Driving Pressure and Survival in ARDS-Amato-ESM-NEJM 2015

Supplementary Appendix
This appendix has been provided by the authors to give readers additional information about their work.
Supplement to: Amato MBP, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory
distress syndrome. N Engl J Med 2015;372:747-55. DOI: 10.1056/NEJMsa1410639
Driving Pressure and Survival in Acute Respiratory Distress Syndrome

SUPPLEMENTARY WEB MATERIAL
Marcelo B. P. Amato, MD 1
Maureen O. Meade, MD, MSc 2
Arthur S. Slutsky, MD 3,4
Laurent Brochard, MD 3,4
Eduardo L.V. Costa, MD 1,5
David A. Schoenfeld, PhD 6
Thomas E. Stewart, MD 2
Matthias Briel, MD, MSc 2,7
Daniel Talmor, MD, MPH 8
Alain Mercat, MD 9
Jean-Christophe M. Richard, MD 10
Carlos R.R. Carvalho 1
Roy G. Brower, MD 11
Cardio-Pulmonary Department, Pulmonary Divison, Heart Institute (Incor), University of So Paulo, So Paulo, Brazil;
Departments of Clinical Epidemiology, Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada;
Keenan Research Centre for Biomedical Science, St. Michaels Hospital, Toronto, Ontario, Canada;
Interdepartmental Division of Critical Care Medicine, and Department of Medicine, University of Toronto, Ontario, Canada;
Research and Education Institute, Hospital Sirio-Libans, So Paulo, Brazil
Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, MA;
Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland;
Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School,
Boston, MA;
Department of Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France;
10
Emergency Department, General Hospital of Annecy, Annecy, France and INSERM UMR 955, Creteil, France;
11
Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
SUPPLEMENTARY WEB MATERIAL

This supplement has additional information on methods and results, organized as:
I) DESCRIPTION OF THE STUDIED POPULATION: (Tables S1-S2; Figure S1)

II) ADDITIONAL RESULTS / ANALYSIS
REFERRED TO IN THE MAIN MANUSCRIPT:
1. Accounting for residual (intrinsic) heterogeneity across the trials (Figure S2)
2. Univariate analysis (Table S3)
3. Length of risk exposure and test of proportional hazards assumption (Tables S4-S6)
4. Sensitivity analysis for different estimates of baseline elastance (Figure S3)
5. Homogeneous P-risks across the trials (Figure S4)
6. Consistency of higher P-risks in the validation cohorts (Tables S7-S8)
7. Tidal volume predicts survival only if normalized to compliance (CRS) (Figure S5)
8. Survival in patients under protective ventilator settings (Figure S6)
9. P (but not VT) predicts Barotrauma after randomization (Figure S7)
10. Mediation analysis: more than grading the severity of lung disease
P strongly mediates survival, independently of baseline elastance of

respiratory system (Figures S8-S9)
VT and PEEP were not independent mediators (Figures S10-S11)
11. P consistently mediates survival benefits across/within trials (Table S9)
III) DETAILS ON STATISTICS AND METHODS:

1. Screening the dataset and compatibility analysis
2. Missing data
3. Double-stratification (used for the analysis shown in Figure 1, main text)
I) DESCRIPTION OF THE STUDIED POPULATION:
Please, refer to the tables and figures within the next pages
Tables S1-S2:
Studied cohorts and baseline patient characteristics recalculated from individual
patient data
Figure S1:
Overview of the results of randomization in each of the trials
Table S1(website): Studied cohorts and baseline patient characteristics recalculated from individual patient data.
The trials in the first four rows were pooled and formed our hypothesis generation sample, used to elect a multivariate model for survival (Model-1, Table 1). The ARDSnetVT
study was used as a first validation sample. The studies in the last four rows (testing a higher vs. lower-PEEP strategy) were pooled and used as a second validation sample.
Years of
recruitment
Patients
(N)
Randomization
Cont. / Treat.
Age
mean (SD)
Sepsis at
Entry (%)
Pneumonia/
Aspiration*
MV.Days
at entry
Interventions
(within treatment-arm)
Outcome Treatment-arm
(RR; 95%CI)
Amato et al.1
1991-1995
53
24 / 29
34 (13)
83%
28%
VT 6mL/kg; P 20cmH2O
PPLAT 40cmH2O;
0.38 (0.180.79)
Stewart et al.2
1995-1996
118
59 / 59
59 (18)
40%
58%
VT 8mL/kg;
PPEAK 30cmH2O
0.99 (0.601.70)
Brochard et al.3
1994-1996
113
57 / 56
57 (15)
n.a.
n.a.
VT < 10mL/kg;
PPLAT 25cmH2O
1.28 (0.732.25)
Brower et al.4
1994-1996
52
26 / 26
48 (16)
23%
54%
n.a.
VT 8mL/kg;
PPLAT 30cmH2O
1.11 (0.482.57)
ARDSnetVT5
1996-1999
861
429 / 432
51 (17)
27%
49%
VT 6mL/kg;
PPLAT 30cmH2O;
0.74 (0.580.93)
ARDSnetPEEP6
1999-2002
545
271 / 274
51 (17)
38%
55%
Higher PEEP guided by

higher PEEP/ FIO2 table;
VT = 6.00.9 mL/kg/pbw
1.11 (0.801.54)
EXPRESS7
2002-2005
Highest PEEP keeping

PPLAT < 30cmH2O;
0.87 (0.691.09)
LOVS8
2000-2006
983
508 / 475
Talmor et al.9
2004-2007
61
31 / 30
Lower vs. Higher
VT-trials :
Higher vs. Lower
PEEP-trials :
767
382 / 385
60 (15)
stopped for futility
61%
72%
1.5
56 (17)
47%
64%

higher PEEP/ FIO2 table;
0.88 (0.711.08)
refract. hypoxemia
53 (20)
48%
20%
n.a.

esophageal-pressure;
0.49 (0.201.24)
vent. free days

stopped for futility
oxygenation
compliance, rs
LEGEND FOR TABLE S1:

n.a. not available information.
ARDSNetTV: First ARDSNet study5 comparing high versus low tidal volume strategies
ARDSNetPEEP: Second ARDSNet study6 comparing high versus low PEEP strategies
*: P < 0.001 - Chi-squared test comparing differences in prevalence of primary ARDS across the trials.
RR: non-adjusted relative-risk (mortality-rate) associated with the treatment arm - calculated by Cox Proportional Hazards regression.
: In the supplement (Figure S1) we present the results of the adjusted relative-risk according to Model-1 (Table 1), where we noticed two important findings:
- the intervention arm in the EXPRESS trial presented a significant reduction in the relative-risk: 0.75 (95%CI: 0.590.96; P=0.02).
- the intervention arm in the ARDSnetPEEP trial presented an inversion of the trend for the relative-risk:0.82 (95%CI: 0.561.12; P=0.29).
(This was related to an important imbalance in covariates at baseline, as reported in the original publication of this trial).
95% C.I. 95% confidence interval;
P: driving-pressure defined as the difference between plateau pressure and PEEP

PPLAT: plateau pressure at airways; PPEAK: peak-inspiratory airway pressure
: means a significant improvement in the variable within the treatment arm
: means a significant decrease in the number of patients suffering refractory hypoxemia during the hospital stay.
: Median of days under mechanical ventilation (intubation) before entering the study.
: The study of Amato et al. was the only one where a target for maximum P was explicit in the lung-protective protocol.
This trial also used a higher PEEP strategy in the treatment arm.
: Except for the study of Amato et al. the VT-trials used the same PEEP strategy in the control and intervention arms
: The PEEP-trials (forming our validation cohort) used the same tidal volume strategy (< 8 mL/kg) in the control and intervention arms.
Table S2 (website): Baseline patient characteristics: recalculated from individual patient data.
The trials in the first four rows were pooled and formed our hypothesis generation sample, used to elect a multivariate model for survival (Model-1, Table 1 - main text).
The ARDSnetVT study (testing a high versus low V T strategy) was used as a first validation sample. The studies in the last four rows (testing a high versus low PEEP
strategy) were pooled and used as a second validation sample.
Risk of Death*
arterial pH at entry
PaO2/FIO2 at entry
Tidal-compliance at entry or
at first day
Amato et al.1
48(35-71)
7.32 (7.24-7.40)
113 (74 - 165)
0.40 (0.32-0.53)
Stewart et al.2
40(26-64)
7.39 (7.33-7.43)
182 (135 246)
0.53 (0.39-0.66)
Brochard et al.3
23(15-36)
7.36 (7.30-7.42)
137 (110 177)
0.52 (0.38-0.64)
Brower et al.4
44(19-64)
7.42 (7.36-7.45)
119 (97 - 147)
0.45 (0.36-0.56)
ARDSnetVT5
39(24-64)
7.41 (7.36-7.45)
123 (89 175)
0.46 (0.36-0.60)
ARDSnetPEEP6
49(29-64)
7.39 (7.32-7.43)
142 (104 200)
0.47 (0.36-0.60)
EXPRESS7
42(23-68)
7.37 (7.31-7.42)
138 (98 180)
0.47 (0.39-0.60)
LOVS8
54(35-74)
7.37 (7.30-7.42)
141 (106 180)
0.45 (0.36-0.58)
Talmor et al.9
60(46-72)
7.38 (7.33-7.42)
135 (108 178)
0.47 (0.39-0.59)
Trial:
Values represent the median, with the interquartile range inside parenthesis
*Risk of Death was calculated according to the equations of APACHE II, APACHE III and SAPS II, depending on the individual scores available in each of the trials.
Tidal compliance is represented in milliliters per centimeter of water / ideal body weight. In the hypothesis generation sample (first four rows) as well as the ARDSnet VT
trial, the value was obtained from the first measurement after randomization, taken a few hours after entry;
ARDSnetVT: First ARDSNet study 5 comparing lower versus higher tidal-volume strategies
ARDSnetPEEP: Second ARDSNet study 6 comparing higher versus lower PEEP strategies
Figure-S1:
Overview of the results of randomization in each of the study-trials.
Hypothesis-generation
Cohort ( N = 336)
Higher vs. Lower VT
study -trials
Adjusted survival
(survival curves were pre-adjusted according to covariates 1-5 of model-1 ; Cox proportional-hazards)
*
Amato et al.
Stewart et al.
First validation
Cohort ( N = 861)
Higher vs. Lower VT
study -trial
Adjusted survival
Days after randomization
Brochard et al.
Brower et al.
Treatment arm
Control arm
* : significant survival differences in the original report
ARDSnetVT
(the study of Amato et al. tested a combined strategy of higher PEEP and lower VT)
: significant survival differences after multivariate adjustment (model-1)
Second validation
Cohort ( N = 2360)
Higher vs. Lower PEEP
study -trials
Adjusted survival
ARDSnet PEEP
EXPRESS
LOVS
EPVENT
II)
ADDITIONAL RESULTS AND ANALYSIS REFERRED TO

