Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome

Tariq A Dam; Harm-Jan de Grooth; Thomas Klausch; Lucas M Fleuren; Daan P de Bruin; Robert Entjes; Thijs C D Rettig; Dave A Dongelmans; Age D Boelens; Sander Rigter; Stefaan H A Hendriks; Remko de Jong; Marlijn J A Kamps; Marco Peters; A Karakus; Diederik Gommers; Dharmanand Ramnarain; Evert-Jan Wils; Sefanja Achterberg; Ralph Nowitzky; Walter van den Tempel; Cornelis P C de Jager; Fleur G C A Nooteboom; Evelien Oostdijk; Peter Koetsier; Alexander D Cornet; Auke C Reidinga; Wouter de Ruijter; Rob J Bosman; Tim Frenzel; Louise C Urlings-Strop; Paul de Jong; Ellen G M Smit; Olaf L Cremer; D Jannet Mehagnoul-Schipper; Harald J Faber; Judith Lens; Gert B Brunnekreef; Barbara Festen-Spanjer; Tom Dormans; Annemieke Dijkstra; Bram Simons; A A Rijkeboer; Sesmu Arbous; Marcel Aries; Menno Beukema; Daniël Pretorius; Rutger van Raalte; Martijn van Tellingen; Niels C Gritters van den Oever; Robbert C A Lalisang; Michele Tonutti; Armand R J Girbes; Mark Hoogendoorn; Patrick J Thoral; Paul W G Elbers

doi:https://doi.org/10.1097/CCE.0000000000000555

Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome

Tariq A Dam, Harm-Jan de Grooth, Thomas Klausch, Lucas M Fleuren, Daan P de Bruin, Robert Entjes, Thijs C D Rettig, Dave A Dongelmans, Age D Boelens, Sander Rigter, Stefaan H A Hendriks, Remko de Jong, Marlijn J A Kamps, Marco Peters, A Karakus, Diederik Gommers, Dharmanand Ramnarain, Evert-Jan Wils, Sefanja Achterberg, Ralph NowitzkyWalter van den Tempel, Cornelis P C de Jager, Fleur G C A Nooteboom, Evelien Oostdijk, Peter Koetsier, Alexander D Cornet, Auke C Reidinga, Wouter de Ruijter, Rob J Bosman, Tim Frenzel, Louise C Urlings-Strop, Paul de Jong, Ellen G M Smit, Olaf L Cremer, D Jannet Mehagnoul-Schipper, Harald J Faber, Judith Lens, Gert B Brunnekreef, Barbara Festen-Spanjer, Tom Dormans, Annemieke Dijkstra, Bram Simons, A A Rijkeboer, Sesmu Arbous, Marcel Aries, Menno Beukema, Daniël Pretorius, Rutger van Raalte, Martijn van Tellingen, Niels C Gritters van den Oever, Robbert C A Lalisang, Michele Tonutti, Armand R J Girbes, Mark Hoogendoorn, Patrick J Thoral, Paul W G Elbers

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

OBJECTIVES: As coronavirus disease 2019 is a novel disease, treatment strategies continue to be debated. This provides the intensive care community with a unique opportunity as the population of coronavirus disease 2019 patients requiring invasive mechanical ventilation is relatively homogeneous compared with other ICU populations. We hypothesize that the novelty of coronavirus disease 2019 and the uncertainty over its similarity with noncoronavirus disease 2019 acute respiratory distress syndrome resulted in substantial practice variation between hospitals during the first and second waves of coronavirus disease 2019 patients.

DESIGN: Multicenter retrospective cohort study.

SETTING: Twenty-five hospitals in the Netherlands from February 2020 to July 2020, and 14 hospitals from August 2020 to December 2020.

PATIENTS: One thousand two hundred ninety-four critically ill intubated adult ICU patients with coronavirus disease 2019 were selected from the Dutch Data Warehouse. Patients intubated for less than 24 hours, transferred patients, and patients still admitted at the time of data extraction were excluded.

MEASUREMENTS AND MAIN RESULTS: We aimed to estimate between-ICU practice variation in selected ventilation parameters (positive end-expiratory pressure, Fio2, set respiratory rate, tidal volume, minute volume, and percentage of time spent in a prone position) on days 1, 2, 3, and 7 of intubation, adjusted for patient characteristics as well as severity of illness based on Pao2/Fio2 ratio, pH, ventilatory ratio, and dynamic respiratory system compliance during controlled ventilation. Using multilevel linear mixed-effects modeling, we found significant (p ≤ 0.001) variation between ICUs in all ventilation parameters on days 1, 2, 3, and 7 of intubation for both waves.

