Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania.
Ann Am Thorac Soc. 2021 Jul;18(7):1202-1210. doi: 10.1513/AnnalsATS.202008-1026OC.
There is an urgent need for improved understanding of the mechanisms and clinical characteristics of acute respiratory distress syndrome (ARDS) due to coronavirus disease (COVID-19). To compare key demographic and physiologic parameters, biomarkers, and clinical outcomes of COVID-19 ARDS and ARDS secondary to direct lung injury from other etiologies of pneumonia. We enrolled 27 patients with COVID-19 ARDS in a prospective, observational cohort study and compared them with a historical, pre-COVID-19 cohort of patients with viral ARDS ( = 14), bacterial ARDS ( = 21), and ARDS due to culture-negative pneumonia ( = 30). We recorded clinical demographics; measured respiratory mechanical parameters; collected serial peripheral blood specimens for measurement of plasma interleukin (IL)-6, IL-8, and IL-10; and followed patients prospectively for patient-centered outcomes. We conducted between-group comparisons with nonparametric tests and analyzed time-to-event outcomes with Kaplan-Meier and Cox proportional hazards models. Patients with COVID-19 ARDS had higher body mass index and were more likely to be Black, or residents of skilled nursing facilities, compared with those with non-COVID-19 ARDS ( < 0.05). Patients with COVID-19 had lower delivered minute ventilation compared with bacterial and culture-negative ARDS ( < 0.01) but not compared with viral ARDS. We found no differences in static compliance, hypoxemic indices, or carbon dioxide clearance between groups. Patients with COVID-19 had lower IL-6 levels compared with bacterial and culture-negative ARDS at early time points after intubation but no differences in IL-6 levels compared with viral ARDS. Patients with COVID-19 had longer duration of mechanical ventilation but similar 60-day mortality in both unadjusted and adjusted analyses. COVID-19 ARDS bears several similarities to viral ARDS but demonstrates lower minute ventilation and lower systemic levels of IL-6 compared with bacterial and culture-negative ARDS. COVID-19 ARDS was associated with longer dependence on mechanical ventilation compared with non-COVID-19 ARDS. Such detectable differences of COVID-19 do not merit deviation from evidence-based management of ARDS but suggest priorities for clinical research to better characterize and treat this new clinical entity.
由于冠状病毒病 (COVID-19)，人们迫切需要更好地了解急性呼吸窘迫综合征 (ARDS) 的机制和临床特征。为了比较 COVID-19 所致 ARDS 和其他病因所致肺炎继发直接肺损伤所致 ARDS 的关键人口统计学和生理参数、生物标志物和临床结局。我们对 27 例 COVID-19 所致 ARDS 患者进行了一项前瞻性观察队列研究，并将其与 COVID-19 前的一组病毒性 ARDS 患者（=14）、细菌性 ARDS 患者（=21）和培养阴性肺炎所致 ARDS 患者（=30）进行了比较。我们记录了临床人口统计学资料；测量了呼吸力学参数；采集了连续外周血标本，以测量血浆白细胞介素 (IL)-6、IL-8 和 IL-10；并前瞻性地对患者进行随访，以评估患者为中心的结局。我们采用非参数检验进行组间比较，并采用 Kaplan-Meier 和 Cox 比例风险模型分析时间事件结局。与非 COVID-19 所致 ARDS 患者相比，COVID-19 所致 ARDS 患者的体重指数更高，且更有可能为黑人或居住在熟练护理机构中（<0.05）。与细菌性和培养阴性 ARDS 患者相比，COVID-19 患者的分钟通气量较低（<0.01），但与病毒性 ARDS 患者相比无差异。各组间静态顺应性、低氧血症指数或二氧化碳清除率无差异。与细菌性和培养阴性 ARDS 患者相比，COVID-19 患者在插管后早期的 IL-6 水平较低，但与病毒性 ARDS 患者的 IL-6 水平无差异。COVID-19 患者的机械通气时间较长，但在未调整和调整分析中，60 天死亡率相似。COVID-19 所致 ARDS 与病毒性 ARDS 有一些相似之处，但与细菌性和培养阴性 ARDS 相比，分钟通气量较低，全身 IL-6 水平较低。与非 COVID-19 所致 ARDS 相比，COVID-19 所致 ARDS 患者对机械通气的依赖性更长。COVID-19 的这些可检测差异不需要偏离 ARDS 的循证管理，但提示需要优先进行临床研究，以更好地描述和治疗这种新的临床实体。
