Patterns of use of adjunctive therapies in patients with early moderate- severe Acute Respiratory Distress syndrome: Insights from the LUNG SAFE Study

BACKGROUND: Adjunctive strategies are an important part of the management of acute respiratory distress syndrome (ARDS). However, their application in clinical practice remains inconsistent. RESEARCH QUESTION: We wished to determine the frequency and patterns of use of adjunctive strategies in patients with moderate-severe ARDS (P/F ratio < 150) enrolled into the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. STUDY DESIGN AND METHODS: The LUNG SAFE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted in 2014 in 459 ICUs from 50 countries. The primary objective of this substudy was to determine the frequency of use of widely available (neuromuscular blockade, prone position) adjuncts versus adjuncts requiring specialized equipment (ECMO, Inhaled vasodilators, HFOV) in patients in the first 48 hours of moderate-severe ARDS (P/F ratio < 150). RESULTS: Of 1,151 invasively ventilated patients with moderate-severe ARDS, 818 pts (71%) received no adjunct within 48h of ARDS onset. Of 335 (29%) that received adjunctive strategies, 248 (75%) received a single strategy, and 85 (26%) receiving more than one adjunct. Of ARDS non-survivors, 67% did not receive any adjunctive strategy in the first 48 hours. Most patients (63%) receiving specialized adjuncts did not receive prone positioning or neuromuscular blockade. Patients that received adjuncts were more likely to have their ARDS recognized, be younger and sicker, have pneumonia, and be more difficult to ventilate, and be in a European high income country than those that did not receive adjuncts. INTERPRETATION: Three in ten patients with moderate-severe ARDS, and only one third of non-survivors, received adjunctive strategies over the first 48 hours of ARDS. A more consistent and evidence driven approach to adjunct use may reduce costs and improve outcomes in patients with moderate-severe ARDS