CONCLUSIONS: This is the first study to clearly demonstrate significant practice variation between ICUs related to mechanical ventilation parameters that are under direct control by intensivists. Their effect on clinical outcomes for both coronavirus disease 2019 and other critically ill mechanically ventilated patients could have widespread implications for the practice of intensive care medicine and should be investigated further by causal inference models and clinical trials.

Original language	English
Pages (from-to)	e0555
Journal	Critical Care Explorations
Volume	3
Issue number	10
DOIs	https://doi.org/10.1097/CCE.0000000000000555
Publication status	Published - Oct 2021

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Dam, T. A., de Grooth, H.-J., Klausch, T., Fleuren, L. M., de Bruin, D. P., Entjes, R., Rettig, T. C. D., Dongelmans, D. A., Boelens, A. D., Rigter, S., Hendriks, S. H. A., de Jong, R., Kamps, M. J. A., Peters, M., Karakus, A., Gommers, D., Ramnarain, D., Wils, E.-J., Achterberg, S., ... Elbers, P. W. G. (2021). Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Critical Care Explorations, 3(10), e0555. https://doi.org/10.1097/CCE.0000000000000555

@article{5da28b461525446092569621366a44e9,

title = "Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome",

abstract = "OBJECTIVES: As coronavirus disease 2019 is a novel disease, treatment strategies continue to be debated. This provides the intensive care community with a unique opportunity as the population of coronavirus disease 2019 patients requiring invasive mechanical ventilation is relatively homogeneous compared with other ICU populations. We hypothesize that the novelty of coronavirus disease 2019 and the uncertainty over its similarity with noncoronavirus disease 2019 acute respiratory distress syndrome resulted in substantial practice variation between hospitals during the first and second waves of coronavirus disease 2019 patients.DESIGN: Multicenter retrospective cohort study.SETTING: Twenty-five hospitals in the Netherlands from February 2020 to July 2020, and 14 hospitals from August 2020 to December 2020.PATIENTS: One thousand two hundred ninety-four critically ill intubated adult ICU patients with coronavirus disease 2019 were selected from the Dutch Data Warehouse. Patients intubated for less than 24 hours, transferred patients, and patients still admitted at the time of data extraction were excluded.MEASUREMENTS AND MAIN RESULTS: We aimed to estimate between-ICU practice variation in selected ventilation parameters (positive end-expiratory pressure, Fio2, set respiratory rate, tidal volume, minute volume, and percentage of time spent in a prone position) on days 1, 2, 3, and 7 of intubation, adjusted for patient characteristics as well as severity of illness based on Pao2/Fio2 ratio, pH, ventilatory ratio, and dynamic respiratory system compliance during controlled ventilation. Using multilevel linear mixed-effects modeling, we found significant (p ≤ 0.001) variation between ICUs in all ventilation parameters on days 1, 2, 3, and 7 of intubation for both waves.CONCLUSIONS: This is the first study to clearly demonstrate significant practice variation between ICUs related to mechanical ventilation parameters that are under direct control by intensivists. Their effect on clinical outcomes for both coronavirus disease 2019 and other critically ill mechanically ventilated patients could have widespread implications for the practice of intensive care medicine and should be investigated further by causal inference models and clinical trials.",

author = "Dam, {Tariq A} and {de Grooth}, Harm-Jan and Thomas Klausch and Fleuren, {Lucas M} and {de Bruin}, {Daan P} and Robert Entjes and Rettig, {Thijs C D} and Dongelmans, {Dave A} and Boelens, {Age D} and Sander Rigter and Hendriks, {Stefaan H A} and {de Jong}, Remko and Kamps, {Marlijn J A} and Marco Peters and A Karakus and Diederik Gommers and Dharmanand Ramnarain and Evert-Jan Wils and Sefanja Achterberg and Ralph Nowitzky and {van den Tempel}, Walter and {de Jager}, {Cornelis P C} and Nooteboom, {Fleur G C A} and Evelien Oostdijk and Peter Koetsier and Cornet, {Alexander D} and Reidinga, {Auke C} and {de Ruijter}, Wouter and Bosman, {Rob J} and Tim Frenzel and Urlings-Strop, {Louise C} and {de Jong}, Paul and Smit, {Ellen G M} and Cremer, {Olaf L} and Mehagnoul-Schipper, {D Jannet} and Faber, {Harald J} and Judith Lens and Brunnekreef, {Gert B} and Barbara Festen-Spanjer and Tom Dormans and Annemieke Dijkstra and Bram Simons and Rijkeboer, {A A} and Sesmu Arbous and Marcel Aries and Menno Beukema and Dani{\"e}l Pretorius and {van Raalte}, Rutger and {van Tellingen}, Martijn and {Gritters van den Oever}, {Niels C} and Lalisang, {Robbert C A} and Michele Tonutti and Girbes, {Armand R J} and Mark Hoogendoorn and Thoral, {Patrick J} and Elbers, {Paul W G}",

