van Meenen David M, Roozeman Jan-Paul, Serpa Neto Ary, Pelosi Paolo, Gama de Abreu Marcelo, Horn Janneke, Cremer Olaf L, Paulus Frederique, Schultz Marcus J
Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
J Thorac Dis. 2019 Dec;11(12):5004-5013. doi: 10.21037/jtd.2019.12.38.
Outcome prediction in acute respiratory distress syndrome (ARDS) is challenging, especially in patients with severe hypoxemia. The aim of the current study was to determine the prognostic capacity of changes in PaO/FiO, dead space fraction (V/V) and respiratory system driving pressure (ΔP) induced by the first prone position (PP) session in patients with ARDS.
This was a post hoc analysis of the conveniently-sized 'Molecular Diagnosis and Risk Stratification of Sepsis' study (MARS). The current analysis included ARDS patients who were placed in the PP. The primary endpoint was the prognostic capacity of the PP-induced changes in PaO/FiO, V/V, and ΔP for 28-day mortality. PaO/FiO, V/V, and ΔP was calculated using variables obtained in the supine position before and after completion of the first PP session. Receiving operator characteristic curves (ROC) were constructed, and sensitivity, specificity positive and negative predictive value were calculated based on the best cutoffs.
Ninety patients were included; 28-day mortality was 46%. PP-induced changes in PaO/FiO and V/V were similar between survivors non-survivors [+83 (+24 to +137) +58 (+21 to +113) mmHg, and -0.06 (-0.17 to +0.05) -0.08 (-0.16 to +0.08), respectively]. PP-induced changes in ΔP were different between survivors non-survivors [-3 (-7 to 2) 0 (-3 to +3) cmHO; P=0.03]. The area under the ROC of PP-induced changes in ΔP for mortality, however, was low [0.63 (95% confidence interval (CI), 0.50 to 0.75]; PP-induced changes in ΔP had a sensitivity and specificity of 76% and 56%, and a positive and negative predictive value of 60% and 73%.
Changes in PaO/FiO, V/V, and ΔP induced by the first PP session have poor prognostic capacities for 28-day mortality in ARDS patients.
急性呼吸窘迫综合征（ARDS）的预后预测具有挑战性，尤其是对于严重低氧血症患者。本研究的目的是确定首次俯卧位（PP）治疗引起的动脉血氧分压/吸入氧分数（PaO/FiO）、死腔分数（V/V）和呼吸系统驱动压（ΔP）变化对ARDS患者的预后评估能力。
这是对规模合适的“脓毒症的分子诊断和风险分层”研究（MARS）进行的事后分析。当前分析纳入了接受PP治疗的ARDS患者。主要终点是PP诱导的PaO/FiO、V/V和ΔP变化对28天死亡率的预后评估能力。PaO/FiO、V/V和ΔP通过首次PP治疗前后仰卧位时获得的变量计算得出。构建受试者工作特征曲线（ROC），并根据最佳截断值计算敏感性、特异性、阳性和阴性预测值。
纳入90例患者；28天死亡率为46%。幸存者与非幸存者之间，PP诱导的PaO/FiO和V/V变化相似[分别为+83（+24至+137）和+58（+21至+113）mmHg，以及-0.06（-0.17至+0.05）和-0.08（-0.16至+0.08）]。幸存者与非幸存者之间，PP诱导的ΔP变化不同[-3（-7至2）和0（-3至+3）cmH₂O；P=0.03]。然而，PP诱导的ΔP变化对死亡率的ROC曲线下面积较低[0.63（95%置信区间（CI），0.50至0.75]；PP诱导的ΔP变化的敏感性和特异性分别为76%和56%，阳性和阴性预测值分别为60%和73%。
首次PP治疗引起的PaO/FiO、V/V和ΔP变化对ARDS患者28天死亡率的预后评估能力较差。
