神经调节通气辅助与压力支持通气在困难撤机中的比较：一项随机试验。

Neurally Adjusted Ventilatory Assist versus Pressure Support Ventilation in Difficult Weaning: A Randomized Trial.

机构信息

From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China (L.L., X.X., Q.S., Y. Yu., F.X., J.X., Y. Yang, H.Q.) the Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands (L.H.).

出版信息

Anesthesiology. 2020 Jun;132(6):1482-1493. doi: 10.1097/ALN.0000000000003207.

DOI:10.1097/ALN.0000000000003207

PMID:32217876

Abstract

BACKGROUND

Difficult weaning frequently develops in ventilated patients and is associated with poor outcome. In neurally adjusted ventilatory assist, the ventilator is controlled by diaphragm electrical activity, which has been shown to improve patient-ventilator interaction. The objective of this study was to compare neurally adjusted ventilatory assist and pressure support ventilation in patients difficult to wean from mechanical ventilation.

METHODS

In this nonblinded randomized clinical trial, difficult-to-wean patients (n = 99) were randomly assigned to neurally adjusted ventilatory assist or pressure support ventilation mode. The primary outcome was the duration of weaning. Secondary outcomes included the proportion of successful weaning, patient-ventilator asynchrony, ventilator-free days, and mortality. Weaning duration was calculated as 28 days for patients under mechanical ventilation at day 28 or deceased before day 28 without successful weaning.

RESULTS

Weaning duration in all patients was statistically significant shorter in the neurally adjusted ventilatory assist group (n = 47) compared with the pressure support ventilation group (n = 52; 3.0 [1.2 to 8.0] days vs. 7.4 [2.0 to 28.0], mean difference: -5.5 [95% CI, -9.2 to -1.4], P = 0.039). Post hoc sensitivity analysis also showed that the neurally adjusted ventilatory assist group had shorter weaning duration (hazard ratio, 0.58; 95% CI, 0.34 to 0.98). The proportion of patients with successful weaning from invasive mechanical ventilation was higher in neurally adjusted ventilatory assist (33 of 47 patients, 70%) compared with pressure support ventilation (25 of 52 patients, 48%; respiratory rate for neurally adjusted ventilatory assist: 1.46 [95% CI, 1.04 to 2.05], P = 0.026). The number of ventilator-free days at days 14 and 28 was statistically significantly higher in neurally adjusted ventilatory assist compared with pressure support ventilation. Neurally adjusted ventilatory assist improved patient ventilator interaction. Mortality and length of stay in the intensive care unit and in the hospital were similar among groups.

CONCLUSIONS

In patients difficult to wean, neurally adjusted ventilatory assist decreased the duration of weaning and increased ventilator-free days.

摘要

背景

在接受机械通气的患者中，撤机困难经常发生，并与不良预后相关。在神经调节辅助通气中，呼吸机由膈肌电活动控制，这已被证明可以改善患者与呼吸机的相互作用。本研究的目的是比较神经调节辅助通气和压力支持通气在撤机困难患者中的应用。

方法

在这项非盲随机临床试验中，将 99 例撤机困难患者随机分配至神经调节辅助通气或压力支持通气模式。主要结局是撤机时间。次要结局包括撤机成功率、人机不同步、无呼吸机天数和死亡率。如果患者在第 28 天仍接受机械通气或在第 28 天前死亡且未成功撤机，则计算撤机时间为 28 天。

结果

所有患者的撤机时间在神经调节辅助通气组（n=47）明显短于压力支持通气组（n=52）[3.0（1.2 至 8.0）天比 7.4（2.0 至 28.0）天，平均差值：-5.5（95%CI，-9.2 至-1.4），P=0.039]。事后敏感性分析还显示，神经调节辅助通气组的撤机时间更短（风险比，0.58；95%CI，0.34 至 0.98）。神经调节辅助通气组有创机械通气撤机成功率更高（47 例患者中有 33 例，70%），高于压力支持通气组（52 例患者中有 25 例，48%；神经调节辅助通气的呼吸频率：1.46（95%CI，1.04 至 2.05），P=0.026）。神经调节辅助通气组在第 14 天和第 28 天的无呼吸机天数明显多于压力支持通气组。神经调节辅助通气改善了患者与呼吸机的相互作用。各组死亡率、重症监护病房和医院的住院时间相似。