Selecting patients for randomized controlled trials based on initial physiologic responsiveness may improve trial efficiency and reduce patient exposure to ineffective treatments.
Physiologic enrichment may improve ARDS PEEP trial efficiency; hypothesis-generating and requires prospective validation before practice change.
Most randomized trials in critical care report no mortality benefit; this may reflect competing pathogenic mechanisms, patient heterogeneity, or true ineffectiveness of interventions. We hypothesize that in acute respiratory distress syndrome (ARDS), randomizing only those patients who show a favorable physiological response to an intervention would help ensure that only those likely to benefit would be entered into the study. If true, this would decrease study "noise" and reduce required sample size, thereby increasing the chances of finding true-positive outcomes. It would also lessen the chances of exposing patients to treatments that are unlikely to help or that could cause harm. We present a reanalysis of randomized clinical trials of positive end-expiratory pressure in ARDS that support this hypothesis.
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Goligher et al. (2015) studied this question.
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