note = "Copyright {\textcopyright} 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.",

year = "2021",

month = oct,

doi = "https://doi.org/10.1097/CCE.0000000000000555",

language = "English",

volume = "3",

pages = "e0555",

journal = "Critical Care Explorations",

issn = "2639-8028",

publisher = "Lippincott Williams and Wilkins",

number = "10",

}

Dam, TA , de Grooth, H-J , Klausch, T , Fleuren, LM, de Bruin, DP, Entjes, R, Rettig, TCD, Dongelmans, DA, Boelens, AD, Rigter, S, Hendriks, SHA, de Jong, R, Kamps, MJA, Peters, M, Karakus, A, Gommers, D, Ramnarain, D, Wils, E-J, Achterberg, S, Nowitzky, R, van den Tempel, W, de Jager, CPC, Nooteboom, FGCA, Oostdijk, E, Koetsier, P, Cornet, AD, Reidinga, AC, de Ruijter, W, Bosman, RJ, Frenzel, T, Urlings-Strop, LC, de Jong, P, Smit, EGM, Cremer, OL, Mehagnoul-Schipper, DJ, Faber, HJ, Lens, J, Brunnekreef, GB, Festen-Spanjer, B, Dormans, T, Dijkstra, A, Simons, B, Rijkeboer, AA, Arbous, S, Aries, M, Beukema, M, Pretorius, D, van Raalte, R, van Tellingen, M, Gritters van den Oever, NC, Lalisang, RCA, Tonutti, M, Girbes, ARJ, Hoogendoorn, M, Thoral, PJ & Elbers, PWG 2021, 'Some Patients Are More Equal Than Others: Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome', Critical Care Explorations, vol. 3, no. 10, pp. e0555. https://doi.org/10.1097/CCE.0000000000000555

TY - JOUR

T1 - Some Patients Are More Equal Than Others

T2 - Variation in Ventilator Settings for Coronavirus Disease 2019 Acute Respiratory Distress Syndrome

