Schmidt Matthieu, Stewart Claire, Bailey Michael, Nieszkowska Ania, Kelly Joshua, Murphy Lorna, Pilcher David, Cooper D James, Scheinkestel Carlos, Pellegrino Vincent, Forrest Paul, Combes Alain, Hodgson Carol
1Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, VIC, Australia. 2Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France. 3Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 4Sydney University Medical School, The University of Sydney, Sydney, NSW, Australia. 5Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia.
Crit Care Med. 2015 Mar;43(3):654-64. doi: 10.1097/CCM.0000000000000753.
To describe mechanical ventilation settings in adult patients treated for an acute respiratory distress syndrome with extracorporeal membrane oxygenation and assess the potential impact of mechanical ventilation settings on ICU mortality.
Retrospective observational study.
Three international high-volume extracorporeal membrane oxygenation centers.
A total of 168 patients treated with extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from January 2007 to January 2013.
We analyzed the association between mechanical ventilation settings (i.e. plateau pressure, tidal volume, and positive end-expiratory pressure) on ICU mortality using multivariable logistic regression model and Cox-proportional hazards model.
We obtained detailed demographic, clinical, daily mechanical ventilation settings and ICU outcome data. One hundred sixty-eight patients (41 ± 14 years old; PaO2/FIO2 67 ± 19 mm Hg) fulfilled our inclusion criteria. Median duration of extracorporeal membrane oxygenation and ICU stay were 10 days (6-18 d) and 28 days (16-42 d), respectively. Lower positive end-expiratory pressure levels and significantly lower plateau pressures during extracorporeal membrane oxygenation were used in the French center than in both Australian centers (23.9 ± 1.4 vs 27.6 ± 3.7 and 27.8 ± 3.6; p < 0.0001). Overall ICU mortality was 29%. Lower positive end-expiratory pressure levels (until day 7) and lower delivered tidal volume after 3 days on extracorporeal membrane oxygenation were associated with significantly higher mortality (p < 0.05). In multivariate analysis, higher positive end-expiratory pressure levels during the first 3 days of extracorporeal membrane oxygenation support were associated with lower mortality (odds ratio, 0.75; 95% CI, 0.64-0.88; p = 0.0006). Other independent predictors of ICU mortality included time between ICU admission and extracorporeal membrane oxygenation initiation, plateau pressure greater than 30 cm H2O before extracorporeal membrane oxygenation initiation, and lactate level on day 3 of extracorporeal membrane oxygenation support.
Protective mechanical ventilation strategies were routinely used in high-volume extracorporeal membrane oxygenation centers. However, higher positive end-expiratory pressure levels during the first 3 days on extracorporeal membrane oxygenation support were independently associated with improved survival. Further prospective trials on the optimal mechanical ventilation strategy during extracorporeal membrane oxygenation support are warranted.
描述接受体外膜肺氧合治疗的急性呼吸窘迫综合征成年患者的机械通气设置，并评估机械通气设置对重症监护病房（ICU）死亡率的潜在影响。
回顾性观察研究。
三个国际大型体外膜肺氧合中心。
2007年1月至2013年1月期间共168例因严重急性呼吸窘迫综合征接受体外膜肺氧合治疗的患者。
我们使用多变量逻辑回归模型和Cox比例风险模型分析了机械通气设置（即平台压、潮气量和呼气末正压）与ICU死亡率之间的关联。
我们获取了详细的人口统计学、临床、每日机械通气设置和ICU结局数据。168例患者（41±14岁；动脉血氧分压/吸入氧浓度为67±19mmHg）符合纳入标准。体外膜肺氧合和ICU住院的中位持续时间分别为10天（6 - 18天）和28天（16 - 42天）。法国中心在体外膜肺氧合期间使用的呼气末正压水平较低，且平台压显著低于两个澳大利亚中心（23.9±1.4 vs 27.6±3.7和27.8±3.6；p<0.0001）。总体ICU死亡率为29%。较低的呼气末正压水平（至第7天）和体外膜肺氧合3天后较低的潮气量与显著较高的死亡率相关（p < 0.05）。在多变量分析中，体外膜肺氧合支持的前3天较高的呼气末正压水平与较低的死亡率相关（优势比，0.75；95%置信区间，0.64 - 0.88；p = 0.0006）。ICU死亡率的其他独立预测因素包括ICU入院至开始体外膜肺氧合的时间、体外膜肺氧合开始前平台压大于30cmH₂O以及体外膜肺氧合支持第3天的乳酸水平。
大型体外膜肺氧合中心常规采用保护性机械通气策略。然而，体外膜肺氧合支持的前3天较高的呼气末正压水平与生存率提高独立相关。有必要进一步开展关于体外膜肺氧合支持期间最佳机械通气策略的前瞻性试验。
