脊髓损伤后机械通气撤机和拔管：西方创伤协会多中心研究。
Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study.
机构信息
From the Department of Surgery (L.Z.K., M.E.K., R.A.C., B.J.R., M.J.C.), University of California San Francisco, San Francisco General Hospital, San Francisco; and Department of Surgery (K.L.K.), Community Regional Medical Center/University of California San Francisco, Fresno, California; Trauma Services (C.K.H.), Scottsdale Healthcare Osborn Medical Center, Scottsdale, Arizona; Department of Surgery (T.H.C.), Gundersen Lutheran Medical Foundation, La Crosse, Wisconsin; Department of Surgery (C.C.Ba.), Virginia Tech Carilion School of Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; Division of Trauma, Surgical Critical Care, and Acute Care Surgery (M.L.S.), Duke University Medical Center, Durham, North Carolina; Department of Surgery (C.C.Bu.), Denver Health Medical Center, University of Colorado, Denver, Colorado; Division of Trauma, Emergency Surgery and Surgical Critical Care (M.D.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (J.M.H.), Via Christi Regional Medical Center, Wichita, Kansas; Department of Surgery (C.H.K.), New York University Langone Medical Center, New York, New York; Department of General Surgery and Trauma (S.J.Z.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (S.D.G.), Oregon Health Sciences University, Portland, Oregon; Department of Surgery (D.V.S.), University of California, Davis Medical Center, Davis, California; Department of Surgery (D.B.P.), Grant Medical Center, Columbus, Ohio.
出版信息
J Trauma Acute Care Surg. 2013 Dec;75(6):1060-9; discussion 1069-70. doi: 10.1097/TA.0b013e3182a74a5b.
BACKGROUND
Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity.
METHODS
Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia.
RESULTS
A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05).
CONCLUSION
While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study.
LEVEL OF EVIDENCE
Prognostic study, level III.
背景
急性脊髓损伤（SCI）后发生呼吸衰竭是众所周知的，但缺乏定义哪些患者需要长期呼吸机支持以及撤机和拔管标准的数据。我们假设，许多 SCI 患者，即使是颈髓 SCI 患者，也可以在不接受长期机械通气及其相关发病率的情况下成功治疗。
方法
在西部创伤协会多中心试验组的主持下，对 14 个主要创伤中心的 SCI 患者进行了回顾性研究。对急性 SCI 患者的综合损伤、人口统计学和结果数据进行了编译。主要结局变量为出院时机械通气的需要。次要结局包括气管切开术的使用以及急性肺损伤和呼吸机相关性肺炎的发生。
结果
共有 360 名需要机械通气的 SCI 患者。因住院后前 2 天内死亡而排除 16 名患者。在纳入的 344 名患者中，222 名（64.5%）为颈髓 SCI。值得注意的是，62.6%的颈髓 SCI 患者出院时无需呼吸机。149 名患者（43.3%）进行了气管切开术，其中 53.7%成功撤机，而未行气管切开术的患者撤机成功率为 85.6%（p < 0.05）。行气管切开术的患者呼吸机相关性肺炎发生率（61.1%比 20.5%，p < 0.05）和急性肺损伤发生率（12.8%比 3.6%，p < 0.05）明显较高，且无呼吸机天数较少（1 天比 24 天，p < 0.05）。在控制损伤严重程度、胸部损伤和呼吸合并症后，颈髓 SCI 后行气管切开术是呼吸机依赖的独立预测因素，与长期机械通气的可能性增加 14 倍相关（比值比，14.1；95%置信区间，2.78-71.67；p < 0.05）。
结论
虽然许多 SCI 患者需要短期机械通气，但大多数患者可在出院前成功撤机。在 SCI 患者中，气管切开术与主要发病率相关，其使用，特别是在颈髓 SCI 患者中，值得进一步研究。
证据水平
预后研究，III 级。
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