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[JAMA在线发表]:肺复张及滴定PEEP增加ARDS患者28天病死率
2017年09月30日 时讯速递, 进展交流 评论数 1
Original Investigation
Caring for the Critically Ill Patient
September 27, 2017

Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial

Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators

JAMA. Published online September 27, 2017. doi:10.1001/jama.2017.14171

Abstract

Importance 背景

The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain.

肺复张及PEEP滴定对ARDS患者临床预后的影响尚不清楚

Objective 目的

To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy.

确定与传统低PEEP策略相比,肺复张及根据呼吸系统最佳顺应性进行PEEP滴定能否降低中重度ARDS患者28天病死率。

Design, Setting, and Participants 设计,场景及研究人群

Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS.

这项多中心随机临床试验于2011年11月17日至2017年4月25日期间,在9个国家120个ICU进行,入选患者为中重度ARDS。

Interventions 干预措施

An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory–system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning.

试验策略为肺复张及根据呼吸系统最佳顺应性滴定PEEP (n = 501;试验组),或对照策略为低PEEP (n = 509)。所有患者均接受容量控制通气模式直至脱机。

Main Outcomes and Measures 主要预后指标

The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality.

主要预后终点为28天全因病死率。次要预后终点包括ICU住院日,总住院日,28天内无机械通气天数,7天内需要引流的气胸比例,7天内气压伤的比例,以及ICU病死率,住院病死率和6个月病死率。

Results 结果

A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, −1.1; 95% CI, −2.1 to −0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality.

共有1010名患者(37.5% 为女性;平均 [SD] 年龄,50.9 [17.4] 岁)入选并接受随访。至28天时,试验组501名患者中277 名 (55.3%),对照组509名患者中 251 名 (49.3%) 死亡(风险比 [HR],1.20;95% CI, 1.01 to 1.42; P = .041)。与对照组相比,试验组6个月病死率增加 (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04),平均无机械通气天数减少(5.3 vs 6.4;差异,−1.1;95% CI, −2.1 to −0.1; P = .03),需要引流的气胸风险(3.2% vs 1.2%;差异,2.0%; 95% CI, 0.0% to 4.0%; P = .03)及气压伤风险(5.6% vs 1.6%;差异,4.0%; 95% CI, 1.5% to 6.5%; P = .001)均增加。ICU住院日,总住院日,ICU病死率及住院病死率无显著差异。

Conclusions and Relevance 结论和意义

In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients.

对于中重度ARDS患者,与低PEEP相比,肺复张及滴定PEEP策略增加28天全因病死率。上述发现不支持在这些患者常规使用肺复张和PEEP滴定。

Trial Registration

clinicaltrials.gov Identifier: NCT01374022

目前有 1 条留言 其中:访客:1 条, 博主:0 条

  1. rorozu : 2017年10月02日16:10:04  -49楼

    杜老板,您对这个研究结果,有何想法?请赐教。谢谢~

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