30 分钟自主呼吸试验会遗漏很多随后在 120 分钟自主呼吸试验中失败的患儿。
A 30-Minute Spontaneous Breathing Trial Misses Many Children Who Go On to Fail a 120-Minute Spontaneous Breathing Trial.
机构信息
Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
出版信息
Chest. 2023 Jan;163(1):115-127. doi: 10.1016/j.chest.2022.08.2212. Epub 2022 Aug 28.
BACKGROUND
The optimal length of spontaneous breathing trials (SBTs) in children is unknown.
RESEARCH QUESTIONS
What are the most common reasons for SBT failure in children, and when do they occur? Can clinical parameters at the 30-min mark of a 120-min SBT predict outcome?
STUDY DESIGN AND METHODS
We performed a secondary analysis of a clinical trial in pediatric ARDS, in which 2-h SBTs are conducted daily. SBT failure is based on objective criteria, including esophageal manometry for effort of breathing, categorized as passage, early failure (≤ 30 min), or late failure (30-120 min). Spirometry was used to calculate respiratory rate (RR), tidal volume (Vt), and rapid shallow breathing index (RSBI), in addition to pulse oximetry and capnography. Predictive models evaluated parameters at 30 min against SBT outcome, using receiver operating characteristic plots and area under the curve.
RESULTS
We included 100 children and 305 SBTs, with 42% of SBTs being successful, 32% failing within 30 min, and 25% failing between 30 and 120 min. Of the patients passing SBTs at 30 min, 40% went on to fail by 120 min. High respiratory effort (esophageal manometry) was present in > 80% of failed SBTs. At the 30-min mark, there were no clear thresholds for RR, Vt, RSBI, Fio, oxygen saturation, or capnography that could reliably predict SBT outcome. Multivariable modeling identified RR (P < .001) and RSBI > 7 (P = .034) at 30 min, pre-SBT inspiratory pressure level (P = .009), and pre-SBT retractions (P = .042) as predictors for SBT failure, but this model performed poorly in an independent validation set with the receiver operating characteristic plot crossing the reference line (area under the curve, 0.67).
INTERPRETATION
A 30-min SBT may be too short in children recovering from pediatric ARDS because many go on to fail between 30 and 120 min. Reassuring values of Vt, RR, and gas exchange at 30 min do not reliably predict SBT passage at 2 h, likely because they do not capture the effort of breathing.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov; No.: NCT03266016; URL: www.
CLINICALTRIALS
gov.
背景
儿童自主呼吸试验（SBT）的最佳时间长度尚不清楚。
研究问题
儿童 SBT 失败的最常见原因是什么，以及何时发生？SBT 120 分钟 30 分钟标记处的临床参数能否预测结果？
研究设计和方法
我们对儿科 ARDS 的临床试验进行了二次分析，其中每天进行 2 小时的 SBT。SBT 失败基于客观标准，包括食管测压以评估呼吸努力，分为通过、早期失败（≤30 分钟）或晚期失败（30-120 分钟）。除脉搏血氧饱和度和呼气末二氧化碳监测外，还使用肺活量计来计算呼吸频率（RR）、潮气量（Vt）和快速浅呼吸指数（RSBI）。使用受试者工作特征图和曲线下面积来评估 30 分钟时的预测模型参数与 SBT 结果的关系。
结果
我们纳入了 100 名儿童和 305 次 SBT，其中 42%的 SBT 成功，32%在 30 分钟内失败，25%在 30-120 分钟内失败。在 30 分钟时通过 SBT 的患者中，有 40%在 120 分钟时失败。>80%的失败 SBT 存在高呼吸努力（食管测压）。在 30 分钟时，RR、Vt、RSBI、FiO2、氧饱和度或呼气末二氧化碳监测没有明确的阈值可以可靠地预测 SBT 结果。多变量模型确定了 30 分钟时的 RR（P<0.001）和 RSBI>7（P=0.034）、预 SBT 吸气压力水平（P=0.009）和预 SBT 回缩（P=0.042）是 SBT 失败的预测因素，但该模型在独立验证集中表现不佳，受试者工作特征图越过参考线（曲线下面积，0.67）。
解释
在从儿科 ARDS 中恢复的儿童中，30 分钟的 SBT 可能太短，因为许多人在 30-120 分钟之间继续失败。30 分钟时 Vt、RR 和气体交换的令人放心的数值并不能可靠地预测 2 小时时的 SBT 通过率，这可能是因为它们没有捕捉到呼吸的努力。
临床试验注册
ClinicalTrials.gov；编号：NCT03266016；网址：www.clinicaltrials.gov。
临床试验
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