IN THE MAIN MANUSCRIPT:
II.1. Accounting for residual (intrinsic) heterogeneity across the trials:

Please, refer to the figure on the next page
Figure S2: Accounting for residual heterogeneity across the trials
Additional details:
As shown in Figure S2, in spite of covariate adjustments according to Model-1, there was some
residual, unexplained heterogeneity in the pooled mortality (both arms considered together)
across trials (P < 0.001). Overall the mortality in the derivation cohort (45.3%) was higher than
that observed in the validation cohorts (33.6% and 34.2%, for ARDSnetVT cohort and second
validation cohort, respectively). This higher mortality was a general trend observed in both arms
of each of the studies (from derivation cohort) and could not be fully explained by their baseline
disease (expressed by the covariates Age, APACHE III, arterial pH, PaO2/FIO2ratio) or by P
applied. The source of this heterogeneity is beyond the scope of this study and might relate, for
instance, to improvements in general patient support, independent of ventilation strategies.
We must stress that this residual heterogeneity did not cause any bias in Table 1 or Figures 1-2
presented in the main manuscript, since we pre-adjusted our survival models according to a
categorical variable "Trial". The reported effects of P on mortality were, therefore, necessarily
calculated in proportion to this intrinsic pooled mortality of each trial.
Figure-S8: Accounting for residual heterogeneities across the trials

( control and
survival are pooledacross
together
fortrials
each trial
)
Figure S2: Accounting
for treatment
residual heterogeneities
the
(control
and treatment are pooled together for each trial)
Adjusted for individual patient
covariates
Adjusted for individual patient

covariates
trial dummy covariate
Adjustment to balance intrinsic differences

in baseline mortality across the trials
(not fully expressed by baseline covariates)
1
2
study-trial:
1
High vs. Low PEEP trials second validation cohort
High vs. Low VT trial ARDSnet first validation cohort
High vs. Low VT trials preARDSnet derivation cohort
Figure S2: Accounting for residual heterogeneities across the trials.

After accounting for differences in baseline covariates, the intrinsic mortality of the derivation cohort remained higher than in the validation cohort. In order to minimize
such intrinsic differences (not fully expressed by baseline covariates), our analysis (Table 1 and Figures 1-2, main manuscript) always included a categorical dummy
variable that balanced the different risks among the trials (the panel on the right shows the respective survival curves after such adjustment).
10
II.2. Univariate analysis:

Please, refer to the table on the next page
Table S3: Univariate
Cox Regression Model 60-Day Mortality.
11
Table S3 (website): Univariate
Cox Regression Model 60-Day Mortality
Hypothesis generation cohort

- Univariate -
First Validation cohort

- Univariate -
(N = 336)
VARIABLES:
(N = 861)
P-value
RR (95% C.I.)
(N = 2360)
P-value
RR (95% C.I.)
0.27
Trial *
Second Validation cohort

- Univariate -
P-value
RR (95% C.I.)
---
< 0.001
Randomized arm
0.93 (0.68 1.28)
0.67
0.74 (0.58 0.93)
0.01
0.90 (0.78 1.03)
0.13
Days on MV before
1.12 (0.97 1.27)
0.16
---
---
---
---
Age
1.03 (0.88 1.22)
0.68
1.73 (1.52 1.97)
< 0.001
1.70 (1.57 1.83)
< 0.001
APACHE/SAPS risk
1.59 (1.34 1.89)
< 0.001
1.51 (1.34 1.69)
< 0.001
1.83 (1.70 1.98)
< 0.001
---
---
1.40 (1.25 1.57)
< 0.001
1.48 (1.37 1.59)
< 0.001
Arterial pH at entry
0.69 (0.61 0.79)
< 0.001
0.66 (0.58 0.77)
< 0.001
0.59 (0.55 0.63)
< 0.001
PaO2/FIO2 at entry
0.73 (0.65 0.83)
< 0.001
0.84 (0.74 0.96)
0.01
0.70 (0.64 0.76)
< 0.001
Tidal compl. at entry
---
---
---
---
0.76 (0.67 0.87)
< 0.001
P at entry
---
---
---
---
1.27 (1.15 1.40)
< 0.001
Tidal compl. 1st day
0.80 (0.66 0.97)
0.02
0.90 (0.74 1.09)
0.29
0.91 (0.87 0.94)
< 0.001
st
1.08 (0.95 1.23)
0.22
0.85 (0.72 1.00)
0.05
1.14 (1.06 1.22)
< 0.001
1.51 (1.28 1.77)
< 0.001
1.39 (1.22 1.57)
< 0.001
1.54 (1.45 1.65)
< 0.001
1.08 (0.91 1.30)
0.37
1.06 (0.98 1.15)
0.16
0.99 (0.88 1.12)
0.92
Organ Failures
PaCO2 - 1 day
st
FIO2 - 1 day
VT - 1st day
st
1.18 (0.88 1.88)
0.12
1.17 (1.07 1.28)
< 0.001
1.30 (1.21 1.41)
< 0.001
st
1.50 (1.26 1.77)
< 0.001
1.32 (1.20 1.45)
< 0.001
1.39 (1.28 1.51)
< 0.001
st
PEEP - 1 day
1.15 (0.98 1.36)
0.09
1.62 (1.38 1.89)
< 0.001
1.13 (1.04 1.22)
0.003
P - 1 day
1.35 (1.16 1.58)
< 0.001
1.19 (1.07 1.33)
0.001
1.50 (1.36 1.67)
< 0.001
Mean PAW 1st day
1.42 (1.19 1.70)
< 0.001
1.48 (1.33 1.65)
< 0.001
1.44 (1.24 1.67)
< 0.001
Respir. rate - 1 day

PPLAT - 1 day
st
12

* Categorical variable with four classes in the hypothesis generation, plus 4 classes in the second validation sample. The first validation sample had only one single
study (ARDS Network tidal volume study).
Methods for defining organ-failures differed within hypothesis generation sample and pooled relative risks could not be calculated.
A random variable (mean = 57; std = 15; as reported in the original publication) was imputed to all patients in the study of Brochard et al.
Abbreviations: RR: relative risk associated to 1 standard-deviation (STD) increment in the respective variable;
By normalizing RR according to STD, the strength of the association of different variables with survival can be grossly compared as the RR per se
(using 1/RR when RR < 1). For instance, in the second validation sample, P showed stronger association with survival (1.50) than tidal-compliance. (1/0.91 = 1.10).
95% C.I.: 95% confidence interval; VT = tidal-volume; PPLAT = plateau-pressure; P = driving-pressure; Mean PAW= mean airway pressure; FIO2= fraction of
inspired oxygen; PEEP = positive end-expiratory pressure; tidal compl. = tidal-compliance.
13
II.3. Length of risk exposure and test of proportional hazards

assumption:
Please, refer to the tables on the next pages
Table S4:
Non-parametric Correlation Between Individual Values Observed During the First Day of
Mechanical Ventilation (Ventilation-Variables), and the Individual Values Observed in
the Following Days
Table S5:
Multivariate Cox Regression Model (60-day Hospital Mortality) comparing the
performance of Ventilation-Variables on Day 1 versus Days 1 to 3.
Table S6:
Comparison of the Original Model 1 (with constant hazards) versus Alternative Models
with Time-Dependent Covariates Included..
14
Table S4 (website):
Non-parametric Correlation Between Individual Values (Ventilation-Variables Observed During the First Day of Mechanical
Ventilation) and the Individual Values Observed in the Following Days
(data from the ARDSNetPEEP trial)
Spearman correlation coefficient

