{"id":16887,"date":"2019-02-21T05:13:56","date_gmt":"2019-02-20T21:13:56","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=16887"},"modified":"2019-06-02T06:33:32","modified_gmt":"2019-06-01T22:33:32","slug":"jama%e5%9c%a8%e7%ba%bf%e5%8f%91%e8%a1%a8-epvent-2%e7%a0%94%e7%a9%b6%e6%98%be%e7%a4%ba%ef%bc%8c%e9%a3%9f%e9%81%93%e5%8e%8b%e6%8c%87%e5%af%bcpeep%e8%ae%be%e7%bd%ae%e4%b8%8d%e8%83%bd%e6%94%b9%e5%96%84","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=16887","title":{"rendered":"[JAMA\u5728\u7ebf\u53d1\u8868]: EPVent-2\u7814\u7a76\u663e\u793a\uff0c\u98df\u9053\u538b\u6307\u5bfcPEEP\u8bbe\u7f6e\u4e0d\u80fd\u6539\u5584ARDS\u60a3\u8005\u9884\u540e"},"content":{"rendered":"\n

Original Investigation\u00a0February\u00a018,\u00a02019<\/h3>\n\n\n\n

Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure\u2013Guided Strategy vs an Empirical High PEEP-Fio2<\/sub> Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial<\/h1>\n\n\n\n

Jeremy R.\u00a0Beitler,\u00a0Todd\u00a0Sarge,\u00a0Valerie M.\u00a0Banner-Goodspeed,\u00a0et al; for the EPVent-2 Study Group<\/h3>\n\n\n\n

JAMA.\u00a0<\/em>Published online February 18, 2019. doi:10.1001\/jama.2019.0555<\/h3>\n\n\n\n

Abstract<\/h2>\n\n\n\n

Importance<\/strong>\u00a0\u80cc\u666f<\/h2>\n\n\n\n

Adjusting positive end-expiratory pressure (PEEP) to offset pleural pressure might attenuate lung injury and improve patient outcomes in acute respiratory distress syndrome (ARDS).<\/p>\n\n\n\n

\u8c03\u6574PEEP\u5bf9\u6297\u80f8\u8154\u5185\u538b\u80fd\u591f\u51cf\u8f7bARDS\u60a3\u8005\u80ba\u635f\u4f24\uff0c\u6539\u5584\u4e34\u5e8a\u9884\u540e\u3002<\/p>\n\n\n\n

Objective<\/strong>\u00a0\u76ee\u7684<\/h2>\n\n\n\n

To determine whether PEEP titration guided by esophageal pressure (PES<\/sub>), an estimate of pleural pressure, was more effective than empirical high PEEP\u2013fraction of inspired oxygen (Fio2<\/sub>) in moderate to severe ARDS.<\/p>\n\n\n\n

\u4e0e\u7ecf\u9a8c\u6027\u9ad8PEEP-Fio2<\/sub>\u8bbe\u7f6e\u76f8\u6bd4\uff0c\u786e\u5b9a\u98df\u9053\u538b(PES<\/sub>)\uff08\u7528\u4e8e\u4f30\u6d4b\u80f8\u8154\u5185\u538b\uff09\u6307\u5bfcPEEP\u6ef4\u5b9a\u5bf9\u4e8e\u4e2d\u91cd\u5ea6ARDS\u60a3\u8005\u662f\u5426\u6709\u6548\u3002<\/p>\n\n\n\n

Design, Setting, and Participants<\/strong>\u00a0\u00a0\u8bbe\u8ba1\uff0c\u573a\u666f\u53ca\u7814\u7a76\u4eba\u7fa4<\/p>\n\n\n\n

Phase 2 randomized clinical trial conducted at 14 hospitals in North America. Two hundred mechanically ventilated patients aged 16 years and older with moderate to severe ARDS (Pao2<\/sub>:Fio2<\/sub>\u00a0\u2264200 mm Hg) were enrolled between October 31, 2012, and September 14, 2017; long-term follow-up was completed July 30, 2018.<\/p>\n\n\n\n

\u5728\u5317\u7f8e14\u6240\u533b\u9662\u8fdb\u884c\u7684\u4e00\u98792\u671f\u968f\u673a\u4e34\u5e8a\u8bd5\u9a8c\u30022012\u5e7410\u670831\u65e5\u81f32017\u5e749\u670814\u65e5\u4e4b\u95f4\uff0c\u5171\u7eb3\u5165200\u540d\u63a5\u53d7\u673a\u68b0\u901a\u6c14\u7684\u6210\u5e74\u4e2d\u91cd\u5ea6ARDS\u60a3\u8005 (Pao2<\/sub>:Fio2<\/sub>\u00a0\u2264200 mm Hg)\uff1b\u957f\u671f\u968f\u8bbf\u4e8e2018\u5e747\u670830\u65e5\u7ec8\u6b62\u3002<\/p>\n\n\n\n

