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Impact of Respiratory Effort Parameters on Clinical Outcomes in Respiratory Failure Patients (Effort-I): A
Phruet Soipetkasem1, Touchapong Taksinwarajarn2, Detajin Junhasavasdikul2
1Division of Critical Care Medicine Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Background:
Excessive or insufficient respiratory drive and inspiratory effort during mechanical ventilation may worsen outcomes through patient self-inflicted lung injury or diaphragm disuse. We evaluated whether bedside measures of respiratory drive and effort during the first 48 h of ventilation were associated with outcomes in critically ill adults with acute respiratory failure.
Methods:
In this single-center, prospective, observational study, adults aged 18-75 years with acute respiratory failure requiring invasive mechanical ventilation and a PaO2/FiO2 ratio >150 mmHg were enrolled within 24 h of ICU admission. Airway occlusion pressure at 100 ms (P0.1) and occlusion pressure (Pocc) were measured at baseline and at 12, 24, 36, and 48 h. Calculated respiratory muscle pressure (Pmus) and calculated transpulmonary driving pressure (ΔPL) were calculated from Pocc. Median values over the first 48 h represented exposure. The primary outcome was 28-day ventilator-free days (VFDs). Secondary outcomes included 28-day mortality, oxygenation changes, and correlations with Richmond Agitation-Sedation Scale scores. Multivariable Poisson and Cox regression analyses were performed.
Results:
A total of 206 patients were included. Patients within prespecified preferred ranges (P0.1 1.5-3.5 cmH2O, calculated Pmus 5-10 cmH22O, and calculated ΔPL ≤20 cmH2O) had more 28-day VFDs than those with low or high values. In multivariable Poisson regression, low and high P0.1, low calculated Pmus, and high calculated ΔPL were independently associated with fewer VFDs. In multivariable Cox regression adjusted for age, immunocompromised status, peak airway pressure, and APACHE II score, calculated ΔPL >20 cmH2O was independently associated with increased 28-day mortality (hazard ratio 6.57, 95% confidence interval 2.29-18.86; P < 0.001). Both low and high P0.1 were also independently associated with mortality (hazard ratios 3.75 and 4.81, respectively). Oxygenation improved in patients with preferred effort levels, whereas ΔPL >20 cmH2O was associated with new-onset hypoxemia. Richmond Agitation-Sedation Scale scores correlated most strongly with calculated Pmus (r = 0.76), followed by P0.1 (r = 0.50) and ΔPL (r = 0.43).
Conclusions:
Early respiratory drive and inspiratory effort within preferred physiological ranges were associated with more VFDs and lower mortality. Calculated ΔPL showed the strongest association with adverse outcomes, supporting bedside monitoring of drive and effort during assisted ventilation.
Trial Registration:
NCT06433076. Registered 29 May 2024, retrospectively registered.
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