Ventilator-variables:
Mean value
st
FIO2 - 1stday
st
VT - 1 day
Respir. rate - 1stday
Plateau Press. - 1st day
PEEP - 1st day
Driving Press. - 1st day
Mean PAW 1stday
Mean value Mean value Mean value Mean value
1 day
2ndday
3rdday
4thday
1
1
1
1
1
1
1
0.64*
0.87*
0.70*
0.66*
0.73*
0.64*
0.69*
0.51*
0.79*
0.59*
0.56*
0.62*
0.51*
0.63*
0.47*
0.75*
0.54*
0.56*
0.58*
0.52*
0.57*
7th Day
0.29*
0.68*
0.36*
0.51*
0.48*
0.52*
0.50*
* :P < 0.001 ; P-value of the two-tailed test of significance for the Spearmans-Rho correlation-coefficient. The correlation was
calculated between individual data collected at day one (first 24 hs. after randomization) and data at each of the following days,
for the same respective patients.
15
Table S5 (website):
Multivariate Cox Regression Model (60-day Hospital Mortality) comparing the performance of VentilationVariables on Day 1 versus Days 1 to 3.
(data from the ARDSNetPEEP trial)
Considering Ventilation-Variables
to 1st day.
Considering Ventilation-Variables to
3rd day
- Multivariate -
- Multivariate -
(Valid cases = 483)
(Valid cases = 328)
RR (95% C.I.)
P-value
RR (95% C.I.)
P-value
Model:
(1) Age
1.88 (1.54 2.29)
< 0.001
1.84 (1.46 2.33)
< 0.001
(2) APACHE III
1.79 (1.51 2.12)
< 0.001
1.73 (1.38 2.18)
< 0.001
(3) Organ Failures
1.09 (0.89 1.34)
0.39
1.21 (0.95 1.53)
0.12
(4) arterial pH at entry
0.59 (0.47 0.75)
< 0.001
0.64 (0.48 0.85)
< 0.001
(5) PaO2/FIO2 at entry
1.00 (0.78 1.28)
0.81
0.94 (0.73 1.20)
0.72
(6) FIO2 - 1 day
0.99 (0.78 1.25)
0.77
0.86 (0.65 1.13)
0.27
(7) Driving-pressure
1.59 (1.22 2.07)
0.001
1.70 (1.23 2.35)
0.001
139.9
(P =2 x10-26)
85.1
st
Model Chi-Square
(change after including all covariates)
(P = 5 x10-15)
The average values in time were used for ventilator-variables collected from days 1 to 3.
Only patients surviving longer than 1or 3 days were respectively included in the Cox survival model. This explains why the overall Chi-Square decreased,
despite a preserved association between individual covariates and survival.
RR: adjusted relative risk associated to 1 standard-deviation increment in the respective variable.
95% C.I. 95% confidence interval
16
Table S6 (website):
Comparison of the Original Model 1 (with constant hazards) versus

Alternative Models with Time-Dependent Covariates Included.
Original
Alternative models after addition of time-dependent covariates
model
( RR and P-values below refer to the long-term hazard observed during the 60-day period)
RR P-value
RR
P-value
RR
(2) Age
1.59 < 0.001
1.71
< 0.001
1.59
(3) APACHE/SAPS-risk
1.38 < 0.001
1.38
< 0.001
0.68 < 0.001
0.68
0.87 < 0.001
(6) Driving Press. - 1st day
1.41 < 0.001
P-value
RR
P-value
RR
P-value
RR
P-value
< 0.001
1.58
< 0.001
1.59
< 0.001
1.58
< 0.001
1.24
< 0.001
1.39
< 0.001
1.38
< 0.001
1.38
< 0.001
< 0.001
0.69
< 0.001
0.80
< 0.001
0.68
< 0.001
0.68
< 0.001
0.87
< 0.001
0.87
< 0.001
0.87
< 0.001
0.92
0.33
0.87
< 0.001
1.41
< 0.001
1.40
< 0.001
1.40
< 0.001
1.40
< 0.001
1.35
< 0.001
Model 1 (constant hazards)
Time-dependent covariate added

(exerting a multiplicative hazard
during the first week)
Age
APACHE III
Transient hazards observed

during the first week *
1.38
1.74
(0.001)
P-value
(<0.001)
arterial pH
at entry
PaO2/FIO2
at entry
Driving Press. 1st day
0.56
0.77
1.49
(<0.001)
(0.02)
( 0.12 )
(RR for the first week versus

RR for the rest of the period)
RR: hazard or relative-risk associated to 1 standard-deviation increment in the respective variable

* : This hazard refers to 1 standard-deviation increment in the time-dependent variable indicated just above. This number should be compared to the hazard observed during
the rest of the 60-day period (indicated by the gray cells).
17
Additional details: (related to Tables S4-S6 above)

As we excluded patients with early death or weaning (i.e. death or weaning within the first 24
hours following randomization), we necessarily included patients exposed to ventilation risk
factors for at least 24 hours. We also assumed that a fixed, ongoing hazard should be related
to the average value of the variable observed during the first 24 hours of mechanical
ventilation, despite possible fluctuations of the variable in the next few days. To test the validity
of this assumption, we performed three additional series of analysis described below. One
important observation here is our censoring procedure: to avoid competing risks, we censored
all patients discharged to home before day-60 as alive at day-60 (instead of censoring them as
alive at the date of discharge)10. Thus, our analysis basically represents the estimation of risks
during hospital stay (i.e. focusing on hospital mortality), avoiding biases caused by unknown
risk exposition at home.
First, we assessed the relationship of a ventilation variable to its respective value in the next
few days. Such analysis is illustrated in Table S4. There was a high degree of correlation,
especially for tidal volume, in which the relationship remained significant for several days. Thus,
a value measured in the first 24 hours was generally representative of values for the
subsequent several days.
Second, we checked if the inclusion of any additional information on days 2 and 3 of
mechanical ventilation could improve our survival model. Variables representing either the
ventilator parameters observed once during days 2 or 3, or the average values during the first 2
or 3 days, were included stepwise in model 1.This analysis, however, required that patients
have survived and have remained on mechanical ventilation for at least 2 or 3 days, decreasing
substantially the number of valid cases. One example of such an analysis is presented in
Table S5, performed with the data from the ARDS Network PEEP trial6. We chose this single
18
trial because of the lowest number of early deaths and missing cases (until day 7) of
mechanical ventilation. As shown, the effect-size of most ventilation variables was either
maintained or increased after considering longer periods of time exposure, suggesting an
ongoing, cumulative effect. However, the power of the analysis decreased and confidence
intervals widened due to the smaller sample size. After also considering the potential survival
bias introduced by such procedure -the selection of healthier patients, able to survive the first 3
days11 - we preferred to use the simpler and more powerful analysis, only considering risk
exposure to 24 hours of mechanical ventilation.
Finally, we tested the possibility that ventilation covariates exerted only transient effects that
diminished after a few days. This would represent a violation to the proportional hazard
hypothesis, which assumes an ongoing hazard till the end of the 60-day period. Thus, using the
approach suggested by Kasal et al.12, we assigned, for each covariate, a respective timevarying covariate that allows a different hazard (higher or lower) to be applied over days 0 7,
in addition to the fixed hazard (constant during the 60days) already included in the model.
Whenever this new time-dependent covariate brought additional information to the model (at a
significance level of P < 0.01), we considered that there was a non-proportional hazard (higher
or lower) during the first week of mechanical ventilation. Such analysis is presented in
Table S6. The most relevant non-proportional hazards were observed for lower values of
baseline arterial-pH and higher values APACHE-III/SAPS-risk, both conditions associated with
higher mortality during the first week(in addition to their long term hazard). High drivingpressures, however, did not impose additional risks during the first week.
We concluded, therefore, that high driving-pressure exposure during the first days of
mechanical ventilation was strongly associated to a fixed, ongoing hazard during the first 60day after randomization. There was no need of more sophisticated models, with timedependent variables, to describe such relationship.
19
II.4. Sensitivity analysis for different estimates of

baseline-elastanceRS
As a surrogate of the severity of underlying lung disease, baseline-elastanceRS should be

ideally calculated from baseline data, providing independent measurements that are not
affected by treatment. For instance, a higher-PEEP might decrease lung elastance after
randomization due to an immediate promotion of lung recruitment, but not because of an actual
change in the underlying lung disease. Thus, baseline-elastanceRS might be underestimated in
in the treatment arm, if measured after randomization (even if a few minutes later).
To circumvent this potential bias, whenever we had to use post-randomization data to calculate
baseline-elastanceRS (necessary for the earlier VT-trials), we calculated it as stratified
elastanceRS-ranks, performed within each treatment arm, for each trial. These ranks were
subsequently scaled within the [-0.5 to 0.5] interval. This procedure was performed under the
reasonable assumption that the systematic changes in ventilation parameters due to
randomization might affect the absolute values of elastanceRS, but could hardly affect the
ranking of individual elastancesRS within the respective study-arm. In the next few paragraphs,
we will demonstrate the good plausibility of this assumption.
By using our second validation cohort, in which we measured individual data of baselineelastance (pre-randomization, when the patients received VT = 82 mL/kg/PBW and PEEP =
104 cmH2O), as well as individual data of post-randomization elastanceRS, we could compare
the information provided by the two estimates of elastance (baseline-elastance as actually
measured versus stratified elastance-ranks measured post-randomization, using N = 1656
patients enrolled in three PEEP-trials). We observed that (Figure S3, next page):
20
Figure S3: correlation between
ElastanceRS estimated from baseline data

versus
( baseline data )
Baseline Elastance respiratory system (PBW)
stratified ElastanceRS ranks (estimated from post-randomization data).
Rank of Elastance respiratory system

