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[JAMA在线发表]:小潮气量通气不改善非ARDS患者机械通气时间
2018年11月09日 时讯速递, 进展交流 评论数 1

Original Investigation

Caring for the Critically Ill Patient

October 24, 2018

Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial

Writing Group for the PReVENT Investigators

JAMA. Published online October 24, 2018. doi:10.1001/jama.2018.14280

Abstract

Importance 背景

It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS).

对于并非罹患ARDS的危重病患者,尚不清楚有创机械通气时是否应当使用小潮气量。

Objective 目的

To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy.

明确小潮气量通气策略与中等潮气量相比是否更有效。

Design, Setting, and Participants 设计,场景和研究人群

A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands.

荷兰6个ICU于2014年9月1日至2017年8月20日进行的一项随机临床试验,入选患者为接受机械通气的非ARDS患者,且预计24小时内不会拔管。

Interventions 干预措施

Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484).

采用小潮气量(n = 477)或中等潮气量(n = 484)的有创机械通气。

Main Outcomes and Measures 主要预后指标

The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax.

主要预后指标为28天内无机械通气存活天数。次要预后指标包括ICU及医院住院日;ICU病死率,住院病死率,28天及90天病死率;发生ARDS、肺炎、严重肺不张或气胸。

Results 结果

In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, –0.27 [95% CI, –1.74 to 1.19] P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [–1.09 to 1.89] ; P = .58) and hospital (median, 14 vs 15 days; –0.60 [–3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55).

研究共入选961名患者(65%为男性)中位年龄 68 岁(四分位区间[IQR],59-76)。至第28天,小潮气量组475名患者无机械通气中位天数为21天 (IQR, 0-26),中等潮气量组480名患者无机械通气中位天数为21天 (IQR, 0-26)(平均差异–0.27 [95% CI, –1.74 to 1.19] P = .71)。两组患者ICU住院日(中位数 6 vs 6 天;0.39 [–1.09 to 1.89] ; P = .58)、总住院日(中位数 14 vs 15 天;–0.60 [–3.52 to 2.31]; P = .68)、28天病死率(34.9% vs 32.1%;风险比[HR], 1.12 [0.90 to 1.40]; P = .30)和90天病死率(39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54)无显著差异。两组患者以下不良事件发生率也没有显著差异:ARDS(3.8% vs 5.0%; 风险比 [RR], 0.86 [0.59 to 1.24]; P = .38),肺炎 (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67),严重肺不张 (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94) 和气胸 (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55)。

Conclusions and Relevance 结论与意义

In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy.

对于预计24小时内无法拔除气管插管的未合并ARDS的ICU患者,与中等潮气量相比,小潮气量通气策略不能增加无机械通气天数。

Trial Registration

ClinicalTrials.gov Identifier: NCT02153294

目前有 1 条留言 其中:访客:1 条, 博主:0 条

  1. zhuzh898 : 2018年11月12日21:13:08  -49楼

    看了下这篇文章的全文,不是很懂 ,请问哪里老师能指点一下。

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