1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA. 2Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA.
Pediatr Crit Care Med. 2017 Nov;18(11):1019-1026. doi: 10.1097/PCC.0000000000001305.
Literature regarding appropriate use of inhaled nitric oxide for pediatric acute respiratory distress syndrome is sparse. This study aims to determine if positive response to inhaled nitric oxide is associated with decreased mortality and duration of mechanical ventilation in pediatric acute respiratory distress syndrome.
Retrospective cohort study.
Large pediatric academic medical center.
One hundred sixty-one children with pediatric acute respiratory distress syndrome and inhaled nitric oxide exposure for greater than or equal to 1 hour within 3 days of pediatric acute respiratory distress syndrome onset.
Patients with greater than or equal to 20% improvement in oxygenation index or oxygen saturation index by 6 hours after inhaled nitric oxide initiation were classified as "responders."
Oxygenation index, oxygen saturation index, and ventilator settings were evaluated prior to inhaled nitric oxide initiation and 1, 6, 12, and 24 hours following inhaled nitric oxide initiation. Primary outcomes were mortality and duration of mechanical ventilation. Baseline characteristics, including severity of illness, were similar between responders and nonresponders. Univariate analysis showed no difference in mortality between responders and nonresponders (21% vs 21%; p = 0.999). Ventilator days were significantly lower in responders (10 vs 16; p < 0.001). Competing risk regression (competing risk of death) confirmed association between inhaled nitric oxide response and successful extubation (subdistribution hazard ratio = 2.11; 95% CI, 1.41-3.17; p < 0.001). Response to inhaled nitric oxide was associated with decreased utilization of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation and lower hospital charges (difference in medians of $424,000).
Positive response to inhaled nitric oxide was associated with fewer ventilator days, without change in mortality, potentially via reduced use of high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. Future studies of inhaled nitric oxide for pediatric acute respiratory distress syndrome should stratify based on oxygenation response, given the association with favorable outcomes.
关于吸入一氧化氮在儿科急性呼吸窘迫综合征中的合理应用的文献很少。本研究旨在确定吸入一氧化氮的阳性反应是否与儿科急性呼吸窘迫综合征患儿的死亡率和机械通气时间的降低有关。
回顾性队列研究。
大型儿科学术医疗中心。
161 例儿科急性呼吸窘迫综合征患儿，在儿科急性呼吸窘迫综合征发病后 3 天内吸入一氧化氮时间大于或等于 1 小时。
吸入一氧化氮后 6 小时氧合指数或氧饱和度指数增加大于或等于 20%的患者被归类为“反应者”。
在吸入一氧化氮开始前和吸入一氧化氮开始后 1、6、12 和 24 小时评估氧合指数、氧饱和度指数和呼吸机设置。主要结局是死亡率和机械通气时间。反应者和非反应者之间的基线特征，包括疾病严重程度，相似。单变量分析显示，反应者和非反应者之间的死亡率无差异（21%比 21%；p = 0.999）。反应者的呼吸机天数明显减少（10 天比 16 天；p < 0.001）。竞争风险回归（死亡的竞争风险）证实了吸入一氧化氮反应与成功拔管之间的关联（亚分布危害比=2.11；95%CI，1.41-3.17；p < 0.001）。吸入一氧化氮的反应与高频振荡通气和体外膜肺氧合的应用减少以及医院费用降低有关（中位数差异为 424,000 美元）。
吸入一氧化氮的阳性反应与呼吸机天数减少有关，死亡率无变化，可能通过减少高频振荡通气和体外膜肺氧合的应用。鉴于与良好结局的关联，未来对儿科急性呼吸窘迫综合征吸入一氧化氮的研究应根据氧合反应进行分层。
