Department of Anesthesia, Critical Care, and Pain Medicine and.
Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Am J Respir Crit Care Med. 2021 Nov 15;204(10):1153-1163. doi: 10.1164/rccm.202009-3539OC.
In acute respiratory distress syndrome (ARDS), the effect of positive end-expiratory pressure (PEEP) may depend on the extent to which multiorgan dysfunction contributes to risk of death, and the precision with which PEEP is titrated to attenuate atelectrauma without exacerbating overdistension. To evaluate whether multiorgan dysfunction and lung mechanics modified treatment effect in the EPVent-2 (Esophageal Pressure-guided Ventilation 2) trial, a multicenter trial of esophageal pressure (Pes)-guided PEEP versus empirical high PEEP in moderate to severe ARDS. This reanalysis of the EPVent-2 trial evaluated for heterogeneity of treatment effect on mortality by baseline multiorgan dysfunction, determined via Acute Physiology and Chronic Health Evaluation II (APACHE-II). It also evaluated whether PEEP titrated to end-expiratory transpulmonary pressure near 0 cm HO was associated with survival. All 200 trial participants were included. Treatment effect on 60-day mortality differed by multiorgan dysfunction severity ( = 0.03 for interaction). Pes-guided PEEP was associated with lower mortality among patients with APACHE-II less than the median value (hazard ratio, 0.43; 95% confidence interval, 0.20-0.92) and may have had the opposite effect in patients with higher APACHE-II (hazard ratio, 1.69; 95% confidence interval, 0.93-3.05). Independent of treatment group or multiorgan dysfunction severity, mortality was lowest when PEEP titration achieved end-expiratory transpulmonary pressure near 0 cm HO. The effect on survival of Pes-guided PEEP, compared with empirical high PEEP, differed by multiorgan dysfunction severity. Independent of multiorgan dysfunction, PEEP titrated to end-expiratory transpulmonary pressure closer to 0 cm HO was associated with greater survival than more positive negative values. These findings warrant prospective testing in a future trial.
在急性呼吸窘迫综合征（ARDS）中，呼气末正压（PEEP）的效果可能取决于多器官功能障碍对死亡风险的影响程度，以及精确滴定 PEEP 以减轻肺不张而不加重过度膨胀的程度。为了评估多器官功能障碍和肺力学是否改变了 EPVent-2（食管压力指导通气 2）试验中的治疗效果，该试验是一项多中心食管压力（Pes）指导的 PEEP 与中度至重度 ARDS 中经验性高 PEEP 的比较试验。对 EPVent-2 试验的重新分析评估了基线多器官功能障碍（通过急性生理学和慢性健康评估 II（APACHE-II）确定）对死亡率的治疗效果的异质性。它还评估了将呼气末跨肺压滴定至接近 0 cm HO 的 PEEP 是否与存活率相关。所有 200 名试验参与者均被纳入。治疗效果对 60 天死亡率的影响因多器官功能障碍严重程度而异（= 0.03 用于交互作用）。在 APACHE-II 值低于中位数的患者中，Pes 指导的 PEEP 与死亡率较低相关（危险比，0.43；95%置信区间，0.20-0.92），而在 APACHE-II 值较高的患者中可能有相反的效果（危险比，1.69；95%置信区间，0.93-3.05）。无论治疗组或多器官功能障碍严重程度如何，当呼气末跨肺压接近 0 cm HO 时，PEEP 滴定的死亡率最低。与经验性高 PEEP 相比，Pes 指导的 PEEP 对存活率的影响因多器官功能障碍严重程度而异。独立于多器官功能障碍，与更积极的负值相比，将 PEEP 滴定至接近 0 cm HO 的呼气末跨肺压与更高的存活率相关。这些发现值得在未来的试验中进行前瞻性测试。
