Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
Department of Administration, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
Crit Care. 2021 Jun 30;25(1):230. doi: 10.1186/s13054-021-03645-y.
Individualized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT) has potential interest in the optimization of ventilation distribution in acute respiratory distress syndrome (ARDS). The aim of the study was to determine whether early individualized titration of PEEP with EIT improved outcomes in patients with ARDS.
A total of 117 ARDS patients receiving mechanical ventilation were randomly assigned to EIT group (n = 61, PEEP adjusted based on ventilation distribution) or control group (n = 56, low PEEP/FiO table). The primary outcome was 28-day mortality. Secondary and exploratory outcomes were ventilator-free days, length of ICU stay, incidence of pneumothorax and barotrauma, and difference in Sequential Organ Failure Assessment (SOFA) score at day 1 (ΔD1-SOFA) and day 2 (ΔD2-SOFA) compared with baseline.
There was no statistical difference in the value of PEEP between the EIT group and control group, but the combination of PEEP and FiO was different between groups. In the control group, a significantly positive correlation was found between the PEEP value and the corresponding FiO (r = 0.47, p < 0.00001) since a given matched table was used for PEEP settings. Diverse combinations of PEEP and FiO were found in the EIT group (r = 0.05, p = 0.68). There was no significant difference in mortality rate (21% vs. 27%, EIT vs. control, p = 0.63), ICU length of stay (13.0 (7.0, 25.0) vs 10.0 (7.0, 14.8), median (25th-75th percentile); p = 0.17), and ventilator-free days at day 28 (14.0 (2.0, 23.0) vs 19.0 (0.0, 24.0), p = 0.55) between the two groups. The incidence of new barotrauma was zero. Compared with control group, significantly lower ΔD1-SOFA and ΔD2-SOFA were found in the EIT group (p < 0.001) in a post hoc comparison. Moreover, the EIT group exhibited a significant decrease of SOFA at day 2 compared with baseline (paired t-test, difference by - 1 (- 3.5, 0), p = 0.001). However, the control group did show a similar decrease (difference by 1 (- 2, 2), p = 0.131).
Our study showed a 6% absolute decrease in mortality in the EIT group: a statistically non-significant, but clinically non-negligible result. This result along with the showed improvement in organ function might justify further reserach to validate the beneficial effect of individualized EIT-guided PEEP setting on clinical outcomes of patients with ARDS.
ClinicalTrials, NCT02361398. Registered 11 February 2015-prospectively registered, https://clinicaltrials.gov/show/NCT02361398 .
应用电阻抗断层成像（EIT）的个体化呼气末正压（PEEP）在优化急性呼吸窘迫综合征（ARDS）的通气分布方面具有潜在的应用价值。本研究旨在确定 EIT 早期个体化 PEEP 滴定是否可以改善 ARDS 患者的预后。
共有 117 例接受机械通气的 ARDS 患者被随机分为 EIT 组（n = 61，根据通气分布调整 PEEP）或对照组（n = 56，低 PEEP/FiO 表）。主要结局为 28 天死亡率。次要和探索性结局为无呼吸机天数、ICU 住院时间、气胸和气压伤的发生率，以及与基线相比第 1 天（ΔD1-SOFA）和第 2 天（ΔD2-SOFA）的序贯器官衰竭评估（SOFA）评分差异。
EIT 组和对照组的 PEEP 值没有统计学差异，但两组的 PEEP 和 FiO 组合不同。在对照组中，由于使用了给定的匹配表来设置 PEEP，因此 PEEP 值与相应的 FiO 值之间存在显著的正相关（r = 0.47，p < 0.00001）。EIT 组中发现了不同的 PEEP 和 FiO 组合（r = 0.05，p = 0.68）。两组死亡率（21% vs. 27%，EIT 组 vs. 对照组，p = 0.63）、ICU 住院时间（13.0（7.0，25.0）vs 10.0（7.0，14.8），中位数（25 至 75 分位数）；p = 0.17）和 28 天无呼吸机天数（14.0（2.0，23.0）vs 19.0（0.0，24.0），p = 0.55）均无显著差异。两组新气压伤的发生率均为零。与对照组相比，EIT 组的第 1 天（ΔD1-SOFA）和第 2 天（ΔD2-SOFA）的 SOFA 评分均显著降低（p < 0.001）。此外，与基线相比，EIT 组在第 2 天的 SOFA 显著降低（配对 t 检验，差异为-1（-3.5，0），p = 0.001）。然而，对照组也显示出类似的降低（差异为 1（-2，2），p = 0.131）。
我们的研究显示 EIT 组的死亡率绝对降低了 6%：这是一个统计学上无显著意义但临床上不容忽视的结果。这一结果以及显示的器官功能改善可能证明进一步研究验证个体化 EIT 指导的 PEEP 设置对 ARDS 患者临床结局的有益效果是合理的。
ClinicalTrials，NCT02361398。2015 年 2 月 11 日注册-前瞻性注册，https://clinicaltrials.gov/show/NCT02361398。
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