Interventions<\/strong>\u00a0\u5e72\u9884\u63aa\u65bd<\/h2>\n\n\n\n

Participants were randomized to PES<\/sub>-guided PEEP (n\u2009=\u2009102) or empirical high PEEP-Fio2<\/sub>\u00a0(n\u2009=\u200998). All participants received low tidal volumes.<\/p>\n\n\n\n

\u60a3\u8005\u88ab\u968f\u673a\u5206\u81f3PES<\/sub>\u6307\u5bfcPEEP\u7ec4 (n\u2009=\u2009102) \u6216\u7ecf\u9a8c\u6027\u9ad8PEEP-Fio2<\/sub>\u7ec4 (n\u2009=\u200998)\u3002\u6240\u6709\u60a3\u8005\u5747\u63a5\u53d7\u5c0f\u6f6e\u6c14\u91cf\u901a\u6c14\u3002<\/p>\n\n\n\n

Main Outcomes and Measures<\/strong>\u00a0\u00a0\u4e3b\u8981\u9884\u540e\u6307\u6807<\/h2>\n\n\n\n

The primary outcome was a ranked composite score incorporating death and days free from mechanical ventilation among survivors through day 28. Prespecified secondary outcomes included 28-day mortality, days free from mechanical ventilation among survivors, and need for rescue therapy.<\/p>\n\n\n\n

\u4e3b\u8981\u9884\u540e\u6307\u6807\u4e3a\u5305\u62ec\u6b7b\u4ea1\u53ca\u5b58\u6d3b\u800528\u5929\u5185\u65e0\u673a\u68b0\u901a\u6c14\u5929\u6570\u7684\u5206\u7ea7\u590d\u5408\u8bc4\u5206\u3002\u9884\u5148\u786e\u5b9a\u7684\u6b21\u8981\u9884\u540e\u6307\u6807\u5305\u62ec28\u5929\u75c5\u6b7b\u7387\uff0c\u5b58\u6d3b\u8005\u65e0\u673a\u68b0\u901a\u6c14\u5929\u6570\uff0c\u4ee5\u53ca\u633d\u6551\u6cbb\u7597\u9700\u6c42\u3002<\/p>\n\n\n\n

Results<\/strong>\u00a0\u7ed3\u679c<\/h2>\n\n\n\n

Two hundred patients were enrolled (mean [SD] age, 56 [16] years; 46% female) and completed 28-day follow-up. The primary composite end point was not significantly different between treatment groups (probability of more favorable outcome with PES<\/sub>-guided PEEP: 49.6% [95% CI, 41.7% to 57.5%];\u00a0P<\/em>\u2009=\u2009.92). At 28 days, 33 of 102 patients (32.4%) assigned to PES<\/sub>-guided PEEP and 30 of 98 patients (30.6%) assigned to empirical PEEP-Fio2<\/sub>\u00a0died (risk difference, 1.7% [95% CI, \u221211.1% to 14.6%];\u00a0P<\/em>\u2009=\u2009.88). Days free from mechanical ventilation among survivors was not significantly different (median [interquartile range]: 22 [15-24] vs 21 [16.5-24] days; median difference, 0 [95% CI, \u22121 to 2] days;\u00a0P<\/em>\u2009=\u2009.85). Patients assigned to PES<\/sub>-guided PEEP were significantly less likely to receive rescue therapy (4\/102 [3.9%] vs 12\/98 [12.2%]; risk difference, \u22128.3% [95% CI, \u221215.8% to \u22120.8%];\u00a0P<\/em>\u2009=\u2009.04). None of the 7 other prespecified secondary clinical end points were significantly different. Adverse events included gross barotrauma, which occurred in 6 patients with PES<\/sub>-guided PEEP and 5 patients with empirical PEEP-Fio2<\/sub>.<\/p>\n\n\n\n

