Early Versus Delayed Enteral Feeding to Treat People With Acute Lung Injury or Acute Respiratory Distress Syndrome (The EDEN Study)

Sponsor

National Heart, Lung, and Blood Institute (NHLBI) (NIH)

Overall Status

Completed

CT.gov ID

NCT00883948

Collaborator

(none)

1,000

Enrollment

Locations

Arms

Duration (Months)

25.6

Patients Per Site

0.6

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are medical conditions that occur when there is severe inflammation and increased fluids in both lungs, making it difficult for the lungs to function properly. Hospital treatment for a person with ALI/ARDS often includes the use of a breathing machine, or ventilator, until the person is able to breathe without assistance. Initiating proper nutrition through a feeding tube early in a person's hospital stay may help to improve recovery, but the optimal timing, composition, and amount of feeding treatments remain unknown. This study will evaluate whether early or delayed full-calorie feeding through a feeding tube is more effective in reducing recovery time and increasing survival rates in people with ALI/ARDS.

Condition or Disease	Intervention/Treatment	Phase
Respiratory Distress Syndrome, Adult	Behavioral: Minimal (Trophic) Feeding Behavioral: Full Feeding	Phase 3

Detailed Description

ALI/ARDS involves extensive inflammation in the lungs that can lead to rapid respiratory failure. These conditions are most commonly caused by pneumonia, generalized infection, or severe trauma to the lungs, but can also be less commonly caused by smoke or salt water inhalation, drug overdose, or shock.

For some people, ALI/ARDS resolves without treatment, but many severe cases result in hospitalization in the intensive care unit (ICU), where 30% to 40% of cases end in mortality. Current treatments for ALI/ARDS include assisted breathing with a ventilator, supportive care, and management of the underlying causes. Enteral feeding, in which patients receive nutrition through a feeding tube, plays an important role in treatment, too. Some recent studies have shown that enteral feeding initiated soon after a patient begins assisted breathing is associated with a shorter hospital stay and a better chance of survival than delayed enteral feeding. However, other studies have shown the opposite, and studies on optimal feeding volume and composition have shown conflicting results. This study will evaluate the effects of early versus delayed full-calorie enteral feeding on mortality, ventilator-free days, ICU-free days, and organ failure in people with ALI/ARDS.

Upon admission to the ICU, a dietary evaluation will be done on each participant to determine goal, or full-calorie, feeding rates, which will be based on body weight and daily energy consumption. Participants will also undergo baseline assessments and procedures, which will include vital sign measurements, blood draws, a frontal chest radiograph, ventilator settings, and placement of a feeding tube. Participants will be randomly assigned to receive initial enteral feedings that are either minimal (trophic) or full-calorie. All participants will begin enteral feeding within 6 hours of treatment assignment.

Participants assigned to initial minimal enteral feedings will receive feedings at 10 cubic centimeters (cc) per hour, to be continued at this rate for 144 hours, provided that the participant remains on the ventilator. After the 144 hours, the feeding rate will be advanced to full-calorie rates.

Participants assigned to initial full-calorie enteral feedings will receive feedings at 25 cc per hour, and the feeding rate will be increased by 25 cc per hour every 6 hours until the goal rate is reached. During enteral feedings, gastric residual volumes (GRVs) will be checked every 6 to 12 hours to assure acceptable levels. Participants will complete enteral feedings upon hospital discharge, Day 28 of treatment, death, or ability to achieve 48 hours of unassisted breathing.

Blood pressure, heart rate, ventilation settings, and various blood factors will be measured during treatment. Phone-based follow-up assessments will occur at Months 6 and 12 after ICU discharge and will include measurements of health-related quality of life; psychological, neurocognitive, and physical activity outcomes; healthcare utilization; and mortality.

