Jensen Erik A, DeMauro Sara B, Kornhauser Michael, Aghai Zubair H, Greenspan Jay S, Dysart Kevin C
Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia.
Alere Inc, Waltham, Massachusetts.
JAMA Pediatr. 2015 Nov;169(11):1011-7. doi: 10.1001/jamapediatrics.2015.2401.
Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population.
To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation.
DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database.
The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses.
The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy.
We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy.
Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.
拔管失败在极早产儿中很常见。目前关于重新开始机械通气相关的长期不良呼吸结局的数据匮乏，这妨碍了对该人群进行拔管试验的风险和益处的评估。
评估在调整机械通气累积持续时间后，多次接受机械通气是否会增加不良呼吸结局的风险。
设计、地点和参与者：我们对2006年1月1日至2012年12月31日出生且正在接受机械通气的极低出生体重（ELBW；出生体重<1000g）婴儿进行了一项回顾性队列研究。分析于2014年11月至2015年2月进行。数据来自艾利新生儿数据库。
主要研究暴露因素是机械通气的累积持续时间和通气疗程数。
主要结局是幸存者中的支气管肺发育不良（BPD）。次要结局是死亡、出院时使用补充氧气和气管造口术。
我们确定了3343例ELBW婴儿，其中2867例（85.8%）存活至出院。在幸存者中，1695例（59.1%）被诊断为患有BPD，856例（29.9%）出院时接受补充氧气，31例（1.1%）接受了气管造口术。接受更多机械通气疗程与BPD风险和出院时使用补充氧气的风险逐渐增加相关。与单个通气疗程相比，2个通气疗程婴儿中BPD的调整后优势比为1.88（95%CI，(1.54 - 2.31)），4个或更多疗程婴儿中为3.81（95%CI，(2.88 - 5.04)）。在调整机械通气累积持续时间后，仅在接受4个或更多通气疗程的婴儿中BPD的几率增加（调整后优势比，1.44；95%CI，(1.04 - 2.01)）。在调整通气时长后，通气疗程数与出院时使用补充氧气风险增加无关。更多的通气疗程并未增加气管造口术的风险。
在ELBW婴儿中，机械通气的累积持续时间较长在很大程度上解释了与重新开始机械通气相关的慢性呼吸疾病风险增加的原因。这些结果支持对接受低通气设置机械通气的ELBW婴儿进行拔管尝试，即使不能保证成功。
