Association of Breathing Effort With Survival in Patients With Acute Respiratory Distress Syndrome

OBJECTIVES: Invasive mechanical ventilation (IMV) is crucial for acute respiratory distress syndrome (ARDS) management, but mortality remains high. While spontaneous breathing is key to weaning, excessive respiratory effort may injure the lung and diaphragm. Most existing data on respiratory effort during IMV are based on brief periods of observation, potentially underestimating the burden of inappropriate efforts. This study aims to characterize the evolution of respiratory effort over time in ARDS patients and its relation to survival. We hypothesized that nonsurvivors would spend a greater proportion of time in the high-effort range during the active breathing phase compared with survivors. DESIGN, SETTING, AND PATIENTS: In this prospective cohort study, we continuously recorded airway pressure, flow, esophageal, and gastric pressures in ARDS patients on mechanical ventilation during 7 days after the onset of spontaneous breathing. We analyzed physiologic respiratory effort variables, focusing on the proportion of time spent within defined effort ranges, and compared these data between ICU survivors and nonsurvivors. Statistical analysis was conducted using variance weighted methods to account for variability in the number of respiratory cycles analyzed per patient. This study is registered at ClinicalTrials.gov under identifier NCT06490523. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 1,485,405 respiratory cycles were analyzed from 26 ARDS patients (19 survivors, seven nonsurvivors). Nonsurvivors spent significantly more time in high effort (12% vs. 3%; p = 0.006). In contrast, survivors spent more time in the moderate-effort range (50% vs. 5%; p < 0.001). The time spend with high dynamic transpulmonary driving pressure (> 25 cm H 2 O) was also significantly different between groups (32% survivors vs. 74% nonsurvivors; p = 0.001). CONCLUSIONS: Patients who die of ARDS are more likely to be exposed to high respiratory effort for prolonged periods of time compared with survivors.