免疫功能低下的急性呼吸窘迫综合征患者：LUNG SAFE 数据库的二次分析。
Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database.
机构信息
Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
Research Center on Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
出版信息
Crit Care. 2018 Jun 12;22(1):157. doi: 10.1186/s13054-018-2079-9.
BACKGROUND
The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients.
METHODS
We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents.
RESULTS
Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio.
CONCLUSIONS
Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge.
TRIAL REGISTRATION
ClinicalTrials.gov, NCT02010073 . Registered on 12 December 2013.
背景
本研究旨在描述免疫功能低下患者急性呼吸窘迫综合征（ARDS）的流行病学、通气管理和结局数据。
方法
我们对纳入大型观察性研究以了解全球严重急性呼吸衰竭影响（LUNG SAFE）的免疫功能低下患者队列进行了事后分析。LUNG SAFE 是一项国际性、前瞻性研究，纳入了来自 5 大洲 50 个国家的 459 个 ICU 中的低氧血症患者。
结果
在 2813 例 ARDS 患者中，584 例（20.8%）为免疫功能低下患者，其中 38.9%患者病因不明。肺炎、非肺部败血症和非心源性休克是 ARDS 的最常见危险因素。免疫功能低下患者的住院死亡率高于免疫功能正常患者（52.4% vs 36.2%；p<0.0001），尽管 ARDS 的严重程度相似。与免疫功能正常患者相比，免疫功能低下患者更频繁地做出限制生命支持措施的决定（27.1% vs 18.6%；p<0.0001）。免疫功能低下患者更常将无创通气（NIV）作为一线治疗（20.9% vs 15.9%；p=0.0048），并且在调整混杂因素后，免疫缺陷仍然与 NIV 的使用独立相关。48%接受 NIV 治疗的患者被气管插管，他们的死亡率与最初接受有创通气的患者无差异。
结论
免疫抑制在 ARDS 患者中很常见，感染是这些免疫功能低下患者发生 ARDS 的主要危险因素。他们的治疗方法与免疫功能正常患者不同，特别是更常将 NIV 作为一线通气策略。与免疫功能正常的患者相比，无论 ARDS 严重程度如何，他们的死亡率都更高，并且更频繁地采取维持生命的措施。尽管如此，这些患者中有近一半仍存活至出院。
试验注册
ClinicalTrials.gov，NCT02010073。于 2013 年 12 月 12 日注册。
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