Kallet Richard H, Zhuo Hanjing, Yip Vivian, Gomez Antonio, Lipnick Michael S
Respiratory Care Services in the Department of Anesthesia and Periopertive Care, University of California, San Francisco at Zuckerberg San Francisco General Hospital and Trauma Center.
Cardiovascular Research Institute, University of California, San Francisco.
Respir Care. 2018 Jan;63(1):1-10. doi: 10.4187/respcare.05270. Epub 2017 Oct 10.
Spontaneous breathing trials (SBTs) and daily sedation interruptions (DSIs) reduce both the duration of mechanical ventilation and ICU length of stay (LOS). The impact of these practices in patients with ARDS has not previously been reported. We examined whether implementation of SBT/DSI protocols reduce duration of mechanical ventilation and ICU LOS in a retrospective group of subjects with ARDS at a large, urban, level-1 trauma center.
All ARDS survivors from 2002 to 2016 ( = 1,053) were partitioned into 2 groups: 397 in the pre-SBT/DSI group (June 2002-December 2007) and 656 in the post-SBT/DSI group (January 2009-April 2016). Patients from 2008, during the protocol implementation period, were excluded. An additional SBT protocol database (2008-2010) was used to assess the efficacy of SBT in transitioning subjects with ARDS to unassisted breathing. Comparisons were assessed by either unpaired tests or Mann-Whitney tests. Multiple comparisons were made using either one-way analysis of variance or Kruskal-Wallis and Dunn's tests. Linear regression modeling was used to determine variables independently associated with mechanical ventilation duration and ICU LOS; differences were considered statistically significant when < .05.
Compared to the pre-protocol group, subjects with ARDS managed with SBT/DSI protocols experienced pronounced reductions both in median (IQR) mechanical ventilation duration (14 [6-29] vs 9 [4-17] d, respectively, < .001) and median ICU LOS (18 [8-33] vs 13 [7-22] d, respectively < .001). In the final model, only treatment in the SBT/DSI period and higher baseline respiratory system compliance were independently associated with reduced mechanical ventilation duration and ICU LOS. Among subjects with ARDS in the SBT performance database, most achieved unassisted breathing with a median of 2 SBTs.
Evidenced-based protocols governing weaning and sedation practices were associated with both reduced mechanical ventilation duration and ICU LOS in subjects with ARDS. However, higher respiratory system compliance in the SBT/DSI cohort also contributed to these improved outcomes.
自主呼吸试验（SBTs）和每日镇静中断（DSIs）可缩短机械通气时间和重症监护病房（ICU）住院时间。此前尚未报道过这些措施对急性呼吸窘迫综合征（ARDS）患者的影响。我们在一家大型城市一级创伤中心，对一组ARDS患者进行回顾性研究，以探讨实施SBT/DSI方案是否能缩短机械通气时间和ICU住院时间。
将2002年至2016年期间所有ARDS幸存者（n = 1053）分为两组：SBT/DSI前组397例（2002年6月至2007年12月）和SBT/DSI后组656例（2009年1月至2016年4月）。排除2008年方案实施期间的患者。使用另一个SBT方案数据库（2008 - 2010年）评估SBT在使ARDS患者过渡到自主呼吸方面的疗效。通过不成对t检验或曼 - 惠特尼检验进行比较。使用单因素方差分析或克鲁斯卡尔 - 沃利斯检验和邓恩检验进行多重比较。采用线性回归模型确定与机械通气时间和ICU住院时间独立相关的变量；当P <.05时，差异被认为具有统计学意义。
与方案前组相比，采用SBT/DSI方案管理的ARDS患者中位（IQR）机械通气时间（分别为14[6 - 29]天和9[4 - 17]天，P <.001）和中位ICU住院时间（分别为18[8 - 33]天和13[7 - 22]天，P <.001）均显著缩短。在最终模型中，仅SBT/DSI期间的治疗和更高的基线呼吸系统顺应性与机械通气时间缩短和ICU住院时间缩短独立相关。在SBT性能数据库中的ARDS患者中，大多数通过中位2次SBT实现了自主呼吸。
基于证据的撤机和镇静方案与ARDS患者机械通气时间缩短和ICU住院时间缩短相关。然而，SBT/DSI队列中更高的呼吸系统顺应性也促成了这些改善的结果。
