急性呼吸窘迫综合征成人患者的插管时机与临床结局
Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome.
作者信息
Kangelaris Kirsten Neudoerffer, Ware Lorraine B, Wang Chen Yu, Janz David R, Zhuo Hanjing, Matthay Michael A, Calfee Carolyn S
机构信息
1Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.3Department of Critical Care Medicine, Taichung Veteran General Hospital, Taichung, Taiwan.4Section of Pulmonary and Critical Care Medicine, Department of Medicine, Louisiana State University School of Medicine New Orleans, LA.5Division of Pulmonary and Critical Care, University of California, San Francisco, San Francisco, CA.6Departments Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA.
出版信息
Crit Care Med. 2016 Jan;44(1):120-9. doi: 10.1097/CCM.0000000000001359.
OBJECTIVE
The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized.
DESIGN
Secondary analysis of a prospective observational cohort study.
SETTING
Vanderbilt University Medical Center.
PATIENTS
Among adult patients enrolled in a large, multi-ICU prospective cohort study between the years of 2006 and 2011, we studied intubated and nonintubated patients with acute respiratory distress syndrome as defined by acute hypoxemia (PaO2/FIO2 ≤ 300 or SpO2/FIO2 ≤ 315) and bilateral radiographic opacities not explained by cardiac failure. We excluded patients not committed to full respiratory support.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
Of 457 patients with acute respiratory distress syndrome, 106 (23%) were not intubated at the time of meeting all other acute respiratory distress syndrome criteria. Nonintubated patients had lower morbidity and severity of illness than intubated patients; however, mortality at 60 days was the same (36%) in both groups (p = 0.91). Of the 106 nonintubated patients, 36 (34%) required intubation within the subsequent 3 days of follow-up; this late-intubation subgroup had significantly higher 60-day mortality (56%) when compared with the both early intubation group (36%, P<0.03) and patients never requiring intubation (26%; p = 0.002). Increased mortality in the late intubation group persisted at 2-year follow-up. Adjustment for baseline clinical and demographic differences did not change the results.
CONCLUSIONS
A substantial proportion of critically ill adults with acute respiratory distress syndrome were not intubated in their initial days of intensive care, and many were never intubated. Late intubation was associated with increased mortality. Criteria defining the acute respiratory distress syndrome prior to need for positive pressure ventilation are required so that these patients can be enrolled in clinical studies and to facilitate early recognition and treatment of acute respiratory distress syndrome.
目的
患有急性呼吸窘迫综合征且病情危急的未插管患者的患病率、临床特征及预后仍未得到充分描述。
设计
对一项前瞻性观察队列研究进行二次分析。
地点
范德比尔特大学医学中心。
患者
在2006年至2011年间纳入一项大型多重症监护病房前瞻性队列研究的成年患者中，我们研究了符合急性低氧血症（动脉血氧分压/吸入氧分数≤300或脉搏血氧饱和度/吸入氧分数≤315）及双侧影像学表现为肺部浸润影且不能用心力衰竭解释所定义的急性呼吸窘迫综合征的插管和未插管患者。我们排除了未接受完全呼吸支持的患者。
干预措施
无。
测量指标及主要结果
在457例急性呼吸窘迫综合征患者中，106例（23%）在符合所有其他急性呼吸窘迫综合征标准时未进行插管。未插管患者的发病率和疾病严重程度低于插管患者；然而，两组的60天死亡率相同（36%）（p = 0.91）。在106例未插管患者中，36例（34%）在随后3天的随访中需要插管；与早期插管组（36%，P<0.03）和从未需要插管的患者（26%；p = 0.002）相比，这个延迟插管亚组的60天死亡率显著更高（56%）。延迟插管组的死亡率在2年随访时仍然较高。对基线临床和人口统计学差异进行调整并没有改变结果。
结论
相当一部分患有急性呼吸窘迫综合征的危重症成年患者在重症监护的最初几天未进行插管，且许多患者从未插管。延迟插管与死亡率增加相关。需要在需要正压通气之前定义急性呼吸窘迫综合征的标准，以便这些患者能够纳入临床研究，并促进急性呼吸窘迫综合征的早期识别和治疗。
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