Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy.
Lancet Respir Med. 2020 Dec;8(12):1201-1208. doi: 10.1016/S2213-2600(20)30370-2. Epub 2020 Aug 27.
Patients with COVID-19 can develop acute respiratory distress syndrome (ARDS), which is associated with high mortality. The aim of this study was to examine the functional and morphological features of COVID-19-associated ARDS and to compare these with the characteristics of ARDS unrelated to COVID-19.
This prospective observational study was done at seven hospitals in Italy. We enrolled consecutive, mechanically ventilated patients with laboratory-confirmed COVID-19 and who met Berlin criteria for ARDS, who were admitted to the intensive care unit (ICU) between March 9 and March 22, 2020. All patients were sedated, paralysed, and ventilated in volume-control mode with standard ICU ventilators. Static respiratory system compliance, the ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air, ventilatory ratio (a surrogate of dead space), and D-dimer concentrations were measured within 24 h of ICU admission. Lung CT scans and CT angiograms were done when clinically indicated. A dataset for ARDS unrelated to COVID-19 was created from previous ARDS studies. Survival to day 28 was assessed.
Between March 9 and March 22, 2020, 301 patients with COVID-19 met the Berlin criteria for ARDS at participating hospitals. Median static compliance was 41 mL/cm HO (33-52), which was 28% higher than in the cohort of patients with ARDS unrelated to COVID-19 (32 mL/cm HO [25-43]; p<0·0001). 17 (6%) of 297 patients with COVID-19-associated ARDS had compliances greater than the 95th percentile of the classical ARDS cohort. Total lung weight did not differ between the two cohorts. CT pulmonary angiograms (obtained in 23 [8%] patients with COVID-19-related ARDS) showed that 15 (94%) of 16 patients with D-dimer concentrations greater than the median had bilateral areas of hypoperfusion, consistent with thromboembolic disease. Patients with D-dimer concentrations equal to or less than the median had ventilatory ratios lower than those of patients with D-dimer concentrations greater than the median (1·66 [1·32-1·95] vs 1·90 [1·50-2·33]; p=0·0001). Patients with static compliance equal to or less than the median and D-dimer concentrations greater than the median had markedly increased 28-day mortality compared with other patient subgroups (40 [56%] of 71 with high D-dimers and low compliance vs 18 [27%] of 67 with low D-dimers and high compliance, 13 [22%] of 60 with low D-dimers and low compliance, and 22 [35%] of 63 with high D-dimers and high compliance, all p=0·0001).
Patients with COVID-19-associated ARDS have a form of injury that, in many aspects, is similar to that of those with ARDS unrelated to COVID-19. Notably, patients with COVID-19-related ARDS who have a reduction in respiratory system compliance together with increased D-dimer concentrations have high mortality rates.
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COVID-19 患者可发生急性呼吸窘迫综合征（ARDS），其与高死亡率相关。本研究旨在探讨 COVID-19 相关 ARDS 的功能和形态学特征，并将其与非 COVID-19 相关 ARDS 的特征进行比较。
这是一项在意大利 7 家医院进行的前瞻性观察性研究。我们纳入了 2020 年 3 月 9 日至 3 月 22 日期间入住重症监护病房（ICU）、经实验室确诊为 COVID-19 且符合柏林 ARDS 标准的连续接受机械通气的患者。所有患者均在 ICU 中接受镇静、麻痹和容量控制通气模式下的标准 ICU 通气机通气。入住 ICU 24 小时内测量静态呼吸系统顺应性、动脉血氧分压与吸入氧分数之比、通气比（死腔的替代指标）和 D-二聚体浓度。当临床需要时进行肺部 CT 扫描和 CT 血管造影。从先前的 ARDS 研究中创建了一个与 COVID-19 无关的 ARDS 数据集。评估了第 28 天的生存情况。
在 2020 年 3 月 9 日至 3 月 22 日期间，301 例 COVID-19 患者在参与医院符合柏林 ARDS 标准。中位静态顺应性为 41 mL/cmH2O（33-52），比与 COVID-19 无关的 ARDS 患者队列（32 mL/cmH2O[25-43]）高 28%（p<0·0001）。297 例 COVID-19 相关 ARDS 患者中有 17 例（6%）的顺应性大于经典 ARDS 队列的第 95 百分位数。两组的总肺重量无差异。23 例（8%）COVID-19 相关 ARDS 患者进行了 CT 肺动脉造影，显示 16 例 D-二聚体浓度大于中位数的患者中有 15 例（94%）存在双侧灌注不足，与血栓栓塞性疾病一致。D-二聚体浓度等于或低于中位数的患者通气比低于 D-二聚体浓度大于中位数的患者（1·66[1·32-1·95] vs 1·90[1·50-2·33]；p=0·0001）。D-二聚体浓度等于或大于中位数且静态顺应性小于或等于中位数的患者与其他患者亚组相比，28 天死亡率明显升高（71 例高 D-二聚体和低顺应性患者中有 40 例[56%]，67 例低 D-二聚体和高顺应性患者中有 18 例[27%]，60 例低 D-二聚体和低顺应性患者中有 13 例[22%]，63 例高 D-二聚体和高顺应性患者中有 22 例[35%]，所有 p=0·0001）。
COVID-19 相关 ARDS 患者的损伤形式在许多方面与非 COVID-19 相关 ARDS 患者相似。值得注意的是，具有呼吸力学顺应性降低和 D-二聚体浓度升高的 COVID-19 相关 ARDS 患者死亡率很高。
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