( post randomization data )
- stratified by arm, and by study-trial -
Figure S3: Correlation between the two estimates for baseline ElastanceRS
Using the data from 1656 patients participating in the higher-PEEP trials, for whom we had measurements of
elastance performed at baseline (average VT = 82 mL/kg/ibw and PEEP = 104 cmH2O), as well as after
randomization, we could check the correlation between the two estimates. In order to avoid post-treatment
bias in the measurements performed after randomization, we calculated elastance ranks within each of the
arms, and within each of the studies. The ranks were then scaled within the [-0.5 to 0.5] interval. This
procedure was performed under the reasonable assumption that the systematic changes in ventilation
parameters due to randomization might affect the absolute values of elastance, but could hardly affect the
ranking of individual elastances within the respective study-arm. As shown, the relationship between both
variables was reasonably linear, with similar slopes and determination coefficients for both arms. This
suggest that the stratified ranking avoided post-treatment bias.
21
1. The relationship between both variables, i.e., baseline-elastanceRS (actually measured)

versus stratified elastanceRS-ranks (from post-randomization data), was reasonably
linear (Figure S3), with similar slopes and determination coefficients (R2 = 0.35;
P<0.001) for both arms. Thus, the predictive power of post-treatment elastanceRS-ranks
for estimating pre-treatment baseline-elastanceRS was not affected by randomization,
suggesting absence of post-treatment bias
2. When we remove the variable P from Model-1, causing a significant loss of predictive
power (P<10-7), the entry of one of both variables representing the underlying lung
disease in the model added similar amounts of predicting information (P<0.001 for both
variables, change in qui-square = 17.7 and 16.4, respectively; RR = 1.21[1.111.33]
and 1.21[1.111.31]), respectively. Thus, both estimates of elastanceRS (pre or posttreatment) carried independent predicting information, beyond the information already
conveyed by other covariates (age, baseline P/F ratio, baseline arterial pH, baseline
APACHE/SAPS risk, Trial).
3. After pre-adjusting Model-1 for post-treatment elastanceRS-ranks, the test of the re-entry
of P in the model was still significant (P=0.0001; RR for 1 STD decrement = 0.61;
95%CI = 0.480.79), showing that the residual variations in P (now mostly related to
the randomized ventilator strategy) were still carrying independent predicting
information. Alternatively, a similar pre-adjustment of Model-1 for baseline-elastanceRS
(pre-treatment) kept unchanged the independent predicting information carried by P
(RR=0.64; 95%CI = 0.500.82; P = 0.0002). Thus, both adjustments subtracted the
same amount of predicting information from the original P variable, probably the
information representing underlying lung disease.
22
4. Finally, we observed that after pre-adjusting model-1 for elastanceRS-ranks (posttreatment), the test of entry of baseline-elastanceRS (pre-treatment) in the model was no
longer significant. This suggest a consistent overlap of information coming from both
methods of estimation of underlying lung disease: there was no further independent
information (correlated with outcomes) in baseline-elastanceRS that was missed in the
prediction models, or in the mediation models.
This sequence of tests shows that, in the hypothesis that baseline-elastanceRS was causing
some confounding effect in our mediation analysis, this bias was equally removed from P
by both adjustments (i.e. using pre or post randomization data).
23
II.5. Homogeneous P-risks across the trials:

Please, refer to the figure in next page
Figure S4:
Relative risk of death associated to increments in P within each of the trials
Additional details:
Model adjustments for unexplained differences in the pooled mortality (both arms together) for
each trial and for differences in effect-size across the trials did not change the relative risk
associated with general increments of one standard deviation in P. The first adjustment was
performed by assigning one dummy variable for each trial in the Cox model (Figure S2); the
effect-size adjustment was performed by assigning one dummy interaction term for each trial
expressing the freedom for each trial to present a peculiar response to P.
After all such adjustments1, the relative risk associated to increments of P was consistently
1.45 (95% CI, 1.28 to 1.64; P < 0.0001), similar to the numbers presented in Table 1, main text.
This analysis suggests a consistency of effects: whatever the individual severity of disease
(expressed by baseline covariates), or whatever the baseline mortality of a specific population
(expressed by the dummy variables representing each trial), increments in P were always
deleterious, and associated with the same risk magnitude across the 9 trials (Figure S4).
The inclusion of such dummy interaction terms in the Cox model did not contribute to its predictive power
(likelihood-ratio test: P = 0.13) suggesting that the effect-size of increments of P was homogeneous across the
different trial populations.
24
Figure S4: Relative risk of death associated to increments in P within each of the trials
Figure-S2: Relative risk of death associated to increments in P within each of the trials
Benefit
Amato etAmato
al.
n=53
Stewart
Stewart et
al.
n = 120
Brochard Brochar
et al.
n = 116
ARDSnet
ARDSnet
VT
n = 861
ALVEOLI
ARDSnet
PEEP
n = 549
EXPRESS
EXPRESS
n = 767
LOVS
LOVS
n = 983
Talmor EPVENT
et al.
OVERALL
COMBINED EFFECTS
Heterogeneity test:
P = 0.13
n = 52
Y Data
Brower
Brower et
al.
Hazard
n = 61
P < 0.0001
n = 3562
0.33
0.5
0.7
1.4
X Data
Adjusted Relative-risk
of death
( for one-standard-deviation increment in P )
Figure S4: Relative-risks associated to increments in P within each of the trials

The relative-risk of death (Cox survival analysis) associated to 1 standard-deviation increment in P
(7.0 cmH2O) measured after randomization (first 24hs.) was calculated for each trial, and for the
combined sample. We performed multivariate adjustment (at patient-level) for covariates specified in
Model 1 (Table 1, main text) plus dummy variables accounting for residual heterogeneities in baseline
mortality among the trials. Error bars represent 95% confidence intervals. There was no significant
heterogeneity of P effects across the trials (P = 0.13; test of driving-pressure-by-trial interaction term),
despite the different distributions of primary cause of ARDS across the trials (P < 0.001, Table S1).
25
II.6. Consistency of higher P-risks in the validation cohorts:

Please, refer to the tables on next 2 pages
Table S7:
Multivariate Cox Regression Model (60-day Hospital Survival)
Original derivation model and posterior test in the ARDSNetVT population (first validation
cohort)
Table S8:
Multivariate Cox Regression Model (60-Day Hospital Survival)
Posterior test of derivation model in the VT trials (derivation cohort combined with the
ARDSNetVT cohort) and in the PEEP trials (second validation cohort) .
This table complements Table 1, main manuscript.
26
Table S7 (website): Multivariate Cox Regression Model (60-day Hospital Survival) Original derivation model and posterior test in the ARDSNetVT population (first validation cohort)
Original Derivation model.

Early ventilation trials
Test of Derivation Model

ARDSNETVT trial
- Multivariate -
- Multivariate -
(Valid cases = 331)
- Multivariate -
(Valid cases = 705)
P-value
RR (95% C.I.)
Refined model
ARDSNETVT trial
Model:
RR (95% C.I.)
(Valid cases = 704)
P-value
RR (95%
P-value
C.I.)
RR(95
(1) APACHE - risk *
1.36 (1.17 1.57)
< 0.001 % C.I.)
1.39 (1.23 1.57)
< 0.001
1.25 (1.10 1.42)
0.001
0.73 (0.63 0.83)
< 0.001
0.82 (0.70 0.96)
0.013
0.72 (0.61 0.83)
< 0.001
(3) P - 1 day
1.42 (1.21 1.66)
< 0.001
1.21 (1.08 1.35)
0.001
1.29 (1.16 1.44)
< 0.001
1.24 (1.05 1.48)
0.014
1.24 (1.09 1.42)
0.001
0.81 (0.71 0.92)
0.001
1.77 (1.55 2.03)
< 0.001
st
st
(4) FIO2 - 1 day

N.S.
(6) Age
N.S.
N.T.
N.T.
Model Chi-Square
(step change after inclusion
of block of covariates)
78.7
(P =3 x10-16)
81.6
(P =1 x10-16)
145.7
(P =1 x10-29)
ARDSnetVT: First ARDSNet study 5 comparing lower versus higher tidal-volume strategies
RR: adjusted relative risk associated to one standard-deviation increment in the respective variable. Values above 1.00 indicate increased mortality-rate. The values used for standarddeviation were: age (17), death-risk (26), arterial pH (0.09), PaO2/FIO2 (60), P (7), FIO2 (0.19).
95% C.I. 95% confidence interval

P - 1st day: average driving-pressure during the first 24 Hs after randomization.
*: Risk of Death was calculated according to the equations of APACHE II, APACHE III, depending on the trial.
N.S.: Non significant entry in the backward/forward process of selection of variables
N.T.: Not tested
27
Table S8 (website): Multivariate Cox Regression Model 60-Day Hospital Survival

Posterior test of derivation model in the VT trials (derivation cohort combined with the ARDSNetVT cohort)
and in the PEEP trials (second validation cohort) . This table complements Table 1, main manuscript
High vs. Lower-VT trials
- Multivariate (N = 1020)
(N = 2060)
P-value
RR(95% C.I.)
High vs. Lower-PEEP trials

- Multivariate -
(N = 3080)
P-value
RR(95% C.I.)
Combined analysis
- Multivariate -
P-value
RR(95% C.I.)
Model 1:
--1.51(1.36 1.69)
1.34(1.20 1.49)
0.69(0.63 0.77)
0.85(0.77 0.95)
1.35(1.24 1.48)
< 0.001
< 0.001
< 0.001
< 0.001
0.004
< 0.001
1.64(1.50 1.79)
1.41(1.29 1.54)
0.68(0.63 0.74)
0.88(0.80 0.96)
1.50(1.35 1.68)
0.83
< 0.001
< 0.001
< 0.001
0.005
< 0.001
1.59(1.48 1.70)
1.38(1.29 1.48)
0.68(0.64 0.72)
0.87(0.81 0.93)
1.41(1.31 1.51)
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
Model 2 (including variables 1-5 as above):

P - 1st day
1.41(1.26 1.59)
Compliance,RS
1.18(0.96 1.44)
< 0.001
0.12*
1.48(1.28 1.71)
0.98(0.88 1.10)
< 0.001
0.75*
1.41(1.30 1.53)
1.01(0.92 1.10)
< 0.001
0.90*

P - 1st day
1.32(1.19 1.47)
st
Tidal Volume - 1 day
1.04(0.95 1.14)
< 0.001
0.42*
1.51(1.35 1.68)
1.05(0.90 1.23)
< 0.001
0.52*
1.40(1.30 1.51)
1.02(0.95 1.10)
< 0.001
0.58*

P - 1st day
1.44(1.10 1.88)
st
Plateau Press. - 1 day
0.94(0.72 1.23)
0.008
0.65*
1.51(1.31 1.75)
0.99(0.87 1.13)
< 0.001
0.90*
1.37(1.22 1.53)
1.04(0.93 1.15)
< 0.001
0.53*