Study Design

Study Type:

Interventional

Actual Enrollment :

1000 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Prospective, Randomized, Multi-Center Trial of Initial Trophic Enteral Feeding Followed by Advancement to Full-Calorie Enteral Feeding vs. Early Advancement to Full-Calorie Enteral Feeding in Patients With Acute Lung Injury (ALI) or Acute Respiratory Distress Syndrome (ARDS)

Study Start Date :

Dec 1, 2007

Actual Primary Completion Date :

Mar 1, 2011

Actual Study Completion Date :

May 1, 2011

Arms and Interventions

Arm	Intervention/Treatment
Experimental: 1 Participants will receive initial minimal (trophic) enteral feeding.	Behavioral: Minimal (Trophic) Feeding Upon admission to the ICU, enteral feeds will be started at 10 cc per hour and continued at this rate for 144 hours. After 144 hours of trophic enteral feeds, the feeding rate will be advanced to full-calorie rates, which will continue for the duration of mechanical ventilation up to Day 28.
Experimental: 2 Participants will receive initial full-calorie enteral feeding.	Behavioral: Full Feeding Upon admission to the ICU, a full-calorie feeding rate will be determined, which will be calculated to deliver 25 to 35 kcal/kg predicted body weight (PBW) each day. Enteral feeds will be initiated at 25 cc per hour. The feeding rate will be increased by 25 cc per hour every 6 hours until goal rate is achieved, which will be administered for the duration of mechanical ventilation up to Day 28.

Arm

Intervention/Treatment

Experimental: 1

Participants will receive initial minimal (trophic) enteral feeding.

Behavioral: Minimal (Trophic) Feeding

Upon admission to the ICU, enteral feeds will be started at 10 cc per hour and continued at this rate for 144 hours. After 144 hours of trophic enteral feeds, the feeding rate will be advanced to full-calorie rates, which will continue for the duration of mechanical ventilation up to Day 28.

Experimental: 2

Participants will receive initial full-calorie enteral feeding.

Behavioral: Full Feeding

Upon admission to the ICU, a full-calorie feeding rate will be determined, which will be calculated to deliver 25 to 35 kcal/kg predicted body weight (PBW) each day. Enteral feeds will be initiated at 25 cc per hour. The feeding rate will be increased by 25 cc per hour every 6 hours until goal rate is achieved, which will be administered for the duration of mechanical ventilation up to Day 28.

Outcome Measures

Primary Outcome Measures

Number of ventilator-free days (VFD) [Measured at Day 28]
Mortality before hospital discharge, with unassisted breathing [Measured at Days 60 and 90]

Secondary Outcome Measures

Number of intensive care unit-free days [Measured at Day 28]
Number of organ failure-free days (liver, kidney, heart, central nervous system, and hematologic) [Measured at Day 28]
Incidence of ventilator-associated pneumonia [Measured at Day 28]
Number of days from first meeting criteria for weaning readiness to Day 28 [Measured at Day 28]
VFDs and mortality in participants with a partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FIO2) less than or equal to 200 or with shock at the time of study entry [Measured at Days 28 and 60, respectively]
Change in plasma and mini-bronchoalveolar lavage (BAL) levels of interleukin (IL)-6, IL-8, von Willebrand factor (VWF), surfactant protein D (SPD), and total protein concentrations [Measured at Day 3]
Health-related quality of life; healthcare utilization; and psychological, neurocognitive, and physical activity outcomes [Measured at Months 6 and 12]
Duration of survival after hospital discharge using the National Death Index [Measured at Months 6 and 12]

Eligibility Criteria

Criteria

Ages Eligible for Study:

13 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Must meet the following three criteria within a 24-hour period of study entry: 1) PaO2/FiO2 less than or equal to 300 (if altitude is more than 1000 meters, then PaO2/FiO2 less than or equal to 300 x [barometric pressure/760]), 2) bilateral infiltrates (patchy, diffuse, homogeneous, or asymmetric) consistent with pulmonary edema on frontal chest radiograph, and 3) requirement for positive pressure ventilation via endotracheal tube
No clinical evidence of left-sided cardiac failure to account for bilateral pulmonary infiltrates
Intention of primary medical team to enterally feed the patient
Undergoes enteral feeding within 48 hours of meeting other inclusion criteria

Exclusion Criteria:

