呼气末正压和呼吸频率改变急性呼吸窘迫综合征患者机械功率和驱动压力与死亡率的关联。

Positive End-Expiratory Pressure and Respiratory Rate Modify the Association of Mechanical Power and Driving Pressure With Mortality Among Patients With Acute Respiratory Distress Syndrome.

作者信息

Tonna Joseph E, Peltan Ithan D, Brown Samuel M, Grissom Colin K, Presson Angela P, Herrick Jennifer S, Vasques Francesco, Keenan Heather T

机构信息

Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT.

Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT.

出版信息

Crit Care Explor. 2021 Dec 9;3(12):e0583. doi: 10.1097/CCE.0000000000000583. eCollection 2021 Dec.

DOI:10.1097/CCE.0000000000000583

PMID:34909696

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8663805/

Abstract

IMPORTANCE

Mechanical power and driving pressure have known associations with survival for patients with acute respiratory distress syndrome.

OBJECTIVES

To further understand the relative importance of mechanical power and driving pressure as clinical targets for ventilator management.

DESIGN

Secondary observational analysis of randomized clinical trial data.

SETTING AND PARTICIPANTS

Patients with the acute respiratory distress syndrome from three Acute Respiratory Distress Syndrome Network trials.

MAIN OUTCOMES AND MEASURES

After adjusting for patient severity in a multivariate Cox proportional hazards model, we examined the relative association of driving pressure and mechanical power with hospital mortality. Among 2,410 patients, the relationship between driving pressure and mechanical power with mortality was modified by respiratory rate, positive end-expiratory pressure, and flow.

RESULTS

Among patients with low respiratory rate (< 26), only power was significantly associated with mortality (power [hazard ratio, 1.82; 95% CI, 1.41-2.35; < 0.001] vs driving pressure [hazard ratio, 1.01; 95% CI, 0.84-1.21; = 0.95]), while among patients with high respiratory rate, neither was associated with mortality. Both power and driving pressure were associated with mortality at high airway flow (power [hazard ratio, 1.28; 95% CI, 1.15-1.43; < 0.001] vs driving pressure [hazard ratio, 1.15; 95% CI, 1.01-1.30; = 0.041]) and neither at low flow. At low positive end-expiratory pressure, neither was associated with mortality, whereas at high positive end-expiratory pressure (≥ 10 cm HO), only power was significantly associated with mortality (power [hazard ratio, 1.22; 95% CI, 1.09-1.37; < 0.001] vs driving pressure [hazard ratio, 1.16; 95% CI, 0.99-1.35; = 0.059]).

CONCLUSIONS AND RELEVANCE

The relationship between mechanical power and driving pressure with mortality differed within severity subgroups defined by positive end-expiratory pressure, respiratory rate, and airway flow.

摘要

重要性

机械功率和驱动压力与急性呼吸窘迫综合征患者的生存率存在已知关联。

目的

进一步了解机械功率和驱动压力作为呼吸机管理临床目标的相对重要性。

设计

对随机临床试验数据进行二次观察性分析。

设置与参与者

来自三项急性呼吸窘迫综合征网络试验的急性呼吸窘迫综合征患者。

主要结局与测量指标

在多变量Cox比例风险模型中对患者严重程度进行校正后，我们研究了驱动压力和机械功率与医院死亡率的相对关联。在2410名患者中，呼吸频率、呼气末正压和流量改变了驱动压力和机械功率与死亡率之间的关系。

结果

在呼吸频率低（<26次）的患者中，仅功率与死亡率显著相关（功率[风险比，1.82；95%置信区间，1.41 - 2.35；P<0.001] 对比驱动压力[风险比，1.01；95%置信区间，0.84 - 1.21；P = 0.95]），而在呼吸频率高的患者中，两者均与死亡率无关。在高气道流量时，功率和驱动压力均与死亡率相关（功率[风险比，1.28；95%置信区间，1.15 - 1.43；P<0.001] 对比驱动压力[风险比，1.15；95%置信区间，1.01 - 1.30；P = 0.041]），而在低流量时两者均与死亡率无关。在低呼气末正压时，两者均与死亡率无关，而在高呼气末正压（≥10 cm H₂O）时，仅功率与死亡率显著相关（功率[风险比，1.22；95%置信区间，1.09 - 1.37；P<0.001] 对比驱动压力[风险比，1.16；95%置信区间，0.99 - 1.35；P = 0.059]）。