Hu Weiwei, Zhang Suming, He Zhengyu, Zhou Yang, Wang Ziwen, Zhang Yang, Zang Baohe, Zhao Wenjing, Chao Yali
Department of Critical Care Medicine, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.
Department of Critical Care Medicine, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China.
Front Med (Lausanne). 2022 Jul 28;9:906903. doi: 10.3389/fmed.2022.906903. eCollection 2022.
Recent studies have mainly focused on the association between baseline intensity of mechanical ventilation (driving pressure or mechanical power) and mortality in acute respiratory distress syndrome (ARDS). It is unclear whether the association between the time-varying intensity of mechanical ventilation and mortality is significant and varies according to the fluid balance trajectories.
We conducted a secondary analysis based on the NHLBI ARDS Network's Fluid and Catheter Treatment Trial (FACTT). The primary outcome was 28-day mortality. The group-based trajectory modeling (GBTM) was employed to identify phenotypes based on fluid balance trajectories. Bayesian joint models were used to account for informative censoring due to death during follow-up.
A total of 1,000 patients with ARDS were included in the analysis. Our study identified two phenotypes of ARDS, and compared patients with Early Negative Fluid Balance (Early NFB) and patients with Persistent-Positive Fluid Balance (Persistent-PFB) accompanied by higher tidal volume, higher static driving pressure, higher mechanical power, and lower PaO/FiO, over time during mechanical ventilation. The 28-day mortality was 14.8% in Early NFB and 49.6% in Persistent-PFB ( < 0.001). In the Bayesian joint models, the hazard ratio () of 28-day death for time-varying static driving pressure [ 1.03 (95% 1.01-1.05; < 0.001)] and mechanical power [ 1.01 (95% 1.002-1.02; = 0.01)] was significant in patients with Early NFB, but not in patients with Persistent-PFB.
Time-varying intensity of mechanical ventilation was associated with a 28-day mortality of ARDS in a patient with Early NFB but not in patients with Persistent-PFB.
近期研究主要聚焦于急性呼吸窘迫综合征（ARDS）中机械通气的基线强度（驱动压力或机械功率）与死亡率之间的关联。目前尚不清楚机械通气的时变强度与死亡率之间的关联是否显著，以及是否会根据液体平衡轨迹而有所不同。
我们基于美国国立心肺血液研究所（NHLBI）急性呼吸窘迫综合征网络的液体与导管治疗试验（FACTT）进行了二次分析。主要结局为28天死亡率。采用基于组的轨迹模型（GBTM）根据液体平衡轨迹识别表型。使用贝叶斯联合模型来处理因随访期间死亡导致的信息删失。
共有1000例ARDS患者纳入分析。我们的研究识别出ARDS的两种表型，并比较了早期负液体平衡（Early NFB）患者和持续正液体平衡（Persistent-PFB）患者，后者在机械通气期间随时间推移伴有更高的潮气量、更高的静态驱动压力、更高的机械功率以及更低的动脉血氧分压/吸入氧浓度比值（PaO/FiO）。Early NFB组的28天死亡率为14.8%，Persistent-PFB组为49.6%（P<0.001）。在贝叶斯联合模型中，时变静态驱动压力[危险比（HR）为1.03（95%置信区间为1.01 - 1.05；P<0.001）]和机械功率[HR为1.01（95%置信区间为1.002 - 1.02；P = 0.01）]与Early NFB患者的28天死亡风险显著相关，但与Persistent-PFB患者无关。
机械通气的时变强度与Early NFB患者的ARDS 28天死亡率相关，但与Persistent-PFB患者无关。