Neuromuscular disease that impairs ability to breathe without assistance, such as cervical spinal cord injury at level C5 or higher, amyotrophic lateral sclerosis, Guillain-Barré syndrome, or myasthenia gravis
Pregnant or breastfeeding
Severe chronic respiratory disease (more information about this criterion can be found in the protocol)
Burns on greater than 40% total body surface area
Cancer or other irreversible disease or condition for which 6-month mortality is estimated to be greater than 50% (more information about this criterion can be found in the protocol)
Allogeneic bone marrow transplant in the 5 years before study entry
Patient, surrogate, or physician not committed to full support (exception: a patient will not be excluded if he/she would receive all supportive care except for attempts at resuscitation from cardiac arrest)
Severe long-term liver disease (Child-Pugh score of 11 to 15)
Diffuse alveolar hemorrhage from vasculitis
Morbid obesity, defined as 1 kg/cm body weight
Unwilling or unable to use the ARDS network 6 mL/kg PBW ventilation protocol
Moribund patient not expected to survive 24 hours after study entry
No intent to obtain central venous access for monitoring intravascular pressures
More than 72 hours since mechanical ventilation initiated
Refractory shock (more information about this criterion can be found in the protocol)
Unable to obtain enteral access
Presence of partial or complete mechanical bowel obstruction
Presence of ischemia or infarction
Current total parenteral nutrition (TPN) use or intent to use TPN within 7 days of study entry
Severe malnutrition with body mass index less than 18.5 or loss of more than 30% total body weight in the 6 months before study entry
Laparotomy expected within 7 days of study entry
Unable to raise head of bed 30 to 45 degrees
Short-bowel syndrome or absence of gastrointestinal tract
Presence of high-output (greater than 500 cc/day) enterocutaneous fistula
International normalized ratio greater than 5.0, platelet count less than 30,000/mm3, or history of bleeding disorder
Intracranial hemorrhage in the 1 month before study entry
Allergy to enteral formula
Requirement for, or physician insistence on, enteral formula supplemented with omega-3 fatty acids (e.g., Oxepa®, Impact®) or treatment with omega-3 fatty acid, gamma-linolenic acid (GLA), or antioxidant supplementation

Contacts and Locations

Locations

	Site	City	State	Country
1	University of San Francisco-Fresno Medical Center	Fresno	California	United States
2	University of California, Davis Medical Center	Sacramento	California	United States
3	University of California, San Francisco (UCSF)-Moffitt Hospital	San Francisco	California	United States
4	Centura St. Anthony Central Hospital	Denver	Colorado	United States
5	Denver Health Medical Center	Denver	Colorado	United States
6	Rose Medical Center	Denver	Colorado	United States
7	University of Colorado Health Sciences Center	Denver	Colorado	United States
8	Washington Hospital Center	Washington DC	District of Columbia	United States
9	Baton Rouge General Hospital-Blue Bonnet	Baton Rouge	Louisiana	United States
10	Baton Rouge General Hospital-Midcity	Baton Rouge	Louisiana	United States
11	Earl K. Long Medical Center	Baton Rouge	Louisiana	United States
12	Our Lady of the Lake Regional Medical Center	Baton Rouge	Louisiana	United States
13	Medical Center of Louisiana	New Orleans	Louisiana	United States
14	Ochsner Clinic Foundation	New Orleans	Louisiana	United States
15	Tulane University Health Sciences Center	New Orleans	Louisiana	United States
16	Johns Hopkins Bayview Medical Center	Baltimore	Maryland	United States
17	Johns Hopkins Hospital	Baltimore	Maryland	United States
18	Union Memorial Hospital	Baltimore	Maryland	United States
19	University of Maryland Shock Trauma Center	Baltimore	Maryland	United States
20	Baystate Medical Center	Springfield	Massachusetts	United States
21	Rochester Methodist Hospital	Rochester	Minnesota	United States
22	St. Mary's Hospital, Mayo Clinic	Rochester	Minnesota	United States
23	Duke University Medical Center	Durham	North Carolina	United States
24	Durham Regional Medical Center	Durham	North Carolina	United States
25	Moses Cone Health System	Greensboro	North Carolina	United States
26	Wesley Long Community Hospital	Greensboro	North Carolina	United States
27	Wake Forest University Baptist Medical Center	Winston Salem	North Carolina	United States
28	Cleveland Clinic Foundation	Cleveland	Ohio	United States
29	MetroHealth Medical Center	Cleveland	Ohio	United States
30	University Hospitals of Cleveland	Cleveland	Ohio	United States
31	Vanderbilt University Medical Center	Nashville	Tennessee	United States
32	Baylor College of Medicine	Houston	Texas	United States
33	Intermountain Medical Center	Murray	Utah	United States
34	McKay-Dee Hospital	Ogden	Utah	United States
35	Utah Valley Regional Medical Center	Provo	Utah	United States
36	LDS Hospital	Salt Lake City	Utah	United States
37	University of Virginia Medical Center	Charlottesville	Virginia	United States
38	Harborview Medical Center	Seattle	Washington	United States
39	University of Washington	Seattle	Washington	United States