\u7814\u7a76\u7eb3\u5165200\u540d\u60a3\u8005\uff08\u5e73\u5747 [SD] \u5e74\u9f84\uff0c56 [16] \u5c81\uff1b46% \u4e3a\u5973\u6027\uff09\u4e14\u5b8c\u621028\u5929\u968f\u8bbf\u3002\u4e3b\u8981\u590d\u5408\u7ec8\u70b9\u5728\u4e24\u7ec4\u95f4\u65e0\u663e\u8457\u5dee\u5f02\uff08PES<\/sub>\u6307\u5bfcPEEP\u7ec4\u66f4\u597d\u9884\u540e\u6982\u7387\uff1a49.6% [95% CI, 41.7% to 57.5%];\u00a0P<\/em>\u2009=\u2009.92\uff09\u3002\u5728\u7b2c28\u5929\u65f6\uff0cAt 28 days, PES<\/sub>\u6307\u5bfcPEEP\u7ec4102\u540d\u60a3\u8005\u4e2d33\u540d(32.4%)\u4ee5\u53ca\u7ecf\u9a8c\u6027PEEP-Fio2<\/sub>\u7ec498\u540d\u60a3\u8005\u4e2d30\u540d(30.6%)\u6b7b\u4ea1\uff08\u98ce\u9669\u5dee\u5f021.7% [95% CI, \u221211.1% to 14.6%];\u00a0P<\/em>\u2009=\u2009.88\uff09\u3002\u4e24\u7ec4\u5b58\u6d3b\u60a3\u8005\u65e0\u673a\u68b0\u901a\u6c14\u5929\u6570\u65e0\u663e\u8457\u5dee\u5f02\uff08\u4e2d\u4f4d\u6570[\u56db\u5206\u4f4d\u533a\u95f4]: 22 [15-24] vs 21 [16.5-24] \u5929\uff1b\u4e2d\u4f4d\u5dee\u5f02\uff0c0 [95% CI, \u22121 to 2] \u5929\uff1bP<\/em>\u2009=\u2009.85\uff09\u3002PES<\/sub>\u6307\u5bfcPEEP\u7ec4\u60a3\u8005\u66f4\u5c11\u63a5\u53d7\u633d\u6551\u6cbb\u7597\uff084\/102 [3.9%] vs 12\/98 [12.2%]\uff1b\u98ce\u9669\u5dee\u5f02 \u22128.3% [95% CI, \u221215.8% to \u22120.8%];\u00a0P<\/em>\u2009=\u2009.04\uff09\u3002\u5176\u4ed67\u9879\u9884\u5148\u786e\u5b9a\u7684\u6b21\u8981\u4e34\u5e8a\u7ec8\u70b9\u6ca1\u6709\u663e\u8457\u5dee\u5f02\u3002\u4e0d\u826f\u4e8b\u4ef6\u5305\u62ec\u6c14\u538b\u4f24\uff0c PES<\/sub>\u6307\u5bfcPEEP\u7ec4\u53ca\u7ecf\u9a8c\u6027PEEP-Fio2<\/sub>\u7ec4\u5206\u522b\u67096\u540d\u53ca5\u540d\u60a3\u8005\u51fa\u73b0\u3002<\/p>\n\n\n\n

\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n

Conclusions and Relevance<\/strong>\u00a0\u7ed3\u8bba\u4e0e\u610f\u4e49<\/h2>\n\n\n\n

Among patients with moderate to severe ARDS, PES<\/sub>-guided PEEP, compared with empirical high PEEP-Fio2<\/sub>, resulted in no significant difference in death and days free from mechanical ventilation. These findings do not support PES<\/sub>-guided PEEP titration in ARDS.<\/p>\n\n\n\n

\u5bf9\u4e8e\u4e2d\u91cd\u5ea6ARDS\u60a3\u8005\uff0c\u4e0e\u7ecf\u9a8c\u6027\u9ad8PEEP-Fio2<\/sub> \u76f8\u6bd4\uff0cPES<\/sub>\u6307\u5bfcPEEP\u8bbe\u7f6e\u4e0d\u80fd\u663e\u8457\u6539\u5584\u6b7b\u4ea1\u53ca\u65e0\u673a\u68b0\u901a\u6c14\u5929\u6570\u3002\u8fd9\u4e9b\u7ed3\u679c\u4e0d\u652f\u6301\u5728ARDS\u60a3\u8005\u8fdb\u884cPES<\/sub>\u6307\u5bfcPEEP\u6ef4\u5b9a\u3002<\/p>\n","protected":false},"excerpt":{"rendered":"

Original Investigation\u00a0February\u00a018,\u00a02019 Effect of Titr […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[32,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16887"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16887"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16887\/revisions"}],"predecessor-version":[{"id":16888,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/16887\/revisions\/16888"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16887"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16887"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16887"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}