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[JAMA最新论文]:50个国家ICU中ARDS的流行病学、治疗情况及病死率
2016年03月08日 时讯速递, 网络资源, 进展交流 暂无评论

Original Investigation | CARING FOR THE CRITICALLY ILL PATIENT

Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries

Giacomo Bellani, John G. Laffey, Tài Pham, et al.

JAMA. 2016;315(8):788-800

doi:10.1001/jama.2016.0291

IMPORTANCE 重要性

Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS).

有关ARDS患者的流行病学、鉴别、治疗及预后的资料非常有限。

OBJECTIVES 目的

To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts—for example prone positioning—in routine clinical practice for patients fulfilling the ARDS Berlin Definition.

评估ICU中ARDS发病率及预后,对于满足ARDS柏林定义的患者,评估临床医生的诊断、机械通气方式及辅助治疗手段(如俯卧位)在常规临床工作中的使用情况

DESIGN, SETTING, AND PARTICIPANTS 设计,场景及患者

The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents.

LUNG-SAFE研究是一项国际多中心前瞻队列研究,入选患者接受有创或无创机械通气。研究于2014冬季年在5大洲50个国家459个ICU中进行,为期4周。

EXPOSURES 暴露

Acute respiratory distress syndrome.

ARDS

MAIN OUTCOMES AND MEASURES 主要结局及指标

The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS.

主要结局为ARDS的ICU发病率。次要结局包括评估临床医生识别ARDS的情况,机械通气的使用,常规临床工作中辅助治疗措施的应用,以及ARDS的临床预后。

RESULTS 结果

Of 29144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H2O. Prone positioning was used in 16.3% (95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9% (95% CI, 31.4%-38.5%) for those with mild, 40.3% (95% CI, 37.4%-43.3%) for those with moderate, and 46.1% (95% CI, 41.9%-50.4%) for those with severe ARDS.

在参研ICU收治的29144名患者中,3022 (10.4%)满足ARDS标准。其中,2377名患者在48小时内发生ARDS,并接受有创机械通气治疗呼吸功能衰竭。轻度ARDS的患病率为30.0% (95% CI, 28.2%-31.9%),中度ARDS为46.6% (95% CI, 44.5%-48.6%),重度ARDS为23.4% (95% CI, 21.7%-25.2%)。在为期4周的研究期间,ARDS约为0.42例/ICU床位,占ICU患者的10.4% (95% CI, 10.0%-10.7%),机械通气患者的23.4%。临床识别比例从轻度ARDS的51.3% (95% CI, 47.5%-55.0%) 到重度ARDS的78.5% (95% CI, 74.8%-81.8%)。不足2/3的ARDS患者潮气量≤ 8 ml/kg理想体重。40.1% (95% CI, 38.2-42.1)的患者测定平台压,82.6% (95% CI, 81.0%-84.1%)的患者PEEP < 12 cmH2O。16.3% (95% CI, 13.7%-19.2%)的重度ARDS患者使用俯卧位。临床识别ARDS患者使用较高PEEP,更多实用肌松药物及俯卧位。轻度ARDS的住院病死率为34.9% (95% CI, 31.4%-38.5%),中度ARDS为40.3% (95% CI, 37.4%-43.3%),重度ARDS为46.1% (95% CI, 41.9%-50.4%)。

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CONCLUSIONS AND RELEVANCE 结论与意义

Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the management of patients with ARDS.

在50个国家的ICU中,ARDS患病率为10.4%。这种临床综合征诊断不足,治疗不充分,病死率高。这些发现提示在ARDS诊治中尚存在改进的空间。

TRIALREGISTRATION clinicaltrials.govIdentifier:NCT02010073

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