首次俯卧位通气后持续改善氧合与危重症新型冠状病毒肺炎患者机械通气脱机及死亡率的相关性：一项队列研究
Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study.
作者信息
Scaramuzzo Gaetano, Gamberini Lorenzo, Tonetti Tommaso, Zani Gianluca, Ottaviani Irene, Mazzoli Carlo Alberto, Capozzi Chiara, Giampalma Emanuela, Bacchi Reggiani Maria Letizia, Bertellini Elisabetta, Castelli Andrea, Cavalli Irene, Colombo Davide, Crimaldi Federico, Damiani Federica, Fusari Maurizio, Gamberini Emiliano, Gordini Giovanni, Laici Cristiana, Lanza Maria Concetta, Leo Mirco, Marudi Andrea, Nardi Giuseppe, Papa Raffaella, Potalivo Antonella, Russo Emanuele, Taddei Stefania, Consales Guglielmo, Cappellini Iacopo, Ranieri Vito Marco, Volta Carlo Alberto, Guerin Claude, Spadaro Savino
机构信息
Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy.
Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
出版信息
Ann Intensive Care. 2021 Apr 26;11(1):63. doi: 10.1186/s13613-021-00853-1.
BACKGROUND
Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO/FiO variation) or non-responders (< median PaO/FiO variation) based on the PaO/FiO percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO/FiO response after the first pronation cycle was associated to liberation from mechanical ventilation.
RESULTS
The median PaO/FiO variation after the first PP cycle was 49 [19-100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO/FiO before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP.
CONCLUSIONS
Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.
背景
俯卧位通气（PP）已被用于改善感染严重急性呼吸综合征冠状病毒2（SARS-CoV-2）疾病（新冠肺炎）患者的氧合。包括肺复张和更好的肺通气/血流匹配在内的多种机制，为使用PP提供了合理依据。然而，并非所有患者在恢复仰卧位后都能维持氧合改善。尽管如此，尚无证据表明PP后持续的氧合反应与机械通气的新冠肺炎患者的预后相关。我们分析了191例因临床原因接受PP治疗的新冠肺炎相关急性呼吸窘迫综合征患者的数据。分析了临床病史、严重程度评分和呼吸力学。根据首次俯卧位通气期间俯卧前和恢复仰卧位后1至3小时之间的动脉血氧分压/吸入氧分数值（PaO/FiO）百分比变化，将患者分为反应者（≥中位数PaO/FiO变化）或无反应者（<中位数PaO/FiO变化）。评估了两组在生理变量、并发症发生率和预后方面的差异。进行了竞争风险回归分析，以评估首次俯卧位通气周期后的PaO/FiO反应是否与机械通气脱机相关。
结果
首次PP周期后的中位数PaO/FiO变化为49[19-100%]，反应者（96/191）和无反应者（95/191）在人口统计学、合并症、通气治疗和PP前的PaO/FiO方面未发现差异。尽管重症监护病房住院时间无差异，但与反应者相比，无反应者的气管切开率更高（70.5%对47.9%，P=0.008），死亡率更高（53.7%对33.3%，P=0.006）。此外，首次PP后的氧合反应与28天机械通气脱机独立相关，并且对PP的氧合反应越高，相关性越强。
结论
首次PP治疗后持续的氧合改善与危重症新冠肺炎患者生存率提高和机械通气时间缩短独立相关。
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