平台压与驱动压的分位数分析：对接受肺保护性通气的急性呼吸窘迫综合征患者死亡率的影响

A Quantile Analysis of Plateau and Driving Pressures: Effects on Mortality in Patients With Acute Respiratory Distress Syndrome Receiving Lung-Protective Ventilation.

作者信息

Villar Jesús, Martín-Rodríguez Carmen, Domínguez-Berrot Ana M, Fernández Lorena, Ferrando Carlos, Soler Juan A, Díaz-Lamas Ana M, González-Higueras Elena, Nogales Leonor, Ambrós Alfonso, Carriedo Demetrio, Hernández Mónica, Martínez Domingo, Blanco Jesús, Belda Javier, Parrilla Dácil, Suárez-Sipmann Fernando, Tarancón Concepción, Mora-Ordoñez Juan M, Blanch Lluís, Pérez-Méndez Lina, Fernández Rosa L, Kacmarek Robert M

机构信息

1CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. 2Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain. 3Intensive Care Unit, Hospital General de Ciudad Real, Ciudad Real, Spain. 4Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain. 5Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain. 6Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain. 7Intensive Care Unit, Hospital Universitario Morales Meseguer, Murcia, Spain. 8Intensive Care Unit, Hospital Universitario A Coruña, Coruña, Spain. 9Intensive Care Unit, Hospital Virgen de La Luz, Cuenca, Spain. 10Intensive Care Unit, Hospital Clínico Universitario, Valladolid, Spain. 11Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain. 12Intensive Care Unit, Hospital Universitario Virgen de Arrixaca, Murcia, Spain. 13Intensive Care Unit, Hospital Universitario N.S. de Candelaria, Santa Cruz de Tenerife, Spain. 14Department of Surgical Sciences, Anesthesiology & Critical Care, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden. 15Intensive Care Unit, Hospital Virgen de la Concha, Zamora, Spain. 16Intensive Care Unit, Hospital Universitario Carlos Haya, Málaga, Spain. 17Critical Care Center, Corporació Sanitaria Parc Taulí, Sabadell, Spain. 18Research Unit, Hospital Universitario NS de Candelaria, Santa Cruz de Tenerife, Spain. 19Department of Respiratory Care, Massachusetts General Hospital, Boston, MA. 20Department of Anesthesia, Harvard University, Boston, MA.

出版信息

Crit Care Med. 2017 May;45(5):843-850. doi: 10.1097/CCM.0000000000002330.

DOI:10.1097/CCM.0000000000002330

PMID:28252536

Abstract

OBJECTIVES

The driving pressure (plateau pressure minus positive end-expiratory pressure) has been suggested as the major determinant for the beneficial effects of lung-protective ventilation. We tested whether driving pressure was superior to the variables that define it in predicting outcome in patients with acute respiratory distress syndrome.

DESIGN

A secondary analysis of existing data from previously reported observational studies.

SETTING

A network of ICUs.

PATIENTS

We studied 778 patients with moderate to severe acute respiratory distress syndrome.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed the risk of hospital death based on quantiles of tidal volume, positive end-expiratory pressure, plateau pressure, and driving pressure evaluated at 24 hours after acute respiratory distress syndrome diagnosis while ventilated with standardized lung-protective ventilation. We derived our model using individual data from 478 acute respiratory distress syndrome patients and assessed its replicability in a separate cohort of 300 acute respiratory distress syndrome patients. Tidal volume and positive end-expiratory pressure had no impact on mortality. We identified a plateau pressure cut-off value of 29 cm H2O, above which an ordinal increment was accompanied by an increment of risk of death. We identified a driving pressure cut-off value of 19 cm H2O where an ordinal increment was accompanied by an increment of risk of death. When we cross tabulated patients with plateau pressure less than 30 and plateau pressure greater than or equal to 30 with those with driving pressure less than 19 and driving pressure greater than or equal to 19, plateau pressure provided a slightly better prediction of outcome than driving pressure in both the derivation and validation cohorts (p < 0.0000001).

CONCLUSIONS

Plateau pressure was slightly better than driving pressure in predicting hospital death in patients managed with lung-protective ventilation evaluated on standardized ventilator settings 24 hours after acute respiratory distress syndrome onset.

摘要

目的

驱动压（平台压减去呼气末正压）被认为是肺保护性通气有益效果的主要决定因素。我们测试了在预测急性呼吸窘迫综合征患者的预后方面，驱动压是否优于定义它的变量。

设计

对先前报道的观察性研究的现有数据进行二次分析。

设置

一个重症监护病房网络。

患者

我们研究了778例中重度急性呼吸窘迫综合征患者。

干预措施

无。

测量和主要结果

在急性呼吸窘迫综合征诊断后24小时，当患者接受标准化肺保护性通气时，我们根据潮气量、呼气末正压、平台压和驱动压的分位数评估医院死亡风险。我们使用来自478例急性呼吸窘迫综合征患者的个体数据推导模型，并在300例急性呼吸窘迫综合征患者的独立队列中评估其可重复性。潮气量和呼气末正压对死亡率没有影响。我们确定平台压的临界值为29 cmH₂O，高于此值时，序数增加伴随着死亡风险增加。我们确定驱动压的临界值为19 cmH₂O，在此值时，序数增加伴随着死亡风险增加。当我们将平台压小于30和平台压大于或等于30的患者与驱动压小于19和驱动压大于或等于19的患者交叉列表时，在推导和验证队列中，平台压对预后的预测略优于驱动压（p<0.0000001）。