37The IP risk score could be useful for comparing the IP rate across ICUs according to a specific level of risk. Requisites for valid comparisons of outcomes among ICUs include an accurate and comprehensive outcome measure, a sufficient sample size with unbiased sampling, and appropriate risk adjustment via application of a valid model to reliably collected data. Iatrogenic pneumothorax should be a good quality indicator because it is clearly associated with ICU mortality. Therefore, the reproducibility of this variable is open to question. Pulmonary capillary pressure was not measured routinely. Finally, cardiogenic pulmonary edema was diagnosed by the investigators based on physical findings, echocardiography results, and the course. In this situation, plateau was not a risk factor for IP in two recent studies 9,30Third, the relatively low number of IPs may have limited the power of the study for identifying risk factors. However, plateau pressure was carefully maintained below 30 cm H 2O in all of the study ICUs. Second, the absence of plateau pressure and tidal volume in the database may have influenced the results of the risk factor evaluation and the IP risk score. Also, because chest radiographs were not obtained routinely after death, cases of IP secondary to cardiac pumping during unsuccessful cardiac resuscitation procedures may have been missed. In addition, because computed tomography was not performed routinely, the incidence of IP may have been underestimated. This may have impacted the β estimates of the covariates and decreased the power of the study. First, symptomatic barotrauma without IPs was not recorded. ![]() Several limitations of our study should be discussed. Moreover, IP was associated with cardiac arrest in 10 patients and occurred immediately before death in 10 other patients, supporting a major risk of death related to IP. We also found a significant LOD score increase after IP. 30However, even in this study, mortality in patients with no air leak (39%) was not significantly lower than that in patients with IP-MV (46%). 35In one study involving a specific group of ARDS patients, IP-MV was not associated with an increased risk of death. This result is in accordance with evaluations of mechanically ventilated patients, 9patients with acute lung injury, 15and patients with AIDS. In contrast to Chen et al. , 10we observed that the increased risk of death was similar for IP-MV and for postprocedural IP. Moreover, using a case–control nested study with careful adjustment on severity at admission and duration of risk exposure, we demonstrated that IP was associated with a greater than twofold increase in the risk of death. ![]() The occurrence of IP increased the duration of ICU and hospital stays. The risk was highest during the first 5 ICU days and decreased slightly thereafter. Cumulative incidence curves showed a 3% risk of IP after 30 days.
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