AU - Dam, Tariq A

AU - de Grooth, Harm-Jan

AU - Klausch, Thomas

AU - Fleuren, Lucas M

AU - de Bruin, Daan P

AU - Entjes, Robert

AU - Rettig, Thijs C D

AU - Dongelmans, Dave A

AU - Boelens, Age D

AU - Rigter, Sander

AU - Hendriks, Stefaan H A

AU - de Jong, Remko

AU - Kamps, Marlijn J A

AU - Peters, Marco

AU - Karakus, A

AU - Gommers, Diederik

AU - Ramnarain, Dharmanand

AU - Wils, Evert-Jan

AU - Achterberg, Sefanja

AU - Nowitzky, Ralph

AU - van den Tempel, Walter

AU - de Jager, Cornelis P C

AU - Nooteboom, Fleur G C A

AU - Oostdijk, Evelien

AU - Koetsier, Peter

AU - Cornet, Alexander D

AU - Reidinga, Auke C

AU - de Ruijter, Wouter

AU - Bosman, Rob J

AU - Frenzel, Tim

AU - Urlings-Strop, Louise C

AU - de Jong, Paul

AU - Smit, Ellen G M

AU - Cremer, Olaf L

AU - Mehagnoul-Schipper, D Jannet

AU - Faber, Harald J

AU - Lens, Judith

AU - Brunnekreef, Gert B

AU - Festen-Spanjer, Barbara

AU - Dormans, Tom

AU - Dijkstra, Annemieke

AU - Simons, Bram

AU - Rijkeboer, A A

AU - Arbous, Sesmu

AU - Aries, Marcel

AU - Beukema, Menno

AU - Pretorius, Daniël

AU - van Raalte, Rutger

AU - van Tellingen, Martijn

AU - Gritters van den Oever, Niels C

AU - Lalisang, Robbert C A

AU - Tonutti, Michele

AU - Girbes, Armand R J

AU - Hoogendoorn, Mark

AU - Thoral, Patrick J

AU - Elbers, Paul W G

PY - 2021/10

Y1 - 2021/10

N2 - OBJECTIVES: As coronavirus disease 2019 is a novel disease, treatment strategies continue to be debated. This provides the intensive care community with a unique opportunity as the population of coronavirus disease 2019 patients requiring invasive mechanical ventilation is relatively homogeneous compared with other ICU populations. We hypothesize that the novelty of coronavirus disease 2019 and the uncertainty over its similarity with noncoronavirus disease 2019 acute respiratory distress syndrome resulted in substantial practice variation between hospitals during the first and second waves of coronavirus disease 2019 patients.DESIGN: Multicenter retrospective cohort study.SETTING: Twenty-five hospitals in the Netherlands from February 2020 to July 2020, and 14 hospitals from August 2020 to December 2020.PATIENTS: One thousand two hundred ninety-four critically ill intubated adult ICU patients with coronavirus disease 2019 were selected from the Dutch Data Warehouse. Patients intubated for less than 24 hours, transferred patients, and patients still admitted at the time of data extraction were excluded.MEASUREMENTS AND MAIN RESULTS: We aimed to estimate between-ICU practice variation in selected ventilation parameters (positive end-expiratory pressure, Fio2, set respiratory rate, tidal volume, minute volume, and percentage of time spent in a prone position) on days 1, 2, 3, and 7 of intubation, adjusted for patient characteristics as well as severity of illness based on Pao2/Fio2 ratio, pH, ventilatory ratio, and dynamic respiratory system compliance during controlled ventilation. Using multilevel linear mixed-effects modeling, we found significant (p ≤ 0.001) variation between ICUs in all ventilation parameters on days 1, 2, 3, and 7 of intubation for both waves.CONCLUSIONS: This is the first study to clearly demonstrate significant practice variation between ICUs related to mechanical ventilation parameters that are under direct control by intensivists. Their effect on clinical outcomes for both coronavirus disease 2019 and other critically ill mechanically ventilated patients could have widespread implications for the practice of intensive care medicine and should be investigated further by causal inference models and clinical trials.

AB - OBJECTIVES: As coronavirus disease 2019 is a novel disease, treatment strategies continue to be debated. This provides the intensive care community with a unique opportunity as the population of coronavirus disease 2019 patients requiring invasive mechanical ventilation is relatively homogeneous compared with other ICU populations. We hypothesize that the novelty of coronavirus disease 2019 and the uncertainty over its similarity with noncoronavirus disease 2019 acute respiratory distress syndrome resulted in substantial practice variation between hospitals during the first and second waves of coronavirus disease 2019 patients.DESIGN: Multicenter retrospective cohort study.SETTING: Twenty-five hospitals in the Netherlands from February 2020 to July 2020, and 14 hospitals from August 2020 to December 2020.PATIENTS: One thousand two hundred ninety-four critically ill intubated adult ICU patients with coronavirus disease 2019 were selected from the Dutch Data Warehouse. Patients intubated for less than 24 hours, transferred patients, and patients still admitted at the time of data extraction were excluded.MEASUREMENTS AND MAIN RESULTS: We aimed to estimate between-ICU practice variation in selected ventilation parameters (positive end-expiratory pressure, Fio2, set respiratory rate, tidal volume, minute volume, and percentage of time spent in a prone position) on days 1, 2, 3, and 7 of intubation, adjusted for patient characteristics as well as severity of illness based on Pao2/Fio2 ratio, pH, ventilatory ratio, and dynamic respiratory system compliance during controlled ventilation. Using multilevel linear mixed-effects modeling, we found significant (p ≤ 0.001) variation between ICUs in all ventilation parameters on days 1, 2, 3, and 7 of intubation for both waves.CONCLUSIONS: This is the first study to clearly demonstrate significant practice variation between ICUs related to mechanical ventilation parameters that are under direct control by intensivists. Their effect on clinical outcomes for both coronavirus disease 2019 and other critically ill mechanically ventilated patients could have widespread implications for the practice of intensive care medicine and should be investigated further by causal inference models and clinical trials.

U2 - https://doi.org/10.1097/CCE.0000000000000555

DO - https://doi.org/10.1097/CCE.0000000000000555

M3 - Article

C2 - 34671747

SN - 2639-8028

VL - 3

SP - e0555

JO - Critical Care Explorations

JF - Critical Care Explorations

IS - 10

ER -