COVID-19 相关急性呼吸窘迫综合征（ARDS）的血管外肺水较非 COVID-19 相关 ARDS 更高：PiCCOVID 研究。
COVID-19 ARDS is characterized by higher extravascular lung water than non-COVID-19 ARDS: the PiCCOVID study.
机构信息
AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive Réanimation (Département R3S), Paris, France.
出版信息
Crit Care. 2021 Jun 1;25(1):186. doi: 10.1186/s13054-021-03594-6.
BACKGROUND
In acute respiratory distress syndrome (ARDS), extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) measured by transpulmonary thermodilution reflect the degree of lung injury. Whether EVLWi and PVPI are different between non-COVID-19 ARDS and the ARDS due to COVID-19 has never been reported. We aimed at comparing EVLWi, PVPI, respiratory mechanics and hemodynamics in patients with COVID-19 ARDS vs. ARDS of other origin.
METHODS
Between March and October 2020, in an observational study conducted in intensive care units from three university hospitals, 60 patients with COVID-19-related ARDS monitored by transpulmonary thermodilution were compared to the 60 consecutive non-COVID-19 ARDS admitted immediately before the COVID-19 outbreak between December 2018 and February 2020.
RESULTS
Driving pressure was similar between patients with COVID-19 and non-COVID-19 ARDS, at baseline as well as during the study period. Compared to patients without COVID-19, those with COVID-19 exhibited higher EVLWi, both at the baseline (17 (14-21) vs. 15 (11-19) mL/kg, respectively, p = 0.03) and at the time of its maximal value (24 (18-27) vs. 21 (15-24) mL/kg, respectively, p = 0.01). Similar results were observed for PVPI. In COVID-19 patients, the worst ratio between arterial oxygen partial pressure over oxygen inspired fraction was lower (81 (70-109) vs. 100 (80-124) mmHg, respectively, p = 0.02) and prone positioning and extracorporeal membrane oxygenation (ECMO) were more frequently used than in patients without COVID-19. COVID-19 patients had lower maximal lactate level and maximal norepinephrine dose than patients without COVID-19. Day-60 mortality was similar between groups (57% vs. 65%, respectively, p = 0.45). The maximal value of EVLWi and PVPI remained independently associated with outcome in the whole cohort.
CONCLUSION
Compared to ARDS patients without COVID-19, patients with COVID-19 had similar lung mechanics, but higher EVLWi and PVPI values from the beginning of the disease. This was associated with worse oxygenation and with more requirement of prone positioning and ECMO. This is compatible with the specific lung inflammation and severe diffuse alveolar damage related to COVID-19. By contrast, patients with COVID-19 had fewer hemodynamic derangement. Eventually, mortality was similar between groups.
TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION
ClinicalTrials.gov (NCT04337983). Registered 30 March 2020-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04337983 .
背景
在急性呼吸窘迫综合征（ARDS）中，经肺温度稀释法测量的血管外肺水指数（EVLWi）和肺血管通透性指数（PVPI）反映了肺损伤的程度。COVID-19 所致 ARDS 与非 COVID-19 所致 ARDS 之间的 EVLWi 和 PVPI 是否不同，尚未见报道。我们旨在比较 COVID-19 相关 ARDS 患者与其他原因所致 ARDS 患者的 EVLWi、PVPI、呼吸力学和血流动力学。
方法
2020 年 3 月至 10 月期间，在三家大学医院的重症监护病房进行的一项观察性研究中，比较了 60 例接受经肺温度稀释法监测的 COVID-19 相关 ARDS 患者与 2018 年 12 月至 2020 年 2 月 COVID-19 爆发前连续入院的 60 例非 COVID-19 ARDS 患者。
结果
COVID-19 组和非 COVID-19 组患者的驱动压在基线和研究期间相似。与非 COVID-19 患者相比，COVID-19 患者的 EVLWi 更高，基线时为 17（14-21）比 15（11-19）ml/kg（p=0.03），最大值时为 24（18-27）比 21（15-24）ml/kg（p=0.01）。PVPI 也观察到类似的结果。在 COVID-19 患者中，动脉血氧分压与吸入氧分数之比的最差比值更低（81（70-109）比 100（80-124）mmHg，p=0.02），俯卧位通气和体外膜肺氧合（ECMO）的应用更为频繁。COVID-19 患者的最大乳酸水平和最大去甲肾上腺素剂量低于非 COVID-19 患者。两组第 60 天死亡率相似（分别为 57%和 65%，p=0.45）。在整个队列中，EVLWi 和 PVPI 的最大值仍然与预后相关。
结论
与非 COVID-19 所致 ARDS 患者相比，COVID-19 患者的肺力学相似，但疾病早期 EVLWi 和 PVPI 值更高。这与更差的氧合和更频繁的俯卧位通气和 ECMO 需求有关。这与 COVID-19 相关的特定肺部炎症和严重弥漫性肺泡损伤相符。相比之下，COVID-19 患者的血流动力学紊乱较少。最终，两组死亡率相似。
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