新型冠状病毒肺炎所致急性低氧性呼吸衰竭患者清醒俯卧位通气成功的因素：一项随机对照试验的分析
Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure: analysis of a randomized controlled trial.
作者信息
Ibarra-Estrada Miguel, Li Jie, Pavlov Ivan, Perez Yonatan, Roca Oriol, Tavernier Elsa, McNicholas Bairbre, Vines David, Marín-Rosales Miguel, Vargas-Obieta Alexandra, García-Salcido Roxana, Aguirre-Díaz Sara A, López-Pulgarín José A, Chávez-Peña Quetzalcóatl, Mijangos-Méndez Julio C, Aguirre-Avalos Guadalupe, Ehrmann Stephan, Laffey John G
机构信息
Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, El Retiro, Coronel Calderón 777, Guadalajara, Jalisco, Mexico.
Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA.
出版信息
Crit Care. 2022 Mar 28;26(1):84. doi: 10.1186/s13054-022-03950-0.
BACKGROUND
Awake prone positioning (APP) improves oxygenation in coronavirus disease (COVID-19) patients and, when successful, may decrease the risk of intubation. However, factors associated with APP success remain unknown. In this secondary analysis, we aimed to assess whether APP can reduce intubation rate in patients with COVID-19 and to focus on the factors associated with success.
METHODS
In this multicenter randomized controlled trial, conducted in three high-acuity units, we randomly assigned patients with COVID-19-induced acute hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula (HFNC) oxygen to APP or standard care. Primary outcome was intubation rate at 28 days. Multivariate analyses were performed to identify the predictors associated to treatment success (survival without intubation).
RESULTS
Among 430 patients randomized, 216 were assigned to APP and 214 to standard care. The APP group had a lower intubation rate (30% vs 43%, relative risk [RR] 0.70; CI 0.54-0.90, P = 0.006) and shorter hospital length of stay (11 interquartile range [IQR, 9-14] vs 13 [IQR, 10-17] days, P = 0.001). A respiratory rate ≤ 25 bpm at enrollment, an increase in ROX index > 1.25 after first APP session, APP duration > 8 h/day, and a decrease in lung ultrasound score ≥ 2 within the first 3 days were significantly associated with treatment success for APP.
CONCLUSION
In patients with COVID-19-induced AHRF treated by HFNC, APP reduced intubation rate and improved treatment success. A longer APP duration is associated with APP success, while the increase in ROX index and decrease in lung ultrasound score after APP can also help identify patients most likely to benefit.
TRIAL REGISTRATION
This study was retrospectively registered in ClinicalTrials.gov at July 20, 2021. Identification number NCT04477655. https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1.
背景
清醒俯卧位通气（APP）可改善冠状病毒病（COVID-19）患者的氧合，若成功实施，可能降低气管插管风险。然而，与APP成功相关的因素仍不明确。在这项二次分析中，我们旨在评估APP是否能降低COVID-19患者的气管插管率，并关注与成功相关的因素。
方法
在这项多中心随机对照试验中，于三个重症监护病房开展，我们将因COVID-19导致急性低氧性呼吸衰竭（AHRF）且需要高流量鼻导管（HFNC）吸氧的患者随机分为接受APP组或标准治疗组。主要结局是28天时的气管插管率。进行多变量分析以确定与治疗成功（未插管存活）相关的预测因素。
结果
在430例随机分组的患者中，216例被分配至APP组，214例被分配至标准治疗组。APP组的气管插管率较低（30%对43%，相对风险[RR]0.70；可信区间[CI]0.54 - 0.90，P = 0.006），住院时间较短（四分位数间距[IQR]为11天[9 - 14]对13天[IQR，10 - 17]，P = 0.001）。入组时呼吸频率≤25次/分、首次APP治疗后ROX指数增加>1.25、APP持续时间>8小时/天以及在最初3天内肺部超声评分降低≥2与APP治疗成功显著相关。
结论
在接受HFNC治疗的COVID-19诱导的AHRF患者中，APP降低了气管插管率并提高了治疗成功率。较长的APP持续时间与APP成功相关，而APP后ROX指数的增加和肺部超声评分的降低也有助于识别最可能受益的患者。
试验注册
本研究于2021年7月20日在ClinicalTrials.gov进行回顾性注册。识别号为NCT04477655。https://clinicaltrials.gov/ct2/show/NCT04477655?term=PRO-CARF&draw=2&rank=1 。
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