P - 1st day
1.36(1.24 1.49)
PEEP - 1st day
0.97(0.80 1.18)
< 0.001
0.78*
1.50(1.34 1.68)
0.99(0.91 1.09)
< 0.001
0.90*
1.41(1.32 1.52)
1.03(0.95 1.11)
< 0.001
0.51*
(1) TRIAL
(2) Age
(3) Risk of Death
(4) Arterial pH at entry

P - 1st day
---
---
28
RR: adjusted relative-risk associated to 1 standard-deviation increment in the respective variable. Values above 1 indicate increased mortality-rate. The values used for
standard-deviation were: age (17), death-risk (26), arterial pH (0.09), PaO2/FIO2 (60), P (7), PEEP (5), Plateau pressure (7), Tidal volume (2), Compliance, RS (0.3). By
normalizing RR in this way, the strength of the association of different variables with survival can be grossly compared as the RR per se (using 1/RR when RR < 1). For
instance, in the combined analysis, P showed stronger association with survival (1.4) than the PaO2/FIO2 (1/0.87 = 1.15)
st
95% C.I. 95% confidence interval; P - 1 day: average driving-pressure during the first 24 Hs after randomization.
* Test of variable inclusion in the model (net contribution to predictive power likelihood-ratio test) where variables 1-6 plus driving-pressure were previously included.
Test of variable inclusion in the model where variables 1-5 plus the extra covariate in the line below were previously included.
Risk of Death was calculated according to the equations of APACHE II, APACHE III and SAPS II, depending on the trial.
Although not shown in the table, the variable mean-airway-pressure was tested before and after inclusion of P in model 1, showing no significant association with survival.
29
II.7. Tidal volume predicts survival only if normalized to

respiratory system compliance (CRS):
Figure S5: Survival impact of
tidal volume, before and after lung-sizing
30
Figure S5: Survival effects of tidal volume, before and after lung-sizing
ResamplingD
D:
Resampling
ResamplingEE:
Resampling
- matched PPLAT,
- decreasing ranks of VT / PBW
25
10
10
Scaling
VT
20
15
88
to
CRS
Instead10 of PBW
66
DRIVING - PRESSURE
25
( cmH2O )
VT / CRS
(P, cmH2O )
44
611
620
611
623
607
1.2
1.2
1.0
1.0
P = 0.92
0.6
0.6
0
30
30
25
25
25
20
20
20
15
15
15
10
10
10
600
1.6
1.4
1.4
0.8
0.8
30
1.6
Relative risk
RELATIVE - RISK ( adjusted )
Relative risk
( adjusted mortality rate* )
( Sub-sample1.6
N ):
1.6
35
S1
S: MATCHED
SPPLAT
S4
SOF
RESAMPLING
, QUINTILES
2
3
5 VT
RELATIVE - RISK ( adjusted )
( mL / kg )
30
( adjusted mortality rate* )
VT / PBW
30
12
PPLAT
PLATEAU-PRESSURE
TIDAL - VOLUME
( cmH2O )
35
35
35
P ( cmH2O )
14
35
PPLAT
- matched PPLAT,
- decreasing ranks of VT / CRS (=P)
624
644
598
PLATEAU-PRESSURE
Figure 1B:
614
1.4
1.4
1.2
1.2
1.0
1.0
0.8
0.8
P < 0.001
0.0001
0.6
0.6
S1 : MATCHED
S2
S3 , QUINTILES
S4
S5 P
RESAMPLING
PPLAT
OF
* : mortality rate adjusted for age, APACHE/SAPS risk, arterial-pH, P/F ratio, and Trial (Cox Proportional Hazard Regression)
*: mortality-rate
for age, APACHE/SAPS
risk,after
arterial-pH,
P/F ratio, and study-trial
Figure S5: Survival
impact ofadjusted
tidal volume,
before and
lung-sizing
(Cox Proportional Hazards Regression)
Using double stratification procedures (like in Figure 1, main manuscript), we partitioned our dataset into five distinct sub-samples (each one
with approximately 600 patients with ARDS), and calculated the relative risk for each sub-sample in comparison with the average risk of the
combined population. Patients are the same as those included in the combined analysis of Table 1.
In the upper scatter/error-bar diagrams (open triangles) we show the average values for plateau pressures across quintiles of tidal volumes
(left) or P (right). In the middle scatter/error-bar diagrams (black squares) we show the average values for tidal volume (left panel, VT scaled
to predicted body-weight, PBW) and for driving-pressure (right panel, VT scaled in proportion to respiratory-system compliance, so
representing P), found in each quintile. The error bars represent one standard-deviation. Note that each resampling (D and E) produced subsamples with comparable mean values for plateau pressures, but very distinct values for tidal volume or P.
At the bottom, we show the respective relative-risk calculated for each sub-sample after multivariate adjustment (at patient-level) for covariates
1-5 specified in Model 1 (Table 1). Error bars represent 95% confidence intervals. A relative-risk of 1 represents the average risk of the pooled
population, which presented an adjusted survival at 60-day of 68%.
Note that reductions in tidal volume per se had no impact on mortality risks, whereas reductions of a re-scaled tidal volume (so representing
P) were associated with a marked risk reduction. Note the mathematical equivalence: P = ( VT / CRS) = VT normalized to CRS
31
II.8. Survival in patients under protective ventilator settings:

Figure S6: Survival in patients under protective ventilator
settings
32
Figure S6:
Figure
2a :
Figure-S4:
Survival in patients under protective ventilator settings

Figure
2a: Subsample
of patients
protective
settings
Subsample
of patients
underunder
protective
settings
( N==1745
1745))
(N
95
( adjusted* )
Cumm. Survival (%)
100
90
P < 0.001
85
80
75
stratification:
(N)
P MEDIAN
14 cmH2O
( 989 )
P >> MEDIAN
14 cmH2O
( 756 )
PPLAT MEDIAN
25 cmH2O
( 955 )
PPLAT > MEDIAN

25 cmH2O
( 790 )
100
95
( adjusted* )
Cumm. Survival (%)
70
90
P = 0.98
85
80
75
70
100
95
( adjusted* )
Cumm. Survival (%)
* : survival adjusted for

Age, APACHE/SAPS risk, Arterial-pH, P/F ratio, and Trial
All with Plateau-pressure 30 cmH2O & VT 7 mL / ibw
90
85
P = 0.30
80
VT > MEDIAN
6 mL / kg
( 867 )
VT < MEDIAN
6 mL / kg
( 878 )
75
70
10
20
30
40
50
60
Figure
S6: Survival
patients P/F
under
"protective"
ventilator settings
*: adjusted for age,
APACHE/SAPS
risk, in
arterial-pH,
ratio,
and study-trial
Survival curves were obtained after multivariate adjustment at patient level (Cox Proportional Hazards model)
for covariates 1-5 specified in Model-1 (Table 1, main manuscript, and Table S8). For each survival plot, the
selected sub-sample (N=1745) was stratified according to the median values of P, plateau pressure and VT,
respectively (median values = 13 cmH2O, 26 cmH2O and 6 mL/kg PBW, respectively, from top to bottom
plots), producing two strata with similar number of patients. Treating ventilator variables as continuous variables
did not improve the association of tidal volume or plateau pressure with survival, but did improve the
association of P with survival (P<0.001).
Note that lower tidal volumes were associated with a paradoxical trend of higher mortality.
33
II.9. P (but not VT) predicts Barotrauma after randomization:
Figure S7: Odds for barotrauma (Pneumothorax) across quintiles of P or V
(combined population of ARDS: N = 3,080)
34
Figure S7:
Figure 2d:
Figure-S5:
Odds for Barotrauma across quintiles of P or VT :

Odds
for Barotrauma
of P or VT:
Combined
population ofacross
ARDSquintiles
( N = 3080)
1.4
1.0
2.2
( adjusted * )
P <<P0.0001
0.001
< 0.0001
1.8
Odds-ratio for Barotrauma
P < 0.0001
2.2
( adjusted * )
*)
( adjusted
for Barotrauma
Odds-ratio
Odds-ratio for Barotrauma
- Combined population of ARDS ( N = 3080 )
PP== 0.87
0.87
1.8
1.4
1.0
0.6
0.6
44
88
12
12
16
16
Driving-pressure
20
24
20
24
(P, cmH2O)
28
28
44
Driving-pressure (P, cmH2O)

*: pre-adjusted for age, APACHE/SAPS risk, arterial-pH, P/F ratio and study-trial
(VT and P co-participating in model-1 )
6
6
88
Tidal-Volume (V , mL/kg.PBW)
Tidal-Volume (VTT , mL/kg[PBW] )
*: pre-adjusted for age, APACHE/SAPS risk, arterial-pH, P/F ratio and study-trial
(VT and P co-participating in model-1)
**::pre-adjusted
adjusted for
risk,
arterial-pH,
P/F and
ratio,
and Trial
forage,
age, APACHE/SAPS
APACHE/SAPS risk,
arterial-pH,
P/F ratio
study-trial
(multivariate
logistic
regression
wherewhere
both P
and V
in Model-1) in Model-1)
(multivariate
logistic
regression
both
TPco-participate
and VT co-participate
Figure S7: Odds-ratio for Barotrauma during the first 28 days after randomization
Barotrauma was strictly defined as pneumothorax requiring chest tube drainage (with 313 events, or 9% of
the sample). The odds-ratio for each quintile was calculated in relation to the average risk of the combined
population (assumed to be 1.00). The mean odds and 95% confidence intervals (error bars, enclosing the
gray zone) for each quintile were calculated after multivariate adjustment at patient level (Logistic regression
model) for covariates 1-5 specified in Model-1 (Table 1, main manuscript). After including tidal volume and
P in the multivariate model, the adjusted odds-ratio for progressive quintiles of both variables were
calculated (each quintile had approximately 600 patients). The number of percentiles was chosen in order to
have at least 40 events per percentile, guarantying reliable confidence intervals. P-values indicate the overall
differences in risk across quintiles (as categorical variable).
.
10
10
12
12
35
II.10. Mediation Analysis:

