), resulting in a marked ΔP gradient across tertiles (median 5, 9, and 12 cmH2O). Higher VT was associated with lower ICU mortality in patients with low ERS (OR 0.52, 95%CI 0.36-0.74) but not in those with high ERS (OR 1.16, 95% CI 0.89-1.51; Pint < 0.001). Higher respiratory rate was associated with worse outcomes, particularly at low ERS, with the association attenuating at higher ERS. The Bayesian optimal VT/PBW decreased continuously with ERS, from 11.4 mL/kg at ERS 0.5 cmH2O/(mL/kg) (≈ ΔP 6 cmH2O) to 4.4 mL/kg at ERS 2.5 cmH2O/(mL/kg) (≈ ΔP 11 cmH2O), while the optimal respiratory rate increased from 15 to 19 breaths/min. At constant alveolar ventilation, 1-cmH2O ΔP increase had comparable prognostic impact to ≈ 3 breaths/min respiratory rate increases. These results were consistent irrespective of ARDS diagnosis.
CONCLUSIONS: The impact of ventilator settings is modulated by ERS. A physiological framework for VT adjustment could consider ΔP along with the respiratory rate required to maintain isocapnia, with outcome effects governed by a trade-off of ≈ 3 breaths/min per 1-cmH2O change in ΔP.