Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
Department of Cardiology, KRH Klinikum Robert Koch Gehrden, Gehrden, Germany.
Crit Care. 2017 May 30;21(1):122. doi: 10.1186/s13054-017-1687-0.
This study investigates differences in treatment and outcome of ventilated patients with acute respiratory distress syndrome (ARDS) between university and non-university hospitals in Germany.
This subanalysis of a prospective, observational cohort study was performed to identify independent risk factors for mortality by examining: baseline factors, ventilator settings (e.g., driving pressure), complications, and care settings-for example, case volume of ventilated patients, size/type of intensive care unit (ICU), and type of hospital (university/non-university hospital). To control for potentially confounding factors at ARDS onset and to verify differences in mortality, ARDS patients in university vs non-university hospitals were compared using additional multivariable analysis.
Of the 7540 patients admitted to 95 ICUs from 18 university and 62 non-university hospitals in May 2004, 1028 received mechanical ventilation and 198 developed ARDS. Although the characteristics of ARDS patients were very similar, hospital mortality was considerably lower in university compared with non-university hospitals (39.3% vs 57.5%; p = 0.012). Treatment in non-university hospitals was independently associated with increased mortality (OR (95% CI): 2.89 (1.31-6.38); p = 0.008). This was confirmed by additional independent comparisons between the two patient groups when controlling for confounding factors at ARDS onset. Higher driving pressures (OR 1.10; 1 cmHO increments) were also independently associated with higher mortality. Compared with non-university hospitals, higher positive end-expiratory pressure (PEEP) (mean ± SD: 11.7 ± 4.7 vs 9.7 ± 3.7 cmHO; p = 0.005) and lower driving pressures (15.1 ± 4.4 vs 17.0 ± 5.0 cmHO; p = 0.02) were applied during therapeutic ventilation in university hospitals, and ventilation lasted twice as long (median (IQR): 16 (9-29) vs 8 (3-16) days; p < 0.001).
Mortality risk of ARDS patients was considerably higher in non-university compared with university hospitals. Differences in ventilatory care between hospitals might explain this finding and may at least partially imply regionalization of care and the export of ventilatory strategies to non-university hospitals.
本研究旨在探讨德国大学医院和非大学医院之间接受机械通气的急性呼吸窘迫综合征（ARDS）患者的治疗和预后差异。
本研究为一项前瞻性、观察性队列研究的亚分析，旨在通过检查以下因素来确定死亡率的独立危险因素：基线因素、呼吸机设置（例如驱动压）、并发症和护理环境（例如，接受机械通气患者的例数、重症监护病房的规模/类型以及医院类型（大学/非大学医院））。为了控制 ARDS 发病时的潜在混杂因素，并验证死亡率的差异，使用额外的多变量分析比较了大学医院和非大学医院的 ARDS 患者。
2004 年 5 月，18 所大学和 62 所非大学医院的 95 个重症监护病房共收治了 7540 名患者，其中 1028 名接受了机械通气，198 名发生了 ARDS。尽管 ARDS 患者的特征非常相似，但与非大学医院相比，大学医院的住院死亡率明显较低（39.3%比 57.5%；p=0.012）。非大学医院的治疗与死亡率增加独立相关（OR（95%CI）：2.89（1.31-6.38）；p=0.008）。当控制 ARDS 发病时的混杂因素时，通过对两组患者进行额外的独立比较也证实了这一点。较高的驱动压（每增加 1 cmHO 的 OR 1.10；p=0.001）也与较高的死亡率独立相关。与非大学医院相比，大学医院的呼气末正压（PEEP）（平均值±标准差：11.7±4.7 比 9.7±3.7 cmHO；p=0.005）较高，驱动压（15.1±4.4 比 17.0±5.0 cmHO；p=0.02）较低，并且通气时间延长一倍（中位数（IQR）：16（9-29）比 8（3-16）天；p<0.001）。
与大学医院相比，非大学医院的 ARDS 患者死亡风险明显更高。医院之间通气治疗的差异可能解释了这一发现，并且至少部分暗示了护理的区域化和通气策略向非大学医院的输出。