More than a marker for the severity of baseline lung disease.
P strongly correlates with mortality, independently of baseline elastance

of respiratory system)
Please, refer to the figures on the next pages
Figure S8:
Mediation in the Lower vs. Higher VT-trials:
Tested mediator: P-changes driven by randomization
Figure S9:
Mediation in the Higher vs. Lower PEEP-trials:
Tested mediator: P-changes driven by randomization
36
Figure S8: Mediation in the Lower vs. Higher VT-trials:

Tested mediator:
P-changes
driven by randomization
Solid arrows in the path diagram represent significant association between variables, with left to right direction representing an independent
model: High vs. Low V trials
Figure 3a
: Mediational
to dependent
relationship.
Red dashed arrows representT non-significant effects.
Tested mediator:
Step 1:
P-changes
Hazard = 0.60
Randomization
Survival effect
(0.48 0.75; P < 0.001 )
Baseline disease
covariates*
Step 2:
Hazard = 0.62
lower P
Survival effect
( 0.52 0.74 ; P < 0.001 )
(-1 STD = - 7 cmH2O)
ElastanceRS
adjustment
Steps 3 & 4:
Hazard = 0.68 (ACME)
-8.4 cmH2O
Randomization
Mediatedproportion:
74%
lower P
P < 0.001
Baseline disease
covariates*
P = 0.004
Survival effect
P = 0.46 ( N.S. effect )
ElastanceRS
adjustment
Top: The first step in our mediational

analysis was the demonstration that
randomization (assignment to lower
tidal-volume arm) had a measurable
impact on survival, after accounting
for baseline risk covariates (Model-1,
Table 1).
Middle: Secondly, we checked if
mediator changes, theoretically
assumed as beneficial, correlated
with better survival. At this step, we
corrected for the baseline-elastance
(of respiratory-system).This allowed
us to examine the exclusive impact of
superimposed variations in P driven
by changes in ventilator settings,
which followed the random treatment
assignment.
Bottom: Finally, a multilinear
regression (mixed effects) calculated
the influence of randomization on the
tested mediator, indicating that
randomization caused a significant
mean reduction of -8.4 cmH2O in P.
Baseline disease
covariates*
*: covariates: age, APACHE/SAPS risk, arterial-pH, P/F ratio, Trial
Subsequently, we jointly calculated the influence of the mediator on survival, after accounting for baseline risk factors, baselineelastanceRS, and the direct effects of randomization. This last step shows that reductions in P mediated most (75%, P = 0.004) of the
original effect of randomization and, consequently, randomization is no longer associated with survival in an independent manner
(characterizing complete mediation).
Implicitly, this last step with significant ACME (average causal mediation effect) also suggests that variations in P had an independent
impact on survival: i.e. patients exhibiting larger reductions in P obtained a survival benefit that exceeded the average benefits found in
the lower-VT arm.
37
Figure S9: Mediation in the Higher vs. Lower PEEP-trials:

Tested mediator:
P-changes
model: arrows
High vs.
Low PEEP
trials effects.
Figure 3c
: Mediational
to dependent
relationship.
Red dashed
represent
non-significant
Tested mediator:
Step 1:
P-changes
Hazard = 0.83
Randomization
Survival effect
(0.72 0.97; P = 0.02 )
Baseline disease
covariates*
Step 2:
We followed the same steps

described in the mediational analysis
of Figure S8.
Top: We first demonstrate that
randomization (assignment to higherPEEP arm) had a measurable impact
on survival, after accounting for
baseline risk covariates (Model-1,
Table 1).
Hazard = 0.57
lower P
Survival effect
( 0.42 0.72; P < 0.001 )
(-1 STD = - 7 cmH2O)
ElastanceRS
adjustment
Steps 3 & 4:
Hazard = 0.91 (ACME)
-1.2 cmH2O
Randomization
Mediatedproportion:
45%
lower P
P < 0.001
Baseline disease
covariates*
P = 0.001
Survival effect
P = 0.18 ( N.S. effect )
ElastanceRS
adjustment
Middle: Secondly, we checked if

mediator changes, theoretically
assumed as beneficial, correlated
with better survival, especially after
pre-adjustment for baselineelastanceRS. This step demonstrated
the significant, independent impact of
superimposed (i.e. caused by
ventilator adjustments) variations in
P.
Baseline disease
covariates*
Bottom: we finally show that

reductions in P had a beneficial
impact, explaining 45% of the original
effects of randomization. The no
longer significant effect of
randomization (red arrow) suggest
complete mediation.
This last step, with significant ACME (average causal mediation effect) also demonstrates that P had a survival effect that exceeds the
main effect of randomization: i.e. patients exhibiting accentuated reductions in P obtained a survival benefit that exceeded the average
benefit found in the respective higher-PEEP arm.
38
Additional details:
The reliability of a randomized clinical trial resides in the lack of correlation between treatment
and baseline condition of patients. This is an essential, well-accepted pre-requisite for
accepting causality implication. The lack of correlation arises from an exogenous, random
process for treatment selection. In case we find a significant correlation between treatment and
outcomes, we can suggest that the benefits are directly caused by treatment, and not by the
circumstantial fact that we applied the treatment in patients with better baseline condition.
Similarly, to suggest that P was more than a risk predictor, working as a mediator of survival,
(i.e. to the extra-survival related to randomized treatment) we had to be sure that the variability
of P observed in our samples were not correlated with baseline disease (i.e. independent
from baseline elastance). Ideally, P variations should be mostly related to ventilator strategy,
implemented according to a randomized process. However, since P is mathematically
correlated with baseline elastance of respiratory system (baseline-elastanceRS), this
independency of P was hardly true and the solution was to first remove (filter out) the
component of P correlated with baseline mechanics, later applying the mediation analysis on
the residual P component.
In multivariate regression analysis, this removal or subtraction of the confounding component
(P-component related to baseline disease) is equivalent to the pre-adjustment of a regression
model by baseline-elastanceRS, if adjusting the same model in which P is simultaneously
tested as an independent explanatory variable. A significant correlation between P and
outcomes would indicate the presence of a residual and independent (orthogonal) source of
variability in P, uncorrelated with baseline disease, which is also affecting outcomes.
Accordingly, in the first logical steps of our mediation analysis (step-2: the check if mediator
changes, theoretically assumed as beneficial, correlated with better survival), we explicitly
tested this hypothesis (Figure S8 and S9). After pre-adjustment of survival Model-1 for
39
baseline-elastanceRS, we checked the correlation between residual changes in P (now mostly

