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新生儿呼吸衰竭体外膜肺氧合期间的肺休息——实践差异与结果

Lung Rest During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure-Practice Variations and Outcomes.

作者信息

Alapati Deepthi, Aghai Zubair H, Hossain Md Jobayer, Dirnberger Daniel R, Ogino Mark T, Shaffer Thomas H

机构信息

1Department of Pediatrics, Nemours, Alfred I. duPont Hospital for Children, Wilmington, DE. 2Center for Pediatric Lung Research, Nemours, Alfred I. duPont Hospital for Children, Wilmington, DE. 3Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA. 4Biostatistics Core, Nemours, Alfred I. duPont Hospital for Children, Wilmington, DE. 5Temple University School of Medicine, Philadelphia, PA.

出版信息

Pediatr Crit Care Med. 2017 Jul;18(7):667-674. doi: 10.1097/PCC.0000000000001171.

Abstract

OBJECTIVE

Describe practice variations in ventilator strategies used for lung rest during extracorporeal membrane oxygenation for respiratory failure in neonates, and assess the potential impact of various lung rest strategies on the duration of extracorporeal membrane oxygenation and the duration of mechanical ventilation after decannulation.

DATA SOURCES

Retrospective cohort analysis from the Extracorporeal Life Support Organization registry database during the years 2008-2013.

STUDY SELECTION

All extracorporeal membrane oxygenation runs for infants less than or equal to 30 days of life for pulmonary reasons were included.

DATA EXTRACTION

Ventilator type and ventilator settings used for lung rest at 24 hours after extracorporeal membrane oxygenation initiation were obtained.

DATA SYNTHESIS

A total of 3,040 cases met inclusion criteria. Conventional mechanical ventilation was used for lung rest in 88% of cases and high frequency ventilation was used in 12%. In the conventional mechanical ventilation group, 32% used positive end-expiratory pressure strategy of 4-6 cm H2O (low), 22% used 7-9 cm H2O (mid), and 43% used 10-12 cm H2O (high). High frequency ventilation was associated with an increased mean (SEM) hours of extracorporeal membrane oxygenation (150.2 [0.05] vs 125 [0.02]; p < 0.001) and an increased mean (SEM) hours of mechanical ventilation after decannulation (135 [0.09] vs 100.2 [0.03]; p = 0.002), compared with conventional mechanical ventilation among survivors. Within the conventional mechanical ventilation group, use of higher positive end-expiratory pressure was associated with a decreased mean (SEM) hours of extracorporeal membrane oxygenation (high vs low: 136 [1.06] vs 156 [1.06], p = 0.001; mid vs low: 141 [1.06] vs 156 [1.06]; p = 0.04) but increased duration of mechanical ventilation after decannulation in the high positive end-expiratory pressure group compared with low positive end-expiratory pressure (p = 0.04) among survivors.

CONCLUSIONS

Wide practice variation exists with regard to ventilator settings used for lung rest during neonatal respiratory extracorporeal membrane oxygenation. Use of high frequency ventilation when compared with conventional mechanical ventilation and use of low positive end-expiratory pressure strategy when compared with mid positive end-expiratory pressure and high positive end-expiratory pressure strategy is associated with longer duration of extracorporeal membrane oxygenation. Further research to provide evidence to drive optimization of pulmonary management during neonatal respiratory extracorporeal membrane oxygenation is warranted.

摘要

目的

描述新生儿呼吸衰竭体外膜肺氧合(ECMO)期间用于肺休息的通气策略的实践差异,并评估各种肺休息策略对ECMO持续时间及拔管后机械通气持续时间的潜在影响。

数据来源

2008年至2013年期间体外生命支持组织注册数据库的回顾性队列分析。

研究选择

纳入所有因肺部原因接受ECMO治疗且年龄小于或等于30天的婴儿。

数据提取

获取ECMO开始后24小时用于肺休息的呼吸机类型及呼吸机设置。

数据综合

共有3040例符合纳入标准。88%的病例使用传统机械通气进行肺休息,12%使用高频通气。在传统机械通气组中,32%采用4 - 6 cmH₂O(低)的呼气末正压策略,22%采用7 - 9 cmH₂O(中),43%采用10 - 12 cmH₂O(高)。与传统机械通气相比,高频通气与ECMO平均(标准误)小时数增加相关(150.2 [0.05] 对比125 [0.02];p < 0.001),且拔管后机械通气平均(标准误)小时数增加(135 [0.09] 对比100.2 [0.03];p = 0.002)。在传统机械通气组中,较高呼气末正压的使用与ECMO平均(标准误)小时数减少相关(高对比低:136 [1.06] 对比156 [1.06],p = 0.001;中对比低:141 [1.06] 对比156 [1.06];p = 0.04),但在幸存者中,高呼气末正压组拔管后机械通气持续时间比低呼气末正压组增加(p = 0.04)。

结论

新生儿呼吸ECMO期间用于肺休息的呼吸机设置存在广泛的实践差异。与传统机械通气相比,使用高频通气以及与中、高呼气末正压策略相比使用低呼气末正压策略与更长的ECMO持续时间相关。有必要进行进一步研究以提供证据来推动新生儿呼吸ECMO期间肺部管理的优化。

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