correlated with randomization) and outcomes. As shown in the respective figures (step-2),
reductions in P were significantly associated with better survival in both cohorts,
independently from baseline lung disease, and exhibiting similar effect-size in both cohorts (RR
for 1 STD change: 0.62; 95%CI: 0.520.74 for lower-VT trials; RR: 0.57; 95%CI: 0.420.72,
for higher-PEEP trials). Fitting the rationale of our a priori hypothesis, the sign of this correlation
was negative, i.e. a reduction in P caused improved survival.
After the demonstration of a strong correlation between superimposed-P changes (defined as
residual variations in P, mostly driven by the changes in ventilator settings following
randomization) and mortality, we performed a stepwise, complete mediational analysis (a
powerful and innovative statistical approach that investigates mechanisms explaining why, and
to which extent, a randomized treatment works13-23).
In our case, the hypothesis was that randomization (treatment assignment represents an
intention to treat bundle including various recommendations like VT reduction, plateau pressure
limitation, respiratory rate and acidosis management, etc.) had an impact of survival in
proportion to variations in superimposed-P, despite the fact that manipulation of P was not
an explicit target in most protocols.
To be a mediator, the variable-candidate must be strongly affected by the randomized
treatment, and must be an intermediate variable within the temporal pathway between
randomization (treatment group assignment) and the outcomes. To be significant, a mediation
analysis requires the demonstration that a variation in the mediator causes an impact on
outcome, which is independent of the main effect of randomization (i.e. it causes an impact
above and beyond that caused by randomization). This means that other factors, besides
randomization, cause some variability in the mediator (ideally at random), and this extravariability must cause an independent impact on outcomes. Sometimes it is possible to show
40
that variations in the mediator explain the whole effect of the randomized treatment (so called
complete mediation), but this is not a pre-requisite to demonstrate mediation.
The mediation analysis must be performed according to a sequence of statistical tests and
logical steps. We here used the sequence described by Kraemer and Shrout, in accordance
with the MacArthur approach 20-22.
The initial step was the analysis of the main effect of randomization, traditionally called as the
direct effect. This was calculated through a Cox survival analysis, using trial as a random effect.
In the original reports, only two1,5 out of the nine trials in our combined sample reported a
statistically significant impact of protective strategies. In a recent meta-analysis24 using a
population that had large overlap with the population of our derivation cohort, investigators
have found a marginal benefit of lower VT strategies. And another patient-level meta-analysis25,
considering only the higher versus lower PEEP trials, showed a benefit of the higher PEEP
strategy, although restricted to a subgroup of patients with more severe hypoxemia.
Differently, our combined analysis showed a more consistent efficacy of protective strategies,
either considering the lower-VT trials separately, or the higher-PEEP trials separately. This
difference was essentially caused by the multivariate adjustment at the patient level, according
to survival Model-1. For instance, the crude relative-risk of lower-VT strategies was 0.82 (95%CI
= 0.671.00) before adjustment, and 0.60 (95%CI = 0.480.75) after adjustment. Similarly,
the crude relative-risk of higher-PEEP strategies was 0.92 (95%CI = 0.791.06) before
adjustment, but 0.83 (95%CI = 0.720.97) after adjustment.
When using the R software for mediation analysis, there is an output called total effect,
estimated by simulation according to the principles described by Imai et al15-18. This output must
provide an equivalent result (for the main effect of randomizarion), although slightly different
41
because of the simulations and different estimation methods. After running 5000 simulations,
the results fitted very well with the estimates provided above:
Relative-risk (Hazard)
P-Value
Total effect for VT-trials:
0.60 (0.480.74)
P < 0.001
Total effect for PEEP-trials
0.82 (0.710.96)
P = 0.01
The second logical step was the check described above (page 32, when discussing the
required adjustment for baseline-elastanceRS), where we tested if mediator changes,
theoretically assumed as beneficial, correlated with better survival. At this step, we added the
pre-adjustment of baseline-elastanceRS in the model, making sure that our analysis was not
biased by confounding effects of the severity of underlying lung disease (potentially inflating the
association between P and survival). Among our tested mediator-candidates, PEEP and
plateau pressures failed at this second step within the higher-PEEP trials. After accounting for
baseline elastance, both variables were not significantly associated with survival.
The next two steps involve the analysis of inclusion of the effects of superimposed-P (i.e.
residual variations in P after subtracting the P variations correlated with baseline lung
disease) in a model where the direct effects of randomization are already taken into account:
42
By using the notation indicated in the diagram above, this analysis involves the demonstration
of 2 separate steps (steps 3 and 4 , Figures S8-S9, above)13,20-22 :
Step-3: to show that superimposed-P was significantly correlated to treatment group
assignment. Accordingly, the coefficient "A" produced by the multivariate regression of the
superimposed-P variable over randomization must be significantly different from zero. The
signal of coefficient A is an important issue in this mediation analysis, since we want to prove
that reductions in P cause improved survival. Thus, it has to be negative. As a
counterexample, plateau-pressures did not pass this logical step for the PEEP-trials, since
randomization caused higher plateau-pressure (,i.e. a positive coefficient A, P < 0.001), but an
improved survival.
Step-4: to show that superimposed-P carried significant survival impact (with a significant
coefficient "B") when included in a multivariate model where treatment group was also included
(as well as baseline-elastanceRS). This procedure is equivalent to the Sobel test, or, when using
the R software for mediation, equivalent to the significance test for the ACME (average causal
mediation effect). The ACME considers the combined effects of steps 3 and 4: both steps have
to present some minimum effect-size to guarantee a significant path through the mediator2.
In the R package for Mediation Analysis, two models are fit, one modeling the effects of randomization
on the mediator, and a second one jointly modeling the effects of randomization (directly) and mediator
(indirectly) on outcomes. Using Monte-Carlo simulations, a mediation proportion is estimated, indicating
43
Whenever the ACME has an important effect, the coefficient "C" (representing the direct effect
of randomization, after multivariate adjustment) becomes weaker after accounting for the
mediating effect (indirect path "A*B"). Ideally, in order to demonstrate complete mediation, "C"
should be virtually zero (non-significant), with a mediation proportion ~100%.
For testing all the steps above, we pre-adjusted our mediational model with the covariates
elected in Model-1 (Table 1, main text), also including the baseline-elastanceRS variable. We
observed that all those covariates were non-specific predictors of survival, uncorrelated with
treatment group. We repeated the stepwise checks for all mediation-candidates, using only one
mediator each time.
how much of the whole risk-reduction in the treatment arm could be explained by the indirect path in
which randomization drives a change in the mediator, which then affects the outcome.
8-10
The rationale used by this package is the same described by Imai et al : suppose that randomized
treatment is denoted as a z=0 (control) or z=1 (treatment), and the mediating variable for a patient is
denoted as M(0) and M(1) if they got treatment 0 or 1. Further suppose that the outcome for a patient
with mediating variable M who got treatment 0 is T(M,0) and if they got treatment 1, T(M,1). Then the
average mediated effect is the average of (T(M(1),1) -T(M(0),1) and T(M(1),0) -T(M(0),0). In other words
it is the effect we would see if the mediating variable changed but treatment did not. This effects needs to
be estimated in a model including the treatment group, the mediating variable and all confounding
variables the affect both the mediating variable and the outcome.
44
VT and PEEP were not independent mediators
Please, refer to the figures on the next pages
Figure S10:
Mediation in the Lower vs. Higher VT-trials:
Tested mediator: VT-changes driven by randomization
Figure S11:
Mediation in the Higher vs. Lower PEEP-trials:
Tested mediator: PEEP-changes driven by randomization
Additional details:
Except for P, no other mediation-candidate consistently passed through the stepwise
mediation tests. Of note, tidal volume was not a significant mediator in the lower-VT trials
(P=0.67, ACME, Figure S10), and PEEP was not a significant mediator in the higher-PEEP
trials (P=0.50, ACME; Figure S11).
45
Figure S10: Mediation in the Lower vs. Higher VT-trials:

Tested mediator:
VT-changes
model: arrows
High vs.
Low VT non-significant
trials
Figure 3b
: Mediational
to dependent
relationship.
Red dashed
represent
effects.
Tested mediator:
Step 1:
VT -changes
Hazard = 0.60
Randomization
Survival effect
(0.48 0.75; P < 0.001 )
Baseline disease
covariates*
Step 2:

of Figure S8.
Top: The first step was the same as

in Figure S8
Hazard = 0.78
Survival effect
lower VT
(-1 STD = - 2.8 mL/kg)
( 0.70 0.87 ; P < 0.001 )
ElastanceRS
adjustment
Steps 3 & 4:
-5.1 mL/kg
P = 0.67 ( N.S. effect )
Middle: VT passed through the

second step.
Baseline disease
covariates*
Mediatedproportion:
0%
lower VT
P < 0.001
Hazard = 0.59
Randomization
Bottom: Finally, VT failed in the last

step required to characterize
mediation.
Survival effect
P = 0.009 ( Independent effect )

ElastanceRS
adjustment
Baseline disease
covariates*
Note that randomization keeps an independent predictive effect at this last step, whereas VT does not. This suggests that the predictive
information provided by treatment group assignment (representing a bundle of intention to treat interventions) exceeds the information
provided by individual levels of VT.
Thus, tidal-volume cannot be considered as an independent mediator of the effects of randomization.
46
Figure S11: Mediation in the Higher vs. Lower PEEP-trials:

Tested mediator:
PEEP-changes driven by randomization
SolidFigure
arrows in
diagram model:
represent
significant
variables, with left to right direction representing an independent
Mediational
High
vs. Low association
PEEP trialsbetween
3cthe: path
to dependent relationship.
dashed
arrows
represent
TestedRed
mediator:
PEEP
-changes
driven non-significant
by randomizationeffects.
Step 1:
Hazard = 0.83
Randomization
Survival effect
(0.72 0.97; P = 0.02 )
Baseline disease
covariates*
Step 2:
Hazard = 0.95
Survival effect
higher PEEP
( 0.87 1.03; P = 0.19 )
(+1 STD = + 4.5 cmH2O)
ElastanceRS
adjustment
Steps 3 & 4:
+6.1 cmH2O
P = 0.50 ( N.S. effect )
Baseline disease
covariates*

of Figure S8.
Top: The first step was the same as

in Figure S9
Middle: PEEP already failed at this

second step, showing that a higherPEEP strategy may be beneficial as a
package (shown in step1), but not in
proportion to PEEP increments.
There was no dose-response to
PEEP.
Mediatedproportion:
0%
higher PEEP
P < 0.001
Hazard = 0.82
Randomization
Survival effect
P = 0.03 ( Independent effect )

ElastanceRS
adjustment
Bottom: PEEP also failed at this last

step, without any independent effect.
Baseline disease
covariates*
Note that randomization keeps an independent predictive effect at this last step, whereas PEEP does not. This suggests that the
predictive information provided by treatment group assignment (representing a bundle of intention to treat interventions) exceeds the
information provided by individual levels of PEEP.
Thus, PEEP per se cannot be considered as an independent mediator of the effects of randomization. Other strategies included in
the bundle, or other intermediate variables affected by high-PEEP strategy are likely more important.
47
II.10. P consistently mediates survival across /within trials

Please, refer to the table on the next page
Table S9:
Mediation effects of P within study-trials (intra-trial mediation effects)
Additional details:
The variable Trial was entered as a random-effect in both mediation models: the mixed-effects
linear regression modeling the effects of randomization on the mediator, and the mixed-effects
Cox regression modeling the effects of both, mediator and randomization on survival. The R
package for mediation was designed to perform multi-level mediation analysis, where
individuals may be correlated within groups (trials), and the different trials may have different
randomization processes. Using a conservative approach, we also considered a moderated
mediation analysis, in which the randomization process could be moderated by the trial
variable, i.e. each study could have a different effect of randomization (direct effect), a different
effect of P (mediating effect), and a different mediation proportion. In fact, this analysis
allowed us to test the intra-trial mediation effect of P, shown in Table S9.
As observed, the ACME had the same consistent trend in all of the nine studies, presenting a
significant value in many of the individual studies. These findings support our pooled analysis
presented in Figure S8 and S9. They also demonstrate that P mediates intra-trials and intertrials effects, i.e. differences between the two arms in each study, and differences in the net
effects of randomization across the studies, with some studies presenting larger benefits of
randomization than others.
48
Table S9 (website):
Mediation effects of P within study-trials (intra-trial mediation effects)
Total effect
(Hazard)
ACME
(Hazard)
Amato et al.1
0.12
0.26
0.07
Stewart et al.2
0.63
0.72
0.14
Brochard et al.3
0.69
0.60
0.03
Brower et al.4
1.16
0.86
0.28
ARDSnetTV5
0.62
0.78
0.10
VT-trials combined
0.59
0.73
0.01
ARDSnetPEEP6
0.90
0.83
0.001
EXPRESS7
0.76
0.91
0.004
LOVS8
0.89
0.96
0.06
Talmor et al.9
0.52
0.97
0.46
PEEP-trials combined
0.83
0.92
< 0.001
Trial:
P-value
(for ACME)
ACME: Average causal mediation effect, calculated according to Imai et al.16,17
Note that the ACME had the same consistent trend in all of the nine studies, presenting a significant value in many of the individual studies. Thus,
P was always responsible for part of the observed effects of randomization (shown as the total-effect). These findings support the pooled
analysis presented in Figures S8-S9. They also suggest that P mediates intra-trials and inter-trials effects, i.e. differences between the two arms
in each study, and differences in the net effects of randomization across the studies, with some studies presenting larger benefits of randomization
than others.
49
III) DETAILS ON STATISTICS AND METHODS:

All statistical tests were two-sided.
III.1. Screening the dataset and compatibility analysis

After pooling the data from the 9 trials 1-9, patients who died or were weaned before the first 24
hours after randomization were excluded from the final analysis (9 patients). This procedure
was necessary because we planned to test the impact of ventilation variables best representing
the first 24 hours of the randomized strategy. Outcomes occurring before this time period would
characterize incomplete or undetermined risk exposure, potentially introducing bias in the Cox
survival model. We also reasoned that a minimum risk exposure of 24 hours was necessary to
affect the outcome, or to minimally override the effects of treatment received before
randomization.
After this first exclusion, we searched for the following incompatibilities in the dataset of each
patient: peak-pressure < plateau-pressure; plateau-pressure < PEEP; minute ventilation
(tidal-volume times respiratory-rate10%); mean-airway pressure > plateau-pressure or meanairway pressure < PEEP; weaning date later than death or discharge date; PaO2/FIO2> 600 or
PaO2/FIO2<35; PaCO2< 10 or PaCO2>150 mmHg; arterial-pH < 6.7 or arterial-pH > 7.7.
When one value was obviously wrong, it was removed from the dataset. When incompatibilities
as above were found, without an obviously spurious datum, the whole set of two or three
incompatible variables were excluded from the data set. Afterwards, all outliers (> 3 standard
50
deviations from the population-sample mean) within baseline or ventilation variables were
assessed. If they were consistent with values on the previous or following days (i.e. within the
range of the individual mean along the time 3 STD), they were retained; otherwise they were
either within-patient-interpolated (when possible) or discarded. If there was more than one
value per day, we assumed that the non-outlier value was representative for that day.
In Tables S1-S2 and Figure S1 we present some descriptive statistics for these trials, after the
incompatibility analysis. In Table S3, we tested the univariate association with survival for each
of those screened covariates.
Finally, we tested the impact of excluding additional 87 subjects whose plateau-pressures were
below 10 cmH2O or Ps were below 5 cmH2O or PEEP values were below 5 cmH2O or tidalcompliance was above 1.25 mL/kg/cmH2O, during the first day after randomization. We
reasoned that such values might indicate errors during data collection, or patients with mild
disease or low risk exposure who might decrease the sensitivity of our analysis. The mortality
rate of these excluded patients was lower (25.3%) than the average mortality of the remaining
population (35.3%; P = 0.07 for the comparison of mortality-rates between excluded vs.
remaining patients).
The performance of Models 1-5 was rechecked within this more restricted sample of 3466
patients. The relative-risk associated with one standard-deviation increment in driving-pressure
or other covariates minimally changed (maximum change of 1% in the relative-risks for all
covariates). After observing this lack of benefit of a more restricted sample, we ultimately
decided to present our results without this filter (as shown in Table 1). The slightly lower
number of patients presented in Table 1 was caused by missing data (see next session).
Whereas patients in the validation sample had their tidal-volumes adjusted according to the
ideal body weight (IBW), most patients in the hypothesis-generation sample had their tidal-
51
volumes adjusted according to actual body weight. The physiological bias generated by this
procedure, in case of prevalent obesity, would be that of a systematically lower tidalcompliance (affecting both arms) in those studies using actual body weight. Since we found
similar mean values for normalized compliance in both samples (P = 0.23), without significant
differences in other markers of baseline lung disease, we concluded that such bias was unlikely
and that the use of actual body weight in these particular patients had the same physiological
consequences as the use of ideal body weight. In sum, 92% of patients in our combined
sample had their tidal-volumes adjusted according to ideal body weight, but we kept the term
IBW for all.
52
III.2. Missing data

In general, the amount of missing data was low (< 10% for individual variables) for first-day
ventilation variables, with only 4 cases of missing data related to main outcome. The same was
not true for plateau-pressure (and consequently P) at baseline, which was only available for
the second validation cohort.
There were no significant differences in the amount of missing data across the trials, except for
age, which was missing in 100% of the cases in one of the trials3, but complete in all other
studies. Thus, we did not consider any special treatment for missing cases of other covariates,
and the incomplete cases were simply excluded from multivariate analysis. To ensure that the
lack of information was at random, not introducing bias in our model, we subsequently tested a
missingness variable for each covariate (coded as 1 if missing, and zero if present) including
them in univariate survival models or in multivariate models where the original covariate was
replaced by its missingness one. From all missingness variables, only missing-age affected the
models, being significantly related to survival (P = 0.002).
Since we could retrieve the mean plus standard deviation of the variable age for all missing
cases (found in the original publication in which individual values were missing3, we replaced
the missing values by an imputed random value obeying similar distribution (mean = 57,
standard deviation = 15, as reported). After this procedure, which allowed us to include an
additional 113 cases in the multivariate analysis, we checked the performance of the
multivariate Model 1 before and after treatment for missing cases. This data handling was
advantageous, increasing the power of our analysis and minimally affecting the relative risk of
other covariates. Thus, this procedure was adopted in our final analysis.
53
III.3. Double-stratification (used for analysis in Figure 1 and Figure S5)
Description of the resampling procedures:

Resampling A: using the combined population shown in Table 1, we first stratified patients into
deciles of PEEP, forming 10 clusters of patients with similar PEEP. Second, we stratified each
cluster into quintiles of progressively higher P (at this point we had 50 classes). And third, for
each strata of P, we merged the 10 clusters of PEEP, finally forming 5 sub-samples with
matched average PEEP, but distinct average P.
Resampling B: Similarly to resampling A, we first formed 10 clusters of patients with similar
P, and then stratified each cluster into quintiles of progressively higher PEEP. Then, for each
strata of PEEP, we merged the 10 clusters of P, finally forming 5 sub-samples with matched
average P, but distinct average PEEP.
Resampling C: Similarly to resampling A, we first formed 10 clusters of patients with similar
plateau-pressure, and then stratified each cluster into quintiles of progressively higher PEEP.
Then, for each strata of PEEP, we merged the 10 clusters of plateau-pressure, forming 5 subsamples with matched average plateau-pressure, but distinct average PEEP.
Resampling D: Similarly to resampling C, we first formed 10 clusters of patients with similar
plateau-pressure, and then stratified each cluster into quintiles of progressively lower VT. Then,
for each strata of VT, we merged the 10 clusters of plateau-pressure, forming 5 sub-samples
with matched average plateau-pressure, but distinct average VT.
Resampling E: Similarly to resampling C, we first formed 10 clusters of patients with similar
plateau-pressure, and then stratified each cluster into quintiles of progressively lower P. Then,
for each strata of P, we merged the 10 clusters of plateau-pressure, forming 5 sub-samples
with matched average plateau-pressure, but distinct average P.
54
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Driving Pressure and Survival in ARDS-Amato-ESM-NEJM 2015

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Supplementary Appendix

Driving Pressure and Survival in Acute Respiratory Distress Syndrome

Research and Education Institute, Hospital Sirio-Libans, So Paulo, Brazil

SUPPLEMENTARY WEB MATERIAL

I) DESCRIPTION OF THE STUDIED POPULATION: (Tables S1-S2; Figure S1)

REFERRED TO IN THE MAIN MANUSCRIPT:

P strongly mediates survival, independently of baseline elastance of

VT and PEEP were not independent mediators (Figures S10-S11)

11. P consistently mediates survival benefits across/within trials (Table S9)

III) DETAILS ON STATISTICS AND METHODS:

I) DESCRIPTION OF THE STUDIED POPULATION:

Higher PEEP guided by

Highest PEEP keeping

Lower vs. Higher

Higher vs. Lower

stopped for futility

Higher PEEP guided by

Higher PEEP guided by

vent. free days

LEGEND FOR TABLE S1:

P: driving-pressure defined as the difference between plateau pressure and PEEP

113 (74 - 165)

182 (135 246)

137 (110 177)

119 (97 - 147)

123 (89 175)

142 (104 200)

138 (98 180)

141 (106 180)

135 (108 178)

Overview of the results of randomization in each of the study-trials.

Days after randomization

Days after randomization

Days after randomization

* : significant survival differences in the original report

: significant survival differences after multivariate adjustment (model-1)

Days after randomization

ADDITIONAL RESULTS AND ANALYSIS REFERRED TO

II.1. Accounting for residual (intrinsic) heterogeneity across the trials:

Figure S2: Accounting for residual heterogeneity across the trials

Figure-S8: Accounting for residual heterogeneities across the trials

Adjusted for individual patient

trial dummy covariate

Adjustment to balance intrinsic differences

Days after randomization

Days after randomization

High vs. Low PEEP trials second validation cohort

High vs. Low VT trial ARDSnet first validation cohort

High vs. Low VT trials preARDSnet derivation cohort

Figure S2: Accounting for residual heterogeneities across the trials.

II.2. Univariate analysis:

Table S3: Univariate

Cox Regression Model 60-Day Mortality.

Table S3 (website): Univariate

Cox Regression Model 60-Day Mortality

Hypothesis generation cohort

First Validation cohort

Second Validation cohort

0.93 (0.68 1.28)

0.74 (0.58 0.93)

0.90 (0.78 1.03)

1.12 (0.97 1.27)

1.03 (0.88 1.22)

1.73 (1.52 1.97)